Monitoring and evaluation of health system support and strengthening programs in Papua New Guinea Emma Field A thesis in fulfilment of the requirements for the degree of Doctor of Public Health UNSW Australia School of Public Health and Community Medicine Faculty of Medicine October 2018 UNSW Supervisors: Dr Sally Nathan Dr Alexander Rosewell Associate Professor Siranda Torvaldsen Abt Associates Supervisor: Mr Geoff Scahill Table of contents Table of contents ........................................................................................................... i Abbreviations and Acronyms ........................................................................................ iii Acknowledgements ...................................................................................................... iv Abstract ........................................................................................................................ v Publications and presentations .................................................................................... vii Topic and scope of this thesis ....................................................................................... x References ............................................................................................................... xii CHAPTER 1: HEALTH SYSTEM SUPPORT AND STRENGTHENING IN PAPUA NEW GUINEA ........................................................................................................................ 1 1. Papua New Guinea ............................................................................................ 2 2. Health system support and strengthening .......................................................... 9 3. Health system support and strengthening in Papua New Guinea ..................... 11 4. Monitoring and evaluation of health system strengthening ............................... 13 5. References ....................................................................................................... 19 CHAPTER 2: EVALUATION OF THE CMCA MIDDLE AND SOUTH FLY HEALTH PROGRAM ................................................................................................................. 28 1. Chapter prelude ............................................................................................... 29 2. Background ...................................................................................................... 29 3. Project overview ............................................................................................... 32 4. Contribution to project ...................................................................................... 33 5. Project outputs ................................................................................................. 34 6. Ethical considerations ...................................................................................... 35 7. References ....................................................................................................... 37 8. Publication ....................................................................................................... 38 CHAPTER 3: LESSONS FROM THE VILLAGE HEALTH VOLUNTEER PROGRAM AND CONSIDERATIONS FOR POLICY ..................................................................... 51 1. Chapter prelude ............................................................................................... 52 2. Background ...................................................................................................... 52 3. Project overview ............................................................................................... 53 4. Contribution to the project ................................................................................ 53 5. Project outputs ................................................................................................. 54 6. Ethical considerations ...................................................................................... 54 7. References ....................................................................................................... 55 8. Manuscript ....................................................................................................... 56 i CHAPTER 4: CONTEXTUAL FACTORS AND HEALTH SERVICE PERFORMANCE IN PAPUA NEW GUINEA ................................................................................................ 89 1. Chapter prelude................................................................................................ 90 2. Background ...................................................................................................... 90 3. Project overview ............................................................................................... 91 4. Contribution to the project ................................................................................ 91 5. Project outputs ................................................................................................. 91 6. Ethics considerations ....................................................................................... 92 7. References ....................................................................................................... 93 8. Manuscript ........................................................................................................ 94 CHAPTER 5: CHALLENGES OF HEALTH PROGRAM MONITORING AND EVALUATION IN LOW RESOURCE SETTINGS ...................................................... 113 1. Chapter prelude.............................................................................................. 114 2. Background .................................................................................................... 114 3. Project overview ............................................................................................. 115 4. Contribution to the project .............................................................................. 115 5. Project outputs ............................................................................................... 115 6. Ethical considerations .................................................................................... 116 7. Manuscript ...................................................................................................... 117 CHAPTER 6: CONCLUSION AND RECOMMENDATIONS ...................................... 131 1. Summary of findings ....................................................................................... 132 2. Recommendations ......................................................................................... 141 3. Conclusion ..................................................................................................... 143 4. References ..................................................................................................... 145 Appendix. Strengthening Health services in Western Province, Papua New Guinea: Progress Report of the North Fly Health Services Development Program and the CMCA Middle and South Fly Health Program ........................................................... 148 ii Abbreviations and Acronyms ANC Antenatal care CAP Community Action and Participation CMCA Community Mine Continuation Agreement DrPH Doctor of Public Health MDG Millennium Development Goal M&E Monitoring and evaluation MRAC Medical Research Advisory Committee NHIS National Health Information System OTDF Ok Tedi Development Foundation OTML Ok Tedi Mining Limited PEPFAR The United States President’s Emergency Plan for AIDS Relief PNG Papua New Guinea RCT Randomised controlled trial TB Tuberculosis UNICEF United Nations Children’s Fund VHV Village Health Volunteer VBA Village Birth Attendant WHO World Health Organization iii Acknowledgements The journey through the Doctor of Public Health (DrPH) can be both challenging and rewarding. While we should embrace the challenges, we need to be supported. I was fortunate to have a team of supporters to navigate the DrPH and foster learning and development. I had the privilege to have been able to undertake the DrPH as part of my work at Abt Associates. My workplace supervisor, Mr Geoff Scahill, has been an endless source of encouragement and an advocate for me during the DrPH. I am also very thankful to my team at Abt Associates and teams for the programs on which I worked. I would like to sincerely thank my academic supervisors Dr Sally Nathan, Dr Alexander Rosewell and Associate Professor Siranda Torvaldsen, who went above and beyond the role of supervisor. I would also like to thank my current supervisor, Professor Ross Andrews from Menzies School of Health Research, for providing time to complete the DrPH. I would like to thank my family and partner for their enduring support, for listening and just being there. In particular I would like to thank Archie for formatting, and Alison and Daniel for proof reading parts of this thesis. I would also like to thank the National Department of Health in Papua New Guinea for providing approval for me to undertake the DrPH on programs operating within the country. I would also like to acknowledge the Ok Tedi Development Foundation, which funds the CMCA Middle and South Fly Health Program. Finally, I would like to thank the people of Papua New Guinea. It has been a privilege to work with inspiring health workers in such a beautiful country. I hope the work of this thesis will contribute to the knowledge to improve the health system. iv Abstract The health system in