Wan nes nomo Place & access to primary care in rural Vanuatu Kirstie Petrou A thesis submitted in partial fulfilment of the requirements for the degree of Bachelor of Arts with Honours, University of Sydney, 2009. Acknowledgements There are many people without whom this project would not have been possible. Firstly, I would like to thank the families on Tanna who welcomed me into their homes, and put up with my being horribly inept at almost everything I tried: tangkiu tumas long Litchen and Alice, my mother and sister in Iquaramanu; Edwin, Elsi and family in Yenamakel who had an uncanny way of always knowing what I needed without ever having to ask; and Julian, Francisco and Junior in Lenakel who taught me how to be a proper haosgel . Without your help and support, none of this would have been possible. Mi hop se bambae mi lukim yu long Tanna bakegen . Thank you to my supervisor John, who on our first meeting, ‘waved his arms around in the air for Vanuatu’ and then offered me his house. Your comments and support have been invaluable – even if you were wrong about the whole broken leg thing. A special thank you to Jeremy, who organized all of my contacts on Tanna, gave me endless advice and helped me fill the many gaps in my own knowledge. I wish there was something appropriate I could say in White Sands language, but all I can remember is ‘narfuknarsisi’ : ‘I’m full’. None of this would have been possible without the support of the hardworking staff at Lenakel Hospital. My deepest thanks to Lui, Janet and Jimmy who welcomed me with warmth, answered my endless questions, and allowed me to sit for hours in the hospital office. Thank you to Estella and Philip who let me (try to) follow them around on rural visits, and when this failed, entertained me with tales of Tanna from the not too distant past. Lisa and Eugene, your cups of tea and banana bread were a welcome change from taro and laplap and maniok and laplap and more laplap and salt… When I did make it to rural health facilities, the staff were unwaveringly friendly and helpful. Special thanks to Jocelyn, who allowed me to sit in on patient consultations, and only afterwards thought to ask why. In Port Vila, Cynthia and John made my early days easier. Without my two favourite ni-Van medical students tirelessly driving me around Vila, I would have spent much more time getting lost and much less time doing fieldwork. Thanks for the kava . I would also like to acknowledge the chiefs who welcomed me into their villages both in Yenamakel and Iquaramanu; thank you for sharing your ‘places’ with me. And finally, thank you to my family, who once again allowed me to wander off into the unknown without (too much) protest, and more than once made special trips to the bank to ensure their first born (grand)child wasn’t trapped on a tropical island, in the middle of the Pacific, penniless and alone. ii Table of Contents Acknowledgements…………………………………………………………………………......ii Table of Contents………………………………………………………………….……….......iii List of Figures…………………………………………………………………….……………vi List of Tables…………………………………………………………………….……………viii Chapter 1: Introduction………………………………………………………………………..1 Chapter 2: Literature Review………………………………………………………………….6 2.1 Access...……………………………………………………………………………7 2.2 Place and access……………………………………………………………………8 2.3 Physical barriers to care……………………………………………………………9 2.4 Cultural barriers to care…………………………………………………………..13 2.5 Conclusion………………………………………………………………………..16 Chapter 3: Country Overview………………………………………………………………..17 3.1 Vanuatu…………………………………………………………………………...18 3.2 Tanna……………………………………………………………………………..21 3.3 Health system…………………………………………………………………….23 3.4 Human resources: the formal system…………………………………………….28 3.5 The informal health system………………………………………………………30 3.6 Kastom in Vanuatu………………………………………………………………30 3.7 Kastom medicine and health beliefs……………………………………………..31 3.8 The importance of place…………………………………………………………36 3.9 Conclusion……………………………………………………………………….37 Chapter 4: Methodology……………………………………………………………………...38 4.1 Desk based research………………………………………………………………39 iii 4.2 Study locations……………………………………………………………………40 4.3 Qualitative techniques: semi-structured interviews………………………………48 4.4 Biases built into interviewing……………………………………………………50 4.5 Qualitative techniques: participant observation………………………………….52 4.6 Language use……………………………………………………………………..53 4.7 Conclusion………………………………………………………………………..54 Chapter 5: Structural barriers to access…………………………………………………….56 5.1 Service location…………………………………………………………………...57 5.2 Human resources………………………………………………………………….60 5.3 Availability of other resources……………………………………………………65 5.4 PC costs…………………………………………………………………………...69 5.5 Transport and infrastructure………………………………………………………72 5.6 Conclusion………………………………………………………………………..76 Chapter 6: Cultural factors…………………………………………………………………..78 6.1 Illness causation…………………………………………………………………..79 6.2 Kastom medicine………………………………………………………………….81 6.3 Community attitudes towards PC………………………………………………...91 6.4 Case studies……………………………………………………………………….93 6.5 Conclusion.……………………………………………………………………...100 Chapter 7: Conclusions ……………………………………………………………………...103 7.1 Barriers to access………………………………………………………………..104 7.1a Structural barriers………………………………………………………104 7.1b Cultural factors………………………………………………………...109 7.2 The relative influence of spatial vs. cultural factors……………………………112 iv 7.3 Traditional medicine vs. biomedicine…………………………………………..114 7.4 Conclusion………………………………………………………………………116 Reference List………………………………………………………………………………...118 Appendix A: Rural health facilities by population………...………………………………123 Appendix B: Alternate health facility lists……..…………..………………………………124 Appendix C: Rural health team schedule, July – December 2009………………………..125 Appendix D: White Sands Health Centre participant observation………………………126 v List of Figures Figure 1: Vanuatu……………………………………………………………………………...19 Figure 2: Typical subsistence produce maniok (tapioca)……………………………………...20 Figure 3: …And aelan kabis (island cabbage) ………………………………….…………….20 Figure 4: The island of Tanna………………………………………………………….………22 Figure 5: Iquaramanu Dispensary, interior….…………………………………………………25 Figure 6: Kitow Health Centre………………………………………………………………...25 Figure 7: Formal PC services available on Tanna. The only maps available of these facilities are hand drawn, displayed on the walls of various health facilities. Each differs slightly in the number of health facilities depicted……………….……………………………………………27 Figure 8: A rural health worker, one of the few trained midwives on Tanna…………………29 Figure 9: The island of Tanna: study sites…………………………………………………….41 Figure 10: Eastern Tanna showing study sites………………………………………..……….42 Figure 11: Lenakel Hospital…………………………………………………………………...42 Figure 12: Iquaramanu (Nafe) Dispensary…………………………………………………….44 Figure 13: A typical kitchen house…………………………………………………………….44 Figure 14: Subsistence farming in Iquaramanu: digging for maniok (tapioca)………………..45 Figure 15: White Sands Health Centre, the old………………………………………………..46 Figure 16: … and the new……………………………………………………………………...46 Figure 17: Cooking with maniok (tapioca)…………………………………………………….47 Figure 18: Preparing laplap , a traditional dish made from grated root vegetables, slow cooked over hot stones………………………………………………………….........................47 Figure 19: Both English and Bislama are commonly used in formal health care settings…….54 vi Figure 20: Human resource shortages mean that while she should have retired 15 years ago, the nurse on the left continued to work…………...………………………………………..62 Figure 21: The White Sands Health Centre’s drug supply was criticised by villagers from Yenamakel……………………………………………………………………………...68 Figure 22: The road leading to Lenakel Hospital……………………………………………...73 Figure 23: …And after 12 hours of light rain………………………………………………….73 Figure 24: Even in kastom villages such as Yakel, where villagers are said to reject Western lifestyles, the doctors were met with excitement……..………………………………...85 vii List of Tables Table1: Disease incidence Lenakel Hospital, 2008……………………………………………24 Table 2: Formal health facilities on Tanna…………………………………………………….26 Table 3: Formal PC fee structure………………………………………………………………28 Table 4: Human resources on Tanna: formal PC workers……………………………………..30 Table 5: Illness causation on Tanna……………………………………………………………34 Table 6: Lenakel Hospital weekday roster……………………………………………………..49 Table 7: Formal PC worker attitudes towards kastom medicine………………………………86 Table 8: Illness type and medical system consulted…………………………………………...90 Table A.1: Rural health facilities by population, Tanna……..……………………………….123 Table B.1: Health facilities according to Lenakel Hospital vaccination team………………..124 Table B.2: Health facilities according to Lenakel Hospital office……………………………124 Table C.1: Six month Lenakel Maternal Child Health and aid post supervision schedule, July- December 2009………………………………………………………………………………..125 Table D.1: White Sands Health Centre: patients seen 29 th June 2009………………………..126 Table D.2: White Sands Health Centre: patients seen 30 th June 2009…...…………………...128 Table D.3: White Sands Health Centre: patients seen 1 st July 2009, general consultations.....129 Table D.4: White Sands Health Centre: patients seen 1 st July 2009, school visit to health centre…………………………………………………………………………………………..131 viii Chapter 1: Introduction Rural health team visit to Ipai Aid Post Chapter 1: Introduction This thesis seeks to examine access to health care in rural Vanuatu. Health 1 has long been recognised by the World Health Organisation (WHO) as a fundamental human