Rural residents of Papua New Guinea's mountainous terrain used to be able to count on efficient village aid posts to look after their health. But the network's deterioration—a result of economic trouble—means some villagers now live a 4-day trek away from care. Stephen Pincock reports.
Papua New Guinea, a mountainous island nation in the southern Pacific, was never going to be an easy place in which to establish a comprehensive health system. Much of the country is blanketed by dense rainforest; the non-forested parts are mainly covered in sodden wetland. More than 85% of its around 6 million people live outside urban areas, scattered across the impenetrable terrain in villages accessible only by air or foot.
There are also cultural challenges. Papua New Guinea has one of the most diverse populations on the planet, with more than 800 languages spoken by hundreds of different tribes, some of which remain untouched by the modern world.
“Even with the best management in the world and a shed-load of cash, it would be very hard to keep all of Papua New Guinea healthy”, says John Reeder, a public-health researcher who has been working in the country for much of the past 16 years. “It's a very difficult country in which to come to grips with a health problem.”
And yet, when Reeder visited the country for the first time he found a surprisingly good system in operation. “When I first went there in 1990 as a volunteer, there was a very good public-health structure”, he says. In those days, most of the population had access to village aid posts that could offer basic health care or refer them to health centres or provincial hospitals for more sophisticated treatment. Crucially, recalls Mathias Sapuri, president of the Medical Society of Papua New Guinea, most people lived within 2—4 h walk of an aid post.
Less than two decades later, however, the situation has become decidedly worse. In February this year, for example, Transparency International reported that some villagers now must travel for 4 days to reach medical aid.
Figures published by the government also acknowledge that about 50% of the aid posts that were operating when the country gained independence from Australia in 1975 have closed during the past decade.
What is more, Sapuri says, a national referral system that provided transportation for patients to health centres or provincial hospitals has evaporated. Patients must now make their own way through difficult terrain to a health centre or hospital. Vital medicines are also in short supply—leaving health centres and even major hospitals without essential drugs.
The impact of this deterioration on the health of Papua New Guineans has been severe. “Over the past 15 years there has been no improvement in our health indicators and it's not getting any better”, says Sapuri. Overall, the average life expectancy for residents of the country is now just 55·1 years, the UN Development Programme reported in 2005. The same report showed that infant mortality in 2003 was 69 per 1000 livebirths and that child mortality was 93 per 1000. Around 35% of children younger than 5 years were below the standard weight for their age, and 27% of the population undernourished.
Meanwhile, the population is increasingly vulnerable to malaria, which is a risk throughout the country at altitudes below 1800 m. “We're facing the same problems as countries in Africa”, says Reeder. “The cheap drugs aren't working any more and [we're seeing] a general breakdown of malaria prevention systems. The systems that were in place 10—15 years ago have gone into a hole.”
As if this wasn't enough, the prevalence of HIV is on the rise. The percentage of the Papua New Guinea population reported as HIV-positive has increased dramatically in just 2 years, according to UNAIDS. In 2003, 0·6% of adults between 15—49 years were infected; by 2006 that figure had risen to 1·8%.
Add to this tale of woe a resurgence in tuberculosis infection rates, says Sapuri, plus the health problems that rural dwellers bring when they come to live in squatter camps on the edge of cities, and you have a system in steep decline.
What is behind the deterioration? In large part, Sapuri argues, the problem is economic. “30 years ago when we moved to the post-independence era, we had a stable economy and the national health budget was sufficient to sustain a health care system”, he says.
But since then, the country's population has tripled while budgets are shrinking in value. For one thing, the local currency, the Kina, has plummeted, shedding much of its value relative to other currencies. On top of this, crucial revenue from a copper mine on the disputed island of Bougainville was taken out of Papua New Guinean coffers when it ceased operation in 1989, adds Rodney Itaki, a physician currently doing a PhD in Japan. “That was a significant reduction in government revenue and all sectors were affected in terms of funding, including health”, says Itaki. “I think the health system never recovered completely from that.”
John Reeder also concurs with this assessment. He has just completed a 6-year post as head of the Papua New Guinea Institute for Medical Research and now works in Australia while maintaining working links with Papua New Guinea. He argues that despite receiving aid from Australia and other international funders “the basic problem is that they don't have enough money to do what they would like to do [to improve the health system]”.
A 10-year strategic health plan drawn up by the government some years ago is “really excellent” he says. But great plans are worth little if the financing is not there to support them.
The problems do not stop there, however. In Reeder's view, a 1992 initiative to decentralise government control also triggered confusion. This amendment to the law on provincial and local government created a disconnection between the different levels of the health system, he says, meaning the country has national officials responsible for setting policy but lacking control over implementation. “This made it very difficult to have a leader with the vision to push through a vaccination programme, for example”, Reeder says.
The impact of this confusion is most apparent in rural areas, says Itaki. “In the old provincial government system from independence up until 1992, aid posts, health centres, and provincial hospitals were the responsibility of the provincial governments. Malaria control programmes and maintenance of infrastructure was also their responsibility”, he says. “The changes created a lot of confusion, as the functions of the provincial government were shifted to what is now called the Provincial Assembly and local government councils. The problem until now has been that the funds have not gone beyond the Provincial Assembly to local government councils.”
One further upshot of this confusion was that some individuals took the opportunity to siphon public money away from the health system, Itaki adds. Michael Manning, the Papua New Guinea representative for Transparency International, agrees. The country rates very poorly on Transparency International's international rating of corruption, and Manning says that “the message that we want to get across is that money that goes into corruption doesn't go into the health system”. It isn't only officials who contribute to this corruption, Manning claims. Most physicians in the country operate their own private clinics and “it's well known that the same medicines you can't get in the hospital are miraculously available at those clinics”.
Sapuri denies this. “It's not an issue of corruption in the health system”, he says, “but lack of funding”. In 2004, the country's total health expenditure as a percentage of gross domestic product was 3·4%. “That really is not sufficient. Ideally we need about 8% or more to have a reasonable, sustained health-care system.”
Sapuri believes that a key issue is the brain drain. In April, the Medical Society warned that the country needed to stem the tide of physicians fleeing the country for better conditions overseas. “Specialists and experienced doctors become frustrated because they are working in hospitals that don't have the facilities they need to deliver proper care”, Sapuri told The Lancet. The Medical Society estimated there were at least 65 Papua New Guinean doctors working overseas—50 of them in Australia and New Zealand, and 15 in other Pacific Island countries. “That sort of number we desperately need.”
The government is not blind to the problems, Sapuri says, “The new health minister Sir Peter Barter is pushing for these problems to be addressed”. Recent initiatives include a government promise to invest 75 million Kina along with overseas aid agencies in rebuilding run-down health facilities.
Meanwhile, Sapuri—who has just completed a 7-year term as Dean of the country's only university medical school—remains optimistic. “I firmly believe that there is hope for us to do things differently in the future and I want to be part of the new direction for Papua New Guinea”, he says.