HIV AND HUMAN RESOURCES CHALLENGES IN PAPUA NEW GUINEA: AN .

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Leadership and managementHIV AND HUMANRESOURCESCHALLENGES INPAPUA NEW GUINEA:AN OVERVIEWHeather Worth, John Rule, Holly Buchanan, Angela Kelly, Angelyn Amos,Miliakere Kaitani, Kel Browne, Graham Roberts and Richard Taylorwww.hrhhub.unsw.edu.auPapua New GuineaAn AusAID funded initiative

The Human Resources for Health Knowledge HubACKNOWLEDGEMENTSThis paper was reviewed internally by HRHHub staff with detailed editing provided byDr Alison Short. External reviews by Dr WilfredKaleva and Dr Joel Negin were appreciated bythe authors and review comments have beenaccommodated in the final document. Theauthors would also like to thank Jim Campbell,Dr Augustine Asante and Dr John Dewdney forideas and comments provided on earlier drafts.This report has been produced by the Human Resources forHealth Knowledge Hub of the School of Public Health andCommunity Medicine at the University of New South Wales.Hub publications report on a number of significant issuesin human resources for health (HRH), currently under thefollowing themes: leadership and management issues, especially atdistrict level maternal, neonatal and reproductive health workforceat the community level intranational and international mobility of health workers HRH issues in public health emergencies.The HRH Hub welcomes your feedback and any questionsyou may have for its research staff. For further informationon these topics as well as a list of the latest reports, summariesand contact details of our researchers, please visitwww.hrhhub.unsw.edu.au or email hrhhub@unsw.edu.auThe International HIV Research Group Human Resources for Health Knowledge Hub 2012Suggested citation:Worth, H et al. 2012, HIV and Human Resources Challenges in Papua New Guinea:An Overview, Human Resources for Health Knowledge Hub, Sydney, Australia.National Library of Australia Cataloguing-in-Publication entryWorth, HeatherHIV and Human Resources Challenges in Papua New Guinea: An Overview /Heather Worth . [et al.]The International HIV Research Group conducts high qualitysocial and behavioural research which provides essentialstrategic information needed to design cost effective andhigh impact interventions and underpins the development ofappropriate policy responses by national partners.This research has been funded by AusAID. The viewsrepresented are not necessarily those of AusAID or theAustralian Government.9780733431692 (pbk.)HIV—Human resources for health—Papua New GuineaHIV—Health services—Papua New GuineaRule, John.University of New South Wales, Human Resources for Health Knowledge Hub.Buchanan, Holly.National Research Institute of Papua New GuineaKelly, Angela.University of New South Wales, International HIV Research GroupAmos, Angelyn.National Research Institute of Papua New GuineaKaitani, Miliakere.University of New South Wales, International HIV Research GroupBrowne, Kel.Rural Enclaves Project, Papua New GuineaRoberts, Graham.University of New South Wales, Human Resources for Health Knowledge Hub.Taylor, Richard.University of New South Wales, Human Resources for Health Knowledge Hub.362.1969792009953Published by the Human Resources for Health Knowledge Hub of the School ofPublic Health and Community Medicine at the University of New South Wales.Level 2, Samuels Building, School of Public Health and Community Medicine,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052,AustraliaTelephone: 61 2 9385 8464Facsimile: 61 2 9385 1104Web: www.hrhhub.unsw.edu.auEmail: hrhhub@unsw.edu.auTwitter: http://twitter.com/HRHHubPlease contact us for additional copies of this publication, or send us youremail address and be the first to receive copies of our latest publications inAdobe Acrobat PDF.Design by Gigglemedia, Sydney, Australia.

CONTENTS2 Acronyms3 Executive summary4 Papua New Guinea: selected HRH indicators5 Introduction6 Aims and Objectives6 (A) The international literature on HIV and HRH challenges9 (B) Human resources for health in PNG11 (C) HIV and human resources in PNG15 (D) HIV prevention in rural economic enclaves: A health workers baseline survey18 Conclusions19 ReferencesLIST OF TABLES10 Table 1. Composition of the PNG Public Sector Health Workforce (2009)10 Table 2. Total Public Sector Financed Health Employees Urban and Rural (2009)13 Table 3. NHATU Course Completions 2007-201013 Table 4. Catholic Health Services HIV Training Program Budget 2008HIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.1

ACRONYMSAIDSAcquired immunodeficiency syndromeNACSNational AIDS Council SecretariatARTAntiretroviral treatment (or therapy)NCDNational Capital DistrictCBOCommunity-based organisationNDoHNational Department of HealthCHWCommunity health workerNGONon-government organisationFBOFaith-based organisationNHATUNational HIV and Aids Training UnitGFATMGlobal Fund to Fight Aids, Tuberculosisand MalariaNHPNational Health PlanNRINational Research InstituteGoPNGGovernment of Papua New GuineaNSPNational Strategic Plan for HIV/AIDSHIVHuman immunodeficiency virusPLHIVPeople living with HIVHRHHuman resources for healthPMTCTPreventing mother to child transmissionHRIHuman resource information systemPNGPapua New GuineaIEAInternational Education Agency of PNGPPTCTPrevention of parent to child transmissionIHRGInternational HIV Research GroupSTISexually transmitted infectionsIMAIIntegrated Management of Adolescent andAdult IllnessUNAIDSJoint United Nations Programme on HIV/AIDSIMCIIntegrated Management of Childhood IllnessUNSWUniversity of New South WalesIRGIndependent Review GroupUNGASSUnited Nations General Assembly SpecialSessionLMICLow and middle-income countriesVCCTVoluntary confidential counselling and testingMCHMaternal and child healthVCTVoluntary counselling and testingMoUMemorandum of UnderstandingWHOWorld Health OrganizationA note about the use of acronyms in this publicationAcronyms are used in both the singular and the plural, e.g. NGO (singular) and NGOs (plural).Acronyms are also used throughout the references and citations to shorten some organisations with long names.2HIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.

EXECUTIVE SUMMARYInformation available in PNG shows thatthe majority of human resource training wasprovided by the National HIV and AIDS TrainingUnit and the National Department of Health inpartnership with other implementing agencies.The HIV epidemic in Papua New Guinea (PNG) presentsmajor challenges, including significant human resourceschallenges. This report presents an overview of the availableglobal literature on HIV and human resources, collatesinformation on the workforce responses to HIV in PNG andhighlights human resource issues specific to HIV in PNG.staffing and absenteeism; isolation from the rest of the healthworkforce; lack of supervision, and irregular salary payments.The overview report concludes with a series of questionsthat relate to workforce planning and deployment, workforcemanagement and training of personnel. The internationalliterature review demonstrates the value of gatheringempirical data on the human resource challenges associatedwith HIV. Gathering information on the extent of trainingand the deployment and roles of graduates is essential toevaluating workforce effectiveness and for the developmentof human resources for health policy, responsive to the HIVepidemic in PNG.The review of international literature identified some majorissues including the lack of trained staff, the large attritionrate of health workers due to poor working conditions and theuneven distribution of HIV health workers in both the privateand public sectors.The concentration of HIV services in urban areas, discriminatoryattitudes among health workers towards people living with HIV(PLHIV) which can negatively influence the quality of serviceprovided, and the effects of skewing the health system andworkforce towards HIV services are also documented in theliterature. In some countries a response to these issues hasbeen task-shifting or task-sharing; however, the usefulnessof this strategy to address human resource issues for HIV inPNG needs further investigation.Information available in PNG shows that the majority ofhuman resource training was provided by the NationalHIV and AIDS Training Unit (NHATU) and the NationalDepartment of Health (NDoH) in partnership with otherimplementing agencies. Yet there is not enough informationto plan for effective HIV workforce development; follow-up ofthose who have been trained has not occurred, and hencethe contribution to services cannot be assessed.Some evidence is presented in this report that the focus onHIV workforce development has occurred at the expense ofother health workforce areas. A research publication fromthe National Research Institute (NRI), PNG, surveying healthworkers in rural economic enclaves, noted that few staff hadreceived the HIV related in-service training they needed.Human resource issues identified included inadequateHIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.3

PAPUA NEW GUINEA:SELECTED HRH INDICATORS2,746Health facilities in PNG4.4%33.8%Doctors and dentists as apercentage of public sectorhealth workforceCommunity health workersas a percentage of publicsector health workforce9656Annual shortfall in output oftrained nursing staffAnnual shortfall innumber of communityhealth workers27.7%Nurses as a percentage ofpublic sector health workforce(Adapted from draft World Bank Report (2011): Health Human Resource Review)Key to acronymsHRH4human resources for healthHIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.

INTRODUCTIONIn PNG an estimated 0.9% of the general adult populationis infected with HIV but the spread of the epidemic hasbeen uneven across provinces [NDoH & NACS 2010]. Theepidemic in PNG is described as concentrated geographicallyand amongst certain populations.In 2010 in PNG, 138,581 HIV tests were reported to havebeen conducted and 4,208 were found to be positive. In theHighlands Region 2010 surveillance data indicates incidenceat 4.4%, in the National Capital District (NCD) 5.2%, andin Momase 2.6% [NDoH 2011 - in draft]. The extent of theepidemic has meant that among many other challenges facedby government, donors and non-government organisations(NGOs), human resources within the health system is acentral issue.New IrelandWewakRabualINDONESIANew BritainMadangKietaBougainvilleLaeDaruPORT MORESBYHIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.5

AIMS, OBJECTIVES AND METHODIn 2011 the HRH Knowledge Hub and the InternationalHIV Research Group (IHRG), both located in the School ofPublic Health and Community Medicine, University of NewSouth Wales (UNSW), planned to undertake a descriptiveaccount of the workforce involved in responding to the HIVepidemic by obtaining data held by the NDoH in PNG.However, existing data was out-of-date, incomplete or couldnot be released, requiring a reframing of the 2012 researchobjectives as:A. To examine the international literature on humanresources and HIVB. To examine the extant available data on the HIVworkforce in PNGC. To present an overview of the human resourcesfor health (HRH) issues specific to HIV in PNG.D. To present data on the only large-scale researchon human resources for HIV in PNG.The international literature was searched using a number ofkey databases – Medline, Web of Science and Proquest. Aswell, Google was used to find key grey literature. The literaturewas searched using five key terms “human resources forhealth AND HIV”; “HIV workforce”; “health workers AND HIV”;“health professionals AND HIV”; “health system AND HIV”.(A) The international literature on HIV andHRH challengesThe deficiency of human resources for HIV has beendescribed as a ‘triple threat’ [Chen et al. 2004] as it increasesthe workload of already burdened health workers, requireshealth workers to deal with patients in palliative care (andtheir families) and it can expose health workers to HIVinfection. There are numerous other related issues: severeshortages of HIV health workers in many countries, lack ofskills required to deal with an evolving epidemic [UNAIDS2010] and changes in epidemic responses [Chen et al.2004; Dolvo 2005; WHO 2006a]. Major issues discussed inthe international literature on human resources and HIV areoutlined below.Insufficient trained staffAs the number of people living with HIV increases and fewerpeople die of AIDS related conditions due to the roll out ofantiretroviral therapy (ART), the number of people needingservices is expected to increase requiring a concomitantincrease in the number of health workers to provide longterm HIV management through treatment [Barnighausen et6Lack of training is one of the primary reasonsfor noncompliance with universal precautionsamong healthcare workers.al. 2007]. This will place an increased strain on the alreadydeficient HRH for HIV service provision in low and middleincome countries (LMICs). Tawfik and Ngoti [2003] arguethat the major issue in the quality of HIV service provision inSouthern Africa is the overburdening of service providers.They found that there are many in the health workforce whomay not have the skills to deal with the changing diseaseburden, and possess less than optimal knowledge and skillsfor managing people living with HIV or the more complicatedstage of AIDS. In some resource-limited settings, the barriersto ART adherence have been identified as the lack of adequatephysician training, healthcare infrastructure, and discontinuitiesin provider-patient relationships [Ivers et al.2009; Meng et al.2006; Xiulan et al. 2011].In India, access to services and quality of care haveboth been compromised by an overburdened healthcaresystem and staff with limited training in administering ART[Vijaykumar 2007]. Lack of training is one of the primaryreasons for noncompliance with universal precautions amonghealthcare workers [Jankovic et al. 2009; Sadoh et al. 2006;Simbar et al. 2011; Wu et al. 2008].Poor working conditions leading to attritionStudies have shown significant attrition rates due to thelabour intensive nature of providing ART [Hanefeld &Musheke 2009; Kober 2004]. The attrition and absenteeismof health workers has been attributed to low salaries, toughworking conditions, inadequate medical supplies and havingto deal with high inpatient death rates.It has been noted that the staff with the most experience inHIV treatment often leave the workforce totally, or go intomore senior management roles, resulting in skills loss for HIVtreatment and increased dependency on other health workerswith less experience in diagnosing and treating HIV [Marchalet al. 2005].Although some studies have found that ART scale-upincreases the burden and workload on the existing healthHIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.

workforce, others have found that ART programs increasedthe motivation and satisfaction of staff, due to the improvedhealth of patients and the increased acquisition of skillsthrough training opportunities [George et al. 2010].Inter-sectoral movementA study completed in Ethiopia revealed that the attritionof HIV health workers from the public sector was due totheir attraction towards NGOs which provide HIV trainingprograms [Elzinga et al. 2010]. It was shown that between2003 and 2007 the number of doctors in the public sectordecreased from 1,613 to 1,037, whereas in the private sectorand within NGOs, the number increased from 419 to 769within the same period. The authors attributed the changeto the attraction of the large funding that these organisationsreceived for HIV programs. In the public sector, the salary fora doctor was approximately 150 per month, which was lowcompared to the salaries provided by NGOs.Furthermore, in many developing countries private sectororganisations are predominantly found in urban rather thanrural areas. If funding and resourcing moves from public toprivate sectors, health workers may also migrate from rural tourban areas. A recent report in Zambia has shown that ruralareas were falling behind in clinical staff allocations and thegap was especially widening in those rural facilities providingHIV services [Brugha et al. 2010].In order to address the issue of staff moving to the private sectorin Botswana, the public and private sectors have collaborated toprovide better access to ART treatment. In a survey completedin 2003, private practitioners indicated a high willingness toprovide ART on private practice premises; it was found thatthese private practices relieved the need for the hiring of extrapersonnel in the public sector, who would have to have beenrecruited from other countries [Dreesch et al. 2007].Negative attitudes amongst health workers toward peopleliving with HIVMany studies in LMICs including China, Vietnam, India,Indonesia, Thailand, Philippines and Bangladesh havedocumented health care workers’ discriminatory attitudes andbehaviours towards PLHIV, these include:1. Denial of treatment and care on grounds of HIV and AIDSstatus [Ahsan Ullah 2011; Anderson et al. 2003; Paxton etal. 2005; Wang & Zhang 2008].2. Delaying treatment without reason [Ahsan Ullah 2011;Paxton et al. 2005; Sringernyuang et al. 2005; Yang et al.2005].A recent report in Zambia has shown thatrural areas were falling behind in clinical staffallocations and the gap was especially wideningin those rural facilities providing HIV services.3. Cessation of ongoing treatment and early discharge fromhospital without valid reasons [Hossain & Kippax 2011].4. Differential treatment, including coerced or mandatorytesting, testing without consent [Hossain & Kippax 2011;Khoat et al. 2005; Paxton et al. 2005].5. Quarantine, compulsory internment, and/or segregationin health institutions [Khoat, et al. 2005].6. Inappropriate (excessive or selective) use of standardprecautions [Bray Preston et al. 2002; Ferrer et al. 2009;Hossain & Kippax 2011; Mahendra et al. 2007; Wang &Zhang 2008; Wu et al. 2008].7. Breaches of confidentiality [Wang & Zhang 2008; AhsanUllah 2011].These discriminatory behaviours have direct negativeconsequences on the quality of health care services[Rajaraman & Palmer 2008]. Various reports indicatecompromised access and quality of care to PLHIV because ofHIV-related stigma [Chan et al. 2008; Khoat et al. 2005; RuizTorres et al. 2007; Vijaykumar 2007]. The literature suggeststhat the knowledge and attitudes of health care workersin relation to HIV is an important factor influencing thewillingness and ability of PLHIV to access health care, andthe quality of the care they receive [Kermode et al. 2005].The stigmatisation of PLHIV and breaches in confidentialityby health workers have led to the avoidance of treatment,negative social implications and diminished employmentopportunities for those identified as HIV-positive [Rajaraman& Palmer 2008].Skewing of the health systemThere is a concern that HIV has claimed disproportionatefunding, infrastructure and human resources relative todisease burden, and that this skewing can distort healthsystems and HRH deployment. In Malawi, it has been notedthat a large proportion of health staff have left governmenthealth services to work in privatised HIV and AIDS programsfunded by overseas universities or NGOs [Kushner et al.HIV and human resources challenges in Papua New Guinea: An overviewWorth, H et al.7

2004]. Negin & Robinson [2010] studied the fundingpatterns for HIV and non-communicable diseases in PacificIsland countries and concluded that external funding did notmatch with disease and mortality figures or local prioritiesand needs, thereby having impacts on the setting of countryhealth policy priorities.However, the World Health Report 2008 argued that inresponding to specific high burden diseases, such as HIV,countries and the health workforces can develop skillsand services in w

HIV and human resources challenges in Papua New Guinea: An overview Worth, H et al. 1 CONTENTS 2 Acronyms 3 Executive summary 4 Papua New Guinea: selected HRH indicators 5 Introduction 6 Aims and Objectives 6 (A) The international literature on HIV and HRH challenges 9 (B) Human resources for health in PNG 11 (C) HIV and human resources in PNG 15 (D) HIV prevention in rural economic enclaves .

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