HUMAN RESOURCES FOR HEALTH
Maternal, neonatal & reproductive healthHUMANRESOURCESFOR HEALTHin maternal, neonatal and reproductivehealth at community levelA profile of Papua New GuineaAngela Dawson, Tara Howes, Natalie Gray and Elissa KennedyHUMAN RESOURCES FORHEALTH KNOWLEDGE HUBwww.hrhhub.unsw.edu.auPapua New Guinea
The Human Resources for Health Knowledge HubThis technical report series has been produced by theHuman Resources for Health Knowledge Hub of the Schoolof Public Health and Community Medicine at the Universityof 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.au Human Resources for Health Knowledge Hub and Burnet InstitutePublished by the Human Resources for Health Knowledge Hub of theon behalf of the Women’s and Children’s Health Knowledge Hub 2011School of Public Health and Community Medicine at the University ofSuggested citation:New South Wales.Dawson, A, Howes, T, Gray, N, Kennedy, E 2011, Human resources forLevel 2, Samuels Building, School of Public Health and Communityhealth in maternal, neonatal and reproductive health at community level: AMedicine, Faculty of Medicine, The University of New South Wales,profile of Papua New Guinea, Human Resources for Health Knowledge HubSydney, NSW, 2052, Australiaand Burnet Institute, Sydney, Australia.Telephone: 61 2 9385 8464National Library of Australia Cataloguing-in-Publication entryFacsimile: 61 2 9385 1104Dawson, A, Howes, T, Gray, N, Kennedy, Ehrhhub@unsw.edu.auHuman resources for health in maternal, neonatal and reproductive health atcommunity level: A profile of Papua New Guinea / Angela Dawson . [et al.]9780733429798 (pbk.)Maternal health services—Papua New Guinea—Personnel management.www.hrhhub.unsw.edu.auPlease contact us for additional copies of this publication, or send us youremail address and be the first to receive copies of our latest publicationsin Adobe Acrobat PDF.Community health services—Papua New Guinea—Personnel management.Howes, Tara.University of New South Wales. Human Resources for Health.Gray, Natalie.Kennedy, Elissa.Burnet Institute. Women and Children’s Health Knowledge Hub.362.1982009953Design by Gigglemedia, Sydney, Australia.
Contents2 Acronyms3 Executive summary4 Papua New Guinea: selected HRH and MNRH indicators5 Key background information6 Overview of maternal, neonatal and reproductive health6 Cadres and roles8 Coverage and distribution12 Supervision and scope of practice13 Teamwork13 Education and training14 Country registration15 HRH policy and plans15 MNRH policy and plans16 Remuneration and incentives16 Key issues or barriers17 Community-based initiatives in MNRH18 Critique18 References20 Appendix 1: Pre- and in-service education and training in Papua New Guinea21 Appendix 2: Country registration in Papua New Guinea22 Appendix 3: Country HRH and MNRH policies in Papua New GuineaLIST OF FIGURES8 Figure 1. Distribution of health workforce across cadres in Papua New Guinea9 Figure 2. Ratio of Community Health Workers per 1,000 people in provincial services in Papua New Guinea9 Figure 3. Nursing Officers per 1,000 people in provincial services excluding hospitals in Papua New Guinea10 Figure 4. Medical Officers per 1,000 people in hospital services in Papua New Guinea10 Figure 5. Health Extension Officers per 1,000 people in provincial services in Papua New GuineaList of Tables5 Table 1. Key statistics7 Table 2. Cadres involved in MNRH at community level in Papua New Guinea11 Table 3. Health worker distribution in Papua New GuineaMNRH at community level: A profile of Papua New GuineaDawson et al.1
AcronymsAIDSacquired immune deficiency syndromeAusAIDAustralian Agency for International DevelopmentGDPgross domestic productHEOhealth extension officerHIVhuman immunodeficiency virusHRHhuman resources for healthMDGMillennium Development GoalMNRHmaternal, neonatal and reproductive healthMoHMinistry of HealthNCDNational Capital DistrictNDoHNational Department of HealthPHCprimary health carePNGPapua New GuineaTFRtotal fertility rateUNAIDSJoint United Nations Programme on HIV/AIDSUNDESAUnited Nations Department of Economic and Social AffairsUPNGUniversity of Papua New GuineaUSPUniversity of the South PacificVBAvillage birth attendantVHVvillage health volunteerWHOWorld Health OrganizationWPROWestern Pacific Regional Office of the World Health OrganizationA note about the use of acronyms in this publicationAcronyms are used in both the singular and the plural, e.g. MDG (singular) and MDGs (plural).Acronyms are also used throughout the references and citations to shorten some organisations with long names.2MNRH at community level: A profile of Papua New GuineaDawson et al.
EXECUTIVE SUMMARYThis profile provides baseline information thatcan inform policy and program planning bydonors, multilateral agencies, non-governmentorganisations and international health practitioners.Accurate and accessible information about the providers ofmaternal, neonatal and reproductive health (MNRH) servicesat the community level (how they are performing, managed,trained and supported) is central to workforce planning,personnel administration, performance management andpolicy making.Data on human resources for health (HRH) is also essentialto ensure and monitor quality service delivery. Yet, despite theimportance of such information, there is a scarcity of availableknowledge for decision making.This highlights a particular challenge to determining theworkforce required to deliver evidence-based interventionsat community level to achieve Millennium Development Goal(MDG) 5 targets.This profile summarises the available information on thecadres working at community level in Papua New Guinea(PNG): their diversity, distribution, supervisory structures,education and training, as well as the policy and regulationsthat govern their practice.The profile provides baseline information that can informpolicy and program planning by donors, multilateral agencies,non-government organisations and international healthpractitioners. Ministry of Health staff may also find theinformation from other countries useful in planning theirown HRH initiatives.The information was collected through a desk review andstrengthened by input from key experts and practitionersin the country. Selected findings are summarised in thediagram on page 4. There are gaps in the collated informationwhich may point to the need for consensus regarding whatHRH indicators should be routinely collected and how suchcollection should take place at community level.MNRH at community level: A profile of Papua New GuineaDawson et al.3
PAPUA NEW GUINEA: SELECTEDHRH AND MNRH INDICATORSMaternal mortality ratio in 2008#312 deaths per100,000 live births0.5 doctorPolicy reference to communitylevel HRH in MNRHper 10,000 peopleYESSkilled birth attendance:81.3%39%of births attended by askilled birth attendantGovernment spending onhealth as a percentage oftotal expenditure on health(2005–2009)(2007)5 nurses and/or midwivesper 10,000 peopleNeonatal mortality ratio in 200926 deaths per1,000 live birthsKey to acronymsHRHMNRHhuman resources for healthmaternal, neonatal and reproductive healthNotes# Confidence interval 184-507, Hogan et al. 2010. Maternalmortality ratio varies widely from 250 deaths per 100,000 livebirths in 2008 (UNICEF 2010) to 733 deaths per 100,000 livebirths in 2006 (Demographic Health Survey of Papua NewGuinea 2006, National Statistical Office of PNG 2009).4MNRH at community level: A profile of Papua New Guinea(Adapted from NDoH PNG 2000b, 2009c; UNICEF 2010; WHO 2010)Dawson et al.
KEY BACKGROUND INFORMATIONTable 1. KEY STATISTICS(Adapted from Hogan et al. 2010, UNDESA 2005, WHO 2010)populationTotal thousands (2008)6,577Annual growth rate (1998–2008)2.5%Health expenditure (2007)Total expenditure on health as a percentage of GDP3.2%General government expenditure on health as a percentage of total expenditure on health81.3%Private expenditure on health as a percentage of total expenditure on health18.6%Off trackMDG 5 statusMaternal mortalityNumber of maternal deaths for every 100,000 live births:UNICEF 2010250Hogan et al.312 (184–507)Number of neonatal deaths for every 1,000 live births (in the first 28 days of life; 2009)26Skilled birth ATTENDANCE (2005–2009)Percentage of births covered by a skilled birth attendant39%A note on health expenditureTotal expenditure on health as a percentage of gross domesticproduct (GDP) has decreased since 2001 from 4.4% to 3.2%(as seen in Table 1), although government expenditure hasremained relatively stable (World Bank 2007).Key to acronymsGDPMDGgross domestic productMillennium Development GoalMNRH at community level: A profile of Papua New GuineaDawson et al.5
OVERVIEW OF MATERNAL, CADRES AND ROLESneonatal ANDREPRODUCTIVE HEALTHImproving maternal and child health in PNG remainschallenging as almost 87% of the population is located inrural areas and many of the areas are geographically isolatedand have poor health infrastructure.The largest provider of health services in PNG is thenational government. It has responsibility for all hospitals,the majority of urban health centres and around half ofregional and rural centres.Over recent years, decentralisation and fragmentation ofthe health system have led to a decrease in the coverageand quality of health services, with the closure of many aidposts, drug shortages, poor staff allocation and inadequatesupervision, particularly in rural and remote areas (NDoHPNG 2009a).Church groups manage half of the rural health services(predominantly financed by public funds) with miningand other private companies operating a small numberof facilities.There is an estimated shortfall of 600 nurses, 100 midwivesand 600 community health workers by some estimates (WHOWPRO 2008).In the last decade, PNG has experienced a decline in annualpopulation growth from 2.6% (1987–1997) to 2.4% in 2007and a reduction in total fertility rate (TFR) from 4.8 in 1990 to4 per woman in 2009 (UNICEF 2010).Despite improvements in child and infant mortality since1990, PNG is unlikely to meet its MDG targets as maternalmortality still remains very high. Maternal mortality ratioestimates for PNG vary widely from 733 (DHS, PNG) to 250(interagency estimate) per 100,000 live births, and thereis ongoing debate about where the true estimate lies. Thepercentage of deliveries attended by health professionals hasdecreased (from 47% in 1990 to an estimated 38% (Molaand Kirby 2011, in press) and the contraceptive prevalencerate remains low (WHO 2009; World Bank 2007).In 2002, PNG became the fourth country in the region todeclare a generalised HIV epidemic, with the current adultprevalence estimated at 1.5%, the highest in the region(UNAIDS 2008).The health system in PNG comprises: one national teaching hospital 19 provincial hospitals 45 urban clinics approximately 500 health centres more than 2,000 aid posts (of which an estimated 30%are not operating).Provincial hospitals provide obstetric and paediatric services,as well as general, surgical, infectious diseases, emergencyand outpatient care. They are also responsible for supportinghealth clinics and centres.Urban clinics, health centres and aid posts provide primaryhealth care and are managed and operated by provincialhealth authorities. They are predominantly staffed by nursesand community health workers.Almost one-third of aid posts are closed due to staff shortagesand lack of drugs, supplies and financial support (Duffield2008; NDoH PNG 2009a).The number of aid posts has significantly reduced over thelast ten years and outreach activities are limited, leaving manyvillages with no health services. Birthing services are availableat most health facilities but not at aid posts.The cadres working in MNRH at the community level and thetasks they perform are outlined in Table 2.6MNRH at community level: A profile of Papua New GuineaDawson et al.
Table 2. Cadres involved in MNRH at community level in Papua New Guinea(Adapted from Cox and Hendrickson 2003)Base or placeStaff involved (name of cadreor description of role)*Marasin Meri (medicine women)Home-basedVillage birth attendant (VBA)/midwifeVillage health volunteer (VHV)Village health aidesPossible service in the communityBasic first aid (including antibiotics and antimalarials), sexual healthinformationEncourages women to go for antenatal care; attends normal deliveries,recognises and refers obstetric complications*Provision of pre-packaged micronutrient supplements, antimalarials,antibiotics, oral rehydration therapy, contraceptives, basic first aidBasic first aid (including antibiotics and antimalarials), health promotionWorks through some public hospitals and health centres. Minimumfour visits per year per clinic recommended (most visits not conductedPeer educatordue to lack of funds). Provides sexual and reproductive healthinformation, especially targeting young people. Currently there is oneprogram run by Anglicare StopAids in NCD and Hagen as well as anAusAID sponsored one at UPNGOutreach centre*Population and family health education through school curriculumSchool teacher(although most teachers find it difficult, if not impossible, to discussissues of adolescent sexual and reproductive health). Not implementedwidely beyond a few pilot programsMen as partners in sexualand reproductive healthAid post orderlyCommunityhealth postCommunity health workerAid postRegistered nurseSmall numbers and limited capacity.Primary medical care. Numbers too small to make any impact andhas poor skill set. Previously the backbone of PHC in PNGParticipates in all routine maternal child health services as there areno midwives in rural areas (bar few in church agency health facilities)Basic antenatal and postnatal care, care of newborns and infants,health promotionParticipates in all routine maternal child health services, monitorsCommunity health workerduring pregnancy and refers to midwives for delivery, conductsdeliveries, but needs orientation on life-saving skills related to maternaland newborn healthBasic antenatal and postnatal care, care of newborns and infants,Rural Health CentresUrban ClinicRegistered nursehealth promotion and deliveries without training, will be trained on thejob to augment the role of midwife(inpatient facilities)Stationed at rural health centres to manage patient care, dailyHealth extension officer (HEO)administration of centre and coordination of community health services(also conducts deliveries and other midwifery duties and thereforerequires training)Notes to Table 2*Reviewers’ commentsThese cadres and level of health facility are not national, they are community based and there is a wide range of variation in levels of staffing and existenceof cadres. Outreach Centres: very few on the ground, these are mainly in some areas with well-equipped, faith-based health services.MNRH at community level: A profile of Papua New GuineaDawson et al.7
COVERAGEAND DISTRIBUTIONFigures 1 to 5 below outline the distribution of health careworkers across cadres and the geographic distribution ofhealth care workers across different provinces.of one community health worker per 1,000 people, basedon 2006 population estimates. However, with current healthtraining inputs, this ratio is unattainable.Nurses are the fastest ageing cadre, with more than one-thirdof specialist nurses (which includes midwives) expected toretire in the short term. The majority (70%) of specialistnurses are over 40 years of age. An additional 3,826community health workers are required to reach a ratioThis section provides an overview of the number of healthworkers who may be engaged in MNRH at community level.Table 3 describes the distribution of this workforce accordingto age, gender and employment in the public and privatesectors where available.Figure 1. Distribution of health workforce across cadresin Papua New Guinea(Adapted from National Human Resource Forum 2008c; National Human Resources Forum 2008d)26% Nurses35% Commuity health workers16% Support staff5% Others3% Medical officers6% Allied health5% Unknown4% Health extension officers8MNRH at community level: A profile of Papua New GuineaDawson et al.
Figure 2. Ratio of community health workers per 1,000 people in provincialservices in Papua New GuineaCommunity health workers per 1,000 people(Adapted from National Human Resource Forum 2008c; National Human Resources Forum 2008d)1.51.20.90.60.3Provincial area GugaEndskhlanpiinSeitastBrNewCentral0.0Figure 3. Nursing officers per 1,000 people in provincial services excludinghospitals in Papua New Guinea(Adapted from National Human Resource Forum 2008c; National Human Resources Forum 2008d)Nursing officers per 1,000 people0.60.50.40.30.20.1Provincial area service (excluding hospitals)SoutSihemrnbuHiWghest N Central0.0Key to acronymsNCDNational Capital DistrictMNRH at community level: A profile of Papua New GuineaDawson et al.9
Figure 4. Medical officers per 1,000 people in hospital servicesin Papua New Guinea(Adapted from National Human Resource Forum 2008c; National Human Resources Forum 2008d)Medical officers per 1,000 Provincial hospital npiinSeitastBrNewCentral0.00Figure 5. Health extension officers per 1,000 people in provincial servicesin Papua New GuineaHealth extension officers per 1,000 people(Adapted from National Human Resource Forum 2008c; National Human Resources Forum 2008d)0.150.120.090.060.03Key to acronymsNCDNational Capital District10MNRH at community level: A profile of Papua New GuineaProvincial area serviceDawson et al.SihemrnbuHiWghest N tNewCentral0.00
Table 3. Health worker distribution in Papua New Guinea(Adapted from Duke et al. 2004, NDoH PNG 2009a, WHO WPRO 2008, World Bank 2007, Yambilafuan 2009 and MedicalSociety of PNG 2011)CadreNumberMean age Ratio toper location1,000 people2,844# 56% are between 30–49 yearsRegistered nurse3,980*0.458,914 61% of nurses are 50 yearsRegistered midwife1567#1 70% are 40 years37% are 50 years3,883# 54% are between 30–49 years57% are 50 yearsCommunity health workerHealth extension officer409# 59% are between 30–49 years64% are 50 yearsAid post orderly864‡Medical officer333‡Medical practitioners48%(rural aid posts)0.610.06727**O&G specialists30Paediatricians34Notes to Table 3#*** †‡NDoH PNG 2009aWorld Bank 2007Medical Society of PNG 2011WHO WPRO 2008The proportion of health extension officers who are women is increasing (Duke et al. 2004)Yambilafuan 20091 Of whom only 152 are currently practising as midwives.MNRH at community level: A profile of Papua New GuineaDawson et al.11
SUPERVISION ANDSCOPE OF PRACTICEHealth extension officers were introduced in the1960s to address human resource ga
The Human Resources for Health Knowledge Hub This technical report series has been produced by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales. Hub publications report on a number of significant issues in human resources for health (HRH), currently under the
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