Health system strengthening in Papua New Guinea: exploring the role of demand-responsive mechanisms

Julienne McKay & Katherine Lepani24 November 2010

Port Moresby

Research paper commissioned by the Lowy Institute

Good time to consider all options

1. Scale of public health challenges heightens need to improve management capacity and ensure value for money

2. Opportunity to create lasting legacy from resource development:

– sovereign wealth fund– proposals to leverage public private partnerships – consideration of broader social policy

instruments

Good time to consider all options

3. Proposed changes to health facility financing and plans to replace drug supply system open up possibilities for wider use of delivery mechanisms previously difficult to operationalise

4. NDOH seeking ways of encouraging families to take greater responsibility for their health and greater use of safe motherhood services

In countries facing similar challenges to PNG

• Increasing use of policy instruments rarely used here: – designed to draw out and respond to people’s

needs and requirements

• Voucher schemes and micro-health insurance– directly influence how and how frequently people

use health services

• Social businesses and social franchises– sensitive to people’s needs and requirements

Growing evidence of impact of these instruments

• Improving population outcomes in relation to malaria, tuberculosis, maternal and infant mortality, and HIV/AIDS– all major health problems faced by people of PNG

• Particularly effective when combined

‘Demand-responsive mechanisms’

Voucher scheme in Cambodia • Operated in conjunction with a government-

run Health Equity Fund– covers user fees, transport and other costs for

eligible patients

• Health facility deliveries increased– 16% 2006– 45% 2008

• Significantly greater than in comparable districts without specific measures to address maternal health

Voucher scheme in Cambodia

• Improvement in health facility performance attributed to combination of measures that addressed low pay and low morale among health workers:• performance-based contracting• increased staff support • improved medical supplies • delivery-based incentive scheme:

– midwives and other health workers receive incentive payment for each live birth attended in a referral hospital or health centre

Social franchising in Vietnam

• Significant improvements in reproductive health care service quality achieved by networking public health facilities:– better clinic infrastructure– increased standardisation of quality services– staff instruction on proactive relationship

management– promotion of a culturally relevant brand– standardised schedule of affordable service fees

Demand-responsive mechanisms build on traditional policy responses

• Constructing, equipping and staffing hospitals and health centres fundamental to delivery of health services

• But provision generally based on assumption that this will both

• improve the delivery of services required by people• people, whether targeted or untargeted, can and will

access these services

Clearly not always the case

• Neither elsewhere nor in PNG

Led to these questions…

• Could demand-responsive mechanisms work in PNG?

• Could they work alongside existing measures? • Would they be compatible with the cultural,

social and geographic context of PNG?

Explored these questions

• Visited areas where could observe interactions and impacts of varying mixes of public and private sector health services

• Drew on social research conducted in PNG over many years

• Combined evidence suggests strong potential for demand-responsive mechanisms to tap into social cultural - and geographic - realities of PNG

Site visits

•Oil Search Limited project area in the Southern Highlands Province

•Lihir Gold Limited project area on Lihir Island, New Ireland Province

•Mt Hagen, Western Highlands

Drawing on cultural values Drawing on cultural values and and

social relationssocial relations• Reciprocal obligations

• Collective mobilisation of resources

Impediment or facilitator?

• Ensure safe transport of pregnant women and their guardians to a designated health facility for supervised delivery

• Facilitate access to STI services by linking with social distribution networks for condoms

• Ensure adequate food supplies and transport to access ART drugs for people living with HIV

• Integrate use of mobile phones in health service referrals and follow-up

Vouchers

Micro-health insurance

•Mutual obligation between communities and health facilities

- Based on pre-purchase of services

•Could also act as an incentive to improve service quality

• Marasin Store Keepers (MSKs) test and treat community members in Marasin Stoas– village trade stores– purpose built stores constructed with community

assistance– price gives modest return to MSKs

• MSKs selected from their communities in consultation with village health committee

• MSKs and village health committees promote awareness of malaria prevention

• MSKs trained, supported and monitored by Oil Search

Social businessOil Search Malaria Treatment Program

Social businesses

• Important lessons for development and implementation elsewhere:– User willingness to pay fair price – Respond to financial incentives– Working through trade stores– Working through stand alone MSKs– Addressing other health issues

Social franchises

• Available evidence reinforces willingness to pay– Easily accessed services– Perceived higher quality– Gender sensitive counselling, support and

follow-up• Promoted by word of mouth

Concluded

• Highly likely that broadening range of policy instruments to include demand-responsive mechanisms could support more effective health system strengthening

• Could be achieved within existing budgets and without substantial ‘aid displacement’

• Reduces likelihood of substantial wasting of additional investment

• Trialing demand-responsive mechanisms, targeting priorities identified in new National Health Plan

• Small scale trialing presents low cost/low risk way of testing feasibility and value in different settings: rural, urban and resource enclaves

• Example: franchised network of health facilities alongside use of vouchers to improve provision and utilisation of antenatal care

Recommend

Acknowledgements

• Ross Hutton, Dr Ronelle Welton and members of the Oil Search Limited Community Health

• Jimmy Peter, Lihir Gold Limited, and Kokonas Komuniti Konsultasen team

• Dr Magdalynn Kaupa• Dr Anna Gorter• Individuals who were consulted and

participated in the feedback session• Three anonymous peer reviewers