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

1. Health system strengthening in Papua New Guinea: exploring the role of demand-responsive mechanisms Julienne McKay & Katherine Lepani 24 November 2010 Port Moresby Research paper commissioned by the Lowy Institute

2. Good time to consider all options • Scale of public health challenges heightens need to improve management capacity and ensure value for money • Opportunity to create lasting legacy from resource development: • sovereign wealth fund • proposals to leverage public private partnerships • consideration of broader social policy instruments

3. Good time to consider all options • 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 • NDOH seeking ways of encouraging families to take greater responsibility for their health and greater use of safe motherhood services

4. 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

5. 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

6. ‘Demand-responsive mechanisms’

7. 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

8. 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

9. 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

10. 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

11. Clearly not always the case • Neither elsewhere nor in PNG

12. 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?

13. 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

14. 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

15. Drawing on cultural values and social relations • Reciprocal obligations • Collective mobilisation of resources • Impediment or facilitator?

16. Vouchers • 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

17. 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

18. Social business Oil Search Malaria Treatment Program • 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

19. 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

20. 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

21. 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

22. Recommend • 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

23. 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