Health
Services Analysis: Aitape Lumi District
*Medical specialist Antony Aindri has asked me to publish this article on his behalf on my page. I have read through this article myself and have found this paper both informative and enlightening. The analysis is spot and his recommendations given are enlightening in the light of our health predicaments experienced within the District. Be informed and enlightened as you read through.
Overview
Aitape-Lumi is a district located in the
West Sepik Province with a population of approximately 72,319, according to the
2011 census. The district's capital is Aitape, and it is situated between Wewak
and Vanimo. The Sandaun Provincial Administration governs the area, and Vanimo
serves as the provincial capital of West Sepik Province. The population is
spread across the coastal, inland, and mountainous regions, with the Lumi area
being the mountainous part. Cultures and lifestyles differ significantly
depending on the location.
Most of the population in Aitape-Lumi makes
a living through fishing, which is the primary source of income for coastal
communities, and farming for those living in the inland and mountainous
regions. Economic development in the district has been minimal due to a lack of
investment and infrastructure, such as adequately sealed roads, bridges,
wharves, and airports. Small and medium-sized enterprises (SMEs) have gained
momentum in recent years, but not all individuals have equitable access to financial
institutions to secure the necessary funding to start a business. As a result,
cash flow is often limited since many people rely on selling their products
quickly. This has resulted in a high rate of unemployment.
The main cash crop in Aitape-Lumi is cocoa,
which provides income for the local population and enables them to pay for
modern goods and services. However, the lack of basic infrastructure, such as
piers and airports, means farmers must transport their crops to Wewak in the
East Sepik Province. This can be challenging, as there is a risk of robbery by
thieves and other criminals along the way.
The number of unemployed youths in
Aitape-Lumi continues to increase yearly, exacerbating the already dire
unemployment situation. Social issues are also on the rise as more young people
turn to illegal activities such as trading or smuggling marijuana in exchange
for motorbikes, weapons, prohibited cigarettes, and other goods from
Indonesians, which they then sell to make a living. It is difficult to blame
them as they are simply trying to survive in a competitive world. However, the
lack of robust and stringent leadership and governance in the district has
impeded development, which has progressed very slowly over the years. Leaders
have worked in isolation rather than collaborating to drive progress within the
community and the province as a whole.
Health is an important government priority
and essential service provided by various entities such as the Government,
Church, and private industries like mining and logging. In Aitape-Lumi
District, health services are primarily managed by two main parties: the
Government and the Catholic Church Health Services (CCHS). Unlike other
districts, the majority (75%) of the health facilities are under the Diocese of
Aitape Health Services, which CCHS governs at the national level. The district
has only one hospital and six health sub-centres, of which the Government
manages only two through the West Sepik Provincial Health Authority (WSPHA).
The health services in Aitape Lumi District
require significant strengthening and improvement. Health outcomes are poor
across many indicators, with worsening trends in critical areas such as
vaccination coverage and maternal health. There has been little progress in
general over the past ten years, leading to increasing inaccessibility to
quality health services. Many people suffer from various health issues, from
communicable to non-communicable diseases. There is a critical issue with the
unavailability of essential medicines and specialized health services in the
area. The district also faces challenges with specialist referral services, as
patients requiring expert medical attention are transported via roads to Wewak
or Vanimo Provincial Hospital by boat or road, incurring high costs. Many
patients do not want to be referred, as they know it will be expensive to seek
specialist health services outside the district, leaving them with no choice
but to return to their respective villages with curable diseases.
Based on the six (6) building frameworks from the World Health Organization
(WHO), this paper presents a brief analysis of our district health services to
evaluate their performance.
(i)
Service Delivery
Good service delivery is a crucial aspect of
any health system. It is a fundamental input to population health and social
determinants of health. The output of health service delivery is defined by
input factors such as the health workforce, procurement and medical supplies,
health financing, health infrastructure, and others. Increased inputs should
lead to improved service delivery and enhanced access to services. To monitor
progress in strengthening and improving health service delivery, it is
necessary to determine the dimensions along which improvement would be
measured. Eight key characteristics can be used to determine if health service
delivery is effective, efficient, and good:
Comprehensiveness
0. A comprehensive
range of health services is all about providing appropriate services to the
needs of the target population. This includes preventative, curative,
palliative and rehabilitative services and health promotion activities.
0.
Accessibility
Health
services must be accessible to every population despite race, disability,
religion, cost, language, culture or geography. Everyone is equal to access
quality health services despite their status in the community. There should be
no barriers, as mentioned above, towards the accessibility of health services
as.
0.
Coverage
The
delivery of health services is not only for sick people. It is designed for all
ill and healthy populations, all income and social groups. No one should be
left behind; all must be covered within the context of providing health
services to the people.
0.
Continuity:
There
should not be a breakdown of the health services. All the required services
must be provided to the people in a continuum state and sustainable across the
network of services, health conditions, levels of care and over the life cycle.
0.
Quality:
Quality
of health service delivery must be maintained at all times. The provision of
health services has to be effective, safe, centred on the patient's needs and
provided in a timely fashion.
0.
People-centeredness:
People
should become the focus of the delivery of health services. All health services
should be organized around the people, not on financing or diseases. The users
should perceive the services provided as responsive and acceptable to them, not
the illness or the funding. People should be involved every time in delivering
health services as they are partners in their health care.
0.
Coordination:
Effective
internal and external coordination will promote effective and robust health
service delivery. Effective coordination will promote the health services'
responsiveness and resilience to emergencies, disasters and other health
issues. Coordinating effectively with other sectors is paramount for good
service delivery.
0.
Accountability and
efficiency:
Health
services must be well managed to achieve the core elements described above with
minimum wastage of resources. In occupying the manager's position, you are
allocated the necessary authority to achieve planned objectives and held
accountable for overall performance and results. Assessment includes
appropriate mechanisms for the participation of the target population and civil
society.
Summary
Strengthening
service delivery is crucial to achieving the health-related Millennium
Development Goals (MDGs). The delivery of health services to people should
embrace the eight characteristics that are mentioned above.
The Aitape Lumi District Health services
have been falling short on several key characteristics for several years.
Several factors have been identified as hindering the progress of health
service delivery, including a lack of coordination. This lack of coordination
has been evident in the district's ineffective delivery of health services. The
Government and church often fail to cooperate and coordinate well in delivering
health services, which is essential to provide comprehensive services to the
target population. Other sectors must be involved in delivering health services
as specified in KRA 5 of the National Health Plan 2011-2021. As health
professionals and managers, we must identify and coordinate with our
stakeholders to deliver health services. Leaving them out of the continuum
delivery process results in challenges that slow the progress of health service
development, preventing us from achieving our five-year term District Health
Plan Goals in alignment with Provincial and National Health Plans.
The geographical landscape of the district
presents a significant challenge in delivering health services, mainly due to
the inaccessibility of road networks within the communities. Over the years,
the Government has not effectively provided basic services, including roads,
which has made it difficult for health professionals to reach the population on
time. Improving road networks and connecting communities will increase
accessibility to health services. The District Development Authority (DDA) must
identify and address these fundamental infrastructure issues to facilitate the
effective delivery of vital services, ensuring that no one is left behind.
Recommendation
1. The Government, through the DDA, should
prioritise funding for delivering essential services that will benefit the
people the most, such as roads, bridges, and harbours. This will undoubtedly
improve the accessibility of health services for the people.
2. The District Health and Church Health
Services should work together fully, rather than partially, to deliver quality,
affordable, equitable, and effective health services. Although the management
of health services may differ, their common objective remains the same. It is
time to set aside internal organizational politics and collaborate to provide
the health services that our people need. We should not think about being a
church employee or government employee, as such a mentality puts the lives of
our people at risk of not receiving the health services they deserve.
(ii)
Health Workforce
The district's ability to achieve its health
goals largely depends on the knowledge, skills, motivation, and deployment of
the people responsible for organizing and delivering health services.
Unfortunately, like in many other districts, the ratio of healthcare workers to
the population is meagre. For example, there is only one doctor for every
10,000 people in the country, which is a poor ratio, especially in areas where
the population is five times higher, leading to delays in delivering health
services to the people.
The health workforce comprises individuals
engaged in activities that aim to improve health. These individuals include
clinical staff, management, and non-clinical staff. Clinical staff members,
such as physicians, nurses, pharmacists, dentists, and medical laboratory scientists,
provide direct patient care. Non-clinical staff members, on the other hand,
provide indirect support services that facilitate the delivery of health care
services. Examples of non-clinical staff include ambulance drivers, cooks, and
cleaners.
Currently, there is a lack of comprehensive
and reliable methodologies to assess whether the health workforce is sufficient
to meet the healthcare demands of a population. Nevertheless, a shortage of
healthcare workers can be inferred from inadequate numbers and skills of
personnel being trained or if there is a misdistribution of their deployment,
as well as losses due to death, retirement or career changes.
Summary
Aitape Lumi District is in dire need of a
qualified health workforce to adequately serve its population. However, there
hasn't been much emphasis on improving the health workforce in the district.
The district's only hospital requires the services of qualified health
specialists such as specialized doctors, dental surgeons, laboratory
scientists, pharmacists, radiologists, and specialized nurses such as midwives
and child nurses. Although there have been some specialists in the past, they
were not sufficient to meet the district's health needs. There is a need for an
adequate number of specialized health personnel to ensure that the hospital
operates at total capacity. Many of the specialized health services at the
hospital are currently being provided by experienced Community Health Workers
who have worked and trained under health missionary expatriates for years. They
continue to work tirelessly to provide health services to the district.
Recommendation:
1. The district requires qualified health
professionals from various specializations to improve the hospital and deliver
the necessary health services to the population. Additionally, we need to
increase the number of specialist health professionals, such as doctors,
laboratory scientists, radiologists, dentists, pharmacists, midwives, and
technicians, to improve the health services provided and ensure they are
equitable to the entire population.
2. The district health system requires
comprehensive, reliable, and timely information on human resources for health.
This includes data on numbers, demographics, skills, services being provided,
and factors affecting recruitment and retention. Such information can help
build an evidence-based plan to ensure an adequate supply of high-quality
health workers in the right place, at the right time, and in suitable
positions. A comprehensive Human Resources Information System (HRIS) can also
assist in decision-making to ensure a gender balance in the health workforce,
particularly to encourage the use of services among underserved or marginalized
communities. For instance, in some settings, access to female providers
significantly affects women's utilization of health services.
(iii)
Health Information Systems
Accurate and dependable information is
crucial for making informed decisions in all aspects of the healthcare system.
It is necessary to develop and execute health system policies, regulate and
govern, conduct health research, develop human resources, provide health
education and training, deliver services, and finance. The health information
system serves as the foundation for decision-making and performs four essential
functions: generating data, compiling it, analyzing and synthesizing it, and
communicating and utilizing it. The system gathers data from various health and
other relevant sectors to ensure its quality, relevance, and timeliness,
transforming it into information that can be used to make decisions related to
healthcare.
Summary
To monitor the progress of development in
the Aitape Lumi District Health Systems, it is essential to have reliable data
systems. However, despite the availability of the Digicel network, the district
network system is somewhat inadequate. As a result, health facilities have
faced challenges in transmitting and receiving health information over the
years.
Under the former Medical Officer in Charge's
leadership, the Raihu District Hospital, the only hospital in the area,
recently installed a Wi-Fi disc. This installation has enabled the hospital to
send and receive health information promptly. However, the data systems need to
be more digital to ensure accurate data entry inputs and outputs.
On the other hand, PNG Power must
consistently provide electricity services to all its customers. A consistent
power supply without interruption would enable the prompt and accurate
processing of health information data. Unfortunately, over the years, the
district has experienced frequent power disruptions that have impeded the
transmission and receipt of crucial health information and management of data.
When disruptions occur continuously, they can damage PCs and slow down data
software through the network offline, making it difficult to generate relevant
health information.
Recommendation
1. Health Information Systems are crucial
for making better decisions. Hospitals should have a systematic information
system that records, manages, and generates data internally and through the
PHA. These systems should be electronic-based and saved in the cloud so that
the hospital can easily retrieve them when needed. Records or data should be
generated to track the flow of revenue, expenditures, and assistance. This
would enable us to improve our spending over time and prioritize accordingly.
2. A proper systemic data system would
enable us to see the trend on how our health programs are delivered and assess
our failures and success to ensure we provide accordingly.
(iv)
Access to essential medicines.
Equitable accessibility to safe, quality,
efficacy and cost-effective in-dated essential medicines, vaccines, and
technology are vital to the population.
Monitoring access to essential medicines is
closely linked with at least two other building blocks discussed - service
delivery and governance. Effective governance will lead to excellent and
effective service delivery, ensuring the availability of essential medicines,
vaccines, and technology. Essential medicines are intended to be consistently
available in adequate amounts, appropriate dosages, assured quality, and at a
price that individuals and the community can afford within the context of
functioning health systems. However, the limited availability, high cost, and
poor affordability of medicines are significant obstacles to treatment access.
Moreover, having standard and high-quality
equipment and diagnostic machines is essential for providing quality and
improved healthcare services. Clinicians would be unable to diagnose accurately
and prescribe the appropriate treatment for specific diseases without proper
diagnostic equipment and machines. Therefore, health facilities require
standard equipment and diagnostic devices such as X-ray machines, laboratory
machines, digital blood pressure machines, and automatic defibrillators to
deliver health services that promote quality, effectiveness, and equitable
accessibility among the population.
Summary
Like other districts, Lumi District Health
Services faces challenges in accessing and having essential medicines
available. Most health facilities within the community frequently experience a
lack of basic essential medicines. These health facilities receive supplies
from the government procurement and supply chain through the Wewak Area Medical
Stores. However, the drugs supplied to the health facilities depend entirely on
the available stocks at the Area Medical Stores, and sometimes only partial
quantities are provided. It has been observed that health facilities, including
the only hospital in the district, often run out of basic essential drugs for
several months. The shortage of medicines is usually beyond the control of
health facility managers and other responsible individuals.
The PHAs used to encounter similar issues,
but they had allocated budgets set aside to procure from Private
Pharmaceuticals Companies when the need arose. Although it was costly, it was
necessary to procure for patients' consumption. However, in the district, there
is usually no allocated budget to procure essential medicines when the needs
arise. This is due to various underlying issues, one of which is insufficient
funds.
Additionally, Raihu District Hospital, the
only hospital in the district, has encountered significant challenges in
providing curative health services, particularly diagnostic services.
Clinicians often make diagnoses based on disease signs and symptoms and their
extensive experience, which is not a standardized medical practice. The
unavailability of technical equipment such as x-ray machines and standard
laboratory equipment hinders accurate diagnosis. Therefore, it is crucial for
the hospital to have high-quality equipment to meet the population's healthcare
needs, which will enable clinicians to make better judgments and prescribe
appropriate medications or treatments. This will reduce drug resistance
resulting from guessing and inaccurate diagnoses.
Recommendation.
1.
Consistent budget allocation for the
procurement of essential medicines and technologies is needed often. This will
enable the smooth procurement of essential medicines and technologies and
ensure the population receive the health services that they deserve on timely
basis.
- The
external Support towards health is vital for the health services
development. Without the external Support the health services cannot
progress. Key Result Area 5 of the National Health Plan 2011-2020 states
clearly of the Stakeholders of the Health, therefore identification of the
important stakeholders and working in partnership will enable not only
strengthening but improving of the health services outcomes in the
district.
(v)
Financing
Health financing is crucial in enabling
health systems to enhance human well-being. It encompasses the processes of
gathering, storing, and utilizing funds to meet the targeted health needs of a
population. Without adequate financial resources, there can be no provision of
health care, no supply of medicines, and no implementation of health promotion
or prevention initiatives. The goal of health financing is to make funding
accessible and create financial incentives for health providers, ensuring that
all individuals have access to both public health and personal healthcare
services. Monitoring and evaluating health financing is integral to maintaining
transparency and accountability in health spending and requires a clear
assessment of its intended outcomes.
Summary
The funding of the district health services
has been a persistent challenge. The Government is the primary funder of health
services, but the management and distribution of the funds to the health
facilities are different. The church-run health facilities receive funding from
the Catholic Church Health Services (CCHS) head office, which the Government of
Papua New Guinea funds. On the other hand, government-run health facilities
receive funding from the West Sepik Provincial Health Authority (PHA). The
employees' salaries are also disbursed through the same channels. In 2021, CCHS
attempted implementing the Alesco payroll system for all its employees. Still,
it has not yet been decided whether it will be handed over to the Department of
Personnel Management (DPM) to be consolidated with other health public servants
working under PHAs or a single payroll system controlled by DPM. Unlike
government-run health facilities, Catholic-run health facilities (CCHS) often
face financial constraints. Due to insufficient funding, they have been forced
to scale down their operations and, in some cases, close. For example, in 2020
and 2021, there were financial issues with the salaries of CCHS employees. With
the church-run hospital providing all the necessary health services to the population,
a strike by the employees and a scaling down of the hospital's essential
services created chaos in the community. This was beyond everyone's control as
there was a delay in the Government's payment to the National Catholic Church
Health Services (NCCHS) in the second quarter, resulting in the employees'
salaries not being paid for two months. The operational and program funding is
often inadequate, and the inconsistency in funding timing harms the health
program's implementation schedule and slows the progress of health development.
Recommendation:
- Funding for health facilities should be provided
consistently and without delay to prevent disruptions in implementing
health programs. Although delays from the Government are inevitable,
regular communication and prompt and responsible dissemination of relevant
information can help employees prepare and avoid confusion and
misunderstandings that could lead to disruptions in district services.
Timely disbursement of employee salaries is also vital to ensure
uninterrupted services.
- The
district hospital, which the Catholic Church Health Services manage
(CCHS), primarily receives funding from the Government through the
National Catholic Church Health Services. However, it receives minimal
support from the West Sepik Provincial Health Authority (WSPHA) regarding
equipment, machines, logistics, human resources, and more. This lack of
support has been attributed to several factors, including the slow
progress of the Memorandum of Agreement (MOA) between the Diocesan Health
Services and the WSPHA. This delay has indirectly affected the health of
the population in the district by preventing the WSPHA from sending
specialist clinicians every quarter to screen, diagnose, treat, and refer
patients as needed. This lack of support is incredibly frustrating, given
that the hospital is run and managed by CCHS but falls under the
jurisdiction of the WSPHA in the eyes of the public. The MOA should not be
a barrier to providing quality and equitable health services to all
populations in the district. It is time for all involved parties to
re-evaluate their decisions and take action to improve health services in
the province.
(vi)
Leadership and Governance
The theme of governance and leadership in
health is becoming increasingly important on the development agenda. Governance
in health is a multi-faceted issue that is closely tied to accountability.
Building a strong and effective health system requires strong leadership and
governance that involves bringing together existing strategic policies,
providing effective oversight, collaborating with stakeholders, following
regulations, and focusing on national system design and accountability.
The demand for increased accountability is
driven by a growing need to show results and increased funding. Accountability
is an integral part of governance in health, managing relationships between
stakeholders, including individuals, households, communities, firms,
governments, NGOs, private firms, and others responsible for financing,
monitoring, delivering, and using health services. The accountability process
should be evident from start to finish, including the delivery of services,
financing to ensure sufficient resources, the performance of service delivery,
and the receipt of information to evaluate and monitor performance. In the
context of health system strengthening, accountability is a crucial component
of the health system. Despite the acknowledged importance of leadership and
governance in improving health outcomes, there is a lack of monitoring and
evaluation in most districts, including Aitape-Lumi.
Summary
The district is facing severe issues with
responsible governance and effective leadership in its health services. The
lack of accountability and transparency in the management and operation of the
district health system is a significant concern. The poor leadership and
governance are reflected in the health facilities, which are run down and
unable to meet the population's healthcare needs. The service quality is limited
and falls short of what is expected due to the absence of essential equipment,
shortage of skilled staff, and inadequate supplies of essential medicines. This
clearly indicates the poor leadership and governance within the district health
system, particularly among those in managerial positions.
Recommendation
1. The managerial positions within the
district health system should be filled based on merit. Individuals with the
appropriate qualifications and skills should be selected to carry out their
duties effectively. This will guarantee that health services are efficiently
provided to the target population, with accountability and transparency
maintained throughout the process.
2. The political support for health services in the district is
inadequate. Over the years, it has been noted that political support is weak
and only appears during critical events, such as when the hospital is facing
financial difficulties. This should not be the case for health services. There
should be consistent political support, not just when critical issues are at
hand.
Conclusion
Health is a collective responsibility, and
every individual plays a role in the delivery of health services. It is
essential to enhance and improve the six building blocks within its framework
to ensure that a health facility achieves its objectives, which align with the
country's health goals. Support from all stakeholders, both internally and
externally, is critical, and political support should be consistent and
available as needed.
Written by,
Anthony Jaol Aindri- BAPharm, MPH&HSM
Edited by Dr Rodney Itaki- MBBS, BMedSci, MPhato, MPH&HSM
19th February 2023
