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.
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.
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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
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.
Anthony Jaol Aindri- BAPharm, MPH&HSM
Edited by Dr Rodney Itaki- MBBS, BMedSci, MPhato, MPH&HSM
19th February 2023
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