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The health perils of a wet Sunday afternoon


THE TEST CRICKET had finished early and I though a quick trawl through the internet might turn up something of interest.

A reference to ‘Strengthening the PNG Health System’ snagged my attention in what was turning out to be a washout of a Sunday afternoon.

Amid the glitz and glamour of a high profile launch in Port Moresby on 25 November, report authors Julienne McKay and Dr Katherine Lepani presented a paper on how to improve PNG’s health delivery system. The audience included Australia’s High Commissioner Ian Kemish and the AusAID head in PNG Stephanie Copus-Campbell.

In a previous PNG Attitude article I had observed: “Australia is taking steps to support its near neighbour. Foreign Minister Kevin Rudd has announced Australia's pledge of $85 million as part of the UN Global Strategy for Women's and Children's Health.”

The ‘Strengthening the PNG Health System’ conference, I thought, was an example of how this new approach was being ushered in to help our nearest neighbour.

Julienne McKay began by maintaining she was not proposing to throw away the many, many good things that had been achieved over the years with PNG’s health services. This statement seemed to fly in the face of deteriorating health services in the towns and cities and a virtual collapse of rural health facilities. Ms McKay went on to say: “What we are proposing is to build on these achievements.”

To deal with increasing rates of maternal and infant mortality, the presenters offered an alternative strategy of providing “voucher systems and micro health insurance schemes”.

Demand responsive mechanisms were referred to as important drivers of future service delivery. Statistics from Cambodia on the increase in the number of births (‘health facility deliveries’ in the presentation overheads) were quoted as demonstrable evidence that such schemes do work.

It was then observed how it was important not to reduce health delivery services. The confusion some people might have had between ‘health delivery’ and ‘health deliveries’ was rather obvious.

By the time I waded further into the paper and accompanying slides, I started to wonder whether we might have been on different planets. But one of the final points made by the presenters took me back to reality.

They had apparently visited Oil Search, Lihir and Mt Hagen in their quest for knowledge. One of the solutions was to have a voucher system whereby those who wanted treatment could obtain their medicine at Marisin Stoa Kipas (MSPs) who would apparently provide pharmaceuticals upon demand, based on what had been developed by the Oil Search Community Health Program.

Clearly there could be no problem at all in providing health vouchers to consumers throughout PNG.

So one presumes that the new approach to Australia’s AusAID health programs in PNG will now include: Marisin Stoa Kipas and health vouchers coupled with micro health insurance.

I wonder who paid for this research and what it actually cost? Probably many thousands of kina that could have been applied to provide rural health in PNG at a time when many are reportedly dying for want of any service being available at all.


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Maria Buka Meri

Millions of dollars in aid and still the Buka Hospital in Bougainville has massive problems in accessing a consistent and reliable water supply. Hmmm, health care.

Reginald Renagi

Generally, things may just change for the better if the PNG government and its leadership takes full responsibility to fix the national health care regime.

It's all a matter of priorities.

The government needs to go back to the basics and do what is critically needed, and its overall efforts being complemented by AusAID with good synergy.

The government should not rely too much on AusAID support in the area of health (and other areas of government support as well).

AusAID is just a stop-gap mechanism. It should be used to complement the existing health system in the country.

Things worked well in the Kiap's time because there were many frontline patrols out to rural PNG (and foot-soldiers on the ground in rural areas).

Also, unlike today with a lot of funding support, most office-workers and bosses in those far-flung days were not slaves to their paper-work.

They got dirty by getting out from behind their desks and went to the bush to check out the remote areas on health extension patrols.

The army (PNGDF) also did the same thing with their 'Preventative Medical Platoons'.

These remote village patrols were done all year around to complement the regular army patrols thorughout the whole country.

This has not been done for some time now for a host of reasons (a separate subject article later on this by the writer).

The PNG government can improve the country's health system if its sets its strategic priorities right as part of the overall national health plan.

This plan will work if it gets well complimented by AusAID in an effective synergistic way than what is being done, or not done now.

Paul Oates

'When you were a kiap, did you transform the areas in which you were involved?' [Peter Warwick, 20 December]

Therein lies the frustration, Peter. We actually visited the people who lived in the areas 'I was involved in' as you put it.

We sat down in the villages and spoke with and listened to what the people had to say. While it is true that we had some authority, that authority was paper thin and could quickly evaporate at any time if we weren't extremely cognisant of how things were.

There was no backup either.

Basic government services were available then, as I've mentioned, albeit on a frontier basis. Yet they did exist and were utilised by the people.

In regard to medical help, aid posts were operational with trained staff available at every three or four villages. Drugs were supplied through the nearest government station medical centre where people went when they needed serious medical assistance. Very serious cases were evacuated to a major hospital in the District.

Compared to the cities, this service may have been rudimentary but it did work and was definitely better than no service at all. It certainly saved my life on patrol on a number of occasions.

Medical staff went with me on annual Census patrols and immunised children with Triple Antigen as well as providing medical assistance to everyone as required. THe medical health of the areas we patrolled was reported on and our reports read by senior staff at Sub District and District level.

But that was just about medical matters. Every other government service was also covered if required.

The recent article on PNG Attitude about medical staff getting their boots dirty is a classic example of what is desperately needed.

This urgent requirement for essential services should not just be limited to medical matters however.

Peter Kranz

The Four Square church near Don Bosco at Two Mile used to offer free (or very cheap) dental care from visiting volunteer specialists, but I think this has stopped now. It was a good idea.

Both James Cook University and Charles Darwin University have tropical medicine expertise and research centres which could be used to boost local PNG health resources. Perhaps interns could be given credit for spending time in PNG?

Peter Warwick

Peter - Great to hear that you are working on your immediates. That's all we can do. The problem is too huge and too difficult to comprehend. We have a limit to our emotions. So why wring our hands until dermatitus appears.

My mother-in-law has no teeth, no money, no income (she does get K200 per month from us which she immediately spends on neglected children and assorted waifs around her), no home (other than the ten sheets of kapa and house poles I provided), no shoes, and I think her underwear is a little deficient.

She flatly refuses to live with us, because her pride has got in the way, and she wants to give us privacy as a married couple.

Paul - It may be the second time, and there may be a third or fourth time. But it is incumbent on us (the sideline commentators) to give AusAID a go.

I have nothing but respect for your previous contribution to PNG, but from Boonah things can look bad, and it is worse than you can think, as you have plumbed.

I have been critical of AusAID, and we may have seen a slight turning around of AusAID, but we are beholden to give them a chance and judge them on results, rather than prejudge them.

I am sure Danielle Cave is cognisant of the controversy surrounding AusAID and is working her backside off to get results.

When you were a kiap, did you transform the areas in which you were were involved?

Stephen Cox

Paul - Your headline tells much more than you realise. Until these experts, well meaning that they may be, actually spend some serious time in the tropics, they will never understand what they are up against.

People in better positions than most locals working in the mines stay off work for two weeks after a minor scratch due to infection issues in the climate, or alternately fly out to a controlled climate to recover or risk death.

In PNG health issues are much different to Australia, but much of the underlying causes are conditions relating to education and hygiene. These issues are worldwide and huge efforts and money allied with bureaucracy have achieved little.

Obviously a better more targeted approach is required and this will never come from studies by the Lowy Institute for the simple reason they are peer reviewed.

Peer reviewed means, in my book, people who underwent the same indoctrination and training and therefore end up having the same outlook and approach to problems.

Unfortunately they also take a very long time to evolve their approach, if they ever do. This means they always come up with a variation of the same answer to problems. Therefore either never fixing the problem or even making it worse.

The health system in Australia is badly lacking and chiefly because of a preponderance of paper shuffling shiny bums and not enough front line workers.

It is easy to read between the lines and see that the PNG system has followed the same path to poor service and lack of accountability.

I believe we should look at a system where some of our medical students at an advanced level of study with useful real experience could be offered a reduction in HECS debt in exchange for time spent serving in health areas of PNG and the Pacific.

The experience they gain is worthwhile by itself, but the rewards of community and friendship with our close neighbours are priceless.

Perhaps a scholarship foundation with such aims would be a long term help in being able to help train locals as well as Australians to work together effectively in addressing this problem and showing the world just how it should be done.

Remember, literally trillions of dollars and millions of hours have gone into similar areas of concern worldwide with scant benefit for anyone as far as long term real solutions being achieved.

It is truly time for real improvements to be made and permanant ones at that. Common sense and a study of historical experience are all that is really needed to find a way forward, not another gab fest of people who really need a wake up call that they are not the centre of the universe.

Fred Hollows showed what can be achieved by a determined individual who gathers like minded helpers and the snowball effect of real benefits would be beyond the grasp of most who look at health from a Western perspective, where it has become a business rather than a service for the community.

Doctors of a century past had much more real world respect than their modern counterparts do today and for good reason,sometimes you have to look back to go forward.

Peter Kranz

I visited my cousins at Seven Mile. They are a family of seven living in two rooms. No running water, no WC. Three to a bed on the floor.

They are lucky - there is an illegal stand pipe in the back garden which provides water for everything (showers included, if it is not raining). And they have a garden with space for some chooks.

Their neighbours live in a shipping container. At least they have space for a garden and a pig.

They offer me a space to sit on a patch of old carpet. They give me some Fanta.

My little nieces and nephews have not had any inoculations since they were babies. The oldest who remembers me says, "Daddy, when will you come and get us?"

The family can only afford for three to go to school. We have helped somewhat with the fees, but this is too little too late.

But everyone is so friendly and so happy! They offer us some food and some boys (aka rascals) to be our security guards. They even offer to kill a chook for dinner. I say no - biscuits will be fine.

We will all go to Church, which is just next door. My God!

Peter Kranz

I am sometimes heartened by the film Schindlers's List. He couldn't help everyone - and he knows this. But he is able to help some. A few is better than none.

It is not a solution to a national dilemma, but sometimes it can be a solution to a personal one.

Mana will get her teeth. Niece will get her AIDS treatment Uncle will get some medicine for his arthritis. We are trying out very best to get baby some help with his eye. It is all we can do.

Maybe the journey of a thousand miles starts with the first steps. God bless!

Paul Oates

G'day Peter Warwick. That's the second time you've suggested that I put up straw men to shoot down. My aim is to try and generate some positive action on what seems to be areas that need attention. Call me passionate you may, for I am.

I may well be a lapun who left PNG when the education, health, law and order and all the other government systems worked, albeit at a frontier level of service. Nonetheless, we were able to effect those services with what is now a miniscule funding level with a field service numbering in the hundreds.

Prior to the post by Danielle Cave, I previously emailed the Lowy Institute Director to offer to discuss how health services could be improved in PNG. I'm still waiting for a response.

I am sure there would be many reading this blog who could and would make some positive contributions to any 'think tank' that might want to investigate what can be better accomplished with the vast amount of resources that seem to disappear every year into that black hole called the PNG government.

Why not consult those readers of PNG Attitude to see if some of us might have some worthwhile suggestions?

Peter Warwick

Peter - The point is appreciated. But what do we do? Just three hours ago, I was followed in a Madang supermarket by a boy with severe skin problems who obviously was hungry.

I bought him some processed meat, biscuits and milk and sent him on his way. He met me outside and asked to be driven home, which I did, and his mother came out and kissed me uncontrollably!

But I cannot be tearful about it, simply because the whole place is bloody tearful. Kids not eating, adults destitute.

I drove away more bitter than ever.

I cannot buy any Kleenex tissues because if I did this for all the neglected children I see, it would be a carton of Kleenex a day, and I would contract eye inflammation and be broke.

The people you and I deal with are a product not a cause.

Write to Somare and tell him that he has neglected his people, and give to some worthy cause to help these people.

I am sure you are a thoroughly decent bloke, but Kleenex tissues are not the answer.

I despair!

Coming from a very WASP conservative family and background, I am shocked that I am thinking of a revolution.

Peter Kranz

Peter Warwick - I think they do live in a Third World country (PNG) which cannot provide decent health care. The evidence shows this.

And I cannot afford to take them all to Australia for treatment. That is he dilemma all of us with PNG family have to confront. I am brought to tears by this.

Peter Warwick

Paul is inclined to create straw men only to shoot them down. Paul's strong point is definiteley not positivism.

Peter - Your relatives do not live in a first world country - what were you expecting? If you are so concerned about them, pay for them to become Oz citizens and entitle them to free everything.

Peter Kranz

An observation from on the ground. My old Mana who is in her 80's and has no teeth (too much buai during her lifetime) but cannot afford dentures. She now has to drink mashed-up food to survive. Cost of dentures - around K600-1,000.

My baby nephew has a twisted eye - strabismus (this can't be treated in PNG) so his mum has been advised to take him to Australia for an operation. Any idea how much this will cost?

My uncle has arthritis in his hip - he cannot afford the medicine for this in PNG.

One of my aunties has lost one eye - not life threatening, but it would be good to have a prosthetic replacement. Not available in PNG.

One of my nieces is HIV positive. What are her chances of decent treatment in PNG?

I won't make any further comments - just point out the facts.

Sad but true.

Paul Oates

Hi Danielle - Thanks for your response. I'll email you direct to say hello.

Danielle Cave

Hi Paul - Thank you for your blog post, an interesting take on this research project and you raise some worthwhile points.

I thought I would assist in clearing up some of your confusion. Up front, let me clarify that I am a Research Associate at the Lowy Institute and that I co-managed this research project and attended the launch in Port Moresby.

* The research was commissioned after extensive consultation with stakeholders in 2009 in PNG and was a response to their stated interest in learning more about demand-responsive mechanisms. It was actually very difficult to find authors who are qualified to do the required research on this topic

* The research was co-funded by the Myer Foundation Melanesia program (a family foundation) and the Pacific Friends of the Global Fund. Both these research programs are housed in the Lowy Institute, a foreign policy think-tank based in Sydney.

No funding was sought from any Australian Government department for this research project nor are either of those programs funded by the Australian Government. Yes, a number of interested Australian Government represenatives did attend the launch, and they attend many of the regular events hosted by the National Research Institute in Port Moresby

* The research was not expensive and adhered to a strict budget. The Lowy Institute is a research-based organisation, not a donor, so therefore we can not provide money to support service organisations such as the PNG Health department

* The research was extensively peer-reviewed, internally and externally, and received very positive feedback, particularly from the organisations in PNG that reviewed the papers. All peer-review comments are handed over for consideration to the authors on an anonymous basis

* I can assure you it was not a glitz and glamour event. We rented a conference room at the National Research Institute in Port Moresby for the two-hour mid-morning launch of this research project and provided coffee, tea and biscuits

If you would like any further information on this recent research project, please don't hesitate to contact me. All the above information and more is available on our website:

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