NOOSA – Australia’s foreign affairs department (DFAT) has just released a report evaluating the contribution that international donors have made to Papua New Guinea’s health system.
The report by Ian Anderson and Renee Martin was presented to DFAT last December, well before the recent outbreak of polio confirmed a shocking reality that many of us suspected - that health services in PNG are going downhill fast and have now reached a danger point.
The report, which you can read in full here, assesses the efforts of six multilateral development partners - the Asian Development Bank; the Global Fund to Fight AIDS, TB, and Malaria; the World Bank and three United Nations agencies, UNFPA, UNICEF and WHO – over a six year period.
Anderson and Martin have done what many consultants do when reporting upon big and powerful organisations – intimating problems while pulling punches about some of the most inimical reasons and about where real responsibility lies.
“The [multilateral development partners] have a generally good record in terms of their overall effectiveness in the PNG health sector,” they write, “but important challenges remain.”
My oath they remain. And they're more than challenges; they are realities that are killing people.
As commentator Matt Morris tweeted wryly, “….challenges like endemic corruption in drug procurement, funding cuts to pay for APEC, a collapsing health system and now polio.”
The C word is often avoided in official discussion about Papua New Guinea as it seems to be in this report (I have not done a full word check but the executive summary avoids it like the plague, if that's not too harsh a metaphor).
When I was in PNG earlier this year and uttered the word ‘corruption’, I was gently chastised by a senior public servant that “we don’t use that language here”.
When I asked how then this topic might be addressed, the response was that there are “significant inefficiencies”.
Matt Morris also pointed out that the report assigns no accountability to donors for the failing health system. And certainly DFAT escapes pretty much unscathed, perhaps because it commissioned the report and was considered not part of the game when in fact, as PNG's major donor itself, it is critical to it.
Australia has fiddled with but never candidly confronted the curse of corruption in the PNG government. DFAT has been part of a problem that is now too late to fix. Australia has seriously let down the people, as differentiated from the fat cats, of PNG.
But let me turn to some of the main points made in the report itself.
It says that the six multilateral development partners all contribute in different ways “according to their own mandates and comparative advantage” and that, “when well-coordinated [note the qualifier], the impact of these six agencies can be larger than the sum of their parts”.
Good old synergy, nice to assume, hard to measure. It crops up again towards the end of the executive summary.
It turns out that DFAT provided about $112 million to the six organisations from 2011–17 and felt itself to be “in a particularly good position to further leverage and magnify the important role played by the MDPs through judicious use of grant financing and policy dialogue”. Well one would hope so.
But let’s look at those important remaining challenges.
Unwittingly pre-empting the polio disaster, the report says that “immunisation rates have essentially stagnated for decades and in some cases declined” and “policy dialogue with [the PNG government] has had only modest success.” In other words, it is rather cavalier in taking notice of what we advise.
The report continues with a register of despair: PNG has the fourth highest rate of stunting in the world; maternal mortality remains one of the highest in the world; there are “stubborn weaknesses” in health financing and the provision of essential drugs to front line services; essential drugs run out of stock; and there is the “double burden of controlling communicable (including drug-resistant) diseases alongside the rapid rise of expensive to treat non-communicable diseases”.
Meanwhile, health spending is decreasing in real terms with a strong suspicion intimated that the PNG government is using donor funding not to add to its own funding but as a substitute for it – thereby depriving the health sector further.
And what are DFAT and the six partners doing about this? Well it turns out that “monitoring and evaluation remains the weak point” with “too many reports [being] descriptive and input-focused, rather than analytical and output/outcome focused.”
“DFAT will need to develop a clearer, overarching - as well as individual agency level- results framework that sets out what DFAT expects [partners] to achieve when using its funds,” the report recommends.
“DFAT also needs to be equipped, including with technical expertise where that is necessary, to be able to more proactively manage its ongoing relations with the MDPs and achieve a sharper results focus.”
Much consultant-speak there, but one later paragraph provides the tell-tale: “Declining levels of immunisation is a worrying reflection of the capacity of the health system more generally, and the ability to manage health security challenges more specifically.”
“But there are also opportunities,” the report says, as if to cheer us up. “PNG has a new Minister for Health who is clearly determined to improve health outcomes. PNG has had an ‘unprecedented’ reduction in the prevalence of malaria and appears to have avoided the early projections of an HIV AIDS crisis.”
And some solutions? The ADB is considering a “substantial” concessional loan, the World Bank has recently finalised a concessional credit and is also considering a concessional loan. These will all “further incentivise and drive reforms in public financial management in the health sector”. Further?
Finalising its executive summary, the report concludes: “DFAT itself is clearly committed to supporting GoPNG reform efforts in the health (and other) sectors…. It will, however, require a transition plan….”
Six years and $112 million later, we need a plan.
I think we need a lot more than that. Total honesty and candour in reporting for a start.