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An odious comparison: PNG & Australian hospitals

The new Royal Adelaide Hospital: K5.5 billion to build and  K2.9 billion a year to operate.


ADELAIDE - My first outstation posting in Papua New Guinea was to Baimuru Patrol Post in the Gulf Province.

In 1970 the station boasted a grass airstrip, a native materials office, a small collection of houses and miscellaneous outbuildings.

There was also a rickety wharf decked with Marsden matting left over from World War II.

Kapuna Hospital
Kapuna Hospital, Gulf Province, in the swamps of the Purari Delta. When tides are high the grounds are flooded and toilets are a continuing problem.

The two main businesses at Baimuru were a sawmill (owned, I think, by Steamships Trading Company) and the Gulf Hotel, the latter establishment mostly frequented by local people (including the two resident kiaps) plus the occasional visitor.

The pub was connected to the government compound by the only road.

It was almost exactly one mile long and, provided it had not rained too much, the station’s one and only Toyota Land Cruiser could negotiate it without too much difficulty.

In bad weather, a dinghy could be used to get to the pub, although the journey back to the station in the dark could be a bit fraught.

Health services were provided by Drs Peter and Lyn Calvert who worked out of Kapuna Hospital which, as near as I can recall, could be reached in about 45 minutes in an outboard powered dinghy or canoe.

The hospital was, and remains, the main provider of medical and nursing services for some 30,000 people who live in and around Baimuru and Kikori.

By Australian standards, it is an astonishingly primitive facility. Australians would struggle to recognise it as a hospital, except perhaps as an historic exhibit of something that existed in the remote colonial past.

Its wards are made of locally milled timber, each with a rusty corrugated iron roof. Ventilation is provided by shutters which are opened and closed according to the weather.

It is a very long time since I saw inside one of those wards, but my recollection is that they were pretty basic facilities, lined with hard wooden trestle beds with only woven grass matting to serve as a mattress.

Despite the chronic lack of resources, the Calverts and their successors have saved countless lives and eased the pain and suffering of huge numbers of patients.

The doctors and nurses who work at Kapuna are doing what I regard as heroic work under very adverse circumstances.

After Papua New Guinea, I spent much of my career as chief executive of South Australia’s largest regional hospital at Mount Gambier and, later, a 300 bed metropolitan teaching hospital (the Repatriation General Hospital).

And whilst at Mount Gambier I presided over the construction of a new 120 bed hospital which boasted all the major facilities, services and technologies you would expect to find in a modern Australian hospital.

In 1997 this medium sized regional hospital cost $A30 million (K72 million) to build and around $15 million (K36 million) a year to operate.

The contrast between the hospitals I managed in South Australia and Kapuna is very stark.

This was brought home to me rather forcefully a few days ago when I visited the new Royal Adelaide Hospital, which the locals call the “nRAH” (pronounced “en rar”).

I had neither seen nor been in the hospital before. I live on the southern fringes of Adelaide and so rarely go into the Central Business District.

My knowledge of the nRAH therefore was restricted to what I had learned through the occasional TV report or newspaper article.

Despite my extensive background in hospitals, it came as a considerable shock to me to discover the enormous scale of a modern, international standard, 800 bed teaching hospital.

NRAH interior
Inside the new Royal Adelaide Hospital

It is a gigantic building and no expense has been spared to ensure it is truly impressive.

The grand main entrance boasts vast areas of elegant ceramic tiles and what look suspiciously like genuine marble pillars. Light floods in through various windows and strategically placed, plant filled atria.

In the background, a volunteer was expertly playing soothing classical music on a baby grand piano. This apparently is a regular feature intended, so I am told, to promote an atmosphere of calm and serenity amongst sometimes anxious patients and relatives.

Inside Kapuna Hospital
Inside Kapuna Hospital

Finding your way around requires a map plus the assistance of helpful volunteers who have learned to unerringly navigate the hospital’s several kilometres of labyrinthine corridors.

My wife and I found our way to the Nuclear Medicine Department wherein was located the hospital’s most impressive and expensive piece of modern technology – a positron emission tomography (PET) machine.

I understand that this machine cost around $A10 million (K24 million) to acquire. Heaven only knows how much it costs to operate each year, but several million dollars seems a likely total. Its main purpose is to examine soft tissue (as distinct from bones) to locate and identify various problems, notably cancerous tumours.

I could not help but reflect upon the cost of what I was seeing.

The nRAH cost $A2.3 billion (K5.5 billion) to build and requires at least $A1.2 billion (K2.9 billion) a year to operate. It is the largest single government organisation in the state and currently is the most modern hospital in the Southern Hemisphere.

It struck me forcefully that the nRAH costs twice as much to operate each year than the entire PNG health system, which was allocated a miserly K1.5 billion in the 2019 national budget for PNG’s nine million people.

I find this very troubling.

While I am grateful to have access to the knowledge, expertise, technology and services available at the nRAH, I remain keenly aware that the people of PNG have nothing remotely like it to meet their health needs.

Instead, they are mostly reliant upon the heroic efforts of a comparative handful of people such as those working at Kapuna, most of whom are obliged to work on a shoe string budget.

While it would be unrealistic to imagine that something like the nRAH could be built or operated in PNG, it is not unrealistic to suppose that something like Mount Gambier Hospital could located in the major regional centres of PNG.

The fact that this is not the case speaks volumes both about the gross imbalance in available resources across the world as well as the dreadful failure of successive PNG governments to meet even the basic health needs of the population.

The provision of basic health services is not rocket science and does not require much more than a comparatively modest range of services, drugs and equipment.

PET scanners and other sophisticated and expensive technologies would add little value compared to the availability of a range of effective drugs, high use consumable items like sutures and dressings and, most importantly, people trained to use them effectively.

In the colonial era, the people we called aid post orderlies had low levels of training and little in the way of drugs or equipment, yet they provided a remarkably effective health service, especially if they were part of a well supported system.

Colonial era aid post
Colonial era aid post

Unless I am mistaken, the aid post orderly system either is no more or has become largely dysfunctional.

Experience shows that countries without a modern and effective health system cannot create and support a genuinely modern economy.

The nRAH reflects a determination by successive governments to ensure that my small and comparatively poor state (by Australian standards at least) has a health system that can and will continue to support a truly vibrant economy and society.

In a way, the health system is a bell wether indicator of a country’s underlying socio-economic status and its prospects more broadly.

By this metric, it seems that PNG is not now, nor in the foreseeable future ever likely to be, able to create and sustain a modern economy.

The serious failure by successive PNG governments to remedy the many deficiencies in the national hospital system has led to a tragic waste of lives, talent and resources.

This is both sad and a great shame.

It is my fervent hope that the PNG government can and will make the effort required to create the health system their people both need and deserve.


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David Vorst

Young Mr Overland - I know of what you speak regarding hospitals and the health system in PNG.

Having now worked here for some 16 years and having been your colleague in South Australia and, like you, having built a 110 bed hospital, but in Port Augusta not Mt Gambier, I can assure you that our efforts to have the Mt Hagen Hospital redeveloped into a fit for purpose patient and staff safe facility have not resulted in any development on the ground.

We spend more than K5,000/day (mainly from deferred maintenance) to give clinicians the drugs and tools they need to treat the 15,000 inpatients, deliver 5,000 babies and province tens of thousands of outpatient services every year.

All out of not fit for purpose buildings many built in the early 1960s and clad in asbestos loaded materials.

Lindsay F Bond

When Marston guesses don't suffice, see:

Hole edges flared for grip to ground, ribs for strength (no joke). Where used as fence panels, tropical breezes are less impeded.

Philip Fitzpatrick

There's a steel-framed wharf at Baimuru near the old office complex which is still pretty solid Chris. It looks like a WW2 effort. Unfortunately all the decking has gone.

They've also got a small landing craft made entirely of rust that still chugs around. Not a lick of paint on it but it still manages to beat the force of the Purari. Took it up to a geology camp on the Aure Scarp about ten years ago.

Chris Overland

Charlie Lynn asked on Twitter: “Would be interesting to know if Chris Overland has ever been contacted by any Australian Government Minister with a responsibility for PNG to get feel for his thoughts based on his real life experiences?”

The short answer is no.

On the few occasions that I have written to a politician on health policy issues I have never had a reply of any sort. They give lip service to wanting to hear the views of constituents but, in practice, are not interested.

The problem is that, as always, suggestions for health system reform involve taking difficult decisions that will upset powerful interest groups, so nothing of consequence ever happens.

Just look at private health insurance. It is a doomed product, getting more prohibitively expensive as each year goes by, yet the government prefers to pretend that all is well. Only a crisis will precipitate action.
Same with aged care which I and many others have repeatedly and consistently pointed to as a failed policy area. The response? Nothing beyond the shuffling of deck chairs. Why? Because the neo-liberal ideological goggles now worn by both major parties prevent them from seeing the bleeding obvious.

Maybe the Covid 19 debacle, for which the government has deftly avoided taking any responsibility so far, will lead to meaningful change but I would not hold my breath.

As for our relationship with PNG, I have no idea if anyone associated with government ever reads PNG Attitude. My guess is that they do but prefer to remain anonymous. If so, they know where we are and what we think.

From what I have read, Charlie Lynn has made many attempts to influence policy relating to the Kokoda Track based upon his extensive real world experience yet, so far as I can ascertain, nothing has actually changed. He seems to be running into the same brick wall of indifference and inertia that bedevils us in so many policy areas.

We are going to need another Gough Whitlam to shake the tree enough to get something useful done in a host of policy areas and, frankly, I do not see that happening anytime soon. Scotty from marketing may be a complete political chancer but his act seems to resonate with far too many Australians who ought to know better.

Chris Overland

Thanks Martin for correcting my 50 year old misunderstanding of how to spell Marston.

It was certainly a good product, still going strong in 1970 and probably for a good few years longer. On the Baimuru wharf it was the wooden piles and beams that were failing, not the matting.

Martin Hadlow

Just a very, very minor point, Chris.

You mention "Marsden matting" from WWII. It is actually Marston matting or, more technically, Pierced Steel Planking (PSP).

The name comes from the town of Marston in North Carolina, close to the major military base of Fort Bragg.

US Army engineers were testing the newly invented PSP during manoeuvres in late 1941 and laid an airstrip close to the small settlement of Marston. The steel planks proved most successful and heavy aircraft were able to land on the strip within hours.

Interestingly, the holes in Marston matting were not only made to reduce the weight of each plank, but also to enable grass to grow through the holes when laid as an airstrip, thus helping with camouflage in combat situations. The steel in the planks also contains special ingredients which made Marston matting almost rustproof and nearly unbreakable.

The amount of matting still in use throughout the Pacific and, indeed, the world, proves both points.

Robert Wilson

Even back in the early and mid 70's when as a Didman patrolling through the mountains serviced from Patrol Posts at Tauta & Bundi and throughout the Ramu nambis from Usino Patrol Post, I fondly remember the dokta bois at their tiny little bush material aid posts scattered throughout the usually tidy compact villages where they were able to help out with a shot of penicillin for leg ulcers gone bad and to treat myriad of minor illnesses that we government officers may fall foul of at various times whilst well out of sight of proper town hospitals. Even back then villagers received good care for a multitude of ailments and accidents but I was horrified to hear on my last visit that many of those well known aid posts had long closed and been closed down for years. Shame on the PNG governments!

Bernard Corden

At the nRAH I wonder how many soft drink and snack dispensing machines are strategically located adjacent to the lifts on each floor and how much visitors are fleeced for parking.

Stephen Charteris

In my view the present health system in PNG is hog tied. Understandably constrained by lack of funds and resources. But also “politics” at every level.

Funding constraints. Yes, the lack of resources is overwhelming but within that limitation I believe Chris is right when he writes that “Despite the chronic lack of resources, the Calverts and their successors have saved countless lives and eased the pain and suffering of huge numbers of patients.”

That also applies today to the many community health workers, nursing officers and others who toil relentlessly often without supervision, functional tools of trade, medicines or consumables to do their best in the face of seemingly insurmountable odds.

And what of politics? Euphemism for almost every foible of human behaviour that results in the best of intentions producing the same old results.

The recent reforms to devolve full accountability for all health facilities to provinces under Provincial Health Authorities while fine in theory does not address that core issue.

In my view accountability to the end user is lacking. It is almost an extinct species both in substance and intent. Could you image the uproar if a regional hospital in Australia was threatened with closure, or the last midwife in town was leaving without a replacement, or the ambulance service decided to stop servicing your area.

This slow inexorable decline in services is what has been happening every day in regional PNG and it is generally met with a resigned shrug and silence. The “elites” are not accountable in any sense we in Australia could accept.

John and Phil, your respective reflections ring completely true. People need solutions.

In my view real reform would empower every community to hold its service providers accountable for the results they produce on the ground.

The number of outreach services every community receives in a quarter, functioning aid posts, health centres, district facilities.

And for the indicators that matter, maternal and childhood mortality, ante natal visits, immunisation coverage, malaria treatment and control and yes Panadol in the local clinic. The list goes on.

I cannot foresee substantive change until and unless a genuine bottom up process is entrenched to ensure that every PHA is held accountable by its people, the people it is mandated to serve for the outcomes they receive.

I would also add a foundation of locally owned and driven first line services to cater for the basics.

On that last point a glimmer of hope. A local Milne Bay NGO has just started to implement that vision. A self-funded, community service delivery mechanism to ensure basic services are delivered regularly and sustainably to maritime communities. In time it might even reach Guasopa.

Philip Fitzpatrick

Here's a hint about why hospitals and everything else aren't up to scratch in PNG.

"Papua New Guinea police accused of gun running and drug smuggling by own minister" (by Ben Doherty, Pacific editor, Guardian Australia - Fri 18 Sep 2020)

Bryan Kramer, the PNG police minister has said it could take a generation to eradicate police corruption.

Papua New Guinea’s police force is the most corrupt public agency in the country, engaged in drug-smuggling, gun-running, and land theft, and beset by “a rampant culture of police ill-discipline and brutality”, its own police minister has said, in an extraordinary condemnation of his own force.

Police minister Bryan Kramer used the occasion of PNG’s independence anniversary to launch a swingeing attack on the police force, saying its endemic corruption would take years, even a generation, to eradicate. His statement follows a concession from the police commissioner, David Manning, that his force includes “criminals in uniform”.

“I found our police force in complete disarray and riddled with corruption,” Kramer wrote online about his first 15 months as police minister.

“The very organisation that was tasked with fighting corruption had become the leading agency in acts of corruption. Add to that a rampant culture of police ill-discipline and brutality.

“Senior officers based in police headquarters in Port Moresby were stealing from their own retired officers’ pension funds.

"They were implicated in organised crime, drug syndicates, smuggling firearms, stealing fuel, insurance scams, and even misusing police allowances.

“They misused tens of millions of kina allocated for police housing, resources and welfare. We also uncovered many cases of senior officers facilitating the theft of police land.”

Kramer said many of the country’s best police officers had retired or were dismissed “for trying to do the right thing”.

Kramer, the MP for Madang Open and sole member of the Allegiance Party he founded, came to parliament in 2017 on a declared platform of transparency and good governance.

He was instrumental in exposing a loans scandal involving Swiss bank UBS that ultimately ended the government of former prime minister Peter O’Neill.

O’Neill’s successor James Marape elevated Kramer to the police ministry in June last year.

Kramer said a little over a year in government had revealed the extent of PNG’s systemic corruption.

“Having spent time on the inside, I can see the extent of corruption in PNG. It is so deep-rooted and so entrenched in every aspect of politics and business that it is almost beyond comprehension, and appears never-ending.

“The country was, and is, on the verge of collapse. Given the extent of the damage, it will take five years just to stop it from sinking further. It will take a generation to turn it around.”

Kramer said the current government was working on sweeping reforms to the police force, “from the top down”.

He told the Guardian last year he expected to be killed for his efforts to reform corrupt institutions of state.

“I have no question of doubt I will eventually get killed for what I do,” he wrote in a Facebook post.

“It goes without saying when you get in the way of those stealing billions in public funds, they will do whatever it takes to get rid of you.”

A recent report funded by the Australian government through its PNG-Australia policing partnership argued the PNG police force was chronically underfunded.

It suggested that a one-off injection of K3.9bn (US$1.1bn) would address a lack of resources, training, and infrastructure.

The report also found PNG faces a severe shortage of police: a ratio of one officer to every 1,145 people, far from the UN’s recommended ratio of one officer for every 450 people.

Manning – installed by Kramer in 2019 as part of his reform of the service – said this month he would implement a “one strike and you’re out” policy for police corruption, violence, or disciplinary infractions.

“I will be the first commissioner of police to admit that there are criminal in uniform in the police force and I am committed to exposing and disposing of them.

"They have continuously displayed a total loss of basic moral values. They do not respect the law. They do not have any sense of duty, commitment or loyalty and act as if they are a law unto themselves. Their free rein ends now.”

This week Manning also ordered all police reservists to stand down, and hand in their uniforms, badges, and weapons because of widespread abuse of their powers.

Manning said regular police members were also abusing the system by not turning up to work because reservists could do their job for them.

In an address at Independence Hill in Port Moresby on Wednesday, the prime minister, James Marape, urged unity across PNG, asking its people to become “better citizens of this country” and to take back the country from the “hands of greed, corruption, complacency, laziness and recklessness”.

PNG’s government is under extreme budgetary pressure at present, having been devastated by Covid-19 lockdowns.

In a supplementary budget passed by the parliament, the government has cut spending by K2.3bn (US$640m), as well as extended its temporary borrowing facility with the Bank of PNG fivefold, from K300m (US$84m) to K1.5bn (US$418m).

John Greenshields | Adelaide

The comparisons are true and most depressing.

In 2017 we stopped our boat at Guasopa on Woodlark [Muyuy] Island with a sick crew member. The local aid post had a sign "No medicine, only Panadol".

The staff were hoping we had brought a consignment with us from Alotau. If we had only known, we would have.

In colonial times, there was a Health boat that made monthly trips around Milne Bay Province with essential government service officers on board.

I'm told that some years after Independence it became a "party boat", and the service was disbanded. Pity the poor, remote villagers.

Australia could assist such a service again, perhaps run by an NGO.

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