Rethinking how primary healthcare services are funded & delivered in rural PNG
CAIRNS – It was nearing dusk when we happened upon the two boys.
Relieved though I was to have found human habitation, I couldn't help observing that a shirtless boy at the front of the canoe likely had tuberculosis.
Having TB in these remote parts of the Western Province is not unusual Not is it unusual that he would have been receiving no treatment.
I was with a group of Western Province locals travelling by dinghy from Obo to Boboa in Lake Murray.
Instead of going the common route along the Strickland and Herbert rivers, some bright spark said he knew a shortcut from Obo through the back swamps to Lake Murray.
When we came across the boys in the canoe and their family it was not only getting dark, we were hopelessly lost a long way from home.
These were real bush people living a true hunter-gatherer lifestyle away from civilisation.
They regarded our predicament with some amusement. But with customary Papua New Guinean assistance to strangers, they guided us through the maze of swamps to a forest enclosed waterway, indicating that we follow it home.
By 10 o'clock that night we had made it to Boboa, and given the bright spark with navigating skills the title, Mr Shortcut.
Tuberculosis is a real tragedy in Papua New Guinea - and seemingly an intractable problem.
While both preventable and treatable, it has been able to proliferate in rural and remote settings rarely reached by health services.
It is safe to say that, unless solutions to enable more widespread healthcare coverage are developed, such situations of out-of-control disease will get worse.
People in villages only occasionally touched by health patrols are detached from regular monitoring of their disease, removed from regular treatment and compliance checking and often from follow-up treatment altogether.
This has resulted in the rise of drug resistant and multiple drug resistant strains of TB, the latter a devil to tame.
These are the symptoms and outcomes of a severely under-resourced health sector with limited capacity to monitor and follow-up patients.
It is no reflection upon the health workers themselves. In my experience they are capable and dedicated people who battle on even without sufficient tools and support to do the job.
Workers I have spoken to are embarrassed, despondent and even distressed by the situation. They understand the gravity of the issue but are generally powerless to do much about it.
Health managers are also hamstrung. They cannot rely upon receiving the quantities of medicines ordered, nor do they have the numbers of workers required to deliver the kind of service necessary to tackle TB and other endemic diseases.
TB is treatable with first-line drugs but time and again patients are forced into treatment ‘holidays’ because medicines run out.
Treatment plans thus interrupted lead to the greater proliferation of drug resistant and multiple-drug resistant strains.
The inability of successive PNG governments to allocate sufficient resources lies at the root of this crisis.
It is a situation that once again highlights the need to rethink the way primary healthcare services are funded and delivered in rural PNG.
By itself the top-down model of service delivery is unable to provide universal coverage or meet demand. We don’t have to keep doing it this way when we know the failed system will not work.
And any honest assessment of the contributing factors would question whether it realistically ever will work.
Either funding for health and health worker training is increased by a hitherto unimaginable order of magnitude or something else must be tried.
Since the former top-down model invokes only magical thinking, it is worth considering what else could be done.
It is apparent that where money is mobilised, private health services proliferate. Port Moresby and Lae are obvious examples.
This is not to suggest that private services hold the key in rural areas, but economic development and empowerment might.
Over the decades there has been a history of grower cooperatives in PNG, some of which have brought a measure of economic independence to remote rural communities.
The North Fly Rubber Growers Cooperative in PNG’s Western Province is an example.
Communities in the remote Middle Fly District, which is up to five days travel by canoe from the health centre at Obo on the Fly River, own family rubber blocks which are visited periodically by the cooperative’s ship, MV Kuku, to buy their cup lump rubber.
There are no roads and no airstrips in this remarkable region of the lushest swampland you could ever imagine. Its communities are scattered in villages and hamlets across thousands of square kilometres of flooded wetland.
If buying rubber from these communities is a commercial reality, then so is service delivery a possibility. The key is identifying a form of economic empowerment.
I believe the North Fly Rubber model offers a blueprint for similar efforts.
The challenge is to create economic empowerment requires three basic initiatives:
the availability of appropriate technologies, for example, in the case of Middle Fly a vessel and storage facilities
the storage and regular collection of produce (for example, semi-processed crops, fish, agricultural items)
their transportation for further processing or for sale as is
Thus income will be generated and, on the back of this, basic services can be delivered.
The boy in the photograph exemplifies the real situation in those many parts of PNG health services will never reach.
In this case, however, the community was served by North Fly Rubber's ship, MV Kuku, which made regular runs to Lake Murray to buy cup lump rubber.
The admirable Warren Dutton, entrepreneur and onetime member of parliament, was somewhat averse to imposing a financial impost through a surcharge on his growers to support health services.
"That is the responsibility of government and the mining company," he said quite reasonably. But I saw the potential to bring services to remote settings using this model, and could not see any other practical way to deliver such services.
What Dutton has achieved since he planted his first rubber tree in Lake Murray in 1967 is truly phenomenal.
Today there are 7,000 family rubber blocks scattered across Middle and South Fly districts and the Kuku, owned by Progress Shipping, continues to service those communities.
An organisation I’m associated with is on the cusp of rolling out a similar model in Milne Bay based on supplying solar power freezers to remote fishing communities.
We will collect and freeze seafood and on-sell it to Alotau and Port Moresby.
When the project reaches scale, it will pay the transport costs to take health teams to these settings.
Every setting is different and has its own potential solutions.
For the people of the Western Province, this model is worth considering and I believe that, with careful planning, community consultation and community participation, it has considerable economic capacity.
At the time of writing plans to implement this model across scattered communities in the maritime province of Milne Bay are close to implementation.
The goal is straight forward: use solar powered technology to facilitate economic activity where presently there is none.
At the apex of effective regional economies there is a union of marketable produce and collection and marketing mechanisms replete with short-term storage capabilities.
The usual apportionment of surpluses to profit and reinvestment are required, of course, but some of the income generated should also be applied to support community-based services.
In the case of Western Province these would include health workers operating scheduled outreach patrols.
At economies of scale, this approach has the potential to enable people in remote settings to play an active part in facilitating the delivery of the services they need.
It will also enable government health (and other) workers to reach settings presently beyond their reach.