|Project Rationale and Linkage to Country/Regional Strategy
The government's long-term Vision 2050; Development Strategic Plan, 2010-2030; and Medium Term Development Plan, 2011-2015 aim to transform PNG's health system to achieve the Millennium Development Goals for health and improve PNG's ranking in the human development index. In support of the government's approach and in line with ADB' operational plan for health, ADB's country partnership strategy for PNG, 2011-2015, which recognizes issues of fragility in PNG, includes health as a priority area.
The health status of the population of PNG has deteriorated since 1980s with severe neglect of the health system, especially in rural areas, where 87% of the population lives. An estimated 40% of rural health facilities have closed or are not fully functioning. Limited resources, deteriorating infrastructure, poorly trained staff, and inadequate and declining access to basic health services are among the main reasons for the decline.
The country has widespread poverty and weak health indicators, particularly for maternal and child health. The infant mortality rate is 57 per 1,000 live births and the maternal mortality rate is 733 per 100,000 live births. The main health problems continue to be communicable diseases, with malaria, tuberculosis, diarrheal diseases, and acute respiratory disease being the major causes of morbidity and mortality. PNG has a generalized HIV epidemic, driven predominantly by heterosexual intercourse. The epidemiological profile of PNG, with a heavy burden of communicable disease, indicates that significant gains in health outcomes could be achieved with simple and effective interventions focused on PHC and health promotion. While some hospital services (e.g., for maternal complications) are essential, more than 80% of health problems can be addressed adequately and at lower cost through the effective delivery of PHC. The current poor health status of the rural population points to a weak PHC system that lacks outreach services such as for child immunization and providing women with the basic support required for safe delivery.
Provinces and districts are responsible for delivering health care services through hospitals, health centers, health subcenters, community health post (CHP), and aid posts. The 1998 Organic Law on provincial and local-level governments significantly decentralized responsibility for delivering health care services to the provinces and districts. However, the law did not adequately address how to implement the changes. In the health sector, only operational responsibilities have been devolved, while capital investments remain centralized in the public investment program. Provinces are allocated a percentage of net government revenue through staffing and health sector functional grants, which cover operational costs but not capital investment costs. Resources, authority, and competency are thus poorly aligned with decentralized responsibility.
To overcome this misalignment, three provinces have so far exercised the option outlined in the 2007 Provincial Health Authorities Act to establish their own provincial health authorities. In addition, the government, recognizing that it needs to prioritize health service delivery in districts and communities, has recently developed the concept of the CHP in 2010. CHPs will provide services at the outer perimeter of the health system. Over time, the government will transform existing aid posts and health sub-centers into a service able to meet the requirements of the National Health Plan (NHP) 2011-2020.
ADB has provided support for the PNG health sector since the 1980s. The completed Health Sector Development Program10 established the Health Sector Improvement Program (HSIP) trust account in 1998, which became a major mechanism for administering extended development assistance to the health sector.
The HIV/AIDS Prevention and Control in Rural Development Enclaves Project has successfully built innovative partnerships with non-state service providers to improve rural PHC service delivery. Under that project, local health authorities in eight provinces established partnerships with six large private companies to improve more than 100 rural health facilities and trained health workers and communities in preventing HIV/AIDS transmission, significantly increasing the number of PHC beneficiaries in project areas.
Building on the lessons and experience of the existing project, the proposed project will support the government in implementing NHP, as it relates to rural health. The project will establish and develop partnerships between state and other health care service providers, including the private sector, churches, nongovernment organizations, and civil society, working at the provincial and district level to strengthen the rural PHC system.
By working through the envisioned partnerships, the project will build human resource capacity in the health sector, improve health information and monitoring systems, and revitalize rural health facilities to strengthen the existing rural PHC system in PNG. The project will expand the coverage and improve the quality of PHC services for the rural population by strengthening the rural health system at the provincial and district level.
The project will be implemented under the sector-wide approach currently in place for the health sector. To avoid replicating government functions, the project will use government systems whenever possible, and the government will be responsible for all facility recurrent costs. The project will focus on infrastructure and training that can help the government deliver health services more efficiently and effectively, building on the strengths of existing health institutions run by the government and others.