PNG Health Sector

Health Service Delivery through Partnerships: Outcomes and Issues including plans for addressing

the Ageing Health Workforce

Mr Pascoe Kase, Secretary Department of Health

19th October, 2016

Overview of “Partnerships” in Health

NDoH is part of the “Brain” of the Health system providing

policy, governance and stewardship

The “Eyes” are represented by the Church, which sees and recognizes the health situation

of our population

The “Nose” represents the private sector and industry, which provide

valuable support services

The “Mouth” represents the government, which has the power to speak for the

Population’s needs

The “Ears” represent the NGOs, who sense the needs of the people and

help them in both rural/remote and urban areas

National Health Plan “KRA.2: “Strengthen Partnerships and

Coordination with Stakeholders”

Establish Public-Private Partnerships (PPPs).

Expand Partnerships with churches, private healthcare providers, and NGOs in rural & remote areas and urban settlements.

Enhance communications, cooperation and reporting with central government agencies and other sectoral departments such as Finance, Treasury, Planning, and Provincial & Local Governments.

Working Collaboratively with all stakeholders to expand the reach of quality health services, through engaging with local community-based organisations.

Coordinate and monitor implementation of National Health Policy, through operating and maintaining a single National Health Information System, and requiring all stakeholders receiving GoPNG or Health Development Partner funding, to provide annual reports and future programming information.

Ensure all stakeholders develop and build service delivery infrastructure in accordance with the National Health Service Standards.

“Health Sector 2014 Partnership Policy” provides for:

Support to the implementation of the National Health Plan 2011-2020 through: Improving and strengthening partnerships that provide affordable, accessible, acceptable,

and responsive to needs, quality healthcare services, effective health systems development, and good governance at all health sector levels.

Ensuring Partners shall:

Comply with the requirements of the “Free Primary Health Care and Subsidized Specialized Health Services Policy” of the government

Acknowledge the “stewardship” role of the NDoH to lead and coordinate partnership

agreements with all stakeholders delivering health services in the country Align their programs and support for government priorities and assist with

strengthening government systems and processes

Health Partner : “Churches”

The most important Health service provider in PNG outside of the government, due to their size and focus on the rural majority of the population, providing approximately 60% of rural and remote healthcare services across the country.

Partnership built on a tow-tier system:

At central level, the partnership between NDoH and the Churches Medical Council (CMC)

At provincial level (and to some extent at the districts level) the partnership between public authorities and the provincial level church authorities

These partnerships at their core, agreement on:

How to achieve universal coverage for particular populations based in specific geographical areas

An operational focus, where health services delivery, supervision, and other functions are planned in a coherent way, taking into account existing activities, staffing and funding available.

Health Partner : “Extractive & Agriculture Industries”

The extractive and agriculture industries are increasing their role in health service provision, particularly in rural and remote areas.

Partnership built on supporting the health system:

In areas where the government struggles to provide services

Through projects such as “Rural Enclaves” where industry activities are integrated with local service provision

Recent experience has raised serious issues with these partnerships regarding:

Sustainability of these services once the extraction industry activity ceases

The need for a more suitable and sustainable financing model

Ensuring that health services provided by these industries are accessible to the local population, irrespective of whether they are directly employed by the particular industry

Health Partner : “Non-Government Organisations (NGOs)”

Within the NGO sector in PNG, there are a handful of national and international NGOs making significant contributions to health service strengthening.

The current Partnership arrangements within the NGO sector are:

Often built on an “ad-hoc” basis and mainly driven by short to medium term objectives

And where neither the cost of the services or the outcomes are rigorously defined

• Civil society (voluntary) groups and institutions are rapidly growing and flourishing in PNG, where local-level groups and associations are organising themselves in pursuit of governance, development and local-community related activities and objective

• These partnerships need strengthening which:

Are similar to the two-tiered approach with Church Partners, at both the central and provincial levels

Are well researched and create agreements that clearly define the services that are paid for, as well as the complete cost of services provided

Health Partner : “Private For-Profit Sector Providers”

The private for-profit health service sector is small but expanding rapidly and there is value in the government entering into partnership arrangements with it, considering that the government already has an obligatory role to regulate and provide licences.

The government and the private sector working in partnership have the potential to positively shape the development of the healthcare services delivery, once this sector has grown over a certain threshold and will have an impact on the overall health system.

These partnerships require effective engagement because:

There are limits to the State’s regulatory role, due to the fact that it was unable to provide effective rules and mechanisms for integrating the private sector into the Health system.

There is no obligation for gaining private for-profit providers’ commitment to follow national health service standards and to pursue public health priorities and objectives.

“Public Private Partnerships” (PPPs)

for health Infrastructure Developments PPPs may be of benefit to the PNG Health sector, particularly if the infrastructure

developments concerned support the government’s intention to deliver services to the rural majority of the population.

PPPs in health are a high-cost option and their long term impact on resources available to deliver health services relevant to the needs of the population has to be carefully considered. Currently considering PPPs for urban hospital infrastructure.

The “Risks” associated with PPPs is:

They “invert” the planning process; that is, the infrastructure will determine the shape and outcomes of the health system in terms of future resourcing.

They may, if projects are not carefully planned inside the health planning process, lead to situations where the cost of projects can impose constraints on spending that will make it impossible to achieve the National Health Plan.

They may create situations where there is a government subsidy to the more prosperous and already better-serviced urban populations at the expense of rural and remote health services delivery.

Wider Health System “Barriers”

to Partnerships Fundamental to effective partnerships are their funding arrangements:

PNG spends significantly less per capita on health services than nearby island states, such as Solomon Islands and Vanuatu.

Real per capita health spending has until very recently been on a declining trend.

NEFC data indicates that the Health sector only receives 31% of the total funding required to deliver the estimated cost of a core level of health services.

PNG Health system funding mechanisms are extremely complicated, are under the control of multiple decision-makers, and are in a continuing state of flux.

Disbursing and allocating resources in the PNG Health system is not easy and several “bottlenecks” exist.

There is limited absorptive capacity when funding is made available due to often late releases of quarterly funding transfers and limited timeframes for spending.

Wider Health System Activity that

will “Strengthen” Partnerships NDoH has a number of very significant projects underway that are relevant to the

further strengthening of health systems in general and partnerships in particular. Some of these arrangements include:

Establishment of Provincial Health Authorities (PHAs) within all provinces of the country, which will streamline the provincial and national government’s activities in health. So far 11 PHAs have been declared/established, with the remaining 10 provinces due for implementation before the end of 2018.

PHAs Boards of Governance are required to establish “Partnership Committees” and develop partnership agreements with all stakeholders providing health services within the province.

Improvements to the supply and distribution of medical supplies, drugs and equipment through the implementation of a new automated M-supply system.

Improvements to health workforce capacities and capabilities through implementation of the Health Workforce Enhancement Plan, to address numbers, training and future staff planning needs.

Dealing with an Ageing Health Workforce

Human Resources are the most important asset within Health Sector.

Without appropriately trained, skilled, motivated and adequate health workers, health services cannot be delivered effectively.

Healthcare workers (Doctors, Nurses, Allied Health & Administrative) are an “ageing” workforce.

The Health Sector not only requires new health workers to replace those leaving the workforce, but must also include additional health workers to fill the ever-increasing demand for health services, resulting from the country’s fast growing population.

Dealing with an Ageing Health Workforce

- “Past” Situation The PNG Health workforce is typified by:

- inadequate in numbers within all Cadres (medical officers, nursing, allied health).

- a poor mix of skills and demographic imbalances.

- inadequately led, managed and supervised.

- a large percentage of ageing health workers.

These issues stem from past years of neglect for the Sector, including:

Insufficient funding for new graduates, to cover increasing population levels.

Lack of sufficient “in-service” and “staff development” training & career-development.

Inflexible work arrangements and “incentives” for health workers to remain in the system.

Dealing with an Ageing Health Workforce

- “Current” Situation Data Collection & Analysis:

of the current healthcare workforce and needs of the future, given population trends and new future workplace skills required (eg: cancer and heart specialists, rural doctors, etc)

Strategy Development & Execution:

GoPNG approved increasing the compulsory retirement age from 60 to 65 years.

implementation of an overarching long-term (30 year) workforce plan, in line with PNG Development Strategic Plan-2030, which addresses:

Recruitment, Training, Incentives & Retention for all Cadres of health workers;

Skills Mix & Workload Distributions to match high need areas, particularly in rural & remote areas;

Streamlining & Integrating structures within new Provincial Health Authorities (PHAs).

Dealing with an Ageing Health Workforce

- “Current” Situation (continued)

Enhanced Support Mechanisms, including:

Seeking ongoing (baseline) Health Sector funding to meet “minimum” requirements for staffing, medical supplies, equipment & facilities as outlined within the National Health Service Standards.

Improving Health Workforce Productivity, through:

Elimination of unnecessary work practices and re-engineering & automating systems to eliminate “time lost”.

Increasing use of advanced technology and labour-saving devices (eg: hand-held tablets for medical records, etc.).

Looking at creative/innovative ways to deliver future health services (eg: Nurse Practitioners)

Reducing absenteeism and assignment of non-clinical duties to other categories of staff.

Improved Monitoring & Evaluation: the ability to maintain the effective implementation of the Long-term workforce Plan

Dealing with an Ageing Health Workforce

- “Possible New Approaches” Possible new approaches, include:

Increasing employment of younger health workers (both skilled and semi-skilled).

Outsourcing some work to International Labour Markets to recruit international health staff Health (Doctors & Nurses) who can fill short-term gaps, until national health staff capacity developed.

Increasing reliance on use of automation and advanced technology for supporting the delivery of healthcare services (eg: Tablets for Medical Data/Records).

Increasing focus on “Disease Prevention” and “Health Promotion” with an emphasis on well-being programmes.

Delaying the retirement of older health workers and retaining them on more flexible work arrangements, eg: part-time 2-3 days per week, job-sharing with another person, etc.

Significantly increasing use of alternative health service delivery models, using senior Nurses more effectively, eg: as “Nurse Practitioners”, “Regional Health Call Centres”, etc.

Dealing with an Ageing Health Workforce

- “A new type of Health Worker will be required” Alongside of professional qualifications, other skills and qualities will be required, including ones

with:

Good Computer skills.

Good Interpersonal Skills, with a Caring & Empathetic nature.

Effective Time Management Skills.

Understanding the requirements for “Patient Confidentiality”.

Being able to deal with problems in a Calm & Effective manner (ie: not being reactive).

An ability to ask for help and guidelines when needed.

An ability to work effectively in Teams.

Being committed to ongoing Professional Development & Continuous Improvement of the Health system.

PNG Health Sector

Health Service Delivery through Partnerships: Outcomes and Issues including plans for addressing the Ageing Health Workforce