AUTONOMOUS BOUGAINVILLE GOVERNMENT
The
Bougainville
Plan for Health
2012 to 2030
Draft 28 April 2012. This draft has been prepared based on the deliberations of a technical working
group of senior Bougainville health personnel and discussions with stakeholders in the ABG health
system.
Contents
Message from the Vice President.......................................................................................... 2
Overview ............................................................................................................................... 3
Priorities ................................................................................................................................ 5
Demography ......................................................................................................................... 6
Health trends ........................................................................................................................ 7
Strategies.............................................................................................................................. 9
Health sector human and financial resources ...................................................................... 10
Timeline .............................................................................................................................. 15
Risks ................................................................................................................................... 19
Governance and management ............................................................................................ 19
Next steps ........................................................................................................................... 20
Appendix 1: Values that underpin the work of the ARB health sector .................................. 21
Appendix 2: Accountability and teamwork statement by health sector leaders .................... 22
Appendix 3: Strategies in detail ........................................................................................... 23
Appendix 4: Performance and trends .................................................................................. 35
Appendix 5: Measuring Progress ........................................................................................ 42
Appendix 6: Linkages between relevant global, national and ARB planning documents...... 43
Appendix 7: Indicators and targets from planning documents ............................................. 45
Appendix 8: Traditional medicine in Bougainville................................................................. 46
Appendix 9: Cost and financing scenarios........................................................................... 48
Appendix 10: Draft timetable of significant events ............................................................... 64
Appendix 11: Prioritisation and sequencing......................................................................... 67
Appendix 12: Technical advisory group for this plan........................................................... 68
1
Message from the Vice President
Too be completed once the VP has reviewed the document.
2
Overview
This is the plan for health in Bougainville for the next 18 years. It will guide our health
services through a period of rapid change; political, economic, environmental and social.
This plan aims for all People of Bougainville to live a long and healthy life. Mamong for
Health expresses the concept of women being central to achieving improvements in health.
(‘Mamong’ means females of all ages in the language of the Tinputz District). ‘Women at the
centre of health development’ is part of ARB’s vision for health and a key factor in improving
the health of the whole population. The role of women, as both the main users of health
services and providers of care within families, is recognized and valued. Empowering
women and improving health literacy among women will enable them to care for both
themselves and others and will lead to better health for all; men, women and children.
In this plan we commit to important goals in the short term – the reduction in deaths of
women in childbirth, the rebuilding of our rural health and hospital buildings, the
development of our health workforce. In the longer term we intend to tackle the health
needs of our children, and drive out the scourge of preventable diseases and malaria. We
will also reconnect with the old ways in the effective use of herbal medicines.
We also need to prepare to meet new challenges. We will face some as yet unknown
diseases, while some conditions will become more important. For example, non
communicable diseases. These are a consequence of increased use and misuse of alcohol
and tobacco coupled with the worse aspects of the modern diet that has too much fat, sugar
and salt. The response to these needs to involve other sectors, working across different
parts of government to achieve a healthier society.
To drive this plan forward we will create the Bougainville Health Authority that will combine
the current Health Division and the Buka Hospital services. This authority will work in close
partnership with the churches, the NGOs, and the private sector in the provision of services.
Executing this plan will face a number of challenges. We will meet these though the
continued commitment of the health workforce, and the ongoing support of our donor
partners and the GoPNG.
In the following diagram, we show the vision is empowered by the Upe, from our flag and our
constitution. The strategies are displayed on the Biruka, the protective and cooling fan
women use. The strategies are driven by the commitment of the sector to core values of
Accountability, Teamwork, People focus, Equity and Quality.
3
4
Priorities
These are the four priorities for the next three years.
Maternal health
Consistent with our commitment to putting women at the centre, the first priority we have is
to improve maternal health for the women of Bougainville. We are already close to achieving
the expectations of the Millennium Development Goal to reduce maternal mortality. With a
committed effort from the sector we will achieve this goal. Success in this area will help build
the momentum for health so that we can tackle other goals in this plan.
Rebuilding the health system infrastructure
The Autonomous Region of Bougainville (ARB) health care infrastructure was partially
destroyed during the crisis, and it is our intention to bring it back to strength. Beginning with
the rural infrastructure, we will progressively rebuild our health facilities, so that all our
population has access to quality health services. This rebuild will first focus on rural health
facilities, followed by a CHW training schools, then hospital facilities in Central and South
region.
Developing and growing the health workforce
The workforce is the fundamental building block for improved health delivery. This plan
makes a priority of increased training and development support for the current workforce, as
well as developing the workforce for the future.
These three priorities cannot wait for the ideal structures to be put in place. Taskforces will
be formed to progress these issues, led by senior people from the sector. These taskforces
will be made up from the different parts of the sector – not just government. The focus will be
on achieving the required results within a specified budget and timeline.
Forming the Bougainville Health Authority
This will combine the Buka Hospital and the rural health services into a single organisation. It
will make all the health service directly accountable to the ABG. It will also enable better use
of scarce existing capacity (eg in HR, medical officers, training) across the Autonomous
Bougainville Government (ABG) health system rather than being confined to a particular
institution.
5
Demography
Demography
The population in Bougainville has grown by 2.6% per cent a year for the last decade. This
means that between 2000 and 2010 the population increased by 60,000. Even if this trend is
partially arrested, we can expect the population to reach 350,000 by 2030. Population
growth depends on fertility, mortality and migration. Improved family planning reduces fertility
and population growth. Infant survival decreases mortality while an ageing population and
NCDs increase mortality. Migration is likely to increasingly play a role in ARB’s population,
and depends on economic and security conditions in ARB and surrounding areas that are
accessible to the Bougainville people. In the table below, we have assumed the rate of
growth will slow to 2.3% (the current average for the Islands region) until 2020, then to 2.0%
for the period 2020 to 2030.
400000
ARB Population trend and projection
350000
300000
250000
Census
200000
Predicted
150000
100000
50000
0
1980
1990
2000
2011
2020
2030
6
Health trends
This plan for health will focus on three long term outcomes:

Maternal health

Infant and child health

A long and healthy life for all Bougainvilleans.
The National Department of Health indicators show ARB as the sixth-best performing
province in PNG, although ARB’s performance dropped in 2010. The performance for 2011,
however, shows there are distinct improvements in ARB’s indicators over the last year. The
North Region has a higher level of performance on most indicators than the South and
Central. This is a major focus of this plan – making a priority of improving service provision in
the Central and South Region, while maintaining improvements in the North.
This plan needs to lift the performance of ARB, by more closely focusing on performance at
all levels and facilities. In many instances the knowledge on how to improve performance
already exists within ARB. The information from high-performers can be used by other health
facilities, districts and regions to lift their performance.
Take, for instance, births in health facilities:
Percentage of births in health facilities: 2006-2011
100%
80%
NATIONAL
60%
KIETA - CENTRAL
BUKA - NORTH
40%
BUIN - SOUTH
20%
ARB
0%
2006
2007
2008
2009
2010
2011
The health plan intends to train health workers undertaking deliveries and to develop the
Arawa and Buin hospitals. This should result in an increase in births in facilities in Central
and South, reduced travelling times for obstetric emergencies and fewer maternal deaths.
7
The result these developments will aim for is that 80% of women in all three regions will give
birth in health facilities under a health worker with training in obstetric care.
Another part of reducing maternal mortality is family planning. Over the last three years, the
North Region has made a dramatic improvement in its family planning services.
Couple years protection / 1000 WRA, 2006-2010
200
150
NATIONAL
KIETA - CENTRAL
100
BUKA - NORTH
BUIN - SOUTH
ARB
50
0
2006
2007
2008
2009
2010
2011
From 2008 till the present they have provided one fifth of women of reproductive age with
contraception. This has resulted in fewer maternal deaths, fewer deliveries and improved
child health. The challenge is for this success to be sustained, and for the Central and South
Region to achieve the same level of performance. If that happens, the predictions of
population growth in this plan would need to be revised downwards and many of the goals
will be achieved earlier.
The strategies outlined in this plan need to be continuously linked to improved performance
against the health indicators. For example, if a facility is improved, or a training course is
conducted, these developments should demonstrate improved performance. The
appendixes discuss the current performance of health facilities across a range of indicators.
8
Strategies
Strengthen health
systems and
governance
Strengthen
partnership and
coordination
Improve service
delivery
Improve child
survival
Good health
• Improve financial resources and management
• Medical supply
• Information and ICT
• Independent planning and monitoring mechanism
• Collaborate with partners.
• Negotiate health improvements with extractive industries
• Increase access to quality health services
• Strengthen the infrastructure
• Health workforce strengthening
• Access to traditional herbal medicine
• Immunisation coverage
• IMCI
• Reduce deaths of neonates
• Reduce malnutrition
Long life
Women at
centre
Improve maternal
health
Reduce
communicable
diseases
• Family planning
• Safe supervised deliveries
• Improved emergency obstrtetric care
• Sexual and reproductive health
• Malaria and TB control
• STI and HIV prevention, care and treatment
• Increase monitoring and surveillance
Prepare for disease
outbreaks and new
population health
issues
• Identify, monitor and report on urgent and emerging threats
• Establish a public health laboratory function
• Addresss the needs of climate change refugees
• Respond to the health challenges of resource extraction
Healthier lifestyles
• Improved prevention and treatment of injuries
• Reduce food and water borne diseases
• Improve housing
• Reduce NCD deaths and illness
Autonomous
Bougainville
health system
• Draw down powers
• Develop a Bougainville Health Authority
• Implement the Bougainville Plan for Health
9
Health sector human and financial resources
Human resources
Health services primarily rely on skilled health workers. Health system performance depends
to a large extent on the skills, training and commitment of the health workforce and their
accessibility by the population.
The current ARB health workforce has approximately 520 people, divided between the ABG
rural health sector (190) the churches (170) and Buka Hospital (117).
The geographic distribution of skilled health workers is uneven, largely concentrated on the
North Region because that is where Buka Hospital is.
Buka General Hospital staff by cadres, 2012
Corporate Services and CEO
Nursing Services
Medical Services
0
20
40
60
80
100
10
The rural health workforce however is well distributed.
The regional distribution of rural health workforce by cadres, 20111
120
HW/Population Ratio
100
(2008)
North
80
828
Central 861
60
South
Central
South 680
North
40
20
0
CHWs
N/O
HEO
M/Os
EHOs
Source: ABG. Building on the Bougainville Strategic Implementation Plan 2011
To meet the requirements of this plan, the health workforce needs to:

increase to keep up with population growth

replace itself as workers retire

increase the skill level of both the current and future health workers.

Increase in the central and south regions
Retraining the large group of workers who had restricted opportunity due to the crisis is an
early priority. In addition, the plan intends to make the most skilled workers, (doctors,
midwives, nurses) more accessible to the rural population, particularly in the Central and
South Region.
As a consequence of the crisis, the health worker training institutions have been lost. The
priority is to re-establish the community health worker (CHW) training school, at the same
time work with existing PNG training institutions to ensure future workforce requirements are
met.
1
These figures need to be updated with 2011 census figures.
11
A taskforce made up of Buka Hospital, the Rural Health Division and the churches will lead
the development of this area to meet the plan’s requirements. The work of the taskforce
includes:

Overcoming immediate under-staffing and up skilling problems through undertaking a
training needs assessment and up-skilling crisis trained workers and up-skilling all
workers involved in maternity care.

Establishing a sustainable pipeline of skilled health workers (HW) for the future by
working with PNG training providers, seeking scholarships, and securing placements
with existing providers for ARB trainees.

Developing ARB’s own training capacity for CHWs and nursing officers and
midwives, beginning with a CHW training school.

Increasing the productivity of current health workforce by measuring and discussing
each facility’s performance, increasing supervision, developing incentives and
performance appraisals.

Establishing a cross-organisational health human resources (HR) information
system.
Financial resources
Currently most of the money coming into the ARB health sector comes from the government
of PNG (GoPNG), with smaller contributions by donors and the ABG government (see table
below). The level of spending is about the bare minimum required to effectively run a health
service, and well below what neighbouring countries are spending on health.
Components of Estimated Recurrent
Health Expenditure ABG 2012
30
100%
25
77.28%
20
Expenditure
15
2012 Kina (Mill)
10
5
17.80%
4.92%
0
ABG
Donors
GoPNG
Total
12
This plan assumes that by 2030 ARB health spending will reach the current average
expenditure on health for Melanesia, which is double the current ARB expenditure, or an
annual real increase of 6%.
Melanesian comparisons – per capita government health expenditure US$2
Comparison of Government Sourced
Health Expenditures Per Capita Melanesian Countries and ABG
160
140
120
Per capita 100
Expenditure 80
US$
60
40
20
0
131
100
143
108
58.59
35
PNG
ABG
Solomons
Fiji
Kiribati
Vanuatu
If expenditure only just keeps up with inflation (6.1%) and population growth (2.3%) then it
will be impossible to staff and run the additional services and facilities outlined in this plan.
Resources would have to be taken from an existing part of the health sector.
The big challenge in financing this plan will come between 2015 and 2020 as a
consequence of changes made as a result of the referendum. If the referendum decision
leads to financial independence from PNG, then there is likely to be a lag period before ABG
is able to generate enough of its own revenue to replace the current GoPNG contribution to
health.
2
National Health Expenditure Indicators WHO 2010. Note: General government health expenditures,
as given by WHO, include capital expenditures and are collected from national health accounts, when
available, and other government sources. Refer to WHO website:
http://www.who.int/healthinfo/statistics/indhealthexpenditure/en/index.html Accessed 30 April 2012.
13
Bringing ABG health expenditure up to US$120 per capita by 2030 on a steady basis
with a 5.92% real increase per year (before inflation)
Possible Government Health Expenditure Trends in
AGB to Reach Target Levels
US$120 per capita by
100
80
Total Government
60
Sourced
Expenditure 2012
40
Kina (Millions)
20
2030
Likely Funding Gap
period
ABG
US$100 per capita by
2025
GoPNG
Total
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
0
The financing of this plan requires a commitment by all partners: the government of PNG,
ABG, donor partners and development banks to a funding pathway as indicated above.
In addition, the different funding mechanisms need to be brought together so that the
Bougainville health system can make optimal and efficient use of the funds. There is not the
management capacity to deal with multiple funders and multiple accountability and reporting
lines.
14
Timeline
2015
ARB achieves MDG 5?
2020
ARB achieves MDG4 ?
2013
ARB achieves 95%
Immunisation coverage
Health Goals
2030
ARB Eliminates Malaria
Life expectancy 75
2017
ARB achieves Universal Coverage ?
2014
Population growth slows to
Xxxx births per year
2013
2014
2015
2016
2012
2017
2018
2019
2020
2021
2022
2023
2024
2025
2019
Arawa Hospital re-built
2012
STI clinics Arawa and Buin
2014
Access to free care
And full immunisation
through DHFF rollout.
2026
2027
2028
2029
2027
Provincial Hospital Upgade
2030
2030
2019
2023
Rural Hospital development (2)
Nursing school established
2015
Rural Health
Infrastructure
rejuvenated
Building Blocks
2018
CHW training school completed
5/1/2012
Timeline – Building blocks and goals
15
Buildings, timing and financing
The changing shape of the ARB health sector
2012
2030
Referrals to other
hospitals
Referrals to other hospitals
reduced
Buka (District)
Hospital
Buka Hospital — enhanced
specialist capacity
Health centres and
sub health centres
Arawa, Buin, Tanamalo, Moratona
District and Rural Hospitals
Aid posts
Health centres and community
health posts accessible to all
BHCP in 300
villages
BHCP in all villages. Herbal
medicines integrated
The crisis has left the ARB health sector with a depleted healthcare infrastructure, as a
consequence of the destruction of key facilities such as Arawa Hospital. A key focus of the
plan is to rebuild this infrastructure over the next 10 years.
This rebuilding will take a different shape to the current health infrastructure. Changes in
communication and transport systems, including roads and bridges, make a big difference to
the way people use health services. The redevelopment of the roading system will mean
people travel to health facilities more easily. This means there will be a need for fewer
facilities, but they will have far greater capacity.
In addition, what is being expected of a health facility has changed. In order to meet the
aspirations of this plan, health facilities need to be offering a higher level of skill and a wider
range of services than is seen currently. The future will see fewer aid posts, and the
development of community health posts with a minimum of three staff. There will be fewer in16
patient facilities in health centres and community health posts – most people requiring more
than a short stay as an inpatient will travel to the hospitals.
Effective transport arrangements between the facilities will be an important part of the health
system.
The plan has indicated a number of buildings that are required for the ABG health sector.
The timing of the building developments depends on the availability of financial and staff
resources to sustain a facility once it is built.
As the table below indicates, some of these are already planned and funded – others will
require further development of a business case to resolve issues of location, size, cost and
staffing.
17
ARB health infrastructure plan
Facility
Start
Finish
Comments
Capital cost
STI Clinics (2)
2012
2012
At Buin and Arawa
AusAID project
funded and
currently
underway
Rural health
service delivery
& rural health
infrastructure
upgrade
2012
2016?
Covers South and
Central Region
ADB/AusAID/
and other
donors. K20m
over 5 years
? 20
?K1m
North
No funding
identified
? 10
? K0.5m
Rural health
service delivery
& rural health
infrastructure
upgrade
Additional Recurrent
staff
costs.
CHW training
school
establishment
?2013
?2016
Increased
availability of
CHWs
K 10m
Arawa District
Hospital
development
?2018
?2020
New/rebuilt
district hospital
K25m
60
?K5m
Rural hospital
development
Tanamalo,
Moratona
?2020
?2019
K20m
?20
? K2m
Buin Hospital
development
?2016
?2021
?K10m
?15
?2.2m
Development
of Buka
Hospital as
provincial
hospital
2022
20222029
K120m
?
? K20m
Nursing school
development
2023?
2030
Children’s
hospital
development
Currently MSF
supporting this
service at K2.2m
per year till 2016
Currently
met by
GoPNG
Post
2030
A full list of sector developments is in Appendix 10.
18
Risks
The Health Plan identifies the risks inherent in health development and also the mitigating
factors.
Risk
Financial resources for health well below
predictions
Financial resources to ARB government well below
that required to sustain health services
Mitigation
Seek agreement on Financial envelope from
GoPNG, ABG, Donors prior to committing to
plan.
Reduce scope of plan to fit available
resources.
Continued instability, restricting access to parts of
ARB, staff insecure.
Decentralise (DHFF) to support local level
activity even when access is difficult.
Instability in PNG government and interruption of
resource flows
Work with Donors to achieve uninterrupted
funding flows. Ensure neutrality of facilities
and personnel.
Increase rate of ABG financial self reliance.
Change in donor policies reducing donor support
Trained Health workers migrate to other countries.
Implementation failure of major priorities
Introduce package of measure to make ARB
attractive for Health workers.
Establishing a project management function
to drive priorities.
Governance and management
The plan is to develop a single ABG health organisation, the Bougainville Health Authority.
This will have a board, and be solely answerable to the ABG through the Minister of Health
(unlike provincial health authorities in other provinces who are answerable to both the
Minister of Health of GoPNG and the Governor).
In order to kick-start the priorities in this plan, three cross-sectoral taskforces will be formed.
They will form part of the executive team of the Division of Health, and their work will be
facilitated by project management and accountancy support.
It is envisaged that these task forces will be in place for a limited time of 3 -4 years. They
would be resourced to get the job done and make sure the services are able to sustain the
work once each taskforce finishes.
19
Next steps
1. The draft plan is reviewed and adjusted by ABG.
2. The plan is finalised and endorsed by ABG.
3. The accountability and teamwork statement formally ratified by the health sector
leaders.
4. ABG commits to support the plan with 15% of ABG revenue and GoPNG
development grant till 2016.
5. The ABG plan for 6% real growth (after inflation adjustments) per annum in financing
2015 to 2030.
6.
The plan is presented to a donor summit and support sought from donors in three
areas:

Commitment to extend existing donor support levels to complete rebuilding of
the health infrastructure

Assistance with bridging finance 2015-2020 in the event of post referendum
financial separation from the GoPNG.

Donor coordination and resource pooling to reduce complexity and align
donor support with the plan.
7. Establishment of Independent advisory group reporting to the Minister of Health to
monitor the roll out of the plan.
8. Establishment of three cross-sectoral taskforces (Maternal health, Facilities, Health
human resources).
9. Establishment of the Bougainville Health Authority
20
Appendix 1: Values that underpin the work of the ARB health
sector
Accountability – The health sector and service providers are accountable to both the
Minister of Health and the communities they serve. Staff shall demonstrate commitment to
the highest ethical standards in all aspects of their work. There should be transparency in
the use of funds and allocation of resources for health.
This plan includes an accountability statement. The leaders of the PNG health sector commit
to this statement and will be held accountable for the sector’s performance.
People focus – Health services will be people-focused, empowering individuals to take
ownership for their own health and to become self-reliant. Health literacy will be promoted at
every opportunity and for all ages. Decisions taken in the health sector will have a peoplefocus at their core and will determine how proposals impact on the health of the people.
Quality – Health services will meet standards and will have skilled professional staff,
adequate medical supplies and equipment appropriate for the level of care provided. The
health sector will strive for excellence, reflect on past performance and apply the wisdom
gained to continuously improve.
Teamwork – Within the health sector and between the health sector and other sectors,
partnerships, networking and teamwork will be promoted to achieve coordinated and
cohesive delivery of services. Teamwork applies across different parts of the sector
(community, primary, secondary, tertiary, public health) and across different health
organizations (hospital, rural health, churches etc.).
Equity – Health is a basic human right that is fundamental to quality of life and a core
commitment made in the ARB constitution: “to govern through democracy, accountability,
equality and social justice”.
All Bougainvilleans have an equal right to quality health care. This means the health sector
will strive to address inequities of health outcomes and service provision, such as the current
under-provision of services for the Central and South Regions.
21
Appendix 2: Accountability and teamwork statement by
health sector leaders
This statement has been crafted and agreed by the technical group who developed the ARB
Plan for Health.
We will focus on results now and avoid excuses
We will be measured by what we deliver and the way it benefits the people of ARB.
Performance will be measured quarterly by the Minister. We accept and expect both rewards
and sanctions based on our performance against recognised indicators and benchmarks.
Teamwork strong cross-government and cross agency collaboration
Our priorities, the delivery of ARB plan for Health, require contributions from across
government (GoPNG, Buka Hospital, and Rural Health Division) and across partners,
including church, donor and private.
We will work based on our contribution to these priorities, not our institutional boundaries,
and push each other to speed up delivery.
We will form and resource time-limited cross-organisational teams when the task requires it
and take responsibility for the whole team’s performance.
Improved communication
Successful communication is critical to our success. Responsibility for proactive
communication, sharing information and strengthening working synergies will be part of our
working culture.
A proactive approach
We are all responsible for identifying solutions, not waiting for others to provide them. We
will improve both our planning processes and implementation.
We will commit annually to a level of service improvement in any given year for each region
and accept independent assessment of the effectiveness of our performance and the
reasons for good and poor performance. Independent assessment will include a process
where communities evaluate our performance.
We will also accept rewards and sanctions based on this performance assessment.
Signed:
22
Appendix 3: Strategies in detail
ABG Goal: Better management, effective programs and healthier
communities
(See ABG’s Medium Term Development Plan (MTDP) 2011-2015, page 131)
There are nine strategies to achieve the goal of better management, effective programs and
healthier communities. They are set out in detail below.
No. Sector Strategy3
1
Improve service delivery
2
Strengthen partnership and coordination with stakeholders
3
Strengthen health systems and governance
4
Improve child survival
5
Improve maternal health
6
Reduce the burden of communicable diseases
7
Promote healthier lifestyles
8
Improve preparedness for disease outbreaks and emerging population health issues
9
The ABG and GoPNG work together to promote a solid basis for an Autonomous
Bougainville health system
3
ABG’s MTDP 2011-2015, page 131
23
Sector strategy 1: Improve service delivery
Objectives
1.1
Increase access to
quality health services
for the rural majority.
Strategies
1.1.1 Expand BHCP into all districts and introduce village
health treasury concept as a way of empowering
communities to address sustainability of Bougainville
healthy community program.
1.1.2 Conduct integrated outreach to ensure 95% population
coverage for Maternal Child Health and disease control.
1.1.3 Remove user fees and decentralize funding through
Direct Facilities Funding for operational activities at all
health centres (HCs), health subcentres (HSCs) and
community health posts (CHPs).
1.1.4 Provide 24 hour access to transport from all HCs to
hospitals for emergencies.
1.2
1.2.1
Rehabilitate and
strengthen PHC and
hospital infrastructure
and equipment.
1.2.2


1.2.3
1.2.4
1.2.5
1.2.6
1.3
The right health
professionals work in
the right places, are
motivated, and deliver
right (quality) services.
1.3.1
1.3.2
1.3.3
1.3.4
1.3.5
Rationalize best locations and type of health facilities
based on an assessment of the population served and
travel time.
Rehabilitate or establish rural health infrastructure
including:
CHPs and HCs resourced to deliver maternal and child
health services
health promotion activities for populations over 3,000
people.
Rehabilitate essential equipment (furniture, medical
equipment, non-medical equipment, refrigeration, static
plant, power and water supply, communications) at HCs,
rural, district and referral hospitals. All equipement
should meet PNG health standards.
Establish district hospitals in Arawa and Buin.
Establish regional hospitals resourced to provide quality
health care.
Establish a major referral hospital for Bougainville.
Develop a human resource implementation plan for ABG.
Focus the plan on increasing the numbers of doctors,
nurses, midwives, community health workers, allied
health workers and health managers and a human
resource information system (HRIS).
Determine the distribution and activity levels of the
current workforce. Prioritize to place the right people
with right skills to provide the most effective delivery of
health services for Bougainville as a whole.
Develop training needs assessment and deliver training
for current and future HHR including developing CHW
and NO training schools.
Ensure regular clinical and management supervision by
personnel trained in supervision to HCs, HSCs and CHPs,
based on checklists and health standards.
Increase staff ceilings for critical health workers and
24
Objectives
Strategies
progressively place medical doctors and visiting
specialists in district hospitals and high volume HCs.
1.3.6 Develop and implement affordable health sector
workforce recruitment, retention and incentive
strategies.
1.4
1.4.1
Promote easy access to
safe and effective forms
of traditional medicine
and practices as part of
the ARB health system.
1.4.2
1.4.3
1.4.4
1.4.5
1.4.6
Compile and keep updated an inventory of safe and
effective herbal medicines used in Bougainville. Publish
the inventory as a booklet.
Develop a quality assurance system for herbal medicines
and practitioners.
Develop techniques for the production and preservation
of herbal medicines.
Train traditional medical practitioners (TMPs) and
traditional birth attendants (TBAs) in primary health
care.
Encourage collaboration between primary health care
providers and TMPs and the sharing of knowledge. Trial
the sharing of premises (aid posts) and the development
of medicinal herb gardens at HCs and primary schools.
Strengthen the Bougainville Traditional Healers’
Association (BouTHA) through management support and
training.
Performance indicator
No 21 Outpatient visits per person per year
25
Sector strategy 2: Strengthen partnership and coordination with stakeholders
Objectives
2.1
The health sector works
collaboratively with all
stakeholders to expand
the reach of quality
health services.
Objectives
2.1.1 Develop the Bougainville Health Board to coordinate
health development.
2.1.2 Establish and strengthen the Bougainville Churches
Medical Council.
2.1.3 Engage community-based organizations in planning,
delivering and evaluating health services.
2.1.4 Merge BHCP into the mainstream health system.
2.1.5 Enhance communication, cooperation, reporting and
coordination with central agencies and other
Bougainville sectoral departments, especially with the
Departments of Treasury, Planning, Finance and
Provincial and Local Level Government.
2.2
2.2.1
Implement ABG public
private partnerships
policy and introduce
innovative and cost
effective options for
delivering services.
2.2.2
Enter into agreements with extractive industries to
reduce health impact and agree mitigation measures
before mining operations begin.
Include private health providers in the health sector
coordinating body.
26
Sector strategy 3: Strengthen health systems and governance
Objectives
3.1
Improve financial
resourcing and
management for health
service delivery.
Strategies
3.1.1 Develop and agree a funding envelope to 2020 with
GoPNG, ABG, donors. Integrate income streams into
single health funding facility. Construct ABG health
accounts.
3.2
3.2.1
Medical supply
procurement and
distribution services are
efficient and
accountable.
3.2.2
3.2.3
3.3
The health sector
proactively identifies
and uses innovative and
evolving ICT solutions
and delivers accurate
and timely information
for planning and
decision making.
3.3.1
3.3.2
3.3.3
3.3.4
3.4
The Minister for Health
is supported by an
external advisory group
which monitors the
implementation of the
Bougainville Health Plan.
3.4.1
3.4.2
3.4.3
3.4.4
3.4.5
Assess the feasibility of ABG procuring its own medical
supplies and the delegation of Pharmaceutical Board
responsibilities.
Develop a ‘Pull’ system for medical supplies
management for all HCs, HSCs, CHPs.
Merge hospital and rural health services medical supplies
systems.
Develop a timely, autonomous and flexible health sector
management information system across all layers and
institutions of the ARB health system linked to a national
patient master index.
Build the capacity of ABG health information officers and
hospital medical records officers to compile, analyse, and
provide quality information for district and hospital
management.
Increase the use of mobile phones for data collection and
transfer.
Ensure all health sector providers including the private
sector support ARB and national health surveillance
systems.
Ensure all stakeholders receiving Government of Papua
New Guinea, health development partner or ABG
funding are guided by the Bougainville Health Plan and
comply with relevant legislation. Ensure stakeholders
provide an audited annual report, including proposed
future programming and expenditure.
The Minister of Health holds the CEO Health accountable
for the delivery of services in accordance with relevant
legislation and the Bougainville Health Plan.
Strengthen the performance monitoring and evaluation
framework, by linking information about and reporting
on performance, HR and financial resources.
Planning, budgets, expenditure and management
decisions are linked to health priorities and evidencebased. Business cases are prepared for all projects
exceeding PNGK1 million.
Ensure committees such as the Bougainville Health
Board, Audit Committee, Professional and
Pharmaceutical Board (if devolved) implement quality
assurance programs and meet reporting requirements in
compliance with legislation.
27
Sector strategy 4: Improve child survival
Objectives
4.1
Increase coverage of
childhood immunization
in Bougainville.
Strategies
4.1.1 Ensure every facility, every day, at every encounter
immunizes children when indicated.
4.2
Reduce case fatality
rates for pneumonia in
children by speeding up
the roll out of integrated
management of
childhood illnesses
(IMCI) to Bougainville.
4.2.1
Decrease neonatal
deaths.
4.3.1
4.3
4.2.2
4.2.3
4.3.2
4.4
Reduce malnutrition
(moderate to high) in
children under the age
of five years.
4.4.1
4.4.2
4.4.3
4.4.4
Build the capacity and capability of all HCs and CHPs to
implement IMCI.
Increase the percentage of communities with the
capacity to implement IMCI in conjunction with BCHP.
Introduce cost effective vaccines, such as pneumococcal
vaccine.
Ensure all HCs and CHPs have the capacity to provide lifesaving support to the neonate.
Ensure 99% coverage of tetanus toxoid for antenatal
mothers.
Adopt the ‘First 1000 Days’ strategy.
Support the continuation of exclusive breastfeeding.
Ensure all babies and children under five have access to
supplementary feeding when and where they require it.
Increase access for mothers and children to
micronutrient supplementation.
Performance indicators
No2
Childhood malnutrition
No9a Measles immunization coverage for children under 1 year
No 9b Third dose TA/pentavalent coverage
28
Sector strategy 5: Improve maternal health
Objectives
5.1
Increase family planning
coverage.
Strategies
5.1.1 Ensure every health facility has the capacity to offer
family planning services at all times.
5.1.2 Advocate for the advantages of having fewer children
and increased spacing of children.
5.2
5.2.1
Increase the capacity of
the health sector to
provide safe and
supervised deliveries.
5.2.2
5.2.3
5.3
5.4
Improve access to
emergency obstetric
care (EOC).
5.3.1
Improve sexual and
reproductive health for
adolescents.
5.4.1
5.3.2
5.4.2
Increase the number of facilities capable of providing
supervised deliveries.
Increase the numbers of health workers skilled in
obstetric care.
Ensure every maternal death (in health facility and in
community) is reported, investigated and audited.
Ensure that practices improve as a result. Report
maternal deaths to the Minister of Health on a monthly
basis.
Increase the capacity of all HCs and CHPs to provide
essential EOC.
Ensure all high-volume facilities are capable of providing
comprehensive obstetric care.
Increase the knowledge of adolescents about sexual and
reproductive health.
Increase cross-sectoral collaboration with schools to
strengthen education of students in sexual and
reproductive health.
Performance indicators
No 10A Proportion of supervised births at health facilities
No 11 Antenatal coverage
No 12 Family planning use
29
Sector strategy 6: Reduce the burden of communicable diseases
Objectives
6.1
Reduce malaria-related
morbidity and mortality
in Bougainville.
Strategies
6.1.1 Galvanize political commitment for malaria control
through setting a goal and an implementation plan for
malaria elimination.
6.1.2 Provide households with long-lasting insecticide-treated
nets (LLIN) to cover all usual sleeping places, and
reintroduce residual spraying where appropriate.
6.1.3 Maximize access to prompt quality diagnosis and
appropriate treatment for malaria.
6.2
6.2.1
Control tuberculosis (TB)
incidence by 2020, with
a decline in cases of
multi-drug-resistant
tuberculosis (MDR-TB).
6.2.2
6.2.3
6.2.4
6.3
Scale up prevention,
treatment, care and,
support for sexually
transmitted infections
(STIs) and HIV to meet
universal access targets.
6.3.1
6.3.2
6.3.3
6.3.4
6.3.5
6.3.6
6.4
Strengthen
communicable disease
surveillance and
monitoring.
6.4.1
6.4.2
Ensure all TB cases have access to tuberculosis directly
observed treatment, short-course (TB DOTS).
Provide HIV counseling and testing for all TB cases.
Strengthen, integrate and implement TB and HIV
collaboration.
Work with ABG to develop an intersectoral approach to
improving the indoor environment of domestic
dwellings.
Increase access to quality HIV counseling and testing
services including prevention of parent-to-child
transmission (PPTCT) counseling.
Increase access to quality antiretroviral (ARV) treatment
for adults and children.
Ensure male and female condoms (and lubricants) are
available and accessible throughout Bougainville.
Increase access to post-exposure prophylaxis (PEP)
services.
Strengthen syndromic management of STIs.
Increase the knowledge of adolescents about sexual and
reproductive health.
Introduce an integrated surveillance and monitoring
strategy for cholera, emerging diseases, neglected
tropical diseases, hookworm, leprosy and other
infectious diseases.
Strengthen epidemic surveillance and response capacity
for communicable diseases with a potential for
outbreaks.
Performance indicator
No 4 Malaria incidence per 1000 population
30
Sector strategy 7: Promote healthy lifestyles
Objectives
7.1
Increase health sector
response to the
prevention of injuries,
trauma, and violence.
Strategies
7.1.1 Increase population-based programs designed to reduce
the number of preventable injuries and trauma.
7.1.2 Increase the roll out of and access to family support
centres.
7.1.3 Increase and build adequate capacity of hospital accident
and emergency departments to address transportrelated injuries. This applies to the existing and two
proposed hospitals as well as the proposed new referral
hospital.
7.2
7.2.1
Reduce the number of
outbreaks of food and
water-borne diseases.
7.2.2
7.2.3
7.2.4
7.2.5
7.3
Reduce morbidity and
mortality from noncommunicable diseases.
7.3.1
7.3.2
7.3.3
7.3.4
7.3.5
7.3.6
7.3.7
Establish water management committees to manage and
control rural water supplies and sanitation.
Increase the number of households that have access to
safe drinking water, and effective waste disposal and
sanitation.
Ensure all health facilities have access to running water,
and effective waste disposal and sanitation.
Ensure public and private buildings comply with
legislation in relation to water supply, sanitation, and
food handling.
Review and improve relevant legislation to enhance the
management and control of rural water supplies.
Increase the focus on population-based health
interventions designed to reduce the impact of
substance abuse and excessive alcohol use, including
home brew. Promote increased levels of physical activity
and improved diet.
Implement population-wide early detection (screening)
and immediate clinical interventions for noncommunicable diseases, such as heart disease, strokes,
diabetes, and cancers with an initial focus on cervical
cancer.
Support employers in ARB to promote healthy diet,
opportunities for regular physical activity and smoke-free
working environments.
Review and improve legislation that will support tobacco
control, and reduce the sales and marketing of drinks
and foods high in fat, salt and sugar.
Improve and expand mental health services to address a
range of mental health issues, including post-traumatic
stress disorder.
Improve disability and community-based rehabilitation
services.
Ensure all public and private sector employees routinely
undergo medical examinations for the early detection of
lifestyle diseases.
31
Objectives
Strategies
Performance indicator
No 6 Diarrhoeal disease in children less than 5 years
No 7 Injuries reported at outpatients per 100 population
32
Sector strategy 8: Improve preparedness for disease outbreaks and emerging
population health issues
Objectives
8.1
Increase capacity of the
health sector to identify,
monitor, report on and
respond to urgent and
emerging health threats.
Strategies
8.1.1 Strengthen capacity of the health sector to report on
notifiable diseases in accordance with international
regulations. Increase the capacity of ARB to coordinate
their responses to epidemic and population health
emergencies.
8.2
Establish Bougainville
Public Health Laboratory
(BPHL) function to
provide services to meet
urgent and emerging
concerns.
8.2.1
Improve capacity and
preparedness of the
health sector to address
the impacts of climate
change.
8.3.1
Ensure the health sector
works collaboratively to
manage population
health threats related to
the growing resources
boom.
8.4.1
8.3
8.4
8.2.2
8.3.2
Extend the functions of the current Buka Hospital
laboratory to include public health laboratory functions.
Ensure it has sufficient capacity and supplies at all times
to respond to disease outbreaks and other emergency
health concerns.
Ensure a functioning and safe blood transfusion service is
available to the health sector and includes HIV blood
screening capability.
Actively engage in the resettlement process for climate
change refugees to ensure their health needs are met.
Ensure every health facility has a disaster preparedness
plan, which includes issues associated with climate
change.
Develop an appropriate response to the health impacts
of mercury and arsenic on miners and their families in
the Panguna Basin.
33
Sector strategy 9: The ABG and GoPNG work together to promote a solid basis for an
autonomous Bougainville health system
Objectives
9.1
Facilitate MOU on
drawdown of health
functions and powers
from NDOH to ABG DoH.
Strategies
9.1.1 National Government and ABG sign MOU.
9.1.2 Develop concept proposal on Bougainville Health
Authority (BHA) and commence legislative review.
9.1.3 Agree legislative framework for BHA with the national
government.
9.2
Create Bougainville
Health Authority.
9.2.1
BHA.
Develop policy and legislative provisions to form the
9.3
Implement Bougainville
Health Plan.
9.3.1
Establish and convene an independent advisory group to
advise the Minister on the implementation of the
Bougainville Health Plan.
Report annually to the ABG parliament on the progress
in implementing the Bougainville Health Plan.
9.3.2
34
Appendix 4: Performance and trends
Data presented in this section is incomplete. Data sources are indicated below each table.
Where available, 2010 Annual Sector Review data has been used because this data has
been verified. It should be possible for ARB DoH to provide some of the missing data for the
best and worst performing health facilities for 2011.This would help to provide a fuller picture
of what is happening. ARB DoH should also confirm the suggested ARB Targets for 2015,
particularly where these have not been extracted from the ARB MTDP 2011-2015.
Once the data is more complete ARB DoH should consider why these patterns are evident
and what practical steps can be taken to improve performance in poorer performing facilities.
In many instances the knowledge on how to improve performance already exists within ARB.
Looking at practices where performance on a particular indicator is high can reveal practices
that might result in better performance if adopted in other health facilities. There needs to be
a good match between strategies outlined in the Bougainville Health Plan and activities that
will improve performance against these indicators.
Health sector strategy 1: Improve service delivery
Objective:
Increase access to quality health services for the rural majority
Indicator:
Average outpatient visits per person per year in hospitals and health centres
ARB 20111
0.9
Best ARB Region
0.9
Buka – North Region and Buin – South Region
2011
Best ARB Health
2.0
Sipai Health Subcentre
Facility 2011
Worst ARB Region
0.8
Kieta – Central Region
2011
Worst ARB Health
0.1
Panguna Health Subcentre
Facility 2011
PNG 20102
1.62
3
PNG Target 2015
ARB Target 2015
1.3
Sources:
1 ARB 2011 data from ‘North Solomons Province General (YTD) Report Jan to Dec 2011’ printed
4/3/122010
2 ‘Annual Sector Review North Solomons Province District Performance 2006-2010’
3 Not available
Outpatient visits in ARB are low at an average of 0.9 visits per person per year in 2011. The
rate has been fairly constant over recent years. Many factors affect outpatient visits and it is
difficult to determine why the rate in ARB is low compared with the PNG average. The rate
may reflect factors such as accessibility, perceived range and quality of services offered
35
and/or preventive measures being taken at the individual or community level. Sipai and Tonu
HSCs both have high outpatient visit rates, exceeding the PNG average.
Health sector strategy 4: Improve child survival
Objective:
Reduce malnutrition (moderate to high) in children under the age of 5years
Indicator:
Percentage of children under five less than 80% expected weight for age
ARB 20101
22%
Best ARB Region
16%
Kieta – Central Region and Buin South Region
2010
Best ARB Health
0%
Buka Hospital, Boku Health Centre
2
Facility 2011
Worst ARB Region
27%
Buka – North Region
2010
Worst ARB Health
73%
Lenoke Health Subcentre
Facility 2011
PNG 2010
28%
3
PNG Target 2015
26%
ARB Target 2015
18%
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
2 ARB 2011 data from ‘North Solomons Province Child Health (YTD) Report Jan to Dec 2011’ printed
4/3/12
3 PNG MTDP 2011-2015
ARB performs better than PNG as a whole. But the percentage of Bougainville children aged
less than 5 years who attend MCH clinics and weigh less than 80% of the expected weight
for their age has been increasing since 2008. This is most notable in the North Region
around Buka. In the south, the rate decreased from 2009 to 2010. The best-performing
health facilities were Boku (0%) in the south and Gagan (2.4%) in the north. The indicator
may reflect food availability and climate conditions as well as health and hygiene practices in
the community.
36
Health sector strategy 4: Improve child survival
Objective:
Indicator:
Increase coverage of childhood immunization in Bougainville
Measles immunization coverage
3RD dose TA/pentavalent coverage at 12
for children less than 1 year
months of age
ARB 20101
63%
63%
Best ARB Region 2010 60% Buka – North Region
80% Buka – North Region
Best ARB Health
Facility 20102
Worst ARB Region
33% Kieta – Central Region
46% Kieta – Central Region
2010
Worst ARB Health
Facility 2010
PNG 2010
50%
51%
3
PNG Target 2015
73%
80%
ARB Target 20154
73%
73%
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
2 Not available
3 PNG MTDP 2011-2015
4 ARB MTDP 2011-2015
For both measles and pentavalent coverage, Bougainville is performing better than PNG.
Rates generally decreased from 2006 to 2009 but have since begun to improve, particularly
between 2010 and 2011. Improvements have been most evident in the North and South with
virtually no change in Central Region. Bougainville’s coverage was higher than the PNG
average in 2010 but well short of the 2015 targets.
Health sector strategy 5: Improve maternal health
Objective:
Indicator:
Increase the capacity of the health sector to provide safe and supervised deliveries
Percentage of
Antenatal coverage (at least 1 visit)
supervised births at
health facilities
1
ARB 2010
56%
76%
Best ARB Region 2010 71%
Buka – North Region
91%
Buka – North Region
Best ARB Health
115% Moratona Health Centre
287%
Buka Urban Clinic
2
Facility 2011
Worst ARB Region
39%
Kieta – Central Region
65%
Buin – South Region
2010
Worst ARB Health
1%
Konga Health Subcentre
36%
Piva Health Centre
Facility 2011
PNG 2010
40%
62%
PNG Target 20153
54%
70%
ARB Target 20154
67%
91%
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
37
2 ARB
2011 data from ‘North Solomons Province Maternal Health (YTD) Report Jan to Dec 2011’
printed 4/3/12
3 PNG MTDP 2011-2015
4 ARB MTDP 2011-2015
Bougainville performed better than PNG as a whole on both supervised deliveries and
antenatal coverage in 2010. Rates for both these indicators, however, have dropped since
2007 except in the North Region where antenatal coverage increased considerably from
2010 to 2011. The main contributor to high rates of antenatal coverage in the north is Buka
Urban Clinic with a rate close to 300%. This rate suggests that people from other areas
attend this facility and/or denominator figures are incorrect. Sipai Health Subcentre, Tearouki
and Buin Health Centres all achieved over 100% antenatal coverage in 2011.
The decline in supervised deliveries has been most serious in Central Region. Buka Hospital
is not reflected in the data above but provides over one quarter of all supervised deliveries.
All three regions are achieving less than the Maternal Health Taskforce recommended 80%
supervised deliveries but several individual facilities are close to the recommendation.
Tearouki Health Centre and Monoitu Health Subcentre exceeded 100% of supervised
deliveries. ARB has some way to go in order to achieve its 2015 targets for both these
indicators and the key may be with these high-performing facilities.
Health sector strategy 5: Improve maternal health
Objective:
Increase family planning coverage
Indicator:
Couple years protection per 1000 women aged 15-44 years
ARB 20101
74
Best ARB Region 149
Buka – North Region
2010
Best ARB Health 780
Buka Urban Clinic
Facility 20112
Worst ARB
15
Buin – South Region
Region 2010
Worst ARB
1
Katuhkuh Health Centre
Health Facility
2011
PNG 2010
74
PNG Target
115
20153
ARB Target 2015 115
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
2 ARB 2011 data from ‘North Solomons Province Family Planning (YTD) Report Jan to Dec 2011’
printed 4/3/12
3 PNG MTDP 2011-2015
38
In 2010 ARB performed at the same level as PNG for contraceptive prevalence coverage.
However, there is huge disparity between the North and the other two regions. There was a
sudden increase in use of modern contraceptives in the North Region in 2009 and again in
2011. This has been attributed to the work of a female obstetrician who was based at Buka
Hospital from 2008 to 2011. Although awareness training was conducted in many parts of
Bougainville there has been very little change in the indicator in the Central and South
Regions from 2006 to 2010 and just a slight increase in 2011. Rates are well below the PNG
average in Central and South Regions and work will have to be focused in these areas in
order to reach the 2015 target.
Health sector strategy 6: Reduce the burden of communicable diseases
Objective:
Reduce malaria related morbidity and mortality
Indicator:
Malaria incidence per 1000 population
ARB 20101
201
Best ARB Region 2010 92
Buin - South Region
Best ARB Health
Facility 20112
Worst ARB Region
329
Buka – North Region
2010
Worst ARB Health
Facility 2011
PNG 2010
236
3
PNG Target 2015
180
ARB Target 20154
200
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
2 Not available
3 PNG MTDP 2011-2015
4ARB MTDP 2011-2015
Malaria has declined on Bougainville since 2006 although less so in the north than the other
two regions. LLIN were distributed from 2006 and may have contributed to the reduction in
malaria cases. The incidence of malaria in Bougainville is less than in PNG as a whole.
However, the Bougainville Health Plan sets ambitious longer term goals. A broader range of
strategies implemented in all regions may be needed to achieve these targets.
39
Health sector strategy 7: Promote healthy lifestyles
Objective:
Reduce the number of outbreaks of food and water-borne diseases
Indicator:
Incidence of diarrhoeal disease per 1000 children less than 5 years
ARB 20101
166
Best ARB Region 2010 114
Buin - South Region
Best ARB Health
Facility 20102
Worst ARB Region
228
Buka –North Region
2010
Worst ARB Health
Facility 2010
PNG 2010
276
PNG Target 20153
ARB Target 2015
100
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
2 Not available
3 PNG MTDP 2011-2015
After slowly but steadily declining from 2006 to 2009 there was a sharp increase in
diarrhoeal diseases in Bougainville in 2010, as was the case nationally. The increase was
more pronounced in the North Region. Despite this increase, Bougainville continued to have
less diarrhoeal disease than PNG. Water and sanitation will need to improve in all areas if
the 2015 target is to be met. Hygiene may also need to improve.
Health sector strategy 7: Promote healthy lifestyles
Objective:
Increase health sector response to injuries, trauma and violence
Indicator:
Total injuries reported at health centre and hospital outpatients per 100
population
ARB 20101
14
Best ARB Region 2010 12
Buin – South Region
Best ARB Health
Facility 20102
Worst ARB Region
18
Kieta – Central Region
2010
Worst ARB Health
Facility 2010
PNG 2010
33
PNG Target 20153
ARB Target 2015
10
Sources:
1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 20062010’
2 Not available
3 PNG MTDP 2011-2015
40
Rates of injury in Bougainville are considerably lower than the national average in all regions
and have decreased between 2006 and 2010. Nonetheless, admission for the treatment of
injuries ranks third overall in the ARB morbidity profile in 2010.
41
Appendix 5: Measuring Progress
Strengthen health
systems and
governance
•Health sector coordination mechanisms in
place
•Adequaccy of health funding
•Medicines supply to facilities
Strengthen
partnership and
coordination
•Bougainville Health Board operating
effectively
•Health agreement part of extraction
industry social licence
Improve service
delivery
•Outpatient visits per year
•Villages served by active Healthy
Communities
•Geographical and financial access barrier
measures
•Numbers of health workers
•Herbal medicine safe and effective use
Improve child
survival
Improve maternal
health
•Under five mortality
•Immunisation rates
•IMCI functioning at all facilities
•Family planning rate
•Maternal mortality
•Supervised deliveries
Reduce
communicable
diseases
•TB, HIV, STI, malaria prevalence
•TB detection rate
•TB treatment rate
•HIV VCT acceptor rate
•ART and PPCT
Prepare for disease
outbreaks and new
population health
issues
•PH laboratory established
•Surveillance reports
Healthier
lifestyles
•Rates of illness and death from injuries,
cancers, diarrhoeal, cardiac and respiratory
illnesses
Autonomous
Bougainville
health system
•Fully functioning, effective Bougainville
Health Authority leading and coordinating
the health sector and accountable to the
ABG
42
Appendix 6: Linkages between relevant global, national and
ARB planning documents
Document
ARB
Constitution
Health related goals/aspirations
ABG shall endeavour to ensure all people in Bougainville enjoy rights and
opportunities and access to education, health services, clean and safe water,
decent shelter, adequate clothing and food security.
Working in partnership with other bodies involved in pursuit of health objectives:
a) promote primary health care
b) pursue universal health care of the highest standard
c) ensure the provision of basic medical services to the population
d) promote water and sanitation management systems at all levels
e) encourage people to grow and store adequate food
f) encourage and promote proper nutrition, particularly for the young and
the people of the Atolls, through mass education and other means
g) recognize herbal medicines
h) protect clans from HIV/AIDS
Vision 2050
‘We will be a Smart, Wise, Fair, Healthy and Happy Society by 2050’
Millennium
Development
Goals
Goal 4: Reduce child mortality – improve child health.
Target 4.A: Reduce by two-thirds, between 1990 and 2015, the under-five
mortality rate.
Goal 5: Improve maternal health.
Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal
mortality ratio.
Target 5.B: Achieve, by 2015, universal access to reproductive health.
Goal 6: Combat HIV/AIDS, TB, malaria, NCDs and other diseases.
Target 6.A: Halt by 2015 and begun to reverse the spread of HIV/AIDS
Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all
those who need it
Target 6.C: Halt by 2015 and begun to reverse the incidence of NCDs and malaria
DSP 2010-2030
Achieve an efficient health system which can deliver an internationally
acceptable standard of health services.
MTDP 20112015
NHP 2011-2020
As per Development Strategic Plan 2010-2030
Goal: Strengthen primary health care for all, and to improve service delivery to
the rural majority and urban disadvantaged. Focus on a ‘back to basics’ approach
with rehabilitation of the foundations of our primary health care system focusing
on improving maternal health, child survival and reducing the burden of
communicable diseases.
Vision: of a healthy and prosperous nation that upholds human rights and our
Christian and traditional values, and ensures: Affordable, accessible, equitable,
and quality health services for all citizens.
Mission: Improve, transform, and provide quality health services through
innovative approaches supporting primary health care and health system
43
Document
Health related goals/aspirations
development, and good governance at all levels.
HSSP 2012-2015
ABG MTDP
2011-2015
Bougainville
Health Summit
2009
As per National Health Plan 2011-2020
Goal: Better management, effective programs and healthier communities
Goal: Improved health status through quality and accessible health services.
Objective 1: Improve management and resources utilization.
Objective 2: Combat HIV/AIDS, malaria and other diseases.
Objective 3: Improve maternal and child health services.
Objective 4: Establish and strengthen partnership with
communities/NGOs/donors.
Improve standard of curative health.
44
Appendix 7: Indicators and targets from planning documents
Indicators and targets from relevant planning documents
2015 PNG
Tailored target
44 per 1000 live
births
PNG
Development
Strategic Plan
2010-30
2030 Target for
PNG
Less than 17 per
1000
27/1000
72 per 1000 live
births
Less than 20 per
1000 live births
113/1000 live
births
111/1000 live
births
274 per 100,000
live births
Less than 100
per 100,000 live
births
ARB Medium Term Development Plan 2011-2015
INDICATOR
Baseline
Infant mortality
rate
Under 5
mortality rate
Maternal
mortality rate
47/1000 in
2000
62/1000 live
births in
2006
123.5/1000
lives births
in 2009
2015 Target
2020 Target
2025 Target
35/1000
26/1000
17/1000
46/1000
37/1000
117/1000 live
births
Millennium
Development
Goals
Life expectancy
59.6 years in
2000
Males 62.2
Females 62.7
Males 64.2
Females 64.7
Males 66.2
Females 67.2
Incidence of
tuberculosis
158/100,000
in 2008
153/100,000
127/100,000
122/100,000
Stabilized or
reversed
Incidence of
malaria
246/1,000 in
2008
200/1,000
154/1,000
108/1,000
Stabilized or
reversed
N/A
N/A
N/A
N/A
Keep incidence
low
1.20% in
2008
1.1%
1.0%
0.9%
Less than 5%
1 in 2011
3
3
4
50% of district
health centres
upgraded to
hospital status
180 in 2008
200
210
230
7500 in PNG
49% in 2008
75%
80%
85%
100%
5.5/100,000
in 2008
8/100,000
12/100,000
17/100,000
50 per 100,000
people
93 in 2008
300
400
500
200 per 100,000
people
229 in 2008
500
600
700
20,000 in PNG
62% in 2008
67%
72%
77%
95%
86% in 2008
91%
95%
98%
100%
59% in 2008
73%
79%
87%
100%
N/A
N/A
N/A
N/A
90%
Incidence of
lifestyle and
coronary
diseases
Under 5s with
moderate to
high
malnutrition
Number of
hospitals in full
operation
Number of
functioning aid
posts
Facilities with
adequate
medical
supplies
Ratio of doctors
per 100,000
people
Number of
nurses
Number of
CHWs
Supervised
delivery
Antenatal care
coverage
Immunization
coverage
Food outlets
implementing
the safe food
code of practice
70 years
Less than 150
per 100,000
people
Less than 100
per 100,000
people
Sources: ABG MTDP2011-2015, p133; MDG 2nd National Progress Summary Report 2009
for PNG p131; PNG DSP 2010-2030 p48
45
Appendix 8: Traditional medicine in Bougainville
Since the inception of the Traditional Health Project (THP) in July 2010, traditional medicine
in Bougainville is gaining recognition and becoming better organized. The THP is a
European Union (EU), Austrian Development Agency (ADA) and Drei Königs Aktion (DKA)
funded project. The project operates under the auspices of the Catholic Diocese in
Bougainville and HorizonT3000, helping with the preservation and safe utilization of local
traditional medicines and practices. The THP supports and helps to implement the
Traditional Medicine Policy of PNG, the goal of which is ‘to improve and maintain health by
providing easy access to safe and effective forms of traditional medicine and practices as
part of the National Health Care System.’
Specifically, the THP aims to:

contribute to knowledge and appreciation of traditional health resources in Bougainville

contribute to improvement of health parameters, in particular maternal health, in
Bougainville

contribute to self sufficiency of Bougainville communities, in particular in rural areas, with
respect to basic health

Preserve and continuously upgrade traditional health care knowledge and skills by
introducing them into the modern health care system in Bougainville
The Bougainville Traditional Health Association (BouTHA) has been formed since the start of
the THP. To date BouTHA has 300 members and 11 smaller associations representing
districts or groups of villages. BouTHA’s dream is to strengthen the health service using safe
and effective traditional medicine and practices and work with health staff to promote a
healthy lifestyle.
In the short time since their inception, the THP and BouTHA have some notable
achievements. Specimens from approximately 100 medicinal plants have been collected,
analyzed and catalogued in conjunction with University of PNG and the Forestry Research
Institute. The information obtained will be used to produce a booklet on medicinal plants
used in Bougainville for health centres, schools and the general public. Members of BouTHA
have been trained as trainers in primary health care and over 500 traditional healers from all
parts of Bougainville have received primary health care training. Bone-setters and massage
therapists have received training on human anatomy and physiology. Traditional birth
attendants upgraded their knowledge in safe motherhood and delivery. Twelve herbalists are
attending a course on rural health management conducted by Divine Word University. Links
between BouTHA and the Bougainville Healthy Communities Project (BHCP) have begun to
46
be established. BHCP includes training on herbal medicines as part of the training for
volunteers and peer educators. Medicinal herb gardens have been established in primary
schools.
In the future, the THP and BouTHA would like to establish more medicinal herb gardens at
health centres and primary schools and include traditional medicine in the upper primary
school curriculum. They want to establish a research institute and/or laboratory that can
determine recommended doses for various herbal remedies. Other ideas include developing
a quality control process for herbal medicines as well as techniques for mass production and
preservation of herbal medicines. THP and BouTHA want to develop accreditation for
traditional medical practitioners and collaborate more with health workers.
47
Appendix 9: Cost and financing scenarios
DRAFT ONLY
Financing issues facing the ABG health sector
1. Overall ABG revenue estimates
Currently, the GoPNG has committed to providing 100 Million Kina per annum financial
support to the ABG over a 5 year period. With low levels of internal revenue, this support is
most important to the ABG, as the post-conflict recovery and development financial needs
are considerable. The ABG has budgeted its plans for the period 2011-2015 to meet certain
development priorities, as indicated below.
Table 1: Estimated revenue required to finance ABG’s priorities for development 20112015 in kina (millions)4
2012
2015
Grants (external)
84.8
92.2
Internal revenue
22.5
24.8
Total
107.3
117.1
Currently, it is estimated the ABG generates about 5 million kina per year through taxes.
These taxes are collected by the GoPNG taxation system with some returned directly to the
ABG, under current agreements. The 2012 and 2015 budgets given in Table 1 assume a
significant increase in taxation revenue over the 2012-2015 period. This taxation base
includes group tax on wages, a goods and services tax, motor vehicle registration fees,
liquor licensing fees, and excise taxes on alcohol and tobacco. The excise taxes are new
and the ABG is hopeful of large revenue gains from these taxes into the future.
The GoPNG also provides financial support to the ABG health sector by funding the Buka
Hospital, salary support for rural health services, financial support for the Church health
services and provision of medical supplies (see below).
4
The Bougainville Administration, pages 71-72
48
There is uncertainty over what level of support would be provided by the GoPNG in the
longer term, after a referendum is held to determine if the ABG would continue as an
autonomous government within the PNG Government, or as an independent nation.
2. Health sector recurrent expenditure estimates
The estimated recurrent expenditure of the ABG health sector is financed from a number of
sources, as given below.
Table 2: Estimated recurrent expenditure ABG health 2012 (Kina 000’s)5
Buka Hospital
8.936
Church health
3.747
Rural Health
3.728
GIF Maintenance (Aust, NZ)
0.9
HIV funding
0.2
MSF
2.149
Rollover
0.076
Med supplies est
5.610
Maintenance costs11
0.36
DHFF (est) (NZ –HSIP)
0.912
Leprosy Mission Health (NZ –HSIP)
0.9613
Total
27.53
Of this 27.53 million kina estimated recurrent expenditure, ABG directly contributes an
estimated 1.355 million kina in recurrent expenditure. The rest is made up of donor
contributions (4.90 million kina) and GoPNG funding (21.27 million kina). The GoPNG is by
5
Autonomous Region of Bougainville, Health Capacity Diagnostic Report (March 2012) Pages 20-21.
An estimated 300,000 kina in revenue added to the quoted figure of 8.6 million kina. Source: Health
Sector Partnership Committee, Agenda Papers (Feb 2012) Page 20.
7 Health Sector Partnership Committee (February 2012) Page 34.
8 Made up of staffing costs of K3 million, recurrent funding of K0.426 million and operational funding to
13 DHCs of K0.29 million. – Source: Autonomous Region of Bougainville, Pages 19-21.
9 MSF Funding is 800,000 euro per year for 4 years (verbal source) = 2.14 million kina per year at 1:
2.67 exchange rate, as at 13 April 2012 – Source www.xe.com.
10 Based on overall PNG medical supplies and equipment spending divided by the population
estimate and indexed for the ABG population. (awaiting an alternative estimate from NDOH).
11 Included in 2011 Restoration and Development Budget rollover – Source: Autonomous Region of
Bougainville, Pages 22-23.
12 Based on verbal discussions with NZAID that DHFF expenditure for 2011 was just short of 1 million
kina. DHFF is the Direct Health Facility Funding program (awaiting an alternative from NDOH).
13 Source: Health Sector Partnership Committee, Agenda Papers (Feb 2012) Page 20.
6
49
far the major contributor to health sector recurrent funding, and is likely to remain so until
sometime between 2015 and 2020. Within this five year period, the referendum has to be
held, after which GoPNG funding will be uncertain.
50
Table 3: Details of recurrent expenditure by contributing entity
Kina (millions)
ABG contribution
Operational costs for 13 health centres
0.29
Health Division recurrent exps (not salaries
0.426
HIV funding
0.2
Rollover of recurrent costs from 2011
0.076
Maintenance costs from restoration and development
0.363
Budget rolled over from 2011
Sub-total
1.355
GoPNG contribution
Buka Hospital expenses (inc. revenue)
8.93
Church health services
3.74
Rural Health staffing costs
3.0
Medical supplies (est)
5.6
Sub-total
21.27
Total government contributions to recurrent funding 2012
22.625
Donor contributions
Maintenance (GIF)
0.9
MSF
2.14
DHFF (NZ through HSIP)
0.9
Leprosy Mission Health (NZ through HSIP)
0.96
Sub-total
4.9
Total Estimated Recurrent Expenditure 2012
27.53
3. ABG health sector capital expenditure estimates
For 2012, ABG is providing 4.5 million kina in capital funding for health infrastructure, as part
its 100 million kina per year (for 5 years) grant from the GoPNG.
51
Table 4: Estimated capital funding ABG from various sources 2012
Kina (millions)
Capital Funding – ABG Infrastructure
ABG (PIP) Restoration and Development Grant 2012
4.5014
Restoration and Development Grant 2011 rolled over15
1.593
Total Government sourced capital funding
6.093
Donor contributions (capital - RHSDP)16
2.93
Total estimated capital funding for 2012
9.023
4. Total estimated expenditure from government sources 2012
This consists of GoPNG recurrent funding, and ABG sourced recurrent and capital funding,
as indicated earlier.
Table 5: Estimate of total government sourced funding ABG 2012
Kina (millions)
Total government contributions to recurrent funding
22.625
Total government sourced capital funding
6.093
Total
28.718
Total government sourced expenditure per capita (Using the
119.82 Kina
17
ABG population estimate of 239668 )
Total government sourced expenditure per capita18 in US$
58.59 US$
14
Autonomous Region of Bougainville, Health Capacity Diagnostic Report (March 2012) Page 21
2011 Restoration and Development Budget rollover – Source: Autonomous Region of Bougainville,
Pages 22-23. Note: 1.593 mill kina is capital funding, 0.363 mill kina is recurrent.
16 ADB Infrastructure Program of US$82 mill over 8 Provinces, 70% spent in Province over 5 years.
17 Source: National Statistical Office of PNG, PNG Census 2011, Preliminary Figures of 234,280
indexed up to 2012 by 2.3% estimate only, Page 5.
18 Using exchange rate of 1 kina = 0.489 US$ - Source www.xe.com.
15
52
5. International comparisons - Per capita government health expenditure US$19
In the chart below is a comparison of US$ per capita government sourced health
expenditures of PNG overall, other Melanesian Pacific countries and ABG. Whilst ABG
appears to be higher than PNG overall, it falls well short of the per capita health
expenditures of the Solomons, Fiji, Kiribati and Vanuatu.
Table 6: Other countries per capita government sourced expenditures
Philippines
Timor Leste
Indonesia
27
32
38
Thailand
Tonga
Samoa
Malaysia
134
140
179
204
New Zealand
Australia
2728
3246
It should be noted there are limitations to the accuracy of these indicators, as they are
dependent on data sourced from each country. However, WHO has gone to some length
19
National Health Expenditure Indicators WHO 2010. Note: General government health expenditures
as given by WHO, include capital expenditures. They are collected from national health accounts,
when available, and other government sources – refer to WHO website:
http://www.who.int/healthinfo/statistics/indhealthexpenditure/en/index.html.
53
over at least ten years to standardise data collection and methods of calculation, to allow
more meaningful comparisons. There are other methods of comparison which take into
account relative purchasing power in each country, but in the interests of not over
complicating the comparisons (since they are a guide only) this has not been done in this
document. Notwithstanding limitations of inter-country health expenditure comparisons, it is
useful to compare government health spending per capita of ABG’s Melanesian neighbours.
The ABG is currently quite close to the US$60 per capita level, which the WHO has
determined would provide enough financing for a health system in a developing country to
deliver all of the specified mix of interventions to treat conditions to meet the health
Millennium Development Goals (MDGs) and interventions targeting non-communicable
diseases.20 However, it will be important over time that the ABG tries to increase its
government-sourced health expenditure to levels comparable to other Melanesian countries,
in order to improve its health services overall, as well as using ongoing workforce and health
system productivity gains.
6. Government-sourced health expenditure growth scenarios
Up to 2015, the ABG can rely on its own funds (using the 100 million kina per year GoPNG
grant) and GoPNG funds to finance its needs for health and other government expenditures.
Beyond 2015, it is uncertain where the sources of government expenditure will come from,
and this is dependent on the outcomes of the referendum. At the moment, GoPNG collects
tax on behalf of ABG and returns an agreed proportion back to ABG. If ABG remains
autonomous, it is uncertain to what extent and how long it will take for overall taxation
imposition and collection responsibilities to transfer to ABG. If ABG becomes an independent
nation, this date will be reliant on the date of the referendum (between 2015-2020) and the
time it takes to totally transfer powers, including all taxation responsibilities. So between
2015 and when there develops a significant revenue stream for the ABG, possibly from 2020
onwards, when the Panguna mine starts to generate revenue, the ABG will need to find a
way to finance its government services, including health. If it becomes independent, it can do
20
From World Health Report 2010 chapter 2 pages 22-23
54
this partially by taking over taxation powers from GoPNG at the time when PNG stops
providing government funding.
With this uncertain context in mind, three financial scenarios for ABG Health are given
below. The expenditure figures include both recurrent and capital expenditures.
Scenario 1: Total government sourced expenditure rises only to match population
increases – so that per capita expenditure stays constant
Up until 2015, GoPNG have committed 100 million kina to ABG, of which it is understood,
the ABG Health division will receive 15%, that is 15 million kina.
In this scenario, expenditure would increase from 2012 to 2013, because of the 15 million
kina introduced to the ABG budget in 2013, and this would stay the same until 2015. From
that point on, expenditure, it is assumed wholly funded by ABG, would stay at the 2015 level
of US$69.12 per capita, but increase with population increases. So whilst the budget would
increase by 2.3% per year to 2020 and then by 2.0% to 2030, it would only be rising with
population increases and there would be no real per capita increase in expenditure.21
Expenditure stays at
US$69.12 per capita
21
For the purposes of these scenarios, it has been assumed population will increase by 2.3% to 2020
and then by 2.0% to 2030.
55
This scenario would mean that by 2030, expenditure per capita would still be well below the
per capita expenditure of ABG’s southern Melanesian neighbours. These countries range
from US$100 to US$143, with a crude average of US$120. This expenditure scenario would
in effect mean that ABG Health would remain severely underfunded and would most likely
not reach its desired health status targets.
Scenario 2: Bring ABG health expenditure up to US$120 per capita by 2030 on a
steady basis with a 5.92% increase per year
US$120 per capita by 2030
Likely funding gap
period
US$100 per capita by 2025
If the ABG decided to reach an expenditure target level of US$120 per capita by 2030, it
would require a percentage increase in annual expenditure from 2015 of 5.92%. It would not
reach US$100 per capita until 2025. With this scenario, it assumes that GoPNG expenditure
would cease by the end of 2015, and from that date onwards the funding would come from
ABG sources. This includes both recurrent and capital funding.
Scenario 3: ABG achieves US$100 per capita government health expenditure 5 years
earlier than scenario 2, by 2020, and a US$120 per capita health expenditure by 2030.
This means ABG would need to have higher percentage annual increases in the first 5 years
to achieve the US$100 per capita target earlier. To achieve these expenditure targets, it
would require an annual percentage increase in the health budget of 10.14% to 2020, and a
3.87% increase from 2020 to 2030 (as indicated by the more gradual curve in the graph after
56
2030. Whilst this scenario allows achievement of the US$100 target earlier, it also means a
much higher percentage increase in funding in the 5 years from 2015, just in the time period
of likely funding uncertainty.
US$120 per capita by
US$100 per capita by 2020
2030
Likely funding gap period
Summary
Scenario 1 would not allow ABG to be sufficiently funded to reach its health status
objectives. Scenario 3 puts too much pressure on funding requirements in the period 2015 to
2020, which is the period of most funding uncertainty. Scenario 2 has a more modest but
steady growth of 5.92% per annum, and allows for a funding target of US$100 per capita to
be achieved by 2025 and US$120 per capita by 2030. Scenario 2 is the most optimum.
7. The recurrent and capital expenditure mix
Because the WHO international comparisons of government-only financial sources quoted
above use both capital and recurrent expenditures combined, so too does this analysis. This
allows projections of target dates for US$100 and US$120 to be developed. However, in
practice, capital and recurrent funding needs to be separated. With the steadily increasing
overall health budget that Scenario 2 outlines (5.92% per annum) from 2015 to 2030, there
is scope to utilise some of the increase for recurrent and some for capital purposes. Because
recurrent health expenditures are generally non-flexible downwards (they can only generally
rise or stay the same, because of locked in recurrent costs like wages and other program
commitments) it is useful to project recurrent costs based on Scenario 2 (5.92% growth) and
57
the 2012 recurrent expenditure estimates. These projections can act as a tool for recurrent
expenditure growth using 2012 as the baseline expenditure.
The graph of estimated recurrent health expenditure to 2030 is given below. Between 2012
and 2015, it rises from 28.72 million kina to 36.27 million kina, due to the commitment of
GoPNG providing the 15 million kina per annum to ABG and the GoPNG providing most of
the recurrent health funding. From 2016, there is a steady 5.92% increase. However, as
indicated in the graph, ABG’s contribution will need to rise dramatically from 2015 to 2016,
from 8.093 million kina to 38.42 million kina, to replace the loss of 21.27 million kina
which up until then would be provided by GoPNG. This situation would arise if ABG was an
independent nation from 2015 onwards. This may or may not be the case, but this
assumption has been made in this document to indicate the possibility of the most critical
funding situation occurring. ABG needs to prepare for such a possibility, given that a
referendum could occur as early as 2015.
Note – See Table below for inflation adjusted data.
As a guide to funding needs to ensure a steady 5.92% growth to 2030, the data has been
provided in Annex 1, also with Kina funding needs taking into account inflation changes.
Capital funding spending can be projected in a similar way using the 2012 government
sourced capital funding estimate as a base. However, this baseline figure for 2012 of 6.093
million kina may or may not be appropriate, and given the need to upgrade health facilities
58
over the next few years, it is probably inadequate. However, the capital funding projections
could act as the minimum required per year to ensure the total government sourced
expenditure (recurrent and capital) reaches the US$120 per capita target by 2030.
In the next few years (probably beyond 2020) ABG could source significant extra capital
funding from its own resources, especially when the government tax and mining royalty
revenue base starts to climb. However, in the intervening period, from now to 2020 at least,
external sources of additional capital funding will be needed to finance planned restoration
and capital development projects in the health sector (e.g. hospitals and health centres and
their equipment requirements).
Note – See Table below for inflation adjusted data.
9. Recurrent and capital expenditure projections taking into account losses in
purchasing power due to inflation
Inflation rates within an economy are an indication of rising prices but not extra resources,
whether they be staffing, operational costs, medical supplies, transport and other recurrent
expenses. Because of inflation, the same resources cost more, and that is why expenditure
data needs to be adjusted by the inflation rate, which is a crude average of the rise in prices
of the same number of goods and services.
59
In the graph and table below, the recurrent and capital expenditure increases projected to
2030 at 5.92% per year, in order to reach a total expenditure target of US120 per capita,
have been adjusted for inflationary price increases. These are the increases which can be
used to guide recurrent and capital budget increases into the future to achieve the
US$120 target by 2030. However, the figures are a guide only and should be treated within
the context of the objectives of the Health Plan, taking into account over time emerging
funding requirements and the limits of funding availability.
For the purposes of the projections a long term 6% inflation rate is used.22
22
This is used given the latest rates of suppliers of goods and services vary from 2.9% to 11.7%
(Australia 2010 2.9%, PNG 2010 6.8%, China 2010 5%, and India 2010 11.7%). Source:
http://www.indexmundi.com/
60
Table 7: Inflation adjusted ABG health recurrent and capital expenditures needed to
ensure a 5.92% steady growth rate in real terms – to achieve a US$120 per capita (in
real terms) expenditure target by 203023
Total
expenditure
(2012 kina
millions)
Total
recurrent
expenditure
needed to
offset 6 %
inflation
Total
capital
expenditure
needed to
offset
inflation
Total
expenditure
needed to
offset
inflation
6.09
28.72
22.63
6.09
28.72
30.18
6.09
36.27
31.99
6.46
38.45
2014
30.18
6.09
36.27
33.91
6.85
40.75
2015
30.18
6.09
36.27
35.94
7.26
43.20
2016
31.96
6.45
38.42
40.35
8.15
48.50
2017
33.85
6.84
40.69
45.30
9.15
54.45
2018
35.86
7.24
43.10
50.87
10.27
61.14
2019
37.98
7.67
45.65
57.11
11.53
68.64
2020
40.23
8.12
48.35
64.12
12.95
77.06
2021
42.61
8.60
51.21
71.99
14.53
86.52
2022
45.13
9.11
54.24
80.82
16.32
97.14
2023
47.80
9.65
57.45
90.74
18.32
109.06
2024
50.63
10.22
60.85
101.88
20.57
122.45
2025
53.63
10.83
64.45
114.38
23.09
137.47
2026
56.80
11.47
68.27
128.42
25.93
154.35
2027
60.16
12.15
72.31
144.18
29.11
173.29
2028
63.72
12.87
76.59
161.87
32.68
194.56
2029
67.49
13.63
81.12
181.74
36.70
218.44
2030
71.49
14.43
85.92
204.05
41.20
245.24
Total
recurrent
expenditure
(2012 kina
millions)
Total
capital
expenditure
(2012 kina
millions)
2012
22.63
2013
Year
23
Note $120 per capita expenditure in 2012 dollars is equivalent to S342 per capita in 2030 dollars.
120X(1.06)18 = US$342.52. If this is divided by 0.489 to convert to kina and then multiplied by the
projected population in 2030 of 350,443 the answer is 245,467,000 kina. This is the same as the
projected total expenditure inflation adjusted in the table above (rounding off explains the small
difference).
61
10. Staffing needs to develop an accounting and finance capacity for ABG Health
It will be important to further develop the accounting and finance capacity of AGB Health by
employing and/or training a suitable person to oversee and manage the ABG health sector
finance system. Ideally, this person would be a qualified accountant, eligible to be a member
of one of the professional accounting bodies recognized in PNG. This would normally require
at least a diploma in accounting or business studies with major studies in accounting. It
would also be useful for this person to have some training in economics. This person could
service the health sector by either working in the overall administration of ABG, but
dedicated to the health services, or working specifically within a proposed health
department, whichever structure may emerge.
11. Health Commitment Table 2012-2030 ABG Health
This table is provided as an accompanying excel spreadsheet. (Health Commitment Table to
2030.xlsx ) It can be used as a finance planning tool for ABG Health. The table indicates on
an annual basis the funds available for planned increases in recurrent and capital
expenditures, and what available funding can be carried forward for later years. It is a
flexible Excel table and can have different financial inputs to the ones utilised currently.
It assumes that funds available in 2012 are fixed and committed. From 2013 to 2015, the
recurrent funding increases as a result of the 15 million kina made available and committed
to ABG Health from the ABG.
This forms the basis of committed funding at 2015.
From 2016 onwards it is assumed there will be no more funding from GoPNG and that all
funds are from the ABG. It is also assumed that from 2016 onwards this funding will
increase by 5.92% per annum to 2030. This funding can be used for recurrent or capital
spending.
Increased expenditures as per the Health Plan priorities are then matched against these
steady annual increases in funding. These expenditures are included as sufficient funding
becomes available.
It is assumed that when recurrent expenditures are included, they then form the basis of an
increased recurrent expenditure base (i.e they stay in the recurrent budget in following
years).
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When capital expenditures are included, they may be included partially over a number of
years, depending on funding available each year, or if small enough they are completed in
one year.
When capital expenditures do span more than a year, related recurrent funding is added
partially over those years to reflect the amount of the project completed and operating.
When a capital expenditure is completed by the end of a year, it is assumed that the full
recurrent spending relating to it will occur in the following year and will then continue
annually.
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Appendix 10: Draft timetable of significant events
Plan timetable and financial impact (Draft 20/04/12)
Event
Begin
Complete
Comments/
Impact
Capital
Recurrent
Health goals
Measles elimination*
2012
2015?
95% measles
vaccine coverage
in all regions for 2
years. Other
WHO criteria to
apply before
elimination can be
declared.
See DHFF
See DHFF
MDG 5 compliance*
2012
2014?
Meet criteria set
by Maternal
Health Taskforce.
MDG 4 compliance*
2012
2018?
Universal health
coverage*
2012
2019?
Free, accessible
primary health
care for 99% of
ARB population.
?
WHO criteria for
elimination.
Malaria elimination
DHFF
Health services
Essential obstetric care in
all health centres and
community health posts
2012
Maternity/ midwife training
program for all existing
staff involved in deliveries
2014?
RHSD funding
Nil
0.2
2014?
All deliveries
conducted by
trained NO/CHW.
RHSD funding
Maximise the
potential of
existing staff.
RHSD funding
Training needs
assessment and training
program developed and
implemented for all
existing staff
2012
2013
ABG tobacco free policy
and practice
2013?
2020?
ABG home brew and
alcohol PH program
2014?
2018?
Develop and implement
nutrition strategy to
address first 1000 days
and NCDs
2014?
2020?
1m
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Plan timetable and financial impact (Draft 20/04/12)
Event
Begin
Complete
Medical supplies move to
Pull system
2013?
2014?
Decision on medicines
purchasing options for
ABG.
2014?
Buka Hospital reaccreditation
2013?
Diagnostics – Digital Xray
established in 2 district
hospitals
2020?
Integration of BHCP into
health services and
coverage of all villages
2013
Introduction of
pneumococcal vaccine
2014?
Medical supplies, and
equipment electronic
inventory and ordering
system
Comments/
Impact
Improved medical
supplies
Capital
Assess impact of
current
approaches and
move to Improved
medical supplies.
Neutral
Recurrent
GoPNG
funded
1m
2014?
1m
Reduced child
admissions for
pneumonia
2015?
Integrated Information
system linking all levels
and facilities
2012
2019?
DHFF facility level funding
and removal of user fees.
2011
2013
Drs deployed to districts
and major facilities –
increasing skills in
facilities.
2013?
2025?
STI clinics (2)
2012
2012
At Buin and
Arawa. AusAID
project currently
underway.
Already
committed
Rural Health Service
Delivery rural health
infrastructure upgrade
2012
2016?
Rural Health
Service delivery
project currently
Already
committed
Increased
utilisation,
increased
performance at
facilities.
3.3M
Buildings
65
Plan timetable and financial impact (Draft 20/04/12)
Event
Begin
Complete
Comments/
Impact
covers South and
Central and is
underway.
Additional support
required for North
region’s rural
facilities.
Capital
Recurrent
CHW training school
establishment
?2012
2018
Increased
availability of
CHWs. Cost
approx K10m.
K10m
K2m
Arawa District Hospital
Development
?2015
2020
Cost of new
District Hospital
$25m.
K25
K5m
Rural Hospital
development Tanamalo,
Moratona
?2020
2022
Cost $5 -10m per
site.
K10m
K2m
Buin Hospital
development
Development of Buka
Hospital as provincial
hospital
?2016
2021
Cost K10m
K10m
K2,2
2022
2029
Cost K100- 120m
if new site
required.
K120m
K20m
Nursing school
development
2023?
2030
Children’s hospital
development
Post 2030
Governance and
management
Establish Health Plan
Independent advisory
group
2012
2012
Advises Minister
on progress of
this plan.
Establish Bougainville
Health Board
2012
2012
Coordinating
mechanism for
health sector
organisations
(church, hospital,
rural, NGO).
Establish Bougainville
Health Authority
2012
2014
Merger Rural
Health and
hospital services.
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Appendix 11: Prioritisation and sequencing
Evidence based business cases should be prepared for all projects exceeding PNG K1
million. Business cases should respond to the criteria below.
PRIORITIZATION
In determining priorities, the health sector will assess various options, by applying and
considering the following principles.
1. Equity
2. Impact
3. Disability adjusted life years (DALYs) gained
4. Technical feasibility
5. Effectiveness
6. Efficiency
7. Cost
8. Opportunity cost
9. Sustainability
10. Consistency with health sector values
11. Cultural acceptability
TIMEFRAME FOR IMPLEMENTATION
In determining when various strategies should be implemented, the health sector will
consider the following principles.
1.
2.
3.
4.
Time to benefit
Pre- requisites in order for strategy to be viable/beneficial. (personnel, finances)
Benefit of small scale introduction before expansion and roll-out
Recurrent cost of maintaining strategy and how this affects ongoing annual
expenditure
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Appendix 12: Technical advisory group for this plan.
This plan was prepared following direction given by the Vice President & Minister for Health
of ARB, The Honourable Patrick Nisira and from four days of discussion with a technical
advisory group from the ARB health sector and consultation with a wide range of
stakeholders.
Plenary sessions were attended by:
Laurence Disin, ABG Chief Administrator
Raymond Masono, ABG Deputy Administrator
Members of the technical group:
1. Dr Pumpara, CEO, ARB Health Division
2. Dr Imako, CEO, Buka General Hospital
3. Simon Disin, Director of Policy, Planning and Administration ARB Health Division
4. Alois Pukienei, Director of Public Health, ARB Health Division
5. Matthew Monei, Director of Corporate Services, Buka GH
6. Vincent Momei, Environmental Health, ARB Health Division
7. Michaelyn Pau, Catholic Church Health Secretary
8. Rev Abi Enoh, United Church Health Secretary
9. Hona Nolan, Women’s Representative,
10. Puara Kamariki, CEO for Human Resource, ARB
11. Maria Cartwright, NGO Health Rep, MSF
12. Ruby Mirinka, Bougainville Healthy Communities Program
13. Aileen Pilau, Health Information Officer
14. Peter Awin , Health Centre
15. Ms. Agnes Titus, UNDP
16. Ross Naylor, Health Economist
17. Dr Isaac Ake, Health Sector Expert and NDoH Representative
18. Dr Joan Macfarlane, Public Health Specialist
19. Prof Don Matheson, Health Planning Specialist and Lead Adviser
Stakeholders Consulted:
Vice President & Minister for Health ARB:
Secretary of Health
NDoH Strategic Policy Division:
Technical Adviser, Health Economics,
Senior Planner (Strategic)
Facilities branch
Asian Development Bank:
WHO Representative:
PNG Finance Consultant :
ARB CEO Finance,
The Honourable Patrick Nisira
Pascoe Kase
Navy Molou
Roselyn Melua,
Mr Ambrose Kwaramb.
Rob Akers
Dr William Adu-Krow
Dr Paulinus Sikosana
Dr Mohammed Salim Reza
Gima Ruba
Graham Kakaroutz
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CEO Planning and Aid Coordination
GoPNG Secretary of Treasury
AusAID
UNICEF, Chief, Child Protection,
NZAID New Zealand Program Aid Manager
UNFPA, Assistant Representative
World Bank Human Development Operations
Lesley Tseraha
Simon Tosali
Dr Geoff Clark
Elaine Bainard
Dr. Grace Kariwiga
Rebecca Lineham
Dr Gilbert Hiawelyer
Ms. Ellen Kulumbu
69