The Bougainville Plan for Health

advertisement

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

400000

350000

300000

250000

200000

150000

100000

50000

0

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 increasin gly 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.

ARB Population trend and projection

Census

Predicted

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%

60%

40%

20%

0%

NATIONAL

KIETA - CENTRAL

BUKA - NORTH

BUIN - SOUTH

ARB

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

100

NATIONAL

KIETA - CENTRAL

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

Good health

Long life

Women at centre

Strategies

Strengthen health systems and governance

• Improve financial resources and management

• Medical supply

• Information and ICT

• Independent planning and monitoring mechanism

Strengthen partnership and coordination

• Collaborate with partners.

• Negotiate health improvements with extractive industries

Improve service delivery

• Increase access to quality health services

• Strengthen the infrastructure

• Health workforce strengthening

• Access to traditional herbal medicine

Improve child survival

• Immunisation coverage

• IMCI

• Reduce deaths of neonates

• Reduce malnutrition

Improve maternal health

• Family planning

• Safe supervised deliveries

• Improved emergency obstrtetric care

• Sexual and reproductive health

Reduce communicable diseases

• 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, 2011 1

120

100

HW/Population Ratio

(2008)

80

60

North 828

Central 861

South 680

40

South

Central

North

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

2012 Kina (Mill)

15

10

17.80%

5

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

Expenditure

US$

100

80

60

40

20

0

35

58,59

100

108

131

PNG ABG Solomons Fiji

143

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

2030

Likely Funding Gap

80 period

Total Government

Sourced

Expenditure 2012

Kina (Millions)

60

40

US$100 per capita by

ABG

GoPNG

Total

20 2025

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?

2013

ARB achieves 95%

Immunisation coverage

2017

ARB achieves Universal Coverage ?

2014

Population growth slows to

Xxxx births per year

2020

ARB achieves MDG4 ?

Health Goals

2030

ARB Eliminates Malaria

Life expectancy 75

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

2012

2012

STI clinics Arawa and Buin

2014

Access to free care

And full immunisation through DHFF rollout.

2015

Rural Health

Infrastructure

rejuvenated

2019

Arawa Hospital re-built

2019

Rural Hospital development (2)

2023

Nursing school established

Building Blocks

2027

Provincial Hospital Upgade

2030

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

Health centres and sub health centres

Buka Hospital — enhanced specialist capacity

Aid posts

Arawa, Buin, Tanamalo, Moratona

District and Rural Hospitals

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 in-

16

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

STI Clinics (2)

Rural health service delivery

& rural health infrastructure upgrade

Rural health service delivery

& rural health infrastructure upgrade

CHW training school establishment

Arawa District

Hospital development

Rural hospital development

Tanamalo,

Moratona

Buin Hospital development

Start

2012

Finish

2012

Comments Capital cost Additional staff

At Buin and Arawa AusAID project funded and currently underway

Recurrent costs.

2012

?2013 ?2016

?2018 ?2020

?2020 ?2019

?2016 ?2021

2022

2016?

2022-

2029

Covers South and

Central Region

North

Increased availability of

CHWs

New/rebuilt district hospital

Currently MSF supporting this service at K2.2m per year till 2016

ADB/AusAID/ and other donors. K20m over 5 years

No funding identified

K 10m

K25m

K20m

?K10m

K120m

? 20

? 10

60

?20

?15

?

?K1m

? K0.5m

Currently met by

GoPNG

?K5m

? K2m

?2.2m

? K20m Development of Buka

Hospital as provincial hospital

Nursing school development

Children’s hospital development

2023? 2030

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 Mitigation

Financial resources for health well below predictions

Financial resources to ARB government well below that required to sustain health services

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.

Instability in PNG government and interruption of resource flows

Decentralise (DHFF) to support local level activity even when access is difficult.

Work with Donors to achieve uninterrupted funding flows. Ensure neutrality of facilities and personnel.

Change in donor policies reducing donor support

Implementation failure of major priorities

Increase rate of ABG financial self reliance.

Trained Health workers migrate to other countries. 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 Strategy 3

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.

1.2

1.3

Rehabilitate and strengthen PHC and hospital infrastructure and equipment.

The right health professionals work in the right places, are motivated, and deliver right (quality) services.

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 Rationalize best locations and type of health facilities based on an assessment of the population served and travel time.

1.2.2 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.

1.2.3 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.

1.2.4 Establish district hospitals in Arawa and Buin.

1.2.5 Establish regional hospitals resourced to provide quality health care.

1.2.6 Establish a major referral hospital for Bougainville.

1.3.1 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).

1.3.2 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.

1.3.3 Develop training needs assessment and deliver training for current and future HHR including developing CHW and NO training schools.

1.3.4 Ensure regular clinical and management supervision by personnel trained in supervision to HCs, HSCs and CHPs, based on checklists and health standards.

1.3.5 Increase staff ceilings for critical health workers and

24

Objectives Strategies

1.4 Promote easy access to safe and effective forms of traditional medicine and practices as part of the ARB health system. 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 Compile and keep updated an inventory of safe and effective herbal medicines used in Bougainville. Publish the inventory as a booklet.

1.4.2 Develop a quality assurance system for herbal medicines and practitioners.

1.4.3 Develop techniques for the production and preservation of herbal medicines.

1.4.4 Train traditional medical practitioners (TMPs) and traditional birth attendants (TBAs) in primary health care.

1.4.5 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.

1.4.6 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.

2.2 Implement ABG public private partnerships policy and introduce innovative and cost effective options for delivering 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.

2.2.1 Enter into agreements with extractive industries to reduce health impact and agree mitigation measures before mining operations begin.

2.2.2 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.

3.2 Medical supply procurement and distribution services are efficient and

3.3 accountable.

The health sector proactively identifies and uses innovative and evolving ICT solutions and delivers accurate and timely information for planning and decision making.

3.4 The Minister for Health is supported by an external advisory group which monitors the implementation of the

Bougainville Health Plan.

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.

3.2.1 Assess the feasibility of ABG procuring its own medical supplies and the delegation of Pharmaceutical Board responsibilities.

3.2.2 Develop a ‘Pull’ system for medical supplies management for all HCs, HSCs, CHPs.

3.2.3 Merge hospital and rural health services medical supplies systems.

3.3.1 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.

3.3.2 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.

3.3.3 Increase the use of mobile phones for data collection and transfer.

3.3.4 Ensure all health sector providers including the private sector support ARB and national health surveillance systems.

3.4.1 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.

3.4.2 The Minister of Health holds the CEO Health accountable for the delivery of services in accordance with relevant legislation and the Bougainville Health Plan.

3.4.3 Strengthen the performance monitoring and evaluation framework, by linking information about and reporting on performance, HR and financial resources.

3.4.4 Planning, budgets, expenditure and management decisions are linked to health priorities and evidencebased. Business cases are prepared for all projects exceeding PNGK1 million.

3.4.5 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 Strategies

4.1 Increase coverage of childhood immunization in Bougainville.

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.

4.3 Decrease neonatal deaths.

4.1.1

4.2.1

4.2.2

4.2.3

Ensure every facility, every day, at every encounter immunizes children when indicated.

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.

4.4 Reduce malnutrition

(moderate to high) in children under the age of five years.

4.3.1 Ensure all HCs and CHPs have the capacity to provide lifesaving support to the neonate.

4.3.2 Ensure 99% coverage of tetanus toxoid for antenatal mothers.

4.4.1 Adopt the ‘First 1000 Days’ strategy.

4.4.2 Support the continuation of exclusive breastfeeding.

4.4.3 Ensure all babies and children under five have access to supplementary feeding when and where they require it.

4.4.4 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 Strategies

5.1 Increase family planning coverage.

5.2 Increase the capacity of the health sector to provide safe and supervised deliveries.

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.

5.2.1 Increase the number of facilities capable of providing supervised deliveries.

5.2.2 Increase the numbers of health workers skilled in obstetric care.

5.3 Improve access to emergency obstetric care (EOC).

5.2.3 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.

5.3.1 Increase the capacity of all HCs and CHPs to provide essential EOC.

5.3.2 Ensure all high-volume facilities are capable of providing comprehensive obstetric care.

5.4.1 Increase the knowledge of adolescents about sexual and reproductive health.

5.4 Improve sexual and reproductive health for adolescents. 5.4.2 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 Strategies

6.1 Reduce malaria-related morbidity and mortality in Bougainville.

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 Control tuberculosis (TB) incidence by 2020, with a decline in cases of multi-drug-resistant tuberculosis (MDR-TB).

6.3 Scale up prevention, treatment, care and, support for sexually transmitted infections

(STIs) and HIV to meet universal access targets.

6.2.1 Ensure all TB cases have access to tuberculosis directly observed treatment, short-course (TB DOTS).

6.2.2 Provide HIV counseling and testing for all TB cases.

6.2.3 Strengthen, integrate and implement TB and HIV collaboration.

6.2.4 Work with ABG to develop an intersectoral approach to

6.3.1

6.3.2 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

6.4 Strengthen communicable disease surveillance and monitoring. for adults and children.

6.3.3 Ensure male and female condoms (and lubricants) are available and accessible throughout Bougainville.

6.3.4 Increase access to post-exposure prophylaxis (PEP) services.

6.3.5 Strengthen syndromic management of STIs.

6.3.6 Increase the knowledge of adolescents about sexual and

6.4.1 reproductive health.

Introduce an integrated surveillance and monitoring strategy for cholera, emerging diseases, neglected tropical diseases, hookworm, leprosy and other infectious diseases.

6.4.2 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

7.2 response to the prevention of injuries, trauma, and violence.

Reduce the number of outbreaks of food and water-borne diseases.

7.3 Reduce morbidity and mortality from noncommunicable diseases.

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.

7.2.1 Establish water management committees to manage and control rural water supplies and sanitation.

7.2.2 Increase the number of households that have access to safe drinking water, and effective waste disposal and sanitation.

7.2.3 Ensure all health facilities have access to running water, and effective waste disposal and sanitation.

7.2.4 Ensure public and private buildings comply with legislation in relation to water supply, sanitation, and food handling.

7.2.5 Review and improve relevant legislation to enhance the management and control of rural water supplies.

7.3.1 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.

7.3.2 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.

7.3.3 Support employers in ARB to promote healthy diet, opportunities for regular physical activity and smoke-free working environments.

7.3.4 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.

7.3.5 Improve and expand mental health services to address a range of mental health issues, including post-traumatic stress disorder.

7.3.6 Improve disability and community-based rehabilitation services.

7.3.7 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.

8.2 Establish Bougainville

Public Health Laboratory

(BPHL) function to provide services to meet urgent and emerging concerns.

8.3 Improve capacity and preparedness of the health sector to address the impacts of climate change.

8.4 Ensure the health sector works collaboratively to manage population health threats related to the growing resources boom.

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.

8.2.1 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.

8.2.2 Ensure a functioning and safe blood transfusion service is available to the health sector and includes HIV blood screening capability.

8.3.1 Actively engage in the resettlement process for climate change refugees to ensure their health needs are met.

8.3.2 Ensure every health facility has a disaster preparedness plan, which includes issues associated with climate change.

8.4.1 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.

9.2 Create Bougainville

Health Authority.

9.3 Implement Bougainville

Health Plan.

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.

9.2.1 Develop policy and legislative provisions to form the

BHA.

9.3.1 Establish and convene an independent advisory group to advise the Minister on the implementation of the

Bougainville Health Plan.

9.3.2 Report annually to the ABG parliament on the progress in implementing the Bougainville Health Plan.

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:

ARB 2011 1

Best ARB Region

2011

Average outpatient visits per person per year in hospitals and health centres

0.9

0.9 Buka – North Region and Buin – South Region

Best ARB Health 2.0 Sipai Health Subcentre

Facility 2011

Worst ARB Region

2011

Worst ARB Health

Facility 2011

PNG 2010 2

PNG Target 2015 3

ARB Target 2015

0.8

0.1

1.62

1.3

Kieta – Central Region

Panguna Health Subcentre

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:

ARB 2010 1

Best ARB Region

2010

Percentage of children under five less than 80% expected weight for age

22%

16% Kieta – Central Region and Buin South Region

Best ARB Health

Facility 2011 2

0% Buka Hospital, Boku Health Centre

27% Buka – North Region Worst ARB Region

2010

Worst ARB Health

Facility 2011

PNG 2010

PNG Target 2015 3

ARB Target 2015

73%

28%

26%

18%

Lenoke Health Subcentre

Sources:

1

ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

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:

ARB 2010 1

Best ARB Region 2010 60% Buka – North Region

Best ARB Health

Facility 2010 2

Worst ARB Region

2010

80% Buka – North Region

33% Kieta – Central Region 46% Kieta – Central Region

Worst ARB Health

Facility 2010

PNG 2010

PNG Target 2015 3

ARB Target 2015 4

Increase coverage of childhood immunization in Bougainville

Measles immunization coverage for children less than 1 year

63%

3 RD dose TA/pentavalent coverage at 12 months of age

63%

50%

73%

73%

51%

80%

73%

Sources:

1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

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: Increase the capacity of the health sector to provide safe and supervised deliveries

Indicator:

ARB 2010 1

Best ARB Region 2010

Best ARB Health

Facility 2011 2

Worst ARB Region

2010

Worst ARB Health

Facility 2011

PNG 2010

PNG Target 2015 3

ARB Target 2015 4

Percentage of supervised births at health facilities

56%

71% Buka – North Region

Antenatal coverage (at least 1 visit)

76%

91% Buka – North Region

115% Moratona Health Centre 287% Buka Urban Clinic

39%

1%

40%

54%

Kieta – Central Region

Konga Health Subcentre

65%

36%

62%

70%

Buin – South Region

Piva Health Centre

67% 91%

Sources:

1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

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:

ARB 2010 1

Best ARB Region

2010

Couple years protection per 1000 women aged 15-44 years

74

149 Buka – North Region

780 Buka Urban Clinic Best ARB Health

Facility 2011 2

Worst ARB

Region 2010

15 Buin – South Region

Worst ARB

Health Facility

1

2011

PNG 2010

PNG Target

2015 3

74

115

ARB Target 2015 115

Katuhkuh Health Centre

Sources:

1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

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:

ARB 2010 1

Malaria incidence per 1000 population

201

Best ARB Region 2010 92

Best ARB Health

Facility 2011 2

Buin - South Region

329 Buka – North Region Worst ARB Region

2010

Worst ARB Health

Facility 2011

PNG 2010

PNG Target 2015 3

ARB Target 2015 4

236

180

200

Sources:

1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

2 Not available

3 PNG MTDP 2011-2015

4 ARB 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:

ARB 2010 1

Incidence of diarrhoeal disease per 1000 children less than 5 years

Best ARB Region 2010

166

114 Buin - South Region

Best ARB Health

Facility 2010 2

Worst ARB Region

2010

Worst ARB Health

Facility 2010

PNG 2010

PNG Target 2015 3

ARB Target 2015

228

276

100

Buka –North Region

Sources:

1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

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:

Indicator: population

ARB 2010 1

Increase health sector response to injuries, trauma and violence

Total injuries reported at health centre and hospital outpatients per 100

Best ARB Region 2010 12 Buin – South Region

Best ARB Health

Facility 2010 2

Worst ARB Region

2010

18 Kieta – Central Region

Worst ARB Health

Facility 2010

PNG 2010

PNG Target 2015 3

ARB Target 2015

14

33

10

Sources:

1 ARB 2010 data from ‘Annual Sector Review North Solomons Province District Performance 2006-

2010’

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

•Under five mortality

•Immunisation rates

•IMCI functioning at all facilities

Improve maternal health

Reduce communicable diseases

Prepare for disease outbreaks and new population health issues

•Family planning rate

•Maternal mortality

•Supervised deliveries

•TB, HIV, STI, malaria prevalence

•TB detection rate

•TB treatment rate

•HIV VCT acceptor rate

•ART and PPCT

•PH laboratory established

•Surveillance reports

Healthier lifestyles

Autonomous

Bougainville health system

•Rates of illness and death from injuries, cancers, diarrhoeal, cardiac and respiratory illnesses

•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 Health related goals/aspirations

ARB

Constitution

Vision 2050

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

‘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 2011-

2015

As per Development Strategic Plan 2010-2030

NHP 2011-2020 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

Bougainville

Health Summit

2009 development, and good governance at all levels.

HSSP 2012-2015 As per National Health Plan 2011-2020

ABG MTDP

2011-2015

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

INDICATOR

Infant mortality rate

Under 5 mortality rate

Maternal mortality rate

Life expectancy

Incidence of tuberculosis

Incidence of malaria

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

Baseline

47/1000 in

2000

62/1000 live births in

2006

123.5/1000 lives births in 2009

59.6 years in

2000

Indicators and targets from relevant planning documents

ARB Medium Term Development Plan 2011-2015

2015 Target

35/1000

46/1000

117/1000 live births

2020 Target

26/1000

37/1000

113/1000 live births

2025 Target

17/1000

27/1000

111/1000 live births

Millennium

Development

Goals

2015 PNG

Tailored target

44 per 1000 live births

72 per 1000 live births

274 per 100,000 live births

PNG

Development

Strategic Plan

2010-30

2030 Target for

PNG

Less than 17 per

1000

Less than 20 per

1000 live births

Less than 100 per 100,000 live births

Males 62.2

Females 62.7

Males 64.2

Females 64.7

Males 66.2

Females 67.2

70 years

158/100,000 in 2008

246/1,000 in

2008

153/100,000

200/1,000

127/100,000

154/1,000

122/100,000

108/1,000

Stabilized or reversed

Stabilized or reversed

Less than 150 per 100,000 people

Less than 100 per 100,000 people

N/A

1.20% in

2008

1 in 2011

180 in 2008

49% in 2008

5.5/100,000 in 2008

93 in 2008

229 in 2008

62% in 2008

86% in 2008

59% in 2008

N/A

N/A

1.1%

3

200

75%

8/100,000

300

500

67%

91%

73%

N/A

N/A

1.0%

3

210

80%

12/100,000

400

600

72%

95%

79%

N/A

N/A

0.9%

4

230

85%

17/100,000

500

700

77%

98%

87%

N/A

Keep incidence low

Less than 5%

50% of district health centres upgraded to hospital status

7500 in PNG

100%

50 per 100,000 people

200 per 100,000 people

20,000 in PNG

95%

100%

100%

90%

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 2011-

2015 in kina (millions )4

Grants (external)

Internal revenue

Total

2012

84.8

22.5

107.3

2015

92.2

24.8

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

Church health

Rural Health

GIF Maintenance (Aust, NZ)

HIV funding

MSF

Rollover

Med supplies est

Maintenance costs 11

DHFF (est) (NZ –HSIP)

Leprosy Mission Health (NZ –HSIP)

Total

8.93

6

3.74

7

3.72

8

0.9

0.2

2.14

9

0.076

5.6

10

0.36

0.9

12

0.96

13

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.

6 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.

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

ABG contribution

Operational costs for 13 health centres

Health Division recurrent exps (not salaries

HIV funding

Rollover of recurrent costs from 2011

Maintenance costs from restoration and development

Budget rolled over from 2011

Sub-total

GoPNG contribution

Buka Hospital expenses (inc. revenue)

Church health services

Rural Health staffing costs

Medical supplies (est)

Sub-total

Total government contributions to recurrent funding 2012

Donor contributions

Maintenance (GIF)

MSF

DHFF (NZ through HSIP)

Leprosy Mission Health (NZ through HSIP)

Sub-total

Total Estimated Recurrent Expenditure 2012

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.

Kina (millions)

0.29

0.426

0.2

0.076

0.363

1.355

8.93

3.74

3.0

5.6

21.27

22.625

0.9

2.14

0.9

0.96

4.9

27.53

51

Table 4: Estimated capital funding ABG from various sources 2012

Capital Funding – ABG Infrastructure

ABG (PIP) Restoration and Development Grant 2012

Restoration and Development Grant 2011 rolled over 15

Total Government sourced capital funding

Donor contributions (capital - RHSDP) 16

Total estimated capital funding for 2012

Kina (millions)

4.50

14

1.593

6.093

2.93

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

Total government sourced capital funding

Total 28.718

Total government sourced expenditure per capita (Using the

ABG population estimate of 239668 17 )

Total government sourced expenditure per capita 18 in US$

119.82 Kina

58.59 US$

22.625

6.093

14 Autonomous Region of Bougainville, Health Capacity Diagnostic Report (March 2012) Page 21

15 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

.

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

Thailand

Tonga

Samoa

Malaysia

New Zealand

Australia

27

32

38

134

140

179

204

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

Likely funding gap period

US$120 per capita by 2030

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$100 per capita by 2020

US$120 per capita by

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 2030 23

Year

Total recurrent expenditure

(2012 kina millions)

Total capital expenditure

(2012 kina millions)

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

2012 22.63

2013 30.18

2014 30.18

2015 30.18

2016 31.96

2017 33.85

2018 35.86

2019 37.98

2020 40.23

2021 42.61

2022 45.13

2023 47.80

2024 50.63

2025 53.63

2026 56.80

2027 60.16

2028 63.72

2029 67.49

10.27

11.53

12.95

14.53

16.32

18.32

6.09

6.46

6.85

7.26

8.15

9.15

20.57

23.09

25.93

29.11

32.68

36.70

50.87

57.11

64.12

71.99

80.82

90.74

22.63

31.99

33.91

35.94

40.35

45.30

101.88

114.38

128.42

144.18

161.87

181.74

43.10

45.65

48.35

51.21

54.24

57.45

28.72

36.27

36.27

36.27

38.42

40.69

60.85

64.45

68.27

72.31

76.59

81.12

7.24

7.67

8.12

8.60

9.11

9.65

6.09

6.09

6.09

6.09

6.45

6.84

10.22

10.83

11.47

12.15

12.87

13.63

2030 71.49 14.43 85.92 204.05 41.20 245.24

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).

61.14

68.64

77.06

86.52

97.14

109.06

28.72

38.45

40.75

43.20

48.50

54.45

122.45

137.47

154.35

173.29

194.56

218.44

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).

62

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.

63

Appendix 10: Draft timetable of significant events

Plan timetable and financial impact (Draft 20/04/12)

Event

Health goals

Measles elimination*

MDG 5 compliance*

Begin Complete Comments/

Impact

2012 2015?

95% measles vaccine coverage in all regions for 2 years. Other

WHO criteria to apply before elimination can be declared.

2012 2014?

2012 2018?

Meet criteria set by Maternal

Health Taskforce.

MDG 4 compliance*

Universal health coverage*

2012 2019?

Malaria elimination ?

Free, accessible primary health care for 99% of

ARB population.

WHO criteria for elimination.

Health services

Essential obstetric care in all health centres and community health posts

Maternity/ midwife training program for all existing staff involved in deliveries

2012 2014?

2014?

2012 2013

All deliveries conducted by trained NO/CHW.

Maximise the potential of existing staff.

Training needs assessment and training program developed and implemented for all existing staff

ABG tobacco free policy and practice

ABG home brew and alcohol PH program

Develop and implement nutrition strategy to address first 1000 days and NCDs

2013?

2020?

2014?

2018?

2014?

2020?

Capital

See DHFF

DHFF

RHSD funding

RHSD funding

RHSD funding

Recurrent

See DHFF

Nil

0.2

1m

64

Plan timetable and financial impact (Draft 20/04/12)

Event

Medical supplies move to

Pull system

Decision on medicines purchasing options for

ABG.

Begin Complete Comments/

Impact

2013?

2014?

2014?

Improved medical supplies

Assess impact of

2013?

current approaches and move to Improved medical supplies.

Buka Hospital re- accreditation

Diagnostics – Digital Xray established in 2 district hospitals

Integration of BHCP into health services and coverage of all villages

Introduction of pneumococcal vaccine

2020?

2013 2014?

2014?

2015?

Reduced child admissions for pneumonia

Medical supplies, and equipment electronic inventory and ordering system

Integrated Information system linking all levels and facilities

DHFF facility level funding and removal of user fees.

2012 2019?

2011 2013

2013?

2025?

Increased utilisation, increased performance at facilities.

Drs deployed to districts and major facilities – increasing skills in facilities.

Buildings

STI clinics (2) 2012 2012

Rural Health Service

Delivery rural health infrastructure upgrade

2012 2016?

At Buin and

Arawa. AusAID project currently underway.

Rural Health

Service delivery project currently

Capital

GoPNG funded

Neutral

1m

Already committed

Already committed

Recurrent

1m

3.3M

65

Plan timetable and financial impact (Draft 20/04/12)

Event

CHW training school establishment

Arawa District Hospital

Development

Begin Complete Comments/

Impact

?2012

?2015

2018

2020 covers South and

Central and is underway.

Additional support required for North region’s rural facilities.

Increased availability of

CHWs. Cost approx K10m.

Cost of new

?2020

2022

District Hospital

$25m.

Cost $5 -10m per site.

Rural Hospital development Tanamalo,

Moratona

Buin Hospital development

Development of Buka

Hospital as provincial hospital

?2016 2021

2022 2029

2023?

2030

Cost K10m

Cost K100- 120m if new site required.

Nursing school development

Children’s hospital development

Governance and management

Establish Health Plan

Independent advisory group

Post 2030

2012 2012

Establish Bougainville

Health Board

Establish Bougainville

Health Authority

2012 2012

2012 2014

Advises Minister on progress of this plan.

Coordinating mechanism for health sector organisations

( c hurch, hospital, rural, NGO).

Merger Rural

Health and hos pital services.

Capital

K10m

K25

K10m

K10m

K120 m

Recurrent

K2m

66

K5m

K2m

K2,2

K20m

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. Time to benefit

2. Pre- requisites in order for strategy to be viable/beneficial. (personnel, finances)

3. Benefit of small scale introduction before expansion and roll-out

4. Recurrent cost of maintaining strategy and how this affects ongoing annual expenditure

67

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

68

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

Related documents
Download