Introduction

A health system can be said to be people centred when the health system captures and responds to needs of the different actors (planners, managers, healthcare workers, people) in the health system (Abimbola et al., 2014).  According the World Health Organisation (WHO) a health system consist of six building blocks and these include (1) health services (2) health workforce (3) health information (4) medical products, technologies and vaccines (5) health financing and (6) leadership and governance (WHO, 2007a). The Papua New Guinea (PNG) national health plan (NDoH, 2011) uses the WHO building blocks framework to plan improvements in the system but unfortunately it does not consider people as the centre of the health system. Rather the PNG health plan is focused on strengthening the building blocks and is disease focused (NDoH, 2011).

The health delivery mechanism in PNG is decentralised with a focus on primary healthcare (Grundy et al., 2019). The health infrastructure network consists of aid posts at the village level up to tertiary level hospitals. Every province has a provincial hospital except Central Province. The only level 7 tertiary hospital is in Port Moresby. The Provincial Health Authorities (PHA), that is being currently rolled out in PNG will unify all health service actors in every province. Church run health institutions provide nearly 50% of rural health service in PNG (Mapira & Morgan, 2011).

A recent health review of the PNG health system (Grundy et al., 2019) has identified numerous areas that need strengthening. Looking globally the Ebola outbreak in Africa showed that weak and fragile health systems can collapse if it faces a major disease outbreak (Kruk et al., 2015; Martineau, 2016). In Europe, the mass migration of people into Europe also exerted pressure on the health systems of European countries (Pottie et al., 2017). From this two major events and from other health threats, health experts realised that  health systems need to be flexible to respond to external health threats and withstand pressure on the system such as an outbreak that increases demand (Kruk et al., 2015). This paper will use the ‘3 plus 2 dimensions’ framework proposed by Hanefield et al (2018, p364) to analyse PNG’s health system and discuss how it can be made to be responsive and resilient.

What is a resilient and responsive health system?

What is a resilient and responsive health system? To understand the concept of resilience and responsiveness within a health system, we need to identify what the health system will respond to and what the system should be resilient against. This means identifying the components of the health system, how these components interact, the external influencers of the system and the things that can negatively affect the system or the threats to the system.

The WHO’s six building blocks health system framework (WHO, 2007a) is used by most countries to make their national health plans, including PNG (NDoH, 2011; F.D.R Ethiopia Ministry of Health, 2015). Health systems have been described as ‘complex adaptive systems’ and that making changes to any of the six building blocks has unpredictable and sometimes negative effect on other components of the system (Paina & Peters, 2012, p367). Although the WHO health system framework helps us understand the mechanisms and interactions of the components, it does not factor people (Hanefeld et al., 2018). Instead the WHO building block framework measures disease outcomes or other health goals as its primary system result output (WHO, 2007a). This gap has been identified and in recent years there has been a move towards ensuring health systems centre around people and their health needs (WHO, 2007b). Such a system has been referred to as a people centred health system (Abimbola et al., 2014). The ability of any health system to respond and be resilient can be cultivated to ensure it responds to the needs of the people who are part of the system or receiving service from the system as well as being resilient against any external threats such as natural disasters or disease outbreaks (Abimbola et al., 2014; Barasa et al., 2018).

Threats to a health system

Threats to a health system can be internal or external (Barasa et al., 2018). Internal threats refer to risks coming from within the health system (Barasa et al., 2018). External threats or risks are those from outside the health system and in the context of health system resilience these threats can be natural or manmade (Hanefeld et al., 2018). For example, disease outbreaks, natural disasters and economic crisis are few examples of external threats to a health system (Hanefeld et al., 2018). World Health Organisation further clarifies public health threats in detail as any new or emerging disease, use of biological or chemical agents in warfare whether it is accidental or deliberate, natural or manmade disasters and any other complex emergencies that affect human health (WHO, 2012). Indentifying potential threats and planning how to respond to these threats helps builds resilience in a health system (Barasa et al., 2018; Hanefeld et al., 2018).

Several chronic and new health threats are challenging the PNG health system (Kaluthotage, 2020). When a health system faces a crisis, routine services are disrupted resulting in increased poor health comes. For example during the Ebola outbreak in Sierra Leone maternal deaths not related to the outbreak increased by 34% (Kaluthotage, 2020). There is fear that during the COVID-19 pandemic, prevailing health problems in PNG may worsen because of increased demand on the PNG health system (Kaluthotage, 2020).

How can health systems be more resilient and responsive?

Resilience in a health system can be cultivated by systemically strengthening the building blocks of the health system (Barasa et al., 2018; Hanefeld et al., 2018). Barasa et al (2018) categorised health system resilience into three broad categories (1) planned resilience (2) adaptive resilience and (3) everyday resilience. Planned resilience is concerned with planning for future shocks to a health system from identified threats, adaptive resilience is to do with ensuring the health system is flexible and responsive to either chronic or acute shocks to the health system and everyday resilience focuses on making sure the health system can handle day to day prevailing health concerns (Barasa et al., 2018). Furthermore, Barasa et al (2018) identified nine factors that need to be cultivated and encouraged to build resilience into a health system. These nine factors are (1) material resources (2) preparedness and planning (3) information management (4) collateral pathways and redundancy (5) governance processes (6) leadership practices (7) organizational culture (8) human capital and (9) social networks and collaboration. In contrast, Hanefield et al (2018, p364) proposed a simpler framework which they termed ‘3 plus 2 dimensions’. Using the ‘3 plus 2 dimensions’ framework (Hanefeld et al., 2018) the building blocks of a health system can be analysed, evaluated and appropriate interventions can be implemented to make the health system more resilient.

How can PNG’s health system be improved to make it more resilient? Building resilience into a health system is a complex process because of the many factors and actors that influence and shape the health system (WHO, 2007a). In an attempt to come to an answer to the question this paper will use the ‘3 plus 2 dimension’ framework proposed by Hanefield et al (2018) to analyse the PNG health system and suggest ways to make the health system more resilient. The three core dimensions that constitute the ‘3 plus 2’ framework (Hanefield et al 2018) also correspond to the WHO building blocks (WHO, 2007a) while the ‘2’ refers to governance and values (Hanefeld et al., 2018). Now that the individual components of the 3 plus 2 dimensions have been identified, the next step is to critically analyse the PNG health system using this lens to identify areas of improvement to build resilience into the health system.

How can PNG’s health system be more resilient and responsive?

The core areas of improvement to strengthen resilience have been identified as health information systems, health finance and funding mechanisms and the health workforce (Hanefeld et al., 2018). The national health information system (NHIS) in PNG need to be improved to enable faster and quality data input and analysis. The PNG health plan assumes a well functioning NHIS and has been identified as an essential pillar for health system strengthening in PNG but progress has been slow (Grundy et al., 2019). Health managers and health planners at the local, district and provincial level need to be trained to use data generated by the health system at the facility level to make timely and appropriate decisions to manage health threats as well response to people’s needs whether it’s the community or needs of the healthcare workforce. A health information  system that is fast and provides early warning data is key to faster response (Kruk et al., 2015).

The next area of health system resilient strengthening is health funding, not only ensuring money is made available but also the systems of ensuring fund allocation and accountability (Hanefeld et al., 2018). For this to occur the health system need to be integrated with other government systems, in this case the government finance system (Kruk et al., 2015). In PNG this has not occurred yet so PNG’s health financing mechanisms need to be integrated with the country’s finance system. Some integration has been made, for example the payroll system (personal communication, Dr Gunzee Gawin, 2018) but other aspects such as procurement needs to be improved (Grundy et al., 2019; Hanefeld et al., 2018).

Health workforce capacity building and ensuring the workforce is trained and know when and how to respond to a shock to the health system is another core component of the ‘3 plus 2’ approach to building resilience in health systems (Hanefeld et al., 2018). The health system including the workforce need to be adaptive (Kruk et al., 2015) and willing to change roles and responsibilities during a disaster or outbreak that can threaten and weaken a health system (Hanefeld et al., 2018). To ensure PNG health workforce is adaptive and responsive, frontline health workers that can respond in a disaster or outbreak need to be trained regularly with refresher courses. A key area of training would need to include mental health training to ensure the workers are mentally resilient to high levels of stress that can occur in a disaster or outbreaks (Narasimhan et al., 2019).

The ‘2’ in the ‘3 plus 2’ framework refers to ‘governance and values’. (Hanefeld et al., 2018, p364). Governance and leadership at all levels of government in PNG has been identified as weak and is contributing to current health problems in PNG (Grundy et al., 2019; Hayward-Jones, 2016; MacKay & Lepanni, 2010). This situation needs to be improved. Introduction and rollout of the PHA system has been commented as one way to improve PNG’s health system including governance at the local level (Grundy et al., 2019).

The PNG health system is not people centred. This view is demonstrated in the PNG health plan which does not take into consideration local beliefs, customs and value systems (NDoH, 2011). Indeed this gap has been identified in the WHO health system building blocks (Hanefeld et al., 2018). The local context in which a health system faces a health threat such as disaster or outbreak has a major influence on how the community or country as a whole respond to shocks to the health system (Hanefeld et al., 2018). For example during the Ebola outbreak in Africa, resilient communities had fewer death rates even though all health facilities were having similar problems (Hanefeld et al., 2018; Martineau, 2016). The current COVID-19 pandemic is threatening the already weakened PNG health system (Kaluthotage, 2020) and how PNG recovers from this health crisis will be influenced by the values, beliefs, traditional customs and the social support structure of PNG communities.

Conclusion

Health systems around the world continue to face health threats and there is a need to ensure health systems are responsive and resilient against these threats. Health systems also need to move away from being disease focused and be people focused. A lot has been done to improve and strengthen the PNG health system but the current system is not people focused as reflected in the current national health plan. It is hoped that the next health plan will be people focused. It is also hoped that strategies aimed at strengthening PNG’s health system will ensure it is responsive to people’s needs, responsive to health threats and be resilient should there be a major disease outbreak or natural disaster. Local context is vital in strengthening health systems to build resilient. In the PNG context, PNG’s cultural diversity, local beliefs, customs and social support structures must be considered in building resilience into the PNG health system.

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