A comparative analysis of the health system of Papua New Guinea and Ethiopia using the World Health Organization health system building blocks as the framework for analysis.

Introduction

Ethiopia is a country located on the North Eastern part of the African continent. Its population projection in 2015 was 90 million with predominantly young people [1]. It has a federal system of government and the country is administratively divided into nine regional states [1]. Ethiopia has been investing heavily in their health system to improve the country’s health indicators since the 1990s and the guiding document has been the Health Sector Transformation Plan (HSTP) implemented in various phases since 1990 [1]. The country has successfully implemented this plan and seen reductions in the morbidity and mortality from malaria, HIV/AIDS and tuberculosis [1].

Papua New Guinea (PNG) had an estimated population of 7 million in 2011 and the population continues to grow at a rate of 3.1% per annum [2]. The country has a weak and fragile health system [3] and has struggled to improve its health indicators. Administratively PNG is divided into 22 provinces and geographically divided into four regions [2]. Although PNG has developed various health plans since political independence in 1975, the latest health plans [4,5,6] outline the country’s aspirations to meet the country’s health needs focusing on primary healthcare delivery at the local level. 

Using the World Health Organization (WHO) six building blocks of a health system as the framework, this article will make an attempt to compare and contrast the health systems of Ethiopia and PNG and try to identify where success has been achieved and where the challenges are. Both countries have had similar challenges in achieving the sustainable development goals (SDGs) [7] but Ethiopia appears to have performed better than PNG. However, there are significant differences between the two countries and some of these differences will be highlighted and discussed within the context of the WHO health system building blocks.

Overview of the health system of Papua New Guinea

The public health system of PNG is based on a decentralized model focusing on primary healthcare (PHC) [2]. The healthcare service delivery structure network consist of aid posts at the village levels, health centers and sub health centers at the ward level, district hospitals, provincial hospitals and regional referral hospitals.  Within the health reforms presently underway, the aid posts will be replaced by community health posts [6]. The National Department of Health is tasked with formulating policies and the monitoring and evaluating framework while the implementation is the responsibility of the provinces and districts. The referral and provincial hospitals is the responsibility of the national department while district hospitals and health centers fall under the jurisdiction of the provincial governments and districts. However, with the present roll out of the Provincial Health Authorities (PHA), health service delivery in the provinces and districts will come under one unifying authority, the PHA.

Churches in PNG provide 50% of rural health services and 48% of services overall [8] and are important actors in PNG health service delivery. Church health facilities are managed under their respective institutional organizational structure but the funding is largely via grants from the PNG national government. The grants are received by the Christian Health Services (formerly known as the Churches Medical Council) and distributed to the various church run facilitates. The private healthcare sector in PNG is very small and largely urban based.

Health financing in PNG is a mixture of government revenue, loans and grants from development partners. Up to 50% of financing of health service is from tax based revenue [2]. Because PNG’s economy is based largely on extractive industry [3], fluctuations in world prices of minerals, oil and gas has meant that the PNG health system has not had consistent funding for many years and suffers from chronic financial constraints. To cater for the limited cash flow and to keep operations going, some hospitals employ user pay policies to generate internal revenue although the PNG NDoH policy is free PHC for all. There is no government health protection strategy or policy to protect the poor from financial catastrophe because of illness or healthcare related expenses.

Health data in PNG is collected using the PNG national health information system. This system is paper based. There are plans to make electronic some aspects of the health information system but progress has been slow.

The health workforce has been described as in crisis [2]. There is an aging health workforce and the training institutions in the country lack capacity to increase the number of the different cadre of healthcare workers required. Movement of healthcare workers into the private sector or overseas is a threat to the health workforce crisis as well.

Overview of the health system of Ethiopia

Ethiopia is a federal parliamentary republic. Administratively the country is divided into 9 regional states with further subdivision of the states into Woredas (districts) and Kebeles (sub-districts) [1]. The present healthcare service delivery structure is based on a decentralized model with a focus on universal health coverage and PHC. The health service structure is a three tier system consisting of health centers and health posts at the village level, district hospitals at the Woreda level, Zonal hospitals at the state levels and specialized hospitals providing tertiary level care [9]. Ethiopia’s current health plan is focused at delivering PHC at the family and village level and the country introduced an innovative program called the Health Service Extension Program (HSEP) in 2003 [9]. The HSEP has been very successful despite challenges and has been credited with improving Ethiopia’s health indicators and reaching the millennium development goals (MDGs) [9]. Ethiopia’s health system is financed from internal revenue generated and from international development partners and non-government organizations [1].

To meet the health workforce needs, Ethiopia has focused on developing capacity at the village and district level. Ethiopia has also increased the number of medical schools in the country.

The health information system of Ethiopia is still paper based but there is a push to go digital. One of the first projects in digitizing the health information system is at the national level and there are plans to roll out into the states and districts.

Service delivery

Ethiopia has a three level health service delivery structure. The three levels are primary, secondary and tertiary [1]. For the last 20 years, Ethiopia has focused on improving health service delivery at the primary level though a program call the Health Extension Program (HEP) that is aimed at building community ownership of primary healthcare delivery [1,9]. The HEP has been credited with improving Ethiopia’s health indicators and achieving some of its millennium development goals (MDGs) [1]. Unfortunately PNG was one of two countries in the world that failed to achieve any of its MDGs [2]. The PNG’s health plan is well written with clearly defined key result areas (KRA) and KRAs 4, 5, 6, 7 and 8 [6] deal with key areas of primary healthcare service delivery. These KRAs factor in the MDGs that has now transited into the sustainable development goals (SDGs) [10]. The health service delivery structure of PNG is a 7 level system [2] but this may change in the future with construction and roll out of the community health posts. These differences in the primary healthcare service delivery mechanisms between PNG and Ethiopia may explain Ethiopia performing better than PNG given that Ethiopia has a simpler service delivery structure (3 levels) whereas PNG’s appear to be more complex (7 levels). Another focus of the Ethiopian government in improving primary healthcare is community ownership through the HEP [1,9], which compared to PNG’s health plan does not consider community ownership but rather community empowerment. When comparing the health indicators between PNG and Ethiopia, PNG has not improved in the majority of its health indicators except perhaps in malaria control [2,3]. Ethiopia on the other hand has done far better.

Health workforce

Ethiopia and PNG both face significant health workforce challenges. Ethiopia has four times more people (30 million) [1] than PNG (8 million) [2]. Comparing PNG and Ethiopia, Ethiopia has progressed in developing its human resource capacity to meet its health needs whereas PNG has not been able to implement any programs or reforms to build the health workforce in terms of numbers and capacity. For example, according to Ethiopia’s Health Sector Transformation Plan (HSTP) “the number of public higher educational institutions have increased from eight to 57. Of these, 34 are universities and hospital-based colleges offering degree programs while 23 are regional health science colleges offering technical and vocational qualifications (level 1 to 5). Private health science colleges have also flourished, with 24 institutions offering accredited programs as of 2012/2013. Specifically, the number of medical schools has risen to 33 (of which 5 are private) and public midwifery schools have reached 49. There has also been parallel expansion in enrollment and graduation outputs. Over sixty thousand health science students were enrolled in public higher education institutions; and an additional 15,834 in private higher educational institutions as of 2012/2013. Annual enrollment of health science students in public higher educational institutions reached close to 23,000 (58 % in regional health science colleges) in 2014. Additionally, the annual intake of medical students rose by more than 2-fold from 1,462 in 2008 to 3,417 in 2014. Graduation output from higher educational institutions has increased close to 16-fold from 1,041 in 1999/2000 to 16,017 by 2012/2013” [1, p46]. Papua New Guinea on the other hand has the lowest health worker to population ratio in the Pacific in all cadres of health workers [2] and has not been able to meet the countries health workforce needs. In the report by Grundy et al [2] some of the factors contributing to the health workforce crisis in PNG include “the current severely constrained training system (capacity, infrastructure, appropriately skilled training workforce, clinical placements), which is unable to meet the needs for existing and new health workforce cadres, the large percentage of the health workforce, especially in rural areas, who are due to retire within the next 10 years – over half will retire within that period and the continued expanding demand for services over the past decade and for the next 10 to 20 years due to a sustained increase in the population” [2, p110].

A similar challenged faced by both Ethiopia and PNG is continuing professional development for its health workers and regulation to maintain quality and credentials. Both countries recognize that ongoing workshops and refresher training for the health workers is an important part of quality in service delivery but both countries have had difficulty in implementing long term sustainable solutions. This has been one of the reasons both countries have seen health workers leaving the public service to work in the private sector or migrate overseas [1,2].

 Health information

A good health information system provides quality data in a timely manner to enable appropriate decision making and planning. Ethiopia and PNG face similar challenges in terms of accuracy, completeness and quality of data collection by their health information system (HIS). However, Ethiopia has performed slightly better than PNG in terms of getting the HIS to function efficiently and provide data that can be used for planning and usage at the point of data generation [1] . Whereas PNG’s HIS is slow and the information compiled from PNG’s HIS is not given to health planners and managers at the district level in a timely and efficient manner [2].

A good HIS is also essential for monitoring and evaluating health interventions. According the PNG health plan, the monitoring and evaluating framework is based on the premise of a good functioning HIS [4,]. The PNG health plan also identifies the HIS as an essential component of the national health plan [2] but no significant improvements have been made to the PNG HIS. Ethiopia on the other hand successfully implemented its HIS in 2008 which is generating data that is used for health planning at the district level [1].

Medical products, vaccines and technologies

Quality of health service delivery is closely linked to the availability of essential medicines, vaccines and medical equipment. In order for that to happen there has to be a robust procurement and delivery system to ensure medicines, vaccines and equipment are delivered to the health facilities on time and in useable conditions. Good transport infrastructure and system that is affordable is required as well. Countries that are struggling in these aforementioned areas will struggle to ensure adequate supplies are delivered and maintain at health facilities for the delivery of quality health services.

Ethiopia and PNG face similar challenges when it comes to supplying and maintaining essential medicines, vaccines and other health products at the local level where primary healthcare is delivered. Ethiopia has implemented various mechanisms to fund, purchase, transport, deliver and maintain health products at health facilities and have seen significant improvement in some of these areas [1]. Ethiopia has also instituted monitoring and evaluation mechanisms of these processes to improve governance and ensure quality of service [1]. In contrast PNG has struggled to improve its procurement and supply system which has affected service delivery at all levels [2]. Weak governance and leadership [3] is one key factor contributing to this observation. Compared to Ethiopia, PNG is one of the most geographically challenging areas with mountainous terrain and people living in hamlets separated by tribal boundaries in the highlands and people scattered over many small islands when it comes to the coastal regions. This means transportation of goods and services is challenging and can be very expensive. These challenges have also hampered delivery of health services in PNG. The health in all policies initiative can be a solution so that there is a whole of government approach to finding solutions to health challenges in PNG.

Health financing

The economic growth focus of Ethiopia and PNG is markedly different. Ethiopia has an agriculture led industrialization economic policy (HSTP) whereas as PNG’s economic growth is largely led by the extractive industry [3]. However, PNG has a large agriculture base to sustain the lives of more than 80% of the population but this potential has not been realized [3]. The socio-economic development in Ethiopia has been far better [1] than what has been happening in PNG where PNG’s health system has been described as failing with the added problems of poor governance, law and order challenges and a very rapidly growing population that is growing at 2.7% per annum [3]. These indicators are reflective of the differences in the proportion of health sector funding as a percentage of gross domestic product (GDP) and effective management of financial resources between the two countries. For example Ethiopia’s health expenditure out of GPD increased from 4.5% in 2007/2008 to 5.2% in 2010/2011 [1] whereas PNG’s health expenditure out of GDP has decreased from 6% in 2005 to 4.3% in 2014 [2]. In fact PNG’s health expenditure is lower than neighboring Pacific countries [2]. For the same period that Ethiopia’s health expenditure was increasing (2007/2008 to 2010/2011), PNG’s health expenditure was declining and remained low [2] below the WHO’s recommendation of 5% of GDP.

The sources of health sector financing in Ethiopia and PNG is the same in that both countries fund their health systems from finance generated internally with assistance from development partners. However, there are some notable differences in the source of internal health finance generation and policy implementation in financial protection for the poor. As part of the health sector reform in Ethiopia one of the key financial mobilization strategies was improving the Retention and Use of Healthcare Financing Reforms (HCRF). In the HCRF, the government of Ethiopia increased the proportion of health facilities generating and retaining their revenue from 20% to 100% [1]. Although the amount of retained revenue generated by health facilities varied between facilities and between regions, on average health centers generated 30% of their total budget while hospitals generated 23% from retained revenue [1]. Public hospitals in Ethiopia were also encouraged to have private wings to cater for high paying clients as a means of generating internal revenue [1], whereas the PNG government has not explored this option of domestic health sector financing. To address the burden of out of pocket expense the Ethiopian government introduced two insurance schemes called the community based health insurance (for the informal sector) and the social health insurance (for the formal sector) as the vehicles for universal health care [1]. To monitor and manage the insurance schemes the Ethiopian government established the Ethiopian Health Insurance Agency [1]. Compared to PNG, there have been proposals for micro-health insurance schemes, social businesses, social franchises and health voucher schemes [11] but no significant progress has been made.

Ethiopia and PNG both face similar challenges in ensuring health sector spending is occurring efficiently adhering to budget and the health needs at the district level. Ethiopia has a target of budget utilization of 90% [1] to ensure that there is increased spending at the local level. There has been under spending at the district level in PNG [2]. To manage, monitor and evaluate health sector spending at the district levels both countries have introduced finance management systems [1,2].

Leadership/governance

Ethiopia and PNG have instituted various reforms in their government structure to decentralized power and decision making down to the state/provincial and district levels. These changes have also meant that health systems in these two countries have had a number of restructuring and decentralization reforms as well.  Although implementation of the decentralized systems remains a challenge in both countries, Ethiopia has fared far better than PNG. The Ethiopian government introduced Business Process Re-engineering [1], a reform aimed at improving leadership, management and governance in the health sector. In a follow up assessment of this reform in 2013 the report showed there were some positive improvements in leadership and governance practices at the district level and there was strong commitment to continue to improve [1]. The report further showed that the various committees established for strengthening governance practices were functioning at acceptable levels but it was noted that continued commitment was required to ensure sustainability and continued improvements [1]. In PNG however, decentralization reforms to improve health services at the district level as outlined in the PNG national health plan [6] have not been successful. The poor governance practices in the health sector in PNG is also reflective of decades of deteriorating governance practices in the entire PNG public service [3]. It is hoped that introduction of the Provincial Health Authority (PHA) legislation in PNG will ensure a one system structure, away from a two system structure, will ensure decentralization reforms are better implemented at the provincial, district and local levels [2].

Conclusion

This article has made an attempt to do a comparative analysis of the health systems of Ethiopia and PNG using the WHO health system building blocks as the template for the analysis. From this analysis it was seen that overall, Ethiopia’s health indicators have improved compared to PNG. Ethiopia focused on implementing a community ownership initiative using the HEP. Community ownership and empowerment is a feature that has not been successful in PNG’s health initiatives. Other areas that has seen Ethiopia improve its health indicators include improvement in governance, increase health spending and successful implementation of procurement, transport and delivery systems for medicines, vaccines and other health commodities. Unfortunately PNG has struggled in all these areas resulting in poor service delivery and worsening health indicators.

References

  1. Ministry of Health, Federal Democratic Republic of Ethiopia. Ethiopian Health Sector Transformation Plan. 2015/16 – 2019/20. 2015 (October).
  2. Grundy, J., Dakulala, P., Wai, K., Maalsen, A., & Whittaker, M. Independent State of Papua New Guinea Health System Review. Health Systems in Transition. 2019. 9(1): 1–201.
  3. Hayward-Jones, J. The future of Papua New Guinea : Old challenges for new leaders. Lowly Institute for International Policy. 2016 (March): 1-24.
  4. Papua New Guinea National Department of Health. National Health Plan 2011 – 2020 Volume 2 (Part B) Reference Data and National Health Profile. 2010. Available from http://www.health.gov.pg/publications/PNGNHP Vol2 PartB_2014.pdf
  5. Papua New Guinea National Department of Health. Papua New Guinea National Health Plan. Chapter 5 Implementing the plan. 2010.
  6. Papua New Guinea National Department of Health. Papua New Guinea National Health Plan 2011-2020, Volume 1, Policies and Strategies. 2011.
  7. United Nations. Transforming our world: the 2030 agenda for sustainable development. 2016. Available from https://doi.org/10.1201/b20466-7
  8. Mapira, P., & Morgan, C. The contribution of church health services to maternal health care provision in Papua New Guinea. PNG Med J. 2011. 54(3–4): 139–146.
  9. Assefa, Y., Gelaw, Y. A., Hill, P. S., Taye, B. W., & Van Damme, W. Community health extension program of Ethiopia, 2003-2018: Successes and challenges toward universal coverage for primary healthcare services. Globalization and Health. 2019. 15(1): 1–11. Available from https://doi.org/10.1186/s12992-019-0470-1
  10. Schmidt, H., Gostin, L. O., & Emanuel, E. J. Public health, universal health coverage, and Sustainable Development Goals: can they coexist? Lancet. 2015. 386(9996): 928–930. Available from https://doi.org/10.1016/S0140-6736(15)60244-6
  11. MacKay, J., & Lepanni, K. Health System Strengthening in Papua New Guinea: Exploring the role of demand-responsive mechanisms. Lowly Institute for International Policy. 2010 (November): 1-38.

About rodney itaki

A physician trying to become a writer.
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