Chapter 3 Committee delegation visit to Papua New Guinea

 

 

Source        Lonely Planet

3.1                   The Committee delegation visited Papua New Guinea from Tuesday 6 October 2009 to Sunday 11 October 2009.  In order to achieve its objectives, the delegation undertook site visits and held meetings with parliamentary and government officials and representatives of community organisations.  The delegation travelled to the capital, Port Moresby, and Western Province, visiting the capital, Daru, and the three treaty villages of Mabadawan, Sigabadaru and Buzi.

Overview of PNG’s health infrastructure (physical and human resources)

3.2                   The PNG health system employs about 12, 400 staff, approximately 85% of whom are doctors, health extension workers, nurses and community health workers.  Infrastructure comprises 614 health facilities.  In addition to the major teaching and national referral hospital, Port Moresby General Hospital, there are 19 provincial hospitals, 52 urban clinics, 201 health centres and 342 sub-centres.[1]

3.3                   In PNG there is a critical shortage of health workers (0. 6 health workers per 1000 people compared to the 2.3 health workers recommended by the World Health Organisation).[2] 

3.4                   As alluded to in the previous chapter, health outcomes in PNG have improved little over the last 30 years. And, the PNG health system struggles to meet the health demands of a growing nation.  In summary, the population of 5. 3 million is growing at 2.7 per cent per annum; 40 per cent of people live on less than $1 a day; life expectancy stands at 59 years; the fertility rate for women is 4. 6 children per woman; and only 40 per cent of the population has access to safe water.  Infectious diseases like pneumonia and diarrhoea are leading causes of death in children, and TB and HIV dominate the disease burden.[3]

Papua New Guinea School of Medicine and Health Sciences (SMHS)

                         Dr John Vince (left ) and Sir Isi Kevau (Dean of SMHS)

3.5                   The delegation was pleased to have the opportunity to visit the country’s only medical school, the Papua New Guinea School of Medicine and Health Science at the University of Papua New Guinea, to meet with Sir Isi Kevau (the School Dean) and Dr John Vince (Professor of Child Health and Deputy Dean), to discuss PNG’s health infrastructure, human resources and health workforce training. The university plays a key leadership role in the region, attracting and educating some 15, 000 students annually, including a large contingent from other Pacific nations, particularly the Solomon Islands, which does not have its own medical school or university. 

3.6                   Australia has had a longstanding relationship with the University of Papua New Guinea, which was established prior to independence, and supporting the training of health workers.

3.7                   Australia currently supports the School of Medicine and Health Sciences (SMHS) through the AusAID administered Health Education and Clinical Services (HECS) Program.  Launched in July 2009, HECS will provide $7. 3 million over 3 years to help deliver and upgrade programs at the SMHS.

3.8                   The SMHS has an operating budget of 61 million kina and has expanded from training doctors and dentists in the 1980s to providing undergraduate and post-graduate studies to some 600 students.  In addition to medicine and dentistry, courses are now available in nursing, radiography, medical laboratory science, community medicine, and pharmacy.

3.9                   To-date the SMHS has produced 1195 medical doctors, 151 clinical specialists, 16 dentists and 165 dental workers, 490 allied health workers, 730 post basic diploma nurses, 180 graduate nurses and 180 community health diploma holders.

3.10               In 2008, 230 health workers graduated.  Amongst the new cohort were 39 doctors, 4 dentists and 1 dental therapist, 102 nurses, 19 medical laboratory technicians, 19 pharmacists and 6 anaesthetists.  Further, some 26 clinical specialists (advanced practice nurses) were produced, with expertise in a range of fields including surgery, public health, obstetrics and gynaecology, and child health.

3.11               Of the students enrolled in 2009, there were 490 undergraduates and 180 postgraduate candidates. This includes 179 medical students, 59 dentistry students and 77 nursing students. The delegation learnt that the ratio of male to female students is 60/40 for doctors and 50/50 for nurses.

3.12               There are 52 full time academic staff (83 % are nationals) and 58 honorary staff (employed by the National Department of Health) at the SMHS. The School has significant problems with filling academic staffing: there were some 37 outstanding academic vacancies as of October 2009. This situation has arisen because of salary disparities with medical doctors employed by the National Department of Health (who get paid more than academics do at the university); and a lack of accommodation for staff. Staffing is supplemented by visiting lecturers through a variety of funding sources.

3.13               After describing the courses offered and the staffing situation at the SMHS (and adding that there were a number of additional colleges throughout the country which offer nurse training), the Dean talked at some length about the benefit of exchange arrangements that had existed in the past (including one with Sydney University) which had built tremendous people-to-people links and institution - institution links.  He noted that these links had been weakened over the years, and that moves to re-establish twinning arrangements would be very beneficial.

3.14               Professor Wronski of the School of Medicine at James Cook University had told the Committee the same thing at the hearing in Cairns, namely, that there is a,

vaccum in the relationships that once drove activity and institutional support…Whilst activity and relationships are growing, not enough resources are being channelled to allow appropriate growth.[4]

3.15               JCU suggests a range of ways to go about re-establishing links, from proposed joint arrangements between universities and hospitals to establishing a separate body in North Queensland – a centre for tropical health and medical workforce- which would interlink with institutions in the region [such as the PNG SHMS] to provide institutional support, staff rotation, student rotations, student and staff exchanges and curriculum development opportunities.[5]  Associate Professor Maguire proposes the establishment of a Western Province Australian Clinicians Network to support capacity building at Daru Hospital and the South Fly Area.[6]

3.16               The Dean told the delegation that there was dialogue underway to establish a memorandum of understanding (MOU) with James Cook University.

3.17               The delegation sees enormous benefits in building and maintaining people –to-people links and, encourages institution-institution links that endure beyond an individual’s tenure.

3.18               The Dean and Dr Vince praised the Australian Federal Government’s Regional Health Strategy which encourages and supports rural clinician training and placements. The Dean referred to the University of Sydney’s School of Rural Health, its satellite clinical schools in rural NSW, and its success in placing medical students in a range of rural and remote settings. He said that he would like to see something similar set up in Papua New Guinea.

3.19               To that end, the Dean proposes establishing two new clinical schools, one in Goroka in the Eastern Highlands and another in Honiara, in the Solomon Islands. He envisages students undertaking residency training in the same region/country where there are enormous opportunities for students to learn about and practice rural medicine.

Recommendation 6
	The Committee recommends that the Australian government encourage and support further institutional partnerships and/or reciprocal exchanges between the School of Medical and Health Sciences at the University of Papua New Guinea and Australian universities.

Meetings with parliamentary and government officials

Minister of Health

The Minister for Health, the Hon. Sasa Zibe MP, and committee delegates

3.20               The delegation greatly appreciated the opportunity to meet with the Minister for Health, the Hon. Sasa Zibe and Mr Wep Kanawi (Acting Director, National AIDS Council Secretariat, and a former Secretary for Health) in the Minister’s office in Port Moresby.

3.21               Discussions were wide-ranging, frank and open.  The Minister warmly welcomed the visit from an Australian parliamentary committee to see PNG’s health system first hand, to assess the impact of Australian assistance on health, and to play a role in strengthening the bilateral relationship.

3.22               Minister Zibe stated that Papua New Guinea was neither proud of its poor health statistics nor the indicators reported in international fora. He acknowledged that malaria, TB and communicable diseases were major killers, that child maternal health was very poor, and services for the aged and disabled were minimal.  An ageing health workforce, inadequate transport infrastructure and weak law and order are amongst a range of contributing factors that inhibit the delivery of drugs and health services.

3.23               The Minister referred to the recent cholera outbreak and the specific challenges that PNG faced in identifying and dealing with an epidemic in which it had no prior experience. On measures to improve water supply and sanitation in rural areas, he informed the delegation that the Ministry of Health has trained a number of water technicians, and a number of development partners, including the European Union, were supporting water programs across the country.

3.24               The Minister was critical of parallel health systems that continue to operate in the country (be they donor or mining company ones). These, he said, hinder rather than strengthen the PNG health system.  He said that that donor health projects tend to attract staff that would otherwise work in the PNG system.  Referring to the Torres Strait ‘package of measures’, the Minister commented that - in order to be sustainable- they too need to be integrated into the PNG health system and not just a ‘one-off’.  The Minister made repeated calls to support the notion of ‘one government, one national department of health, and one health system’ in PNG.

3.25               The delegation was advised that the current national health plan expires in 2010.  The new one, currently being developed, will focus on primary health care. The Minister is also working hard to mandate the establishment of Provincial Health Authorities in every province to consolidate control of PNG health delivery at the sub-national level and improve accountability.  To-date, three provinces (Eastern Highlands, Milne Bay and Western Highlands) have agreed to establish such authorities.

3.26               The Minister and delegates spoke at some length about the impact of climate change. The Committee delegation was told that global warming presents a clear danger to PNG’s biodiversity. One of PNG’s advantages is its vast marine and terrestrial carbon sinks[7] (for instance, nearly two thirds of PNG’s land area is covered in forest). Recognising PNG’s unique biodiversity and its contribution to global diversity, Australia and PNG signed a Forest Carbon Partnership in 2008 which aims to reduce emissions from deforestation and provide alternative livelihoods to logging. [8]

3.27               Observing that water shortages and food security were already an issue, the Minister informed the delegation that PNG had been the first country in the Pacific forced to relocate its people to higher ground. He expressed concerns that this could become more common in the future, and that the displaced may experience mental health problems as a consequence.

Secretary for Health and Executive Manager, National Department of Health

Delegation Chair and Secretary for Health

3.28               The delegation was pleased to meet with Dr Clement Malau, Secretary for Health and Mr Enoch Posanai, Executive Manager, at the National Department of Health (NDoH) in Port Moresby.

3.29               The Secretary opened the meeting by acknowledging the need to strengthen governance, accountability, transparency and ownership of the PNG health system and health services.  Good management of health funds, he said, would improve donor trust in the government.  On the transparency front, the delegation is pleased to see that the Department of Health is one of the only PNG government departments to have its own website, with downloadable copies of departmental documents and public health information, including the Health Worker Newsletter, and information on how to avoid cholera.[9]

3.30               Agreeing with the Health Minister that the fragmentary administration of PNG government health services had led to some gaps in accountability, the Secretary said that, if agreed to by the provinces themselves, the establishment of provincial health authorities would allow the government and provinces to work together more closely.

3.31               Mr Posanai said that, notwithstanding changes to administrative arrangements, the NDoH continued to work at the provincial level to build community health posts, which he believes are key to delivering health in rural areas.  One of the posts being upgraded by the Department is at Buzi – one of the villages visited by the delegation.

3.32               The Secretary and delegates spent some time discussing the human resource deficit in the health sector. The Secretary estimates that, at a minimum, PNG will need to train 30, 000 health workers in coming years to meet the country’s health requirements.  The Secretary expressed concern that the emergence of lifestyle diseases like diabetes, CVD and cancer would place an additional strain on the health system.

3.33               He advised that PNG is developing four regional hospitals as “centres of excellence”, including a new oncology ward at Lae Hospital and trauma facilities at Mount Hagan hospital.

3.34               Delegates asked the Secretary for his views on the health situation in Western Province. The Secretary replied that Western Province was a wealthy province and that it needed to use its resources to deliver better health outcomes. He acknowledged that there are genuine logistical barriers to doing so, including a sparse and spread out population.  The Secretary noted the lack of investment in water and sanitation in Western Province and its health implications. [10]

Site visits to AusAID funded projects

3.35               The delegation made a number of site visits in Port Moresby to organisations that the Australian government supports.  The visits afforded delegates a valuable opportunity to meet paid and volunteer health workers, and to hear their perspectives on the health system and health issues like HIV/AIDS; avoidable blindness and workforce training. These visits complemented the delegation’s more formal meetings with the Minister for Health and Health Secretary, and engagements with other government and civil society stakeholders. The delegation thinks that AusAID is doing tremendous work supporting these organisations.

Poro Sapot

3.36               Run by Save the Children Australia (SCA), the Poro Sapot Project is an STI/HIV intervention that promotes safer sex practices, human rights and well- being. It is the only STI clinic in the country, and the Pacific, that caters specifically for female sex workers and men who have sex with men.  Over 40 per cent of staff is HIV positive and/or members of these vulnerable groups.[11] 

3.37               The project is premised on peers helping each other to change risky sexual behaviour. Sex workers talk to other sex workers and men talk to other men who have sex with men.

3.38               The centre operates in four centres in three provinces in PNG: the capital, Port Moresby; the second largest city, Lae; the capital of Eastern Highlands Province, Goroka; and the second largest town in that province, Kainantu.  There are also outreach services to villages outside of Port Moresby, and around Goroka.  Approximately 40 program staff and 160 peer outreach volunteers operate out of the centres. Some 60-80 people are seen each week at the Port Moresby Centre.  Staff told the delegation that there is an increasing demand for their services.

3.39               Each of the centres make referrals, distributes and promotes safe sex products and materials, and provides a safe space off the street.

3.40               SCA say its reasons for supporting this project, while not perhaps immediately apparent (because it is a children’s organisation), were because it saw the need to reduce the spread of the disease amongst men and women most susceptible to it, and therefore the numbers of children infected into the future.  Moreover, SCA believes that it is a cross-cutting development issue that, if not brought under control, will undo any gains PNG makes as a country.

3.41               Since 2003, AusAID has been the single largest supporter of Poro Sapot, with Family Health International and UNICEF coming on board in recent years to contribute additional funds.

3.42               To demonstrate its reach, Poro Sapot supplied the following figures. In the first six months of 2008, the organisation made contact with some 3, 000 women in sex work, half of them young women. In 9 months (October 2007 – June 2008) sexual health information was communicated to 5, 000 individuals, including over 1, 000 demonstrations on the correct usage of male and female condoms.  In 2008, 2. 6 million male condoms and 50, 000 female condoms were distributed.

3.43               Research conducted from 2004-2007 by the PNG Institute of Medical Research and SCA, showed that there has been an increase in correct and consistent condom use; increased access of STI and voluntary counselling and testing (VCT); and increased knowledge in HIV transmission and prevention. That good news does, however, contrast with little change in the levels of sexual violence in PNG society, experienced by some 40-60 per cent of those surveyed.

3.44               One of the unique features of the Poro Sapot project is the positive working relationship developed with the police in all four centres. Poro Sapot provides training in basic HIV and human rights in order to sensitise the police to issues faced by sex workers and men who have sex with men. It helps police to understand their role in protecting the rights of vulnerable groups. In recent years, Poro Sapot has been invited to talk to new police recruits at the national police training college.

3.45               The delegation was told that there cannot be too many police forces in the world who invite sex workers and men involved in same-sex relations to talk with them about living with HIV and about living positively.

3.46               In turn, the police resource Poro Sapot’s training on legal rights.

3.47               The police also provide security escorts in the Eastern Highlands. Further, on several occasions police have expressed their support by marching with Poro Sapot for World AIDS day.

3.48               Poro Sapot works closely with the National Department of Health, training health care workers, and collaborated on the country’s National Strategic Plan on HIV/AIDS.

3.49               Since 2006, Poro Sapot has collaborated with Dame Carol Kadu MP (the only female parliamentarian in PNG) and her taskforce to revise the colonial PNG laws that criminalise prostitution and sex between men. They contend that decriminalisation –namely, reducing structural discrimination – will go a long way towards lessening the stigma experienced by HIV/AIDS sufferers in PNG. Delegates were told that stigma remains the largest barrier to people seeking advice or treatment.

3.50               Because having HIV/AIDS is a source of shame and the subject is taboo, it is difficult to get people to talk openly about prevention and/or treatment. One of the strengths of Poro Sapot is the way that volunteers approach talking about the disease, its prevention and treatment. Volunteers use peer networks to disseminate information and provide support. The organisation has been successful in getting people to talk about HIV/AIDS. There will be no behaviour change if people do not talk about the disease, why and how it needs to be prevented and/or treated. At the same time some consideration needs to be given to not placing sexual health clinics in prominent areas where people may be too embarrassed to be seen going into them.

3.51               Violence against women is another significant issue. The delegation learnt that that HIV is being transmitted through sexual assaults on women. Female health workers spoke of their concerns about being raped as they go into communities to deliver health services (this is not a rare occurrence) and contracting the disease themselves.

3.52               The delegation valued the chance to meet with staff and volunteers at their workplace and to have the opportunity to speak to some of the clients.  Delegates were struck by the passion and commitment of staff and volunteers for the work they do and the dedicated support they provide to those in their care.

3.53               Poro Sapot has close links with HIV/AIDS networks in the Asia- Pacific region, and regularly shares its experiences with health care colleagues at symposia.

Igat Hope

3.54               Established four years ago, Igat Hope is the peak body representing organisations for people living with HIV/AIDS in PNG, and leads advocacy activities at the national level. 

3.55               Igat Hope was set up as a complementary representative body to the National Aids Council which the National Parliament established, through an act of Parliament, to facilitate a comprehensive response to HIV and AIDS in the country.  That body’s membership comprises 17 government departments, representatives of the private sector through the Chamber of Commerce, the church sector, the non-government sector, the Council of Women, and persons living with HIV/AIDS.

3.56               The Igat Hope secretariat seeks to impress upon the PNG government the vital contribution that NGOs and churches make in delivering services to those living with HIV/AIDS, and to work more closely together with them to improve health outcomes.

3.57               AusAID provided financial support to establish Igat Hope and offers ongoing technical support.

3.58               Secretariat staff reiterated to delegates that one of the biggest ongoing issues for them is dealing with the stigma experienced by people living with HIV/AIDS in PNG society.

3.59               Some of Igat Hope’s achievements to-date include, convening an inaugural national conference of HIV/AIDS service providers in 2008, organising a successful speakers’ program; and participating in the National Aids Council.

3.60               Staff explained that they are working hard to improve the organisation’s capacity and accountability in order to attract more funding.  Recently,   they were successful in obtaining additional support from the Asian Development Bank.

 

Recommendation 7
	The Committee recommends that the Australian government make efforts to link Igat Hope with counterpart organisations in Australia to strengthen their advocacy potential.

 

Susu Mamas

The delegation and staff outside Susu Mamas     

3.61               For the last 33 years, Susu Mamas, a PNG non-profit NGO, has been dedicated to reducing PNG’s high infant and maternal mortality rate and providing care to HIV positive mothers and babies, by supporting nutrition, breast-feeding, infant-feeding, hygiene, antenatal and postnatal care, immunisation, family planning, Voluntary Counselling and Testing (VCT), and outreach services.

3.62               A key focus of the organisation is to prevent parent to child transmission of HIV/AIDS. This is because if a pregnant woman takes antiretroviral drugs before the child’s birth there is a better chance that the baby will be born without HIV. Babies born to HIV mothers are tested for the virus at 6 weeks of age.

3.63               Susu Mamas conducts antenatal clinics every day and provides free education, contraception, and counselling to some 8, 500 to 10, 000 clients a month. The majority of services are run out of Port Moresby.

3.64               Susu Mamas survives on funding from AusAID and corporate sponsors.

3.65               AusAID funding has enabled expansion of the program into two other areas of high HIV prevalence, namely Mt Hagen in the Western Highlands and Lae in Morobe Province.

3.66               The National Department of Health has undertaken to provide core funding to Susu Mamas beyond 2010.

3.67               During its visit to the Port Moresby clinic, the Committee delegation met a young HIV positive woman and her partner, and their HIV negative baby.

3.68               The couple shared their moving story which belied a common scenario.  They described the struggle they had, being unemployed, to buy baby formula (which must be fed to children in lieu of breastmilk in order to prevent transmission of the HIV virus). Baby formula in Port Moresby costs in the region of 49 kina a week, with an inferior version costing about 150 kina a month in Mt Hargan. These costs are prohibitive for the majority of people in PNG who are living below the poverty line.[12]

3.69               Susu Mamas staff described child malnutrition as another significant issue which they seek to address, through education, and, encouraging women who can to breastfeed. The Committee was told that some 50% of children in Morobe exhibit signs of stunted growth, principally through a lack of protein in the first two years of life, with life long adverse impacts on their health.

3.70               The couple that the Committee delegation met spoke highly of the support they received from the staff at Susu Mamas.

 

PNG Eye Care Vision Centre and Optical Workshop

Staff and delegates at Vision Centre, Head, Dr Jarap, third from right         

3.71               The Vision Centre at Port Moresby Hospital was established in October 2008 with AusAID support (see Chapter 2 for more on the strategic partnership between Vision 2020 Australia and AusAID which brought the centre into being).

3.72               The Vision Centre provides low cost eye examinations and glasses, where they are otherwise unavailable, and training for eye care personnel.

3.73               The centre has become very busy since opening a year ago. An Australian optometrist who provides training and support to the centre said that,

It is fantastically rewarding to see the Vision Centre delivering affordable eye care to the people of PNG…new staff have been recruited and trained to help absorb some of the increasing demands…[13]

3.74               The Committee delegation asked staff about the costs of consultations and eyewear.

3.75               Staff replied that a consultation cost 2 kina, and that lenses and frames ranged from 30 kina to 60 kina depending on whether they were ready made or made to order.

3.76               The Head of the Centre, Dr Jambi Garap, advised that there had previously been a monopoly on the supply of glasses but prices had now fallen by half.

3.77               Delegates were very interested to learn about the difficulties of refitting second hand spectacles donated from Australia (and that, such donations are potentially a problem rather than a solution). It is apparently much cheaper and easier for the Centre to order custom-made glasses from China instead.

3.78               The message of NGOs and community organisations in Australia sometimes sending underdeveloped countries items that are not actually all that useful (despite the donors’ very best intentions) was one that surprised the delegation. However, it was a resounding and important message that was repeated throughout the course of the week. 

3.79               As such, the delegation thinks that it could be most useful if there were a contact point within DFAT or AusAID for those community organisations in Australia who wish to donate services or goods to seek basic advice on the suitability of their donation.  Perhaps a website could be established to provide a contact officer’s details together with some basic guidelines about donating, and examples of useful versus less useful donations. The office itself could take a proactive education role as well, disseminating information to community organisations in Australia on best practice for making useful donations to organisations and communities overseas.

 

Recommendation 8
	The Committee recommends that the Australian government consider establishing a contact point within the Department of Foreign Affairs and Trade or AusAID to provide community organisations in Australia with basic information on the suitability of their intended donations to countries in our region.

 

3.80               Dr Garap informed delegates that the Vision Centre model had proved successful and was going to be replicated elsewhere.  Plans are afoot for a further Vision Centre to be located at Mt Hagen in the Western Highlands Province, about 500 km from Port Moresby.

Meetings with other civil society and government representatives on health and HIV/AIDS in Port Moresby

 

3.81               The Committee delegation hosted a well-attended meeting with a wide range of civil society and government representatives gathered to discuss health and HIV/AIDS issues.

3.82               Two parliamentarians were present. Dame Carol Kidu MP, the Minister for Community Development, is well-known for her work as a social justice advocate. In 2007 the magazine Islands Business named her person of the year, in recognition of her efforts towards reducing poverty, domestic violence and child abuse, HIV and AIDS and for advancing women's rights.  In 2009, she was the first Papua New Guinean to be awarded the prestigious Légion d’honneur by France for her dedication to helping women, young girls, children, the physically and mentally impaired and her commitment to fighting discrimination.[14]

3.83               The Hon. Jamie Maxone-Graham MP is Chairman of the PNG Special Parliamentary Committee on HIV/AIDS advocacy, which is a bipartisan committee comprising 11 members of parliament, tasked to report to parliament on: the broad drivers of the epidemic; appropriate legislation; appropriate coordination mechanisms to support the response; progress fostering effective international partnership, and; progress towards establishing and implementing the mandate of District AIDS committees.

3.84               Other attendees at the meeting were Mr Wep Kanawi (Acting Director of the National AIDS Council and a former Health Secretary); Dr Clement Malau (Secretary of Health); Dr Joseph Pagalio (Secretary of Education); Ms Caroline Bunemiga, General Manager of Business Against HIV/AIDS, and representatives from UNAIDS (the Joint United Nations Program on HIV/AIDS) and the National Research Institute.

3.85               Dame Carol Kidu commenced talks reiterating a point that the Minister for Health made to the Committee about the need for development partners to work more closely with the national government to strengthen their systems and structures, and not just to support NGOs and churches.  She said that,’ without government you don’t have a nation’. Equally, she said that the national government needs to better support provincial administrations.  Improvements in coordination between development partners would also be welcome, to avoid duplication and inefficiencies.

3.86               Discussions continued on a range of health issues and health activities underway.  Mr Kanawi spoke about the need to step up action on Millennium Development Goals (MDGs) and HIV/AIDS, especially of concern in the border areas with Indonesia (Western Papua, which borders with Western Province, having the highest HIV/AIDS rates in Indonesia).

3.87               The Hon. Jamie Maxtone-Graham MP emphasised the importance of national ownership and leadership in driving forward any health policies and activities.

3.88               He was particularly keen to learn about the committee’s previous inquiry into obesity in Australia as that it was a health issue that he had an interest in.  The Committee undertook to send Mr Maxtone-Graham a copy of its obesity report tabled in July 2009, as well as a copy of the National Preventative Health Taskforce’s National Preventative Health Strategy, which recommends a wider range of interventions aimed at reducing the chronic disease burden associated with obesity and two other lifestyle risk factors, tobacco and alcohol.

3.89               Dame Carol Kidu spoke about the reference group she is leading, which is looking into amending PNG’s criminal code which still criminalises homosexuality and prostitution. Making these acts legal will, she hopes, help contain the HIV epidemic and improve access to treatment and services for those otherwise afraid of being prosecuted.

3.90               The UNAIDS representative, Country Coordinator, Mr Rwabuhemba, supported Dame Carol Kidu’s remarks about HIV-related stigma remaining a significant issue and of people being too ashamed to seek treatment, irrespective of affordability or access to treatment. In addition to the criminal code undermining the national response to AIDS, he contended that continued gender-based violence does the same. He commended the delegation for its interest in HIV/AIDS, at a time when there were many competing priorities, and in a year that had been so focused on climate change issues.

3.91               Dr Pagalio described the HIV/AIDS and reproductive health education that school students are receiving, and provided the delegation with a copy of the Department of Education’s teacher manual on HIV/AIDS and reproductive health.

Western Province

Delegates and The Hon. Sali Subam MP (third from left) and The Hon. Bob Danaya (Governor of Western Province (fourth from left) being welcomed at Daru airport

3.92               The delegation was delighted to be so warmly received in Western Province by the Governor, the Hon. Bob Danaya; the local member for South Fly, The Hon. Sali Subam MP, who is also the Parliamentary Secretary for Foreign Affairs; Mr William Goineau, Provincial Administrator, other staff of the Western Province Administration, and community representatives.

3.93               The delegation’s visit to Western Province involved a number of formal and informal engagements with provincial health administrators and health workers. 

Meetings in Daru

 

Provincial Health Office

 

Delegates and health representatives at Western Province Health Office

3.94               The delegation spent time at the Western Province Health Office and Daru Hospital talking to a range of representatives, listed in the acknowledgments section in Chapter 5.  A number of topics were covered, including water and sanitation; TB; HIV; child and maternal health; and AusAID assistance.

3.95               The delegation raised the issue of water rationing in Daru, which they had experienced themselves at their accommodation, and sought further information on the water and sanitation situation in town.

 

 Daru foreshore, local markets and boats on which people live

3.96               The delegation was informed that the population in Daru had tripled in the last 20 years, and that royalty payments from the OK Tedi mine continued to bring people into town.  The growing population compounded the lack of investment in all existing infrastructure and services. As mentioned in Chapter 2, water is only available for a few hours a day and less than half the population is connected to an antiquated sewerage system. Subsequently, water borne diseases, including typhoid[15], are endemic.

3.97               A lengthy discussion ensued about TB management. Dr Marome of Daru hospital noted that unsanitary living conditions, poverty and overcrowding were major contributors to the incidence of TB. He told the delegation that diagnosis and treatment compliance remained major issues. He said that while there had been improvements in diagnosing the illness (for instance, there is a TB register and families of patients are screened now as well), there are only two doctors in the country who are able to prescribe second-line treatment. There is a real need for greater monitoring of patients in outlaying areas who are prescribed TB medication. Health workers need to ensure that patients are taking their medication as instructed, in order to get well, to not spread the disease or contribute to drug resistance. TB workers spoke of various difficulties they face in reaching patients in outlaying areas, in some instances, having to walk days to reach them or not having money for fuel for boats (the main mode of transport), challenges in receiving their salaries and in procuring staff accommodation.

3.98               Specimens also have to be sent to Port Moresby or Brisbane for testing, which results in significant delays to treatment.

3.99               The delegation learnt that the WHO has introduced fixed dose combinations of tablets against TB that simplify the prescription of drugs and the management of drug supply, and lessen the risk of Multi-Drug Resistant (MDR)-TB developing. 

3.100           On HIV, and its interaction with TB, it was noted that approximately 20 % of HIV patients also have TB. Patients are automatically screened for HIV and there is an integrated STI clinic at Daru hospital.

3.101           Delegates raised the province’s poor child and maternal health indicators, and asked health professionals to comment on the low supervised delivery rate. Staff noted that there are also only 11 midwives in Western Province (all based in regional centres) to cater for some 7, 000 to 8, 000 births per annum. While expectant mothers living close to Daru do come in to the hospital to give birth, it is much more difficult for those living further away, not least because they may have to walk for several days to get to the hospital.

3.102           Funding issues were brought to the delegation’s attention. Health professionals noted that there were often delays in receiving their budget allocations after the budget is passed down. Further, when the money arrives half way through the year, there is a rush to spend it all in order to receive the same amount the following year.

3.103           Several at the meeting expressed their concern that AusAID funding was not trickling down to the village level for health or education, and stated that this was not value for money for the Australian taxpayer.

3.104           AusAID said that while the Australian government wishes to be transparent about where monies go, funding is increasingly mainstreamed rather than dedicated to stand alone projects. This means that the Australian government works to strengthen the PNG national health system, and, the government of PNG (not Australia) is responsible for disbursing funds to the provinces, and the provinces to the villages.

Daru Hospital

 

Daru hospital staff greeting the delegation

3.105           The delegation was met by hospital staff and taken on a tour of the health facilities, which delegates could see needs upgrading.

3.106           Doctors reiterated that typhoid was endemic and that foodborne and respiratory illnesses are common in Daru.  They noted that there were currently 7 or 8 patients with TB which was a vast improvement on the 35 or so they used to have, prior to the current treatment program.

3.107           The Delegation Chair asked staff to elaborate on the areas of greatest need at the hospital.

3.108           Delegates were told that the hospital is 43 years old. The building and equipment are ageing and require maintenance.  The power supply is not constant.  Drugs have to come from Daru via Port Moresby and be transported by boat so there are supply shortages. There is a 3 to 4 day wait for a bed. Patients have difficulty affording the 10 kina a day hospital fee, the costs being especially prohibitive if they have TB and require treatment for some 6 months. There was one dental therapist but no dentist. Connections with rural services need to be improved. Naturally, patients compare conditions to the ‘better’ facilities available on the Australian side at the Torres Strait clinics.

3.109           Management issues were cited as a major concern. At the time that the delegation was visiting, the hospital had a caretaker management structure in place, in lieu of a hospital board. Staff said that this placed an enormous administrative burden on them and undermined the service they were able to provide patients.

3.110           The local member, the Hon. Sali Subam MP presented architectural drawings for a new hospital in Daru.  Mr Subam said that he had discussed funding the proposed facility with a number of possible donors.

Treaty Villages

 

Map of treaty villages in Western Province            

 

Auslig map, Australia’s maritime zones in the Torres Strait

3.111           Accompanied by the Governor of Western Province, The Hon. Bob Danaya and the local member for South Fly, the Hon. Sali Subam MP, the delegation was thrilled to be able to visit the treaty villages of Mabadawan, Sigabadaru and Buzi in Western Province.

 

Welcome at Mabadawan village

Delegation Chair in mask presented at Mabadawan. AusAID watertanks in background    

3.112           As previously noted, Western Province is Australia’s closest neighbour. At their closest point, Sigabadaru is a mere 15 minute boat ride away from Saibai, compared with a 2 hour boat journey to Daru. Mabadawan is also fairly close to Saibai. Buzi (also spelled Buji) is closest to Boigu Island.         

3.113           Despite the short geographical distance between the two countries, this was the first Australian parliamentary committee delegation ever to visit the area, and the first time that Australian and PNG politicians had been there together.  

3.114           The visit was an important symbolic gesture of the increasing importance placed by both our countries on working together in partnership on a range of cross-border health issues that jointly affect Australia and Papua New Guinea.  The significance of this ‘first’ was noted repeatedly throughout the treaty village visits by the joint-delegation and hosts alike. It was observed that visitors rarely make the extra effort to visit the villages, not least because they are so difficult to reach. The joint delegation’s effort to go beyond Port Moresby and Daru was much appreciated by the locals, and their reception could not have been warmer.

3.115           The delegation received full traditional welcomes from each village which were quite wonderful, and has very fond memories of the day and their generous hosts.

3.116           The visit to the treaty villages was an absolute highlight of the delegation visit and the delegates greatly appreciated the opportunity to meet with village leaders and villagers alike, to view their health facilities and to listen to their health concerns first-hand.

3.117           As mentioned in the previous chapter, the delegation had earlier visited Saibai Island, seen PNG nationals coming ashore and viewed the health facilities on the Australian side of the border. Visiting a representative sample of treaty village communities on the Papua New Guinean side enabled the delegation to compare and contrast both experiences.

3.118           Both sides commented how important visits like these are for those in the PNG and Australian Parliaments alike to view conditions on the ground and to speak to people at the local level.

3.119           Treaty villagers referred to a deterioration in health services. They said that reasonably large sums of money were dedicated to treaty development from both the PNG and Australian governments (including a sum of about 300 million kina for Mabadawan), but they saw little evidence of that translating to better services.

3.120           The delegation visited the health clinic at Mabadawan which is the largest village in the area, with a population of around 750 people, and community aid posts which serve smaller populations at  Sigabadaru (approximately 250) and Buzi (roughly 150).

 

Delegation and staff in the delivery room at Mabadawan clinic      

Delegate and local at the Sigabadaru community aid post radio room       

           

Meeting with Buzi community – AusAID water tanks in background

Drugs on display at Buzi aid post              

3.121           The delegation saw that health facilities and services are basic in the villages. At Mabadawan, the clinic building was indeed deteriorating and in need of upgrade, beds had no mattresses and equipment was sparse.  Staff said access to drugs and sterile equipment was another issue (with drugs having to make their way from the central store in Port Moresby to Daru, and then onward to the villages by boat).  Villagers called for more doctors and nurses, a routine outreach service from Daru and speedier referrals, to minimise patients accessing the clinic on Saibai.  Other issues brought to the delegation’s attention included a shortage of housing for health workers; maintenance delays in fixing broken bore pumps; and outstanding compensation claims for ex-pearl divers who had worked in the Australian pearl diving industry.

                         Delegates and women leaders at Sigabadaru             

3.122           The Governor and local member, Sali Subam MP said they would take the villagers’ representations back to Port Moresby. Mr Subam made a number of announcements. He stated that the Mabadawan health clinic would be upgraded to a Rural District Hospital so villagers would no longer need to travel to Daru Hospital for treatment and that construction was due to begin before his current term expired in 2012.  He added that a boat to assist in the delivery of health services, to be based in Mabadawan, was to be delivered in November, (provided for through his District Service Improvement Program (DSIP) grant). He also said that the district plan sought to redress the health workers’ accommodation issue.

3.123           Mr Subam remarked that he had spoken about treaty village health concerns when he visited Canberra and that he was pleased to be part of a new era of engagement with the Australian government. He noted that both governments were putting in place a package of measures to benefit residents on both sides of the Torres Strait.

3.124           Several commented that the new AusAID funded health communications officer, based in Daru, had already improved access to basic health services, including facilitating information flows; following up on the treatment of TB patients; and building and strengthening relationships between health professionals on both sides of the border. On the issue of improving the delivery of drugs to aid posts, AusAID advised that it is recruiting a manager for pharmaceuticals in Port Moresby to help the Secretary of Health deal with problems in management. Further, the AusAID health adviser in Daru is supporting the Provincial Health Office to improve distribution from province to facilities, including establishing contracted systems to supplement the current ad-hoc arrangements which are that whoever happens to be travelling into the villages takes medical supplies in.

3.125           The delegation learnt that the new health communications officer positions on both sides of the border are performing a critical role. On the basis of their success to date, the Committee thinks that consideration should be given to supporting additional health communications officer positions on both sides of the border to support the two current positions. The Committee heard that compliance is a major issue and it is not realistic to expect one or two officer to monitor everything and everyone.

 

Recommendation 9
	The Committee recommends that the Australian government support  additional health communications officer positions in the Torres Strait and treaty villages of the Western Province of Papua New Guinea.

 

3.126           Obtaining clean drinking water was a major concern of the villagers. The delegation was informed that rainwater tanks provided by AusAID in the villages were greatly valued for their provision of good quality drinking water for some of the year but that they do not provide enough during the dry season, resulting in poor quality water needing to be sourced elsewhere, from wells or rivers. Villagers showed the delegation samples of water drawn from these alternative sources, which were murky in colour and/or full of sediment. They wryly observed that taking medication for illnesses with such water was counterproductive. 

 

Recommendation 10
	The Committee recommends that the Australian government install additional rainwater tanks in treaty villages in the Western Province of Papua New Guinea.

 

3.127           In respect of the water situation in Sigabadaru and Buzi, the Governor acknowledged that broken bore pumps there had been of an inferior quality and would replaced with better quality ones.

3.128           The delegation commented that it was necessary to make clear to locals who was actually responsible (be it the government or the communities themselves) for providing ongoing maintenance, for bore pumps that need fixing or aid post structures that need to be repaired because they have been destroyed by white ants.

3.129           The delegation heard, time and time again, about the lack of available and/or inadequate housing for health workers (be it for health workers at Daru hospital or aid posts in the treaty villages), and this being a major reason why staff were disinclined to work. For instance, in Sigabadaru, a health worker had left because their house had burnt down and was not going to be replaced.

3.130           The delegation believes that housing and support for community ownership of aid posts must form part of the package when installing new aid posts or seeking to improve current ones.

Recommendation 11
	The Committee recommends that any new health facility that the Australian government helps construct should provide for staff accommodation and ongoing maintenance, in consultation and partnership with the local community.

Delegates and children in Sigabadaru     

Roundtable with treaty village stakeholders

3.131           Following its visit to the treaty villages, the delegation was pleased to host a roundtable forum in Daru with a range of invitees with a stake in the health and well-being of treaty villagers (including health officials, customs and quarantine officers, and the police). All participants are acknowledged in Chapter 5.

3.132           The District Administrator reiterated his warm welcome to the first Australian parliamentary delegation to visit Western Province.

3.133           Discussions were wide ranging, covering many of the issues raised during the treaty villages visits. In addition to those already mentioned, and repeated calls to upgrade the health clinic at Mabadawan, the following topics were also mooted.

3.134           There was some broader discussion of the poor economic and social conditions in Daru and the Western Province, and the limited prospects for economic development.

3.135           In respect of the health workforce (and tying in with the theme of poor economic conditions), it was noted that workers in the villages often receive their pay erratically, and that they have to travel significant distances to collect it (which takes them away from patients). Public servants in Daru say they find it difficult to make ends meet on their salaries in a town with such high living costs.

3.136           Quarantine officers noted DIAC’s movement monitoring officers on the Australian side of the border and said that they needed more people on the PNG side, similarly trained, to deal with people movement and quarantine concerns (namely, animal and plant matter being brought back into PNG from the Torres Strait).  The delegation said treaty villagers had told them that while quarantine rules are stringent for those travelling to the Torres Strait, animals such as cats and dogs have been brought back to the villages from the islands on the Australian side. They voiced concern about the potential for zoonotic diseases to spread this way.

3.137           Customs officers commented on the good working relationship that they have with their Australian counterparts. They said that they would like to undertake more Joint Cross-Border Patrols, which they currently do together with Australian and PNG police a few times a year.

3.138           The police acknowledged Australian assistance in providing the police station building but noted that ongoing maintenance costs and fuel for the patrol boat were not covered.

3.139           In recognition of the fact that many health issues extend beyond the health portfolio, the Western Province Deputy Provincial Administrator, Mr Willy Kokoba, wrote to the Australian Department of Health and Ageing in September 2009 to request a Cross-Border Regional Review (CBRR). As an alternative to the Health Issues Committee deliberations, the proposed review would take into account a broader community development approach which would include food security, income earning opportunities, transport and communications, cultural issues, fisheries and law and justice.  

3.140           The proposal was distributed to all Health Issues Committee (HIC) members requesting comments prior to it being submitted to the Joint Advisory Council (JAC) in late October 2009.[16]

3.141           Following that, the WP Provincial Administrator intervened instructing that the CBRR be presented to the Provincial management team for review prior to submission to JAC. It was discussed and endorsed at the December 2009 Provincial management Team (PMT) meeting. It will now be refined and presented to the next HIC for discussion. If endorsed by HIC, it will then proceed to JAC.[17]

3.142           On the matter of an alternative forum for discussion of treaty related health issues to the Health Issues Committee, the delegation thinks that complementary consultative mechanisms should be considered. The Committee notes that there are elements of fear and mistrust in the current process by some locals on both sides and thinks that there may be other creative and fruitful ways to facilitate engagement at the local level.

3.143           The delegation and participants in the roundtable on treaty development found the roundtable format one useful way for a range of stakeholders to engage on treaty issues. Another possibility is the establishment of something similar to a set-up the Committee saw work fairly well in the remote Australian indigenous community of Maningrida in the Northern Territory when it visited there, in relation to a previous inquiry. The Government Business Manager in Maningrida had successfully facilitated the establishment of a Community Reference Group (CRC), comprised of local elders, leaders and community representatives. The CRC there believed that it should be one of the first ports of call for all government business on health or other service delivery matters. The Committee saw that this forum appeared to work well allowing different voices in the community to be heard, and for people to discuss government business in an informal but structured and respectful manner with each other and with government officials. More than anything it is a collaborative process and trust building exercise.

 

Recommendation 12
	The Committee recommends that the Australian government, in conjunction with the Papua New Guinean government, facilitate more creative and inclusive forums in which locals on both sides of the treaty zone border can engage on health and other treaty related issues with each other and with government officials of both nations.