Last week, Development Policy Centre Visiting Fellow Andrew McNee shared his thoughts on a recent report on maternal and child health in PNG. Here, report authors Chris Morgan and Abbey Byrne respond.
We were delighted to read Andrew McNee’s thoughtful reflection on our report from the Burnet Institute, Compass and World Vision on the potential of Family and Community Care to improve maternal and child health in Papua New Guinea (PNG). While we have tried to compile the best international evidence, our ideas very much flow from direct experiences of talking with families and health staff in remote or rural villages in that country. Too many women’s groups relay stories, recent stories, of avoidable deaths and preventable diseases afflicting mothers and newborns. These experiences bring about a driving force from within communities, scandalous as it is, which we believe can and should be nurtured in order to generate change.
Andrew McNee’s overall thesis, especially his concluding paragraphs, contain suggestions that are hugely important to the future of health in PNG. Further research on how to effect improvement is essential in this setting that has seen too little and too slow change in the past decade. The health system remains weak and under-resourced. Nevertheless, there are community programs, officers-in-charge of health centres, nurses and managers of district health offices, and many professional health workers who manage to deliver health services under adverse conditions and in spite of insufficient support from the system. Understanding how to improve service provision should begin with these ‘surprising successes’. There is a need for properly conducted implementation research to unearth the treasures in the details of how rural health facilities and their staff have managed to serve their communities, as well as how some of the most outstanding community health programs and Village Health Volunteers (VHVs) have managed to get at least some care to rural families.
It is important to point out that, in our report, we are not so much calling for a major expansion of VHV services. It would be facile to propose that such an approach in isolation would be the solution to PNG’s maternal health crisis. What we are expressing is the importance of giving closer consideration of the potential in existing community health programs and their VHVs. Internationally, this cadre are now often called “trained lay health workers” and are increasingly seen as important for the expansion of coverage of health services in resource-poor settings (check out: Lewin and colleagues’ Cochrane Review: ‘Lay Health Workers in primary and community healthcare for maternal and child health and the management of infectious disease’, Cochrane Database Syst Rev 2010: 31-209; or Bhutta and colleagues’ ‘Global experience of community health workers for delivery of health-related Millennium Development Goals: a systematic review, country case studies and recommendations for scaling up.’ WHO Geneva, 2010.) AusAID’s recently released health thematic strategy includes a case study of Nepal’s experience in reducing maternal and child deaths, noting the contribution of that country’s 55,000 female community health volunteers to this effort. The report drew on examples of success in other developing countries with the hope that global lessons can be applied in PNG where appropriate.
Over the past 15 years, there has been considerable investment in this VHV cadre in PNG by NGOs, churches and the PNG government. VHVs are valued by communities and, to some extent, also represent a community’s desire to do something to improve their own health outcomes. The last count we know of (in approximately 2003) suggested there may be 6,000 trained lay health workers in PNG which, although not equivalent to professional staff in health facilities, is still a considerable resource. Our reading of the plans of the PNG government and other development partners is that, while this group is acknowledged, they are not truly seen to be an integral part of health system strengthening. Their role is often treated as solely one of education and communication (both crucially important to health and generation of ownership and demand for health services) rather than one that also includes delivery of health services. Yet in many programs across PNG they are delivering services – hence the importance of Andrew McNee’s call for greater documentation of such successes.
We wholeheartedly agree with the need to better document how existing programs are delivering services – especially those surprising successes. One of the primary suggestions emerging from our research is the re-establishment of a national forum of VHV programs to encourage information sharing, improved practices, agreed quality standards, and stronger linkages between health and community development programs. We would also like to see family and community care, and the role of VHVs, factored into district planning for expanding coverage of health care services. Lastly, we hope that our report can enable existing community health programs to review this evidence against their own experience and practice – aiming to refocus implementation on those packages of interventions likely to have the highest impact.