Management, manpower, money : a select review of health and population in Papua New Guinea

; *. ~~~~~~~~~~~~~~~~~~~~~4 Report No. 8959-PNG Papua New Guinea Management, Manpower, Money: A Select Review of Health and Population in Papua New Guinea February 25, 1991 Population and Human Resources Operations Division Country Department V Asia Region FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otheiwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS Currency Unit - Kina (NGK) US$1 - NGK 0.98 NGK1 - US$ 1.02 (as of March 31, 1990) FISCAL YEAR January - December ABBREVIATIONS AND ACRONYMS ADB - Asian Development Bank APO - Aid Post Orderly CHW - Community Health Worker ASH - Assistant Secretary of Health CBD - Community Based Distribution DFP - Department of Finance and Planning DPM - Department of Personnel Management EPI - Expanded Program of Immunization FAS - First Assistant Secretary FP - Family Planning HC - Health Center HCMU - Health Curriculum and Media Unit HEO - Health Extension Officer HO - Hospital Orderly ERS - Human Resources System HS - Health Sub-Center IMR - Infant Mortality Rate ISN - Indicator of Staffing Need NA - Nurse Aide NACPP - National Advisory Committee on Population Policy NCD - National Capital District NDOH - National Department of Health NEC - National Executive Council NO - Nursing Officer NPC - National Population Commission MCH - Maternal and Child health MOB - Ministry of Health NRC - Management Resource Committee MSP - Management Support for Provinces Program PDH - Provincial Division of Health PHEO - Provincial Health Extension Officer PIP - Public Investment Program PNGFPA - Papua New Guinea Family Planning Association PNGIMR - Papua New Guinea Institute of Medical Research REU - Regional Epidemiology Unit RSU - Regional Support Unit TFR - Total Fertility rate UNFPA - United Nations Population Fund UNICEF - United Nations Children's Emergency Fund USAID - United States Agency for International Development  FOR OFCIAL USE ONLY PAPUA NEW GUINEA MANAGEMENT. MANPOWER, MONEY: A SELECT REVIEW OF HEALTH AND POPULATION IN PAPUA NEW GUINEA Table of Contents Pane No. SUMtAEY AND KEY RECOMMENDATIONS .R..E.....A..... ..................... i A. Introduction and backzround ... . # . ................ i B. Key Sectoral Issues . ....... . .. ................. . iv Organization, Management and Planning . . . . . . . . . . . iv Quality of Service ... . .... . . . . . . . vi Use of Personnel . . . . . . . . . . . . . . . . vii Population . . . . . . . ... . . . . . . . . . . . . viii Financing the Sector . . . . . . . * . . . . . . ix C. Princival Recommendations ... . . . . . . . #. ... x Policy and Planning .... . . . . . . * ... ..... xi Quality of Services .......................... xi Population . ... . .*. * . * . *.... . . . . . *. . xi Financing . . . . . . . . . . . . . . xii 1. INTRODUCTION .*. .*.*. .* . * . . . . . . . . . . .1. A. The Setting . . . . * * * * * . * . * . . . * * * . . * * 1 B. Achievements in Health . . . . . . .. . . . . .1 C. Health Policy and Priorities . . . . . . . . . . . . . . 1 D. Economic Situation and Health . . . . . . . . . . . . . . . 3 E. Focus and Role of Report . . . . . . . . . . . ..... 4 2. ORGANIZATION. MANAGEMENT AND PLANNING .. . ............ . 5 A. Decentralization .... . . . . . ... . . ....... . 5 B. Center-Provincial Relations ... . . . . . * . . . . . . . 5 C. Manazement . . . . . . . . . . . . 4 4 . . . . . . . . . . . 7 D. Health Planning . . . . . . . . . . . . . . . . . . . . . . . 9 This report is based on the findings of a mission to Papua New Guinea conducted from March 12 to 30, 1990. The mission comprised Dr. Michael Porter (Mission Leader); Ms. D. Donaldson (Health Economist); Dr. J. Devdney ( Health Manpower); Mr. H. Jones (Management/Population Specialist); and Dr. P. Garner (Public Health Specialist). Mr. Jin He and Ms. G. Ssali assisted in the preparation of the report. This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  ii 3. QUALITY OF SERVICES .... . . . . . . . . . . . . . . . . . . . . 11 A. Organization of Health Services . . . . . . . . . . . . . . ll National Department of Health . . . . . . . . . . . . . . . 11 Provincial Health Services . . . . . .... . . . . . . 12 Church Health Services .......... ........ 14 Urban Health Services ......... .......... 15 B. Health Sector Performance ................. 15 Impact on Mortality ... ......... . . ........ . 15 Access to Services ......... ... . ...... 17 Quality of Services . .......... ......... 17 Coverage of Women and Children's Health ... . . . . . . . 18 Efficiency of Rural Health Services . . . . . . . . . . . 20 C. Support For Service Delivery s . . . . . . . . . . . . ... . 21 Management of Services ... . ... .................. . 21 Transportation . . . . . . . . . . .. . . . . .. .... . . . 25 gIousing . . . ....... ..................... * .......... * ... . 25 Community Responsibility for Health . . .. . . ....... 26 4. USE OF PERSONNEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 A. The Health Work Force . .................. 27 Information Sources . ..... . .. ...... 27 Size of Work Force . . . . .. . .. . . ........ 28 Distribution of Staff . . . . . . .. 30 Doctors .... . . . . . . . . . . . . . . . . . . * * . 33 Community Health Workers ................. 34 Regulating Recruitment ............... .. . 35 B. Health Manpower Planning and Information Systems ... . . . 36 C. Training and Staff Development . . . . . . . . . . . . . . . 37 Pre-service Training . .. . . . . . . . . . . . . .... 37 In-service TrainingceTra.n.. . . . . . 38 Post-basic Training ..............*...... 39 Training Problems and Possible Solutions . . . . . . . . . 39 5. POPULATION AND FAMILY PLANNING . . . . . . . . . . . . . . . . . . . 42 A. Demographic BackRround . . . . . . . . . . . . . . . . . . . 42 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . 43 Population Growth Rate . . . . .............. 43 B. Population Policy . . . . . . . . . . . . . . . . . . . . . 43 C. The Family Planning Program ..... . . .. . . . .. . 46 Service Delivery . . . 4 4 . 46 Coverage . . . . . . . . . . . . . . . . . . . . . . . . 47 Contraceptive Methods ................... 48 Foreign Assistance . . . . . . . . . . . . . . . . . . . . 49 The Family Planning Association . . . . . . . . . . . . . . 49 D. Program Development Proposals . . . . . . . . . . . . . . . 50 Program Administration . . . ............. 51 Program Strategy . . . ............ . 52 Targets . . . . . . . . . . 4 . . . . . . 4 . . 4 53 Services . . . . . . . . . . . . . . . . . . . . . . . . . 53 Outreach . . . . . . . . . . . * . . * . .*. . . . . 54 Information and Education . . . i. . ... . . .. .. . .. 55  iii Resources . . . . . . . . . . . . 4 . . . . . 55 6. HEALTH SECTOR FINANCING . . . . . . . . . . . . . . . . . . . . . . . 57 A. Overview . . . * * . * . . . . . . . . . . . . . . . . . 57 B. Institutional Framework for Planning and Budgetinr . . . . . 57 C. Trends in Sector Financinz . . . . . . . . . . . . . . . . . 61 Overall Trends. . . . . . . . . . 61 Recurrent Budget . . .. ........ ... . ..... 62 Investment Budget . . . . . . .. . . . . . . . . . . . .. 63 D. Issues in Recurrent Expenditure Management . . . . . . 64 Program Budgeting. . . . . . . . . . . . . . 64 Allocation of Budget Among Programs . . . . . . . . . . . . 64 Allocation Among Provinces ........... **.... 65 Allocation by Input . . . . . . . . . ........... 65 S. Outlook for Sector Financina Reauirements . . . . . . . . 67 F. Ootions for Resource Mobilization in Sector . . . . . . . . 67 User Fees - Hospitals and Rural Health Facilities. . . . . 67 Charges for Drugs ..................... ....... 71 Insurance . . . . . . . . . . . . ........ . . . . . . 72 Earmarked Taxes . . . . . . . . . * 4 . 73 BIBLIOGRAPHY ..................... . ... .. ...... ... . . 74-79  iv TABLES IN TEXT Table 1.1 - Comparative Health Data--Estimated Average Rates for 1985-1989 .*. . . . . . . . . . . . . . . 2 Table 3.1 - Estimates of Mortality Indicators in PNG 1946-1980 . . . . . . . . . . . . . . . . . . . . ................. 16 Table 3.2 - Immunization Coverage Figures from Provincial Monthly Reports . . . . . . . . . . . . . . * . . . 20 Table 4.1 - Government Health Staff, Occupational Category and Sex, PNG, 1988 . . . . . . . . . . . . . . . . 29 Table 4.2 - Government Subsidized Church Positions . . . . . . . . 30 Table 4.3 - Population ('000) per Health Service Worker in Five Provinces of PNG, 1988 . . . . . . . . . . . . 31 Table 4.4 - Nursing Personnel Employed in Primary and Higher Level Health Service Delivery, PNG, 1988 . . . . . . . . . . . . . . . . . . . . . 32 Table 4.5 - Highest and Lowest Nursing Service ISN, Hospitals PNG 1988, by Category of Hospital . . . . 33 Table 4.6 - Pre-service Training: Total Planned and Actual Intakes to Training 1986-88 and Planned Annual Intake 1991-1995 . . . . . . . . . . 38 Table 5.1 - Population Projection Assumptions . . . . . . . . . . . 42 Table 5.2 - Population Projections . . . . . . . . . . . . . . . . 43 Table 5.3 - Percentage of Methods Adopted by new Acceptors by Year . . . ..... . . . . . . . . 48 Table 6.1 - Trends in Government Health Expenditure 1975-1990 * * * * * * ...... .. .*..... . . . . . . 62 Figure 3.1 Infant Mortality Rate by Province from the 1980 National Census . . . . . . . 16 Figure 3.2 Immunization Coverage Figures for Morobe Province from Information Statistics and from a Separate Sample Survey .9.9.9.9.99..999... ........ 24 Figure 6.1 Flow of Public Sector Recurrent Expenditure for Health, 1986 . . ........... . 58  v ANNEXES Annex 1 Standardization - Health Facility Norms Annex 2 Some Recommendations for Improved Service Delivery Annex 3 Draft Family Planning Policy Statement Annex 4 Table 1 GDP, Government Expenditure and Government Expenditure Health 1975-1990 Table 2 Provincial Health Expenditure from Natirnal and Provincial Governments (1986-1988) Table 3 Trends in Government Health Expenditure Table 4 Health investment Under the Public Investment Program (1990-1994) Table 5 Foreign Assistance for the Health Sector, 1986-1996 Table 6 NDOH, Other National Departments and Statutory Bodies, Expenditures and Estimates, 1985-1990 Table 7 Government Recurrent Expenditures and Estimates for Hospitals, 1985-1990 Table 8 Government Recurrent Expenditures and Estimates for Rural Health 1985-1990 Table 9 Government Expenditures and Estimates for Church Health Services 1985-1990 --able 10 Projections for GDP, Health Expenditure per Capita, Estimated Health Budget Requirements, and Financing GAP, 1990-1995 Table 11 Distribution of Health Facilities Table 12 Health Personnel: Numbers Employed by Occupational Category, 1985, 1988 a.ad 1990 (Target Numbers), Excluding Those in the Private Sector Annex 5 Use of Allocation Models  PAPUA NEW GUINEA MANAGEMENT. MANPOWER AND MONEYs A SELECT RMVIEW OF HEALTH AND POPULATION SMA AND NKY RECOMMENDATIONS A. Introduction and Backaround i The extension of basic health services to almost everybody has been a notable achievement and a strong indication of the Government's commitment to social development. With limited resources, the development of health and family planning services has been hampered by difficult terrain and poor communications but the Government is now able to claim that 95% of the population is within a two hour walk of a health facility, either Government or mission managed. Topographically, the country encompasses extensive mangrove swamps and alpine meadows with tiers of steep sided valleys occupying the intervening terrain. Physically moving around the country is difficult. although new roads and light plane transport means that, gradually, the population has had better access to the external world. The rugged countryside has contributed to cultural and linguistic diversity, a consequence ultimately reflected in the highly de-centralized form of Government which was adopted at independence in 1975. Although there is much modernization underway the benefits do not reach all sectors of society. Educational attainments, particularly among women, are limited and the pool of educated and trained staff, while growing, remains relatively small. Serious obstacles to delivery of health and family planning services exist wherever one turns and nothing is achieved without considerable effort and expense. ii The missions have made a significant contribution to the development of health facilities in rural areas and continue to play a role in training health manpower and providing services. However, the level of mission support is inexorably lessening as the basis of their financial support erodes. Between diminishing mission support and difficulties in maintaining Government facilities in face of financial and staffing constraints, it is questionable whether the claim of 95% coverage remains valid. Numbers of facilities are no longer manned, despite being nominally "on the books" and some have been closed. The extent of this trend is not well documented, but the situation appears to be getting worse. iii The health status of the population has been improving. However, precise knowledge of key health indicators is dated, for it is derived from the 1980 census. Between 1946 and 1980, the infant mortality rate (IMR) declined from about 250/1000 live births to 72/1000 live births with strong regional differences. Since 1980, surveys continue to show marked variation in IHR even within a single province (para.3.16). It is not possible to draw any overall conclusions about the trend in IMR since 1980 from such surveys and, unfortunately, a decision was reached to exclude questions related to mortality from the 1990 census. Despite increased access to health services, maternal mortality rates in rural areas remain high and unchanged varying between 7-20/1000 births. Life expectancy has risen from 31 years in 1946 to 50 years in 1980, which is a low figure. While there has been progress much  ii remains to be achieved in reducing infant and maternal mortality, the most sensitive indicators of the nation's health. iv Based on 1980 data, the crude birth rate is estimated to be 35 per 1000 persons and the fertility rate about 5.3, figures which contain significant regional differences. Trends in these figures are not discernable but it is likely that the total fertility rate has been increasing as established practices controlling fertility are eroded. Although 85% of the population is married, increasing urbanization of the population is accompanied by a breakdown in traditional relationships - one result is an increase in young unmarried mothers although the scale of this problem is unknown. PNG society is going through a period of profound change, the demographic impact of which is far from clear. Certainlys the population may be expected to grow at an accelerated rate unless an effective family planning program is introduced. Family planning services are offered through Government and some mission health facilities but the program is essentially passive and has had no notable effect on the low use of contraceptives. Little progress has been made in clearly linking acceptance of family planning to the health, even survival, of mothers and children. The effect of unrestrained fertility will place an enormous demand on resource3 as PNG struggles to develop. A realistic projection, which assumes constant fertility and a gradual improvement in life expectancy coupled with a decline in the death rate, is that by 2015 the population of PNG will be 7.4 millions. v Morbidity and mortality information is derived from health facilities data and provides an approximate paradigm for the pattern of illness in the community. Conditions associated with motherhood and infancy and communicable diseases dominate the epidemiological profile for cause of death and reason for visits to health facilities, a pattern characteristic of underdeveloped tropical countries. For women, obstetrically related conditions are the leading reason for visiting health services while, for the population at large, malaria, pneumonia, tuberculosis and ill-defined intestinal infections dominate the communicable disease picture. Typhoid has shown an increase recently while sexually transmitted diseases, after going through a period of increased incidence, appears to be lessening somewhat, although the well known inability to monitor sexually transmitted diseases accurately has to be borne in mind. AIDS appeared for the first time in 1987 and the number of known fRV positive cases doubles with each passing year. vi The features of malaria have shown little change over the past few years, but the trial introduction of impregnated nets has reduced the malaria parasite rate by 74% in areas where they have been used. The widespread availability of anti-malarial drugs has also helped mitigate the worst ravages of this problem despite growing drug resistance to chloroquin. Acute respiratory diseases, including some vaccine preventable diseases, are the leading cause of childhood morbidity and mortality. Most cases are viral in origin but are aggravated by superimposed bacterial infections which are, however, amenable to medical intervention. Nutritional status of young children (6-36 months) significantly affects the outcome of such infections - a survey in 1982 revealed that 38% of children were less than 80% of the standard weight for age. The incidence of tuberculosis remains steady but some success has been a-hieved in reducing the case fatality rate, although  iii rising drug resistance may affect this favorable trend. vii People seek help for their health needs through a hierarchy of facilities ranging from a provincial hospital to the most basic, an aid-post, of which, there are about 2,200 distributed across the country. The Port Moresby General Hospital is the apex of the system but communications are such that it really only serves the National Capital District (NCD) and immediate area. For most people, the main access points are the health centers, sub- centers and aid-posts. Services offered through these facilities are quite varied and little move has been made -oward standardization. In part, this reflects the division of facilities anaged by Government and those by missions (para.3.12). Use of health service outlets also varies, but, overall, low utilization rates prevail. Service outputs are particularly low in areas of child and maternal health care and conducting supervisory and outreach activities, which are affected by limited budget allocations for travel and subsistence. viii Since 1975, successive governments have generally supported development of social services as a matter of policy and, accordingly, health services have received favorable budgetary treatment. The one exception to this treatment was the 1985-88 period, when allocations for health declined. This stance has been reversed since 1988 and the Government has moved to restore support for social services to previous levels. But the misfortune of 1989 dealt a blow to this policy and produced another setback for the health services. Although relatively spared, nevertheless budgetary allocations for health have been reduced in response to the crisis. The twin budgetary reverses over the past five years have forced a more critical assessment of sectoral performance and constraints, focussing on resource availability and utilization, use of manpower and organization and management of services. Diminished resource availability has also heightened awareness of the economic cost of unchecked population growth. A consensus is emerging that a more serious effort is necessary to address the population issue. ix The National Health Plan for 1986-90 did not contain an explicit statement of health policy which was inferred by Government's pursuit of a primary health care strategy emphasizing, among other things, community responsibility for health. The period was viewed to be one of continuity rather than change and to be marked by consolidation rather than expansion. A more recent statement of health policies and strategies, prepared by the Department of Finance and Planning (DFP), was contained in Volume 1, Development Policies and Strategies, 1990 Budget Documents and proposes a number of inter-related strategies to attain improved health conditions in PNG. The approaches were comprehensive: preference was given to prevention over curative approaches to health} rural health services with emphasis on women and children and community development and manpower development were highlighted; and improvement in major hospitals and urban health services was also envisaged. The recently completed 1991-95 health plan, prepared by the National Department of Health (NDOH), has provided a fresh opportunity to take stock and reach decisions over future policy directions for health. The select review of issues included in this report contributed to the formulation of the plan.  Iv B. Key Sectoral Issues x The sector faces some singular and complex challenges. For the next health plan period policies and strategies will have to grapple with fundamental institutional and financial constraints to futu.e sectoral development. The fabric of center-provincial relations is at the core of much of the sector's difficulty, affecting the quality and coverage of health services. Unless corrected, continued unequal distribution of financial and human resources will perpetuate and deepen disparitiea across provinces. The growing difficulty in sustaining rural health services at previous levels is associated particularly with inadequate non-salary recurrent budgets and staffing problems. A step toward improving the level of services offered to the rural populace has been taken with the introduction of a better qualified rural health worker but their place and role requires careful articulation within the framework of a rural health service strategy, which is wanting. Efficiency within rural health services is low and has to be improved in conjunction with an effort to mobilize increased financial resources within the sector. Available health indicators (para.3.16) suggest that intensive attention needs to be given to maternal and child health (MCH) care to reap the benefits which improved MCH performance would render. An additional constraint is the rapidly growing population but a consensus on policy and programs to reduce fertility and enhance maternal and child health care has been slow to emerge. xi Current health status is not really known. Special studies have contributed somewhat to an understanding of progress in health over the last decade, but much of any present statement about health still depends on projections based on progress between the 1971 and 1980 censuses and, consequently, on conditions prevailing in the immediate post-independence period. Lack of recent comprehensive data on health status leaves the country bereft of knowledge of where it stands today. The decision not to include key mortality questions in the 1990 census is a serious handicap for future policy determination and planning strategies. Papua New Guinea cannot afford to wait a further decade, an elapsed time of twenty years, before knowing what progress has been achieved in health. Organization. Manaaement and Planning xii Decentralization of responsibility for delivery of health services to the provinces in 1983 was the outcome of the Organic Law on Provincial Government legislated in 1977 (para.2.2). Further decentralization of responsibility down to district level has recently been undertaken in a number of provinces. The impact of decentralization has been to weaken the ability to deliver services and erode the standards and quality of care especially in rural areas. Seven years experience with decentralization has accumulated. It is important to understand the effects of this decision and a review of the effect of decentralization on performance of the health services is indicated. The crucial step would be to assure that such a review has sufficient prestige. Likely, the authority of the National Executive Council (NEC) would be essential, and would have to be sought through a submission by the Ministry of Health.  v xiii Given the nature of national-provincial relations, ways to improve linkages between them have to be sought. With a decentralized administrative system, the NDOR must devise a comprehensive communications strategy which includes provision for a standard reporting and information system, giving as much attention to inputs as it does to outputs. Communications must be seen as a vehicle by which the multitudinous, independent units comprising the health sector can be provided with direction from NDOH and this means not only that an effective statistical system is introduced, but also a system whereby both NDOH and the provinces are clearly aware at any time of the others concerns and needs to which responses can be made quickly; the present system does not have this capacity and new ways, such as liaison officers at the NDOH, should be considered. Stationing a person at national headquarters with the specific purpose of representing provincial views and concerns and, conversely, keeping the provinces abreast of developments at the capital would facilitate communications and trust (para.2.10). Such a person would provide a linkage between NDOH and GFP at the center and with the provinces on matters of provincial health plans and budgets. However, the prevailing opirion at NDOH is that the proposed Regional Support Units ((Rsu) para.3.5) will provide an adequate avenue for an exchange of views between provincial and central authorities. Cooperation between NDOH and DFP in discussing provincial recurrent budget allocations has been improving lately. Better coordination would bring focus on targeting budgets to program priorities and relate national policy to provincial program activities, a process which will be assisted by provinces following NDOH's lead in moving to program budgeting. xiv Providing a more uniform and skilled management system than is presently available would contribute to a more integrated health service. Given that the political process of decentralization is unlikely to be reversed, the NDOH has to determine what is politically possible. Two directions suggest themselves - the first is to create a unified managerial cadre (which would not necessarily undermine the authority of the provinces) (para.2.9) and the second is to create a statutory authority which would allow uniform conditions of service for all categories of the health work force throughout the country (para.4.17). Such initiatives would need to be viewed in a longer-term context. xv NDOH's circumscribed authority is no more evident than in the exercisa of developing health policy and preparing five year health plans. Collaboration between the center and provinces in reaching decisions on policies and plans has the merit that provincial authorities participate in the process and agree to a set of policies and plans. The national authorities expect that policies derived through this process will be pursued at the provincial level. However, there are no sanctions available for NDOH to ensure compliance with national health policy. In the past, national health policy has been expressed through inference rather than clear statement of sectoral goals. Given the current uncertain climate and likelihood of rapid changes, instituting five-year rolling plans rather than fixed plans might be more appropriate (para.2.14) although, as NDOH has indicated, this would entail increased demands on time and resources. However, in addition to being more responsive to current situations, annual modifications of plans provide opportunities to improve dialogue on critical matters with the provinces.  vi Quality of Service xvi Rationalizing the mix of service delivery points will lead to better defined standards of facilities, staff categories and particularly levels of care (para.3.27). This should, in turn, provide the NDOH and the Provincial Divisions of Health (PDH) with better means of monitoring the delivery of health services and thus be in a situation where advice can be more effectively focussed. It will result in better accountability, since, with given input norms, outputs can be calculated with improved precision; the performance expected of managers and staff can be laid down with greater clarity and supervision thereby enhanced. The establishment of more precise input norms than those currently in use will also facilitate the planning process and, should it unfortunately become necessary to introduce further financial cuts, it can be used to direct them towards discrete areas of expenditure which will not seriously undermine the major thrusts of government policy. This process should also include services run by the churches and provide a better way of determining subsidies. Once the norms have been established and accepted, provinces should be encouraged to accelerate the development of contracts with the churches to obviate the uncertainties of output delivery inherent in the current method of calculating subsidies (para.6.7). xvii If attention is paid to setting out input norms and thus more readily measurable outputs and through the five-year plan strategies are introduced by which these needs are addressed, then basic problems such as the deteriorating quality of rural care, limited achievements in improving maternal and child care, the less than adequate standard of management, ineffective supervision, as well as the lack of adequate and cheap transportation should be closer to solution. These operational problems will, however, also require specific actions to ameliorate and solve them. As an example, with quality of care in the rural areas in some decline, specific action must be targeted towards redressing this situation. If Community Health Workers (CHW (para.xx)) are to play the role expected of them, they must occupy established posts with security of tenure. Substantial investment in housing and the level of facility which their training demands for them to provide an effective service, and a conscious policy of providing a secure environment for female Community Health Workers to operate are three examples of such strategies. The capabilities of the staff of the health services in PNG are considerable, but they are at present being dissipated; implementation of the broad strategies outlined above and other detailed suggestions listed for ease of reference in Annex 2 should help to provide better cohesion, without undermining the various levels of managerial authority, and result in a high quality of health care. xviii Gains in health status may be made through effective MCH care services. Maternal mortality is high and not improving and, while better, the situation regarding infant mortality needs attention. While given support at national level, at provincial level MCH coverage and concern over the quality of services receives relatively less attention and emphasis. Whereas NCH services should be the strong point of the health system they are, to a large extent, the weakest element in PNG (para.3.21). Cultural attitudes, domination by men of much of the delivery system, low internal efficiency of  vii rural health services and susceptibility to vagaries in available budget with resultant reductions in logistic and supervisory support conspire against effective MCH services. The issue is complex and cuts across the grain of the difficulties facing sectoral performance - budget, management, policy and priorities and appropriate staff. U of Personnel xix There have been improvements in manpower data needed to assess the manpower situation but there are obvious gaps such as church health services and the private sector which the Human Resources System (HRS) does not cover (para.4.5). Decentralization has seriously eroded career prospects, undermining motivation especially among the senior ranks of those expected to administer health programs. Such problems do receive the attention of the provincial assistant secretaries, although no effective resolution has been forthcoming. The provision of specialist manpower planning expertise at NDOH and the provision of a good data base are essential in answering these problems. Administrative difficulty in moving staff poses a major constraint to improving the internal efficiency of the delivery system. Even intra- provincially it is difficult to relocate staff - hence problems of over and under-staffing of facilities, although another problem in posting staff is the availability of staff housing. xx A strong desire to improve the quality of health services offered to the rural population led to the creation of a new and better trained cadre of rural health workers - the community health workers - to replace aid-post orderlies (APO) and nurse aides (NA(para.4.15)). This laudable initiative was launched in 1986 and early graduates are now appearing in the workforce. The implication of their presence in the rural health scene has not been fully articulated within the context of a future strategy for rural health services, particularly as it might relate to aid posts manned by APOs. As aid-post vacancies or closures increase and as only a limited number of CHW's to replace APOs tvill be available in the foreseeable future, some consolidation in points of provision of rural services is inevitable. It is unclear what is going to replace the aid-posts. The implication of CHW training and intent to upgrade services in rural areas is that aid-posts will evolve into a community health post manned by two staff capable of providing a fuller range of services. There are indications that, in some provinces, plans are afoot which would do just this. If such a system is going to be successful it will have to be fully supported with implications for recurrent and investment budgets. Determination of the scale of need and over what period of time change is expected to be implemented requires, first, a central-provincial dialogue to agree on a strategy for the future development of rural health services. Such a strategy will be based on the growing availability of CHWs in the workforce, a real emphasis on preventive and promotive health programs and the almost certain limited resource availability. xxi Low enrollment in the medical school, increasing attractiveness of private practice and emerging public preferences for physician's services serve to heighten the growing shortage yet increasing demand for doctors in the public sector (para.4.12). These trends will intensify with time. The traditional response has been to use expatriate doctors but this represents an  viii expensive strategy. More sustainable approaches have to be developed. Improving the inducements to enter medical school and emoluments on graduating need exploration as do ways of meeting the interests of doctors to conduct private practice yet also serve the public health services. Conditional licensing is one possible approach to the latter. In the short to medium term selectively upgrading some nurses and Health Extension Officers (HEO) to the role of practitioner, with restrictive licenses, could increase the level of services available within the system. The growth in demand for private medical care has to be met by increasing accessibility by private practitioners to hospital and related services. A system to bridge the various interests is there but needs development and a changed regulatory environment to permit hospitals to generate an increasing share of their costti from the private sector. Population xxii Despite the availability of contraceptives through the health services, they are little used and population growth goes unchecked. In replacing the current passive approach by an active stance, a re-vitalized family planning (PP) program should focus, in the first instance, on meeting existing demand, consistently following up acceptors and ensuring continuity of supplies. Training staff about FP and mc.bilizing demand generation activities form part of a longer term strategy to bolster PP acceptance. Adoption of family planning not only reduces fertility but contributes to the health and well being of both mothers and children. Contraceptive services improve the health of the mother and children by spacing births, preventing high parity births and confining births to mothers aged 20-34 years and leads to reductions in maternal and infant mortality. For the purpose of synergistically attaining demographic and health objectives, better linkages between family planning services and existing maternal and child health programs need to be forged - failure to do so will diminish progress in these areas. xxiii There are two steps in setting a context for a successful fertility reduction strategy. Moves to develop a national population policy and more coherent approach to issues of population have been taken and represent the first step. But the process needs encouraging and accorded a more urgent priority. Once a population policy has been framed, one way forward would be to establish a National Population Commission (replacing the defunct National Advisory Committee on Population Policy) responsible to Parliament and with the authority to coordinate and monitor implementation of the country's population policy (para.5.8). The small unit within DFP should use its limited resources to act as a secretariat for a National Population Commission (Npc). xxiv The operational centerpiece of a program of population activities would be a national family planning program whose locus of responsibility would logically be within NDOH. A family planning policy as the second step to strengthen national efforts to reduce population growth would provide the Minister of Health with the authority to direct a national family planning program and enlist the contributions of other branches of the Government and the private sector. Within NDOH, a senior executive, with responsibility and accountability to implement and monitor a family planning program, would be  ix required to sustain the impetus that such a social program requires. Financina the Sector xxv Development of health services has proceeded over the past five years in an unfavorable economic climate, and per capita expenditures for health have been declining. Real growth in rural health recurrent budgets has been 11% over the past five years, somewhat less than growth in the hospital sector (14.1%) over the same period. The original 1990 budget allocation for rural health was reduced by 3.4% as part of Government's budget trimming exercise. In addition, the devaluation of the Kina in January 1990 reduced the real allocations for pharmaceutical supplies, vehicles, fuel and other imported health inputs. Salaries, which are indexed, take an increasing share of the health budget as total resources shrink. The overall result will be to make the actual delivery of quality health services even more difficult over the next five years at least. xxvi Cuts in budget allocations are felt most keenly by the rural health services, particularly programs expected to reap longer term benefits - the maternal and child health programs. Underfunding of non-salary recurrent costs has diminished the ability to support and supervise rural health services and has affected the quality and efficiency of those services. Increased allocations for operation of rural health services are needed if those services are going to be sustained at their previous standards. Any shift in allocations has to be matched by moves to improve internal efficiency. For instance, a vulnerable item to budget cuts, transport, is essential to sustain supervisory activities and the ability to conduct clinics. A transport policy is urgently needed since the existing system of hiring transport is clearly inefficient, expensive and easily targeted for cutbacks in funding. Investment in transport would appear to be the most cost-effective solution although it would require managerial inputs, and a reliable maintenance system must be assured. xxvii A threefold difference in per capita expenditure on health between provinces points to a major inequity in the distribution of resources across the country. The maldistribution is embedded in the organic Law, and actions to moderate the effect of the law are circumscribed by its intent. Population growth and movements which are known to have taken place over the past ten years may well aggravate the situation and create additional pressure to address the issue once the 1990 census data is available. Current ability to redress inequities is limited. A major vehicle in the hands of the national government is the investment budget and application of donor or borrowed funds to the health sector. NDOH must play a more positive role in the national budget process. Past poor liaison between NDOH and DFP has hindered NDOH's ability to direct those resources to the less well endowed provinces, for allocative decisions have largely been determined by DFP. Recent organizational changes within DFP are likely to facilitate better coordination between the two departments and improve the focus for decisions about the spread of investment resources between provinces and programs. But this liaison needs to be ensured. xxviiiExternal sources largely finance the sectoral investment program. The  x future capital requirements to improve rural health facilities to match staffing and program needs will be sizable, even assuming consolidation of rural health services in response to financial and staffing constraints, demographic changes and efficiency issues. The scale of investment resources required has to be determined once a rural health strategy has been agreed upon between the national and provincial authorities. Priority should be given to meet future requirements of the rural health services when resource allocation decisions are reached. Fortunately, the national Government controls the investment strategy and is in a position to redirect future investment away from the emphasis on urban and secondary services, evident during recent years. xxix It is unlikely that the health sector will receive a greater share of government resources than it receives now, yet projections indicate a substantial shortfall in sectoral needs if health services are going to be maintained at previous standards. Currently, the public sector accounts for 88% of all expenditures for health. a very high proportion which will diminish in face of constrained Government budgets and changes in patterns of delivering medical services. The potential for recouping up to 30% of the recurrent budget is present and the principles and systems are there, although revisions are called for (para.6.41). Although health insurance has a limited market, nevertheless steps need to be taken to increase the recovery of costs of services provided to insured persons. Hospital charges have been fixed since 1978 and the regulations which govern those charges need amending in such a way that revisions are possible on a regular basis. Revenue generation at hospitals would also be possible by permitting private practitioners more access to hospital facilities. Differentials between the fees for services provided at primary and secondary levels of care need to be established, to provide some nominal deterrence to seeking hospital based care when alternatives exist. Retention of revenue generated by the health authorities is essential if the services are not going to be allowed to deteriorate. However, agreement regarding fee retention by the health authorities has yet to be reached. Control by NDOH over revenues raised would, in principle, also permit some re-distribution of resources towards rural health services. However, with the greatest potential to increase cost recovery within the sector, the hospitals will want to see their interests furthered, increasing the spending differential between different levels of service. This natural tendency has to be guarded against. C. Princinal Recommendations xxx The select nature of this review imposes limits on the range and depth of the report's recommendations. The key issue confronting the sector is the institutional framework within which policy and priorities are determined and services delivered. The report addresses that framework and makes some suggestions about improving sectoral performance within the environment imposed by the country's legal basis. Only key suggestions are indicated here - additional recommendations are included in the body of the report and in Annex 2. The measures proposed are not spelt out in detail but are intended to provoke discussion and debate among national and provincial authorities as to the policy and operational options for future development of health and population services in PNG.  xi Policy and Plannina o Under the authority of the National Executive Council* undertake a rigorous assessment of the benefits and disadvantages accruing from seven years experience of decentralization of health services. * Give consideration to a process of developing rolling five-year health plan to provide a more responsive instrument of policy to an uncertain financial environment. * Examine ways to strengthen national-provincial relations, using as a basis for discussion the idea of creating liaison officers with responsibility for coordinating programs and activities between different levels of administration with particular emphasis on provincial health plans and budgets. * Take steps to improve liaison between NDOH and DFP over recurrent and investment budget decisione for national and provincial health services. Ouality of Services * Give consideration to creation of a statutory body - Health Services Commission - as a means to provide uniform conditions of service for the workforce across the country. * In lieu of the failure of the 1990 census to provide critical mortality information, prepare and undertake a sufficiently detailed demographic survey as soon as is feasible. * Allocate and deploy resources to ensure that maternal and child health programs are sufficiently supported and emphasized. * Establish input norms for all levels of facilities and staffing and undertake a province by province assessment of resources with a view to rationalize the distribution and use of resources and improve the internal efficiency of the delivery system. * In consultation between national and provincial health authorities, develop a comprehensive rural health strategy with a focus on the role, deployment and utilization of community health workers. * Consider alternative strategies to ensure the availability of doctors or persons of comparable competence, such as an HEO practitioner, in the public services. PoDulation e Finalize a national population policy. * Create a National Population Commission with authority to coordinate and monitor population activities.  xii * NDOH should prepare a family planning policy for approval by NEC to give impetus and direction to a national family planning program. * The locus of responsibility for conduct of a national family planning program should be in NDOH. Promulgation of a national family planning policy would provide the Minister of Health with the necessary authority to ensure full cooperation of other departments and legitimacy to enlist other support. * The clear linkage between good maternal and child health care and family planning acceptance requires systematic development among providers and clients. linancina * Increase or re-allocate resources to sustain rural health services particularly for supplies, transport and maintenance. * Develop an investment strategy reflecting the requirements of better rural health services. 3 Raise fees for health services, modifying the regulatory framework as needed and ensuring that revenues are directed to support and develop health services. Steps will need to taken to ensure the equitable distribution of revenues collected to offset the bias towards secondary level care development. * Examine alternatives to melding the interests of private practitioners and public sector facilities in terms of retaining the services of private practitioners for publicly provided services and enhanced revenue generation by hospitals. * Increase the mandate of the Office of the Insurance Commissioner to oversee the life/health insurance industry and move towards obtaining full cost recovery for services provided to insured persons.  -1- 1. INTRODUCTION A. The Setting 1.1 The physical and cultural context in which health services are delivered in Papua New Guinea is perhaps as difficult as anywhere in the world. The country comprises the eastern half of the island of New Guinea and some 600 small and scattered islands to the east and north in the Bismarck and Solomon Seas covering a total land area of over 460,000km2. Mountainous terrain, dissected by swiftly flowing rivers and dotted with swamps, makes communication on the mainland and in many of the islands extremely difficult and impedes the delivery of health services. To provide quality basic services in such an environment is not easy. The predominantly rural (872) population is now about 3.7 million and is distinguished by clans and some 700 language groups, both of which vary in size from a few hundred to several thousand people. Whilst this provides a rich cultural heritage, it also produces communications barriers of a different kind as well as personal loyalties and identities which color the decision making processes of individuals and groups. Some 80% of the population still relies on subsistence farming for its livelihood. B. Achievements in Health 1.2 Since independence, there has been a concerted effort by government, with significant assistance from church missions in rural areas, to improve access to basic curative and preventive health services throughout the country. Achievements since 1975 have been notable. A network of facilities has been established so that, currently, it is stated that 95X of the people are within a two hour walk of a health facility. Extension of services to even the remotest areas of the country has contributed to a significant fall in the infant mortality rates (IMR) from 133/1000 live births in 1971 to 7211000 live births in 1980, the last year for which comprehensive and reliable information is available. During the same period there was a steady increase in life expectancy at birth from about 40 years (1971) to about 50 years (1980). -Although much has been accomplished and health services have made a seminal contribution to the well-being and development of PNG society, comparative health data (see Table 1.1) from adjacent countries indicate that PNG still has much to be accomplished. But PNG's progress in improving health conditions has to be viewed against formidable geographic obstacles, poor communication infrastructure and a limited resource base as a starting point. C. Health Policy and Priorities 1.3 Successive governments since 1975 have provided strong support for health service development. The only hiatus in this position occurred during the 1985-1988 period when there was a deliberate reduction of budget support for health services. Even then, health services absorbed a greater proportion of government spending than many neighboring countries. The advent of the current Government in 1989 saw a restoration of previous spending priorities, and the health sector began to recover some of the budget allocation lost over the prior three years. The economic crisis of 1989, with the closure of the  -2- Bougainville mine, has thrown this trend into jeopardy and, with it, any immediate hope of restoring services to pre-1985 levels. Table 1.1. COMPARATIVE HEALTH DATA--ESTIMATED AVERAGE RATES FOR 1985-1989 Country IMR L.E.(m) L.E. (f) CBR CDR TFR Indonesia 71 58.4 62.1 28.7 9.1 3.5 Papua New Guinea 63 53.2 54.8 35.9 11.7 5.3 Philippines 45 61.6 65.4 31.5 7.6 3.9 Solomon Islands 53 62.6 64.1 41 7.8 6.6 Thailand 31 63 67.1 22.6 7.1 2.6 Notes: IMR -- infant mortality rate; L.E. (m) -- male life expectancy, and L.E. (f) -- female life expectancy. CBR -- crude birth rate; CDR -- crude death rate; and TFR -- total fertility rate. 1.4 Nowhere is health policy explicitly stated but rather implied through the five year National Health Plans and annual budget documents prepared by the Department of Finance and Planning (DFP). Chapter 1 of the 1990 budget Development Policy and Strategies document dealt with Social Policies and Strategies, health and population occupying the first two sections, perhaps a significant statement of government priority. The principal sectoral objectives indicated in the 1990 budget document related to improving health status by emphasizing preventive health care, disease control, reducing malnutrition, and improving health behavior. But almost equal stress was granted to sustaining standards of hospital services, improving the quality of urban health care and improving manpower skills and distribution. In setting these objectives, there was little dialogue with the health authorities, and, as most health expenditures to attain these objectives are spent by the provinces, there is little control over the allocation of budget resources within provinces to activities expected to attain stated goals. 1.5 The process of preparing a five year health plan offers the opportunity for the National Department of Health (NDOH) to develop policy, which emerges from the process rather than directs its outcome. Previous health plan documents have been largely a rendering of past achievements and an expression of what each administrative and program head proposes for the ensuing five years and provided little sense of overall guidance and direction. Development of the next five year plan for 1991-1995 has had the merit of being a better planned and more participatory exercise between the national and provincial authorities than has been attempted previously. Further, through a strategic planning workshop, a serious effort was mounted to identify problems and develop strategies to address key issues identified through consultative discussions. For the next plan period, five main subjects of emphasis are foreseen - communicable disease, personal and  -3- community responsibility for health, organization and management, money and manpower. Involvemenlt of provincial authorities in reaching a consensus on the key problems marks a measure of hope that treatment of these problems will be accorded priority when decisions over resource allocations are made at provincial level. Meanwhile, the issuance of the next five-year health plan is an occasion for a fresh statement of health policy by NDOH. D. Economic Situation and Health 1.6 Economic growth over the past five years has been largely driven by the mining sector and less progress has been made in developing non-mining sources of revenue. Closure of Bougainville mine (para.1.3) has had an adverse effect on the Government's ability to implement its programs resulting in downward adjustment in resource allocations for all sectors in 1990, although health was relatively spared. Reliance on mining has contributed to increasing maldistribution of income over the country aggravating existing inequalities in resource distribution. The rapid response by Government to the 1989 crisis bodes well for PNG's ability to recover from its immediate financial difficulties. Provided the stabilization and structural adjustment initiatives are firmly implemented, then the medium term prospects remain reasonably optimistic. New mineral projects are expected over the next five years, lessening reliance on a single mine although not on the sector as a whole. Growth of the non-mining sector will depend on implementation of the present structural reforms and further development of agricultural and forestry resources. Moving towards a more balanced economy will take time as will emergence from the immediate financial difficulties. 1.7 The policy realignment of the 1985-88 period led to reduced social sector spending. During the 1990 budget reduction exercise, in response to closure of the Bougainville mine, the health sector experienced another cutback although the level of reduction was less than experienced by some other government departments. The period between the current Government's accession to power in 1988 and closure of Bougainville mine in 1989 was a brief one of reprieve and some budget restoration for health. But recent events have clearly demonstrated that the halcyon days are over. Government spending on health is already high by international comparator standards (para.6.1) and the sector cannot expect this proportion (currently 10.3X) to go higher. An extraordinarily high proportion of total health expenditure is derived from the public purse (88%). This is not sustainable without serious deterioration in the level and quality of health services and, in the future, individuals will have to absorb a greater share of health costs. Health authorities at the center are totally aware of the dilemma between the need for increased resources to sustain sectoral growth and diminishing ability of the public sector to finance health services. Already some steps have been taken to diversify sources of revenue for financing health services. Overcoming obstacles to maximizing these sources will mean modifying DFP's revenue retention policies and creating a favorable regulatory framework to enhance the potential of alternative revenue sources. Clear linkage between revenue enhancement and expenditure for health is essential. To complement diversification of income sources it is necessary to increase the internal efficiency of the national and particularly provincial health services. Less attention has been directed to this latter question by the health authorities,  -4-. in part, because of the seemingly intractable provisions governing the distribution of staff. E. Focus and Role of Regort 1.8 Preparation of the third health plan since independence has offered PNG an opportunity to take a critical look at what has been achieved and what directions to adopt for the future. The two most significant developments for tle sector over the past decade have been the decentralization of health services to provincial control in 1983 and the dual financial setbacks of 1985 and 1989. The next health plan has to take account of these twin factors. Responding to the financial crisis, NDOR has initiated several studies to seek solutions to this issue. A careful strategy to prepare the next plan was developed by NDOH, forging a closer working relationship of national and provincial health staff through a series of meetings to determine priorities and strategies for the ensuing five years. Decisions for the future have to be reached within the framework of diffused responsibilities and decreasing resources. 1.9 Following a meeting between the Bank and NDOH in November 1988, a request was received for the Bank to field a mission to undertake a select review of what were agreed to be critical issues and where the Bank was considered to have some comparative advantage. Organization and management, delivery of services, manpower and financing were identified as the issues to be addressed in this report. Because of the key role which health services play in delivering family planning services and the growing concern over population growth, the report also undertook an analysis of population activities. The report is expected to contribute to Government's determination of strategies to be pursued over the next five years in attaining sectoral priorities.  -5- 2. ORGANIZATION. MANAGEMENT AND PLANNING 2.1 The basic result of decentralization has been to lower the standards and limit the coverage of quality health care throughout the country. When the quality of services is low, people will go elsewhere if that is possible, and where the basic organizational units are small and virtually autonomous, there are few remedies available to improve the situation. When one considers the problems in delivering quality care, decentralization inhibits solutions because responsibility is so diffuse. In the short term, attempts to offset the centrifugal forces will require systems to improve policy dialogue and planning coordination between the center and provinces and better management links along the same axis. Policy development and planning is hindered by the paucity of data and the failure to include key mortality questions in the 1990 census aggravates the problem. After seven years of experience, the benefits and disadvantages of decentralization as carried out in PNG require thorough and critical assessment - sooner rather than later. A. Decentralization 2.2 Constitutionally, Papua New Guinea is a democracy based on the "Westminster" patter" with three branches of government - legislative, executive and judicial. On Independence the country had only a central government, but pressures for decentralization, which had become a political issue in the last years of colonial administration, resulted in the passing of the Organic Law on Provincial Government in 1977. This law redistributed power and resources to the 19 new provincial governments. The legislative functions of the provinces are vested in their elected assemblies and their executive functions are carried out by an executive council chosen by the assembly and headed by a Premier. The Organic Law provided only the mechanism for decentralization and the process of determining which health functions should be held by the central government or which should be devolved and transferred to provincial governments took some time and it was not until the 1983 budget that health decentralization was completely effected. In some provinces, further decentralization to district level has been, or is in the process of being, taken. Together with the transfer of responsibility for government functions to the provinces went the transfer of resources - primarily staff and funds - needed to carry out those functions and this process has, in some cases, been further transferred to district level. As is discussed below, the process has created ambiguities and uncertainties which underlie many of the difficulties in providing health services. B. Center-Provincial Relations 2.3 Underpinning the difficulties of delivering effective health services to a predominantly rural population is the weak administrative relationship between the central government and the 19 provincial governments. Health had been listed in the Organic Law as a concurrent subject, one which was open to both levels of government and on which provincial government could legislate in the absence of national legislation. Most of the current extensive legislation on health matters is, however, national legislation which is, to a large degree, administered by provincial governments. Organizationally, the central government retained the functions of national legislation, policy  -6- formulation and planning, and the monitoring of standards of health activities throughout the country. It retained control of pharmaceutical services and national hospitals. Of the functions which were nominally retained, many were delegated to provincial governments and they included provincial hospitals, malaria control and a wide variety of extensi-n serviceis. The essential bases of the health delivery system, including service centers from provincial hospitals downward to aid posts, family health services and supervision of the disease control program were transferred to provincial governments. 2.4 In practice, this means that the national government, represented by the NDOH, plays no part in the administration and management of the bulk of health services in Papua New Guinea. Although it has the authority to monitor standards of health delivery, it has no sanctions with which that authority can be re-enforced. Theoretically, the central government could reverse transferred functions and withdraw delegated functions, but that is currently politically impossible. So the NDOH acts as an advisory body, a technical body which the provincial governments may or may not call on for assistance and support; where decentralization has been taken to district level, the Provincial Division of Health (PDH) is in the same situation. The organization of the NDOH represents a horizontal, integrated approach to service delivery in which few specific programs are the identifiable responsibility of a senior official. 2.5 Each province represents a department of government with a secretary, responsible to the provincial Premier, in charge. A division of the department, headed by an assistant secretary (or advisor in some provinces), is responsible to the provincial secretary for health matters. Where decentralization to district level has taken place the senior officer in charge of the largest facility in the district, usually a health extension officer (HEO) in charge of a health center, is responsible to the district manager for the health affairs of the district, in addition to his clinical duties. Thus there are no direct lines of managerial authority from center to district and such is the autonomous nature of provincial and district authority that there is, in effect, no supervision or quality checks from higher levels. The NDOH is left with little more than moral suasion to effect its remit; organizationally, there is no focus for its monitoring function. 2.6 The NDOH does not have even the financial sanctions to exercise authority despite the fact that some 93.32 of all health expenditures in Papua New Guinea derive from the central government. Since 1983, the NDOH has, in fact, had little input into or influence over allocations for national budgetary support for provincial health activities, either in allocations between provinces or between the various types of services and programs. Budgets are prepared at provincial level by the Assistant Secretaries of the PDHs and submitted to the provincial secretary for finance for submission to the Budget Priorities Committee and eventual inclusion in the provincial budget (see para.6.4). The province then submits the budget to the national Management Resources Committee (MRC). Although copies of the budget should be made available to relevant sectoral departments at national level this practice is not necessarily followed. If advised, the departments may send observers, who are allowed to participate in discussions, to MRC meetings. It has been difficult for NDOH to influence financial decisions, although in 1990  -7- it did have the Indicator of Staffing Need (ISN) system, a tool for assessing staffing requirements, approved for discussions in the Management Resource Committee (MRC) on financial allocations. 2.7 Decentralization has also meant that the NDOH has no control over be-ath service staff outside its own limited authority. Whilst it makes decisions about the numbers and types of personnel to be trainedD decisions to post those trained are made by the Department of Personnel Nanagement (DPM) reflecting requests from PHDs to create or fill vacant poets. Decentralization has resulted in the creation of small cadres of staff and inhibited both their career and transfer opportunities. Decentralization to districts exacerbates these problems which are compounded by the small size of the units involved. Provincial populations varied at the time of the 1980 census from 311,000 (Morobe) to 64,000 (Gulf); in Chimbu province, where decentralization is taking place at present, the average size of a district is some 30,000. Small staff groups allow little room for flexibility in rostering and virtually no opportunities for career development, considerations which are discussed with other personnel matters in chapter 4. 2.8 Despite the fact that the 1986-1990 national Health Plan categorizes various types of facilities by coverage, services provided and some indicators of acceptable staffing patterns, decentralization of health administration has resulted in relatively wide variations in different provinces. Thus one now sees "mini sub centers", "two-person aid posts", "major health centers", "district hospitals", or "district health centers". Whilst there must be flexibility in adapting norms to particular circumstances, there is also a need for service patterns to be maintained in order clearly to identify the health care responsibilities which should be provided by each facility. This topic is discussed further in chapter 3. C. Manaxement 2.9 Decentralization has also produced a situation in which management responsibilities have been thrust on people who were inadequately trained for those responsibilities. It also encourages the intrusion of purely political factors in to what should be routine administrative decisions. Without a clear organizational framework, distinct lines of authority, and out-dated duty statements (job descriptions), the task of managing provincial health services in Papua New Guinea is extremely difficult. The national government is acutely conscious of this problem and, in response, has started a course in Community Health at the University of Papua New Guinea and with external assistance has established a program of Managemc