When faced with an endless list of proposals for investments to improve health outcomes, upgrading service delivery infrastructure in rural areas is often hard to justify – particularly in resource-constrained health systems. Building health infrastructure in remote rural environments with small catchment populations inevitably raises questions about efficiency, cost effectiveness, and opportunity costs when compared to investing in telehealth and mobile clinics, often touted to better meet the needs of rural populations.
In 2012, Papua New Guinea (PNG) began an ambitious restructuring of its rural health service delivery strategies to respond to declining health services utilization and decaying infrastructure. One of the key features of the reform was the introduction of the community health post (CHP) as a Level 2 service.
The CHP was designed as a primary health level facility replacing the aid post (Level 1) to provide a broader range of services to a wider catchment population. So, how has the new system worked out so far in PNG?
CHPs initially faced parochial barriers as villagers feared losing their aid posts. It took extensive consultations with communities to explain the rationale and agree on an acceptable location for the CHP to serve the populations of multiple villages. In some regions there was also a long history of tribal fighting that had effectively established “no-go” areas for members of some clans. Access and safety were thus addressed during the consultations to agree on optimal locations for CHPs.
In many remote locations, village birthing has traditionally been attended only by women relatives of the mother, so the health benefits of delivery supervised by trained health workers in a clinical setting needed to be heavily promoted.
Another challenge was limited availability of state-owned land, so once an acceptable site was located, land payments needed to be made to customary landowners. Both of these factors resulted in a long lag time between agreement about the site and completion of construction, with the first CHPs being opened only at the end of 2016.
Throughout the whole process, rural health workers were upskilled in reproductive health, obstetrics care, health promotion, family planning, and management of childhood illnesses. They were allocated to the CHPs and provided with new housing on site as an incentive to relocate and continue to serve in those locations.
In addition, PNG invested in developing a digital health information system to report and monitor service delivery and provide real time surveillance of disease outbreaks.
Another important investment was to establish architectural, engineering and clinical standards so that all CHPs are constructed to the same standards and provide the same range and level of health services. This ensures consistency of health infrastructure and medical equipment irrespective of the source of financing; the specific standard design also ensured that the CHPs are environmentally sustainable by generating their own electricity from renewable sources (where there is no access to mains power) and harvesting and using rainwater.
The CHPs are constructed of durable materials to minimize the risks of loss or damage to fire, vandalism or termite infestation and to reduce maintenance requirements. Most construction materials specified have manufacturer backed guarantees of 40 years.
As of today, a total of 23 CHPs have been commissioned and opened in seven PNG provinces. Although both the number of CHPs and their reporting duration is limited, the digital health reporting system enables us to explore the initial experience. More importantly, we can determine whether or not this new level of health service delivery has improved access and outputs.
Let’s look at the experience of Enga, a Highlands region province that ranks 7th out of 22 in the 2017 National Health Sector Annual Performance Report. Enga progressively commissioned four CHPs from August 2018 in remote locations where there were previously no reporting health facilities.
The first quarter of reporting since then shows that average daily outpatient presentations at each CHP are between 27 and 32 for a wide range of general complaints and for discretionary services such as antenatal care, family planning, and immunizations. During the same period, 84 patients were admitted for low acuity inpatient care.
Maternal mortality is a critical issue for the health system in PNG, where skilled professional supervise just over 40% of births. Enga CHPs had already provided 90 first antenatal consultations and supervised 34 births during the first quarter of operation, and one could assume that over the next few months the number of births reported will rise to reflect the first antenatal visit numbers as women return for further antenatal care and supervised births. The CHPs are in such remote locations that it is highly likely that many of these births would have previously occurred in villages.
The four CHPs have also provided immunizations for 239 children under one year of age during the same period. We can therefore conclude that health services utilization has increased with the introduction of CHPs in Enga.
Where the CHPs replaced an existing facility that had no designated inpatient beds, we can get a better picture of the before-and-after situation for supervised births and treatment of patients.
At Gurney in Milne Bay Province there had been 56 supervised deliveries at the old aid post during 2016, compared to 149 at the new CHP in 2018. General inpatient numbers also jumped to 260 from 51 over the same period. The situation is similar in Alkena in the Western Highlands, where the number of supervised reported deliveries increased from 27 to 46 from the aid post to CHP.
This suggests that the introduction of strategically located, well-equipped CHPs staffed by competent health workers will improve accessibility, public acceptance and thereby demand for health services from those rural populations with access to the new facilities.
Encouraging ownership of the physical asset by the population that it serves and by the authority that oversees standards and regulations are also critical to the long-term sustainability of both the assets and the service. Whilst it is early days, the establishment of local Health Committees that accept responsibility for routine maintenance of the buildings, gardens and grounds and for security is further engaging those communities with their health service.
The early data collected through the digital health information system in five provinces provides irrefutable evidence of increased utilization of maternal and child health services in those communities where CHPs have been established. The evident enthusiasm of those communities for engagement with their new health services also bodes well for the foreseeable future. Only time will tell whether this initial impact is long lasting or attributable solely to the “halo effect.”