96547   Knowledge Brief     Health, Nutrition and Population Global Practice A  SNAPSHOT  OF  HEALTH  EQUITY   IN  PAPUA  NEW  GUINEA:   AN  ANALYSIS  OF  THE  2010   HOUSEHOLD  INCOME  AND   EXPENDITURE  SURVEY   May 2015 KEY MESSAGES • In Papua New Guinea the poorest quintile is most vulnerable to illness, yet has the lowest utilization rates of healthcare facilities. • When looking at age groups the elderly (> 55) are the most vulnerable to illness and the least likely to seek treatment. • The lack of healthcare workers and the distance to facilities are among the most dominant reasons cited for not utilizing heath care in the poorest quintile. • The perceived quality of services is a barrier to health care utilization across all quintiles. • Out-of-pocket (OOP) payments have minimal catastrophic impact, yet have been found to still be a barrier to utilization — especially amongst the poorest quintile. • The government should focus on and prioritize strengthening the health services delivery to achieve Universal Health Coverage. analysis in the future. Whilst the findings in this brief are not Introduction new, they serve as a reminder of the barriers to health care utilization and reinforce the key issues that impact access to Papua New Guinea (PNG) faces a number of formidable PNG’s health system. obstacles to achieving equitable health care for the whole population. All aspects of health care access in PNG — Sickness Reporting and Health Services including geographical access, qualified health workers, infrastructure, medicines and medical supplies — favour the Utilization richest quintiles. The PNG government is striving to change this Health equity is the “absence of systemic disparities in health reality but the achievements to date are still quite limited. between groups with different levels of underlying social 1 advantages/ disadvantages” . Better understanding PNG’s This brief analyses the finding of the 2010 Household Income health equity issues can improve resource distribution based on and Expenditure Survey. It highlights a baseline that can be need. used for current programs and more in-depth health equity The illness reporting (Figure 1) shows the poorest quintile of the population has a higher percentage of illness, that is, need. The Page 1 Page 1 HNPGP Knowledge Brief • poorest are also the least likely to seek treatment when having has attempted to meet this challenge by providing facilities such reported some health discomfort (Figure 2). as mobile clinics and public health posts in remote areas, however members of the remote communities have When looking at sickness reporting by age groups it was found underutilized these facilities/ initiatives. that the elderly (> 55) are the most vulnerable to illness. When looking at health care utilization by age it showed that the elderly Quality of healthcare is a barrier to healthcare access and were the second least likely group to seek treatment, with only utilization across all quintiles, especially in the poorest quintiles. the 13-24 age bracket lower. Figure 1: Illness reporting in the 30 days prior to the PNG HIES 2010 Figure 3: Reasons for not visiting a health facility, between survey, by wealth quintiles. poorest and richest 29.0%   Illness  repor*ng  across  quin*lies  in  the  last  30  days   28.5%   70%   Richest   Poorest   28.0%   60%   50%   27.5%   40%   27.0%   30%   26.5%   20%   10%   26.0%   0%   25.5%   25.0%   Poorest   Q2   Q3   Q4   Richest   Figure 2. Percent of people who sought treatment for their health complaint, by quintiles. 57.7%   56.2%   56.0%   Out-of-Pocket Payments 54.3%   OOP spending on health is considered catastrophic when “a 49.1%   household’s financial contributions to the health system exceed 40 percent of income remaining after subsistence needs have 3 been met” — that is, expenses are high relative to the resources available to the household and thus disrupts the household’s 4 normal living standards . Poorest   Q2   Q3   Q4   Richest   Like other Pacific Island countries PNG has relatively low OOP expenditure for health, especially when compared with many of the Asian countries. The statistics indicate that the OOP Distance to healthcare facilities and the lack of health workers at payments have minimal catastrophic impact on PNG households. facilities were amongst the most dominant reasons cited for not OOP took up no more than 30 percent of total consumption in utilizing health facilities in the poorest quintile (Figure 3). any household in PNG. Only 0.02 percent of households spent PNG faces a critical shortage of health workers. PNG currently more than 20 percent of their total consumption on OOP, and has 6 health workers per 10,000 people, well below the 23 that 0.23 percent of households spent more than 10 percent of their 2 WHO recommends are needed to achieve the MDGs . In budgets. When examining how OOP is distributed across quintile addition to the low numbers of health workers, the current groups, the two poorest quintiles of the population spend a higher workforce has been found to be inadequately trained, aging and proportion of their consumption on health as compared to the demotivated by poor working conditions, including pay and richer population. infrastructure. Staffing shortages, poor conditions, and Whilst OOP payments have been found to have minimal insufficiently trained staff are felt most acutely in the poorer/ rural catastrophic impact, the expense of healthcare has still been areas. shown to be a barrier to healthcare utilization, especially The terrain and a predominately rural and scattered population amongst the poorest. Therefore, it still affects the equity of the (only 12.5 percent of PNG’s population live in urban centres) health system. make ease of physical/ geographical access to health services a challenging deliverable for the PNG government. The GoPNG What are the Policy Implications? Page 2 HNPGP Knowledge Brief 1. Overall the priority should be to use available funds more Conclusion efficiently and equitably. The government of PNG is moving towards Universal Health Coverage, along with many other The key factor to improving health equity in PNG is increasing developing countries. The goal is to ensure that all people access to health care to those most in need, i.e. the poorest obtain the health services they need without suffering quintile and the elderly. To achieve this the GoPNG will need to financial hardship when paying for them. The government of continually monitor and address the barriers to health care PNG has strived to provide “Free Primary Health Care and utilization for these groups. Effective use of available funds will Subsidized Secondary Care”. Now, the government should help PNG achieve equitable access to healthcare across the focus on and prioritize strengthening health services population. delivery, which includes having a health workforce that can support an affordable, efficient, well-run health system that meets priority health needs. An effective health system End Notes requires good governance, sound systems of procurement, sufficient supply of medicines, current health technologies 1. Braveman, P. & Gruskin S. (2003). Defining equity in health. and well-functioning health information systems. Journal of Epidemiology & Community Health, 57(4), 254-258. 2. World Health Organization. http://www.who.int & 2. Access to quality health facilities and healthcare workers http://www.who.int/workforcealliance/countries/png/en/ needs to be continually improved and monitored. This 3. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. improvement must include an increase in the number of (2003). Household catastrophic health expenditure: a multi-country trained health workers. Provision must be made for ongoing analysis. Lancet. (362), 111-7. professional learning, including interpersonal and teamwork 4. O’ Donnell, O., E. van Doorslaer, R. Rannan-Eliya, A. Somanathan, skills. Health workers must have access to suitable working S. R. Adhikari, B. Akka- zieva, D. Harbianto, C. G. Garg, P. environments and appropriate resources (that is, medicines, Hanvoravongchai, A. N. Herrin, M. N. Huq, S. Ibragi- mova, A. Karan, S.-M. Kwon, G. M. Leung, J.-F. R. Lu, Y. Ohkusa, B. R. medical supplies and up-to-date protocols). These Pande, R. Racelis, K. Tin, L. Trisnantoro, C. Vasavid, Q. Wan, B.- improvements will nurture the health worker- patient M. Yang, and Y. Zhao. Forthcoming. (2008) “Who Pays for Health relationship by improving the attitudes of the workforce and Care in Asia?” Journal of Health Economics, 27 (2), 460 – 475 the confidence patients have in the health workers’ skills. Attention must be paid to engaging and retaining health workers in rural areas.   This HNP Knowledge Note highlights the key findings 3. The utilization of healthcare facilities needs to be monitored from a study by the World Bank titled ‘A Snapshot of and improved, especially amongst the poorest quintiles. health equity in Papua New Guinea: An analysis of the Funding must commensurate with need. Initiatives geared 2010 Household Income and expenditure survey.’ Wayne toward the most vulnerable that are not increasing Irava, Katie Barker, Aparnaa Somanathan, Xiaohui Hou utilization, that is, mobile clinics or patrol visits need to be reviewed and amended. Though increased resources were Please contact Xiaohui Hou at xhou@worldbank.org for any inquiries on this work. allocated to these initiatives, the on-time receipt of funding by the front line services remains an issue. The cost and Financial support for this work was received from the distribution of medicine needs to be improved and Australian Government. monitored. 4. OOP payments need to be continuously improved and   monitored. This includes measuring the effects that the Free Primary Health Care policy, the impact of a potentially tighter fiscal space, and the ramification of delays in cash . releases to facilities all have on OOP payments, especially in the poorer quintiles. Whilst OOP payments have minimal catastrophic impact, the expense of healthcare has still been shown to be a barrier to healthcare utilization, especially amongst the poorest and thus affects the equity of the health system. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic and on PNG go to: www.worldbank.org/health and http://www.worldbank.org/en/country/png Page 3