Building social currency with foreskin cutsa coping mechanism of Papua New Guineahealth workers and the implications fornew programmesAnna Tynan1 Andrew Vallely23 Angela Kelly24 Martha Kupul2 Richard Naketrumb2

Herick Aeno2 Peter Siba2 John M Kaldor3 and Peter S Hill1

1Australian Centre for International amp Tropical Health School of Population Health The University of Queensland Herston Road HerstonQueensland 4006 Australia 2Sexual amp Reproductive Health Unit Papua New Guinea Institute of Medical Research PO Box 60 GorokaEastern Highlands Province 441 Papua New Guinea 3Public Health Interventions Research Group The Kirby Institute University of NewSouth Wales 45 Beach Street Coogee New South Wales 2034 Australia and 4International HIV Research Group School of Public Healthand Community Medicine The University of New South Wales Sydney Australia

Corresponding author Australian Centre for International amp Tropical Health School of Population Health The University of QueenslandHerston Road Herston Queensland 4006 Australia E-mail annatynanuqconnecteduau

Accepted 28 August 2013

Background Recent research as part of a multi-disciplinary investigation on the acceptability

and impact of male circumcision for HIV prevention in Papua New Guinea

(PNG) has shown that health workers (HWs) undertake unauthorized forms of

penile cutting practices in public health facilities or in community settings at

times within a traditional context Participation in these activities shares

common features with coping mechanisms strategies used by HWs to alleviate

the burden of unsatisfactory living and working conditions Coping mechanisms

however are typically described as motivated by economic advantage but in

PNG evidence exists that the behaviours of HWs are also influenced by

opportunities for social capital

Methods Twenty-five in-depth interviews (IDIs) were completed with a variety of HWs

from 2009 until 2011 and were triangulated with findings from 45 focus group

discussions and 82 IDIs completed with community members as part of a wider

qualitative study Thematic analysis examined HW participation in unauthorized

penile cutting services

Results The emergence of unauthorized practices as a coping mechanism in PNG is

compelled by mutual obligations and social capital arising from community

recognition and satisfaction of moral professional and cultural obligations

Using the example of unauthorized penile cutting practices amongst HWs

in PNG the research shows that although economic gains are not expli-

citly derived evidence exists that they meet other community and socio

cultural responsibilities forming a social currency within local traditional

economies

Conclusions Coping mechanisms create an opportunity to extend the boundaries of a health

system at the discretion of the HW Fragile health systems create opportunities

for coping mechanisms to become institutionalized pre-empting appropriate

policy development or regulation in the introduction of new programmes In

order to ensure the success of new programmes the existence of such practices

and their potential implications must be addressed within programme design

and in implementation and regulation

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

The Author 2013 all rights reserved

Health Policy and Planning 20131ndash10

doi101093heapolczt072

1

Health Policy and Planning Advance Access published October 8 2013 at U

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Keywords Coping mechanisms unauthorized practices penile foreskin cutting social

capital Papua New Guinea health system

KEY MESSAGES

Coping mechanisms have been typically described as motivated by economic advantages however in Papua New Guinea

evidence exists that the behaviours of public servants are influenced by capital derived from relationships or satisfaction

of religious cultural or moral obligations

Fragile health systems create opportunities for unauthorized practices to become institutionalized pre-empting

appropriate policy development or regulation even before new programmes are introduced

The success of health programmes underpinned by informal systems will not be achieved merely through bureaucratic

regulation but with strategies that encompass and recognize differences within organizational cultures and communities

IntroductionCoping mechanisms are strategies used by health workers

(HWs) to alleviate the burden of unsatisfactory living and

working conditions such as poor supervision inadequate or

intermittent remuneration or working in hostile environments

in low- and middle-income countries (McPake et al 2000

Schwalbach et al 2000 Macq et al 2001 van Lerberghe et al

2002 Ferrinho et al 2004a) Along with health system failures

coping mechanisms are shaped by social political and institu-

tional environments in which HWs operate and are as import-

ant in shaping how health services function and are perceived

as are planned health reforms and management (Roenen et al

1997 Schwalbach et al 2000 Macq et al 2001 van Lerberghe

et al 2002) Coping mechanisms include unauthorized practices

or activities that fall outside standard treating practices that can

impact on service delivery and may include illegal and non-

illegal activities This article will examine Papua New Guinean

(PNG) HWs engagement in unauthorized penile cutting

activities

Coping mechanisms and their relationship withhealth systems

Coping mechanisms arise due to extreme discrepancies between

social economic and professional expectations of HWs and real-

life situations (Table 1) (Schwalbach et al 2000 van Lerberghe

et al 2002 Garcıa-Prado and Gonzalez 2007) There are a

number of different types of coping mechanisms which are

described in the literature These include HWs receiving

informal payments or under-the-counter payments for other-

wise free services (Delcheva et al 1997 Giedion et al 2001

Falkingham 2004 Lindelow and Serneels 2006 Tediosi 2008

Liu and Sun 2012) misappropriating drugs or other supplies

(Israr et al 2000 Ferrinho et al 2004a Lindelow and Serneels

2006) moonlighting in other roles or dual practice (Ferrinho

et al 2004a Jan et al 2005 Gonzalez and Macho-Stadler 2013)

preferential treatment including accelerated access to health

services for friends family or those who are able to afford

bribes or under-the-counter payments (Roenen et al 1997) and

other unexplained absenteeism (Chaudhury et al 2005 Manzi

et al 2012) There has also been a move to acknowledge other

potential coping strategies for HWs such as receiving in-kind or

in-gratitude payments like access to accommodation or food for

services they perform (Roenen et al 1997 Chereches et al

2013) using time or resourcesmdashsuch as health service ve-

hiclesmdashfrom government projects for personal use (McPake

et al 1999 Macq et al 2001 Ferrinho et al 2004b) and

exploitation of allowances and per diems designed to enable

supervision or attendance at courses (McCoy et al 2008 Smith

2003 Vian et al 2011)

Engagement in coping mechanisms has consequences for the

equity and efficiency of health systems and quality of health

care (Garcıa-Prado and Gonzalez 2007 Jumpa et al 2007

Kiwanuka et al 2011) Health system impacts include compe-

tition for time (due to HWs being less available at public

facilities thereby compromising service delivery) conflict of

interest (for example when HWs lower the quality of services

they provide in the public sector in order to drive patients to the

private sector) and brain drain (or inequitable distribution of

HWs between public and private rural and urban primary and

tertiary and poor and rich settings) (Macq et al 2001 van

Lerberghe et al 2002 Ferrinho et al 2004b Kiwanuka et al

2011 Ashmore 2013) Misuse by HWs of their privileged access

to resources such as pharmaceuticals contributes to financial

losses in the health-care system as well as the growing sense of

mistrust and disrespect for HWs and their institutions

(Ferrinho et al 2004a) Informal payments or under-the-counter

payments provide a financial barrier to those who canrsquot afford

to pay and as a result again jeopardize the necessary trust

between user and provider and public expectations of health

service delivery (van Lerberghe et al 2002 Dabalen and Wane

2008) Inappropriate or unnecessary attendance at training

sessions primarily to obtain the per diem allowances creates

inefficiencies in health systems including reduced HW avail-

ability (van Lerberghe et al 2002 Conteh and Kingori 2010

Vian et al 2011)

Although coping mechanisms may be considered a part of

corrupt practices of government employees or labelled as the

result of poor motivation or inefficient practice there is

evidence that coping mechanisms are not necessarily due to

predatory behaviour but a strategy to deal with difficult

situations that can have positive impacts as well

2 HEALTH POLICY AND PLANNING

Ta

ble

1

Typ

eso

fco

pin

gst

rate

gie

sam

on

gH

Ws

curr

ency

exch

an

ged

an

dim

pact

on

hea

lth

syst

em

Are

ao

rp

roce

sso

fh

ea

lth

syst

em

fail

ure

Co

pin

gst

rate

gy

Typ

es

of

curr

en

cye

xch

an

ge

dP

oss

ible

resu

lt

Hu

man

reso

urc

ing

In

ad

equ

ate

hu

man

reso

urc

ing

In

ad

equ

ate

train

ing

an

dsu

per

visi

on

of

HW

s

Lack

of

com

pu

lso

ryed

uca

tio

n

H

Wass

um

eso

ther

role

san

dre

spo

nsi

-

bil

itie

so

uts

ide

train

ing

R

elia

nce

on

info

rmal

net

wo

rks

for

gu

id-

an

ceo

nap

pro

pri

ate

pra

ctic

e

Reg

ula

ratt

end

an

ceat

wo

rksh

op

san

dtr

ain

ing

(in

clu

din

go

vers

eas)

S

oci

al

reco

gn

itio

nan

dp

rest

ige

M

ora

lsa

tisf

act

ion

of

Hip

po

crati

co

ath

or

reli

gio

us

con

vict

ion

tose

rve

P

rofe

ssio

nal

sati

sfact

ion

an

dse

lf-

fulf

ilm

ent

thro

ugh

ach

ievi

ng

oth

ersk

ills

G

ener

al

inef

fici

ency

of

hea

lth

serv

ice

In

crea

sed

com

pli

cati

on

s

Red

uce

dco

mm

un

ity

tru

stin

hea

lth

wo

rker

san

dth

eir

inst

itu

tio

ns

H

Wst

ress

an

dd

issa

tisf

act

ion

wit

hh

ealt

h

syst

em

Hea

lth

fin

an

cin

g

L

imit

edfu

nd

ing

for

serv

ice

D

iffi

cult

ies

ob

tain

ing

fun

din

g

Lo

ww

ages

H

Ws

rece

ivin

gin

form

al

paym

ents

for

oth

erw

ise

free

serv

ice

R

ecei

vin

ggif

tslsquoi

nk

ind

rsquo

Mo

on

ligh

tin

gin

oth

erro

les

incl

ud

ing

pri

vate

hea

lth

sect

or

or

agri

cult

ure

usi

ng

tim

eo

rre

sou

rces

fro

mgo

vern

men

t

pro

ject

s

Pil

feri

ng

dru

gs

an

dm

edic

ines

P

erd

iem

sfo

rtr

ave

lan

dtr

ain

ing

E

con

om

ic

sup

ple

men

tlo

wsa

lari

esw

ith

cash

an

dtr

ad

itio

nal

eco

no

mie

s

Pro

fess

ion

al

sati

sfact

ion

an

dse

lf-f

ulf

il-

men

tb

yp

art

icip

ati

ng

ino

ther

role

s

So

cial

use

skil

lsas

HW

togain

com

mu

-n

ity

pre

stig

ean

dre

cogn

itio

n

C

om

pet

itio

nfo

rti

me

O

utf

low

of

reso

urc

esfr

om

the

pu

bli

c

sect

or

C

on

flic

tso

fin

tere

st

Hig

hp

rice

of

hea

lth

care

D

iscr

imin

ati

on

of

pati

ents

acc

ord

ing

to

cap

aci

tyto

pay

In

ad

equ

ate

serv

ice

del

iver

y

Med

icin

esan

dte

chn

olo

gy

In

suff

icie

nt

med

icin

esan

dte

chn

ical

equ

ipm

ent

for

the

man

agem

ent

of

pate

nts

G

ener

al

lack

of

basi

csu

pp

lies

M

isap

pro

pri

ati

ng

dru

gs

or

oth

ersu

pp

lies

for

fam

ily

or

oth

eracq

uain

tan

ces

O

verc

harg

ing

pati

ents

for

dru

gs

an

d

oth

ersu

pp

lies

H

Ws

usi

ng

reso

urc

esto

pro

vid

eu

nre

c-o

gn

ized

ad

dit

ion

al

serv

ices

of

the

org

an

izati

on

S

oci

al

usi

ng

acc

ess

tore

sou

rces

as

aH

W

tosa

tisf

yco

mm

un

ity

or

cult

ura

lo

bli

gati

on

M

ora

lsa

tisf

act

ion

of

Hip

po

crati

co

ath

or

reli

gio

us

con

vict

ion

tose

rve

E

con

om

ic

sup

ple

men

tlo

wsa

lari

esw

ith

cash

an

dtr

ad

itio

nal

eco

no

mie

s

L

ow

qu

ali

tyo

fd

iagn

osi

san

dp

resc

rip

tio

n

Deg

rad

ati

on

of

qu

ali

tyca

re

Co

un

terf

eit

dru

gs

F

inan

cial

loss

toth

eh

ealt

hsy

stem

Hea

lth

info

rmati

on

syst

ems

P

oo

racc

ou

nta

bil

ity

an

dre

cord

kee

pin

g

Lim

ited

acc

ess

top

rofe

ssio

nal

dev

elo

p-

men

tan

dre

sou

rces

U

nex

pla

ined

ab

sen

teei

sm

Eco

no

mic

su

pp

lem

ent

low

sala

ries

wit

h

cash

an

dtr

ad

itio

nal

eco

no

mie

s

So

cial

sati

sfact

ion

of

cult

ura

lo

bli

gati

on

s

fost

erin

gre

lati

on

ship

s

G

ener

al

inef

fici

ency

of

hea

lth

serv

ice

W

ork

do

ne

inp

riva

tese

cto

rn

ot

cap

ture

d

Hea

lth

serv

ices

L

imit

edse

rvic

eava

ilab

ilit

y

Po

or

wo

rkin

gco

nd

itio

ns

incl

ud

ing

po

or

faci

liti

esan

dre

sou

rces

W

ork

ing

inch

all

engin

gan

dd

an

ger

ou

s

envi

ron

men

ts

N

epo

tism

for

bet

ter

hea

lth

serv

ice

F

aci

lita

tio

no

fq

ueu

eju

mp

ing

for

rela

-

tive

san

dfr

ien

ds

S

oci

al

pre

ssu

reto

get

spec

ial

trea

tmen

to

ro

ther

sfa

vou

rs

Un

exp

lain

edab

sen

teei

sm

S

oci

al

sati

sfact

ion

of

cult

ura

lo

bli

gati

on

s(i

ncl

ud

ing

soci

al

pre

ssu

reto

get

spec

ial

trea

tmen

to

ro

ther

sfa

vou

rs)

fost

erin

g

rela

tio

nsh

ips

E

con

om

ic

acc

ess

totr

ad

itio

nal

eco

no

my

or

lsquoin

kin

drsquo

paym

ents

D

iscr

imin

ato

ryp

ract

ice

L

ow

uti

liza

tio

no

fse

rvic

e

Sta

teH

Ws

bec

om

ele

ssava

ilab

leto

wo

rk

inth

ep

ub

lic

sect

or

bu

td

on

ot

resi

gn

L

ow

qu

ali

tyo

fd

iagn

osi

san

dp

resc

rip

tio

n

HW

fati

gu

e

Lea

der

ship

an

dgo

vern

an

ce

P

oo

rle

ad

ersh

ipan

du

nd

erst

an

din

go

f

com

mu

nit

yse

rvic

en

eed

s

HW

ass

um

esre

spo

nsi

bil

itie

sfo

rall

face

tso

fth

ese

rvic

esan

dra

tio

nali

zes

act

ion

s

them

selv

es

S

oci

al

sati

sfact

ion

of

cult

ura

lo

bli

gati

on

s(i

ncl

ud

ing

soci

al

pre

ssu

reto

get

spec

ial

trea

tmen

to

ro

ther

sfa

vou

rs)

fost

erin

gre

lati

on

ship

s

Mo

ral

sati

sfact

ion

of

Hip

po

crati

co

ath

or

reli

gio

us

con

vict

ion

tose

rve

G

ener

al

inef

fici

ency

of

hea

lth

serv

ice

N

ocl

ear

un

der

stan

din

go

fh

ow

pu

bli

cse

cto

rex

ists

E

mer

gen

tp

ract

ices

bec

om

ein

stit

uti

on

ali

zed

COPING MECHANISMS OF PAPUA NEW GUINEA HEALTH WORKERS 3

(van Lerberghe et al 2002 Ferrinho et al 2004a) These positive

impacts include increased HW motivation mobilization of

additional resources minimizing the budgetary burden on the

public sector to retain skilled staff as HWs and stabilization of

qualified personnel (van Lerberghe et al 2002 Ferrinho et al

2004a Ferrinho et al 2004b Kiwanuka et al 2011) They also

offer an opportunity to address a number of other difficulties

HWs face in developing countries including poor resource

availability lack of trust for the department of health poor

perceived career opportunities inadequate staffing and a range

of other challenges (Table 1) (Garcıa-Prado and Gonzalez 2007

Kiwanuka et al 2011 Ashmore 2013) Coping mechanisms have

also been typically described as motivated by economic advan-

tage but in PNG a country known for health system

difficulties in implementing even basic programmes (Izard

and Dugue 2003 Thomason 2006 Davy and Patrickson 2012

Tynan et al 2012) evidence also exists that the behaviours of

public servants are influenced by social benefits such as capital

derived from relationships or satisfaction of religious cultural

or moral obligations (van Amstela and van der Geest 2004

Tivinarlik and Wanat 2006 Jayasuriya 2011 Razee et al 2012

Tynan et al 2013)

This article explores how engaging in unauthorized penile

cutting practices in PNG forms a type of coping strategy that is

not primarily motivated by personal financial gains but the

acquisition and exchange of social currency including mutual

obligation social recognition and prestige professional satis-

faction and self-fulfilment (Macq et al 2001 van Lerberghe

et al 2002) Exploration of HW engagement in penile cutting

practices provides particular and unique insights into coping

mechanisms in PNG Understanding how and why

unauthorized practices exist will not only provide an oppor-

tunity to develop strategies to address concerns or deal with

possible consequences but also provide insight into the extent

of adaptation of health systems to the sociocultural environ-

ment in which they operate

Unauthorized penile cutting in PNG

Penile cutting practices have become of significant interest

since large-scale clinical trials in Africa showed that male

circumcision (MC) has a protective efficacy of around 60 in

preventing HIV acquisition in heterosexual men (Auvert et al

2005 Bailey et al 2007 Gray et al 2007 WHOUNAIDS 2007

Siegfried et al 2009) In some communities where MC for HIV

prevention is being considered evidence exists of a considerable

variety of already established penile cutting practices within

communities that have not been shown to be protective against

HIV (Brown et al 2001 Vincent 2008 Hill et al 2012) That is

these penile cutting practices often do not involve full circum-

ferential cut and removal of the foreskin but rather incisions

that do not alter the size of the foreskin or minimize the

exposure of langerhans cells that have been described as

vulnerable to the HIV virus (McCoombe and Short 2006 Pask

et al 2008 Kigozi et al 2009 Doyle et al 2010) PNG is one such

context where a recent study categorizing the various types of

penile cutting demonstrated that these cuts do not conform

with the guidelines for medical circumcision (Hill et al 2012)

Penile cutting in PNG has a complex history embedded in

religion and traditional ritual and more recently has included

contemporary practices that are the outcome of peer influence

and the evolving sociocultural environment (Williamson 1990

Kempf 2002 MacLaren et al 2011a Hill et al 2012 Kelly et al

2012a Kelly et al 2012b) HWs in PNG have been observed to

be engaging in these penile cutting practices justifying their

actions on both medical and non-medical grounds utilizing

health system resources without the formal approval of the

Department of Health (MacLaren et al 2011b Tynan et al 2011

Hill et al 2012) In a recent study almost a quarter of the 33

frontline HWs interviewed reported regularly engaging in penile

cutting services that operated outside the current regulations of

the PNG health system and a number of other HWs reported

that they were aware of colleagues being involved in

unauthorized penile cutting practices (Tynan et al 2011)

Services included providing instructions on how to perform a

foreskin cut for non-health-related purposes supplying equip-

ment such as spatula scalpel plaster bandage and gauze from

the health facility to men to perform penile cutting at home or

providing penile cutting services to their communities for

contemporary or traditional reasons (Tynan et al 2011) These

findings are supported by another study of 483 PNG men with

a penile foreskin cut for non-health-related reasons who

reported that HWs were the second most likely persons to

have performed the procedure (MacLaren et al 2011b)

Community obligations and other sociocultural responsibil-

ities play an important role in the fabric of many PNG

communities and potentially interface with the health system

(de Renzio 2000 van Amstela and van der Geest 2004

Tivinarlik and Wanat 2006 Bainton 2008 Reilly and Phillpot

2008) Strong links to community responsibilities have been

shown to outweigh other organizational ties in PNG resulting

in some HWs performing duties outside their role description

(Razee et al 2012 Tynan et al 2013) Further to this the wantok

system in PNGmdashloosely defined as a set of obligations between

individuals of similar geographic origin kinship language

group andor social or religious associationsmdashhas particular

application for engaging in certain practices (de Renzio 2000

Tivinarlik and Wanat 2006 Reilly and Phillpot 2008) In the

public service this clan-based allegiance has been shown to

commonly override the responsibilities of organizational pro-

cesses inadvertently leading to conflict of interest and nepo-

tism within education business and health service networks in

PNG (de Renzio 2000) The wantok system thus serves as a form

of social economy where social capital or resources derived

from specific social structures can be accumulated by actors

(including HWs) within the community and then used to

pursue their own interests (Baker 1990)

MethodsStudy design

This research is part of a multi-disciplinary investigation on the

acceptability and impact of male circumcision for HIV preven-

tion in PNG and used qualitative methods to explore HW

participation in unauthorized penile cutting practices in PNG

Unauthorized practices were defined as those activities that

were not considered a part of a HWrsquos expected role within the

health system or did not conform to standard treating practice

however involved the use of HWrsquos medical skills health system

4 HEALTH POLICY AND PLANNING

(van Lerberghe et al 2002 Ferrinho et al 2004a) These positive

impacts include increased HW motivation mobilization of

additional resources minimizing the budgetary burden on the

public sector to retain skilled staff as HWs and stabilization of

qualified personnel (van Lerberghe et al 2002 Ferrinho et al

2004a Ferrinho et al 2004b Kiwanuka et al 2011) They also

offer an opportunity to address a number of other difficulties

HWs face in developing countries including poor resource

availability lack of trust for the department of health poor

perceived career opportunities inadequate staffing and a range

of other challenges (Table 1) (Garcıa-Prado and Gonzalez 2007

Kiwanuka et al 2011 Ashmore 2013) Coping mechanisms have

also been typically described as motivated by economic advan-

tage but in PNG a country known for health system

difficulties in implementing even basic programmes (Izard

and Dugue 2003 Thomason 2006 Davy and Patrickson 2012

Tynan et al 2012) evidence also exists that the behaviours of

public servants are influenced by social benefits such as capital

derived from relationships or satisfaction of religious cultural

or moral obligations (van Amstela and van der Geest 2004

Tivinarlik and Wanat 2006 Jayasuriya 2011 Razee et al 2012

Tynan et al 2013)

This article explores how engaging in unauthorized penile

cutting practices in PNG forms a type of coping strategy that is

not primarily motivated by personal financial gains but the

acquisition and exchange of social currency including mutual

obligation social recognition and prestige professional satis-

faction and self-fulfilment (Macq et al 2001 van Lerberghe

et al 2002) Exploration of HW engagement in penile cutting

practices provides particular and unique insights into coping

mechanisms in PNG Understanding how and why

unauthorized practices exist will not only provide an oppor-

tunity to develop strategies to address concerns or deal with

possible consequences but also provide insight into the extent

of adaptation of health systems to the sociocultural environ-

ment in which they operate

Unauthorized penile cutting in PNG

Penile cutting practices have become of significant interest

since large-scale clinical trials in Africa showed that male

circumcision (MC) has a protective efficacy of around 60 in

preventing HIV acquisition in heterosexual men (Auvert et al

2005 Bailey et al 2007 Gray et al 2007 WHOUNAIDS 2007

Siegfried et al 2009) In some communities where MC for HIV

prevention is being considered evidence exists of a considerable

variety of already established penile cutting practices within

communities that have not been shown to be protective against

HIV (Brown et al 2001 Vincent 2008 Hill et al 2012) That is

these penile cutting practices often do not involve full circum-

ferential cut and removal of the foreskin but rather incisions

that do not alter the size of the foreskin or minimize the

exposure of langerhans cells that have been described as

vulnerable to the HIV virus (McCoombe and Short 2006 Pask

et al 2008 Kigozi et al 2009 Doyle et al 2010) PNG is one such

context where a recent study categorizing the various types of

penile cutting demonstrated that these cuts do not conform

with the guidelines for medical circumcision (Hill et al 2012)

Penile cutting in PNG has a complex history embedded in

religion and traditional ritual and more recently has included

contemporary practices that are the outcome of peer influence

and the evolving sociocultural environment (Williamson 1990

Kempf 2002 MacLaren et al 2011a Hill et al 2012 Kelly et al

2012a Kelly et al 2012b) HWs in PNG have been observed to

be engaging in these penile cutting practices justifying their

actions on both medical and non-medical grounds utilizing

health system resources without the formal approval of the

Department of Health (MacLaren et al 2011b Tynan et al 2011

Hill et al 2012) In a recent study almost a quarter of the 33

frontline HWs interviewed reported regularly engaging in penile

cutting services that operated outside the current regulations of

the PNG health system and a number of other HWs reported

that they were aware of colleagues being involved in

unauthorized penile cutting practices (Tynan et al 2011)

Services included providing instructions on how to perform a

foreskin cut for non-health-related purposes supplying equip-

ment such as spatula scalpel plaster bandage and gauze from

the health facility to men to perform penile cutting at home or

providing penile cutting services to their communities for

contemporary or traditional reasons (Tynan et al 2011) These

findings are supported by another study of 483 PNG men with

a penile foreskin cut for non-health-related reasons who

reported that HWs were the second most likely persons to

have performed the procedure (MacLaren et al 2011b)

Community obligations and other sociocultural responsibil-

ities play an important role in the fabric of many PNG

communities and potentially interface with the health system

(de Renzio 2000 van Amstela and van der Geest 2004

Tivinarlik and Wanat 2006 Bainton 2008 Reilly and Phillpot

2008) Strong links to community responsibilities have been

shown to outweigh other organizational ties in PNG resulting

in some HWs performing duties outside their role description

(Razee et al 2012 Tynan et al 2013) Further to this the wantok

system in PNGmdashloosely defined as a set of obligations between

individuals of similar geographic origin kinship language

group andor social or religious associationsmdashhas particular

application for engaging in certain practices (de Renzio 2000

Tivinarlik and Wanat 2006 Reilly and Phillpot 2008) In the

public service this clan-based allegiance has been shown to

commonly override the responsibilities of organizational pro-

cesses inadvertently leading to conflict of interest and nepo-

tism within education business and health service networks in

PNG (de Renzio 2000) The wantok system thus serves as a form

of social economy where social capital or resources derived

from specific social structures can be accumulated by actors

(including HWs) within the community and then used to

pursue their own interests (Baker 1990)

MethodsStudy design

This research is part of a multi-disciplinary investigation on the

acceptability and impact of male circumcision for HIV preven-

tion in PNG and used qualitative methods to explore HW

participation in unauthorized penile cutting practices in PNG

Unauthorized practices were defined as those activities that

were not considered a part of a HWrsquos expected role within the

health system or did not conform to standard treating practice

however involved the use of HWrsquos medical skills health system

4 HEALTH POLICY AND PLANNING

supplies or impacted on delivery of other services The quali-

tative research methods included in-depth interviews (IDIs)

with 25 frontline HWs involved in sexual and reproductive

health and data triangulation with findings from an additional

45 focus group discussions (FGDs) and 82 IDIs completed with

community members as part of a wider qualitative study on

community perceptions about masculinity and penile foreskin

cutting and penile modifications in PNG The fieldwork was

completed in five diverse social and geographical locations

around PNG including Central Province (CP) Eastern

Highlands Province (EHP) East Sepik Province (ESP)

Madang Province (MP) and West New Britain Province

(WNB) from 2009 until 2011 (Figure 1) Approval for the

research was obtained from research ethics committees at both

the PNG Institute of Medical Research (PNGIMR) and the

University of Queensland

Sampling and data collection for fieldwork

An iterative purposive sampling technique was used to identify

potential study participants following initial interviews with key

national and local stakeholders at each study location IDIs and

FGDs were completed with a variety of HWs from various

government and non-government health facilities around PNG

men who had undergone penile cutting inserts or associated

practices and other community leaders who had unique

insights and lived experiences in the study area Interview

guides were developed following extensive literature review and

discussions among the research team and followed a number of

themes including types of services provided and knowledge of

penile foreskin cutting in PNG Interviews were completed

by the in-country research team from the PNGIMR and a

researcher from the University of Queensland Interviews were

conducted in either English or PNG pidgin (the most widely

spoken of PNGrsquos three national languages) as per the partici-

pantrsquos preference digitally recorded transcribed verbatim and

translated into English

Data analysis

The framework analysis method appropriate for the analysis of

qualitative data for policy-oriented studies was used to analyse

the data (Braun and Clarke 2006) All IDIs and FGDs were

initially double coded by the in-country research team at the

PNGIMR In cases of discrepancy in coding a third researcher

coded the selected text in question Preliminary analysis of the

HW interviews showed the differing roles that HWs played in

penile cutting in PNG Themes were further updated as the

analysis developed and organized around identification of

whether respondents discussed unauthorized penile cutting

practices or services that operated outside the rules and

regulations of the health system and reasons for their

participation These themes were further triangulated with

IDIs and FGDs completed with community members to assist in

exploring the interconnections of the sociocultural context in

which the HW was participating Final codes were developed by

the first author and adjusted as required following review from

fellow authors

Figure 1 Map of PNG with study provinces highlighted

COPING MECHANISMS OF PAPUA NEW GUINEA HEALTH WORKERS 5

Results and DiscussionAnalysis of the data revealed a number of additional motivators

and obligations other than direct financial gain that prompted

the provision of unauthorized penile cutting These included a

change in social standing meeting of cultural obligations roles

within traditional economies and participating in traditional

roles as a dual practice In the sociocultural context of PNG

these unauthorized practices seem to arise from the need to

cope with the pressures of community expectations within a

failing health system and are not entirely about alleviating the

burden of unsatisfactory living and working conditions The

relationships gained or maintained by the HWs through

participating in unauthorized practices influence the social

standing of the HWs which is further amplified by percep-

tions from the community that HWs are technically safer

practitioners Their response to the social and cultural pressures

on them to engage in penile cutting does generate a lsquocurrencyrsquo

that provides a form of social investment and exchange for the

HW within their local sociocultural environment (Table 1)

How performance of foreskin cuts boosts HWs socialcurrency in PNG

The HW as a cultural lsquobrokerrsquo facilitating access to services

The role HWs played with connecting the community to the

health system was varied According to the respondents it was

quite common that knowing someone working within the

health service provided ease of access to health staff and

facilities for assistance with penile cutting

What they normally do ismdashthey come and see somebody

that they know in the hospital and then that fellow will

come around and inform us that these guys are coming for

or they want to do circumcision [Medical Officer WNB]

HWs suggested that the reasons the community members

approached them was because they were embarrassed or

concerned about the anticipated attitudes of other HWs

However indirect access to the health service also had the

potential to reduce the costs associated with transport and time

off work or even the reported waiting times if they went

through the usual formal channels One HW reported that he

had been waiting for over 6 months to get his son circumcised

at the provincial hospital Therefore accelerated access to

health services via complex kinship networks or wantoks

often free of formal charges has a significant worth

The HW as lsquobig manrsquo social recognition and prestige

The social recognition obtained in being able to assist commu-

nity members with penile cutting forms a source of significant

social capital for the HW in PNG where men can achieve

status fame and authority as lsquobig menrsquo (a title of status or

leader) through their actions (Bainton 2008) Access to unique

skills even where this did not result in higher wages provided

an opportunity to augment existing status within the commu-

nity HWs advised that based on their observation of what was

happening in their community they were aware that their skills

in penile foreskin cutting could be used to build their

reputation Their technical skills could be further developed

with experience and would then respond to a range of differing

requests from the community

Sometimes I do full removal Get rid of the skin and later

when there is only half of the skin I use to sew it suture

So there are two types I do for circumcision One is lsquoopen

cutrsquo (dorsal slit cut only) especially in their community

where it is their custom and the other is the lsquoround cutrsquo

(full circumcision) Because of my health worker training I

am able to apply the skills I know and perform what they

(the community) want [Community Health Worker WNB]

Possession of exclusive knowledge or recognition through skills

or position in a community has important implications for

many communities of PNG (de Renzio 2000 Bainton 2008)

The status of the lsquobig manrsquo in PNG is not gained through

acquisition of leadership roles in the community but rather the

outcome of a series of acts which elevate the person above

others as an acknowledged standing in interpersonal relations

(Sahlins 1963 de Renzio 2000) Individual status may be

distinguished according to professional standing income and

the subsequent capacity for conspicuous consumption resulting

in the power of influence in the community (Bainton 2008)

For the HW providing a special service for a community

member may assist in elevating their own community position

Likewise a HW providing a special service for a lsquobig manrsquo in the

community also involved an exchange of recognition

the big man for example radio announcer or bank

managers they come These big men when they come they

say lsquoyou touched my body (penis) so here is 50 kina for you

have some drinks (beer)rsquo Only those big men help us (give

us money) Not small boys not other men no only big man

like bank managers radio managers They say lsquowhen you

are finish you go and get a 6 pack and wash your handsrsquo

[Community Health Worker ESP]

The opportunity to elevate social standing was also evident in

communities which engaged in traditional penile cutting

activities In these communities there seemed to be a particular

impetus for HWs to perform penile cutting either due to

community expectation or the role the HW perceived they

played in the community In essence HWs in traditional cutting

communities were able to participate in distinct dual practices

in their community one as a HW and the other as a recognized

traditional penile cutting practitioner Dual practice in the

health sector has previously been described as HWs working

concurrently in the public and private sector to mitigate low

salaries and other unsatisfactory conditions (Ferrinho et al

2004b) In PNG dual practice may take the form of engaging in

work that is part of traditional culture with the use of public

system resources and may be seen as a potential opportunity to

elevate social standing or be a part of facilitating customary

practices in the community

The HW as a player benefits from local economies

HWs reported that the penile foreskin cutting services they

provide were typically on a voluntary basis for non-identified

medical reasons and conducted outside of usual work hours for

6 HEALTH POLICY AND PLANNING

no arranged payment However distinction was made between

payment to the hospital or a wage to the HW and payment lsquoin

kindrsquo due to gratitude or for a assisting with a customary or

contemporary practice For customary penile cutting practices

this involved payment to the HW by customary means such as

shell money and lsquokaruka nutsrsquo (an edible nut popular and

widely available particularly in the highlands of PNG) which

have substantial value in traditional economies (Strathern

1993 Bainton 2008 Lederman 2009) or invitations to custom-

ary celebrations In other provinces it was common that offers

of fruit and other foodstuff were provided in appreciation of the

service Therefore although the participants reported that

money rarely changed hands and then only in gratitude for

services or with customary payments there was still an

economic benefit obtained through traditional economies but

this itself could produce unpredictable outcomes

The tradition of compensation in PNG may also extend to HWs

motivation to engage in unauthorized practices Compensation in

PNG is expected following many different kinds of loss

including death during clan fights or other accidents and there

is considerable pressure to pay to ensure further trouble and

bloodshed is prevented (Trompf 1994 Strathern and Stewart

2000) Various factors influence the amount of compensation

that needs to be paid including the nature of the event the

relationship of the parties involved and the economic or social

position of the guilty party (Trompf 1994 Goddard 1996

Strathern and Stewart 2000) HWs have also been implicated

in cultural compensation claims by providing services for a fee

where unexpected complications resulted from the service or

outcomes were considered unsatisfactory by the client (van

Amstela and van der Geest 2004) Obligation to participate in

unauthorized practices however may be driven by fear of

repercussions arising from perceived responsibilities from their

professional roles For example HWs not only feel pressure to

assist with dealing with complications sustained from a penile

cut completed by non-HWs but also risk sharing the blame for

negative outcomes Committing to undertake the procedure

themselves may seem to limit these risks

This fear may also impact on a HWs decision not to engage in

a service For example one HW was concerned about the

possibility of a national MC programme for HIV prevention for

fear that this would raise community expectations of complete

protection from HIV and could result in retribution in the event

of a circumcised man becoming HIV-positive

If our awareness [health promotion] goes wrong the

consequences will come back to us If circumcised men

are infected they will point their fingers to us the health

people and say lsquoYou said I will not get it and I went for

circumcision but now I got it and your words are liesrsquo They

will not believe us and this has its consequences too

[Health Extension Officer EHP]

The HW as ethical practitioner fulfilment of moral obligationand professional satisfaction

Justification for engaging in unauthorized penile cutting

practices according to most respondents was due to the

perceived failings of the health system to respond appropriately

to the potential complications following penile foreskin cutting

undertaken by non-HWs HWs saw their participation as a

necessary part of their responsibility of being a HW in PNG

Reasons for engagement in regular unauthorized practices

centred around a genuine concern that the men from the

community would perform the penile foreskin cut in precarious

ways regardless of whether they had HW support or not In

some cases HWs even reasoned that if they could not provide

the services themselves then supplying the equipment and

instructions for the desired penile foreskin cut would assist in

ensuring safety of the procedure

Many times they come and ask me for equipment And

many times I get cross at them and reject them I tell them

that they should come to me and I will do it But since

many will not come out like I said already they are very

young and are ashamed to come So when I recognize their

problem I now give them equipment and just advise them

how they should do it [Health Extension Officer EHP]

The sense of responsibility to compensate for the failings of the

health system combined with a deep sense of need for service

and religious conviction have been shown to be key motivators

of HWs engagement in health services in PNG (Jayasuriya et al

2011 Razee et al 2012 Tynan et al 2013) Participation in

unauthorized practices assists in satisfaction of moral respon-

sibility as a HW and committed religious practitioner as well as

general professional self-fulfilment

ConclusionsCoping mechanisms create an opportunity to extend the

boundaries of a health system at the discretion of the HW

(van Lerberghe et al 2002) In the case of PNG the emergence

of unauthorized practices as a coping mechanism is compelled

by mutual obligations where HWs are obliged to share

professional skills and access to resources as part of communal

social capital rather than engage in cash economies Likewise

HWs acquire social currency or resources and status which arise

from social networks and communities by providing preferen-

tial treatment and resources amongst these networks (Tynan

et al 2011) This has implications not only for quality control of

services conducted in informal environments and medico-legal

issues around accreditation but also for introduction of new

programmes that may overlap with the sociocultural environ-

ment such as male circumcision for HIV prevention

The introduction of new health programmes requires concerted

efforts from all sections of the health system However in the

case of fragile health systems opportunities are created for

unauthorized practices to become institutionalized pre-empting

appropriate policy development or regulation even before new

programmes are introduced If practices are already informally

established this creates difficulties in measuring the impact of

new intervention programmes because of misreporting or under-

reporting and delivery of services that do not conform to

standards If there is a male circumcision programme introduced

in PNG for HIV prevention the regulation of the dorsal foreskin

slit procedure within the health system will be imperative

Current research to determine whether dorsal slit procedures

offer any protective effect in terms of HIV acquisition will play a

significant role in determining what form of regulation would be

COPING MECHANISMS OF PAPUA NEW GUINEA HEALTH WORKERS 7

appropriate There will also be significant tensions across cultural

domains arising from conflicts around preferred ways and

reasons for engaging in particular practices The coping strategies

adopted by the HWs for the provision of unauthorized penile

cutting practices in PNG end up undermining the existing system

because the provider creates their own working conditions and

income in the form of social and economic gains Yet the

relationships and systems that develop even if they have

negative consequences for the health system are the result of

HW desire and obligations to fulfil their full range of social

responsibilities and often are seen by them as consistent with

their professional roles Although some may draw parallels with

HWs continued engagement in female genital cutting in other

countries (Caldwell et al 2000 Shell-Duncan 2001

Christoffersen-Deb 2005) MCmdashand dorsal slit penile cuttingmdash

does not involve the same negative clinical social and cultural

consequences

In order to ensure the success of new programmes which

already have an established informal system it will be

important to acknowledge the existence of such practices and

ensure understandings of potential implications are included

within the programme design (Berman and Cuizon 2004

Jumpa et al 2007 Kiwanuka et al 2011) It has been argued

that even in an adverse socio-economic environment it is

feasible to create conditions that allow individual providersrsquo

strategies to remain compatible with equity and quality while

responding to their aspirations for survival social status and

professional satisfaction (Roenen et al 1997) Improvement of

working conditions in a place such as PNG however is more

than a combination of adequate salary and access to resources

(Segall 2000 van Lerberghe et al 2002) It also means

developing good supervision and support acknowledging the

complex role HWs play in their communities and harnessing

these conditions for positive outcomes Perhaps most import-

antly it requires a social environment that reinforces profes-

sional behaviour and boundaries and acknowledgement that

legislation and regulation are not enough This study used

penile cutting practices as a focus however it is likely that

reasons for engaging in coping mechanisms for other

unauthorized practices are likely to be similar in PNG What

is clear nonetheless is that HW management in PNG extends

beyond the boundaries of health organizations into the complex

sociocultural environment in which they work

AcknowledgementsThis study was supported by an Australian Agency for

International Development (AusAID) Australian Development

Research Award (ADRA) for the Male Circumcision

Acceptability and Impact Study PNG (MCAIS)

Conflict of interest statement None declared

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Auvert B Taljaard D Lagarde E et al 2005 Randomized controlled

intervention trial of male circumcision for reduction of HIV

infection risk the ANRS 1265 Trial PLoS Med 2 e298

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Anthropol 19 194ndash212

Baker W 1990 Market networks and corporate behavior Am J Sociol 96

589ndash625

Berman P Cuizon D 2004 Multiple Public-private Jobholding of Health Care

Providers in Developing Countries An Exploration of Theory and Evidence

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Braun V Clarke V 2006 Using thematic analysis in psychology Qual Res

Psychol 3 77ndash101

Brown JE Micheni KD Grant EM et al 2001 Varieties of male

circumcision a study from Kenya Sex Transm Dis 28 608ndash12

Caldwell JC Israel OO Caldwell P 2000 Female genital mutilation

conditions of decline Population Res Policy Rev 19 23ndash55

Chaudhury N Hammer J Kremer M Muralidharan K Rogers FH 2005

Missing in action teacher and health worker absence in developing

countries J Econ Persp 20 91ndash116

Chereches RM Ungureanu MI Sandu P Rus IA 2013 Defining

informal payments in healthcare a systematic review Health Policy

110 105ndash14

Christoffersen-Deb A 2005 lsquoTaming Traditionrsquo medicalized female

genital practices in Western Kenya Med Anthropol Quart 19 402ndash18

Conteh L Kingori P 2010 Per diems in Africa a counter-argument

Trop Med Int Health 15 1553ndash55

Dabalen A Wane W 2008 Informal payments and moonlighting in

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Davy CP Patrickson M 2012 Implementation of evidence-based

healthcare in Papua New Guinea Int J Evid-Based Healthcare 10

361ndash68

de Renzio P 2000 Bigmen and Wantoks social capital and group

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Delcheva E Balabanova D Mckee M 1997 Under-the-counter pay-

ments for health care evidence from Bulgaria Health Policy 42

89ndash100

Doyle SM Kahn JG Hosang N Carroll PR 2010 The impact of male

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health care evidence from Tajikistan Soc Sci Med 58 247ndash58

Ferrinho P Omar M Fernandes M et al 2004a Pilfering for survival

how health workers use access to drugs as a coping strategy Hum

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Ferrinho P van Lerberghe W Fronteira I Hipolitp F Biscaia A 2004b

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Savedoff WD (eds) Diagnosis Corruption Fraud in Latin Americarsquos

Public Hospitals Washington DC Inter-American Development

Bank pp 163ndash98

Goddard M 1996 The snake bone case law custom and justice in a

Papua New Guinea Village Court Oceania 67 50ndash63

8 HEALTH POLICY AND PLANNING

Gonzalez P Macho-Stadler I 2013 A theoretical approach to dual

practice regulations in the health sector J Health Econ 32 66ndash87

Gray RH Kigozi G Serwadda D et al 2007 Male circumcision for HIV

prevention in men in Rakai Uganda a randomised trial Lancet

369 657ndash66

Hill P Tynan A Law G et al 2012 A typology of penile cutting in Papua

New Guinea results of a modified Delphi study among sexual

health specialists AIDS Care 24 77ndash86

Israr SM Razum O Ndiforchu V Martiny P 2000 Coping strategies of

health personnel during economic crisis A case study from

Cameroon Trop Med Int Health 5 288ndash92

Izard J Dugue M 2003 Moving Toward a Sector-wide Approach Papua New

Guinea the Health Sector Development Program Experience Manila

Asian Development Bank

Jan S Bian Y Jumpa M et al 2005 Dual job holding by public sector

health professionals in highly resource-constrained settings prob-

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Jayasuriya R Razee H Bretnall L et al 2011 Voices from the Field Factors

Influencing Rural Health Worker Performance in Papua New Guinea

Sydney Australia The University of New South Wales

Jumpa M Jan S Mills A 2007 The role of regulation in influencing

income-generating activities among public sector doctors in Peru

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Kelly A Kupul M Aeno H et al 2012a More than just a cut a

qualitative study of penile practices and their relationship to

masculinity sexuality and contagion and their implications for

HIV prevention in Papua New Guinea BMC Int Health Hum Rights

12 10

Kelly A Kupul M Fitzgerald L et al 2012b lsquoNow we are in a different

time various bad diseases have comersquo Understanding menrsquos

acceptability of male circumcision for HIV prevention in a

moderate prevalence setting BMC Public Health 12 1ndash13

Kempf W 2002 The politics of incorporation masculinity spatiality and

modernity among the Ngaing of Papua New Guinea Oceania 73

56ndash77

Kigozi G Wawer M Ssettuba A et al 2009 Foreskin surface area and

HIV acquisition in Rakai Uganda (size matters) AIDS 23 2209ndash13

Kiwanuka SN Rutebemberwa E Nalwadda C et al 2011 Interventions

to manage dual practice among health workers Cochrane Database

Syst Rev 7 1ndash22

Lederman R 2009 What Gifts Engender Social Relations and Politics in

Mendi Highland Papua New Guinea Cambridge Cambridge

University Press

Lindelow M Serneels P 2006 The performance of health workers

in Ethiopia results from qualitative research Soc Sci Med 62

2225ndash35

Liu T Sun M 2012 Informal payments in developing countriesrsquo public

health sectors Pacific Econ Rev 17 514ndash24

MacLaren D Tombe R Redman-MacLaren M et al 2011a A research

based classification of penile cutting in PNG a synthesis of

research findings from the ADRA and NHMRC studies Joint

National Policy Forum on Male Circumcision for HIV Prevention in Papua

New Guinea Port Morseby Papua New Guinea Institute of Medical

Research and James Cook University

MacLaren D Tombe R Redman-MacLaren M et al 2011 lsquoStronger or

tougherrsquo reasons for penile cutting in Papua New Guinea

Australasian HIVAIDS Conference Canberra Australasian Society

for HIV Medicine p 75

Macq J Ferrinho P De Brouwere V van Lerberghe W 2001 Managing

health services in developing countries between the ethics of the

civil servant and the need for moonlighting Hum Resour Health

Dev J 5 7ndash24

Manzi F Schellenberg J Hutton G et al 2012 Human resources for

health care delivery in Tanzania a multifaceted problem Hum

Resour Health 10 3

McCoombe SG Short RV 2006 Potential HIV-1 target cells in the

human penis AIDS 20 1491ndash5

McCoy D Bennett S Witter S et al 2008 Salaries and incomes of health

workers in sub-Saharan Africa The Lancet 371 675ndash81

McPake B Asiimwe D Mwesigye F et al 1999 Informal economic

activities of public health workers in Uganda implications for

quality and accessibility of care Soc Sci Med 49 849ndash65

McPake B Asiimwe D Mwesigye F Ofumbi M Streefland P Turinde A

2000 Coping strategies of health workers in Uganda Stud Health

Serv Organ Policy 16 157ndash62

Pask AJ McInnes KJ Webb DR Short R 2008 Topical oestrogen

keratinises the human foreskin and may help prevent HIV

infection PLoS ONE 3 1ndash4

Razee H Whittaker M Jayasuriya R Yap L Brentnall L 2012 Listening

to the rural health workers in Papua New Guineamdashthe social

factors that influence their motivation to work Soc Sci Med 75

828ndash35

Reilly B Phillpot R 2008 lsquoMaking democracy workrsquo in Papua New

Guinea social capital and provincial development in an ethnically

fragmented society Asian Survey 42 906ndash27

Roenen C Ferrinho P Van Dormael M Conceicao MC van

Lerberghe W 1997 How African doctors make ends meet an

exploration Trop Med Int Health 2 127ndash35

Sahlins MD 1963 Poor man rich man big-man chief Political types in

Melenesia and Polynesia Comp Stud Soc His 53 285ndash303

Schwalbach J Abdula M Adam Y Khan Z 2000 Good Samaritan or

exploiter of illness coping strategies of Mozambican health care

providers In Ferrinho P van Lerberghe V (eds) Studies in Health

Services Organisation amp Policy 16 117ndash30

Segall M 2000 From cooperation to competition in national health

systemsmdashand back impact on professional ethics and quality of

care Int J Health Plan Manage 15 61ndash79

Shell-Duncan B 2001 The medicalization of female lsquocircumcisionrsquo

harm reduction or promotion of a dangerous practice Soc Sci Med

52 1013ndash28

Siegfried N Muller M Deeks JJ Volmink J 2009 Male circumcision for

prevention of heterosexual acquisition of HIV in men Cochrane

Database Syst Rev 2 CD003362

Smith DJ 2003 Patronage per diems and the lsquoworkshop mentalityrsquo the

practice of family planning programs in Southeastern Nigeria

World Dev 31(4) 703ndash15

Strathern A 1993 Violence and political change in Papua New Guinea

Bijdragen tot de Taal- Land- en Volkenkunde 149 718ndash36

Strathern A Stewart PJ 2000 Accident agency and liability in New

Guinea Highlands compensation practices Bijdragen tot de Taal-

Land- en Volkenkunde 156 275ndash95

Tediosi F 2008 Access to medicines and out of pocket payments for

primary care evidence from family medicine users in rural

Tajikistan BMC Health Serv Res 8 109

Thomason J 2006 Health reform in Papua New Guinea and the Pacific

PNG Medical Journal 49 69ndash75

Tivinarlik A Wanat CL 2006 Leadership styles of New Ireland high

school administrators Anthropol Educ Quart 37 1ndash20

Trompf GW 1994 Payback The Logic of Retribution in Melanedian Societies

Cambridge

Tynan A Vallely A Kelly A et al 2011 Health workers health facilities

and penile cutting in Papua New Guinea implications for male

circumcision as an HIV prevention strategy PNG Med J 54 109ndash22

COPING MECHANISMS OF PAPUA NEW GUINEA HEALTH WORKERS 9

Tynan A Vallely A Kelly A et al 2012 Vasectomy as a proxy

extrapolating health system lessons to male circumcision as an

HIV prevention strategy in Papua New Guinea BMC Health Serv Res

12 299

Tynan A Vallely A Kelly A et al 2013 Socio-cultural and individual

determinants for motivation of sexual and reproductive health

workers in Papua New Guinea and their implications for male cir-

cumcision as an HIV prevention strategy Hum Resour Health 11 7

van Amstela H van der Geest S 2004 Doctors and retribution the

hospitalisation of compensation claims in the Highlands of Papua

New Guinea Soc Sci Med 59 2087ndash94

van Lerberghe W Conceic C Van Damme W Ferrinho P 2002 When

staff is underpaid dealing with the individual coping strategies of

health personnel Bull World Health Organ 80 581ndash84

Vian T Miller C Themba Z Bukuluki P 2011 Perceptions of per diems

in the health sector evidence and implications Boston University

U4 Anti-Corruption Resource Center 4

Vincent L 2008 lsquoBoys will be boysrsquo traditional Xhosa male circumci-

sion HIV and sexual socialisation in contemporary South Africa

Cult Health Sex 10 431ndash46

WHOUNAIDS 2007 Press Release WHO and UNAIDS announce

Recommendations from Expert Meeting on Male Circumcision for

HIV Prevention 28 March httpwwwwhointhivmediacentre

news68enindexhtml accessed 7 July 2013

Williamson MH 1990 Gender in the cosmos in Kwoma culture Sepik

Heritage Tradition and Change in Papua New Guinea Sydney

Crawford House Press

10 HEALTH POLICY AND PLANNING

Tynan A Vallely A Kelly A et al 2012 Vasectomy as a proxy

extrapolating health system lessons to male circumcision as an

HIV prevention strategy in Papua New Guinea BMC Health Serv Res

12 299

Tynan A Vallely A Kelly A et al 2013 Socio-cultural and individual

determinants for motivation of sexual and reproductive health

workers in Papua New Guinea and their implications for male cir-

cumcision as an HIV prevention strategy Hum Resour Health 11 7

van Amstela H van der Geest S 2004 Doctors and retribution the

hospitalisation of compensation claims in the Highlands of Papua

New Guinea Soc Sci Med 59 2087ndash94

van Lerberghe W Conceic C Van Damme W Ferrinho P 2002 When

staff is underpaid dealing with the individual coping strategies of

health personnel Bull World Health Organ 80 581ndash84

Vian T Miller C Themba Z Bukuluki P 2011 Perceptions of per diems

in the health sector evidence and implications Boston University

U4 Anti-Corruption Resource Center 4

Vincent L 2008 lsquoBoys will be boysrsquo traditional Xhosa male circumci-

sion HIV and sexual socialisation in contemporary South Africa

Cult Health Sex 10 431ndash46

WHOUNAIDS 2007 Press Release WHO and UNAIDS announce

Recommendations from Expert Meeting on Male Circumcision for

HIV Prevention 28 March httpwwwwhointhivmediacentre

news68enindexhtml accessed 7 July 2013

Williamson MH 1990 Gender in the cosmos in Kwoma culture Sepik

Heritage Tradition and Change in Papua New Guinea Sydney

Crawford House Press

10 HEALTH POLICY AND PLANNING