ICT CLUSTER PNG

PNG’s Health and Civil Registry Data and its

Challenges Papua New Guinea

Eli Mada

5/1/2014

This paper seeks to understand the current status of Papua New Guinea’s health and civil registry data, identifies the challenges involved and recommends few points of intervention.

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Table of Contents 1. Context – health and civil registry in PNG ...................................................................................... 2

2. Health information systems, civil registry and development ......................................................... 2

From civil registries to vital statistics to guide policy development ................................................... 3

3. Challenges and limitations .............................................................................................................. 3

Fragmented system ............................................................................................................................ 3

Lack of quality and timely data ........................................................................................................... 4

Inefficient ICT infrastructure and service ........................................................................................... 4

4. What does this mean for the rural populace? ................................................................................ 5

5. Way forward ................................................................................................................................... 6

6. References ...................................................................................................................................... 7

Appendix 1: Number (and %) of selected health facilities and services provided in PNG, 2010 .... 9

Appendix 2: Indicators on ICT infrastructure and access in Papua New Guinea .......................... 10

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1. Context – health and civil registry in PNG Health care in Papua New Guinea (PNG) is provided through a unified system1 of community aid posts2, rural health centres3 and provincial hospitals. A network of over 2,672 aid posts, 14 district and rural hospitals4, 201 health centres and 69 urban clinics are supported by 22 provincial hospitals and one national hospital. Those who provide health care include community health workers, nursing officers, health extension officers and doctors. The provincial health office coordinates health services within the province, while the PNG Department of Health (DoH) provides an advisory role to the provinces. The DoH staff have overall responsibility for maintenance of policy and standards, providing technical advice, coordination of the health information system, health planning and data systems. The DoH monitors the performance of the health system using a computerized national health information system. Health information systems are considered vital for assessing population health needs, managing health service delivery and evaluating program coverage and effectiveness. The computerized health information system was established in PNG in 1989. By 2002 the system was centrally managed and regarded as providing quality data for monitoring and planning, with links across all health system levels. The system uses a well-defined set of performance indicators for monitoring performance of health facility, district, province and nationally. 2. Health information systems, civil registry and development

Importantly, to understand health conditions in a particular country, and/or to tackle specific diseases, requires a good understanding of the country’s demographic profile. Mainly its age and gender structure, age-standardized morbidity and mortality, and the geographic distribution of its population. More so, population data are essential to describe the demographic contexts in which health conditions occur (Ashwell and Barclay 2010). Indications of morbidity and mortality say much about a population’s state of development, and considering the impact of fertility on a population’s age and gender structure, it appears only logical that the provision of reliable and timely demographic data on one hand, and of planning –and-policy-relevant information on the other, are two obvious areas where demography can contribute towards existing health information systems and (health) program monitoring. Setel and colleagues (2007) argue that civil registration has a dual function, both statistical and legal; it also helps with economic development. (CR) has a civil role; but it is also an integral part of a good statistical system, along with censuses and surveys and other administrative records. CR provides legal documentation to protect citizenship, property, and other economic, social and human rights. But it also provides regular, frequent, and timely information on the dynamics of population growth, size, and distribution, and a record of births and deaths by age, sex, and cause of death. These statistics are essential for planning basic social services and infrastructure development, and for understanding and monitoring health issues. Once in place, data from civil registration systems cost less to collect than conducting a census or survey. Also, these data are based on a record of events rather than on an individual’s recollection of those events.

1 See Appendix 1

2 At the village level, aid posts serve a population of between 500 and 3000. As a traditional village community has less

than 500 people, each aid post serves between one and 6 villages. Aid-post health workers provide basic primary health care and provide information on healthy lifestyle practices to prevent illness. 3 A health centre and its staff serve a population of between 2000 and 20,000. Each health centre provides curative and

preventive health services and acts as a referral centre for between 3 and 5 aid posts 4 District health centres and hospitals coordinate health services within the district and act as a referral point for acute

conditions for their sub-district level health centres.

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According to the United Nations, civil registration can be defined as the continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events pertaining to the population as provided through decree or regulation in accordance with the legal requirements of a country. Civil registration is carried out primarily for the purpose of establishing the legal documents provided by the law. These records are also a main source of vital statistics. Indeed, complete coverage, accuracy and timeliness of civil registration are essential for quality vital statistics.

From civil registries to vital statistics to guide policy development

Worldwide civil registration systems have largely stagnated, during the past five decades in terms of their vital statistics potential. Vital statistics derived from civil registration systems are global public goods5, in which governments of developing countries, including PNG, and development partners need for generation of comprehensive and detailed health outcome data (Axline 2008). Undoubtedly, such data are key components of building the evidence base for health improvement. Vital statistics can be used in several ways to guide public health policy and practice. For instance, in 1850s, William Farr6 devised ‘league tables’ of unhealthy cities and compared them with healthy districts to generate increased public debate (Szreter 1991). Another example is drawn from Murray and his colleges (2006), where general vital statistics from small areas are still used to identify mortality differentials within developed countries that have a low mortality. Routine data from civil registration, which showed a substantial increase in deaths from lung cancer in men, led Doll and Hill to identify the causal association between smoking and lung cancer, and subsequently tobacco, as a principle cause of several other diseases of public-health importance (Doll and Peto 1976; Doll and Hill 1999). These examples show how vital statistics derived from civil registration systems have been instrumental in guiding policies and priorities for health development. 3. Challenges and limitations

Fragmented system

There is an unclear allocation of responsibilities for service delivery which creates significant barriers to improving access to services. Health services are provided by the Government and non-state providers, mainly the churches and to lesser degree economic operators and primarily financed by public funds. To date, a high level of fragmentation in the institutional and fiscal relationships between national, provincial and lower levels of government has contributed to the poor health outcomes. Improving of rural health services is perceived as a key to improve health outcomes and attaining the health related MDGs. Mahapatra (2007) insists that the inability to make or sustain improvements in vital statistics at country level is due to two major failures: first, governments have not made civil registration systems a priority, and second, development partners do not yet recognise these systems as key components of development infrastructure. Yet this brings out an even grimmer, vicious cycle. It occurs when lack of CR systems prevent citizens from exercising their basic rights by rendering them

5 Public good in the sense that such information is essential but has no incentive for one country to compile

and publish international vital statistics. The UN Statistics Division is the primary agency responsible at the international level for collecting, compiling, and disseminating official national data for fertility and mortality. WHO is mandated via its constitution to collect, compile and publish relevant vital statistics including causes of death. 6 The first Superintendent of Statistics in Britain’s Office of the Registrar General

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undocumented and thus invisible. Extensive research by the Inter-American Development Bank (IDB) has been aimed at shedding light on this particular situation in Latin American and the Caribbean (LAC). Nonetheless, in PNG, there is a lack of consistency across all levels of the health system. Inaccurate population denominators were being used to calculate health statistics, and this showed discrepancies across all levels (Ashwell and Barclay 2010). Problems of under-and-over reporting, inaccurate calculations, transcription errors and discrepancies in recorded data occur regularly.

Lack of quality and timely data

Measuring progress has been hampered by the lack of quality and timely data; this is especially true when measuring progress toward goals that rely on civil registry for their information, such as Goal 4 on reducing child mortality. Available data in the new edition of World Development Indicators show that of the 144 countries for which data are available, more than 100 countries remain off-track to reach the MDG 4 by 2015, and PNG is no exception. Evidently, correct reporting of cause of death is particularly difficult in developing countries where many deaths occur at home without medical care or certification. One may ask, why has it been so difficult to make credible progress on the health-related, goals? Obviously, it is not solely because of a lack of data; but the quality, that is knowing, what causes death, which is surely a necessary condition to guide policies, priorities, and programs to reduce them. In high income countries, this information is routinely available from death registration records, which are part of the civil registration systems of countries. Around half of the world’s population live in countries where causes of death are only partially recorded and are of limited use, or where deaths are not recorded at all. Agreeably, Mahapatra and colleagues (2007) highly consider the present status of vital statistics derived from civil registration systems, with particular attention to cause-of-death statistics as an important element of vital statistics for public-health policy.

Evidently, a country without a properly established CR system is not going to obtain –as Sulekha Patel correctly argues - comprehensive and timely quality data related to births and causes of deaths. The lack of this kind of data makes it extremely difficult for a country not only to self-report on its Millennium Development Goals (MDG) progress, but importantly, undermines the capacity to design good public policies aimed at improving the welfare of its citizens. In other words, the lack of comprehensive CR systems and data has an impact on the effectiveness of the government. Although DoH monitors the performance of the health system using a computerized national health information system, Ashwell and Barclay’s (2010) evaluation found that the health-centre data failed to provide a complete and accurate assessment of community health status within the national health information system.

Inefficient ICT infrastructure and service

Ideally, most countries have introduced civil registration systems which generate some vital statistics, but their usefulness has been restricted because of many systematic difficulties. Good statistical systems should have the ability to meet the information needs of their users in an efficient, credible and objective manner (Hill, Vapattanawong et al. 2007). In terms of ICT infrastructure and access7, there are 139,000 fixed telephone line subscribers and about 2.7million subscribers for mobile cellular subscription. The issues we face are many in terms of access to ICT, they include, access to electricity, high cost of ICT equipment (eg. laptop, desktop, mobile phone, software programs, etc.), education (acquiring technical knowledge and skills to benefit from ICT), language (not everyone can read and understand English language), external

7 See Appendix 2

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migration of skilled human resource, and lack of government support and role in catalysing ICT development with the private sector. In terms of usage of internet services, and accessibility, statistics from the State of Broadband 2012: Achieving Digital Inclusion for All report (http://www.broadbandcommission.org/Documents) affirms that PNG is one of the lowest ranked countries, with almost 2% of the population of more than 7million, use the internet, and only 2.5% have access to internet in their households. This clearly displays the challenges faced for ICT in PNG. Another compounding factor is the insufficient supply of electricity in the country, with rugged terrains and a challenging topography. In PNG, we have what you call planned outages and unplanned outages. Planned outages is when power is put off when maintenance work is to be carried out; unplanned is when a transformer and some faults are within the grid causes the blackout. Every month we have about 10 planned outages and about an estimated 16 unplanned outages nationwide. This is just one example of how frequent power outage occurs. More so, the challenging geographical terrains of PNG itself, being mostly mountains with coastal lowlands and rolling foothills, where most of its population live in rural areas, where it is difficult and more expensive to access information and communication. 4. What does this mean for the rural populace?

The lack of civil registration mainly affects indigenous and rural populations, those living in poverty, and women. Individuals who have not been enrolled in the civil registry are unable to obtain a legal identification document and are at great risk of facing lifelong exclusion from social, political and economic benefits and rights. The lack of civil registration creates an important barrier to access education, health, social and financial services; one such example is conditional cash transfer programs. The IDB has increasingly focused on supporting the improvement of the CR system in LAC through the strengthening of identity management systems that build on universal civil registration, with a linkage to timely reporting of vital statistics. Ashwell and Barclay’s (2010) research highlighted problems in evaluating community interventions or local service performance, in the case where reliable village-data is absent. As the health information system does not allow reporting of villages separately or tracking of changes in health status over time, the evaluation found that village claims of improved physical health that led to increased use of health services and reduced maternal and child mortality could not be substantiated statistically. In reality, health centre staff may or may not utilize aid-post data to monitor health services and illness trends locally and to assess community level health workers’ performance. If it is not used in this way, aid-post data is superfluous because it is not included in the national health information systems. Since aid-post and health data does not differentiate by village, there is no direct way to measure the impact on physical health in communities that have taken steps to prevent illness occurring. Nor can the other communities needing assistance because of a disease outbreak be identified. Therefore without village-level baseline data the system cannot monitor change among villages or aid posts, evaluate community health activities or review performance (Ashwell and Barclay 2010). In order to improve administrative and institutional capacity we need to focus both on supply of services and demand for services. Improving the reach and presence of CR agencies is also necessary to strengthen the capacity for self-reporting on MDGs. So far more has been done on the demand side, for instance through registration campaigns, with important work still to be done to improve the quality of the CR service on the supply side. However, we are missing information about the real impact of the lack of civil registration and legal identity because we lack the data to properly analyze

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and measure it. Variables that are necessary to shed further light on the problem are the legal, institutional and technological facets of CR systems. Hopefully, developing a database on civil registries (nationally and regionally), there will be relevant data that will be used to answer –quantitatively speaking– many important questions such as: does the legal framework underpinning civil registries influence their effectiveness? What is the impact of institutional capacity on the quality of service delivery? How does ICT of civil registries affect registration rates? Are there clear incentives for obtaining birth certificates? If so, are these incentives coming from public or private sector initiatives?

5. Way forward Despite its impact on development, civil registries are yet to take roots in developing countries. Implementing good CR systems is not easy; it requires political commitment, a supportive legal framework, mobilization of financial and human resources, and, critically, the trust of its citizens. As a result, many countries have opted to adopt interim approaches to measure and monitor vital events and related socio-demographic information. As dependence on these measures grows, national authorities have fewer incentives to invest in complete civil registry systems. Coordinating many players to improve policy coherence and technical cooperation is paramount. This paper further suggests that there be a change in national policy to include aid-post data in health-centre statistics. Also there should be differentiate data by village at aid-post and health centre level – to record village identity next to client diagnosis/service provided. This would allow data to be disaggregated by village and for communities to be compared within the aid post / or health centre catchment area. Capacity building and training is equally important. It is important to train health centre staff to scrutinize aid-post data, monitor health services, illness trends and assess community level health worker performance. ICT is a tool of development, and increased access to information and communication brings knowledge, thus bringing power to the people as well. Although ICT access is improving in PNG, the challenges remain wide. Hopefully, the government will realize the importance of people’s access to ICT, and most importantly the benefits ICT will bring in systems of implementing government programs and policies, in service delivery to the people and in awareness of important issues that need to be disseminated. Once ICT’s benefits are realized together with its disadvantages, it will make it manageable for developing countries to contextualize ICT policies in provision, management and regulation. There is a need to strengthen governance and leadership capacity at national, provincial and district levels. Given the importance of CR to measure and monitor development and welfare outcomes, there is an urgency to implement these systems in developing countries.

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6. References Ashwell, H. and L. Barclay (2010). "Problems measuring community health status at a local level: Papua New Guinea's health information system." Rural & Remote Health 10(4).

Axline, W. A. (2008). Paper Prepared for Presentation at the Workshop Reforming Decentralisation and Sub-National Fiscal Policy in Papua New Guinea. Workshop Location: Port Moresby.

Bakker, M. "Demographic data collection through the rural population register in Papua New Guinea." Broadband Commission for Digital Development (2012). State of Broadband 2012: Achieving Digital Inclusion for All. Retrieved from http://www.broadbandcommission.org/Documents Chandramohan, D., K. Shibuya, et al. (2008). "Should data from demographic surveillance systems be made more widely available to researchers?" PLoS medicine 5(2). Doll, R. and A. Hill (1999). "Smoking and carcinoma of the lung." Bulletin of the World Health Organization 77(1): 84-93.

Doll, R. and R. Peto (1976). "Mortality in relation to smoking: 20 years' observations on male British doctors." British medical journal 2(6051): 1525.

Evans, T. & Stansfield, S. (2014). Health Information in the New Millennium: A Gathering Storm. Retrieved from http://www.scielosp.org/scielo.php?pid=S0042-96862003001200003&script=sci_arttext Hesse, B. and R. Moser (2003). Health Information National Trends Survey (HINTS), 2003. Ann Arbor, MI, Inter-university Consortium for Political and Social Research. Hill, K., A. D. Lopez, et al. (2007). "Interim measures for meeting needs for health sector data: births, deaths, and causes of death." The Lancet 370(9600): 1726-1735. Hill, K., P. Vapattanawong, et al. (2007). "Epidemiologic transition interrupted: a reassessment of mortality trends in Thailand, 1980–2000." International journal of epidemiology 36(2): 374-384.

Iduhu, H. (2010). Country Paper on ICT Industry. UN-ESCAP Expert Group Meeting Bangkok, Papua New Guinea: Department of Communications and Information: 3-12. Kelegai, L. K. and M. R. Middleton (2001). "Conquering the frontier: developing human resources for ICTs in Papua New Guinea." Mahapatra, P., K. Shibuya, et al. "Civil registration systems and vital statistics: successes and missed opportunities." The Lancet 370(9599): 1653-1663. Murray, C. J., S. C. Kulkarni, et al. (2006). "Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States." PLoS Medicine 3(9): e260.

National Department of Health, Papua New Guinea. National Health Service Standards for Papua New Guinea Vol.1. 2011-2020. Government of Papua New Guinea, June 2011 (Draft). National Department of Health, Papua New Guinea. Papua New Guinea National Health Plan 2011-

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2020, Performance Assessment Framework. Government of Papua New Guinea, 2011. National Department of Health, Papua New Guinea. Transforming our Health System towards Health Vision 2050. National Health Plan 2011-2020, Volume 1: Policies and Strategies. Government of Papua New Guinea, June 2010. National Department of Health. Assessment of Sector Performance, 2006-2010: National Report. 2011 Sector Performance Annual Review. Government of Papua New Guinea, 2011. Papua New Guinea: Health Human Resource Review. Meeting human resource constraints and improving health outcomes. World Bank, 2011 (unpublished document) Setel, P. W., S. B. Macfarlane, et al. (2007). "A scandal of invisibility: making everyone count by counting everyone." The Lancet 370(9598): 1569-1577. Siope, V. (2011). "4Telecommunication." The Political Economy of Economic Reform in the Pacific: 63. Szreter, S. (1991). "The GRO and the public health movement in Britain, 1837–1914." Social History of Medicine 4(3): 435-463.

United Nations Statistics Division. (2014). Civil Registration Systems. Retrieved from: http://unstats.un.org/unsd/demographic/sources/civilreg/default.htm

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Appendix 1: Number (and %) of selected health facilities and services provided in PNG, 2010

Government Mission Other* Total (%)

Provincial Hospitals 208(95.2) 2

9(4.8) 22 (0.5)

There is one provincial hospital in each province including Port Moresby General Hospital in the National Capital District which is also the national referral hospital. There is also one specialist psychiatric hospital run by the government. Four provincial hospitals double as regional hospitals. Currently all hospitals are funded by the government. Core clinical services and subspecialty clinical services are provided by respective medical specialists and specialist nurses on-site. In principle, a wide range of clinical support programs as well as public health programs are available in these tertiary hospitals. However, many provincial hospitals are experiencing lack of resources while Port Moresby General Hospital is serving a population larger than its capabilities.

Urban clinics 48 (69.6) 10 (14.5) 11 (15.9) 69 (1.7)

Urban health clinics provide similar services as health centres

District and Rural Hospitals 5 (37.5) 7 (50.5) 2 (14.3) 14 (0.3)

Provide full basic health services including medical, surgical, obstetric, paediatric, trauma and 24-hour emergency care for both inpatients and outpatients. District hospitals cover a population of 40,000 to 300,000 depending on availability and accessibility of other health facilities nearby.

Health centres 149 (74.1) 48 (23.8) 4 (2.1) 201 (4.8)

Rural health centres and sub enters provide services including management of chronic and acute conditions, basic surgical care, deliveries, and paediatric care, and function as intermediary referral points between district lower level facilities and district hospitals. The government more commonly runs the larger health centres, Health centres serve a population of 5,000 to 20,000.

Health sub centres 158 (36.9) 263 (61.5) 7 (1.6) 428 (10.2)

Rural. Deliver the same services as health centres (above). Church groups more commonly run the smaller sub enters.

Aid posts (open) 2008 2,672 (77%) 2,672 (63.9)

Rural aid posts comprise more than 70 percent of all health facilities and deliver basic health care including other and child care, and community-based health promotion. Staffed by community health workers with two years training. Aid posts are designed to cover a population group of about 1,000 people each.

Aid posts (closed) 2008 776 (23%) 776 (18.6)

A significant number have closed due to shortages in funding, staff, and other resources. Where there are no aid posts, village health volunteers, village birth attendants and Marasin Meri (medicine women) provide basic first aid and health education in villages and homes.

Total 3, 828 (95.1) 330 (7.9) 24 (0.6) 4,181 (100)

Government Mission Other* Total (%)

Source: National Health Plan 2011-2020. Vol.2 and Health Human Resource Review of the World Bank, 2007

8 Includes 4 hospitals that also play the role of Regional Hospitals

9 Jiwaka and Vunapope have a designated role as interim provincial Hospitals

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Appendix 2: Indicators on ICT infrastructure and access in Papua New Guinea

Source: Commonwealth Telecommunications Organisation (http://www.cto.int/country-ict-data/)

8 AM radio broadcast stations 19 FM radio broadcast stations 4 Television broadcast stations 5 Internet Service Providers Network of microwave radio, satellite and intra-city optical fibre transmission

systems International links to over 160 countries in the world and domestic services to all

urban centers and major villages

Source: Department of Communication and Information, 2010