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Public/Private Partnership Improves Healthcare Outcomes in Papua New Guinea

Topics: Safety/health

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Papua New Guinea (PNG) ranks 157th out of 187 countries on the United Nations (UN) Human Development Index, with extremely high under-5 mortality (5.4% of children will die before the age of 5). In 2013, ExxonMobil PNG (EMPNG) facilitated a public/private partnership (PPP) to improve healthcare education at the University of Papua New Guinea (UPNG) and clinical management in child health at Port Moresby General Hospital and other PNG facilities, as well as strengthen public health capacity. The complete paper reviews the aspects and results of this program.

Introduction

PNG is one of the more diverse countries in the world, geographically, biologically, linguistically, and culturally. Communicable diseases are a recognized problem in PNG, with pneumonia, diarrhea, tuberculosis (TB), malaria, newborn infections, and other communicable diseases being responsible for 62% of deaths nationwide. Malnutrition remains a significant contributor to morbidity, mortality, and national economic loss. PNG has the fourth highest rate of stunting in the world because of chronic malnutrition—48% of children experience this deficiency. Malnutrition also contributes to nearly 30% of hospital deaths of children.

In recent years, TB, including drug-resistant TB, has emerged as a public health crisis in PNG. With 432 cases per 100,000 population annually, PNG has the sixth highest incidence rate of TB cases worldwide. Twenty-six percent of these TB cases occur in children, which represents the highest such percentage in the world.

An adequate number of well-trained healthcare workers is essential to address these issues as well as other health priorities in PNG. The country suffers from a severe shortage of doctors, with 0.05 physicians per 1,000 population. By comparison, neighboring Australia has 3.52 doctors per 1,000 population. Additionally, while the national government is recommending at least 300 new doctors to be trained per year, only one medical school, The University of Papua New Guinea School of Medicine and Health Sciences (UPNG-SMHS) exists; it produces approximately 50 doctors per year.

To build healthcare capacity, a needs assessment was conducted. Historically short-term expatriate secondments of faculty to UPNG were 1–3 months and, while beneficial, were unable to provide consistent teaching rotations. Barriers to long-term secondments to UPNG included locating suitable candidates, logistical and safety issues, isolationism, and an extremely high cost of living for expatriates in Port Moresby.

Port Moresby General Hospital (PMGH) is a 1,000-bed hospital in the capital, and the nation’s only tertiary and referral hospital. It is also adjacent to UPNG-SMHS and serves as the primary teaching hospital for medical students, nurses, and other health professionals. While all departments at PMGH are busy, the pediatrics department admits nearly 4,000 children yearly; internal reports document a 9–10% mortality.

Methodology

The Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) and Texas Children’s Hospital (TCH), the PNG government, and EMPNG undertook a comprehensive needs assessment to identify gaps in child health and public health. This would serve as the basis of a multiyear public/private partnership among UPNG-SMHS, the PNG National Department of Health, and BIPAI-TCH through funding from EMPNG. Key findings from the assessment included critical needs in training and education at UPNG-SMHS, the development of public health and child health capacity, and improved care of children at PMGH, with a focus on malnutrition and TB.

A monitoring and evaluation program was implemented to capture key indicators in both public and child health. These indicators included education information, such as the number of lectures developed, the courses and workshops taught, and government programs supported. Contributions and technical assistance to key government health priorities were included, such as guideline development, research projects mentored and supported, and national training in child health and public health. Clinical indicators at PMGH for work in malnutrition and TB were also captured.

Results

Education and Research. Over the 5-year PPP, significant capacity in both public- and child-health education was achieved. Annually, at least 200 students received lectures in both public and child health, including undergraduate medical students, postgraduate medical students, nurses, and other health-sciences disciplines such as pharmacy. In addition to one-on-one mentoring, routine research training was supplied to the Departments of Orthopedics and Pathology. Additionally, a master’s degree in public health program was established at UPNG-SMHS.

Malnutrition. The PPP contributed to updating national guidelines for child malnutrition with both the PNG government and local partners. Subsequently, 53 national staff throughout the country were trained in the management of severe malnutrition. Training and implementation support was also provided to three rural health facilities. With a fully embedded pediatrician at PMGH, malnutrition guidelines were introduced rapidly. At the PMGH malnutrition and TB ward, an overall increased trend in diagnosing malnutrition was documented, as was a decreased trend in mortality (Fig. 1). Weight gain improved from the start of the program from 1.4 g/kg/day [poor, per World Health Organization (WHO) guidelines] to 6.1 g/kg/day (moderate).

Fig. 1—Mortality in the malnutrition and TB ward at PMGH.

 

TB and Human Immunodeficiency Virus (HIV). The PPP worked closely with government and key stakeholders to improve care and treatment for children with TB. This included participating in national technical working groups and contributing to and updating national treatment guidelines for TB and drug-resistant TB. The program also ­engaged stakeholders to create and deliver the country’s first child-TB training workshop. This workshop updated and trained 70 healthcare workers. Additionally, the BIPAI-TCH Global TB Program assisted the PNG government in developing, writing, and implementing a project plan to disseminate a newly formulated child-TB medication. The medication is endorsed by the WHO and is easier to administer to children than past medications. PNG was the fourth country worldwide to make the medication available.

To improve HIV testing, bedside mentoring and awareness was practiced continually, resulting in an overall increase in HIV testing in children with malnutrition. In total, 1,635 of 2,192 (75%) malnourished children were tested for HIV. Of those tested, 209 of 1,635 (12.7%) were found to be HIV-positive, highlighting the impact of HIV on malnourished children.

Grant Assistance. The PPP was able to provide technical assistance and grant writing on behalf of UPNG-SMHS, with funds provided to PNG institutions directly. The program helped secure outside funding of more than $1 million for TB, $23,000 for research, and the donation of new and used medical equipment.

Discussion

Shortage of faculty in PNG affects every aspect of care and training at PMGH and UPNG-SMHS. This issue is not unique to PNG, and many medical schools in resource-limited settings are plagued by surges in the student/teacher ratio; face challenges in the volume and quality of research; and can support only limited efforts to improve patient care. Partnering with government and key stakeholders to identify priority areas to build capacity is essential.

PPPs such as the featured program provide long-term benefits to the country because the staff who are trained will then be able to train others to continue the work and potentially expand such services to other areas in PNG. This is achieved by seconding faculty into government institutions (UPNG-SMHS, PMGH), after which the PPP provides critical capacity to fulfill government priorities. In the previously described example involving malnutrition, the National Department of Nutrition was directly supported in developing, writing, and implementing national malnutrition guidelines. At the local level for malnutrition at UPNG-SMHS and PMGH, medical staff were trained on proper care and treatment of malnourished children. The same was achieved in the area of child TB. The 70 staff trained in child TB are now leading and disseminating best practices throughout the country. PPPs are important to local healthcare capacity, improving the health of the community and ultimately the services available to the project work force and their families.

While disease-specific programs exist that are frequently, and appropriately, supported by donors in PNG, no programs exist that support government institutions such as the medical school and hospital directly with full-time faculty. Ultimately, it will be the nation’s medical school that trains doctors, nurses, and other healthcare workers who serve the population and build national capacity. By supporting the nation’s only medical school, capacity is built at the ground level.

Through long-term faculty attachments to UPNG, the ability to increase the number of residents who may be retained as the next generation of faculty can ensure sustainable growth and capacity. Improved clinical care may be achieved through PPPs by increasing faculty, developing clinical mentoring, and developing and implementing guidelines.

This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper SPE 199373, “A Public/Private Partnership To Improve Healthcare Outcomes in Papua New Guinea,” by Henry Welch, Texas Children’s Hospital, Nirven Kumar, ExxonMobil, and Michael Mizwa, Texas Children’s Hospital, et al., prepared for the 2020 SPE International Conference and Exhibition on Health, Safety, Environment, and Sustainability, originally scheduled to be held in Bogota, Colombia, 28–30 July. The paper has not been peer reviewed. (As of August 1 this paper is not available on OnePetro.org).

 

Public/Private Partnership Improves Healthcare Outcomes in Papua New Guinea

01 August 2020

Volume: 72 | Issue: 8

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