- Email: [email protected]
Decline in child health in rural Papua New Guinea
15 Oleske JM. Preventing disability and providing rehabilitation for infants, children and youths with HIV/AIDS. NIH publication no 95-3850. Bethesda, MD: US Department of Health and Human Services/National Institute of Child Health and Human Development, January, 1995. 16 Ferris F, Flannery J, eds. A comprehensive guide for the care of persons with HIV disease—module 4: palliative care. Toronto: Mount Sinai Hospital/Casey House, 1995. 17 James L, Johnson B. The needs of parent of pediatric oncology patients during the palliative care phase. J Pediatr Oncol Nurs 1997; 14: 83–95. 18 DeTrill M, Kovalcik R. The child with cancer. Influence of culture on truth-telling and patient care. Am NY Acad Sci 1997; 809: 197–210. 19 Tasker M. How can I tell you? Secrecy and disclosure with children when a family member has AIDS. Bethesda, MD: Association for the Care of Children’s Health, 1992. 20 Oleske JM, Ruben-Hale A. Enhancing supportive care and promoting quality of life: clinical practice guidelines. Pediatr AIDS HIV Infect Fetus Adolesc 1995; 6: 187–203. 21 United Nations. Convention on the rights of children. New York: United Nations, 1991. 22 Levetown M. Ethical aspects of pediatric palliative care. J Palliat Care 1996; 12: 35–39. 23 CDC. Guidelines for the use of antiretroviral agents in pediatric HIV infection. MMWR Morb Mortal Wkly Rep 1998; 47 (RR-4): 1–43 [published erratum appears in MMWR Morb Mortal Wkly Rep 1998; 47: 315]. 24 Oleske JM, Rothpletz-Puglia PM, Winter H. Historical perspectives
25 26 27
28
29 30 31 32 33 34 35
on the evolution in understanding the importance of nutritional care in pediatric HIV infection. J Nutr 1996; 126: 2616S–19S. Pellegrino ED. Emerging ethical issues in palliative care. JAMA 1998; 279: 1521–22. Reiter G, Kudler N. HIV and palliative care: part I and II. AIDS Clin Care 1996; 8: 21–34. Grubman S, Gross E, Lerner-Weiss N, et al. Older children and adolescents with perinatally acquired HIV infection. Pediatrics 1995; 95: 657–66. El-Sadr W, Oleske JM, Agins BD, et al. Evaluation and management of early HIV infection. Clinical practice guideline no 7. AHCPR publication no 94-0572. Rockville, MD: Agency for Health Care Policy and Research/Public Health Service/US Department of Health and Human Services, January, 1994. Rothpletz-Puglia PM. Perspectives in practice: case report of children infected with HIV. Topics Clin Nutr 1997; 12: 69–77. Welch K, Kissinger P, Bessinger R, et al. The clinical profile of end stage AIDS. AIDS Patient Care STD 1998; 12: 125–29. Czarniecki L, Boland M, Oleske JM. Pain in children with HIV disease. PAAC Notes 1993; 5: 492–95. Oleske J, Boland M. When a child with a chronic condition needs hospitalization. Hosp Pract 1997; 32: 167–81. Corner J. Is there a research paradigm for palliative care? Palliat Med 1996; 10: 201–08. Billings JA, Block S. Palliative care in undergraduate medical education. JAMA 1997; 278: 733–38. Martinson IM. Pediatric hospice nursing. Ann Rev Nurs Res 1995; 13: 195–214.
Decline in child health in rural Papua New Guinea Trevor Duke From 1960 to 1980 Papua New Guinea made impressive gains in tackling child mortality. The under-5 mortality rate fell by an average of 3% per year from 204 per 1000 livebirths in 1960 to 112 per 1000 livebirths in 1980. Since then no improvement has occurred. By contrast, the mortality rate in this age group in the overall East Asia and Pacific Region has continued to fall by 2·5% per year.1 In 1999, the mortality rate among children younger than 5 years in Papua New Guinea is more than twice that of the overall East Asia and Pacific region (54 per 1000 livebirths). The most optimistic figures for the current infant mortality rate and mortality rate in children under age 5 years puts the national rate at 77 per 1000 livebirths and 100 per 1000 livebirths, respectively,2 which at best represents no progress during the past 10 years. According to UNICEF, only four countries in the world have failed to improve the mortality rate among children under age 5 years since 1980: Burma (Myanmar), Niger, Zambia, and Papua New Guinea.1 In Papua New Guinea, 85% of the population live in rural areas and it is rural children who have fared worst. The Highlands of Papua New Guinea are home to 40% of the nation’s population. In the Eastern Highlands Province—a rural population of 380 000—the infant mortality rate increased from 55 per 1000 livebirths in 1980 to 100 per 1000 livebirths in 1994.3 During the same time, in the National Capital District, the major urban area which surrounds Port Moresby, the infant mortality rate increased from just 35 per 1000 livebirths to 41 per 1000 livebirths.3 Lancet 1999; 354: 1291–94 Department of Paediatrics, Goroka Base Hospital, PO Box 392, Goroka, Eastern Highlands Province, Papua New Guinea (T Duke MD ) (e-mail [email protected])
THE LANCET • Vol 354 • October 9, 1999
I explore the current major preventable causes of child deaths in rural Papua New Guinea—particularly in the Highlands—why there has been a decline in health outcomes, and where the solutions may be.
Mortality burden The major causes of child mortality in Papua New Guinea are pneumonia, malnutrition, measles meningitis, low birthweight, and neonatal sepsis. Malaria is common in coastal regions. Pneumonia causes about 40% of all deaths among children under age 5. Most neonatal deaths are caused by bacterial sepsis combined with low birthweight; 23% of babies have low birthweight.1 Malnutrition, although rarely recorded as a cause of death,4 is widespread in the Highlands. 35% of children in Papua New Guinea have moderate or severe malnutrition.1 In 1998, 62% of children who died in Goroka Hospital had moderate or severe malnutrition. Malnutrition is rarely caused by inadequate availability of food since the land in the Highlands is usually fertile. Contributing factors to childhood malnutrition are poor maternal health, poor knowledge about feeding, the frequency of low birthweight, and the social structure in which adoption practices are common. At Goroka Hospital in 1998, adoption of very young infants by non-lactating women, or infant abandonment, were responsible for 59 (45%) of the 131 children who were admitted with marasmus. Maternal mortality contributes substantially to adoption and subsequent malnutrition. 10% of infants with marasmus were born to mothers who died during childbirth. Less than a third of women in Papua New Guinea give birth in a health facility, or with the help of a skilled health worker. Estimates of the rate of maternal mortality range from 370 per 100 000 livebirths2 to 930 per 100 000 livebirths, which is more
1291
than four times that of the overall East Asia and Pacific region. The panel shows the main child-health issues in the Eastern Highlands Province where avoidable deaths occur at least every week. In a prospective audit of child deaths, we defined avoidable factors as factors that could have been avoided with basic clinical, social, or publichealth interventions. In 180 consecutive deaths in children seen at Goroka Hospital over 13 months (inhospital deaths and children dead on arrival), we identified potentially avoidable factors in 97 children (table). Even if one takes the most optimistic view of child mortality, with 10 000 births, there are 770 infant deaths in the East Highlands Province each year. If the community factors we identified, which occurred in 37% of all hospital deaths, existed in the rest of the deaths throughout the Province, the additional number of deaths with potentially avoidable factors would be 225. As the population of the Eastern Highlands Province is 20% of the entire Highlands, child deaths, which have important avoidable factors, may number about 1000 each year throughout the Highlands. Deaths are caused by a combination of endemic diseases, entrenched adverse social circumstances, and heath-care failures; poverty is not readily irradicable and the degree of avoidability for individual deaths cannot be quantified. Population-based data do not exist. Despite this complexity, it is essential to know where the burden of mortality, which may be amenable to interventions, lies.
Causes of increased child mortality Lost health services During the late 1970s and early 1980s, there were welldeveloped systems of hospitals in larger towns, health centres in rural populations, and aid posts that serviced Key issues in child health in rural Papua New Guinea ●
At least 56% of aid posts are closed; many others are derelict or exist in structure only, with few drugs, and no provision for regular delivery of vaccine.
●
Most childhood deaths occur in villages, and most children never receive medical assistance.
●
Public-health services for mothers and children are sporadic at best, and non-existent in many areas. Most remote rural areas have no doctor and many have no child-health services.
●
Immunisation rates are low, and many children still die of vaccine-preventable diseases.
●
The major causes of death are pneumonia, malnutrition, measles, meningitis, low birthweight, and neonatal infections. Effective vaccines against pneumonia and meningitis cannot be introduced until a working infrastructure for maternal and child health services is re-established.
●
Social practices where children are given away make a substantial contribution to malnutrition and infant mortality.
●
Educational attainment among mothers is low.
●
There is poor organisation of clinical care in rural hospitals and health centres, and avoidable deaths are common.
●
Management, planning skills, and funding at district level are inadequate to rebuild the health service. Provinces must have medical officers who have an understanding of epidemiological data as directors of provincial public health.
●
There is an inequitable distribution of doctors in the country. Training doctors and nurses as specialists in rural child health must be a priority.
1292
Cause of death
Number of children
Community factors Delayed initial presentation (⬎7 days) Vaccine-preventable disease Failure of outpatient treatment, health centre not functioning Absconded from previous hospital because no care provided Adoption leading to extreme malnutrition Child neglect/abandonment
17 12 4 5 10 6
Maternal health No antenatal care Village delivery of high-risk mother No screening for maternal syphilis Prolonged ruptured membranes or labour at home (⬎48 h) Prolonged obstructed labour in hospital (⬎24 h) Incorrect use of vacuum extraction
19 6 9 8 3 2
Hospital factors Nosocomial infection Failure to start antibiotics when indicated Pulmonary aspiration Failure to correct severe anaemia Other failures to carry out standard child management
17 6 2 2 9
In some cases more than one avoidable factor was present, but only factors that occurred in more than one case are presented.
Potentially avoidable factors in 180 consecutive child deaths seen at Goroka Hospital
remote villages. Health extension officers, who were trained to deliver basic rural health services, managed health centres and aid-post orderlies dispensed medicine and health advice at aid posts. Maternal and child health patrols visited remote villages, where they were responsible for antenatal care of mothers, child and maternal immunisation, monitoring of child growth, and preventative health education. By 1982, 93% of the population lived within 2 h walk from a primary healthcare facility.5 Now the public-health system has broken down. By 1997, no district in Eastern Highlands Province had regular maternal and child-health patrols. The reasons given for this change are the unavailability of vehicles for the patrols, no funding to provide fuel for vehicles, the deterioration in the roads, the threat of rascol (criminal) activity, and inadequate assistance and support from local administrators. In 1998, 82 (56%) of 147 the aid posts in the Eastern Highlands Province were officially closed. Retrenchments and unannounced drifting of rural health staff have meant that most other aid posts, although officially open, are unmanned. At health centres there is a constant shortage of essential drugs, including penicillin and antituberculous drugs, and few aid posts have any medicines. More than 50% of the new refrigerators, purchased within the past 5 years for storage of vaccines, do not function. Vaccine coverage is low: in Eastern Highlands Province in 1997, coverage was no greater than 33% for immunising doses of any vaccine. Deaths from vaccinepreventable diseases are common, particularly from measles and its fatal sequelae of subacute sclerosing panencephalitis, and from whooping cough. The tuberculosis-control programme no longer functions. In Eastern Highlands Province, screening for maternal syphilis is only done at Goroka Hospital and two health centres. Throughout the province syphilis kills about 40–50 babies each year, and causes four to five times as many abortions and stillbirths. Underlying causes In the middle of the 1990s, responsibility for public health was devolved from one administrative office in each province, which, for example, served 380 000 people in the Eastern Highlands, to eight district health
THE LANCET • Vol 354 • October 9, 1999
offices that each serve 25 000–60 000 people. These were the health reforms under Organic Law (a constitutional reform that led to massive decentralisation). The theoretical advantage of the reforms was that most of the responsibility for health care would reside with communities, rather than with central government. Unfortunately, little training or supervision occurred with this major shift in health administration. For the health service to function effectively instead of requiring one office in each of the 20 provinces with competent management, planning skills, and a vision for the health of the people, the system now requires 89 district offices throughout the country with these attributes. The district offices responsible for the distribution of funds for health are also responsible for education, roads, bridges, water supplies, and settling land disputes and tribal fights. Where child health sits in this list of priorities depends on the background, skills, and insight of the district administrators. Few administrators have a background in health care, and none in the Eastern Highlands Province have training in public-health administration. Training Health extension officers were once the managerial and clinical foundation on which rural health services were built.6 The clinical training of health extension officers now takes place in an underfunded, dilapidated hospital where the availability of drugs is inadequate, oxygensupply pipes have become blocked with rust, the staff attend work sporadically, and difficulties with law and order frequently disrupt clinical care. This provides lessons in resource deprivation and mediocrity and sensitisation to decay. Academic medicine has failed to respond to this crisis in regional health. In the 1970s and 1980s, medical students from the University of Papua New Guinea came to the Highlands for training in regional child health. Because this training is now deemed too expensive, graduates have had only 10 weeks of rural-health experience during the final year of their training. The National Capital District has more doctors than in the whole of the Highlands, but the population of the National Capital District is only 21% of that of the Highlands. Papua New Guinea has six doctors to every 100 000 people; the National Capital District has five times as many.3 These inequitable ratios have not changed since the 1970s,7 and are justified by some because many doctors at the capital’s hospitals are in specialist training. The argument that the quality of clinical care and supervision in rural hospitals is inadequate for undergraduate medical training is spurious, and only perpetuates these difficulties. To put the position of rural child health into context, western medicine was unknown in the Highlands before 1930. As late as 1960, before the public-health system was established, the infant mortality rate in some rural areas was 500 per 1000 livebirths. In the late 1970s and early 1980s, rural health was strongly supported by expatriates. A process of nationalisation of health services occurred in the middle of the 1980s. Now citizens of Papua New Guinea staff most hospitals. This is an impressive achievement by medical and nursing educators in Port Moresby, but during the 1990s, the nationalisation process has lead to rapid losses of international workers from universities. This removal of
THE LANCET • Vol 354 • October 9, 1999
a universal base of skills, ideas, and experience from universities and hospitals will have long-term detrimental effects, particularly on medical training.
Are there solutions? Community health services The highest priorities must be the re-establishment of community-based health services. Such services will help avoid deaths from vaccine-preventable diseases, delayed presentation, and treatment failure among rural outpatients, which occurs in 18% of all inhospital child deaths. Aid posts must be rebuilt, regular maternal and child-health patrols, and the vaccine cold-chain, must be re-established, so that immunisation, monitoring of child growth, and health promotion can be provided in remote villages. More orderlies for aid posts need to be trained and employed to give standard treatment for common childhood illnesses. Aid posts should have facilities for all maternal and child-health services. For this change to be acceptable to communities, more women need to be trained as orderlies. A screening programme for syphilis should also be established. Failure of basic maternal care was implicated in 14% of all child deaths in our audit of avoidable child mortality (panel). Communities must maintain and take responsibility for aid posts, and orderlies must be accountable to their community and to the district and provincial authorities. In a revision of the health reforms, the National Department of Health should direct the provinces, and the provinces should direct, supervise, and audit the activities of health-care centre staff and aid-post orderlies. Funding for effective and disciplined supervision, which has been absent,8 must not be seen as a waste of health spending. In whatever form the Government health services will be an insufficient solution. Until communities stop seeing health as something provided by the Government and start seeing health as something they desire for their families and a goal to work towards as a whole community, early and preventative health-seeking behaviour are unlikely to improve (factors which are implicated in about 25% of deaths). If deaths from starvation are to be tackled, the practice of infant adoption, which is accountable for 5% of all deaths, must be addressed through education in communities and by legislation, if necessary. Real social change that empowers women to plan families safely, avoid their own early death, and take care of their own children, will come about only with educational and economic development9 in rural areas, together with cultural change in the status of women. Semiformal training of village women in the basics of child health would increase community involvement in health and broaden knowledge of health-care issues among the main stakeholders. Role of aid Between 1992 and 1996, the USAid-funded Child Survival Program (CSP) supported maternal and childhealth services in the Highlands. The CSP paid health workers an unprecedented allowance for providing walking health patrols to remote areas. When the CSP ceased, so did this new allowance, and so too did the walking patrols. Aid will be ineffective unless it results in sustainable improvements in the way health care is
1293
delivered by those who have a mandate to do so.10 The Asian Development Bank now offers large lowinterest loans to Papua New Guinea for specific projects in rural health. When several of these loans close, millions of dollars have not been drawn upon. Under Organic Law, the small districts are now responsible for health projects and service delivery. For Papua New Guinea to spend aid dollars on rural health productively, districts must submit proposals for project funding to the provincial health offices, who in turn seeks funding from the Asian Development Bank, or other donors. Major aid donors have almost no presence in rural communities, and know little about why child health is failing. Rural health workers are poorly funded, understand some of why their health system is failing, but do not have the skills to access funds, or to plan and implement programmes. Before aid-sponsored improvements in child mortality can occur, this skills gap must be bridged. One solution may be for alliances to develop between provincial and district health offices, major financial donors, and non-government organisation. The role of non-governmental organisations would be to teach skills in planning and management to help local people, and assess programmes at a community and district level.
The challenge Derek Summerfield11 has said that it is an aphoristic truth that societies run the moral economy they can, or want to afford. In other words, until it becomes profitable to keep more children alive, there may never be sufficient political volition to adequately fund and sustain effective publichealth systems that will reduce child mortality. This attitude may be the greatest threat to progress in child health in Papua New Guinea. There is much strong evidence that improvements in child health are a cost-effective intervention for a developing country.9 Those who set priorities of health care in Papua New Guinea need to understand that minor reductions in services (just the closure of one aid post, just one misappropriated maternal and child-health vehicle, and just one vaccine refrigerator that breaks down and is not repaired), when repeated frequently over many years have a major cumulative effect on child mortality. All those involved in the administration of health need to be convinced that lowering child mortality is achieveable, and worthy of real effort and commitment. After 15 years of decay, this objective would be a paradigm shift for health care in the country. References 1
Training Clinical undergraduate medical training must have a balance of time to better reflect the geographical distribution of mortality. Training should be in urban and rural hospitals, health centres, and communities. Rural annexes for the medical faculty should be reestablished in regional centres, as they were in the past. The specialty of regional paediatrics in a developing country is of paramount importance. This position should have the broadest definition: the coordinator of acute and public-health child services throughout the entire province, who should train others in how to get treatment to the people who need it. The orientation of obstetric training towards the needs of most rural women who deliver babies in villages without any skilled assistance may have an even greater effect on maternal and neonatal mortality.
1294
2 3 4
5
6 7 8 9 10 11
UNICEF. Statistical tables. In: The state of the world’s children, 1998. New York: Oxford University Press, 1999: 91–127. Department of Health Papua New Guinea. 1996 DHS Survey. Waigani: PNG Department of Health, 1997. Department of Health. Disease patterns. In: PNG National Health Plan. Waigani: PNG Department of Health, 1996: 40–46. Department of Health. Health situation on Papua New Guinea. In: PNG National Health Plan. Waigani: PNG Department of Health, 1996: 5–14. Reilly Q. Papua New Guinea: resistance encountered and overcome. In: Tarimo E, Creese A, eds. Achieving health for all by year 2000: midway report of country experiences. Geneva: WHO, 1990: 213–28. Pataki-Scweizer KJ. Communication in the field: the aid post orderly and the health extension officer. PNG Med J 1983; 26: 178–81. Shann F. Port Moresby or the bush? PNG Med J 1979; 22: 170–76. Alto WA. Primary health care in Melanesia: problems and potentials. PNG Med J 1996; 39: 315–20. The World Bank. World Development Report 1993: investing in health. Oxford: Oxford University Press, 1993: 1–17. Decosas J. Developing health in Africa. Lancet 1999; 353: 143–44. Summerfield D. If children’s lives are precious, which children? Lancet 1998; 351: 1955.
THE LANCET • Vol 354 • October 9, 1999
25 26 27
28
29 30 31 32 33 34 35
on the evolution in understanding the importance of nutritional care in pediatric HIV infection. J Nutr 1996; 126: 2616S–19S. Pellegrino ED. Emerging ethical issues in palliative care. JAMA 1998; 279: 1521–22. Reiter G, Kudler N. HIV and palliative care: part I and II. AIDS Clin Care 1996; 8: 21–34. Grubman S, Gross E, Lerner-Weiss N, et al. Older children and adolescents with perinatally acquired HIV infection. Pediatrics 1995; 95: 657–66. El-Sadr W, Oleske JM, Agins BD, et al. Evaluation and management of early HIV infection. Clinical practice guideline no 7. AHCPR publication no 94-0572. Rockville, MD: Agency for Health Care Policy and Research/Public Health Service/US Department of Health and Human Services, January, 1994. Rothpletz-Puglia PM. Perspectives in practice: case report of children infected with HIV. Topics Clin Nutr 1997; 12: 69–77. Welch K, Kissinger P, Bessinger R, et al. The clinical profile of end stage AIDS. AIDS Patient Care STD 1998; 12: 125–29. Czarniecki L, Boland M, Oleske JM. Pain in children with HIV disease. PAAC Notes 1993; 5: 492–95. Oleske J, Boland M. When a child with a chronic condition needs hospitalization. Hosp Pract 1997; 32: 167–81. Corner J. Is there a research paradigm for palliative care? Palliat Med 1996; 10: 201–08. Billings JA, Block S. Palliative care in undergraduate medical education. JAMA 1997; 278: 733–38. Martinson IM. Pediatric hospice nursing. Ann Rev Nurs Res 1995; 13: 195–214.
Decline in child health in rural Papua New Guinea Trevor Duke From 1960 to 1980 Papua New Guinea made impressive gains in tackling child mortality. The under-5 mortality rate fell by an average of 3% per year from 204 per 1000 livebirths in 1960 to 112 per 1000 livebirths in 1980. Since then no improvement has occurred. By contrast, the mortality rate in this age group in the overall East Asia and Pacific Region has continued to fall by 2·5% per year.1 In 1999, the mortality rate among children younger than 5 years in Papua New Guinea is more than twice that of the overall East Asia and Pacific region (54 per 1000 livebirths). The most optimistic figures for the current infant mortality rate and mortality rate in children under age 5 years puts the national rate at 77 per 1000 livebirths and 100 per 1000 livebirths, respectively,2 which at best represents no progress during the past 10 years. According to UNICEF, only four countries in the world have failed to improve the mortality rate among children under age 5 years since 1980: Burma (Myanmar), Niger, Zambia, and Papua New Guinea.1 In Papua New Guinea, 85% of the population live in rural areas and it is rural children who have fared worst. The Highlands of Papua New Guinea are home to 40% of the nation’s population. In the Eastern Highlands Province—a rural population of 380 000—the infant mortality rate increased from 55 per 1000 livebirths in 1980 to 100 per 1000 livebirths in 1994.3 During the same time, in the National Capital District, the major urban area which surrounds Port Moresby, the infant mortality rate increased from just 35 per 1000 livebirths to 41 per 1000 livebirths.3 Lancet 1999; 354: 1291–94 Department of Paediatrics, Goroka Base Hospital, PO Box 392, Goroka, Eastern Highlands Province, Papua New Guinea (T Duke MD ) (e-mail [email protected])
THE LANCET • Vol 354 • October 9, 1999
I explore the current major preventable causes of child deaths in rural Papua New Guinea—particularly in the Highlands—why there has been a decline in health outcomes, and where the solutions may be.
Mortality burden The major causes of child mortality in Papua New Guinea are pneumonia, malnutrition, measles meningitis, low birthweight, and neonatal sepsis. Malaria is common in coastal regions. Pneumonia causes about 40% of all deaths among children under age 5. Most neonatal deaths are caused by bacterial sepsis combined with low birthweight; 23% of babies have low birthweight.1 Malnutrition, although rarely recorded as a cause of death,4 is widespread in the Highlands. 35% of children in Papua New Guinea have moderate or severe malnutrition.1 In 1998, 62% of children who died in Goroka Hospital had moderate or severe malnutrition. Malnutrition is rarely caused by inadequate availability of food since the land in the Highlands is usually fertile. Contributing factors to childhood malnutrition are poor maternal health, poor knowledge about feeding, the frequency of low birthweight, and the social structure in which adoption practices are common. At Goroka Hospital in 1998, adoption of very young infants by non-lactating women, or infant abandonment, were responsible for 59 (45%) of the 131 children who were admitted with marasmus. Maternal mortality contributes substantially to adoption and subsequent malnutrition. 10% of infants with marasmus were born to mothers who died during childbirth. Less than a third of women in Papua New Guinea give birth in a health facility, or with the help of a skilled health worker. Estimates of the rate of maternal mortality range from 370 per 100 000 livebirths2 to 930 per 100 000 livebirths, which is more
1291
than four times that of the overall East Asia and Pacific region. The panel shows the main child-health issues in the Eastern Highlands Province where avoidable deaths occur at least every week. In a prospective audit of child deaths, we defined avoidable factors as factors that could have been avoided with basic clinical, social, or publichealth interventions. In 180 consecutive deaths in children seen at Goroka Hospital over 13 months (inhospital deaths and children dead on arrival), we identified potentially avoidable factors in 97 children (table). Even if one takes the most optimistic view of child mortality, with 10 000 births, there are 770 infant deaths in the East Highlands Province each year. If the community factors we identified, which occurred in 37% of all hospital deaths, existed in the rest of the deaths throughout the Province, the additional number of deaths with potentially avoidable factors would be 225. As the population of the Eastern Highlands Province is 20% of the entire Highlands, child deaths, which have important avoidable factors, may number about 1000 each year throughout the Highlands. Deaths are caused by a combination of endemic diseases, entrenched adverse social circumstances, and heath-care failures; poverty is not readily irradicable and the degree of avoidability for individual deaths cannot be quantified. Population-based data do not exist. Despite this complexity, it is essential to know where the burden of mortality, which may be amenable to interventions, lies.
Causes of increased child mortality Lost health services During the late 1970s and early 1980s, there were welldeveloped systems of hospitals in larger towns, health centres in rural populations, and aid posts that serviced Key issues in child health in rural Papua New Guinea ●
At least 56% of aid posts are closed; many others are derelict or exist in structure only, with few drugs, and no provision for regular delivery of vaccine.
●
Most childhood deaths occur in villages, and most children never receive medical assistance.
●
Public-health services for mothers and children are sporadic at best, and non-existent in many areas. Most remote rural areas have no doctor and many have no child-health services.
●
Immunisation rates are low, and many children still die of vaccine-preventable diseases.
●
The major causes of death are pneumonia, malnutrition, measles, meningitis, low birthweight, and neonatal infections. Effective vaccines against pneumonia and meningitis cannot be introduced until a working infrastructure for maternal and child health services is re-established.
●
Social practices where children are given away make a substantial contribution to malnutrition and infant mortality.
●
Educational attainment among mothers is low.
●
There is poor organisation of clinical care in rural hospitals and health centres, and avoidable deaths are common.
●
Management, planning skills, and funding at district level are inadequate to rebuild the health service. Provinces must have medical officers who have an understanding of epidemiological data as directors of provincial public health.
●
There is an inequitable distribution of doctors in the country. Training doctors and nurses as specialists in rural child health must be a priority.
1292
Cause of death
Number of children
Community factors Delayed initial presentation (⬎7 days) Vaccine-preventable disease Failure of outpatient treatment, health centre not functioning Absconded from previous hospital because no care provided Adoption leading to extreme malnutrition Child neglect/abandonment
17 12 4 5 10 6
Maternal health No antenatal care Village delivery of high-risk mother No screening for maternal syphilis Prolonged ruptured membranes or labour at home (⬎48 h) Prolonged obstructed labour in hospital (⬎24 h) Incorrect use of vacuum extraction
19 6 9 8 3 2
Hospital factors Nosocomial infection Failure to start antibiotics when indicated Pulmonary aspiration Failure to correct severe anaemia Other failures to carry out standard child management
17 6 2 2 9
In some cases more than one avoidable factor was present, but only factors that occurred in more than one case are presented.
Potentially avoidable factors in 180 consecutive child deaths seen at Goroka Hospital
remote villages. Health extension officers, who were trained to deliver basic rural health services, managed health centres and aid-post orderlies dispensed medicine and health advice at aid posts. Maternal and child health patrols visited remote villages, where they were responsible for antenatal care of mothers, child and maternal immunisation, monitoring of child growth, and preventative health education. By 1982, 93% of the population lived within 2 h walk from a primary healthcare facility.5 Now the public-health system has broken down. By 1997, no district in Eastern Highlands Province had regular maternal and child-health patrols. The reasons given for this change are the unavailability of vehicles for the patrols, no funding to provide fuel for vehicles, the deterioration in the roads, the threat of rascol (criminal) activity, and inadequate assistance and support from local administrators. In 1998, 82 (56%) of 147 the aid posts in the Eastern Highlands Province were officially closed. Retrenchments and unannounced drifting of rural health staff have meant that most other aid posts, although officially open, are unmanned. At health centres there is a constant shortage of essential drugs, including penicillin and antituberculous drugs, and few aid posts have any medicines. More than 50% of the new refrigerators, purchased within the past 5 years for storage of vaccines, do not function. Vaccine coverage is low: in Eastern Highlands Province in 1997, coverage was no greater than 33% for immunising doses of any vaccine. Deaths from vaccinepreventable diseases are common, particularly from measles and its fatal sequelae of subacute sclerosing panencephalitis, and from whooping cough. The tuberculosis-control programme no longer functions. In Eastern Highlands Province, screening for maternal syphilis is only done at Goroka Hospital and two health centres. Throughout the province syphilis kills about 40–50 babies each year, and causes four to five times as many abortions and stillbirths. Underlying causes In the middle of the 1990s, responsibility for public health was devolved from one administrative office in each province, which, for example, served 380 000 people in the Eastern Highlands, to eight district health
THE LANCET • Vol 354 • October 9, 1999
offices that each serve 25 000–60 000 people. These were the health reforms under Organic Law (a constitutional reform that led to massive decentralisation). The theoretical advantage of the reforms was that most of the responsibility for health care would reside with communities, rather than with central government. Unfortunately, little training or supervision occurred with this major shift in health administration. For the health service to function effectively instead of requiring one office in each of the 20 provinces with competent management, planning skills, and a vision for the health of the people, the system now requires 89 district offices throughout the country with these attributes. The district offices responsible for the distribution of funds for health are also responsible for education, roads, bridges, water supplies, and settling land disputes and tribal fights. Where child health sits in this list of priorities depends on the background, skills, and insight of the district administrators. Few administrators have a background in health care, and none in the Eastern Highlands Province have training in public-health administration. Training Health extension officers were once the managerial and clinical foundation on which rural health services were built.6 The clinical training of health extension officers now takes place in an underfunded, dilapidated hospital where the availability of drugs is inadequate, oxygensupply pipes have become blocked with rust, the staff attend work sporadically, and difficulties with law and order frequently disrupt clinical care. This provides lessons in resource deprivation and mediocrity and sensitisation to decay. Academic medicine has failed to respond to this crisis in regional health. In the 1970s and 1980s, medical students from the University of Papua New Guinea came to the Highlands for training in regional child health. Because this training is now deemed too expensive, graduates have had only 10 weeks of rural-health experience during the final year of their training. The National Capital District has more doctors than in the whole of the Highlands, but the population of the National Capital District is only 21% of that of the Highlands. Papua New Guinea has six doctors to every 100 000 people; the National Capital District has five times as many.3 These inequitable ratios have not changed since the 1970s,7 and are justified by some because many doctors at the capital’s hospitals are in specialist training. The argument that the quality of clinical care and supervision in rural hospitals is inadequate for undergraduate medical training is spurious, and only perpetuates these difficulties. To put the position of rural child health into context, western medicine was unknown in the Highlands before 1930. As late as 1960, before the public-health system was established, the infant mortality rate in some rural areas was 500 per 1000 livebirths. In the late 1970s and early 1980s, rural health was strongly supported by expatriates. A process of nationalisation of health services occurred in the middle of the 1980s. Now citizens of Papua New Guinea staff most hospitals. This is an impressive achievement by medical and nursing educators in Port Moresby, but during the 1990s, the nationalisation process has lead to rapid losses of international workers from universities. This removal of
THE LANCET • Vol 354 • October 9, 1999
a universal base of skills, ideas, and experience from universities and hospitals will have long-term detrimental effects, particularly on medical training.
Are there solutions? Community health services The highest priorities must be the re-establishment of community-based health services. Such services will help avoid deaths from vaccine-preventable diseases, delayed presentation, and treatment failure among rural outpatients, which occurs in 18% of all inhospital child deaths. Aid posts must be rebuilt, regular maternal and child-health patrols, and the vaccine cold-chain, must be re-established, so that immunisation, monitoring of child growth, and health promotion can be provided in remote villages. More orderlies for aid posts need to be trained and employed to give standard treatment for common childhood illnesses. Aid posts should have facilities for all maternal and child-health services. For this change to be acceptable to communities, more women need to be trained as orderlies. A screening programme for syphilis should also be established. Failure of basic maternal care was implicated in 14% of all child deaths in our audit of avoidable child mortality (panel). Communities must maintain and take responsibility for aid posts, and orderlies must be accountable to their community and to the district and provincial authorities. In a revision of the health reforms, the National Department of Health should direct the provinces, and the provinces should direct, supervise, and audit the activities of health-care centre staff and aid-post orderlies. Funding for effective and disciplined supervision, which has been absent,8 must not be seen as a waste of health spending. In whatever form the Government health services will be an insufficient solution. Until communities stop seeing health as something provided by the Government and start seeing health as something they desire for their families and a goal to work towards as a whole community, early and preventative health-seeking behaviour are unlikely to improve (factors which are implicated in about 25% of deaths). If deaths from starvation are to be tackled, the practice of infant adoption, which is accountable for 5% of all deaths, must be addressed through education in communities and by legislation, if necessary. Real social change that empowers women to plan families safely, avoid their own early death, and take care of their own children, will come about only with educational and economic development9 in rural areas, together with cultural change in the status of women. Semiformal training of village women in the basics of child health would increase community involvement in health and broaden knowledge of health-care issues among the main stakeholders. Role of aid Between 1992 and 1996, the USAid-funded Child Survival Program (CSP) supported maternal and childhealth services in the Highlands. The CSP paid health workers an unprecedented allowance for providing walking health patrols to remote areas. When the CSP ceased, so did this new allowance, and so too did the walking patrols. Aid will be ineffective unless it results in sustainable improvements in the way health care is
1293
delivered by those who have a mandate to do so.10 The Asian Development Bank now offers large lowinterest loans to Papua New Guinea for specific projects in rural health. When several of these loans close, millions of dollars have not been drawn upon. Under Organic Law, the small districts are now responsible for health projects and service delivery. For Papua New Guinea to spend aid dollars on rural health productively, districts must submit proposals for project funding to the provincial health offices, who in turn seeks funding from the Asian Development Bank, or other donors. Major aid donors have almost no presence in rural communities, and know little about why child health is failing. Rural health workers are poorly funded, understand some of why their health system is failing, but do not have the skills to access funds, or to plan and implement programmes. Before aid-sponsored improvements in child mortality can occur, this skills gap must be bridged. One solution may be for alliances to develop between provincial and district health offices, major financial donors, and non-government organisation. The role of non-governmental organisations would be to teach skills in planning and management to help local people, and assess programmes at a community and district level.
The challenge Derek Summerfield11 has said that it is an aphoristic truth that societies run the moral economy they can, or want to afford. In other words, until it becomes profitable to keep more children alive, there may never be sufficient political volition to adequately fund and sustain effective publichealth systems that will reduce child mortality. This attitude may be the greatest threat to progress in child health in Papua New Guinea. There is much strong evidence that improvements in child health are a cost-effective intervention for a developing country.9 Those who set priorities of health care in Papua New Guinea need to understand that minor reductions in services (just the closure of one aid post, just one misappropriated maternal and child-health vehicle, and just one vaccine refrigerator that breaks down and is not repaired), when repeated frequently over many years have a major cumulative effect on child mortality. All those involved in the administration of health need to be convinced that lowering child mortality is achieveable, and worthy of real effort and commitment. After 15 years of decay, this objective would be a paradigm shift for health care in the country. References 1
Training Clinical undergraduate medical training must have a balance of time to better reflect the geographical distribution of mortality. Training should be in urban and rural hospitals, health centres, and communities. Rural annexes for the medical faculty should be reestablished in regional centres, as they were in the past. The specialty of regional paediatrics in a developing country is of paramount importance. This position should have the broadest definition: the coordinator of acute and public-health child services throughout the entire province, who should train others in how to get treatment to the people who need it. The orientation of obstetric training towards the needs of most rural women who deliver babies in villages without any skilled assistance may have an even greater effect on maternal and neonatal mortality.
1294
2 3 4
5
6 7 8 9 10 11
UNICEF. Statistical tables. In: The state of the world’s children, 1998. New York: Oxford University Press, 1999: 91–127. Department of Health Papua New Guinea. 1996 DHS Survey. Waigani: PNG Department of Health, 1997. Department of Health. Disease patterns. In: PNG National Health Plan. Waigani: PNG Department of Health, 1996: 40–46. Department of Health. Health situation on Papua New Guinea. In: PNG National Health Plan. Waigani: PNG Department of Health, 1996: 5–14. Reilly Q. Papua New Guinea: resistance encountered and overcome. In: Tarimo E, Creese A, eds. Achieving health for all by year 2000: midway report of country experiences. Geneva: WHO, 1990: 213–28. Pataki-Scweizer KJ. Communication in the field: the aid post orderly and the health extension officer. PNG Med J 1983; 26: 178–81. Shann F. Port Moresby or the bush? PNG Med J 1979; 22: 170–76. Alto WA. Primary health care in Melanesia: problems and potentials. PNG Med J 1996; 39: 315–20. The World Bank. World Development Report 1993: investing in health. Oxford: Oxford University Press, 1993: 1–17. Decosas J. Developing health in Africa. Lancet 1999; 353: 143–44. Summerfield D. If children’s lives are precious, which children? Lancet 1998; 351: 1955.
THE LANCET • Vol 354 • October 9, 1999