Despite the sound history of health policy and planning, it has not passed the implementation test. The Department of Health has no control over most of the planning, budgetary and staffing decisions that affect the implementation of national health policies. The Department has made commendable progress to deliver on its obligations under the organic law, and overcome the inherent dysfunction caused by it. A number of important building blocks are in place to facilitate the implementation and monitoring of key health policies within the OLPGLLG. These include:
A National Health Administration Act, which provides a framework for the planning and coordination of provincial health services and the roles and responsibilities of the various levels of government in health;
A National Health Plan which clearly outlines health policy for the next ten years;
Minimum standards for district health services, which articulate the health service requirements for districts;
Partnership agreements which set out the basis of national-provincial funding and performance;
A performance-monitoring framework, which is the basis for monitoring health system performance; and
A Functional Expediture Review of Health Services and Policy Options for Reform.
The National Health Administration Act, passed in late 1997, establishes a framework for health planning and coordination between the Department of Health and provincial and district authorities. The act provides a rational basis for balancing the practical reality of provincial control, with the organic law vision for national policy setting and technical supervision by national line departments. Despite the clarity of the National Health Administration Act, there remains a significant blurring of roles and accountability in its implementation.
The National Health Plan 2001–10 provides the policy basis for the sector. The plan is sound, but its ultimate successful implementation remains in question. The quality of the National Health Plan as a policy framework notwithstanding, the decentralized service delivery and funding structure mandated by the OLPGLLG, coupled with unreliable government transfers, poses a significant challenge to the successful delivery of health services.
A further problem is the disjunction between the sectoral planning systems and the multi-sectoral district-based planning system, which forms the basis for budgeting at both the local and provincial levels. Integrating health planning into these systems represents a major challenge for health staff, particularly because the system of planning at district level is intertwined with political processes. While this will have the benefit of ensuring that plans meet local needs, there is a real capacity deficit at district level in many provinces in terms of planning, management and utilization of information.
Minimum standards for district health services. Under the law, provincial and local-level governments are supposed to ensure that quality health services are planned, resourced, delivered and sustained. In order to form a basis for defining what this means in practice, the Department of Health has developed minimum standards for district health services. These form the basis for service planning, implementation, and evaluation at provincial and district health service levels. The key issues which remain to be tested in relation to the standards are whether, in an aggregate sense, the minimum standards are affordable. A second issue is whether the provisions of the law, in reality, provide an effective basis for the Department of Health to enforce the standards. A third issue is who will enforce the standards, and how will they do so.
Partnership Agreements have been developed between the department and each province. These agreements set out the respective commitments of both parties. The most important requirements for continued participation by provincial government will be a commitment to implement the National Health Plan in the province, and the maintenance of agreed levels of funding by the provincial government for health services and activities. The agreements also define target performance levels for each province.
In 2001, however, not one province allocated the targeted 15 per cent of its discretionary budget to health, and seventeen provinces allocated less than 10 per cent of their discretionary funds to health (Provincial Health Finance Review 2001). This has called into question the value of the partnership agreements as a means of leveraging provincial governments to carry out their assigned obligations. Poor health service delivery in one province can impact negatively on other provinces and the nation. Papua New Guinea needs a healthy population and it is not the prerogative of one province to determine not to support a fundamental building block for economic development — a healthy productive population.
A Performance Monitoring Framework was designed to operationalize a national system of performance monitoring that can be used as part of the partnership agreements to define agreed levels of performance for provinces.
The 2001 Functional and Expenditure Review of the health sector highlighted the incapacity of staff with sufficient skills to manage complex health functions independently at 89 different district locations around the country, as envisaged by the OLPGLLG. The review also noted key issues with the intergovernmental financing arrangements under the OLPGLLG: the funding formulae based on population and area, rather than the actual cost of delivering transferred functions; the lack of ability to address inter-provincial inequity; and the multiple sources of funding for health. The overwhelming conclusion of the review was that the new structure has not worked in the health sector (PSRMU 2001).