How Politics and Geography Hinder Health Service Delivery in Papua New Guinea

Malika Knapp

As one of the world’s most culturally and linguistically diverse nations with a predominantly rural population base, Papua New Guinea (PNG) has unique health service delivery challenges, contributing to its suboptimal health status. PNG has the highest maternal mortality rate in the South-West Pacific region, with 215 deaths per 100,000 live births. The HIV prevalence rate in PNG has increased in recent decades, despite many neighbouring western Pacific nations experiencing a decline. PNG also has the third-highest fertility rate in the Asia-Pacific, with 3.1 births per woman. These deteriorating health outcomes can largely be explained by PNG’s unmet need for sexual and reproductive health (SRH) services, such as contraception, family planning, and access to testing and treatment for HIV.

What is sexual and reproductive health?

According to the United Nations Population Fund (UNFPA), SRH is defined as having the freedom to decide if, when, and how often to have children, as well as access to safe and affordable contraception. SRH service delivery has both direct and indirect benefits, which can improve societies' health, development, and economic outcomes. Access to contraception and family planning is essential to improve maternal and child health, with a demonstrable impact on significantly reducing unintended pregnancies, abortions, maternal deaths, and HIV prevalence.

I recently returned from PNG on a two-week study tour, visiting health clinics and nurses in rural villages. The tour focused on the unique challenges that influence SRH service delivery in the country. These challenges include a decentralised political structure, cultural and linguistic diversity, and mountainous topography.

How does political decentralisation influence sexual and reproductive health service delivery?

Since PNG’s independence in 1975, the country has had a system of political decentralisation, defined as an arrangement where power, funds, and resources are dispersed from the centre (national government) to the periphery (sub-national levels of government). This system of decentralisation also extends to health service delivery, as healthcare is organised in a pyramidal arrangement. Provincial and district hospitals form the top of the pyramid by providing emergency care, and health clinics provide basic surgical care and serve as referral points and aid posts, forming the ‘backbone’ of primary healthcare and providing rudimentary healthcare services. Theoretically, this arrangement of healthcare delivery in PNG is designed to serve the needs of a geographically dispersed and predominantly rural populace better.

Political decentralisation directly impacts the flow of funds and is thus the primary structural mechanism that determines, and most often hinders, SRH service delivery in PNG. Despite increases in the national health budget in recent decades, a 2013 report found that health service delivery, management, and infrastructure have in fact declined, with many health centres experiencing a lack of health staff and a shortage of drugs due to funding shortages.

Further, decentralisation determines the allocation and distribution of funding and resources from the national government to the Provincial Health Authority (PHA), which is responsible for the provision of health services in PNG. A widespread problem at aid posts and health centres in PNG is the inconsistency and infrequency of receiving funding, which directly impacts the SRH services the clinic can provide, such as HIV testing and contraceptives. During visits to the Rai Coast, Gabagaba village, and Pari village, all health clinics expressed that a lack of, or delay in funding, was the primary barrier to delivering SRH services.

Decentralisation partly contributes to poor SRH service delivery as a more dispersed political and economic organisational structure means more room for corruption. This is due to a lack of accountability mechanisms, poor financial management, and limited oversight of the distribution, control, and utilisation of funds. In practice, this means that in many villages, funding simply disappears before it even reaches aid posts and health clinics, and it is almost impossible to trace funds accurately.

How does geography influence sexual and reproductive health service delivery?

Geographic factors, such as topography and distance, directly influence access to SRH facilities and contribute to poor service delivery in PNG. The primary geographic barriers in PNG include mountainous topography, dispersed islands, lack of transport infrastructure, and a largely rural population, with 80% of the population living in rural areas. During a visit to one of the health clinics in the Rai Coast District, an employee working in the community health industry explained the challenges of delivering SRH services, which are intensified by the Rai Coast’s geographic isolation and the dispersion of the population across the mountains, and away from main roads. These geographic barriers result in most rural health clinics frequently experiencing a shortage of medical equipment, including vaccines, and a lack of trained health staff.

PNG’s geographically dispersed and rural population means health facilities are spread thin, reducing the availability and accessibility of SRH services. For example, on the Rai Coast, there are just seven health centres and 34 aid posts, although studies have found that most are non-operational or unreachable due to a lack of infrastructure such as roads and bridges.

How does culture influence sexual and reproductive health service delivery?

Cultural sensitivities and the taboo nature of SRH, coupled with PNG’s high levels of gender inequality, serve as indirect barriers to women accessing SRH services. While visiting a health clinic in Rai Coast, an employee in the community health industry explained that the clinic lacks teenage women using the SRH services they provide. This is not an isolated issue as it is largely due to the stigma surrounding sexual health, which is a major inhibitor for women accessing SRH services across the country.

The social stigma of SRH has resulted in a lack of knowledge and social dialogue about available SRH services, particularly for young unmarried women. In many villages, only married men and women can access family planning services or contraceptives due to the preconceived notion that it would encourage young women to engage in premarital sex. Many studies have shown that most women are not accessing SRH services simply because they are not informed that they are available to them. Aid posts and health clinics in Gabagaba Village and the Rai Coast further reported the lack of young women accessing their contraceptive services.

Thus, PNG’s deteriorating health outcomes are closely linked to the country’s poor SRH service delivery, which is hindered by a complex interplay of political, economic, cultural, and geographic factors.

Malika Knapp is currently studying a double degree in international relations and medical science at the Australian National University. Passionate about the intersection between global health, gender equality and geopolitics, she has volunteered for NGOs and nonprofits in Tanzania, Nepal and Cambodia focused on women’s empowerment and promoting youth political participation. She is a former Girls Run the World embassy program delegate, recipient of a New Colombo Plan Mobility Grant for a political economy study tour in Papua New Guinea and delegate at the 2024 World Health Summit in Berlin. For the last 6 months she undertook an exchange semester at Stockholm University and in the future she aspires to work in the field of global health diplomacy and international development in the Asia Pacific and Africa.