Comments

Very well said, Ellen, I couldn't agree more. There are certainly supply-side issues to take care of, but demand also needs to be looked at very closely. And, any proposed policy needs to recognise that those demand-side constraints will likely vary considerably, particularly in a country as diverse (culturally, economically, geographically) as PNG.

Hi Camilla, I agree, particularly, the idea of giving PNG women the ‘opportunity to express their views and experiences around childbirth’. There are several processes to follow, including consultations with women and various stakeholders before introducing any legislation. PNG continues to have persistent woeful maternal health outcomes despite huge investments by development partners in the health sector, growth over a decade before the current economic conditions, several major policy and political reforms and changes, and numerous studies on health service delivery. However, there has been limited attention given to significance of user (demand)-side factors that shape health beliefs of users, which ultimately influences health care-seeking behaviours (HSB), health service utilisation and outcomes. Maternal health outcomes and indicators cannot be improved if the focus of improving this area is provider (supply)-driven. The use of legislation to make it mandatory for all women in PNG to deliver babies in formal, modern biomedical health facilities, is like using a whip to force someone against their will. Without addressing barriers at health facility levels (supply-side) and not having an understanding of the constraints faced by mothers in accessing and utilising health services (demand-side), and introducing legislation to influence women to deliver at health facilities is insensitive. It does more harm than good. This is symbolic violence where the State uses legislation to legitimate its power and imposition over other groups and classes. There are deeper socio-cultural, economic, and physical factors to address on both supply-side and demand-side of health services. Any intervention to address maternal health outcomes need to understand these factors for the interventions to be practical and useful. Interventions aimed at improving maternal health service delivery are doomed to fail without considering barriers on the demand-side that prevent health service utilisation.

As far as agriculture, international development and economic coherence I understand and support this tax. I wonder whether through increasing the costs borne by farmers, the backpacker tax could lead to increased costs of fruit - really a detrimental outcome from a dietary perspective?

Thanks, Tony. Yes this is certainly prime territory for an RCT!

Hi Neil, Thanks for your useful notes. I've also read some critiques elsewhere of the JSY initiative, but didn't want to get too bogged down into the details in this post (not least because India and PNG are such vastly different contexts, and I think there can be real dangers in applying a cut-and-paste approach to interventions). Clearly any approach has to be comprehensive and evidence-based, taking these kinds of lessons into account but also being aware of the potential for unintended consequences. Thanks again, Camilla

Hi Camilla, Addressing demand side issues, such as compensating for the cost of travelling to a health clinic, is a good idea. Making it compulsory is a recipe for disaster, although one would need to seriously question any enforcement of the policy. An important question to be answered, which also applies to basic education, is what are the main demand side constraints. As with schooling, issues around cost (fees, travel costs, etc.) is important but not necessarily the main demand side constraint. I would argue, as you also mention, that service quality concerns are probably just as important. The Cuban doctors idea is great, but unless they bring their own water, electricity, drugs, equipment, and support staff then quality is not likely to improve. An RCT is needed to test how quality improvements, incentive payments to women for supervised births, and a combination of both treatments, impact on levels of supervised births and maternal mortality. Of course, this evidence is needed before important policy decisions are made.

Paraphrasing the IEG World Bank re: cash incentives increase facility deliveries but they also increased the fertility rates and without investment in health service strengthening, they did not alter the maternal mortality rates. My notes - not a quote ....Increasing utilisation of services alone does not necessarily lead to better health outcomes within the services. Janani Suraksha Yojana (JSY), a government initiative in India, gave cash to women who delivered in a hospital or health facility. The initiative also gave health workers incentives with a cash transfer for every delivery they attended. This combined effort led to a highly significant increase in both facility births and skilled birth attendance in general. Note JSY found a significant increase in SBA but also finds that while the cash incentives do increase facility deliveries, they also increased fertility rates and had no discernible effects on neonatal or maternal mortality. Note other successful interventions of this type included health system strengthening (e.g Progresa and CSR).

Hi Peter, I think what this shows is the complete lack of leverage the Australian government has in PNG. The Manus agreement under which Australia committed to pay for 50% of the Angau reconstruction also committed the PNG Government to pay for the other 50% and for PNG to meet "ongoing recurrent operational costs" See http://dfat.gov.au/geo/papua-new-guinea/Pages/joint-understanding-between-australia-and-papua-new-guinea-on-further-bilateral-cooperation-on-health-education-and-law-and.aspx Yet not only is Australia proceeding with the reconstruction without any funding from PNG (as Daniel Flitton has reported) but we are proceeding in the face of PNG slashing recurrent funding for Angau. It's not that PNG is cutting back because Australia is picking up the slack (the major investments are still to be made) but rather PNG cutting back and Australia proceeding regardless. Regards Stephen

I am appalled by the fact that there are many PNG women who also support that view “yu no man, yu meri" (even some educated and civilised). I have witnessed alot myself and when I tried to correct them I was ridiculed. In a gender biased society we may think that our own women would stand together and support the worthy cause of breaking the cycle but that is not the case. Also on that note I give credit to a few good men who know a woman's worth and support their leadership. Coming from the Highlands it is even worse. We are silenced and told off in public gatherings that we are women and it is not in our place to stand up and talk. Only when we bring in money and material things then the podium is granted and praises are in order (I am already feeling really disgusted just writing this). It is such a shame there are many women leaders who have the potential to bring about alot of positive changes but are discouraged by the fact that even though they put their hands up to represent the minority the support is never there. In future we would like to see many women in parliament. But how long will it take before we reach that point? I do not know. What I know now is that the mentality still exists and is quite strong.

Thanks Stephen The name "ANGAU" is particularly poignant in the context of Australia/PNG relations, both prior to 1975 and currently. Excuse me while I provide further background, from https://en.wikipedia.org/wiki/ANGAU_General_Hospital. STARTS: ANGAU stands for the Australian New Guinea Administrative Unit, which was an Australian Army unit that was formed on 21 March 1942 during World War II and was responsible for the civil administration of the Territory of Papua and the Mandated Territory of New Guinea. Following Japan's entry in the war, the civil administration of both Papua and the Mandated Territory of New Guinea was taken over by an Australian Army military government and came under the control of ANGAU from February 1942 until the end of World War II CURRENTLY: In September 2013, it was reported that the hospital had deteriorated over the last 20 years and that its buildings had become infested with termites. The renovation of the hospital is a core condition of the asylum-seeker deal between Australia and PNG made on July 19, 2013. ANGAU has only 12 of the 32 specialists it needs, and just 55 per cent of its 729 total staff.[7] In February 2014, the Australian Minister for Foreign Affairs, Julie Bishop, stated: "The Australian Government has committed to redevelop the ANGAU Hospital. The original hospital is now 50 years old. It was built in 1964 and is run down, it has been attacked by termites over time, there is asbestos in the building, so we need to work very hard to lift the standards to something that is world class."[8] Over K300 million has been invested in the redevelopment of Angau, including the master plan and 50 percent of the capital cost of renovation works. It will take two years to plan and design the new Angau hospital, while the major construction work will commence in 2016–17. ENDS So - is the PNG Government cutting back because Australia is picking up the slack ?

Educated and informed voters is an important point John and this is definitely a challenge for PNG. But i think PNG voters are more educated than they were in the previous elections about, not only the inefficiency of the government but also on the electoral processes and the importance of their votes. But we'll have to wait and see whether that will translate to some form of political change alluded to in the article. Bal

Hi Bri, a good observation. Although arguable whether the right to vote was legitimately exercised, people were given the opportunity to vote nevertheless. The concern in the article is not so much that issue, but a likelihood for change in PNG political leadership. Bal