Project Design Document - Joint Integrated Rural Health Patrols
1.0GENERAL INFORMATION
Principal Contact & Position: / Yaman KutluPNG Country Program Manager
Telephone Number(s): / (+61) 2 99760112
Fax Number: / (+61) 2 99766992
E-mail Contact: /
2.0PROJECT DESCRIPTION
2.1Project Brief
Project Name: / Joint Integrated Rural Health PatrolsRegion(s): / New Ireland Province, Papua New Guinea
Sector(s) / Primary Health Care
Implementing Partner(s): / New Ireland Government – Division of Health
Primary Beneficiaries: / 280 Health Workers
Secondary Beneficiaries: / 76 Local Community
Expected Start-up Date: / 1 January 2013
Expected Finish Date: / 31 December 2021
Project Duration: / 8 years
Estimated AUD Value ADI contribution:
2.2Context Analysis
The health sector in PNG faces several problems, including high infant and maternal mortality rates, infectious diseases (including tuberculosis and HIV), and acute shortage of resources such as essential drugs. The challenges associated with poor physical access and infrastructure makes service delivery expensive and out-of-reach to many citizens, especially rural populations.
These problems are compounded by a decentralized and fragmented health care system that has led to a lack of coordination and oversight of responsibilities between national and provincial/district government agencies, hospitals, and health clinics.The Ni District Government areas operate 27 Health Centres whilst the 49 Aid Posts are the responsibility of the Local Level Governments which in total serve 76 distinct communities. In PNG, there is substantial evidence thatprovincial health offices do not undertake supervisory visitsto districts and districts in turn, do not provide support andsupervision to sub-districts.
Less than half of provincial health facilities received aprovincial health officer visit between 2002 and 2007 (BurnetInstitute 2007, Foster et al. 2009). Davy (2007) reported thatsome community health workers had not been visited by adistrict team for years.There is no doctor dedicated to primary health care in New Ireland. In addition, evidence from the PNG Fiscal Commission showed that NI Government Division of Health was not spending its allocation of Health Sector Improvement Funds
This project has been designed based on the following ADI organisational objectives:
Objective 1: Deliver and strengthen primary health care services in rural and remote communities
Objective 3: Increase the capacity of health workers to manage and deliver primary health services through training and education
Objective 4: Improve access to primary health care services by rural and remote communities
Objective 7: Advocate for improvements in the health system in our areas of operation
2.3Description of the Proposed Project
The need for this project was identified during a scoping visit by an ADI team to New Ireland Province in August 2010 at the request of the Governor, Sir Julius Chan. The team toured a number of health facilities throughout the province and had discussions with administrative staff, health facility staff and community leaders in regards to their health needs. A second visit between November 29 and December 10 by Director Chris Lavers and ADI’s Public Health Advisor sought further information to inform the project design
Subsequently the New Ireland Provincial Government (NIPG) signed an MoU in December 2010 and allocated 400,000 kina per year to rural health patrols. NIPG provides a vehicle, accommodation, fuel, transport for patrols and health staff to work alongside the ADI doctor from this budget. Patrols commenced in May 2011, following a trip in April 2011 by ADI General Manager, Delene Evans and ADI President Dr. Peter Macdonald. The project design was informed by meetings with Provincial Program Managers and District Health staff. This proposal is an overview of the continued implementation of this project from the commencement of a new MOU signed in 2013.
2.4Anticipated Target Group(s)/Beneficiaries
Primary Beneficiaries
Increase the clinical capacity of 280 health workers through case based training and group training focusing on how to diagnose and treat.
Secondary Beneficiaries
The Local Level Government areas have 27 Health Centres, and 49 Aid Posts. This equals 76 distinct communities. The project will increase access by rural communities to a wide range of health servicesthrough Integrated Patrols to all 8 LLGs for the first cycle and patrols to 6 out of 8 LLGs in the second cycle as per the Annual Patrol Schedule. This equates to a total of 46 visits to health centers receiving clinical, dental and eye health. It is anticipated that approximately 4000 patients will be treated by the doctor; 5000 people by the dentist and 3000 people by the eye nurse in 2013. This includes visits by dental staff to schools. Community education is undertaken by Provincial staff during health facility visits.
2.5Implementing Partners
Partner / Role / Relationship StatusNew Ireland Provincial Government / Establish health groups and provide Training of Trainers (TOTs) and follow-ups over 9 months. / MOU signed and Project Agreement signed
This project assists in delivering the following related partner objectives:
1Conducting “integrated outreach patrols” in accordance with the “Partnership for Development” between the Governments of Australia and Papua New Guinea, dated 10 June 2009 and one of three Minimum Priority Activities (MPA’s) in health;
2“Primary health care services” and “HIV Aids prevention” identified in the National Medium Term Development Strategy ;
3Provincial Medium Term Development Strategy: ‘To generate direct improvements in the quality of life of the people through the provision of equal and adequate access to quality social services.”
4Achievement of the 2011- 2015 Medium Term Strategic Health Plan for New Ireland which is focussed on ‘back to basics’
5Achievement of NDOH plan as outlined in the National Department of Health Corporate Plan 2009 – 2013:
Health Outcome Priorities / 1. Fully immunise every child under 1 year age
2. Reduce maternal mortality
3. Reduce malaria prevalence
4. Reduce the rate of increase of HIV and AIDS, and STI
5. Reduce the incidence of TB
6. Increase access to health services for the urban poor
Key Result areas / Main categories
1. Healthier communities
2. Improved Support for Service delivery
3. Better Management.
Sub categories
1. Policy & Planning
2. Monitoring and Evaluation
3. Service improvement
4. Enabling Functions
5. Governance
6. Partnership and Advocacy
6Contributing to achievement of parts of provincial and district annual activity plans
3.0PROJECT DESIGN
Integrated Rural Health Patrols are a joint initiative between NIPG Division of Health and ADI which aim to improve the health of New Ireland’s 160,000 people through improved access to a range of clinical and health administrative services.The detail of the project is a result of discussions, negotiations and learning that took place with the following groups and persons:
1Interviews with all personnel in Provincial Health, CEO Kavieng Hospital and staff, Provincial Administrator, the Provincial Implementation Committee, the Governor, Provincial Planner, Catholic Health Service, United Health Service, Radio New Ireland, the village leader of the village next to ADI house, and discussions with various shopkeepers and resort owners.
Notes on these discussions are contained in Trip Reports August 2010, Trip Report November/December 2010 and Trip Report April 2011.
2Presentations to the Senior Executive group of New Ireland Province, the Governor and Provincial Implementation Committee, and senior health staff over the three trips
3Formation and facilitation of 4 meetings of the Rural Integrated Health Patrol team comprising of the Provincial Program Managers for Education, Family Health, Environmental Health, Disease Control and the Health Information Officer and Medical Supplies and Logistics officer, and Kavieng District health manager to specifically address patrol logistics and details. Face to face meetings were also held with individual officers.
4Meetings with the faith-based health service providers, Catholic Health and United Health.
5Several meetings with the administration office of Provincial Heath and Health Sector Improvement Fund representative to cost the patrol program for 2011.
6Discussions with a range of shopkeepers, City Pharmacy and resort owners, and Westpac bank on our presence and program in New Ireland
7ADI volunteer patrol doctors
3.1Theory of Change
Management HypothesisIntervention HypothesisDevelopment Hypothesis
(Implementation Team)(Boundary Partners or (Wider Community or
Primary Beneficiaries) Secondary Beneficiaries)
3.2Millennium Development Goals(MDGs)
This project is targeting three Millennium Development Goals:
- GOAL 4: REDUCE CHILD MORTALITY
-Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
- GOAL 5: IMPROVE MATERNAL HEALTH
-Target 5.A: Reduce by three quarters the maternal mortality ratio
- GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
-Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
3.3Outcomes:
Outcome 1
Support the NI health system provide a wide range of clinical, preventative and promotional health services through integrated rural patrols
Outcome 2
Build the clinical capacity of health workers at health centre level so they can better manage in the absence of a doctor.
3.4Planned Outputs & Activities
Outputs
Output 1.1 Improve access by remote communities to a wide range health services through timely, well organized and widely communicated rural integrated patrols
These operational principles were agreed with NI health staff to guide patrol implementation:
- The sequencing of health patrol visits is based on visiting the most inaccessible, faraway health centres initially and working back to the more accessible health centres;
- Provide as wide a range of health services as possible on patrol – preventative, curative and promotional;
- Provincial team will take the lead on the first round of patrols and thereafter the District health team will take the lead, supported by the Provincial Program Managers;
- Length of a visit to a health centre will be 3 days;
- Doctor stays at the health centre for the entire time doing clinics with case based teaching followed by group clinical teaching. The rest of the patrol team allocates their time between the health centre, associated aid posts and schools;
- Each patrol to be promoted on the health radio to each health centre, Radio New Ireland and Radio East New Britain to encourage villagers to present when the patrol team arrives;
- Patrol reports to be widely disseminated for information and action.
Integrated health patrol teams to the maximum of 12 include:
- The doctor will conduct clinics at the health center. The doctor’s role is to provide curative services and train local health workers in clinical assessment and treatment using case based teaching and group teaching in subjects they request.
- Two dentists/dental therapists
- An eye nurse will do a clinic at the health centre. Eye conditions were the fourth most common condition treated by the ADI doctor in 2011. This has been piloted in the first patrol for 2012 and it was found the eye services are an essential component of the program.
- The District health manager, program managers from provincial/district health who undertake supervision eg LLG Managers, and health promotion in communities and dental staff who do school health checks as well.
- A TB coordinator will join the patrols to address the escalating crisis in TB where possible. TB was the third most common condition treated by ADI doctors in 2011.
- PAP smear/STI’s clinician
- Physiotherapist
- 2 drivers/boatman
The patrols rotate between Namatanai and Kavieng Districts to ensure equity and much needed respite for district health teams after a long patrol.
Output 1.2 Support and assist staff in the implementation of national, provincial and district health plans by advocacy to health centres by LLG, District and Provincial health staff, and increasing the supervisory visit rate
To increase the health knowledge of communities so they can take care of their health. Health promotion and environmental education will be undertaken by Provincial and District health staff. During each patrol ADI wilLundertake an audit on each health center in terms of staffing, infrastructure, understanding and application of NDOH objectives, and management of the facility to assist in future infrastructure and health planning. The patrols will assist Provincial and District health staff to undertake their annual activity plans in remote locations, and provide strengthening to Health Management services through facilitating program supervision by LLG, district and provincial health staff aimed at strengthening the management and administrative systems that support health workers.
Output 2.1 Build the clinical capacity of health workers through case based training and small group training on site and on subjects nominated in a staff learning needs survey and on request
Clinical capacity building of health staff has been identified as a key output for this proposal. Health workers need to manage in the absence of doctors. Clinical capacity building will be based on the following activities:
- Clinical case based training during patient consultations
- Clinical training to all the staff on subjects they request.
- Training on the use of diagnostic medical equipment as part of clinical assessment
Thus during Integrated Rural Health Patrols, the ADI doctor’s role is:
- See patients with serious illnesses or difficult diagnosis that the health workers have screened, and recommend appropriate advice and treatment;
- Provide on-site clinical training of staff so they can improve the quality of health services delivered to their communities through two key approaches:Case based training focused on history taking, examination, discussion of diagnoses, investigations and treatment; and group training on common topics requested by staff;
- Provide clinical and administrative assistance to government health staff when requested;
- Collect information about each health centre that will assist NIPG in health planning including staffing, training needs and infrastructure improvements;
Specific training needs to be addressed on patrol have been drawn from the National health goals and a training needs survey completed in 2011:
- Clinical assessment and diagnosis;
- Safe Motherhood;
- Maternal Health (detection and management of high risk pregnancy);
- Immunization and child health should be included as part of the latter two areas;
- Information related to HIV/AIDs/STIs, particularly information and skills related to counselling
- Neonatal resuscitation
- Malaria protocol
- Emergency obstetrics
- Pneumonia and respiratory conditions.
- TB – diagnosis and treatment.
From the training needs analysis, active learning style is preferred by NI health staff. This includes
•Hands on / practical – eg using equipment, case studies, scenarios
•Interactive – role play; group work
•Handouts – booklets, wheels, notes, Powerpoint slides
•Simple PowerPoint – minimal words, lots of pictures, type size min 20 point.
•Before and after quizzes
PDD – Integrated Patrol Project
3.5Project Log-Frame
New Ireland Joint Integrated Rural Health Patrols Logframe
Objective / Indicators / Means of Verification / AssumptionsHealthier remote communities in New Ireland /
- Positive changes in the health centres visited by ADI patrols in New Ireland
Supervisory checklist
ADI reports / Provincial government commitment to maintaining integrated health patrol model, including funding
Outcome 1
Support the NI health system provide a wide range of clinical, preventative and environmental health services through integrated rural patrols /
- Integrated rural patrol system established and maintained by NI provincial health department
- Increase in number of rural communities receiving health services
- Following capacity-building for NI provincial health staff there is improved commitment and coordination of support to rural health centres
NI provincial government policy and budget
Feedback from rural health centres and community leaders / Availability and commitment of different government sectors at different levels to support of and participation in integrated patrol model
Outputs
1.1 Improve access by remote communities to a wide range health services through timely, well organized and widely communicated rural integrated patrols /
- Each NI health centre receives annual or bi annual visits by an integrated patrol team
- Integrated patrol teams provide medical, disease control, dental, optical and community/environmental health information and services
- A dedicated New Ireland person provides logistics and communications of integrated patrols
Appointment of Integrated Patrol Coordinator
People and expertise on each patrol
Community Feedback / Continued collaboration and commitment from provincial and district personnel
1.2 Support and assist staff in the implementation of national, provincial and district health plans by advocacy to health centres by LLG, District and Provincial health staff, and increasing the supervisory visit rate /
- Each integrated health patrol includes representatives from District and Provincial health staff
- Key areas in national, provincial and district health plans are demonstrably included in integrated health patrol activities
- Annual schedule for integrated patrols to each NI health centre are produced and included in provincial budget after the project concludes
Feedback from provincial health personnel
NI provincial government policy and budget / Continued collaboration and commitment from provincial and district personnel
Outcome 2
Build the clinical capacity of health workers at health centre level so they can better manage in the absence of a doctor. /
- Health workers demonstrate improved knowledge and clinical capacity in the areas of Safe Motherhood, Maternal health and Clinical Assessment and Diagnosis, and other expressed needs
Patrol Reports
Surveys with health staff / Low turnover rate of health centres staff during project implementation
Motivation of health workers remains positive
2.1 Build the clinical capacity of health workers through case based training and small group training on site and on subjects nominated in a staff learning needs survey and on request /
- Health workers clinical assessment skills improved through training on the use and care of donated diagnostic equipment
- By the conclusion of the project 80% of targeted health workers receive a minimum of 80 hours of case based training and 20 hours of group teaching from ADI supported doctors in the areas of Safe Motherhood, Maternal health and Clinical Assessment and Diagnosis, TB, Malaria, and respiratory.