TM 5541: Managing Effective Health Programmes

Assignment One: Population Profile

Samantha Leggett: SN 12494652

26/8/2011

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Managing Effective Health Programmes TM5541

Assignment One: Population Profiling

A: Introduction

Population to be profiled: Those who might access a ‘one stop’ treatment and referral

centre for survivors of intimate partner, family and sexual violence in Papua New

Guinea’s National Capital District. The term ‘Intimate Partner Violence’ (IPV) will be

used throughout this report for ease of communication.

Port Moresby is the capital city of Papua New Guinea (PNG); the city and its surrounds

comprise the nation’s National Capital District (NCD). Port Moresby is a small but

sprawling city comprising both formal housing suburbs and informal settlement1 areas

both within the city and on its outskirts; census data from 2000 reveals some 55

informal settlements. NCD covers an area of approximately 240 square kilometres

(AusAID 2008). A series of more in-depth maps can be found in Appendix A.

The people of Papua New Guinea can be divided as coming from one of three major

geographic regions: the Highlands which encompass the interior mountainous region of

the country; the coastal areas of the main island; and the outlying islands. Over 800

languages are spoken in PNG. It is suggested that this is a reflection of the historical

isolation of individual communities and thus their cultural heterogeneity (Chand and

Yala, 2006).The population of NCD encompasses peoples from each region of PNG

and kinship groups tend to dominate certain settlements.

1 In PNG an informal settlement exists when the residents have no formal land tenure (Asian Development Bank (2002). Priorities of

the poor in Papua New Guinea. Retrieved August 14, 2011.

http://www.adb.org/Documents/Reports/Priorities_Poor/PNG/default.asp

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B: Demographic Characteristics

The 2010 census has not yet been carried out due to logistical issues but was planned

for July of this year (NSO, 2011). There is also a lack of any disaggregated data to city

or community level (NRI, 2010; Storey, 2010) and no labour force survey exists (World

Bank, 2004). Many of the existing policies, strategies and reports etc about PNG are full

of inconsistent demographic, socioeconomic and other data for which the source is

often unknown. This gives rise to concern regarding the validity and reliability of the

data, in addition to its relevance to the contemporary PNG context (Storey, 2010). Little

is therefore also known regarding livelihoods, forms of vulnerability and levels of

poverty. ‘Best-guesstimates’ may therefore be the only demographic information

provided.

The population of Papua New Guinea is currently estimated to be around 6.5 million

(WHO, 2010) and NCD is home to approximately 600,000 people and is growing rapidly

largely due to high levels of rural to urban migration (Amnesty, 2006; Oxfam, 2010).

Based on the 2000 census data and internal migration statistics provided by the Asian

Development Bank (ADB, 2006) the population of NCD looks set to swell by around a

further 33,000 people over the next five years. Storey (2010) argues that annual urban

growth rates in PNG are reaching 4.5%. AusAID (2008) demonstrate that from 1980 to

2000 the settlement population of NCD grew by 7.8%, around twice that of the overall

NCD growth rate, with the outer settlements seeing the most dramatic population

increase (Chand and Yala, 2006). Chand and Yala (2006) predict that the settlement

population in NCD will double every nine years.

In recent years urban migration has increased upon numbers previously seen with the

advent of high profile projects such as PNG LNG2 leading some to believe that better

employment opportunities are to be found in the nation’s capital. In reality, rural

2 The Papua New Guinea Liquefied Natural Gas (PNG LNG) Project is a multi-billion dollar development that will see gas production, processing and storage facilities installed in the Southern Highlands, Western and Gulf Provinces. The initial phase investment is estimated at US$15 billion and the LNG will provide a long-term power supply to China, Taiwan and Japan. Retrieved October 4, 2010. http://www.pnglng.com/project/index.htm

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migrants (mostly young adult males) join an expanding class of urban poor who engage

in casual work or who are unemployed and who have no option but to make their homes

in the growing settlements (AusAID, 2008; Macintyre, 2008).

In addition to the growth in the urban poor (Oxfam, 2010), there is a growing degree of

socioeconomic diversity among NCD residents. An emerging middle class of Papua

New Guineans, some financially rich due to natural resource projects on their traditional

lands elsewhere in the country, (pers. comm. E. Johnson, World Bank) join a growing

number of expatriates employed on such projects, and PNG nationals who work in the

public and private sectors in NCD. The unemployment rate for the whole of PNG is

estimated at 2.9% (CIA, 2011) but again, disaggregated data is not available.

C: Epidemiological characteristics

The epidemiological characteristics discussed will be specific to intimate partner

violence.

A recent study by Garcia-Moreno et al. (2005) across seventeen low, middle and high

income countries on the incidence of all forms of Intimate Partner Violence (IPV) found

that between 17-71% of women had experienced one or more kinds of abuse in their

lifetime. Not only is the prevalence of IPV in PNG some of the highest in the world (50-

70% of women experience one or more forms of abuse in most areas of PNG and 100%

of women in some Highland regions report IPV; Lewis et al., 2008), it also takes some

of the most extreme forms, particularly in a time of peace (MSF, 2009; Amnesty, 2006;

Toft, 1985; Oxfam 2010).

A study on trauma at Port Moresby General Hospital (PoMGH) found that 90% of

casualty attendances were attributed to ‘domestic violence’ and in another urban PNG

hospital 49% of ‘domestic violence’ related injuries were fractures; 25% of these are

estimated to result in permanent disability (Watters & Dyke, 1996). The mechanism of

women’s injuries seen at health centres around PNG was researched by Amnesty

(2006) and it was found that IPV including kicking, punching, verbal abuse, burning and

cutting accounted for 80-90% of the injuries seen. Lewis et al. (2008) suggest that the

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incidence and severity of IPV in Papua New Guinea is under reported in all areas due to

a number of variables (e.g. poor data collection, lack of willingness/prevented from

seeking help). Women seeking services and therefore being included in the data are

likely to be a very small proportion of those actually experiencing IPV.

The most recent data regarding family and sexual violence is provided by MSF (2011),

who run two centres that treat and support survivors of intimate partner and family and

sexual violence outside of NCD. One of these centres is in Lae, PNG’s second largest

urban locale. The data provided is shocking: of the population treated 6% were under 5

years of age, 17% 5-12 and 26% 13-17 years. MSF (2011) also stress that both the

adults and children they treat are just the tip of the iceberg.

There are a broad range of factors to suggest that the incidence and severity of IPV as

experienced by women in NCD is grave: Toft (1985) argues that the incidence of IPV is

slightly lower in urban populations but that the frequency and severity is somewhat

greater. It must be noted that this research is now 25 years old and much has changed

since it was conducted. Although studies in other parts of the world suggest that IPV is

more prevalent in rural areas (Vakili et al., 2010) Ganster-Breidler’s (2009) multi centre

study in PNG demonstrates that the incidence of IPV is significantly higher in urban

centres as compared to rural locations around the country. Given this data, in addition

to the rates of rural to urban migration, it could be supposed that the prevalence of IPV

in NCD could rival, if not exceed that of both rural and urban centres in other areas of

the country.

Mortality data in this area does not exist.

D: Health services found in NCD

Finding immediate care is critically important after a sexual assault. The provision of

medical care within the first few days after rape is vital to limit serious physical, sexual

and mental health consequences, both immediate and long term (MSF, 2011).

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In recent and comprehensive reviews of service provision within NCD it has been found

that although services exist to support survivors of IPV, they are fragmented, under

resourced and lack the coordination and capacity to be truly effective. Very little seems

to exist in the way of dedicated immediate medical care, awareness raising, prevention

strategies or to address behaviour change. Training services appear to be ad hoc and

no database of trainings or trainees are maintained. Additionally, services are not

always available on a continuous basis as provision is dependent on funding and

capacity (Oxfam, 2010; Amnesty, 2006). A list of IPV specific health related services

can be found in Appendix B.

In addition to the IPV specific services found in NCD there are also 14 National

Department of Health run health centres and 24 aid posts. This data states that there is

one medical officer per 50,832 people and one nursing officer per 4707 of the

population. It must be noted however that these statistics are drawn by the National

Research Institute (NRI) from data obtained in the 2000 census and that the population

of NCD has tripled in the intervening years (NRI, 2010). No information is available

regarding other health services provided by international health agencies and faith

based groups e.g. Marie Stopes International and Anglicare Stop AIDS and it is unclear

whether these services are included in the official data.

E: Geographical and environmental characteristics of the area that would have an impact upon the populations’ health and wellbeing

Poverty arises from a complex array of factors and urban poverty encompasses not only

insufficient income but also inadequate access to services (e.g. education, health care,

water, sanitation, and information), vulnerable livelihoods, lack of capabilities and

exclusion from social, political and economical life (Storey, 2010)

Insecure land tenure and poverty are also closely associated (AusAID, 2008). Living

conditions in informal settlement areas are often difficult due to no on-site clean water,

no formal sanitation arrangements, no electricity, poor housing and crime (ADB, 2002).

For example, in NCD the majority of urban settlers obtain their water from taps outside

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their settlements. A certificate of water connection is required by PNG Power in order

for a power line to be connected and therefore most houses in settlements have no

power. Kerosene is a common form of fuel for cooking and lighting3. The PNG 2006

Demographic Health Survey (NSO, 2006) demonstrates that only 12.4% of households

have electricity, 9.1% of households have a piped water supply and 5.3% of households

have their own flushing toilet.

ADB (2002) state that women and children are affected by poverty to a greater extent

than men; In addition to the drivers of poverty already discussed, women interviewed

also cited inequality, the demands of the extended family and a lack of help to improve

livelihoods as effectors. Women also stated that they shoulder the burden of child

raising and most women interviewed said that domestic violence was part of married life

(ADB, 2002).

F: Social determinants of health

Although IPV pervades all classes of society it can ordinarily be generalized that people

with the lowest socio economic status are at most risk of violence; this risk is intensified

by poverty related factors such as poor housing, lack of education and unemployment

(Vakili et al., 2010; Xu et al., 2005). By contrast, research specific to PNG has

demonstrated that the urban elite either experience a similar frequency of IPV to women

from lower socioeconomic classes, or that the incidence may be slightly lower but that

the severity is greater. Education level and state of employment in PNG does not

appear to offer protection (Hermkens, 2008; Lewis et al., 2008; Oxfam 2010; Toft,

1985). WHO (2005) supports that in a developing country context becoming more

educated and economically empowered may initially increase a woman’s risk of

3 The main adverse health effects of chronic exposure to kerosene are respiratory irritation, eye irritation, and dermatitis. Adverse CNS symptoms may also be experienced: restlessness, ataxia, drowsiness, convulsions, coma and death (Chilcot, R. P., (2006). Compendium of Chemical Hazards: Kerosene (Fuel Oil). Health Protection Agency. Retreived August 20, 2011. http://www.who.int/ipcs/emergencies/kerosene.pdf 20/8).

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violence from an intimate partner with the likely explanation that greater empowerment

may bring more resistance to patriarchal norms within society.

Rigidly defined gender roles are associated with a high incidence of IPV (Hermkens,

2008; Eves, 2006; Klomegah, 2008). Practices such as the payment of bride-price4

reinforces a husband’s sense of entitlement of control and authority over his wife which

serves to enhance a woman’s subordinate status (Marshall & Furr, 2010; Ellsberg et al.,

2008; Garcia-Moreno et al., 2005; Amnesty, 2006). Ellsberg et al. (2008) cite bride-price

as the number one factor in Melanesia in perpetuating violence by men against their

wives and a significant indicator of why a woman might stay in an abusive relationship:

it is mostly unlikely that she, or her family will have the means to pay back the bride

price to the husband’s family if she chooses to abandon the marriage (Oxfam, 2010).

As a result of urban to rural migration traditional communities are being separated and

urbanization calls for the re-definition of family and kinship values and gender roles in a

time of transition between tradition and modernity for many people (Hermkens, 2008).

Research demonstrates that unemployment in males can lead to feelings of frustration

and disempowerment and that the perceived threats surrounding the re-definition of

gender roles can all be reflected in an increased level of violence (Amnesty, 2006;

Bradley, 2001; Oxfam, 2010; Storey, 2010).

Traditional social values and kin-based societies (in the context of PNG this is known as

the wantok system5) focus on taking care of those in need. Those who have more have

traditionally helped those who have less but this traditional support system is breaking

down. In many communities those with more, now do not necessarily have enough to

4 In PNG this denotes the ‘payment’ of objects and money by a man’s family to a woman’s family in exchange for her hand in marriage, The bride-price symbolizes the exchange of rights over a women from her own family to her husband’s (Toft, S. (1985). Domestic Violence in Papua New Guinea. Monograph Number 3. Port Moresby: Law Reform Commission).

5 The “wantok” (lit. one talk) system is PNG’s safety net, under which the extended family and clan members are obligated to support each other. It also functions as an informal country-wide news network (UNDP, (2004). Millennium Development Goals, Progress Report for Papua New Guinea 2004. Retrieved October 6, 2010. http://www.undp.org.pg/documents/mdgs/National_MDG_Progress_Report_2004.pdf

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share. Household income is likely to be met via a number of sources, both formal and

informal such as markets, informal sector work or sometimes criminal activity.

Consequently, incomes can fluctuate on a regular basis, as do the relative costs of

urban living. The number of people dependent upon these incomes is an important

consideration. Household members may vary over time as do the number of income

earners in proportion to dependents (Story, 2010).

G: Difficulties experienced accessing data and information

As previously discussed, there is a paucity of comprehensive, easily accessible,

disaggregated and up-to-date data. For example the National Research Institute of

Papua New Guinea’s 2010 District and Provincial profile information is largely drawn

from the last census which was conducted in the year 2000. It provides no information

regarding district size or population density for each area of NCD, nor are maps

available within the document. Concern is also expressed by authors regarding the

validity and reliability of data and its relevance to the contemporary PNG context.

Much of the demographic and health related data I have gained for this assignment is

as a result of having expatriate friends working in various government departments and

for international health agencies. I have emailed a number of PNG nationals for

assistance (e.g. National Department of Planning and the NRI) but have not had any

return contact from them. Discussions with friends and work colleagues in PNG reveal

not just a widespread lack of capacity, but unpaid department utility bills which mean no

internet access and sometimes no telephone access for local workers.

H: Discussion regarding how a sound knowledge of the above data/characteristics of a population might be useful to professional practice

Intimate Partner Violence is one of the most serious and pervasive social and public

health issues facing PNG (King and Lupiwa, 2010). Health systems in low and middle

income countries tend to be plagued by resource shortages, inefficient and inequitable

use of available resources, poor service quality and low coverage rates. The poorer

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sections of societies within these countries seem to bear the brunt of these problems

(Oliveira-Cruz et al., 2003).

As a health care worker, and particularly an expatriate, in order to be able to contribute

effectively to enhancing existing services, direct the strategic planning of future services

and improve local capacity to access services it is imperative that one understands the

characteristics of the local population. Being aware of the populations attitudes, beliefs,

biases and behaviours that can influence health seeking behaviour and patient care can

also help clinicians improve access to and quality of care (Heyes et al., 2011; Markova

and Broome, 2007). Additionally, knowledge of who is providing specific services, and

how or whether agencies are working together can reveal inadequacies or gaps in

services and can assist with planning better service delivery (Mays et al., 2009).

Furthermore, knowing which agencies are delivering which services helps one to know

what funding is coming from where and may serve to demonstrate how disparities in

spending impact upon population health. This in turn supports effective allocation of

resources and the appropriate direction of future funds (Mays et al., 2009).

An in-depth knowledge of one’s population (including epidemiological and demographic

transitions) and the services available to them helps to plan how services can reach the

socially disadvantaged; effective healthcare delivery improvement helps to reduce both

health and social inequalities and demonstrates that the social basis of health and the

impact of social inequality should not be ignored (Shircore & Ladbury, 2009).

A self-aware health service should be familiar with and able to contribute to the political

argument around health issues affecting their population; health services may be in a

position to act as advocates and lobbyists for communities on health issues, including

social health concerns and an in-depth understanding of one’s population will facilitate

these actions (MSF, 2011). A better understanding of how public health funds are used

and their impact upon service delivery and outcomes is also vital to enable policy

makers to make more informed decisions about the nation’s investment in public health

services when they are being lobbied (Mays et al., 2009).

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I: Conclusion

This report has profiled the population who might access a ‘one stop’ treatment and

referral centre for survivors of intimate partner, family and sexual violence in Papua

New Guinea’s National Capital District. Research has shown that Papua New Guinea’s

National Capital District is a socially complex urban centre with a growing number of

urban poor living in informal settlements around the city. The social and environmental

determinants of health indicate that the inhabitants of these settlements, which also

include members of the ‘middle class’ in NCD (office workers, middle managers etc) as

well as the urban poor, are disadvantaged by their lack of access to health services and

their lack of knowledge regarding existing services.

However, as has been discussed, a paucity of comprehensive, easily accessible,

disaggregated and up-to-date data has made providing a comprehensive report of these

inequalities very challenging. This difficulty in sourcing data, and the fact that much of

the data that does exist is over a decade out of date, has an inevitably negative impact

on the viability of enhancing future service delivery, and targeting future funding

opportunities, as well as advocacy and lobbying for change.

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Appendix A

Maps of Papua New Guinea’s National Capital District

NB Please note that settlement areas are marked on the maps by pink shaded areas.

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Appendix B

Organisations providing services related to Intimate Partner Violence in NCD

Type of Service Name of Organisation

Safe House/Emergency Accommodation Family Support Centre, Haus Ruth, Meri Safe

Haus, Lifeline, ICRAF

Counselling Family Support Centre, NCD Welfare, Haus

Ruth, Meri Safe Haus, Lifeline, ICRAF, World

Vision, Catholic Family Services, PNG

Women’s Foundation, Salvation Army,

WeCare, YWCA, Anglicare, Poro Sapot, St

Johns

Income Generating Activities Haus Ruth, World Vision, Salvation Army,

WeCare, YWCA

Advocacy with Police and Courts Haus Ruth, World Vision, Salvation Army,

WeCare, YWCA, Poro Sapot

Education and Training NCD Welfare, Haus Ruth, Meri Safe Haus,

Lifeline, World Vision, Catholic Family

Services, PNG Women’s Foundation,

WeCare, YWCA, Papua Hahine, Anglicare,

Poro Sapot, Marie Stopes

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Life Skills Training World Vision, Catholic Family Services,

Salvation Army, YWCA, Anglicare, Poro Sapot

Paralegal/Legal Aid NCD Welfare, Haus Ruth, ICRAF, Catholic

Family Services, Salvation Army, YWCA, Poro

Sapot

Promotion and Protection of Rights Haus Ruth, World Vision, Catholic Family

Services, WeCare, YWCA, Papua Hahine,

Poro Sapot, Marie Stopes

Welfare Provision Family Support Centre, NCD Welfare, Haus

Ruth, Meri Safe Haus, Catholic Family

Services, Salvation Army

Medical/Health Lifeline, World Vision, Anglicare, Poro Sapot,

Marie Stopes, St John’s, PoMGH

Other services G4S (security service)

Taken from: Oxfam (2010) p.40, ‘Violence Against Women. Review of Service Provision in

National Capital District’.

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