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An AusAID funded initiative
Public health emergencies workforce
HUMAN RESOURCES FOR
HEALTH: PRACTICE AND
POLICY IMPLICATIONS FOR
EMERGENCY RESPONSE
ARISING FROM THE
CHOLERA OUTBREAK IN
PAPUA NEW GUINEA
Papua New Guinea
Alexander Rosewell, Sibauk Bieb, Geo Clark, Berry Ropa, Enoch Posanai, Geo Miller,
C Raina MacIntyre, Anthony B Zwi
ACKNOWLEDGEMENTS
This paper was reviewed internally by Graham Roberts
and Lisa Thompson of the Human Resources for Health
Knowledge Hub. The external review by Dr Clement Malau was
appreciated by the authors, and review comments have been
incorporated into the fi nal document.
© Human Resources for Health Knowledge Hub 2013
Suggested cita on:
Rosewell, A 2013, Human resources for health: prac ce and
policy implica ons for emergency response arising from the
cholera outbreak in Papua New Guinea, Human Resources for
Health Knowledge Hub, Sydney, Australia.
Na onal Library of Australia Cataloguing-in-Publica on entry
Rosewell, Alexander.
World Health Organiza on, Port Moresby, Papua New Guinea
& School of Public Health and Community Medicine, Faculty of
Medicine, University of New South Wales, Sydney, Australia
Human resources for health: prac ce and policy implica ons
for emergency response arising from the cholera outbreak in
Papua New Guinea / Alexander Rosewell ... [et al.]
9780733432415 (pbk.)
Cholera—Epidemiology
Epidemics—Papua New Guinea
Medical policy—Papua New Guinea
Bieb, Sibauk.
Na onal Department of Health, Port Moresby, Papua New
Guinea.
Clark, Geoff .
World Health Organiza on, Port Moresby, Papua New Guinea
Ropa, Berry.
Na onal Department of Health, Port Moresby, Papua New
Guinea
Posanai, Enoch.
Na onal Department of Health, Port Moresby, Papua New
Guinea
Miller, Geoff .
Capacity Building Service Centre, Papua New Guinea
MacIntyre, C Raina.
School of Public Health and Community Medicine, Faculty of
Medicine, University of New South Wales, Sydney, Australia
Zwi, Anthony B.
School of Social Sciences, Faculty of Arts and Social Sciences,
The University of New South Wales, Sydney, Australia
614.514
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Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 1
CONTENTS
2 Acronyms
3 Summary
4 Introduc on
6 Challenges, strategies, lessons learnt, and prac ce and policy implica ons
16 Discussion
17 Conclusion
18 References
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
2
CPHL Central Public Health Laboratory
HIV human immunodefi ciency virus
IHR Interna onal Health Regula ons
MSF Medecins Sans Fron ères
NDoH Na onal Department of Health
NSO Na onal Sta s cal Offi ce
NTF Na onal Cholera Task Force
TB tuberculosis
WHO World Health Organiza on
A note about the use of acronyms in this publica on
Acronyms are used in both the singular and the plural, e.g. NGO (singular) and NGOs (plural).
Acronyms are also used throughout the references and cita ons to shorten some organisa ons with long names.
ACRONYMS
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 3
SUMMARY
Health services in Papua New Guinea experience
challenges in the availability and distribu on of all
cadres of health professionals. In recent years, a large
cholera outbreak has placed signifi cant pressure on
clinical and public health services.
We describe some of the challenges to cholera
preparedness and response in this human resource-
limited se ng, the strategies used to ensure eff ec ve
cholera management, some lessons learnt as well as
issues for public health policy and prac ce.
Cholera Task Forces were useful to establish a clear
system of leadership and accountability for cholera
outbreak response and ensure effi ciencies in each
technical area.
Cholera outbreak preparedness and response
was strongest when human resource and health
systems func oned well prior to the outbreak.
Communica on relied on coordina on of exis ng
networks and methods for empowering local leaders
and villagers to modify behaviours during the
outbreak.
In addi on to establishing and working towards
human resource targets for diff erent cadres of clinical
staff , similar targets should be established for all
cadres of public health professionals involved in
health emergency preparedness and response, and
public health services more widely.
In line with the na onal health emergencies plan,
the successes of human resource strategies during
the cholera outbreak should be built upon through
emergency exercises, especially in non-aff ected
provinces.
Popula on needs for all public health professionals
involved in health emergency preparedness and
response should be mapped and planning should be
implemented to increase the numbers in relevant
areas. Human resource planning should be integrated
with health emergency planning.
It is essen al to maintain and strengthen the human
resource capaci es and experiences gained during
the cholera outbreak to ensure a more eff ec ve
response to the next health emergency.
It is essential to maintain and strengthen
the human resource capacities and
experiences gained during the cholera
outbreak to ensure a more eff ec ve
response to the next health emergency.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
4
INTRODUCTION
Papua New Guinea is the largest Pacifi c Island
country, with 800 culturally and linguis cally diff erent
groups divided into 4 regions, 20 provinces and
89 districts. The threat of natural disasters and
emergencies, including cyclones, tsunamis, volcanic
erup ons, earthquakes, tribal fi gh ng, drought,
fl ooding and mudslides, is widespread [ABC News
2007; BOM 2007; Dent et al. 1995; Taylor et al. 1998].
The popula on growth rate is high (2.7% per year),
and it is es mated that by 2020 the popula on will
be almost 9 million compared to the es mated 6.1
million in 2006 [NSO 2006]. Papua New Guinea has
a young popula on, with 40% of the popula on
under 15 years, a crude birth rate es mated at 35.0
per 1,000 popula on and a life expectancy currently
es mated at 62 years for men and 65 years for
women [NSO 2006].
In recent decades, the epidemiological profi le has
remained rela vely sta c, with the major health
problems largely unchanged. Previous surveys
es mated the infant mortality rate at 64 per 1,000
live births, child mortality at 25 per 1,000 live births
[NSO 2006], and maternal mortality at 700 - 800 per
100,000 live births.
Infec ous diseases, malnutri on, trauma, diff erent
types of violence, and the complica ons of pregnancy
and childbirth con nue to be the main health
problems for the majority of the rural popula on
[WHO 2013].
However, in recent mes, incidence of infec ous
diseases has grown as a result of the increased size
and mobility of the popula on, and the growth of
densely populated peri-urban squa er se lements
around the major provincial ci es. Papua New Guinea
is strengthening its systems to iden fy, assess and
respond to health emergencies in line with the Asia
Pacifi c Strategy for Emerging Diseases [WHO WPRO
2010].
Papua New Guinea has the highest gross domes c
product in the Pacifi
c, yet it invests only a
small percentage (3.1%) in health [WHO 2013].
As a consequence, un l recently, there were
approximately 11,000 health workers, mostly
community health workers (n=3883), nurses
(n=2844) and doctors (n=333). This equates to 0.5
community health workers, 0.5 nursing offi cers and
0.05 doctors per 1,000 popula on compared with the
interna onally recommended ra o of 2.5 (doctors,
nurses and midwives) per 1,000 popula on. To meet
these standards, Papua New Guinea would need to
add 13,000 health staff [Malau 2008a].
The health workforce is not distributed according to
the needs of the popula on; while most (87%) of the
popula on live in rural areas, almost half (46%) of the
health workers are hospital-based in mostly urban
areas [Malau 2008a].
While funding and expenditure for health services
have increased over the past few years, there has not
been an increase in employment of health workers.
This is largely due to salary increases and goods-
and-services budget reduc ons that result in fewer
services provided to the growing popula on.
Further human resource issues include weak
standards of pa ent care, unhealthy workplace
prac ces, run-down and inadequate infrastructure
and equipment, and educa on and training that may
not always meet the needs of the health care system
[Dawson et al. n.d.]. The ter ary educa on system is
currently unable to produce enough quality health
workers [Malau 2008b].
The cholera outbreak was fi rst iden fi ed in two
coastal villages of Morobe Province in 2009. Over the
next two years, the outbreak aff ected approximately
half the provinces, moving along the north coast to
the southern coast before aff ec ng the Autonomous
Region of Bougainville [Horwood et al. 2011]. There
were in excess of 15,000 offi cial no fi ca ons and 500
deaths of all ages; however, the true number of cases
is likely to be much higher as much of the popula on
did not have health system access, and exis ng
surveillance systems faced important challenges.
There were in excess of 15,000 official
notifications and 500 deaths of all ages;
however, the true number of cases is
likely to be much higher as much of the
popula on did not have health system
access, and exis ng surveillance systems
faced important challenges.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 5
Na onal cholera case management guidelines were
developed in line with global best prac ce. Mild or
moderately dehydrated pa ents were treated at
community-level rehydra on points, while pa ents
requiring intravenous fl uids were referred to
cholera treatment units and centres. Public health
interven ons were aimed to increase access to safe
water, hygiene and sanita on.
When a health crisis such as a cholera outbreak
occurs, strategies for health workforce preparedness
are crucial and must be in place to limit outbreak-
associated morbidity and mortality [WHO 2010].
Human resource strategies should address
distribu on of workers to rural areas, supervision,
team approaches, remunera on and condi ons for
rural health workers.
When cholera emerged in July 2009 [Rosewell et
al. 2011b] , no strategy was in place to address
the supply of clinical or allied health workers. The
subsequent spread of the disease to neighbouring
provinces not only provided signifi cant challenges
to health authori es [Horwood et al. 2011] but also
provided an opportunity to implement and evaluate
novel human resource strategies.
The purpose of this report is to outline 10 challenges
that were encountered by health authori es during
the cholera outbreak. For each challenge iden fi ed,
we describe the strategies employed and the lessons
learnt to improve management of human resources
in future health emergencies.
Methods
A qualita ve approach was used to review human
resource strategies during the cholera outbreak. Data
gathering methods included document review, key
informant interviews and observa on. De-iden fi ed
informa on was analysed using an interpre ve
process informed by clinical and situa onal
knowledge.
This refl ec ve process led to the iden fi ca on of 10
key challenges, under which results were grouped
and further analysed, leading to an understanding
of lessons learnt based on the informa on available.
Finally, results were fed back to relevant in-country
experts in order to validate the accuracy of the
fi ndings. The 10 key challenges will now form the
framework for discussion of results.
When a health crisis such as a cholera
outbreak occurs, strategies for health
workforce preparedness are crucial
and must be in place to limit outbreak-
associated morbidity and mortality.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
6
Challenge 1– Multisectoral coordination
Mul sectoral coordina on has been used eff ec vely
in Papua New Guinea to address protracted
epidemics like the HIV epidemic; however, the
infl uenza pandemic in 2009, followed closely by
the cholera outbreak, was the fi rst me that many
partners had to work together to respond to a
na onally declared acute health emergency.
Strategy – Establish cholera task forces
The Na onal Department of Health (NDoH)
demonstrated excellent leadership for the dura on
of the cholera outbreak. A crucial measure that
enabled na onal leadership was the establishment of
a Na onal Cholera Task Force (NTF) that coordinated
the required mul sectoral response.
The NTF consisted of a general coordinator and fi ve
subgroups, each with an opera onal focal point
in the following technical areas: communica on,
surveillance and laboratory, public health measures,
clinical management and infec on control as well as
logis cs. The NTF was replicated at subna onal levels
with the crea on of Provincial Cholera Task Forces,
which helped to manage the outbreak, iden fy gaps
and develop cholera response plans for submission to
the government for addi onal funding support.
Lessons learnt – Task forces are e ective for
outbreak management
Working together, the NTF and Provincial Cholera
Task Forces established a clear system of leadership
and accountability for cholera outbreak response in
each sector, enabled NDoH to demonstrate its overall
leadership, and provided a framework for eff ec ve
partnerships among interna onal and na onal
humanitarian actors in each sector at all levels of
government.
While largely successful, several subgroups of the
NTF did not have a focal person, which limited the
eff ec veness in these areas during the outbreak.
In provinces where there was a good working
rela onship between the Provincial Health Offi ce
and provincial hospitals prior to the outbreak,
coordina on generally func oned much be er than
in provinces where the rela onship was poor.
In provinces where the Provincial Health Offi ce and
provincial hospitals did not work cohesively prior
to the outbreak, collabora on became exacerbated
during the crisis, especially in the absence of good
leadership. In one province, provincial hospital staff
had to perform the ac vi es normally conducted by
the Provincial Health Offi ce due to the lack of staff for
cholera response.
Through task forces, policy issues were iden fi ed and
then moved forward through exis ng systems within
health authori es. For example, health authori es
were able to take advantage of the momentum
of the outbreak to disseminate zinc for cholera
management. This may be an ini al step towards its
ins tu onalisa on.
Aside from pandemic infl uenza, na onal and
subna onal disaster response plans did not consider
disease outbreaks such as cholera as a na onal
emergency. As such, responses and coordina on
were not mely and o en required na onal support
and leadership.
The corresponding fi nancial commitments for public
health emergencies were not clearly ar culated,
meaning fi nancial commitments were made at the
last moment, resul ng in resources being diverted
from formal budget commitments, which impacted
on planned ac vi es.
Health authori es experienced a lack of clarity in
the roles and responsibili es of the diff erent levels
of government, making it diffi cult to implement
ac vi es through or with the na onal disaster.
NDoH experienced signifi cant challenges in seeking
support from the Department of Finance and
Treasury due to a lack of understanding of public
health emergencies. NDoH was required to seek
Cabinet approval for emergency funds, as funding
from exis ng health sectoral alloca ons would be
outside of budget appropria ons.
Furthermore, the Public Service Commission and
the Department of Personnel Management had not
understood the nature of opera ons during public
health outbreaks and the complexity of managing 30
diff erent cadres of health workers.
Practice and policy implications – Ensure outbreak
task forces coordinate outbreaks
The provision of con nued support by the
Government of Papua New Guinea to health
CHALLENGES, STRATEGIES, LESSONS LEARNT,
AND PRACTICE AND POLICY IMPLICATIONS
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 7
The process of conducting risk assessment
and the subsequent prioritisation of public
health measures is crucial for effectively
managing health emergencies, especially
in the context of concurrent emergencies.
authori es in coordina ng the response to health
emergencies of all causes through emergency task
forces is important.
The roles and responsibili es of task forces could be
outlined under the emergency response structure
in the na onal health emergencies plan. In this
plan, each subgroup of the task force could have
a corresponding offi ce iden fi ed to coordinate
ac vi es.
In line with the na onal health emergencies plan,
health authori es may consider running emergency
exercises to build on the cholera experience,
especially in non-aff ected provinces.
Challenge 2 – Concurrent emergencies
The cholera outbreak in Papua New Guinea
commenced during the containment phase of the
2009 infl uenza pandemic, when intensive contact-
tracing ac vi es were s ll under way. In addi on to
the cholera outbreak, an outbreak of mixed ae ology
was also causing widespread morbidity and mortality
in Morobe Province [Rosewell et al. 2011a].
For a country that had previously iden fi ed few
health events causing widespread morbidity and
mortality across mul ple jurisdic ons, Papua New
Guinea was experiencing an outbreak of cholera in
the coastal areas as well as an outbreak of shigellosis
and infl uenza in the highlands region of the same
province. These events increase the complexity in the
planning of human resources for health.
Strategy – Prioritise interventions
Ac vi es of the Pandemic Infl uenza Task Force were
put on hold and did not resume un l the planning
of the na onal pandemic infl uenza vaccina on
campaign, more than a year a er the pandemic
commenced. The capacity to respond to one health
event and not another was largely due to the lack
of available staff and management systems within
NDoH.
Cholera quickly became the focus because of the
high mortality early on and the simpler surveillance
requirements. While cholera surveillance requires
only a clinical diagnosis, pandemic infl uenza
required sending refrigerated diagnos c samples to
an overseas reference laboratory within two days.
While pandemic infl uenza may have been causing
widespread mortality, exis ng systems were unable
to measure the impact, thus placing all priority on
cholera.
Lessons learnt – Prioritising interventions is crucial
following risk assessment
The process of conduc ng risk assessment and the
subsequent priori sa on of public health measures is
crucial for eff ec vely managing health emergencies,
especially in the context of concurrent emergencies.
Greater capacity to respond to health emergencies
would be enabled by increasing staffi ng levels in
relevant areas of health emergencies.
The current staff numbers at all levels of government
are vastly inadequate for running systems that
generate informa on for risk assessment of health
emergencies in Papua New Guinea [Malau 2008c].
For example, without addi onal staff who can
support provincial disease control offi cers with
data management, ongoing surveillance, outbreak
detec on and verifi ca on processes between or
during health emergencies, risk assessment will
remain challenged and priori sa on of interven ons
may be based on scant informa on.
Practice and policy implications – Strengthen
human resources and risk assessment capacity
Health authori es may consider strengthening risk
assessment capacity and staffi ng at na onal and
subna onal levels. As has been done for clinical
staff , health planners may try developing or adop ng
benchmarks for staff -to-popula on ra os for eff ec ve
risk assessment systems.
Establishing a commi ee to coordinate all health
emergencies may be useful to ensure concurrent
health emergencies are addressed simultaneously
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
8
rather than priori sing one emergency and not
addressing another.
Challenge 3 – Provincial coordination
Health emergency coordina on is a full- me role
during the emergency period. Provincial Health
Offi ces, led by the Provincial Health Advisor, have a
mandate to coordinate health emergencies at the
subna onal level in Papua New Guinea; however,
Provincial Health Offi ces are constantly responding
to complex health issues with limited resources and
are frequently understaff ed to respond to protracted
emergencies such as a cholera outbreak. In this
context, Provincial Health Advisors may be unable to
lead a coordinated response for a protracted period.
Strategy – Recruit external coordinators
Two main models of subna onal cholera task force
coordina on were adopted: (1) the cholera task force
coordinator was the Provincial Health Advisor, and
(2) the coordinator was a respected, eff ec ve leader
from outside the government system.
The external coordinators had established leadership
capabili es and were respected and trusted by local
authori es. One external coordinator came from
Lutheran Health Services, and another came out of
re rement, following a career in public health.
Strategy – Manage cholera response funding
Timely cholera control ac vi es were carried out
when the Provincial Cholera Task Forces engaged
meaningfully with the provincial governments to
communicate the implica ons of cholera in order to
facilitate their contribu on and support.
The importance of this rela onship is paramount,
given the signifi cance of the fi nancial contribu on
that provincial governments can make to cholera
response. In addi on to fi nancial support, approvals
from provincial governments may be required to
transfer staff between districts.
Lessons learnt – External sta can e ectively
coordinate outbreak response
Flexibility in the subna onal coordina on modality
was useful, as both models of coordina on worked
eff ec vely. In the more challenging se ngs, recrui ng
coordinators from outside the provincial government
system was successful.
The Provincial Disaster Coordinator is not always the
most appropriate coordinator of a health emergency.
Task forces with ac ve mul sectoral par
cipa on
were most eff ec ve.
Lessons learnt – Quarantined emergency response
funds are essential at all levels
Provinces that maintained a quaran ned emergency
response fund that could be immediately accessed
were able to quickly implement control measures
such as mobilising rapid response teams.
The emergency response budget must be able to
cover the travel costs of relocated staff and their
allowances. The fi nancial accounts of Provincial
Health Offi ces must be acqui ed to ensure that task
forces have control of the funding allocated for health
emergencies and can use it for interven ons that
they have priori sed.
In one se ng, the accounts of the Provincial Health
Offi ce had not been acqui ed for several years. In this
context, NDoH was obliged to disburse emergency
funding to the provincial hospital account, taking
control of funding away from the Provincial Cholera
Task Force. As a result, the funding allocated to the
response by the hospital did not correspond to the
interven ons priori sed by the task force.
Practice and policy implications – Coordinators
can be identi ed and trained in preparedness
An evalua on of the coordina on models established
in responding to the cholera outbreak would facilitate
preparedness for the next emergency. Reviewing
the degree of mul sectoral par cipa on is essen al
during the “between emergency” phase, as is the
iden fi ca on of ways to maintain the task force.
From a na onal perspec ve, a database of
experienced coordinators could be maintained
to enable their deployment in future health
emergencies. Provinces could iden fy poten al
health emergency coordinators to provide these
individuals with further training and opportuni es to
par cipate in health emergency exercises.
A quaran ned emergency fund must be maintained
for health emergency response at all levels of the
health system. Strengthening subna onal capacity
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 9
to plan for and manage emergency funds would limit
reliance on na onal support in future.
Challenge 4 – Outbreak and behaviour
change communication
Outbreaks are frequently marked by unpredictability,
uncertainty, confusion and a sense of urgency.
Communica on failure and delays can hamper
outbreak response by delaying control measures,
undermining public trust and compliance, and
unnecessarily prolonging social and economic turmoil
[WHO 2005].
The limited reach of mass media in Papua
New Guinea presents signifi cant challenges to
communica ng standardised informa on in a mely
way that is required during health emergencies. The
vast majority of the popula on live in rural areas,
where 29% of households have a radio and 4% have
a television, thus limi ng the reach of mass media.
Furthermore, only about half of the popula on
will complete primary school educa on, thereby
restric ng the eff ec veness of wri en materials [NSO
2006].
It is well known that behaviour change during
outbreaks can either drive or limit disease
transmission. The adop on of personal protec ve
measures is o en crucial for limi ng disease spread
and reducing mortality. Trusted informa on sources
are required to disseminate messages that will lead
to behaviour adop on [WHO 2005].
Strategy – Involve local leaders and existing
networks
During the cholera outbreak, health authori es
ac vely conveyed messages via radio, television and
community leaders, such as chiefs in the Autonomous
Region of Bougainville. The Secretary of Health
served as a strong advocate throughout the outbreak.
In an eff ort to address health informa on needs and
change behaviour at the community level, health
authori es communicated messages with loudhailers
at communal points and carried out other types of
mass gathering communica ons.
Health authori es also met with village leaders to
discuss key personal protec ve behaviours as well
as the barriers to their adop on. The leaders then
organised volunteers to communicate the messages
to the community.
Health authori es also used the HIV network, made
up of faith-based organisa ons, non-governmental
organisa ons and members of the civil society, for the
distribu on of key messages and materials to aff ected
and unaff
ected communi es.
Lesson learnt – Local leaders are important for
behaviour change
It was noted on several occasions that the behaviour
changes required of a community during cholera
outbreaks are diffi cult to achieve, even if only
required for a limited me (months) while the
outbreak is occurring in the community.
Communi es are more likely to adopt recommended
behaviours following repeated visits and messaging
from respected persons such as village leaders, ward
councillors, health workers or those organised by
such leaders. Anecdotally, one-off visits by persons
with loudhailers instruc ng the popula on what
they should do did not appear to change behaviours
during the period of the outbreak.
When health authori es try to achieve behaviour
change results without involving the community, the
human resource burden is beyond the scope of their
capacity.
Behaviour change messages and materials required
standardisa on, which was best achieved from the
central level. Their development could have been
melier and may have benefi ed from a pre-exis ng
repository of communica on tools.
Communities are more likely to adopt
recommended behaviours following
repeated visits and messaging from
respected persons such as village leaders,
ward councillors, health workers or those
organised by such leaders.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
10
Practice and policy implications – Involve local
leaders and networks in preparedness
Local leaders and networks, including ward
councillors, are important in disaster and emergency
preparedness planning ac vi es. Behaviour change
messages and communica on tools for cholera
and other outbreak-prone diseases should be
standardised at the na onal level with technical
sign-off by NDoH. These could be maintained in
repositories at na onal and subna onal levels.
The lack of a media unit with trained personnel in
NDoH to disseminate public health informa on was
noted as a defi ciency and could be emphasised for
the future.
Challenge 5 – National laboratory capacity
In the 1960s, stool culture was conducted at
provincial hospital laboratories as well as the na onal
laboratory in Papua New Guinea. More than fi ve
decades later, when cholera was reported in West
Papua, Indonesia [ProMED Mail 2008], none of the
government laboratories, including the Central Public
Health Laboratory (CPHL) and the na onal cholera
reference laboratory, had the materials to perform
stool culture to iden fy cholera.
Also, signifi cant human resource challenges existed
at CPHL, none more signifi cant than the leadership
vacuum created by the Director’s posi on being
vacant for approximately two years, despite the
comple on of a successful recruitment process.
Strategy – Identify stakeholders and provide tools
In this context, the Pathology Department at the Port
Moresby General Hospital off ered to perform stool
culture to support cholera surveillance if they were
given laboratory reagents. Despite their limited staff ,
the Pathology Department conducted training of
provincial laboratories to diagnose cholera for staff of
provincial laboratories in two provinces.
Lessons learnt – Timely recruitment of laboratory
management is key to functionality
Na onal cholera surveillance worked eff ec vely
with only one func oning laboratory in Papua New
Guinea. However, the vacant Director posi on at
CPHL could impact signifi cantly on overall laboratory
func on and the capacity to take on new work (e.g.
cholera surveillance) during crises.
Re-establishing diagnos c capacity during outbreaks
worked well at the provincial level; however, further
support will be necessary to ensure sustainability of
the training.
Practice and policy implications – Ensure national
laboratory capacity before subnational capacity
Na onal laboratory capacity should be established
prior to rebuilding capacity at the subna onal level.
The dra emerging diseases na onal plan should be
fi nalised to ensure that cholera is the next disease
included in the external quality assurance program.
Reviewing the recruitment processes that occurred
for the laboratory Director posi on may be useful to
ensure similar delays are not experienced in future.
Challenge 6 – Surveillance sta ng
Prior to the arrival of pandemic infl uenza A (H1N1)
2009, only one staff member within NDoH was
working on outbreak surveillance and response.
Despite being an experienced and capable
surveillance offi cer, the burden of conduc ng
outbreak surveillance and response for a country of
6.5 million inhabitants was overwhelming, especially
in the context of concurrent emergencies.
Strategy – Establish a command and control centre
with temporary sta
In response to this situa on, na onal health
authori es established an emergency opera ons
centre and employed two addi onal staff , a
surveillance offi cer and an administra ve assistant, to
perform its func ons. Similar command centres were
established at the subna onal level.
Lessons learnt – E ective surveillance systems rely
on adequate numbers of trained sta
Timely surveillance of outbreaks is a realis c goal
in Papua New Guinea, but it is reliant on adequate
numbers of staff . During the cholera outbreak,
the command and control centres facilitated
the informa on management component of the
health emergency. Given the limited staff and data
management capacity at the subna onal level, the
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 11
na onal surveillance staff were frequently required to
perform provincial data entry.
Practice and policy implications – Additional sta
are required in subnational surveillance
Surveillance of health outbreaks is not possible
without adequate staffi ng at all levels. For this
reason, health authori es established six to eight
new posi ons in the surveillance, risk assessment and
outbreak response unit within NDoH at the end of
2011.
Ensuring appropriate training for new staff members
will be essen al for eff ec ve health protec on
func ons within the health authori es.
Provincial health authori es may consider replica ng
the na onal surveillance, risk assessment and
response structure at the subna onal level. Offi cers
in charge of health facili es in rural and remote areas
as well as the district disease control offi cers are
crucial to the func on of strong repor ng systems.
Ins tu onalisa on of incen ves for outbreak
surveillance, including training, feedback and
epidemiological and clinical assistance, should be
strongly considered [Paterson et al. 2012] at the local
or district level.
Challenge 7 – Provincial data management
capacity
Cholera surveillance at the subna onal level was
conducted by provincial disease control offi cers.
In addi on to weekly surveillance, however, they
were responsible for all other disease control
programs (including HIV, TB and malaria), they were
involved in bednet distribu on for malaria control,
they supported outreach immunisa on and they
inves gated acute health events.
The impact of having only one staff member for
surveillance during the cholera outbreak was
signifi cant. Given the lack of provincial data managers
in surveillance and outbreak response, subna onal
data were rarely shared with na onal surveillance
offi cers, and the na onal outbreak profi le was
frequently based on old and incomplete data. In this
context, approximately 50% of health facili es would
receive at least one suppor ve visit from a provincial
health offi cer [Malau 2008a].
Strategy – Borrow sta from other programs
In the provinces with weak cholera surveillance, the
system was characterised by a lack of involvement
of those mandated to conduct disease surveillance.
However, in provinces where cholera surveillance
func oned well, good data managers were borrowed
from other programs. In one province, the TB data
manager was seconded to the cholera outbreak team
for daily data entry, analysis and repor ng to the
Provincial Cholera Task Force.
During the outbreak, NDoH piloted a new mobile
phone-based repor ng system that enabled mely
data to be received from remote sites (where there
is mobile phone network coverage), poten ally
enabling health authori es and the community to
respond earlier and more eff ec vely to outbreaks.
Lessons learnt – Seconding sta is not sustainable
Suppor ve visits to the provinces were some mes
the only way to s mulate the fl ow of data to the
na onal level, where data entry may have occurred
for the fi rst me. Data managers who were recruited
to work under the disease control offi cer during
the cholera outbreak were crucial at the me of
the emergency. However, because the situa
on
con nued for several months, the well-performing
health workers returned to their original program,
and it took some me to replace them.
Considera on should be given to making the data
manager posi on a permanent one at the provincial
level. If data managers were available between
outbreaks, they could support the commencement
of a weekly repor ng system for syndromes of public
health importance.
In provinces where there were challenges with the
fl ow of cholera surveillance data, large amounts
Ins tu onalisa on of incentives for
outbreak surveillance, including training,
feedback and epidemiological and clinical
assistance, should be strongly considered
at the local or district level.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
12
of data were some mes never forwarded to the
na onal level. In one province that reported
approximately 600 cholera cases, health care workers
at one remote district hospital later reported they
had treated and line listed more than 1,000 cases that
never made their way into the surveillance system.
The mobile phone repor ng system has important
human resource considera ons in that data are
texted by the health care worker at the health facility
and are automa cally uploaded into a database for
automa c analysis. A major advantage of this system
is that it does not rely on a provincial health offi cer
to collect and collate the data, as this step is done
automa cally when the clinician sends the data via
SMS. The current staff constraints at the Provincial
Health Offi ces (and NDoH) to collect surveillance data
may be overcome in this system, enabling eff ec ve
response by relevant authori es.
Practice and policy implications – Mobile phone
reporting works with few sta
Provincial disease control staff require support from
data managers and ongoing training. Each provincial
hospital could have a designated surveillance focal
person to coordinate syndromic surveillance in
children and/or adult outpa ent departments.
Mobile phone repor ng enabled mely surveillance
data to be received from remote areas during a
cholera outbreak in the context of limited staff in
subna onal surveillance system. The system has the
poten al to be rolled out na onally.
Challenge 8 – Rapid response processes
Prior to the infl uenza pandemic, na onal-level
technical support to provincial health authori es for
outbreak inves ga ons was provided on an ad-hoc
basis by the one surveillance offi cer from NDoH, with
li le technical collabora on from other disciplines
within the health authori es.
Strategy – Formalise rapid response teams
The cholera outbreak was the fi rst me NDoH
formally established a rapid response team for a
disease outbreak. This is a promising ini a ve that
should be supported with appropriate materials
and training. Sending young professionals to fi eld
epidemiology training programs in India has increased
the number of capable staff available for conduc ng
outbreak inves ga ons.
Lessons learnt – Formalising the rapid response
team was simple and e ective
Once the Senior Execu ve Management of NDoH
decided to formalise the na onal rapid response
team, ac on was swi ly taken. Within weeks, the
na onal rapid response team had completed its fi rst
inves ga on, confi rming cholera and micronutrient
defi ciencies associated with high mortality among
internally displaced persons. In addi on to the
technical support provided in fi eld epidemiology,
assistance was provided to provincial authori es in
outbreak communica on and water, sanita on and
hygiene.
Practice and policy implications – All provinces
need a trained rapid response team
Provincial health professionals who return from
interna onal fi eld epidemiology training programs
should formalise rapid response teams to strengthen
outbreak inves ga on and response capacity at
the provincial level. Human resource targets such
as a fully adopted na onal workforce plan and at
least one trained fi eld epidemiologist per 200,000
popula on are useful considera ons [Ijaz et al. 2012].
Monitoring the crea on and training of rapid
response teams remains an important feature of
implemen ng the na onal health emergencies plan.
Challenge 9 – Initial clinical surge capacity
at cholera treatment centres
Due to the high ini al case-load experienced
by provincial hospitals and the limited hospital
infrastructure for maintaining essen al services,
external treatment centres were established within
Monitoring the creation and training
of rapid response teams remains an
important feature of implemen ng the
na onal health emergencies plan.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 13
hospital grounds. Eff ec ve case management during
cholera outbreaks requires a large number of trained
clinical staff [Dawson et al. n.d.], with community
interven on frequently required.
Unfortunately, most of the provincial hospitals lacked
the necessary clinical employees to run the external
treatment centres for 24 hours a day, seven days a
week. In the context of the human resource crisis in
Papua New Guinea [Dawson et al. n.d.] and a “new
disease” for clinicians, ensuring such services was
extremely challenging.
Strategy – Rotation of sta across the province
Hospitals frequently organised rota ons of clinical
staff from district health facili es to come to the
provincial capital to work in the cholera treatment
centres. In this way, suffi cient clinicians were
available to manage cases, and the centres could
be used as a training centre for district staff who
worked in facili es where cholera cases were yet
to present. However, this strategy leaves district
facili es understaff ed or completely without staff for
extended periods, due to the limited capacity to back-
fi ll posi ons.
Lessons learnt – Leadership and training enable
e ective sta rotation policies
In the context of infl exible systems for recrui ng
clinical staff as outbreak surge capacity, the rota on
of district staff appeared to be a successful strategy
for ensuring adequate case management, training
staff and preparing staff from unaff ected districts.
However, managing the available human resources to
staff cholera treatment centres, mobilising response
teams to aff ected rural areas and maintaining rou ne
services in rural facili es was a complicated juggle.
Stakeholders felt the success of the strategy was due
to the strong provincial leadership and the ini al
training of a core group of clinical staff largely by
Médecins Sans Fron ères (MSF Holland).
The ini al treatment centre established by MSF
enabled clinical management training of many health
care workers who had never been exposed to cholera
and provided a pla orm for opera onal research
[Rosewell et al. 2012].
The training ensured the nurse unit managers
and other clinical staff were competent not only
in eff ec vely managing cholera cases but also in
running a treatment centre. Running the centre
involved ac vi es such as rostering, clinical audits
to understand drivers of mortality, ongoing training,
cleaning, provision of water and sanita on,
procurement and stocking, infec on control and
mortuary services.
The strategy was less eff ec ve in loca ons where
exis ng leadership was weak. In such loca ons,
stakeholder technical assistance was rejected,
fi nancial resource alloca on did not correspond to
interven ons priori sed by the provincial task force,
and the rotated district staff did not always perform
the ac vi es they were recruited to perform.
During the later stages of the outbreak, experienced
cholera treatment centre teams from the fi rst-
aff ected provinces were recruited to work in cholera
treatment centres in other provinces with high
mortality.
This was eff ec ve for improving the management
of cases and the treatment centre during the period
the team was on the ground. However, it did li le
to improve the situa on in the longer term, as
opportuni es to share the exper se of clinical staff
from previously aff ected provinces were not seized
and not much was done to improve systems.
Staff rota on also enabled clinical staff to witness
their colleagues trea ng cases of this “new disease”
and not ge ng sick or dying. In this way, experienced
staff were able to reassure colleagues who had fl ed
their health facili es for fear of the disease.
Cholera outbreaks, like the one in Papua New
Guinea, can be expensive if they carry on for
months in se ngs with limited infrastructure. The
... managing the available human
resources to staff cholera treatment
centres, mobilising response teams to
aff ected rural areas and maintaining
rou ne services in rural facili es was a
complicated juggle.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
14
cholera treatment centres were ini ally staff ed with
clinicians, infec on control offi cers and security
guards, at a cost of approximately 30,000 Papua New
Guinea kina per month.
Practice and policy implications – Outbreak
preparedness includes surge capacity
strengthening
Cholera is a diarrhoeal disease that may cause
outbreaks that stretch the capacity and resources of
the health system. While capacity needs may vary
during and between outbreaks, cholera should be
treated the same as other outbreak-prone diseases
and (where possible) should be integrated into
rou ne hospital services.
Contact lists of trained clinical staff must be kept
updated. Preparedness for the next waves of cholera
outbreak or future health emergencies could include
iden fi ca on of the minimum number of staff to
operate outbreak management units, iden fi ca on
and documenta on of case-load thresholds to
trigger addi onal recruitments, ongoing training
and exercises to ensure staff competency and safety,
and prepara on of con ngency arrangements
such as memorandums of understanding with key
stakeholders for staffi ng needs. Reten on of trained
and/or experienced staff on the rosters for surge
capacity would be a useful considera on.
Practice and policy implications – Integrate cholera
into existing services
The na onal referral hospital and the provincial
hospitals in Papua New Guinea do not have
established isola on wards. Where cholera treatment
centres were established to deal with the high case-
load, exit strategies proved very diffi cult. Hospitals
did not wish to shut down the cholera treatment
centres in case another wave of the outbreak
occurred and there was no isola on facility to receive
the pa ents.
However, cholera has been a protracted emergency
in some provinces, with transmission occurring for
more than one year. Ways to integrate cholera into
the rou ne business of hospitals and to manage
associated staffi ng, costs and other issues are
currently being considered across the country.
Challenge 10 – Community access to
rehydration
The health system in Papua New Guinea faces
signifi cant challenges in providing services to the rural
majority [Foster et al. 2009]. Recent decades have
seen a decline in the number of func onal aid posts
that are staff ed with health workers. In this context,
the mely establishment of rehydra on points at
the community level is crucial for limi ng mortality
associated with cholera outbreaks.
Strategy – Involve unpaid volunteers
When cholera struck remote areas with aid
posts, community health workers were typically
responsible for managing cases, with volunteers
from the community frequently assis ng with case
management and infec on control. In some urban
areas, volunteers were paid to run the rehydra on
points; in others, they performed this func on
without remunera on.
Lessons learnt – Rosters and volunteers are
essential for sta rotation in remote settings
In se ngs where health care workers were present,
unpaid volunteers o en provided safe water to the
makeshi treatment centres, monitored intravenous
fl ask needs of pa ents in their homes prior to moving
to makeshi treatment facili es, and prepared
rehydra on solu ons for pa ents as well as chlorine
solu ons for infec on control. Such ac vi es enabled
health care workers to catch up on much-needed
sleep during intense periods of transmission in
remote areas.
To complement the important contribu ons of
volunteers, district health authori es developed
rosters of staff from nearby facili es to ensure that
While capacity needs may vary during and
between outbreaks, cholera should be
treated the same as other outbreak-prone
diseases and (where possible) should be
integrated into routine hospital services.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 15
clinicians shared shi s with community health
workers during periods of intense transmission. In
se ngs where strong local leadership was absent,
a func onal roster system was a challenge and staff
were frequently overburdened, placing pa ent lives
at risk.
In one urban loca on, subsequent to the intense
phase of the outbreak when only small numbers of
cases were presen ng to the provincial hospital, 15
rehydra on points strategically located around the
community remained opera onal, each staff ed by
three paid volunteers.
It should be recognised that there is generally an
expecta on in the community that volunteers will be
paid for their me, which could be seen as a rela vely
low-cost way of achieving outcomes in the context of
an understaff ed health system.
Practice and policy implications – Volunteers
require a exible approach
Health authori es may consider reviewing the
diff erent approaches taken to recruit and remunerate
community volunteers, with a view to iden fying the
strategy that works best for a given situa on. This
may facilitate community involvement in outbreak
response and ensure support for clinical staff in a
cost-eff ec ve, sustainable way.
Health authorities may consider reviewing
the different approaches taken to recruit
and remunerate community volunteers,
with a view to iden fying the strategy that
works best for a given situa on.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
16
DISCUSSION
Papua New Guinea is strengthening its capacity to
iden fy, assess and respond to health emergencies
in line with requirements of the Interna onal Health
Regula ons (IHR). To support the implementa on of
IHR, the country has adopted components of the Asia
Pacifi c Strategy for Emerging Diseases, which outlines
areas of achievement rela ng to health emergencies.
Key to this area is the development of a na onal
health emergencies plan, which has been recently
dra ed by health authori es.
To achieve the objec ves of the na onal health
emergencies plan, capable public health professionals
are needed for the mely, eff ec ve response to public
health emergencies at na onal and subna onal
levels. As a result, objec ves of the na onal health
emergencies plan are best achieved if the required
human resources are clearly iden fi ed and ar culated
in the na onal human resources plan.
Clinicians are the backbone of primary health care
in Papua New Guinea and include: community
health workers, health extension offi cers, nurses and
doctors. They are essen al in the implementa on of
mortality-reduc on interven ons during outbreaks,
and for ensuring the ongoing func on of essen al
health services. For these reasons, mapping and
projec ng popula on health needs in terms of clinical
staff has been priori sed in Papua New Guinea.
However, a variety of cadres of public health
professionals are required for health emergency
planning, preparedness and response. They include
offi cers trained in environmental health, health
promo on, logis cs, communica ons, laboratory
diagnosis and surveillance, data management, fi eld
epidemiology as well as monitoring and evalua on.
The crea on of a cadre of trained fi eld
epidemiologists to monitor disease trends, provide
intelligence to those conduc ng risk assessments,
inform decision-makers about poten al disease
threats and guide the response during a public health
emergency is essen al.
The Papua New Guinea response to cholera
demonstrates system inadequacies, including the
systems that iden fy, develop and make projec ons
on human resource requirements for health.
Generally, loca ons that func oned well prior to the
epidemic responded be er to it.
Pre-service training, opportuni es for ongoing
training, increased supervisory visits, produc on,
u lisa on of all cadres of public health professionals,
supervision and support, fi nancial support and
incen ves, housing and training in supervision and
outreach have all been previously iden fi ed as areas
for strengthening [WHO 2010].
Developing human resource targets is important
for achieving desired health system outcomes. The
target of at least one trained fi eld epidemiologist per
200,000 popula on is an example of benchmarks that
should be established for Papua New Guinea [Ijaz
et al. 2012]. However, there are a number of other
cadres of public health professionals that are required
for emergency response, all of which are currently
in limited supply and would also benefi t from such
targets.
These cadres should also feature in the mapping and
projec ons of public health professional needs in
any fully adopted na onal workforce plan and may
be a considera on for targets rela ng to their ra o
to the popula on. Registra on systems for all health
professionals (clinical and public health) will provide
more detailed data regarding the workforce.
To achieve the objec ves of the na onal
health emergencies plan, capable public
health professionals are needed for the
timely, effective response to public health
emergencies at national and subnational
levels.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea 17
CONCLUSION
The human resources for health context in Papua
New Guinea made emergency response a challenge
during the cholera outbreak. While the outbreak
response was generally well managed, improvement
to human resource systems prior to the next
emergency will enable a more eff ec ve response.
Popula on needs for all public health professionals
involved in health emergency preparedness and
response should be mapped and planning should be
implemented to increase the numbers in relevant
areas. Human resource planning should be integrated
with health emergency planning.
It is essen al to maintain and strengthen the human
resource capaci es and experiences gained during
the cholera outbreak to ensure a more eff ec ve
response to the next health emergency.
It is essential to maintain and strengthen
the human resource capacities and
experiences gained during the cholera
outbreak to ensure a more eff ec ve
response to the next health emergency.
Rosewell, A et al.Prac ce and policy implica ons for emergency response arising from the cholera outbreak in Papua New Guinea
18
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THE KNOWLEDGE HUBS FOR
HEALTH INITIATIVE
The Human Resources for Health
Knowledge Hub is one of four hubs
established by AusAID in 2008 as
part of the Australian Government’s
commitment to mee ng the Millennium
Development Goals and improving
health in the Asia and Pacifi c regions.
All four Hubs share the common goal of
expanding the exper se and knowledge
base in order to help inform and guide
health policy.
Human Resource for Health Knowledge Hub
University of New South Wales
Some of the key thema c areas for this Hub include
governance, leadership and management; maternal,
newborn and child health workforce; public health
emergencies; and migra on.
www.hrhhub.unsw.edu.au
Health Informa on Systems Knowledge Hub
University of Queensland
Aims to facilitate the development and integra on
of health informa on systems in the broader health
system strengthening agenda as well as increase local
capacity to ensure that cost-eff ec ve, mely, reliable
and relevant informa on is available, and used, to
be er inform health development policies.
www.uq.edu.au/hishub
Health Finance and Health Policy Knowledge Hub
The Nossal Ins tute for Global Health (University of
Melbourne)
Aims to support regional, na onal and interna onal
partners to develop eff ec ve evidence-informed
na onal policy-making, par cularly in the fi eld of
health fi nance and health systems. Key thema c
areas for this Hub include compara ve analysis of
health fi nance interven ons and health system
outcomes; the role of non-state providers of health
care; and health policy development in the Pacifi c.
www.ni.unimelb.edu.au
Compass: Women’s and Children’s Health
Knowledge Hub
Compass is a partnership between the Centre for
Interna onal Child Health, University of Melbourne,
Menzies School of Health Research and Burnet
Ins tute’s Centre for Interna onal Health.
Aims to enhance the quality and eff ec veness of
WCH interven ons and focuses on suppor ng the
Millennium Development Goals 4 and 5 – improved
maternal and child health and universal access to
reproduc ve health. Key thema c areas for this
Hub include regional strategies for child survival;
strengthening health systems for maternal and
newborn health; adolescent reproduc ve health; and
nutri
on.
www.wchknowledgehub.com.au
Human Resources for Health Hub
Send us your email and be the fi rst to receive copies of
future publica ons. We also welcome your ques ons
and feedback.
HRH Hub @ UNSW
School of Public Health and Community Medicine
Samuels Building, Level 2, Room 209
The University of New South Wales
Sydney, NSW, 2052
Australia
T +61 2 9385 8464
F + 61 2 9385 1104
hrhhub@unsw.edu.au
www.hrhhub.unsw.edu.au
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A strategic partnership initiative funded by the Australian Agency for International Development
