Climbing mountains to conduct VAs 

Discover how new strategies implemented by Bloomberg Philanthropies, the University of Melbourne (UoM), the Australian Department of Foreign Affairs and Trade (DFAT), the Papuan National Department of Health (NDOH) and the Papuan Department of Provincial and Local Government Affairs (DPLGA) improve field staff roles and CRVS process. Follow Martha Wame, Field Coordinator for the Bloomberg Data for Heath (BD4H) initiative in Papua New Guinea (PNG), as she travels by car, boat and foot to conduct Verbal Autopsies (VA) in rural communities.

Martha Wame is one of the Field Coordinators for the BD4H initiative in PNG. Her role is to facilitate the transfer of death notifications from remote communities to health centres. When she receives a death notification, she schedules the VA interview.

Martha resides in Alotau, a town approximately 78km (48 miles) from Rabaraba. Rabaraba is a coastal government station that she passes to reach remote wards in the Makamaka Local Level Government (LLG) area. 'Rabaraba' means “far, far away” in Papuan dialects. In Martha's case, this also has a literal meaning.

Generally speaking, 78km of road can take an hour and a half by car. For Martha, there are no roads that connects Alotou to Rabaraba. So she must drive 2 hours north of Alotou, then find a local boat taxi to pay for a 3-hour trip to Rabaraba.

Martha Wame on top of a mountain on her way to rural wards.
Martha hikes mountains to reach wards

During her trip she must also be cautious. PNG has a high crime rate; acts of piracy, theft and violence are common. This restricts her passage to certain areas and to be safe, she must be accompanied in a group.

Martha passes through Rabaraba, then travels onwards to remote areas in Makamaka LLG.  Here she spends approximately two weeks to a month visiting surrounding communities. These communities are known as wards. As there are no roads, she must walk for hours to reach families and homesteads, sometimes hiking mountains and rough terrain. 

Martha travels via boat taxi to reach Rabaraba

A common route Martha travels to reach the rural wards of Makamaka LLG 
Most wards have an individual acting as a residential Ward Recorder employed by the DPLGA. It is the role of the ward recorder to register activities in their communities, including birth and death notifications. Martha collects death notifications from these ward recorders.
05-18_Papua New Guinea_19_Ward recorder with WRB, Rabaraba
Ward recorder with ward record book, Rabaraba

Before leaving Alotou, Martha received death notifications from specific wards in Makamaka LLG. So she knows that VA interviews are required in specific wards. Whilst passing through these wards, Martha conducts VA interviews with family members of the deceased to record the possible cause of death (COD). On average she can conduct over 50 VA interviews on a trip like this. 

In addition to ward recorder death notifications and VAs, she also collects notifications from Community Health Workers (CHW) and Health Extension Officers (HEO).  Funded by the NDOH, these roles are similar to the roles of nurses and doctors, they also act as birth and death notification agents. 

At the end of her trip, Martha returns to Alotau with collated death notifications, a valuable source of COD data, and very strong legs. 

This is one example out of the many trips our field coordinators have made to collect mortality data in PNG. It is evident that the field coordinator is doing much more than facilitating the transfer of data. There are people who are better placed to be acting as notification agents and conducting VAs.

In November 2019, the government of PNG discussed new strategies to streamline the collection of notifications and VA data. To understand the new strategy, we must look to the past and current circumstances of CRVS in PNG.

In 2016 Bloomberg Philanthropies pledged to assist PNG through the Data for Health (D4H) initiative to strengthen CRVS. With a high priority on:

  1. Strengthening the collection and sharing of birth and death data from communities.
  2. Strengthening national mortality reporting.

A partnership formed between the NDOH, DPLGA, Bloomberg Philanthropies, DFAT and UoM. It was determined that UoM would drive the D4H initiative in collaboration with the PNG government, with support from Bloomberg Philanthropies and DFAT.

PNG has a population of over 8 million people with 87% residing in remote communities. As 85 to 90% of deaths occur outside of hospitals, VA was identified as the key intervention to implement in order to capture COD data.

05-18_Papua New Guinea_19_Ward recorder with WRB, Rabaraba
Ward recorder with ward record book, Rabaraba
Children in class at Port Moresby - Creative Commmons, Ness Kerton

Martha's trip demonstrated that the current process works, but it requires improvement. Ward recorders should be delivering death notifications to health centres for the system to be sustainable but due to particular limitations the role is underutilised. 

The limitations come down to technology, resources and incentive. It is uncommon for ward recorders to capture notifications digitally. Those who have adopted digital methods often experience poor signal reception. Most rely on paper forms to capture deaths in the community and deliver to health centres. But this can require the ward recorder to walk for hours. Paper methods can also be restricted by access to simple things like a pen and paper, access to a printer or running out of supplied forms.

Above all, ward recorders are not paid regularly to perform their roles and therefore have little incentive to record and deliver notifications. Similarly, the roles of the HEO’s & CHW’s are underutilised for VA purposes. As VA is a new tool, it is not included in their job descriptions. This means that field coordinators have been the main source of reliable COD data to date.

"Field Coordinators like Martha have been the key to our verbal autopsy data."

- Dr John Hart

"Field Coordinators like Martha have been the key to our verbal autopsy data." – Dr John Hart

Dr John Hart and Dr Viola Kwa
Dr John Hart and Dr Viola Kwa
John and Viola drive the data analysis and present new findings from VA and MCCOD data. Prof. Ian Riley, John and Viola represent UoM D4H and are the acting secretariat for the PNG National Burden of Disease committee. 

Professor Ian Riley, Doctor Viola Kwa and Doctor John Hart from the University of Melbourne are the key drivers for the D4H initiative in PNG. Together they discuss ideas with the PNG government and suggest how best to put in place CRVS strengthening interventions. Together they have organised training sessions nationwide along with the implementation of VA and Medical Certificate Cause Of Death (MCCOD) interventions in Alotau, Talasea and Tambul-Nebilyer districts. Due to their efforts in these districts, approximately 40% of deaths have been captured in CRVS systems. Recently they presented COD data collected from VAs to the PNG government – A first for the nation.

Although hundreds of ward recorders, CHW’s and HEO’s have been trained in MCCOD and VA, the amount and quality of the data will continue to be hindered until the limitations are addressed. 

05-18_Papua New Guinea_15_Ward recorder training at Rabaraba
Ward recorder training, Rabaraba

The solution starts with the National Burden of Disease Committee of PNG. The committee was created by Prof. Ian Riley and local country coordinators to analyse mortality data and support VA and MCCOD activities. Since its conception the committee has evolved, and the PNG government have taken ownership.

On the 26th of November the committee met at the School of Medicine and Health Sciences. Here, John, Viola and Ian presented a new strategy that detailed two key suggestions:

  1. To streamline the capture of death notifications, support is required from the DLPGA to instate ward recorders as official notification agents. Furthermore, the DLPGA must also provide them with the tools and incentives to deliver death notifications. 
  2. To the increase the capture of notifications and cause of death data in remote communities, VAs and MCCOD must be an official requirement in job descriptions of the Community Health Workers and Health Extension Officers. This requires support from the NDOH and provinces. 

It was suggested that direct supervisors will need to be strategic about how CHWs and HEOs conduct VAs. Verbal Autopsies can be conducted within 12 months after a death. So when death notifications are received, VA interviews can be integrated into pre-existing campaigns like immunization drives or outreach visits, and be performed by health staff at remote aid posts in each area.

The new strategy received full endorsement and all parties agreed to a timeline and plan for role change integrations. Initially, the change in roles will be limited to approximately three health centres across UoM’s existing sites. Once complete, the role changes will expand to another three sites; East Sepik, Enga and Port Moresby General Hospital.

"It's all about moving towards sustainability and getting the government to take the lead; to think how best this works in each local area."

- Dr Paison Dakulala

“It’s all about moving towards sustainability and getting the government to take the lead; to think how best this works in each local area” - Dr Paison Dakulala

CRVS Committee_
The National Burden of Disease Committee, PNG
The committee is chaired by the deputy secretary for health and comprised of senior staff from the NDOH, School of Medicine and Health Sciences and the Institute for Medical Health Research.

Simultaneous to these activities, the UoM and NDOH have been rolling out the electronic National Health Information System (eNHIS) with support from DFAT and Bloomberg Philanthropies. 

eNHIS will be a game changer for CRVS in PNG. The system will enable death notifications from across the nation to come directly to the NDOH.

Depending on the details of the death notification, eNHIS will either trigger the completion of an MCCOD certificate or a VA interview will be assigned to the staff responsible.

The death notification form on the eNHIS platform

To date, birth and death notification forms have been incorporated into the system due to the efforts of UoM. eNHIS has trialed for two years in eight provinces and will be rolled out to all 22 provinces by the end of 2020.

Big changes are in progress that will benefit Papua New Guinea and the staff who conduct MCCOD and VA activities. Whilst Rabaraba may still be far away for field coordinators like Martha, important changes to roles and CRVS process are very near.

Martha with a child from Makamaka LLG

For more information on CRVS in Papua New Guinea have a look at the resources below.

An analysis of cause of death data from PNG
PNG: Targeted interventions for sustainable change
CRVS strengthening in PNG

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