Papua New Guinea

Climbing mountains to conduct VAs

Martha Wame is one of the Field Coordinators for the Bloomberg Philanthropies Data for Health initiative in Papua New Guinea. 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 Verbal Autopsy interview.

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

Martha Wame hikes to reach rural wards to conduct verbal autopsies

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

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

Generally speaking, 78km via road can take an hour and a half by car. For Martha, there isn’t a road that connects Alotou to Rabaraba. She must drive 2 hours north of Alotou, here she finds a local to pay for a 3-hour boat trip to Rabaraba.

Martha Wame sits in a boat taxi on her way to Rabaraba

Martha travels via boat taxi to reach Rabaraba

During her trip she must also be cautious. Papua New Guinea (PNG) has a high crime rate; acts of piracy, theft and violence are common. This limits her travel to certain areas and when she does travel, she must be accompanied in a group. 

Martha will travel via Dogura or Rabaraba and then onward to Makamaka LLG where she spends approximately two weeks to a month visiting surrounding communities. As there are no roads, she must walk for hours to reach families and homesteads, sometimes hiking mountains and rough terrain to reach her destination. 

A common route Martha travels to reach the rural wards of Makamaka LLG 

Among most of these wards are ward recorders. Ward recorders are employed by the Department of Provincial and Local Government Affairs (DPLGA) to record activities in their communities, including birth and death notifications. Martha collects all death notifications from these ward recorders.

Prior to her trip, she received notifications from wards in the Makamaka LLG. So she knows that Verbal Autopsy (VA) interviews are required in specific wards. She conducts VA interviews with the 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. 

Whilst passing through communities she also collects any notifications from Community Health Workers (CHW) and Health Extension Officers (HEO). These roles are funded by the National Department of Health (NDOH) and are similar to the roles of nurses and doctors. They can 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 an example of one out of the many trips our field coordinators have made to collect mortality data in PNG. Martha's trip demonstrates that the field coordinator is doing much more than facilitating and ward recorders, CHWs and HEOs are far better placed to be acting as notification and VA agents.

In November 2019, new strategies were discussed with the PNG government in order to streamline notifications and VA data collection. To understand the new strategy, we must look to the past and current circumstance of Civil Registration and Vital Statistics (CRVS) in PNG. In 2016, PNG joined the Bloomberg Philanthropies Data for Health (BD4H) initiative. BD4H pledged to assist PNG in the implementation of interventions to strengthen CRVS systems. With a high priority on two interventions:
1) Strengthening the collection and sharing of birth and death data from communities.
2) Strengthening national mortality reporting. 
To achieve this, a partnership formed between PNG government departments, BD4H, the Australian Department of Foreign Affairs and Trade (DFAT) and the University of Melbourne (UoM). It was decided that UoM D4H would drive the implementation of the interventions in collaboration with the PNG government and support from BD4H & DFAT.

Image of children in class in Port Moresbey

Children in class at Port Moresby - Creative Commmons, Ness Kerton

PNG has a population of over 8 million people with 87% residing in remote communities. Medical Certification of Cause of Death (MCCOD) practices only record deaths in hospitals and 85 to 90% of deaths occur outside of hospitals. This means that the only way to capture COD data from remote communities is through the VA intervention.

Together, Professor Ian Riley, Doctor Viola Kwa and Doctor John Hart are the driving force for the UoM D4H initiative in PNG. They discuss ideas with the PNG government and suggest how best to put in place CRVS strengthening interventions. To date they have organised many training sessions nationwide, as well as driven the implementation of VA and MCCOD interventions in Alotau, Talasea and Tambul-Nebilyer districts. Due to their efforts in these districts, approximately 40% of death notifications have been captured in the CRVS systems. Additionally, they have presented COD data collected from VAs to the PNG government – A first for the nation.

Dr John Hart and Dr Viola Kwa

Dr John Hart and Dr Viola Kwa

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

Martha's trip demonstrated that the current process works, but it requires improvement. Ward recorders should collate and deliver death notifications to health centres for the system to be sustainable. However, due to various limitations they are underutilised as notification agents. 

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 are often subjected to poor signal reception. Most rely on paper forms to capture deaths in the community and deliver to health centres. This can require walking 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 not utilised for VA purposes. VA is a new tool and therefore not included as a requirement in their current job descriptions. This means that field coordinators have been the main source of reliable COD data.

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 these limitations are addressed. The solution starts with the National Burden of Disease Committee of PNG. The committee was set up by Professor Ian Riley and local country coordinators to analyse mortality data and support UoM D4H verbal autopsy and MCCOD activities. Since its conception the committee has evolved, and the PNG government have taken ownership.

The National Burden of Disease Committee meets on the 26th of November at the School of Medicine and Health Sciences, Port Moresby

The National Burden of Disease Committee of PNG meets on the 26th of November, 2019

The committee is chaired by the deputy secretary for health and comprised of senior staff from; the National Department of health, the School of Medicine and Health Sciences and the Institute for Medical Health Research. Additionally, Prof Ian Riley, Dr Viola Kwa and Dr John Hart represent UoM D4H and are the acting secretariat for the committee. John and Viola drive the data analysis and present new findings from VA and MCCOD data. 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 can be integrated into pre-existing campaigns like immunization drives or outreach visits, and be performed by health staff at more remote aid posts in each area.

UoM D4H received full endorsement from all parties for the new strategy. UoM D4H, DPLGA, NDOH and provincial administrations agreed upon a timeline and plan for role change integrations. The plan is to start small, then expand. Initially the change in roles will be limited to approximately three health centres across UoM D4H’s existing sites. Once complete, the role changes will be expanded 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

Simultaneously, UoM D4H and NDOH have been running VA implementation parallel to the current rollout of the electronic information system with the support of DFAT and BD4H. The electronic National Health Information System (eNHIS) will be a game changer for CRVS in PNG. The system will enable all death notifications to come directly to NDOH from across the nation. Depending on the details of the death notification, the system will either trigger completion of an MCCOD certificate or VA and will be assigned to the person responsible.

To date, birth and death notification forms have been incorporated into the system due to the efforts of UoM D4H. The eNHIS has been trialled over two years in eight provinces and will be rolled out to all 22 provinces by the end of 2020.

A screenshot of the death notification form on the eNHIS platform

Screenshot of the Death Notification form on the eNHIS platform

Big changes are in progress that will benefit PNG as a country and the staff who conduct MCCOD and VA activities. Whilst the wards of Makamaka LLG and Rabaraba may still be far, far away for field coordinators like Martha, vital changes to CRVS processes are very near.

Martha Wame with a child from a rural ward

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