With the support of United Nations Population Fund (UNFPA), NSV has been operational in PNG since 1997 following the training of 25 PNG health care professionals in Indonesia to obtain an international certificate of NSV from the Association for Voluntary Surgical Contraception International (AVSC). The NSV program has been integrated within public health services and non-government organizations (NGOs), similar services that may be called upon to incorporate a MC program. However, the momentum to sustain a NSV program has been very difficult in PNG according to the results of 14 KIIs (frontline HWs, n = 7; upper level health system officials, n = 7) representing four NSV services in PNG (Table ). Difficulties with transportation, access, staffing, training, financing and resources were all described as barriers. The following results are presented within the WHO building blocks of a health system and include the analysis of key documents including government reports and policy documents.
Overview of four NSV services that took part in this research
Leadership and governance
No-scalpel vasectomy (NSV) provides an important component of the NDoH family planning program for safe motherhood, as well as a strategy to address population growth in PNG (an identified concern since independence in 1975). The NSV program is overseen by the NDoH with the decentralized health system resulting in provincial governments being responsible for administrating and prioritizing the service at a local level. NSV has been highlighted within numerous PNG policy documents including the National Health Plan (2011–2020); Reproductive Health Policy (2009); National Family Planning Policy (2007); and National Population Policy (2000–2010); to assist in reducing the burden of maternal mortality and morbidity in PNG, as part of the Millennium Development Goal to improve maternal health. However despite this support, the NSV program competes with a number of other priorities within provincial and national health departments. As a result, control of the program as a nationwide effort is often underpinned by provincial and district level priorities resulting in mixed results throughout the country. Table describes the structure and leadership of the 4 NSV services analysed.
National level officials acknowledged that there were historical difficulties for effective governance and leadership of the NSV program for various reasons. In particular, leadership on strengthening the health system in general was seen as a much needed priority for the success of any program.
"Getting the health systems right in the first place is a priority. Because at the moment our health systems are in tatters, they have collapse, anything outside a couple of successful provincial hospitals. And nothing else much works."
"KII upper health system"
Other key issues highlighted by upper lever health system officials include the effectiveness and efficiency of the government to organise an effective program, including promotion and implementation Table (quote 1 & 2). Being able to translate policy into practice was also acknowledged by one government official as a key issue.
Illustrative quotes for Leadership, Governance and Health Financing
"Family planning has been identified as an important issue. So in terms of priorities it is in the policy document. Now it is the question of translating it into actual operations and this does rely on the capacity of the facilities. However, you also have got national provincial and district government. So we can come up with a policy or a statement saying that the priority is this, but when it goes to actual service delivery it depends if it is a priority at the other levels. There may be other challenges that they may face."
"KII Upper Health System Official"
Sustainability of services was often described to be heavily reliant on key drivers within provincial government and frontline health services as well as ongoing financial commitment from both provincial and national governments. As one provincial health official who worked within a province with a successful NSV program explained:
"At the provincial level, we have a budget for family health services because one of our priorities is family health services including safe motherhood. Vasectomy falls within this. Because now we can see that our population is increasing at a very alarming rate. And compared with economic development, the population is just growing miles. We understand this, so in this province one of our priorities is the family planning program."
"KII Provincial Health Official"
The impact of poor leadership was evident with many of the frontline health workforce. According to frontline HWs interviewed, feelings of poor support from government including difficulties accessing funds and resources was often a problem. As a result, many had difficulties with maintaining momentum for the service.
"…I could have done better but I got stranded, logistically, the transport and all this. And the thing is the province they didn’t give me enough support. And also in my district, even though they knew NSV was very important, they couldn’t fund it. They couldn’t support me."
"KII frontline HW"
Funding for the NSV service has been historically sourced from a variety of government and multinational organizations, in particular the UNFPA and Health Sector Improvement Program (HSIP). With funding coordination at national government level, provincial governments are responsible for obtaining money and allocating it to the service accordingly. Participants reported ongoing difficulties with accessing funds to support NSV activities including supervision of newly trained health workers, providing outreach services and obtaining equipment Table (quote 3, 4 & 5). This was not only described as being due to actual availability of funds, but also to the limited maneuverability of funds through the system, resulting in reported delays:
"So we have no funding for the training and we are still waiting, I don’t know where the funding will come from. The funding will come, but from which source I don’t know. I am still waiting. I will just wait."
"KII frontline HW"
In two of the provinces reviewed, NGOs have been able to bridge the gap by providing financial or technical support to the training program or outreach services. Maries Stopes and Pathfinder International are the only two NGOs currently operating in PNG that have become involved with the NSV program. Pathfinder International provides financial support for training and allowances for outreach services in Madang Province. Marie Stopes operates at urban clinics and provides peri-urban outreach services in Port Morseby, NCD, as well as supporting NSV programs in more remote areas of Central Province. Small user fees were required by one NGO to access the service. NGO support is not available in all provinces but some provinces, such as EHP, have successfully implemented NSV programs without direct local-NGO support.
Systemic issues such as funding, and provincial and national government support resulted in uneven service deliver across provinces and over time (Figure ). Other key factors were poor supervisory support and training for staff; staff migration; inadequate program monitoring and evaluation; poor integration of the NSV program with other health services; and transport and logistical difficulties.
No-Scalpel Vasectomies carried out in Papua New Guinea, 2002 – 2006. [Adapted from O'Connor, M. (2007).].
High demand and increasing waiting lists for the NSV service were commonly experienced in rural areas. However, waiting lists also existed in urban settings due to irregular financial support of designated staff, as well as inflexible times at which the service could be offered:
"Last year, we had two clients that were booked for vasectomies, but the doctor who was going to do the vasectomies wanted to do it on a Saturday, and these two guys, they go to church on Saturdays, so they couldn’t come. And they are still on the waiting list."
"KII frontline HW"
Raising expectations within communities for services through promotional activities resulted in a construction of obligation between worker and potential client. With increasing awareness and demand, but no service to support this, creation of dissatisfaction within the community became evident. For example, one respondent described an incident where he was confronted by a man who was particularly frustrated with waiting for the service.
"One client arrived here with a very bad temper. And he says “I am waiting and waiting and I have already four children.” He wanted to try and sue me for not arranging to go to him [in his village] because while he was waiting he had two sets of twins. And that made him really angry. So he came and said “your program is not a good program.” So he was not just talking about the procedure itself but the waiting that existed for us to go out and do the procedure. That was one of my struggles that I had."
"KII frontline HW"
According to frontline HWs an increasing demand for NSV services had been observed and was believed to stem from increasing economic pressures and demand for land experienced in communities as people continued to have large families. One HW also reported that after providing NSV services within a small community, he discovered that some men appeared to have been motivated by a desire to have more sexual partners without the fear of having more children.
Health information systems
A challenge with developing efficient and effective health information systems in PNG was a concern for all upper health system officials.
"Our population is so scattered and so remote, we try to build up our surveillance as much as possible. And because of the remoteness of our communities it is a great challenge to us. And try to build up a system that will enable us to get information quickly, to respond to it quickly. But you know it has been a great challenge to us."
"Upper Health System Official"
This was evident in the review of the NSV program with details of national statistics for NSV services difficult to obtain prior to 2002. Estimates derived by triangulating data from several sources, suggest that the data recorded in Figure may represent only about 50% of the total number of vasectomies conducted. This raises questions about demand:
"…the national picture for me at the moment is, well I know that the demand is there for vasectomy services and that there are limited service providers. That is the general picture, the general statement I can make. But in reality in terms of hard data, I cannot prove that."
"KII upper level health official"
Numbers on waiting lists were also often difficult to ascertain. No data on adverse events, including infection rates or failure rates, appeared to be systematically collected by any of the NSV services reviewed. Post-operative monitoring was also rarely completed due to the difficulties of access, population mobility and limited ability to contact people in PNG e.g. lack of mobile phone ownership or access in rural areas. These difficulties were noted to be a significant problem by all upper level health officials.
Access to essential medicines, equipment and other resources
All frontline HWs reported that access to essential medicines and equipment for the NSV service was not a real problem despite upper level health officials suggesting that access difficulties were a common problem in PNG and likely had a significant impact on NSV service provision. However frontline HWs did report significant difficulties in accessing drugs for other components of the family planning service.
"I order the drugs through the local guys, but they told me that the won’t be ordering drugs for family planning commodities. Now family planning drugs are coming from Moresby. Like the vaccines. So I ordered them in November and I still haven’t got the supplies here [4
months later]. And ah we called this morning and they said the person who is in charge for doing the order for the, the family planning orders, he has been sacked or something. So now we are running out of things and have to send people elsewhere."
Lack of transport for the NSV program, particularly for outreach visits, was considered more of an important obstacle by all frontline HWs. To deliver outreach programs, the HWs reported needing to rely on vehicles from other programs to assist.
"Equipment and drugs for the NSV I would not say is really bad, I think there is enough. But the biggest problem is that we do not have transport. At one stage, I thought that I was going to get a vehicle so I started planning my program to go from district to district there, and not be restrictive to the district here.However, it was given to someone else."
Expanding human resources has been a key objective of government policy since the initiation of the NSV program in 1997. HWs at different levels have been trained including doctors, health extension officers (HEOs), nursing officers (NOs) and community health workers (CHWs). Difficulties with attrition of trainees and in implementing the NSV accreditation program continue to be reported by both frontline HWs and upper health system officials.
"I have trained health workers but we don’t know how they progress. I have no idea where they are now, or whether they are performing the procedures or not. So it is a sad story to me… It’s a waste of funds and all that, just training them and leaving them like that."
"KII frontline HW"
Training and support supervision are provided by a small number of clinicians in PNG and even fewer clinicians are currently able to certify HWs as vasectomists. A certified vasectomist would be expected to have demonstrated competent skills by completing 50 supervised vasectomies (fewer than 50 if they are a medical doctor) as well as proficient theoretical knowledge to implement the procedure. However, with limited supervisors available, many HWs who have received training have subsequently been left unsupervised and uncertified. Little information was available about what happens to those who are trained but unable to complete the supervision and certification program. This was a concern of both upper level health officials and frontline HWs.
"The training part is easy, we can do that. The difficult bit is the follow up. Follow up supervision. That has been really poor. Even from the beginning. I was in Madang, we trained 50 or 53 health workers. And so far we have only certified two of them."
"KII Upper level health official"
These difficulties with implementing the training and supervision program were reported as due to a lack of staff to deliver the program, but also to difficulties with accessing funds and general travel to areas in PNG. Frontline HWs who have been certified all describe long periods of waiting to be officially certified and recognized as a vasectomist.
"I am a CHW. I did my training on vasectomy as hands on training. And they certified me with a certificate from UNFPA; they gave me a certificate last year, early last year. But I went previously for more than 10
years, on vasectomies before that."
"KII frontline HW"
There were also reports from respondents admitting to performing unsupervised NSV, despite not being officially certified.
Upper level health officials acknowledged the importance of frontline HW’s initiative and dedication to their post-training program. The onus on frontline HW to promote services within the community and to maintain strong communication with trainers and upper level health officials, was considered an important factor in staff retention difficulties and an inability of the service to prevent staff migration to other programs.
It was unanimous among all upper level health officials and those involved in training that among all HWs, CHWs were the most likely to remain dedicated to providing and sustaining NSV services. This was considered a result of their work being conducted directly within communities.
"CHWs are interested, because they are right at the post where the population is. So it really acts like something that is very important to them, that is why they have been so successful."
"KII frontline HW"
Community engagement was identified as an integral part of a successful NSV program due to CHWs ability to promote the service.