2
Children at Buk Bilong Pikinini. Port Moresby, PNG 2013
Photo: Ness Kerton / Department of Foreign Affairs and Trade, the Australian Government 2013
Papua New Guinea Child Health Policy and Plan 2009-2020 (Updated 2015).
Port Moresby, Papua New Guinea. 2015
PNG National Department of Health and Paediatric Society of PNG
Printed with support from the RE Ross Trust (Victoria)
UPDATED EDITION 2015
CHILD HEALTH
POLICY AND PLAN
2009-2020
PAPUA NEW GUINEA
3
FOREWORD .................................................................................................................................................................... 6
ACKNOWLEDGEMENT................................................................................................................................................ 7
ABBREVIATIONS ........................................................................................................................................................... 8
EXECUTIVE SUMMARY ............................................................................................................................................ 10
1.1 Global and historical context .................................................................................................................... 13
1.2 Need for and intent of the policy ............................................................................................................. 13
1.3 Audience ................................................................................................................................................... 13
CHAPTER 2. POLICY DIRECTIONS ........................................................................................................................ 15
2.1 Policy goals.............................................................................................................................................. 15
2.2 Policy objectives ...................................................................................................................................... 15
2.3 Policy principles ...................................................................................................................................... 15
2.4 Guiding principles of partnership in Child Health Policy ........................................................................ 15
2.5 Population policy ..................................................................................................................................... 16
2.6 Core government commitments and policies ........................................................................................... 16
2.7 Legislation ................................................................................................................................................ 17
3.1 Human resources ..................................................................................................................................... 19
3.2 Service delivery ....................................................................................................................................... 19
3.3 Medical products and technology ............................................................................................................ 20
CHAPTER 4. POLICY CONTENT ......................................................................................................................... 21
4.1 Integrated management of childhood illness (IMCI) ................................................................................ 21
4.2 Expanded Program of Immunization ........................................................................................................ 21
4.3 Standard treatment guidelines.................................................................................................................. 21
4.4 Neonatal care ............................................................................................................................................ 21
4.5 Breast feeding, nutrition and micronutrients ........................................................................................... 22
4.6 Quality improvement in hospital care ...................................................................................................... 22
4.7 Pneumonia ............................................................................................................................................... 22
4.8 Malaria ..................................................................................................................................................... 23
4.9 Tuberculosis ............................................................................................................................................ 23
4.10 HIV ........................................................................................................................................................ 23
4.11 Paediatrician training ............................................................................................................................. 23
4.12 Child health nurses and midwives ......................................................................................................... 24
4.13 Community health workers .................................................................................................................... 24
4.14 Continuing professional development ................................................................................................... 24
4.15 Adolescent health................................................................................................................................... 24
4.16 Cancer, heart disease, paediatric surgery ............................................................................................... 24
4.17 Child protection and social services ...................................................................................................... 24
4.18 Child disability ...................................................................................................................................... 25
CHAPTER 5. MONITORING AND EVALUATION ............................................................................................ 26
5.1 Policy development in child health .......................................................................................................... 26
VOLUME II SECTION I. CHILD HEALTH PLAN .................................................................................................. 27
CHAPTER 6. INTRODUCTION .................................................................................................................................. 28
6.1 Child health in PNG: recent progress and current challenges ......................................................................... 28
6.2 Child mortality ..................................................................................................................................................... 29
6.3 Common causes of childhood illness and death ................................................................................................ 29
6.4 Health facility network ........................................................................................................................................ 30
6.5 Human resources in child health ........................................................................................................................ 30
4
6.6 Population issues and Family Planning ............................................................................................................... 31
CHAPTER 7. PROGRAM AREAS .............................................................................................................................. 32
7.1 Integrated Management of Childhood Illness (IMCI) ...................................................................................... 32
Progress in the components of IMCI in PNG ..................................................................................................... 32
Health systems issues ......................................................................................................................................... 32
7.2 Expanded Program of Immunization ................................................................................................................ 33
7.3 Standard Treatment and Clinical Guidelines .................................................................................................... 35
7.4 Neonatal Care ....................................................................................................................................................... 36
Early essential newborn care .............................................................................................................................. 36
Appropriate models of neonatal care .................................................................................................................. 36
Care of the low birth weight baby ...................................................................................................................... 37
Neonatal sepsis ................................................................................................................................................... 37
Baby Friendly Hospital Initiative ....................................................................................................................... 37
A centre of excellence for neonatal care............................................................................................................. 38
Activities ............................................................................................................................................................ 38
7.5 Nutrition and Malnutrition ................................................................................................................................. 39
Malnutrition ........................................................................................................................................................ 39
Breast feeding promotion ................................................................................................................................... 39
Complementary feeding ..................................................................................................................................... 39
Micronutrients .................................................................................................................................................... 40
Vitamin A ........................................................................................................................................................... 40
Deworming ......................................................................................................................................................... 40
Zinc .................................................................................................................................................................... 40
Growth monitoring every time a child receives vaccines ................................................................................... 40
Nutritional support to sick and malnourished children ....................................................................................... 40
Human resources for nutrition ............................................................................................................................ 41
Essential nutrition requirements ......................................................................................................................... 41
7.6 Improving Quality of Hospital Care .................................................................................................................. 43
WHO Pocketbook of Hospital Care for Children training course ...................................................................... 43
Improving oxygen supplies and the management of severe pneumonia ............................................................ 43
Paediatric Hospital Reporting (PHR) program ................................................................................................... 44
Hospital outreach services .................................................................................................................................. 44
Improving the care of children with chronic illnesses ........................................................................................ 45
Improving hospital care for sick adolescents...................................................................................................... 45
7.7 Pneumonia ............................................................................................................................................................ 46
Causes................................................................................................................................................................. 46
Treatment ........................................................................................................................................................... 46
Prevention ........................................................................................................................................................... 47
Surveillance ........................................................................................................................................................ 47
7.8 Malaria.................................................................................................................................................................. 49
Prevention with long lasting mosquito nets ........................................................................................................ 49
Diagnosis and treatment ..................................................................................................................................... 49
Activities and future directions........................................................................................................................... 49
7.9 Tuberculosis ......................................................................................................................................................... 51
Essential measures to reduce child TB ............................................................................................................... 51
TB and HIV ........................................................................................................................................................ 52
GeneXpert testing and multi-drug resistant TB in children ................................................................................ 52
7.10 HIV AND AIDS .................................................................................................................................................. 52
5
Priorities in paediatric HIV ................................................................................................................................ 53
7.11 Training of paediatricians ................................................................................................................................. 55
Training of paediatricians for the next 10 years ................................................................................................. 55
Sub-specialty training ......................................................................................................................................... 55
7.12 Child health nurses and midwives ................................................................................................................... 56
7.13 Community Health Nurses ............................................................................................................................... 58
7.14 Continuing professional development ............................................................................................................. 58
CPD for paediatricians ....................................................................................................................................... 58
CPD for other health workers ............................................................................................................................. 58
7.15 Adolescent Health ............................................................................................................................................... 60
A model of adolescent services within a hospital ............................................................................................... 60
7.16 Childhood Cancer, Heart Disease and Paediatric Surgery ........................................................................... 62
Childhood cancer ................................................................................................................................................ 62
Children with heart disease ................................................................................................................................ 63
7.16 Child protection and social services ...................................................................................................................... 65
Child abuse and neglect ...................................................................................................................................... 65
Reducing domestic violence ............................................................................................................................... 65
Universal education ............................................................................................................................................ 65
Birth registration................................................................................................................................................. 65
7.17 Children with disabilities ................................................................................................................................... 66
Prevention of disability....................................................................................................................................... 66
Support services for children with disabilities .................................................................................................... 66
7.18 Urban and environmental health ....................................................................................................................... 68
Features of healthy environments for children: .................................................................................................. 68
7.19 Child health research ......................................................................................................................................... 69
CHAPTER 8. CHILD HEALTH ADVISORY COMMITTEE .................................................................................. 71
Appendix 3. Child health contact addresses ............................................................................................................. 98
Appendix 4. Core indicators and monitoring ......................................................................................................... 100
Acknowledgements ....................................................................................................................................................... 103
6
FOREWORD
It is with great pleasure that I introduce this updated PNG Child Health Policy and Plan.
Improving child health and education are vital for the future of Papua New Guinea. Sadly, in the last 30
years, child death rates in PNG have been among the highest in the Asia and Pacific regions. The
encouraging news is that in recent years child death rates have reduced, and this is because of a
comprehensive approach that is outlined in this plan. However there is still a very long way to go to achieve
acceptable child survival, health and development. Improvements in child health have not been shared by all.
The poor have missed out. Also child survival gains are not evenly distributed throughout the country. Some
districts have child mortality rates that are 3-4 times higher than the better performing districts. The
challenges are many, including difficult geographical access, weak health systems and limited human
resources. Preventable and treatable diseases such as pneumonia, diarrhoea, malnutrition, HIV and
tuberculosis remain some of the biggest causes of child death. Many of these diseases also cause disability
and long term problems that limit quality of life, educational outcomes and productivity.
The good news is that there are effective interventions to reduce the burden of these illnesses, all of which
are included in this Child Health Policy and Plan, and child health indicators are starting to improve. The
plan emphasizes the importance of primary health care, improving quality of care, disease prevention and
improving the human resources for health. Much can be done, even with limited resources, because of the
commitment of people.
This Child Health Policy and Plan complements our overall National Health Plan and Medium Term
Development Framework. The aim of the National Health Plan is to improve the health of all Papua New
Guineans through the development of a health system that is responsive, effective, affordable, acceptable and
accessible to all people. This National Child Health Plan shows the detail of the child health component of
the overall National Health Plan, and sets out activities and programs that will result in the post-MDG
aspirations being achieved.
With sufficient investment in child health and education, this plan can be fully implemented and our goals
for Child Health can be achieved. Non-health sector policy contexts are also vital; there needs to be
improvements in community development and engagement for better use of health facilities and care
seeking, increased access to education and improved literacy for girls and women, curbing of domestic
violence, increased male involvement in families, and the more equitable sharing of the favourable economic
conditions.
This plan will be used at National, Provincial and local level; by Provincial Health to guide their annual
implementation plans; and to inform health workers, the community and the Government’s partners about
child health priorities and the approaches being adopted.
Special thanks are due to the Paediatric Society of PNG, Family Health Services Branch and the Child
Health Advisory Committee of the National Department of Health for their key roles in reviewing and
revising this plan.
________________________________
Hon. Mr. Michael B Malabag, MP
Minister for Health & HIV& AIDS
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ACKNOWLEDGEMENT
Improving child and maternal health is a major commitment of the PNG National Department of Health and
Provincial Departments of Health. To achieve the Millennium Development Goals for Child Health and the
post-MDG goals of sustainable development, will require that all people responsible for the health and
wellbeing of children focus on the one strategy and work with commitment together. This policy and plan
outlines a comprehensive approach that will result in real and sustained improvements in health services for
children.
It is a tragedy that children in PNG still die unnecessarily, from preventable and easily treatable diseases,
malnutrition and neglect. Our health service can contribute substantially, not only to preventing these deaths,
but by the respectful and caring way we treat children and their families, in minimizing the effects of social
disadvantages and poverty on health and development. We should treat people as we would want to be
treated ourselves; with timely, considerate and effective care and good communication.
The first edition of this document was developed between 2007 and 2009, and was substantially updated
between 2014 and 2015. Many people contributed ideas and suggestions or reviewed various drafts.
Contributions to the writing of this plan were made by members of the Paediatric Society of Papua New
Guinea; Family Health Services of Department of Health; Child Health Advisory Committee; Division of
Child Health, School of Medicine and Health Sciences, University of Papua New Guinea; and Centre for
International Child Health, University of Melbourne.
On behalf of the National Department of Health, I would like to convey my sincere gratitude to all that were
involved in reviewing and revising this very comprehensive and evidence-based Child Health Policy, Plan
and Strategic Implementation Plan for 2016-2020.
I look forward to this Child Health Policy and Plan being promoted and implemented at all levels of
governance by all cadre of health workers, as well as everyone else who contribute one way or the other in
the development and well-being of the children of Papua New Guinea. I would ask you to please read this
document carefully and do what you can to help us implement it.
______________________
Mr. Pascoe Kase
Secretary for Health
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ABBREVIATIONS
IMCI Integrated Management of Child hood Illness
ART Antiretroviral therapy
HIV Human Immune Deficiency
AIDS Acquired Immune Deficiency Syndrome
NDoH National Department of Health
CHP Child Health Policy
EPI Expanded Program on Immunization
IYCF Infant and Young Child Feeding
PPTCT Prevention of Parent to Child Transmission
WHO World Health Organization
WPRO Western Pacific Regional Office
UNICEF United Nations International Children
UPNG University of Papua New Guinea
SMHS School of Medicine and Health Sciences
NGO Non Government Organization
CHW Community Health Worker
FBO Faith Based Organization
HEO Health Extension Officer
ANC Antenatal Clinic
TB Tuberculosis
PTB Pulmonary tuberculosis
EPTB Extra-pulmonary tuberculosis
FDC Fixed Dose Combination
MDR-TB Multi-drug resistant tuberculosis
PCR Polymerase Chain Reaction
NHIS National Health Information System
MDG Millennium Development Goal
CHAC Child Health Advisory Committee
CAP Community Action Program
VHV Village Health Volunteer
VBA Village Birth Attendant
DHS Demographic Health Survey
HFS Health Facility Survey
AIP Annual Implementation Plan
HSIP Health Sector Improvement Program
9
SIA Supplementary Immunization Activity
STM Standard Treatment Manual
DOTS Directly Observe Treatment Strategy
BFHI Baby Friendly Hospital Initiative
10
EXECUTIVE SUMMARY
The first edition of the national Child Health Plan was produced in 2009. It was designed as a road-map for
the development of health services for children in PNG from 2009 to 2020, and was incorporated as the child
health component of the National Health Plan 2011-2020.
The Plan was reviewed in 2014 and 2015 by members of the PNG Paediatric Society, the National
Department of Health and the University of PNG, and this revised Policy and Plan was endorsed on 3rd June
2015. It is recognised that much progress had occurred in the first five years of the Plan. These included:
reducing malaria, increasing the use of insecticide-treated bed nets, the introduction of new vaccines against
pneumonia and meningitis, slowing of the HIV epidemic, PCR for early infant diagnosis of HIV, improved
paediatricians coverage in provinces, better surveillance and outcome data at hospital level. In addition there
have been other improvements: training, improved guidelines, and increased zinc and vitamin A. However
there is much work to be done, many old problems exist and new problems have emerged. This updated
version of the Child Health Policy and Plan aims to re-frame efforts in the next five years 2016-2020.
Background to the first edition
The first edition of the Child Health Plan 2009-2020 followed the World Health Organization (WHO) and
the United National Children’s Fund (UNICEF) launching the joint Child Survival Strategy for the Western
Pacific Region in 2005.
1
In September 2005, at the fifty-sixth session of the Western Pacific Regional
Committee of the World Health Organization, the PNG Government, through the Health Minister supported
and endorsed the WHO/UNICEF Regional Child Survival Strategy.
2
This strategy was designed to put child
health higher on the political, economic and health agendas, renew efforts to reduce child mortality with
support being mobilized by the regional office and donors, and expand current child and reproductive health
activities. For the development of the first edition of the Child Health Plan meetings and consultations were
held between July 2007 and September 2008 with child health people from the Department of Health, the
Child Health Advisory Committee (CHAC), the PNG Paediatric Society, the University of PNG, nursing
personnel, provincial health staff, nutritionists and members of the community.
Major recommendations of the WHO/UNICEF Regional Child Survival Strategy were to have technical
interventions that have proven effectiveness in reducing child mortality in low income countries, outlined in
the Lancet Child Survival Series of 2004. The Regional Child Survival Strategy focuses on the importance of
integrated service delivery and continuum of care, universal access to key child survival interventions as a
goal with a focus on major causes of mortality, scaling up and quality improvement at all levels of the health
system. The key child survival interventions are: safe motherhood, neonatal care, breast feeding and
complimentary feeding, micronutrient supplementation, the Expanded Program on Immunization (EPI), the
Integrated Management of Childhood Illnesses (IMCI) and improving the quality of hospital care, malaria
control and insecticide treated materials. In PNG three other components have been added to the essential
list: HIV prevention and antiretroviral treatment; scaling up TB prevention and treatment; and promoting
family planning.
The Western Pacific regional strategy also called for:
One effective high level co-ordination mechanism (such as a Child Health Committee)
One integrated national plan for child survival
One national monitoring and evaluation system measuring core child survival indicators
This Child Health Policy and Plan 2009-2020 describes a balanced and integrated program that incorporates
almost all of the essential interventions proven to reduce child mortality in low income countries,
3
in an
integrated service delivery. This document emphasizes the strong EPI that has developed over years. The
policy and plan also emphasizes the importance of Safe Motherhood, Neonatal Care, and case management
which are crucial to reducing the high rates of neonatal mortality. ‘Integration’ should be between all child
health programs, and between maternal and child health, and between child health and disease-specific
programs, such as Roll-Back Malaria, nutrition, the National TB program and HIV.
This document includes sustainable activities in service delivery, training and continuing education which
have been introduced successfully in recent years, and which strengthen each level of the health service. The
plan also describes the co-ordinating committee (Child Health Advisory Committee, CHAC), which has
responsibility for implementation, oversight, and monitoring.
11
This plan also describes the core indicators that would enable progress to be monitored by CHAC. These are
simple, measurable, and objective indicators of progress towards establishment of sustainable programs with
high coverage, and progress toward the achievement of the Millennium Development Goal targets,
particularly MDG-4 (the reduction of the under five mortality rate by two thirds between 1990 and 2015. In
PNG this target is an U5MR of around 32 per 1,000 live births).
The Child Health Policy and Plan recognizes that other areas are important to child health in PNG, including
adolescent health, family planning and maternal health. Adolescent health has been largely neglected by
medical services in many countries, including PNG; paediatricians have concentrated on children aged 0-12
years, and adult physicians have focused on those over 18 years of age. A focus on adolescents is an
opportunity to protect children from acute and chronic infections including STDs, HIV/AIDS, lifestyle
diseases, chronic non-communicable disease and social problems which result in the majority of the disease
burden in adults in PNG. It is also an opportunity to promote good health for future mothers and fathers.
Family planning is crucial to achieving progress in child and maternal survival and other health outcomes.
Nutrition is important to ensure that girls enter their reproductive years in good health and minimize
complications during pregnancy and delivery.
The plan recognizes the central importance of people if the technical interventions known to be effective for
child survival are to be scaled up. Increased training of child health nurses and nutritionists, training of
pediatricians as leaders in child health, and teaching the components of this plan in pre-service nursing,
community health worker, HEO, and under-graduate medical training will be important.
Throughout the plan we have listed key messages for provincial health staff. These are designed to assist you
implement the plan. At the end of the plan we have listed key contacts. If you have any questions about the
child health, please contact the relevant people.
Figure 1. Map of Papua New Guinea
12
VOLUME I
CHILD HEALTH POLICY 2009–2020
UPDATED 2015
13
CHAPTER 1. BACKGROUND
Improving child health, education and welfare are vital for the future of Papua New Guinea. Improving child
health and reducing child deaths has profound economic and social benefits for a country. Between the
1970s and 1990s, child death rates in PNG were among the highest in the Asia and Pacific regions. The
encouraging news is that in recent years child death rates have reduced, and this is because of the
comprehensive approach that is outlined in this policy and plan. Significant progress has occurred in the last
10 years, but there is still a very long way to go to achieve acceptable child survival, health and
development.
The challenges are many, including difficult geographical access, weak health systems and limited human
resources. Preventable and treatable diseases such as pneumonia, diarrhoea, malnutrition, neonatal sepsis,
birth asphyxia, HIV and tuberculosis remain some of the biggest causes of child death. Many of these
diseases also cause disability and long-term problems that limit quality of life, educational outcomes and
productivity. Many problems have emerged, including social problems within urban environments, the
challenges of adolescent health, the care of children with chronic illnesses, and child and family mental
health.
The good news is that there are effective interventions to reduce the burden of these conditions, all of which
are included in this Child Health Policy and Plan, and child health indicators are starting to improve. The
policy and plan emphasizes the importance of primary health care, improving quality of care, disease
prevention and improving the human resources for health.
1.1 Global and historical context
In 2005, the World Health Organization (WHO) and the United National Children’s Fund (UNICEF)
launched the joint Child Survival Strategy for the Western Pacific Region.
1
In September 2005, at the fifty-
sixth session of the Western Pacific Regional Committee of the World Health Organization, the PNG
Government, through the Health Minister supported and endorsed the WHO/UNICEF Regional Child
Survival Strategy.
2
This strategy was designed to put child health higher on the political, economic and
health agendas; renew efforts to reduce child mortality with support being mobilized by the Regional office
and donors; and expand current child and reproductive health activities.
1.2 Need for and intent of the policy
To assist a better understanding of the current situation and to provide some baseline data the Child Survival
Country Profile: Papua New Guinea was published in 2006. This policy and plan was developed in response
to the WHO/UNICEF Regional Child Survival Strategy. A series of meetings and consultations were held
between July 2007 and June 2009 with child health people from the Department of Health, the Child Health
Advisory Committee, the PNG Paediatric Society, nursing personnel, provincial health staff, nutritionists and
members of the community.
Major recommendations of the WHO/UNICEF Regional Child Survival Strategy are to have technical
interventions that have proven effectiveness in reducing child mortality in low income countries, outlined in
the Lancet Child Survival Series. The Regional Child Survival Strategy focuses on the importance of
integrated service delivery and continuum of care, universal access to key child survival interventions as a
goal with a focus on major causes of mortality, scaling up and quality improvement at all levels of the
system. The key child survival interventions are: safe motherhood, neonatal care, breast feeding and
complimentary feeding, micronutrient supplementation, the Expanded Program on Immunization, the
Integrated Management of Childhood Illnesses (IMCI) and improving the quality of hospital care, malaria
control and insecticide treated materials. In PNG three other components have been added to the essential
list: HIV prevention and antiretroviral treatment; scaling up TB prevention and treatment; and promoting
family planning.
1.3 Audience
This policy and plan will be used at national, provincial and local level to guide their annual implementation
plans and to inform health workers, the community and the Government’s partners about child health
priorities and the approaches being adopted. The policy and plan will also be shared with international
14
development partners, donor agencies, NGOs and other stakeholders both within the public and private
sector.
15
CHAPTER 2. POLICY DIRECTIONS
2.1 Policy goals
The goals of the Child Health Policy and Plan are to reduce child mortality and to improve the general
quality of health and development of the children of Papua New Guinea.
2.2 Policy objectives
The objectives of the Child Health Policy are:
To improve the quality, access and delivery of health services to children and young people of Papua
New Guinea
To reduce the neonatal, infant and under five year old mortality as per the Millennium Development
Goals (MDG-4)
To reduce the burden of childhood tuberculosis and HIV
To address chronic non-communicable diseases of children
To build a comprehensive and sustainable child health program for the post-2015 agenda
2.3 Policy principles
It is the right of every child to good health and protection from harm. The Government of Papua New Guinea
recognizes that and had been a signatory to the 1989 United Nations Convention of the Rights of the Child.
Furthermore, the Government of Papua New Guinea recognizes that the future of this young and developing
nation depends on the wellbeing of its most important resource - the children, who will be the leaders of the
nation.
Thus the Government of Papua New Guinea recognizes this Child Health Policy as the instrument through
which its vision and goals of developing a better Papua New Guinea becomes a reality.
2.4 Guiding principles of partnership in Child Health Policy
The scope and level of partnership for child health in Papua New Guinea depends on the following
principles:
Responsibility for Policy
The overall responsibility for health policy formulation (including the Child Health Policy and Plan),
monitoring and evaluation and the health status of the children of PNG is maintained by the Government of
Papua New Guinea through the National Department of Health. The National Department of Health will
consult its partners and aims for consensus in all cases of common concern.
Responsibility for Service Provision
Provision of health services to the children of Papua New Guinea pertains to the different service delivery
partners: Government agencies (hospitals, health clinics, provincial, district and public health offices),
church health services, non-government organizations (NGO), private health care organizations, schools and
universities of health care worker training and development partners (local and international partners and
agencies).
Complementarities
All external partners shall strive to support and complement the services of Government and other
institutional agencies, and align with the content of this policy and plan, rather than run parallel services.
Identity and Autonomy
The identity and autonomy of each partner is respected.
Equity
16
The allocation of resources for implementation of the Child Health Policy and Plan shall be made in
accordance with disease burdens, the most effective use of resources, and with the aim of reducing inequity.
Transparency and Accountability
Inputs, outputs and outcomes pertaining to the attainment of the child health goals are agreed to, reported by,
and shared among partners.
2.5 Population policy
Paediatricians, obstetricians and other maternal and child health workers are aware that one of the factors in
PNG that has the potential to derail all the positive gains made so far is uncontrolled population growth.
PNG now has almost a 3% population growth rate with a projected doubling time of 20 years. This means
that in 10 years time the child and adolescent population will have been increased by around 2 million.
This will put immense pressure on resources with a requirement in commensurate increases in number of
health facilities, personnel, schools, jobs etc. Moreover there will most likely be detrimental effects on
overall socio-economic status of families, provision of education and increase in social discord, urban drift,
food insecurity, degradation of the environment, the further loss of biodiversity, natural flora and fauna, and
land shortages and increase in land disputes.
There is abundant evidence of an adverse effect on child health and mortality of narrow birth spacing. Infant
mortality is very high for children born following a birth interval of less than 2 years after the previous birth;
IMR is 71 per 1,000 live births, compared with 42 per 1,000 live births for children born 3 or more years
after the previous birth.
The Paediatric Society, the Society of Obstetricians & Gynaecologists and Family Health Services advocates
that population policy needs to be dealt with at the highest levels, with the utmost urgency. The country’s
political leadership must be made aware of the need to address this issue at the national level and legislate
for a concerted effort, and at a community level. This will require mobilisation of all segments of society as
the ill effects of the population explosion will impact on all areas of life.
2.6 Core government commitments and policies
This Child Health Policy and Plan complements PNG’s overall National Health Plan (2011-2020), Medium
Term Development Framework, and builds on the previous National Health Plan 2001-2010. The aim of the
National Health Plan is to improve the health of all Papua New Guineans through the development of a
health system that is responsive, effective, affordable, acceptable and accessible to all people. This Child
Health Policy and Plan shows the detail of the child health component of the overall National Health Plan,
and sets out activities and programs that will result in the MDG and post-MDG aspirations being achieved.
Thus, this Child Health Policy and Plan applies to:
The total health care system in Papua New Guinea provided by government, faith-based
organizations, NGOs and private health services.
All health care facilities and non-facility based services such as those provided in homes and villages
All registered health care workers
The Child Health Policy and Plan can be read together with other key policy documents, including:
Constitution of Papua New Guinea (1975)
Papua New Guinea National Strategic Plan: 2010 – 2050 (September 2008)
Organic Law for Provincial and Local Level Government (Department of Provincial and Local
Level Government Affairs, November 1998)
National Health Plan 2001 – 2010 (National Department of Health, August 2000)
Corporate Plan 2009 – 2013 (National Department of Health, 2008)
National Health Plan 2011 – 2020 (National Department of Health, 2009)
17
Minimum Standards for District Health Services in Papua New Guinea (Ministry of Health, May
2001)
Policy on Partnership in Health (Ministry of Health, 2002)
National Policy on Expanded Program on Immunization (National Department of Health, 2004)
National Nutrition Policy (March 1995, Revised 2015)
National Policy on Integrated Management of Childhood Illness (National Department of Health
(National Department of Health, 2009)
National Policy on Family Planning (National Department of Health, 2009, Revised and updated
2014)
National Policy on Sexual and Reproductive Health (National Department of Health, 2008, Revised
and updated 2014)
Village Health Volunteer Policy (National Department of Health, July 2000)
Health Workplace Policy on HIV&AIDS (Ministry of Health, December 2005)
Community Health Posts Strategy (Ministry of Health, 2009)
National Health Reform Legislation 2009
2.7 Legislation
The Child Health Policy and Plan (CHPP) in its formulation and implementation notes the importance of a
sound legislative environment to support the goals, objective and strategies of the plan
The CHPP acknowledges the presence of the following Legislations under the Ministry of Health that have
bearings on the health of children in the country.
National Health Administration Act 1997
Organic Law on Provincial and Local Governments
Public Hospital Act 1994
HIV/AIDS Management Act
Provincial Health Authorities Act 2007
Christian Health Services Act
Medicines and Cosmetics Act
Food Sanitation Regulation 2001
National AIDS Council 2007 (Amendment) Act 2007
Institute of Medical Research (Amendment) Act 2007
Other Legislation relevant to child health but placed under the administration of other government
departments includes the following.
Adoption Law
Civil registration
Child Welfare Act
Education law (for primary school education)
Deserted Wives and Children Act
The CHPP is also mindful of Government’s commitment to the international agreements and
obligations relevant to adolescent and child health as listed below.
Millennium Development Goals
18
Convention on the Rights of the Child (CRC)
International Conference on Population and Development (ICPD)
In the term duration of the CHPP, it is recommended that the following new legislation be
considered by the NDoH for the promotion of health of children.
Code of Marketing of Breastmilk Substitutes
Food safety and Food Standards
Child Protection– Lukautim Pikinini Act 2009
19
CHAPTER 3. HEALTH SYSTEMS
WHO has proposed a framework of six building blocks to analyse health systems. The six building blocks
are service delivery, information, medical products and technology, human resources, health financing, and
leadership. This policy and plan recommends, by order of priority, the following three components of Health
Systems to be serious addressed.
Human resources
Service delivery
Medical products and technology
3.1 Human resources
Numbers
The Child Health Policy and Plan advocates for more appropriate numbers of paediatric health staff to be in
place during the tenure of the plan. The paediatric health workforce includes paediatricians, non-specialist
doctors, rural health doctors, child health nurses, general nurses, nutritionists, community health workers,
social workers and allied health staff. Ongoing assessment of the required number of paediatric staff in the
workforce needs to be undertaken at least every three years especially as new hospitals and other health
facilities are built and current services are expanded.
Training
Undergraduate training of additional students in medicine needs to be supported and negotiated with the
Higher Education section under the Ministry of Higher Education, Research, Science and Technology.
Service training of the paediatric health workforce is strongly supported and promoted by the Child Health
Policy and Plan , as is continuing professional development. In the Child Health Policy and Plan this is
outlined in several sections: including Section 5.5; and Appendix 1: Projection of Paediatrician Training
2015-2020, which tabulates and outlines the required number of paediatric health workforce for the nation at
all levels. Furthermore, Appendix 2: Projection of Paediatrician Sub-specialty Training 2015-2020, outlines
the need for specialized training in the discipline. Indeed attaining and maintaining the right number of the
paediatric health workforce will ensure the proper implementation and achievement of the Child Health
Policy and Plan. There is a need for scaling up the training of paediatric nurses, general nurses and other
cadres of health workers including laboratory staff and biomedical technicians who have a role in activities
relating to health service provision for children and mothers.
Welfare of health workers
The welfare of doctors and paediatric staff should be seriously considered as a priority issue. Indeed the
performance of health staff is greatly enhanced when their welfare is adequately addressed and satisfied.
Basic family concerns such as housing, security, transport, telecommunication, water and electricity,
depending on the station of assignment, should be ensured. Good welfare consideration of staff will lead to
enhanced performance and greater job satisfaction.
3.2 Service delivery
The Child Health Policy and Plan supports the new projects of Community Health Posts for improving
service delivery. It also promotes the concept of Primary Health Care in service delivery for rural and
community level. Up-scaling and improving the quality of services in the provincial and district hospitals is
promoted during the tenure of Child Health Policy and Plan. The Child Health Policy and Plan advocates for
the resumption of services at closed aid posts. Management authorities for aid posts need to prioritise
resource allocation to these stations as their role and services are vital for early management and referral of
the population.
Laboratory services should be available at all district hospitals. Needless to mention, basic diagnostic
instruments and equipment should be made available to health centres for early diagnosis of conditions such
as malaria and anaemia. Chest radiographs, bacteriology facilities (including cerebrospinal fluid microscopy
and culture and blood culture and bacterial antigens) should be available at all provincial hospitals.
20
3.3 Medical products and technology
The Child Health Policy and Plan requires the maintenance of adequate medicine and drug supplies in all
health facilities. The further development of basic equipment and technology appropriate to the level of
health services provided should also be ensured.
Provision of all medicines contained in the Standard Treatment Manual.
The introduction of new medicines to treat resistant infections including multi-drug resistant (MDR)
tuberculosis and multi-resistant bacterial infections, and second-line therapy for HIV.
An oxygen supply program based on oxygen concentrators and pulse oximeters in all provincial and
rural hospitals and major district health centres in the country. Where power supplies are inadequate
solar power will be trialled.
To improve immunization coverage, health facilities including community health posts need a
functioning refrigerator. Missed opportunities in vaccination lead to disease outbreaks.
The use of medical communication technologies is a priority for provincial and rural hospitals.
Modern methods of communication such as mobile phones, radio or telemedicine via the Internet
should be explored to improve the quality of care in remote areas, timely medical referrals, and
continuing education for remote health staff.
Newer diagnostic technologies for tuberculosis should be evaluated and introduced if they are found
to be effective. Guidelines will be developed for the appropriate use of GeneXpert MTB/RIF to help
detect multi-drug resistant tuberculosis.
Rapid diagnostic tests for other diseases, such as encephalitis and meningitis will be evaluated for
effectiveness and added value.
Further developments of computerised reporting systems, including the Paediatric Hospital
Reporting (PHR) program.
21
CHAPTER 4. POLICY CONTENT
The Policy document is broken up into program areas, but there is integration across all of these programs.
This document outlines the policies, which are expanded upon in the Child Health Policy and Plan, and the
specific activities to achieve these, timelines and costing are detailed in the Strategic Implementation Plan,
which is in Section II of this document.
4.1 Integrated management of childhood illness (IMCI)
IMCI provides a strategy for training primary health workers in primary care case management of common
illnesses in children. Since the initial adaptation work of IMCI in PNG in 1998, progress has been gradual.
The Child Health Policy aims in IMCI between 2009 and 2020 include to:
Improve the co-ordination and structure for IMCI
Expand and sustain IMCI training in all provinces and districts
Improve integration between programs and ensure that IMCI is taught in all courses of child health
4.2 Expanded Program of Immunization
Childhood vaccines have been responsible for substantial advancements in child health and reductions in
mortality in PNG in the last 30 years. The EPI is a major component of the Child Health Policy and Plan.
The policy aims and the strategies required to achieve these aims are carefully described separately within
the PNG Comprehensive Multi-year Plan National Immunization Programme 2011-2015 and EPI policy.
4.3 Standard treatment guidelines
The aim of the Standard Treatment Manual is, according to the preface of the first edition, to: ‘allow the
busy nurse, health extension officer or doctor to prescribe quickly standard treatments that are simple, safe
and effective’. The STM is now in its ninth edition. The policy aim is to have the latest child health
recommendations in the Standard Treatment Manual available to and used by every health worker when
managing children.
4.4 Neonatal care
In PNG neonatal mortality makes up 50% of infant mortality, so reducing neonatal mortality is vital to
improving child survival. Two thirds of neonatal deaths are associated with high risk pregnancies, labour and
delivery. Although there are many factors, prematurity, low birth weight, deliveries that are not supervised
by skilled health workers, and neonatal sepsis account for the majority of deaths in the first month of life in
PNG.
Efforts to reduce neonatal mortality are closely linked to safe motherhood programs, including the National
Strategic Action Plan to Reduce Maternal and Newborn Mortalities and the WHO Integrated Management of
Pregnancy and Childbirth (IMPAC). Antenatal clinics (ANC) continue to be important to prevent neonatal
illness.
The policy aims in neonatal care are to provide the highest possible level of care for newborns in health
facilities and within communities:
Encourage access to the highest possible quality ANC and delivery care by skilled birth attendants
Ensure that Essential Early Newborn Care is provided to all newborns
Implement Minimal Standards of Neonatal Care in provincial and district hospitals and health
centres
Promotion of breast feeding (see also breast feeding, nutrition and micronutrients section of this
plan, below)
Provide understandable information on newborn care available to all mothers
Develop centre of excellence for neonatal care and training at Port Moresby General Hospital and
major provincial hospitals
22
Support a program of neonatal care and resuscitation training for nurses, midwives and doctors, as
part of Hospital Care for Children training
4.5 Breast feeding, nutrition and micronutrients
Nutrition is a vital but neglected part of health care in Papua New Guinea. The rates of malnutrition are
unacceptably high and contribute substantially to high child mortality, poor growth, poor development, and
high infectious disease morbidity. About 11% of all paediatric hospital admissions have severe malnutrition.
An even greater percentage of children in hospitals and the community suffer from moderate malnutrition,
which increases the risk of death from pneumonia, diarrhoea, tuberculosis, HIV and malaria. Two-thirds of
all child deaths are associated with moderate or severe malnutrition. Between 2009 and 2020 the National
Department of Health aims to:
Support, protect and promote exclusive breast feeding from birth up to 6 months
Support adequate complementary feeding from 6 months onwards
Increase human resource capacity for child nutrition among nurses, doctors and nutritionists
Improve co-ordination between programs
Community promotion of proper breast feeding practices and adequate complementary feeding
Improve vitamin A coverage
Achieve high coverage of deworming
Improve health facility and community services for management of malnutrition
Support programs for school health and nutrition
4.6 Quality improvement in hospital care
Families will bring their children to health facilities if they are confident they will receive good care and are
treated with kindness and respect. Improving community demand requires quality health services,
community engagement and awareness of the signs of childhood illness.
In many hospitals and health centres there are major deficiencies in drug supplies, basic equipment,
buildings and facilities, training and support for health staff, and provision of a family friendly environment.
Improving the management of malnourished children, improving triage and emergency care, oxygen
administration, supportive care and monitoring apply whether children have pneumonia, tuberculosis, HIV
or less common conditions. These can be partly addressed by a program of training for nurses, better use of
guidelines, better facilities and equipment, improved data collection to follow outcomes and measure impact,
and a focus on key areas such as malnutrition. Efforts to improve the availability of food supplies on hospital
wards, improve the detection of children at high risk of malnutrition and improve malnutrition management
of are also crucial. The policy aims in quality improvement are to:
Ensure all sick children have access to good quality care
Improve oxygen systems and the treatment of pneumonia
Standardized hospital data reporting and paediatric surveillance
Improve the care and management of adolescents in hospitals and other health facilities
Improve the co-ordination and care for children with chronic illnesses
4.7 Pneumonia
Acute lower respiratory infection is the most common cause of serious illness and death in children in PNG,
accounting for 27% of all hospitalisations. Pneumonia and bronchiolitis are particularly prevalent in
highlands provinces, where they accounts for 30-40% of all admissions. A comprehensive strategy to address
pneumonia is outlined in the Child Health Policy and Plan. Pneumonia policy is a cross-cutting issue that
involves most program areas in this policy and plan.
23
4.8 Malaria
Malaria is endemic in all coastal provinces of PNG. An objective of the current PNG National Health Plan is
to reduce malaria disease and mortality by 50% by 2020. In 2009-2014 4.8% of mortality in children was
from malaria. Between 2009 and 2020 the policy aims in childhood malaria include:
Improve the prevention and management of malaria among mothers and children
Improve the tendering process, procurement and supply of all essential drugs and supplies
Improve leadership, research and co-ordination of the childhood malaria
4.9 Tuberculosis
Childhood tuberculosis (TB) is a large burden in PNG. Childhood TB represented over 30% of all TB treated
in PNG in 2005-6. This is twice the expected case load of paediatric TB and indicates that there is a high
community transmission rate and that the TB control programme is not functioning well. It also reflects the
impact of HIV epidemic on TB cases. Pulmonary and extrapulmonary TB contribute substantially to high
rates of child mortality, malnutrition, chronic respiratory disease and impaired neurological and cognitive
development. Improving the detection, prevention and management of children with TB was considered by
the Paediatric Society as a major priority in child survival, and was added to the list of goal areas identified
by the Western Pacific Region. The policy aims in childhood TB by the National TB Program and between
2009 and 2020 include:
Improve the ability of health workers to diagnose and treat TB
Improve co-ordination and leadership of child TB
Address multi-drug resistant TB in children
Address high rates of non-adherence, defaulting and relapse among children with TB
4.10 HIV
PNG has a generalized HIV epidemic. Based on improved surveillance, mainly using antenatal clinic data,
the revised national HIV prevalence rate is estimated at 0.92%, down from previously reported 2% some
years ago. To effectively address childhood HIV involves strengthening prevention strategies for adults, and
addressing specific areas of disease prevention and treatment among newborns and children. The policy aims
in childhood HIV between 2009 and 2020 include to:
Improve the prevention of HIV infection in newborns
Improve the care of children with HIV
Improve co-ordination and leadership of child HIV
4.11 Paediatrician training
Paediatricians are crucial to maintaining progress in child health and survival. The paediatrician’s role in
provinces is multi-faceted. They need to provide the highest standard of appropriate care to all children, to
teach other staff about child health, to manage the child health service, to play a supportive role to public
health services and primary health care providers. Particularly they need to liaise with Provincial Health
Advisors to ensure that child health programs are planned for and implemented in their provinces. Much of
the progress in child health in the last decade has been because of the leadership and technical support
provided by provincial paediatricians. The policy aims in this area include:
Achieve the National Health Minimum Standard for specialist paediatricians
Develop a paediatric workforce with appropriate subspecialty skills
Support programs for continuing professional development for paediatricians, paediatric trainees,
child health nurses and other child health workers
24
4.12 Child health nurses and midwives
Child health and midwifery nursing need a major influx of resources. The policy in this area is to achieve the
standard of one child health nurse and one midwife in every health centre, and at least one per shift in every
hospital. To do so more paediatric nursing courses are urgently needed.
4.13 Community health workers
PNG has a policy of upgrading aid post to be community health posts. The intention is to have these staffed
by three officers; one of whom is a community health worker with training and skills in maternal and child
health care. The services that will be offered at community health posts for mothers and children will include
all essential MCH services: antenatal care, deliveries, basic newborn care, immunizations, growth
monitoring, and management of common childhood illnesses, and referral of very sick children.
4.14 Continuing professional development
It is a policy of the PNG Department of Health that some form of effective continuing professional
development should be available to all health workers.
4.15 Adolescent health
A healthy adolescence requires informed and safe choices about risk-taking behaviour such as smoking,
alcohol and other drugs, sexual activity, diet and relationships. Adolescence is a time when interventions and
healthy choices may reduce the risk of chronic physical illness in adulthood, and reduce the risk of adverse
mental health and substance abuse problems. The programs currently in place to address issues affecting
adolescence are very limited. The policy aims in this area are to:
Provide appropriate facilities for adolescent health services
Improve human resources for adolescent health
Provide training for a paediatrician in adolescent health, to act as a national resource-person for this
area
Provide training for other health workers in adolescent health
4.16 Cancer, heart disease, paediatric surgery
While childhood cancer and heart disease are not as common as infectious diseases, adequate resources need
to be allocated to ensure the effective management of these conditions:
Improve the management of childhood cancer and ensure wide access to services
Improve the management of congenital and acquired heart disease in children and ensure wide
access to services
4.17 Child protection and social services
Many children are at risk of neglect and abuse, with little social support or protection. Such children include
many orphans, adopted infants, displaced children, abandoned babies, and those living in crowded conditions
in urban settlements. The number of orphans is increasing because of HIV and the breakdown of traditional
village structures. Natural disasters or civil conflict give rise to displaced children, unplanned urbanization is
increasing, all meaning the number of at risk children is increasing. The consequences are extreme, including
malnutrition, physical and emotional injury, preventable infection with HIV and other sexually transmitted
infections.
1. Improved reporting, documentation and surveillance systems for child abuse and neglect are needed
2. Improved preventative and treatment services need to be in place for children at risk of neglect and
abuse
3. Health workers can make a major contribution to identifying at-risk, abused or neglected children
and through liaison with social and legal services help to mitigate the effect on health and
development of the child
25
Legislation, strategies and training for health workers in protection, prevention and management of child abuse
and neglect are required
4.18 Child disability
Many children in PNG live with disabilities. Diseases causing disability include birth asphyxia, low birth
weight, congenital anomalies, meningitis, chronic infection including HIV and tuberculosis, trauma, and
malnutrition. These illnesses may result in cerebral palsy, the most common physical disability in childhood,
or result in sensory loss such as blindness, deafness, or intellectual and learning problems, and epilepsy.
Health consequences include malnutrition, increased risk of pneumonia, skin problems and dental decay. In
addition to direct health consequences children with disabilities are vulnerable to socio-economic exclusion
and disadvantage; more than 90% of children with disabilities in developing countries do not attend school.
Children with disabilities are also at increased risk of physical and sexual abuse, and neglect. This policy
aims to:
Prevent disability through improved newborn care, vaccines, improving rates of breast feeding and
child nutrition and improving child safety through legislation
Improve developmental screening, referral and support services for children with disability
26
CHAPTER 5. MONITORING AND EVALUATION
Implementation of this Child Health Policy and Plan will be monitored on an ongoing basis by collection of
performance indicator data, by regular reviews by the Child Health Advisory Committee and the annual mid-
year reviews by the Paediatric Society.
5.1 Policy development in child health
In line with the WHO / UNICEF Regional Child Survival Strategy recommendations, in 2006 the
Department of Health established a National Child Health Advisory Committee. The Child Health Advisory
Committee (CHAC) has a key role in coordinating and supervising Child Health activities. The CHAC
reviews all child health policy areas, new evidence and information and provides recommendations to the
National Department of Health. It meets quarterly, overseeing many child health activities. It is a vital link
between child health workers, institutions and the NDOH.
Having a forum for discussion of policy issues is essential. The NDoH supports the Paediatric Society to
meet twice a year to discuss and formulate child health policy, and to report back to the Child Health
Advisory Committee on recommendations and progress of the Child Health Policy and Plan.
Support the Child Health Advisory Committee as the major technical advisory body on child health
Support the Paediatrics Mid-Year meeting each June, and the Paediatric Mini-Symposium in
September as forums for child health policy advice and oversight of progress to the Department
27
VOLUME II
SECTION I. CHILD HEALTH PLAN
28
CHAPTER 6. INTRODUCTION
6.1 Child health in PNG: recent progress and current challenges
Papua New Guinea is a high priority country for the achievement of the Millennium Development Goals,
because the baseline child, infant and neonatal mortality rates and the maternal mortality ratio were among
the highest in the Western Pacific Region. Other targets, such as those for universal primary education and
poverty alleviation also have much scope for improvement. The PNG MDG-4 target is for a reduction in
under-five mortality from 90 (in 2000) to 32 per 1,000 live births and a reduction in infant mortality from 64
(in 2000) to 24 per 1,000 live births. The goals are feasible and achievable, although the timeframe needs to
be extended beyond 2015 to the end of the life of this plan (around 2020).
In terms of child survival interventions, PNG now has, included in this plan, almost all of the technical
strategies identified by the Bellagio group in the Lancet Child Survival Series in 2003. However, coverage
for most essential interventions has been low, with many remote communities missing out on many essential
services. Coverage for preventative and treatment strategies is limited by relatively weak health systems,
particularly affecting remote rural areas. Health systems have been weakened by low levels of financing,
lack of supervision and support for rural health workers, limited human resources, deficiencies in building
and equipment maintenance, drug procurement and distribution, limited community engagement with the
health service, and low health worker morale in many areas.
However, the health system in PNG also has several great strengths, and systems are changing with more
provinces taking responsibility for policy implementation and active implementation. Much progress is being
made through the Provincial Health Authorities that are being established. The other great strength in PNG is
the strong commitment by nurses and paediatricians to the health and welfare of all children. Recent
successes in PNG have included:
Achieving much higher measles vaccine coverage than ever before, through incorporating 3-4 yearly
supplemental immunization activities into the routine EPI
The designation of PNG as polio-free
Progress in technical policy including the publication of the 9th edition of the Standard Treatment
Manual for children, which includes zinc as treatment for diarrhoea, six-monthly vitamin A
supplementation to all children
Haemophilus inflenzae type b vaccine, successfully introduced as the pentavalent vaccine in 2008
Introduction of the pneumococcal conjugate vaccine in 2014
Increase in the number of paediatricians serving clinical and public health needs of provinces, and
the development of substantial capacity of paediatricians in IMCI, EPI, HIV, neonatal care, public
health, child nutrition, research, oncology and cardiology. There have been 30 paediatricians trained
since 2000, and these people are filling many important roles in child health throughout the country
The National Department of Health, the Paediatric Society and other partners are committed to overcoming
the obstacles to achieving higher coverage with standard treatment and essential preventative interventions.
In the development of this plan a consultative process was undertaken to review the child health program for
its content and coverage of essential interventions, identify the obstacles to achieving better overage, make
recommendations about how these obstacles can be overcome, and describe mechanisms for evaluating
whether action is taken and whether improvements occur. This provided an important framework for
addressing these issues over the next decade.
However, there are several major obstacles to achieving MDG-4. The HIV epidemic shows some signs of
slowing, but HIV infection still accounts considerable proportion of child deaths. The establishment of
parent to child prevention (PPTCT) programs in all provinces is going a long way to addressing this;
however, unless HIV is better controlled among adults, infants will continue to be affected. Tuberculosis in
children is also a major obstacle to achieving improved child health, leading to severe chronic disease,
disability and malnutrition. The high rates of childhood TB reflects the weak TB control system, and now
multi-drug resistant TB represents new challenges. Other obstacles to achieving MDG-4, and general
improvements in child development, are the poor social situations in many urban settlements and some rural
communities and poor nutritional outcomes. Infants and children in many urban settlements live in extremely
29
crowded and often unstructured households, where breast feeding often gives way to early weaning, poor
quality complementary feeding, bottle feeding, and where informal adoption is common. In these
environments deaths due to combinations of severe malnutrition, diarrhoeal disease, acute respiratory
infection and tuberculosis are too common. It will be essential to address malnutrition to achieve reductions
in under-five mortality. A significant constraint to services being delivered within such communities is their
sometimes dangerous and volatile environments, which makes them places into which health workers are
understandably reluctant to venture.
If MDG-4 is to be achieved by 2020 there will need to be major focuses on improving, supervising and
supporting rural health services; on outreach EPI services; on infant and young child nutrition and growth
monitoring linked to vaccines; on economic development that benefits poorer communities and those in
remote rural areas; and targeting poorer communities in both rural and urban areas to improve essential
health services and education. But it is feasible with a co-ordinated effort.
6.2 Child mortality
In PNG in 2000 the estimated under-five mortality rate was 92 per 1,000 live births, a slight down-ward trend
on the consistently high mortality rates seen throughout the 1980s and 1990s. Since 2004 there has been a
concerted effort by child health organizations in PNG to systematically improve the situation. In 2004 the
estimated under-five mortality was 88 per 1,000 live births. In 2014, for the year 2012 UNICEF’s State of the
World’s Children lists the under-five and infant mortality rates as 68 and 48 per 1,000 live births
respectively. The neonatal mortality rate was estimated at 24 per 1,000 live births in 2012. These data are
consistent with earlier trends from the 2006 Demographic and Health Survey (DHS). Mortality data from the
latest PNG census (2011) are not yet available. PNG’s modified MDG-4 target is an under-five mortality rate
of 32 per 1,000 live births by 2015. Feasibly this could be achieved by around 2020 if there is a slight
increase in current rate of progress.
Figure 2. Mortality trends for children in the first 5 years of life in PNG, 1955-2012
4-7
6.3 Common causes of childhood illness and death
Since 2009 data have been gathered annually on the common causes of child admissions using the Paediatric
Hospital Reporting system.
8;9
Pneumonia remains the most common reason for admission (27% of
0
50
100
150
200
250
Child mortality trends in PNG 1955-2012
PNG
30
admissions in 2009-14), followed by neonatal conditions (20% of admissions), diarrhoeal disease (10% of
admissions) and malaria (6% of admissions). In the post-neonatal period, pneumonia (23% of deaths) and
meningitis (24% of deaths) were the leading causes of death. Neonatal deaths accounted for 28% of all
hospital deaths. The leading causes of death in neonates were: birth asphyxia (53% of neonatal deaths),
neonatal infections (27% of neonatal deaths) and very low birth weight (35% of neonatal deaths). In the post-
neonatal period, children presenting with HIV (12.1% case fatality rate), malnutrition (23.3% case fatality
rate), meningitis (19.2% case fatality rate), tuberculosis (13.2% case fatality rate), and severe pneumonia
(9.6% case fatality rate) had the highest risk of death. Severe malnutrition either directly caused or
contributed to 36% of all deaths in 2012.
8
In previous studies in Goroka and Port Moresby either moderate
or severe malnutrition was a factor in two-thirds of all child deaths.
10;11
There are several references summarizing the common causes of childhood illness and mortality in PNG.
6.4 Health facility network
PNG has a network of base or provincial referral hospitals, district hospitals or health centres at a district
level, and health sub-centres, urban clinics and aid posts at a village and community level. However access
to primary care services is poor in many areas, because of remoteness, poor road conditions and the closure
of many aid posts. In 2006 only 69% of 2633 aid posts were considered open, and several provinces had very
low proportions of aid posts open (Eastern Highlands 34%, Enga 44%, East Sepik 51%). NHIS data suggests
only 36-50% of births occur in a health facility.
6.5 Human resources in child health
Without increased numbers of trained health staff this plan cannot be fully implemented, and PNG’s MDG-4
goal will not be reached.
There is a need for many more child health nurses and midwives. In the first five years of this plan (2009-
2013) there have been investments in midwifery training, with increased training places at School of
Medicine and Health Sciences (SMHS), University of Papua New Guinea, and other midwifery schools,
supported by the Australian Government. However the same progress has not occurred in child health /
paediatric nursing. In 2014 there is only one post-graduate child health nursing courses in PNG. This is at
SMHS, Taurama Campus. This school trains about 20 midwives and paediatric nurses annually. Another
child health course in Goroka University was closed down around 2009 after a few years of functioning. A
review of PNG’s nursing workforce in 2002-3 estimated that there was a need for 435 more midwives and
200 more paediatric nurses. Each of the four regions in the country needs one post-graduate midwifery
course and one child health nursing course.
Reviewing and standardizing the curricula of courses which teach maternal and child health (community
health workers, child health / paediatric nurses, midwifery, HEO, medical students) to ensure the content
contains essential child health training interventions and the contents of this plan was done in the first five
years of this plan.
Since the closure of the Nutrition Course at the College of Allied Health Sciences (CAHS) in 1982, there has
been a steady decline in number of nutritionists and nutrition positions in provinces. In 2009 nutrition
positions were filled in 9 provinces and in 3 provinces nutrition positions have been vacant for extended
periods of time. The number of nutrition positions at Health Department Head Quarters had declined from 7
to 2.
There has been an increase in the number of paediatricians since 2000. Thirty paediatricians have graduated
from SMHS between 2000 and 2014. Now paediatricians are working in 17 of 22 provinces, and many hold
other senior positions within the NDoH, University, National Capital District and working with non-
government child health organizations. However, there is still a major short-fall of paediatricians. Without at
least two paediatricians in each of the provinces it is very difficult for paediatricians to focus on both public
child health and clinical issues. Central, Gulf, Western Province, Manus and the two new provinces Hela and
Jiwaka still do not have a paediatrician, so less specialist expertise is available to these provinces’ child
health activities. This plan sets out a workforce and training plan and timeline for achieving this (see
paediatricians training and Appendix 1 and 2).
There is now increasing need for paediatricians to take national ‘portfolio’ responsibility for key aspects of
child health. This approach is reflected in this plan, with paediatricians since 2009 being identified to provide
31
leadership in neonatal care, childhood tuberculosis, Infant and Young Child Feeding (IYCF) and adolescent
health, childhood cancer, and heart disease. There is a need for further training and credentialing in these and
other specialist areas.
The SMHS is understaffed, with as few as 40% of teaching positions unfilled in 2013.
Gaps are not just in training, but in workforce planning, accreditation of certain cadres of health workers
(including child health nurses), and incentives for rural service.
In many districts village health volunteers – which include village birth attendants and other village health
workers - have a role in delivering maternal and child health services in remote communities. Village health
volunteers are mostly supported by churches and other non-government agencies. This cadre of health
workers is currently unregulated, and there is little standardization of practice or quality assurance. There is a
need to determine appropriate content and durations of training, skill-set, standards of practice, supervision,
remuneration, and integration with the formal health system. There is evidence from other countries that
village health workers can reduce neonatal mortality. The effect of village birth attendants on maternal
mortality is less certain. The links between VHWs, community health (aid) posts, and government and
church run health centres still needs to be strengthened.
6.6 Population issues and Family Planning
The Paediatric Society of PNG and Family Health Services Division of the National Department of Health
are aware that one of the factors in PNG that has the potential to derail all the positive gains made so far is
uncontrolled population growth. PNG now has almost a 3% population growth rate with a projected doubling
time of 20 years. This means that in 10 years time the paediatric population will have been increased by
around 2 million.
These will put immense pressure on resources with requirements for commensurate increases in number of
health facilities, personnel, schools, jobs etc. Moreover there will most likely be detrimental effects on
overall socio-economic status of families, provision of education and increase in social discord, urban drift,
food insecurity, degradation of the environment and land shortages.
In addition, for the health of families there are major consequences of unplanned pregnancies and lack of
access to family planning. There is abundant evidence of an adverse effect on child health and mortality of
narrow birth spacing. Infant mortality is very high for children born following a birth interval of less than
two years after the previous birth; IMR is 71 per 1,000 live births compared with 42 per 1,000 live births for
children born three or more years after the previous birth.
The Paediatric Society and Family Health Services advocates that population policy and family planning
availability needs to be dealt with at the highest levels, with the utmost urgency. The country’s political
leadership must be made aware of the need to address this issue at the national level and commit to a
concerted effort. This will require mobilisation of all segments of society as the ill effects of the population
explosion will impact on all areas of life.
The Paediatric Society will undertake within its own membership to more actively promote family planning
in the clinical setting as well as advocate for wider solutions to population control. In this we work closely
with the Obstetrics and Gynaecology Society.
32
CHAPTER 7. PROGRAM AREAS
7.1 Integrated Management of Childhood Illness (IMCI)
IMCI is a primary care case management approach to common diseases of children. IMCI involves different
activities and interventions aimed at the care of sick child, prevention of childhood diseases, and promotion
of healthy growth of children. IMCI has the potential to make a major contribution to health system reforms
and it fits into the governmental priority agenda to upgrade the aid posts to community health centers, in
order to improve access to basic health services in rural settings.
Since the initial adaptation work of IMCI in PNG in 1998, progress has been slow. IMCI went through
adaptation 1999-2000, and the program was piloted in Heganofi and Madang districts in 2001, supported by
WHO. At the same time the Australian Government supported training in the IMCI 10-step checklist in many
provinces, and the development and piloting of the young infant IMCI checklist. But 15 years later coverage is
low. National coverage will only be achieved if provinces take this on, if program simplification occurs, and
if IMCI is more adapted to be taught in pre-service health training colleges. In 2009, there was an update of
IMCI diagnostic algorithms and was included in the National Plan of Roll-Out of all Components of IMCI
Strategy. This document explains in detail the activities of IMCI implementation.
Progress in the components of IMCI in PNG
Training for case management
Since 1999 Training of Trainers courses have been done throughout the country, driven initially by the
Australian Government Women’s and Children’s Health Program. This training was in the 10-step checklist
and of five day duration, often combined with reproductive health training. District training courses followed
in 2000-2002. In 2003 the young infant checklist was finalized and 10 day trainings were conducted, especially
in the pilot districts supported by World Health Organization (WHO) and in East Sepik. In 2005, 10 day
training courses were done again in regions to strengthen provincial and eventually district training
supported by the HSIP.
Until now only a few provinces have made substantial progress in district training. There have been
insufficient follow-up visits after training and limited supervisory visits with case management observation,
both of which are recommended to optimize the effect of training on clinical practice.
IMCI training can be included in provincial and district annual implementation plans (AAPs), along with
follow-up visits after training and supervisory visits with case management observation. This has not
happened in most provinces in the last decade.
Pre-service training commenced with training tutors in 2003-2004 initially in Lae for the Goroka and Lae
Schools of Nursing. Community health worker schools have incorporated IMCI from 2004. Some schools
have developed their own syllabus incorporating IMCI training. The University of PNG now ensures that
medical students learn IMCI in their clinical practice at the children’s outpatient department of Port Moresby
General Hospital, and IMCI is included in the Bachelor of Clinical Nursing (Midwifery and Child Health)
program at the SMHS.
Health systems issues
Although limited, there is some evidence of health system strengthening and impact on quality of care. A
study done in 2007-8 showed that in districts in which IMCI training had been carried out, case management
was more comprehensive and communication with parents was better (Moses Moti, MPH thesis). Improving
health systems at a district level will take much more than IMCI training, it will in part require communities
to take responsibility for the governance and oversight of health centres, through local boards. This is
increasingly done successfully with schools, where local boards monitor the quality of teaching and take
responsibility for maintaining infrastructure and support to teachers. This model of community engagement
is worth trying in district health centres.
Future needs
Improving co-ordination and structure for IMCI
33
For IMCI to be sustained, co-ordination should be strengthened at all levels of health system. At the National
level, a National IMCI coordinator will assist the Child Health Technical Advisory and Chief Pediatrician to
coordinate IMCI and represent IMCI on the Child Health Advisory Committee (CHAC). The
implementation of IMCI is also supported by NDoH Advisor for the Child Health and Manager of Family
Health Branch. At the provincial and district levels the positions of provincial and district coordinators
would greatly assist in IMCI implementation. The IMCI coordinators should be responsible for organizing
IMCI trainings for health staff and village health volunteers / workers, follow-up after training visits,
supervisory visits with case management observation, arrange logistics operations for IMCI, contacting the
health facilities (including aid posts) on regular basis and supporting health information system regarding
child health. IMCI coordinators should also ensure that child health programs are well reflected in annual
work plans.
A database of all IMCI trainers and trained health workers should be developed and maintained.
The implementation of IMCI strategy at the district level should be based on the local district plans.
Incorporation of Infant and Young Child Feeding (IYCF) counselling training, supervision and follow-up
into the national IMCI program will be important for sustaining improvements in child nutrition.
Sustaining IMCI
Expansion and sustaining of IMCI will require:
Inclusion of IMCI and IYCF training
Follow-up after training and supervisory visits with case management observation into provincial
annual implementation plans
Incorporation of IMCI and IYCF into pre-service and post-graduate training
Establishing a proper structure to implement and sustain IMCI on the provincial and district level
through IMCI provincial and district coordinators
Implementation of components of the IMCI Strategy are described in IMCI Policy document and National
Plan of Roll-Out of All Components of IMCI Strategy.
Key messages for Provincial and District Health Staff
Create and fill positions of provincial IMCI coordinators
Create training units at a provincial hospitals
Include IMCI and IYCF training in your annual implementation plans
Include “follow-up after training” as part of your IMCI training
Support community engagement in local health services, this may include appointing local ‘community
health boards’ to oversee the activities of health centres, rural hospitals and aid posts
7.2 Expanded Program of Immunization
Immunization services are provided through the network of around 700 Maternal and Child Health (MCH)
clinics run from health centres and hospitals. Modes of delivery are static, mobile and opportunistic, and
services are routine and supplementary. It has been estimated that 30% of the children are reached through
outreach services, although the frequency and regularity of mobile services is variable, and have diminished
over time.
There is now a policy to extend EPI delivery to a community health post level. This will require the
upgrading of aid posts, training of more community health workers, and installation of cold chain equipment
at an aid post level, many of which will require solar-powered vaccine refrigerators.
Supplemental immunization activities (SIA) were done in 1996 for polio eradication and in 2003-2005 and
again in 2008-09 and 2014 in response to epidemics of measles. These were remarkably successful, at one
stage bringing the measles vaccine coverage to an estimated average level of 86% of one year old children.
Now, integrated MCH outreach activities are being encouraged from the national level and SIAs will be
conducted at sub-national levels were routine coverage is below average.
34
Administratively, EPI is under the Family Health Branch in the Health Improvement Branch of the
Department of Health. At the national level, the EPI management team includes an EPI Manager. In
addition, the team includes; a Cold Chain / Logistics Officer, and a Vaccine Management Officer.
At the regional level, there are four Regional Cold Chain Logistics Officers based in one province within the
region; all are funded by DFAT and supported by WHO. Provincial Cold Chain Logistics Officers are
responsible for the management of vaccines at provincial level with support from the provincial family
health coordinator. At the district level, EPI is managed by the district manager through the health facility
nurse in charge.
Up to June 1995 the EPI had a vertical reporting system. Since, July 1996, EPI reporting systems are
organized as part of NHIS. Though timeliness of the reporting has improved considerably, there still remain
problems of data completeness and accuracy.
The Health Department is strengthening disease surveillance, including that for diseases targeted under EPI
through the introduction of an integrated surveillance system in the Disease Control Unit to which most of its
reports flow through NHIS and sentinel reporting.
The broad aims of the EPI program include:
High quality immunization services that reach every child and mother
Elimination of measles
Maintenance of PNG’s polio-free status. Based on WHO recommendations, to replace oral polio
vaccine (OPV) with inactivated (injectable) polio vaccine (IPV) in 2018 to achieve the “End-Game
for Global Eradication of Polio”.
Introduction of Rubella vaccine as measles-rubella in 2015
Elimination of maternal and neonatal tetanus
Control of hepatitis B, and improve birth-dose coverage
Introduction of new vaccines against the commonest causes of mortality in children, building on the
introduction of Hib (Haemophilus influenzae type b) vaccine in 2008. In particular, in 2014 the
introduction of a conjugate vaccine against Streptococcus pneumonia, the commonest cause of
bacterial pneumonia and meningitis. The vaccine is PCV 13, the 13-valent pneumococcal conjugate
vaccine. This is supported by Gavi, the Vaccines Alliance
Introduction of Human papilloma virus (HPV) vaccine in school health and adolescent health
programs
Improving vaccine preventable disease surveillance system. This includes Acute Flaccid Paralysis
(AFP) and Acute Fever and Rash (AFR) surveillance, plus outbreak identification of whooping
cough and cholera. The Paediatric Hospital Reporting system also provides a mechanism for
hospital-based surveillance for VPDs utilizing a network of paediatricians at provincial hospitals
Ensure all children receive at least 2 doses of vitamin A, at 6 and 12 months, according to the
Vitamin A policy. Expand vitamin A supplementation in to second year of life by adding two
additional doses at 18 and 24 months
Consideration of the role of rotavirus vaccine in reducing deaths from diarrhoea, and the gathering of
disease-burden information. This is underway with rotavirus studies having been conducted in Port
Moresby and Goroka, showing that rotavirus causes about 40% of all diarrhoea cases admitted to
hospital
The targets and strategies required to achieve these aims are more fully described within the Papua New
Guinea Comprehensive Multi-Year Plan National Immunization Programme 2011-2015.
12
Key activities
include management and planning at a national, provincial and district level, training and supervision,
monitoring and evaluation, surveillance and laboratory support, cold chain and logistics, effective schedules
for service delivery, improving communication and community links and revitalizing school-based
immunisation programs. Strengthen the integration of vaccine distribution with other programs and
activities, particularly IMCI, long lasting insecticide-treated mosquito net distribution, vitamin A, hospital
services, and family planning will be important for efficient delivery of child health interventions.
35
Supporting birth registration will be important for better understanding coverage of vaccines at a village
level.
Key messages for Provincial and District Health Staff
Support immunizations at every opportunity
Outreach MCH services are an important way to reach many rural children and mothers, make sure
these are functioning in your province
Improve the facilities and services at community health posts to increase coverage of vaccines in
remote villages
Support and organize targeted Supplementary Immunization Activities (SIA) sub-nationally,
especially in the poor performing districts
The Hib vaccine and the new pneumococcal conjugate vaccine will prevent many cases of
meningitis and pneumonia.
Raise awareness of the importance of vaccination and these new vaccines
Immunization is everybody’s business, everyday!
During immunization activities, do growth monitoring (plot weight on the growth chart), give
vitamin A and offer family planning.
7.3 Standard Treatment and Clinical Guidelines
The first edition of the PNG Standard Treatment Manual was published in 1975, and the ninth edition in
2011 (reprinted with corrections in 2013).
13
The PNG Standard Treatment Manual is probably the longest
running evidence-based treatment guideline in a developing country, and has a unique place in the health
culture of PNG.
14
The research underpinning the original STM and its subsequent editions have also
influenced development of global paediatric treatment recommendations, such as the WHO programs for
Acute Respiratory Infection and IMCI.
The original aim of the Standard Treatment Manual was, according to the preface to ‘allow the busy nurse,
health extension officer or doctor to prescribe quickly standard treatments that are simple, safe and
effective.’
Child health has become increasingly complicated in the last two decades, but there is still a need to keep it
as simple as possible for front-line health workers. The ninth edition (2011) included several changes,
including changes to TB treatment with the introduction of fixed-dose combination therapy, HIV, care of the
septic child, use of ceftriaxone in meningitis, zinc for diarrhoea and other areas.
The STM may need to be simplified to maintain its relevance to primary health workers.
The activities required in the life of this plan include:
Revising the 2016 (Tenth Edition) Standard Treatment Manual
Revision of other Paediatric Treatment Manuals
Other technical resources will need updating and printing in the life of this plan, including Paediatrics for
Doctors in PNG and Child Health for Nurses and HEOs.
The WHO Pocketbook of Hospital Care for Children will need to be purchased and distributed annually,
along with the training CD.
Key messages for Provincial and District Health Staff
Encourage all health staff to carry and use the STM whenever they provide care for a child
Support training courses for health staff in Standard Treatment and Hospital Care for Children
36
7.4 Neonatal Care
Neonatal deaths are those that occur in the first 28 days of life. The neonatal mortality rate in PNG is
estimated to be about 24-28 per 1,000 live births, comprising about 40% of infant mortality. Two thirds of
neonatal deaths are associated with high risk pregnancies, labour and delivery. Although there are many
factors, prematurity, low birth weight, deliveries that are not supervised by skilled health workers and early
neonatal sepsis account for the majority of neonatal deaths in PNG. Only about 50% of mothers deliver their
babies in a health facility with a skilled birth attendant. Most births are not officially registered; so many
still-births and neonatal deaths are not counted.
Efforts to reduce neonatal mortality are closely linked to safe motherhood programs, including the National
Strategic Action Plan to reduce Maternal and Newborn Mortalities, the WHO Integrated Management of
Pregnancy and Childbirth (IMPAC), and Early Essential Newborn Care.
Quality antenatal care (ANC) is important in the prevention of maternal complications and neonatal illness.
ANC interventions include maternal screening for common diseases like malaria, syphilis and HIV, and
haemoglobin checks to identify anaemia. All pregnant mothers should have a minimum of three ANC visits
during pregnancy, have two tetanus toxoid injections if primiparous (and one if multiparous), and take
prophylactic anti-malarials and iron / folate throughout the pregnancy. All mothers with high risk
pregnancies need qualified medical personnel to supervise the delivery, and emergency obstetric care must
be available.
Increasing health facility deliveries and improving the quality of early essential newborn care is vital to
reducing neonatal mortality in PNG. This will require increased number of nurses who have midwifery
skills, improvements in primary and district health facilities, and community demand.
Early essential newborn care
Many newborn babies do not receive basic care in the first hour after birth. Babies born in a village without a
skilled attendant may be subject to asphyxia (lack of oxygen), birth trauma, cold exposure or infection, and
these are often not recognized or treated in timely and appropriate ways. However, even babies born in a
hospital or health centre may miss out on essential newborn care. They may be left to become hypothermic,
they may be excessively suctioned leading to stress, and they may be separated from their mother and not
have the opportunity to feed from the breast and stay warm. Each of these stresses lead to an increased risk
of infection, hypothermia, hypoglycaemia and death. Early essential newborn care requires that babies are
dried thoroughly, put immediately in skin-to-skin contact with the mother, assessed for adequacy of
breathing, have delayed cord clamping for 1-3 minutes until pulsations stop, are allowed to suck on the
breast early so they receive colostrum, and not be separated from their mother.
It is essential for a newborn baby to receive good nutrition at the start of his or her life to ensure good growth
and development. Breast milk provides all that the baby needs to grow and be healthy. In the 2005 National
Nutrition Survey, 84% of mothers initiated breast feeding within 24 hours. However, few breast fed in the
first hour. In some health facilities, “pre-lacteal” feeding (i.e. feeding of formula before breast milk) is still
done. Breast feeding should be initiated within one hour of birth, and skin-to-skin contact established to
encourage early initiation of breast feeding. Improving breast feeding techniques and support for new
mothers will help eliminate pre-lacteal feeding.
The International Code of Marketing of Breast-Milk Substitutes is an essential tool to ensure that babies are
exclusively breast fed in all health facilities.
Early Essential Newborn Care, the WHO Action plan for healthy newborn infants in the Western Pacific
Region (2014–2020), also includes the care of the sick and low birth weight newborn. This is taught in
Hospital Care for Children training.
Appropriate models of neonatal care
Improving neonatal care requires models of care that are appropriate at each level of the health service:
health centres, district hospitals, referral hospitals. The model of care involves training for nurses, CHWs
and doctors, guidelines, basic equipment, physical infrastructure, drugs, referral criteria, audit and reporting
37
of outcome data. The model of care will focus on the management of common illnesses in newborns:
neonatal sepsis, low birth weight, birth asphyxia and congenital malformations.
Improving training in neonatal care is important, as currently the number of nurses trained in neonatal care is
inadequate, and all who deliver newborns should be trained in early essential newborn care.
Needs assessments will be conducted of what is required for provincial and district hospitals, and health
centres to achieve minimal standards of neonatal care in equipment, staffing, physical facilities. Standards of
neonatal care at different hospital levels have been developed, endorsed by the Ministry of Health and
published by the Paediatric Society in the PNG Medical Journal.
15;16
Care of the low birth weight baby
Low birth weight (LBW) babies should remain with their mothers, so they receive the benefit of skin-to-skin
warmth and breast feeding.
Guidelines for the management of very low birth weight babies (VLBW 1,000-1,500g) are contained in the
WHO Pocketbook of Hospital Care for Children, and the PNG Standard Treatment Manual. Training on care
of the LBW and VLBW baby is contained within the Hospital Care for Children training program.
The target for improving survival in low birth weight infants will be those that are more than thirty weeks
gestational age or weighing 1,000g or more. Currently the mortality rate for VLBW babies (1,000-1,500g) is
high (35% of 1700 admissions in 2009-14). With improved models of neonatal care this can be reduced.
Figure 3. Skin-to-skin contact keeps baby warm and encourages breast feeding
(From Early Essential Newborn Care, WHO Western Pacific, 2014)
Neonatal sepsis
Sepsis is a common cause of neonatal death. Umbilical cord infection is a common cause of neonatal sepsis
in PNG, and much of the problem occurs in babies born in villages. Appropriate cord care would prevent
this. To increase the proportion of newborns receiving this essential newborn care, an information brochure
for mothers and a pre-packed newborn cord care kit is being developed. This kit will include a vial if gentian
violet, cotton wool swabs and soap, plus the New Mother’s Brochure, which will explain all the
interventions that every newborn should receive (early breast feeding, Vitamin K, Hepatitis B and BCG
vaccines).
Baby Friendly Hospital Initiative
This was started in 1989, supported by WHO and UNICEF and was implemented in three hospitals in PNG.
However, donor funds ceased and the impetus for continuing was less. The BFHI is as important as ever,
with increasing pressures on mothers to feed in alternative ways, the mounting evidence that early solid
feeding is a major risk factor for pneumonia, HIV and uncertainty around breast feeding, and the lack of
enforcement of the Baby Feeds Supply (Control) Act 1984. Having policies of exclusive breast milk feeding in
hospitals in PNG is important to showing a lead to mothers and the community on the importance of breast
38
feeding. A recent initiative in ANGAU Hospital showed that the BFHI can be successfully introduced
without external funding.
A centre of excellence for neonatal care
PNG needs a facility for training nurses in good quality neonatal care, and the large population of Port
Moresby requires a facility for sick newborns to receive the best care that can be provided. There are over
14,000 babies born in Port Moresby each year. The Neonatal Unit at PMGH admits about 1,000 sick
newborns each year, mostly with low birth weight, prematurity, sepsis and birth asphyxia. In the first five
years of this plan a new neonatal unit was built. Having centres of excellence in neonatal care in major
provincial hospitals, emphasizing Early Essential Newborn Care, low cost technology and standard treatment
provide a good model for other provincial hospitals throughout the country. The aim is not to strive for high
technology neonatal intensive care units, but units that support essential newborn care and, where safe, high
quality care for babies with very low birth weight, sepsis, birth asphyxia, correctable congenital
malformations and other sick babies can be provided, with their mothers. Improvements are needed for many
neonatal units in provincial hospitals in the next five years.
Activities
Below are some other important activities in neonatal care in provinces:
Promote and train staff in early essential newborn care, as described above.
Develop and implement models of neonatal care at district hospitals. Review hospitals to assess to
what degree they comply with minimal standards of neonatal care, and what would be required to
achieve this level (space, basic equipment, essential drugs, human resources, training, auditing,
infection control measures, etc)
Undertake facility improvements to labour wards and special care nurseries
Train staff in care of the sick newborn, neonatal resuscitation and early essential newborn care
through the Hospital Care for Children training
A Neonatal Resuscitation flow chart has been developed for labour wards and special care nurseries.
This will be distributed to all hospitals and health centres where babies are born. Neonatal
resuscitation training will be done, integrated within the WHO Pocketbook of Hospital Care for
Children course
Modify neonatal resuscitation for training health workers/volunteers in management of birth
asphyxia at health centres and community levels
Promote and train staff in Kangaroo Mother Care as part of the quality of care for very low birth
weight babies
Improve the reporting of neonatal diseases (low birth weight, birth asphyxia, neonatal sepsis and congenital
malformations) through the Paediatric Hospital Reporting program and the existing NHIS
Key messages for Provincial and District Health Staff
Promote and train staff in early essential newborn care
Review hospitals to assess what would be required to achieve standards of neonatal care (space,
basic equipment, essential drugs, human resources, training, auditing, infection control measures,
referral guidelines, etc)
Undertake facility improvements to labour wards and special care nurseries
Train staff in care of the sick newborn, neonatal resuscitation and early essential newborn care
through the Hospital Care for Children training
Encourage skin-to-skin (‘Kangaroo’) care
For assistance with neonatal care issues contact the provincial paediatrician
39
7.5 Nutrition and Malnutrition
Nutrition is a vital but often neglected part of health care in Papua New Guinea.
Malnutrition
The rate of malnutrition is unacceptably high and contributes substantially to high child mortality, poor
growth and neurodevelopment and high infectious disease morbidity. The Paediatric Hospital Reporting
program data indicates that 11% of 97,000 children admitted to hospitals between 2009 and 2014 had severe
malnutrition, and the mortality rate was 18%. A recent (2014) survey at Port Moresby General Hospital
showed the rate of severe malnutrition to be as high as 20% among in-patient children. Most of the
malnutrition at PMGH was associated with other chronic illnesses, but under-feeding and low calorie intake
is a potent cause. In addition, many other children suffer from moderate malnutrition, which increases the
risk of death from pneumonia, diarrhoea, tuberculosis, HIV and malaria.
10;11
Two-thirds of all child deaths in
PNG are associated with moderate or severe malnutrition.
The 2005 National Nutritional Survey showed over half of all children under five years of age had some
degree of malnutrition. Contributing factors towards malnutrition include early weaning, inappropriate
feeding, adoption and infections. Improving rates of exclusive breast feeding for six months and improved
quality of complementary feeding is crucial to achieving better nutrition throughout childhood.
The National Nutrition Survey showed that stunting and underweight are a serious public health problem
(prevalence above 40%). Levels of stunting and wasting are particular high in the first two years of life. The
prevalence is higher in rural than in urban areas, and Momase is the region where the highest proportion of
children are affected.
Given the high prevalence of malnutrition in the second year of life, nutrition services should be expanded,
and opportunities must be created to reach children between 13 and 24 months old. Many children do not
attend well-baby clinics once immunizations are completed. More emphasis should be placed on education
on adequate complementary feeding, both in quality and quantity, and on growth monitoring and plotting the
weight chart with each vaccine.
Breast feeding promotion
There is a need to promote proper breast feeding practices, and to integrate different programs that have a
nutrition component. Existing programs include IMCI, Infant and Young Child Feeding (IYCF) and the
Baby Friendly Hospital Initiative (BFHI). IYCF trains health workers to support breast feeding and effective
complimentary feeding, and aims to improve knowledge and skills among adolescents and soon-to-be-
parents. Apart from health workers, targeted groups for training include village health volunteers, school
health workers, and mothers of high risk babies (such as low birth weight), nutritionists and teachers.
The WHO recommends initiation of breast feeding within the first hour of life, exclusively breast feeding for
the first 6 months of life, and continued breast feeding until two years of age or older. Reviews have shown
that initiation of breast feeding within the first 24-hours of birth is associated with a 45% reduction in all
cause and infection-related neonatal mortality, and is thought to mainly operate through the effects of
exclusive breast feeding.
There are impediments to improving infant nutrition in PNG, including private businesses and public service
facilities that don’t provide breast-feeding friendly work environments, infant formula companies that
promote their products to midwives and young mothers, and pharmacies and other outlets illegally selling
infant feeding bottles. These obstacles need to be addressed by education, updating of the existing legislation
by including provisions of the International Code of Marketing Breast-Milk Substitutes and enforcing
existing legislation.
Complementary feeding
Health workers should become conversant in what to advise mothers on the introduction of adequate
complementary feeding. Mothers and caregivers often introduce foods too early, and very often
complementary foods are not sufficiently energy dense, not frequent enough, and have low protein content.
40
Micronutrients
Support should be given to efforts to fortify staple foods, such as rice and flour with multiple micronutrients
including iron, iodine, zinc, thiamine, riboflavin and folate. Locally grown foods that are naturally full of
micronutrients should identified and be encouraged to be grown in family food gardens. This will require
collaborative effort from the different stakeholders such as agriculture.
Vitamin A
The target population for vitamin A supplementation is children six months to five years. The current
Standard Treatment Manual recommends two doses, given at six and 12 months. To improve vitamin A
coverage it would be valuable to expand vitamin A supplementation into the second year of life, by adding
additional doses at 18 and 24 months. Vitamin A is delivered through EPI. There is a need to record vitamin
A administration in the NHIS and Baby Health Record Book. Include a dose of vitamin A to post-natal
mothers.
Deworming
De-worming with albendazole should be given with vitamin A at 12 months of age, then at regular intervals
thereafter, every 3-4 months if possible.
Zinc
Zinc is part of standard treatment for children with diarrhoea and malnutrition. Zinc is currently not widely
available in PNG, and efforts should be put into distribution of zinc to all health facilities.
Growth monitoring every time a child receives vaccines
Growth monitoring is an important part of child health. Its impact is dependent on whether staff have
weighing scales, are able to understand how to plot a weight chart accurately, understand the meaning of a
flat or falling weight line, and counsel the caregiver appropriately. In remote areas in PNG there is a lack of
weighing scales. Health workers can take a history of the child’s dietary intake and counsel mothers and
other caregivers on feeding appropriate for the child’s age. In addition, evaluation of milestones is helpful to
assessing the nutritional and development state of the child. Measuring mid upper arm circumference
(MUAC) is useful in areas where scales are lacking. Regular growth monitoring is an important part of child
health in PNG, and it should occur at least at every vaccine visit and every presentation with illness.
The ability to measure height would allow identification of severe acute malnutrition (SAM) and moderate
acute malnutrition (MAM). Again, impact will be highly dependent on staff understanding how to measure
and plot height, and their acceptance.
Nutritional support to sick and malnourished children
The mortality rate for severe malnutrition in provincial hospitals is 20%. Currently, in most hospitals,
children with acute severe malnutrition do not receive the frequency or volume of feeds they need, basic
complications such as hypoglycaemia and hypothermia are not monitored for. A staged, systematic approach
to the management of acute severe malnutrition follows WHO and PNG standard treatment guidelines, and is
part of the Hospital Care for Children training course. Improvements in the management of severe acute
malnutrition in PNG hospitals may reduce the very high mortality rate among children with severe
malnutrition.
There is a need for hospitals to improve services, both for in-patients and in the community for children with
poor nutrition.
In most hospital Nutrition Rehabilitation Units (NRU) have been closed down or operating under difficult
circumstances. The re-establishment of nutrition rehabilitation units and the appointment of nutritionists in
hospitals are important.
Training in the management of acute severe malnutrition.
Training in the outpatient management of moderate acute malnutrition
41
There is a need for provincial health offices to work with departments of agriculture to support better
nutrition in the community.
Some countries have replaced NRU’s with community-based distribution of RUTF (ready-to-use therapeutic
foods). Development of local manufactured RUTF is crucial to sustaining supply. This requires coordinated
inter-sectoral collaboration (including DAL, NARI, UNITECH, SMHS, DOH-Nutrition and Food Safety).
Human resources for nutrition
It is of concern that the number of nutritionists has decreased over the years. PNG has no dieticians in the
Department of Health, let alone dieticians specializing in child health. Use of ready-to-use therapeutic feeds
should be explored in children with malnutrition, tuberculosis and HIV. There is a great need for dieticians
and nurses to assist with the implementation of nutrition programs in hospitals and the community.
The Health Department Nutrition Unit has proposed to create at least one position for dieticians at Level 1
and Level 2 (combined with a training program for local dieticians). Dieticians could advise on food services
for malnourished children.
Given the central importance of nutrition there is a need for a paediatrician trained in nutrition to help
provide national leadership in this area.
Essential nutrition requirements
Affordable and proven nutrition interventions through actions at health facilities, in communities and
through communication channels are available. In summary, these include:
Exclusive breast feeding (EBF) from birth to six months
Adequate complementary feeding from about 6–24 months with continued breast feeding for at least
two years
Appropriate nutritional care of the sick and severely malnourished children
Adequate intake of vitamin A for women and children
Adequate dietary intake of iron for women and children
Adequate supplementation to pregnant women with: iron, folic acid, and calcium
Adequate intake of iodine by all members of the household
Reduction in malnutrition and its consequences therefore depends on interventions started before or during
foetal development and infancy.
Key messages for Provincial Health Offices
Every time attends a health centre to receive vaccines, they should be weighed and have their weight
plotted on their growth chart in the Infant Record Book. A flat or falling weight curve indicates the
child requires help. Don’t wait until a child has severe malnutrition to do something about it
Re-establish a Nutrition Rehabilitation Unit in your province
Train staff in nutrition and the management of acute severe malnutrition, using IYCF training and
the WHO Hospital Care for Children courses
Create a position for a nutritionist in the province and nutrition officers for your districts
Promote exclusive breast feeding from birth up to six months of life, and support education for
mothers in complementary feeding
Have breast feeding friendly policies in all work environments
Enforce the Baby Feeds Supply (Control) Act 1984 (under revision: this Act after it is completed
will be called the Infant and Young Child Feeding Act, and will prohibit the selling of infant feeding
bottles without a prescription from a paediatrician)
Support your hospitals to be accredited as ‘Baby Friendly’
42
43
7.6 Improving Quality of Hospital Care
In many hospitals and health centres there are problems in supplies of drug and basic equipment, buildings
and facilities, limited training and support for health staff, and lack of a family and child friendly
environment. Improving the quality of paediatric care will improve outcomes and generate community
demand. Improving the management of malnourished children, triage and emergency care, oxygen
administration, supportive care and monitoring is relevant whether children have pneumonia, tuberculosis,
HIV, or less common conditions. This can be addressed by a program of training for nurses, better use of
guidelines, better facilities and equipment (including oxygen), and improved data collection to follow
outcomes and measure impact. Efforts to improve the availability of food supplies on hospital wards,
improve the detection of children at high risk of malnutrition, and improve malnutrition management are also
crucial.
Paediatricians and child health nurses have important roles in improving quality within hospitals and
throughout their provincial and district health services.
Standards are available, in official technical guidelines such as the Standard Treatment Manual and the
WHO Pocketbook of Hospital Care for Children. Outcome data are being monitored in many hospitals and
quality improvement initiatives started based on these data.
WHO Pocketbook of Hospital Care for Children training course
Training in clinical guidelines and quality of care is designed to improve the holistic management of sick
children at a hospital level. It was adopted in 2009, and successful training courses conducted in Kimbe,
Wabag, Mendi, Goroka, and Mt Hagen. The training addresses all the stages of management of any sick
child, and teaches health workers how to use the guidelines in everyday clinical practice. The 4-day training
course is a vehicle for teaching about current issues and changes to treatment (such as the improvements in
the management of childhood TB, changes to Prevention of Parent to Child Transmission, new vaccines, use
of zinc in diarrhoea, improved management of malnutrition, Early Essential Newborn Care). Copies of the
WHO Pocketbook have been distributed to colleges of training, the School of Medicine and to hospitals,
through the paediatricians. Training CDs are available from the Paediatric Society.
Improving oxygen supplies and the management of severe pneumonia
In PNG the most common cause of death among children under five years old is pneumonia. Hypoxaemia
(low oxygen levels in the blood) is the major complication of pneumonia leading to death. Hypoxaemia is
also a complication of other common diseases, particularly among newborns. Children with severe
pneumonia need both antibiotics and oxygen, but oxygen shortages are common due to the cost and complex
logistics of transporting oxygen in cylinders. Detection of hypoxaemia using clinical signs can be difficult.
Pulse oximetry is the most reliable, non-invasive way of detecting hypoxaemia. In 2003 the Health
Department and the Paediatric Society started a trial of oxygen concentrators, machines that generate oxygen
from ambient air, and pulse oximeters. It was hoped that the installation of a reliable, sufficient and cheap
source of oxygen in hospitals coupled with the use of pulse oximetry would make a significant difference to
child survival rates in PNG. The oxygen concentrator / pulse oximeter project was implemented successfully
in 9 hospitals by 2008, reducing mortality from pneumonia in the first five hospitals by 35% (from 5% to
3.2%).
17;18
There will be an expansion of the oxygen concentrator / pulse oximeter program to all provincial and rural
hospitals and major district health centers in the country. Funding will be required for equipment,
installation, commissioning and training (for clinical staff and hospital engineers), and for the oxygen team
(paediatrician, biomedical engineer and nurse administrator) to provide regular support to each of the
hospitals involved.
44
Figure 3. A high dependency unit in a provincial hospital will improve quality of care
Paediatric Hospital Reporting (PHR) program
In 2009 a computer program called Paediatric Hospital Reporting (PHR) was introduced to standardize
hospital statistics, understand disease burdens and monitor mortality rates and quality of care. The program
records all admissions and outcomes, common diagnoses in sick children, and outcomes. This program
produces standardized reports and calculates case fatality rates. The diagnostic classifications used are
consistent with ICD-10 classification system, WHO guidelines and PNG standard treatment classification
systems. A single data summary sheet is generated by the program for any selected time period describing
admissions, deaths and case-fatality rates for common diseases, co-morbidities, vaccine-preventable diseases
and age-specific mortality rates. The data from all hospitals are combined, and the lessons in terms of policy
and practice are considered by the Child Health Advisory Committee. Five annual reports of child morbidity
and mortality have been published (2010-2014). The program has enabled the reporting of the causes and
outcomes of over 97,000 admissions in 17 hospitals over six years.
With the introduction of new vaccines, such as Hib vaccine in 2009 and pneumococcal vaccine in 2014, and
the increased efforts to identify and control outbreaks of measles, and to maintain PNG’s polio-free status,
there is a need to increase the quality, timeliness and accuracy of vaccine-preventable disease surveillance.
In 2008 there was a strengthening of vaccine-preventable diseases (VPD) reporting. The system is
coordinated at the Health Department, jointly by the Disease Control Branch and Family Health Services.
These departments work with provincial and national health offices, aiming for timely responses to reported
outbreaks. The PHR also enables reporting of hospital presentations of all vaccine preventable diseases:
measles, rubella, acute flaccid paralysis, pertussus, tuberculosis, Hib and pneumococcal meningitis, tetanus.
Hospital outreach services
Hospitals should support rural health services by regular outreach to rural health clinics. These can be
coupled with teaching, assessments of equipment, drug and infrastructure needs, clinical reviews of patients
and encouragement for rural health staff.
45
Improving the care of children with chronic illnesses
In every district or province there are many children with chronic non-communicable illnesses: epilepsy,
asthma, rheumatic or congenital heart disease, cerebral palsy, diabetes, cancer, or the long-term effects of
neonatal illness. While each condition is uncommon compared to pneumonia and febrile illnesses, taken
together these chronic conditions comprise a very large burden of disease. Preventable complications,
including malnutrition, poor control of the primary disease, non-compliance with prophylaxis and loss to
follow up lead to a large burden on the health system of complications and preventable deaths, and a large
social and economic burden on families and communities. Children with chronic conditions need consistent
long-term follow up and care. Models of care for chronic conditions need to include basic and ongoing care
at a primary health and district level, and specialist care at a provincial hospital level. This requires clear
treatment plans, effective communication between primary and referral levels, parental education and
empowerment, and mechanisms to provide medicines for less common diseases near where the patients live.
Even less addressed than chronic physical conditions are mental health and developmental problems. Some
services for children with developmental problems such as cerebral palsy, impaired vision and deafness
exist, but are rudimentary and often dependant on philanthropy. Services for disabled children need to be
better coordinated and supported, and specific skills in holistic care for such children need to be taught in
health training curricula for nurses, doctors and paediatricians.
Improving hospital care for sick adolescents
Providing appropriate facilities for sick adolescents is an important initiative. A model of an adolescent area
in a children’s ward will be developed (see adolescent health).
Key messages for Provincial Health Offices
Each province needs at least 2 paediatricians to care for sick children and to support provincial child
health programs. If you don’t have the required number, consider creating a provincial position
Good quality hospital care depends on trained staff, including child health nurses, consider sending
nurses for post-basic training in midwifery or child health nursing
Make sure all health workers who treat children have a copy of the PNG Standard Treatment Manual
and the WHO Pocketbook of Hospital Care for Children
Conduct training in Hospital Care for Children for your provincial and district health staff who treat
children
Oxygen is an important intervention for children with pneumonia and other common problems,
invest in oxygen concentrators and pulse oximeters, and if needed solar power for health centres and
district hospitals
46
7.7 Pneumonia
Acute lower respiratory infection is the most common cause of serious illness and death in children in PNG,
accounting for 30-40% of all hospitalizations. Pneumonia, the commonest cause of ARI, is particularly
prevalent in highlands provinces. A comprehensive strategy to address pneumonia is outlined in this Child
Health Policy and Plan. Interventions to reduce pneumonia morbidity and mortality are included in many
program areas, but are brought together in this section to illustrate the multi-faceted strategy required.
Causes
The major bacteria causing pneumonia are Streptococcus pneumonia (pneumococcus or Sp) and
Haemophilus influenzae (Hi). The most common pathogenic Sp serotypes are 2, 5, 6B, 7, 14, 19F, 23F. Both
typable and non-typable strains of Hi cause pneumonia in PNG children; about 20% of all Hi strains are Hi
type b. Viruses, particularly respiratory syncitial virus (RSV) and influenza are also common, and occur in
seasonal outbreaks. Viruses are often associated with secondary bacterial infection. In the last 10 years with
the increase in HIV infection, other pathogens are increasing in prevalence. In HIV affected children H.
influenza and S. pneumoniae are the most common causes; however, Pneumocystis jiroveki, Staphylococcus
aureus, and enteric Gram negative bacilli (such as Klebsiella spp and E. coli) are found more commonly in
HIV-infected than HIV-uninfected children. Tuberculosis is also a common pathogen in HIV-infected and
uninfected children causing pneumonia.
Pneumonia mortality is highest in children with malnutrition, neonates, young infants and those with HIV.
Risk factors for pneumonia include:
Indoor air pollution, including smoke from fires for cooking or warmth inside poorly ventilated
houses
Parental smoking (throughout infancy and childhood, and in-utero exposure to cigarette toxins)
Low birth weight and prematurity
Absence or inadequate of breast feeding, such as among adopted children
Feeding of solids and semisolids in the first weeks or months of life, a common practice in some
parts of PNG
HIV infection
In this plan, given its importance to child health and mortality pneumonia is reflected in almost all program
areas: EPI, IMCI, neonatal care, quality improvement in hospital care, paediatric surveillance, standard
treatment and clinical guidelines, human resources and others.
Treatment
Treatment of pneumonia occurs in primary health centres, district and provincial hospitals and referral
hospitals. For decades the Standard Treatment Manual has guided treatment of pneumonia. In recent years
health workers have been trained in IMCI algorithms, although the roll-out of this has been fragmented.
STM and IMCI case management instructions are consistent with each other, and the IMCI Checklist is
incorporated into the STM. Lack of availability of standard antibiotics in some health facilities at various
times has reduced access to good treatment. Absence of basic equipment such as oxygen, oxygen cannulae,
nasogastric tubes and intravenous cannulae are common everyday problems in many hospitals, and need to
be addressed.
Training on the management of severe pneumonia is provided in the WHO Hospital Care for Children
training course. This includes management of complex and simple cases, and identification and management
of complications and comorbidities including hypoxaemia, malnutrition, HIV, anaemia and heart failure. It
includes all stages of management, including triage, history, examination, diagnosis, treatment, supportive
care and monitoring, discharge planning and follow-up.
A program started in 2004 to improve oxygen supplies and pneumonia treatment has produced good results.
This program, based on use of oxygen concentrators and pulse oximeters for detection of hypoxaemia
47
reduced case fatality rates in five hospitals by 35%. This program is now in many hospitals and will be
extended to all provincial hospitals and district level hospitals during the life of this plan.
During the life of this plan, a simple system of CPAP (continuous positive airway pressure) will be trialled in
an effort to further reduce mortality from ARI and neonatal respiratory distress. CPAP is highly effective in
Western countries, and is increasingly being used in developing countries in Africa and Asia, and has been
shown to significantly reduce mortality in children with pneumonia in Bangladesh. CPAP may be an adjunct
to antibiotics, oxygen and good supportive care.
During the life of this plan there will be consideration of changing from chloramphenicol to benzylpenicillin
(or ampicillin) and gentamicin as first line treatment for severe pneumonia in the Standard Treatment
Manual tenth edition.
Prevention
Immunisation
Immunisation with existing vaccines in the EPI schedule (pertussis, BCG, measles) helps prevent certain
types of pneumonia. In 2008 PNG introduced the Hib vaccine, which will prevent a proportion of pneumonia
due to Haemophilus influenzae.
Vaccine strategies against S. pneumoniae (pneumococcus) have previously been trialled in PNG. The
pneumococcal polysaccharide vaccine was used in the 1980s showing protective effect against all-cause
mortality when given to infants as young as nine months. PNG has funding support from Gavi for the
introduction of pneumococcal conjugate vaccine (PCV). The vaccine is the 13-valent pneumococcal
conjugate vaccine which contain most of the serotypes commonly found in studies in PNG children. Use of
PCV13 commenced in 2014.
Other types of prevention
These are equally as important as immunisation and include:
Reducing indoor air pollution by reducing cigarette smoke exposure throughout infancy and
childhood, and in-utero cigarette exposure, and reducing cooking smoke exposure in homes
Improving rates of exclusive breast feeding and childhood nutrition
Improving nutrition in very low birth weight babies and other maternal strategies to reduce
prematurity
Prevention of parent to child transmission of HIV
Early care seeking when children have signs of pneumonia
Surveillance
There are two methods of surveillance: laboratory and clinical. In 2007-08 a laboratory-based surveillance
system for meningitis was established in eight sentinel sites. This system is designed to monitor the
effectiveness of the introduction of Hib and pneumococcal vaccine, and is also providing valuable
information on the burden of other vaccine preventable meningitis pathogens, particularly pneumococcus.
Sustaining this system will rely in part on hospitals purchasing latex agglutination test kits for detecting CSF
pathogens. Latex antigen test kits should be included on the medical catalogue of drugs and diagnostics.
The Paediatric Hospital Reporting system enables the standardised reporting of hospital admission data on
pneumonia and other common childhood illness, and case fatality rates. In the six years 2009-14 the PHR
documented 26,000 cases of pneumonia, with an overall case fatality rate of 5%. Severe pneumonia makes
up more than 40% of all pneumonia cases admitted to hospitals and has a case fatality rate of about 10%.
Sustaining this surveillance system will require effort and some small ongoing resources, computer being
purchased for the paediatric wards, and having ward clerks and nurses trained in basic data entry.
Key messages for Provincial Health Offices
Create community awareness of the dangers of indoor air pollution (cigarette smoke and cooking
smoke) on children’s lungs
48
Support introduction of the pneumococcal conjugate vaccine (PCV 13) against Streptococcus
pneumoniae, the most important bacterial cause of pneumonia
Other vaccines also prevent pneumonia: measles, BCG, pertussis, and vitamin A also prevents
pneumonia
Promote exclusive breast feeding, avoidance of early solid feeding
Make improvements to services at community health (aid) posts, to include immunization services
and IMCI case management and standard treatment
49
7.8 Malaria
Malaria is endemic in all coastal provinces of PNG, and is increasingly found in the highlands region. An
objective of the PNG National Health Plan was to reduce malaria disease and mortality by 50% by 2010. In
the early 2000s it was estimated that 7% of mortality in children under the age of five years was from
malaria.
Malarial drug resistance is a major problem. Rates of resistance to chloroquine and amodiaquine are high. In
the 2005 Standard Treatment Manual artemisinin-based combination therapy was introduced. In 2012 the
proportion of deaths from malaria had fallen to 4%, and the case fatality rate for children hospitalised with
malaria was between 3-5%. Reductions in malaria deaths have been largely due to better prevention
methods, particularly the use of insecticide-treated bed-nets.
The Roll-Back-Malaria Strategy was introduced in an effort to reduce the burden of malaria.
Current principles of treatment and malaria control include:
Prevention with long lasting mosquito nets
Prevention measures include protection against mosquito bites and chemoprophylaxis against malaria.
Insecticide-treated bed-nets are one of the safest methods of preventing and controlling malaria. Studies from
other countries have found that use of these insecticide-treated materials leads to a 19% reduction in child
mortality, 40-60% reduction in infection, and also a reduction in maternal anaemia, pre-term delivery and
low birth weight. Use of insecticide treated nets also has an important effect on population-based malaria
control. The blood meal is denied for the female mosquito and this prevents development of eggs and results
in a reduction in vector population and reduced transmission. Bed-nets have been widely distributed in PNG,
with uptake rates of 30-40%. These rates are low, but there has still been a significant effect on malaria cases
and severity. Falciparum malaria is now much less common, while Vivax malaria - not as well prevented by
bed-nets - remains a major problem in PNG.
People living in endemic areas, and travelers to such areas, should be encouraged to adopt protective habits
and use protective measures against mosquito bites. These include closing doors and windows in the
evenings to prevent entry of mosquitoes into houses; using mosquito repellent lotions, creams, mats or coils
and regular use of bed nets.
Diagnosis and treatment
Investigations for malarial parasites, either a blood slide or rapid diagnostic test, should be done where
possible in all cases of fever, and treatment with effective doses of antimalarials should be administered,
according to severity classification based on the Standard Treatment Manual. Many patients fail to complete
treatment due to either lack of understanding, belief that when feeling well treatment is no longer necessary,
and sometimes due to perceived or real adverse effects.
Activities and future directions
Improvements in the management and control of malaria in children will be closely aligned with the overall
malaria control program.
Key issues in the next few years include:
Improve supplies of artemether-lumefantrine, and increase use of rapid diagnostic tests to guide
treatment of children with fever
Ensuring that the formulations of all standard antimalarial drugs are appropriate for children
Supporting efforts to increase the use of diagnostics in clinical decision making
Considering the implications of research in PNG and elsewhere on intermittent chemoprophylaxis
measures for infants (IPTi)
Introducing artesunate suppositories for pre-referral treatment in health centers, and including this in
the Standard Treatment Manual
50
Improving reporting mechanisms from the district to provincial health level and to NHIS, and
improving the reporting of malaria cases and case fatality rates from hospitals
Establishing the extent of other causes of fever, such as dengue, by utilizing new technologies for
diagnosis
Improving the tendering process, procurement and supply of all essential drugs and supplies.
Establish a sustainable mechanism to deliver antimalarial drugs and related supplies to all levels of
the health service
Create a position of National Coordinator of childhood malaria, to establish seminal sites for surveillance,
provide evidence for treatment and prevention recommendations, and link other child health programs (such
as IMCI, hospital care, standard treatment) and with the malaria department
Key messages for Provincial Health Offices
Artemether-Lumefantrine (Coartem) is highly effective treatment for malaria
Coartem is safe and effective, but costs more than older drugs, so it is important that we improve
diagnosis of malaria. Support the use of rapid diagnostic tests in deciding who to treat
Bed-nets save lives. Distribute them at every opportunity
51
7.9 Tuberculosis
Childhood tuberculosis (TB) is a huge burden in PNG. In 2009-14 there were over 7,000 children admitted
to hospitals participating in the PHR program, and over 800 deaths, with a case fatality rate of 11%. This
represents a fraction of the cases of TB in children. Childhood TB reflects high the transmission rate of TB
in the community. Treatment completion rates are far too low, and children ceasing treatment even before
the completion of the intensive phase is a common reason for relapse with worse forms of TB, many
untreatable, and this leads to severe chronic disability and many preventable deaths. Pulmonary and
extrapulmonary TB contribute substantially to child mortality, malnutrition and impaired neurological and
cognitive development. Improving the detection, prevention and management of children with TB was
considered by the Paediatric Society as a major priority, and was added to the areas of child survival
identified by the Western Pacific Region. Ensuring children with TB are identified and complete treatment
under supervision should be the primary aim.
Progress in child TB will require reforms to the way TB is treated. In 2010 there was the introduction of
paediatric fixed-dose combinations (FDC), but these have been problematic because of poor availability.
Some of the problems of TB include:
19
Lack of TB drug supplies
Too early discharge
The lack of formal supervision in the community
Children ceasing treatment even before completion of the intensive phase
Lack of implementation of preventative strategies, including isoniazid preventative therapy
Some recent improvements to the management of TB in children include:
Introduction of fixed-dose combination therapy
Training health workers on child TB management. Training on tuberculosis is now incorporated
within the Hospital Care for Children course, and training modules have been developed for this and
piloted in the highlands provinces in 2013-2015
The 2011 Standard Treatment Manual included standardized regimens for FDC therapy. Ethambutol
replaced streptomycin for all cases requiring four drugs in the two-month intensive treatment phase,
regardless of age. Elimination of the use of streptomycin was because of ototoxicity and painful
injection, and high risk of streptomycin resistance
Essential measures to reduce child TB
Improve diagnosis: TB in children is diagnosed on the basis of clinical features: epidemiology,
history and examination. Chest x-ray, acid-fast bacilli testing and GeneXpert MTB/RIF on gastric
aspirate or sputum for older children, and Mantoux testing are useful if available. Screening should
be done for all child contacts of adults with TB. Screening does not need complex tests, it can be
done by based on symptoms and signs, thus can be done in health centres and district hospitals
Do not discharge patients with TB too early. Keep all children in hospital for the full duration of
their intensive phase treatment (2 months) whenever this is feasible. To do this child and family
friendly health facilities are needed, where children can go to school while they receive supervised
treatment
Address community follow-up: have outreach TB nurses follow-up patients from hospital wards to
home and supervise their care
Address poor drug supplies: ensure TB drug availability in all health facilities where TB is treated
and train health staff in their use
Prevention: ensure that in TB clinics a nurse should screen all exposed children and start isoniazid
preventative therapy if the child does not have symptoms of TB
52
TB and HIV
Where HIV viral particle PCR testing is available, HIV-exposed newborns should have a PCR test at six
weeks of age. If the HIV PCR test is negative, BCG should be given. In health facilities where the PCR test
is not available, BCG should be given to all newborns of HIV affected mothers at birth, and the infant
closely followed up. It is an aim to have HIV PCR testing of HIV affected infants introduced in all hospitals
during the life of the Child Health Policy and Plan.
HIV-infected children who do not have a clinical diagnosis of TB should be started on isoniazid prophylaxis
to prevent TB.
Ensure availability of tuberculin solution (purified protein derivative, PPD) in hospitals. Mantoux testing still
has an important role in child TB diagnosis and it should be available at all hospitals.
GeneXpert testing and multi-drug resistant TB in children
During the life of this plan there will be use of GeneX-pert MTB/RIF testing in more provincial hospitals,
and development of guidelines for testing indications and interpretation. GeneXpert diagnoses TB disease
and Rifampicin resistance, and is the first step in identifying children with multi-drug resistant (MDR) TB.
However, GeneXpert should not be relied upon to diagnose TB, as it is insensitive. TB is still diagnosed on
the basis of clinical features (epidemiology, history, examination, and radiology, Mantoux testing and Xpert
if available).
GeneXpert testing should be done on all children who are:
Contacts of known MDR cases or suspected MDR cases
Relapsed or re-treatment cases
HIV positive
Failing treatment despite supervised treatment and proven adherence
Guidelines for treatment of MDR-TB are available from the National TB program, and will be finalised and
incorporated into training.
Key messages for Provincial Health Offices
Fixed-dose combination therapy for TB has been introduced, including for children
Children with TB should not be discharged until (1) they complete the intensive phase of TB drugs,
(2) their parents or caregivers understand the disease and the importance of adherence to TB
medicines, and (3) they have a safe and supportive environment to go home to. If children are
discharged early there is a high risk of defaulting and relapse with a worse form of TB. This causes
many preventable deaths of children
Every province needs paediatric TB nurses and a disease control officer who can liaise between
hospitals, health centres and families affected by TB
Support training for health staff in child TB management, as part of the Hospital Care for Children
course
7.10 HIV AND AIDS
PNG has a generalized HIV epidemic. The first case of HIV was detected in PNG in 1987. Based on
improved surveillance, mainly using antenatal clinic data, the revised national HIV prevalence rate is
estimated at 0.92%, down from previously reported 2% some years ago. Although a recent report also
indicated HIV rates to be levelling off, the drivers of HIV in PNG are still the same, therefore, we cannot be
complacent about HIV in PNG.
The best way in preventing children from being exposed to the HIV virus is to keep their parents negative
(Primary Prevention). However, the data shows that PNG has a generalized epidemic with heterosexual
transmission being the most common mode of transmission. This, in combination with the slow start in
trying to control the epidemic, has exposed many parents and their children to the HIV virus and
subsequently many children have developed AIDS.
53
A major priority in HIV among children is the Prevention of Parent to Child Transmission (PPTCT). This
treatment is being extended throughout the country. Drugs are available but human resources are
increasingly stretched. Antiretroviral programs for mothers and children are now available in many of the
major hospitals. The human resource implications of scaling up HIV treatment and prevention programs has
not been fully appreciated and is providing stresses and challenges for provincial health systems, and those at
Port Moresby General Hospital. There is an urgent need for providing a paediatric HIV nurse and a midwife
trained in PPTCT in each province.
In 2012 the Department of Health adopted a policy of initiating treatment for all HIV-positive women
diagnosed during pregnancy, regardless of whether a CD-4 count can be done or not. This is in line with
WHO policy in this area.
In the last ten years AIDS and HIV related infections have been in the top ten commonest causes of
admissions and deaths in paediatric wards. Assuming that a third of the exposed children may become
infected, there will always be a group of children who will require ART as part of managing their illness.
For children with HIV infection in PNG life until recently has been of poor quality with numerous recurrent
infections and malnutrition requiring multiple admissions to the children’s wards. HIV has been a huge
burden on individual families and on an overburdened health system. Introducing ART has increased
survival and improved quality of life for many HIV-positive children.
HAART therapy was introduced into the public health system in 2003. Paediatric ART formulations became
available in 2007-8. This has made treatment a lot more child friendly and easier for the family to adhere to.
Management has to be age specific (as children are not small adults), and needs to include cotrimoxazole
prophylaxis for pneumocystis pneumonia (PCP), isoniazid for prevention of tuberculosis, and nutritional
rehabilitation and support.
To assist with malnutrition ready-to-use therapeutic food (RUTF, e.g. Plumpi-Nut) has been made available
since 2007, but has not been widely used. Moreover malnutrition in this setting requires more than RUTF
and hence it is recommended that each facility providing care for HIV infected children must set up its own
nutritional rehabilitation program.
Paediatric HIV management should be an integral part of management of childhood illnesses and must be
included in training for those who run MCH services. Paediatric HIV and AIDS have been included in the
standard treatment for children in into the Hospital Care for Children training course and IMCI.
Priorities in paediatric HIV
(1) PPTCT: Strengthen the implementation of the PPTCT program in provinces. Increase counseling and
testing, PPTCT and ART in all provincial hospitals.
(2) Antiretroviral therapy
Increase access to ARV to level 1-5 hospitals
Update to newer and more effective regimens
(3) Cotrimoxazole and isoniazid prophylaxis
(4) Inclusion of HIV step in IMCI check list, and training on HIV in Hospital Care for Children training
(5) Feeding and nutrition
Exclusive breast feeding for the first six months of life for all HIV exposed children should be
encouraged because its protective effect outweighs the risk of breast milk related transmission
Emphasize avoiding mixed feeding (formula and breast milk) because of the increased risk of HIV
transmission
Strengthen and support nutritional programs in health care and community settings for HIV exposed
and infected children, including the use of RUTF.
Replacement formula feeding in exceptional cases, where it is safe, feasible, available, affordable.
Discuss with paediatrician first
(6) Emphasize involvement of fathers (husbands) and the supportive role that the wider family can play.
Fathers’ involvement is important for family planning, support and further contact tracing
(7) Involvement of senior clinicians providing care and treatment to children infected and affected by HIV
(8) Family planning practices should be discussed during clinic visits
54
(9) Adolescent services for primary prevention of HIV
Key messages for Provincial Health Offices
Prevention of Parent to Child Transmission of HIV is a high priority and will reduce the number of
HIV affected children. Please support the PPTCT program, childhood ART and HIV care in your
province
Support the training of paediatric nurses and midwife trained in HIV, to coordinate the HIV
prevention and treatment program
55
7.11 Training of paediatricians
The paediatrician’s primary role in a provincial hospital is to provide the highest standard of appropriate care
to all children. However it is equally important for him/her to play a supportive role to public health services,
surrounding district hospitals, and primary health care providers.
It is necessary to increase specialist manpower in order to effectively provide a supportive role at the
provincial level. The ultimate aim is to cover all provincial hospitals with an adequate number of
paediatricians.
Training of paediatricians for the next 10 years
Currently five provinces (Manus, East Sepik, Gulf, Hela and Jiwaka) do not have a paediatrician. Between
2014 and 2016 the likely increase in workforce, taking attrition into account is between 0-4, and between
2017 and 2018 the possible increase is between 6 and 10. It is thus highly unlikely that all provinces will
have a paediatrician by 2016, but it is possible by 2018.
As per National Health Minimum Standards on specialist (paediatrician) manpower requirement for
hospitals, there must be a minimum of two paediatricians in all provincial hospitals and five in Level 1
hospitals (PMGH). In addition there is a need to train young paediatricians in subspecialty areas and a need
for young paediatricians to take on academic roles in teaching and research. If the minimal standards are to
be reached by 2020 it is imperative that a minimum of six DCH candidates enter the programme each year
and continue into MMed training. This requires active recruiting. In the longer term, the National Health
Plan envisages the establishment over a time frame of 20 years of four regional hospitals with PMGH or a
new hospital as a National Referral Hospital offering high quality tertiary level services. This will require a
workforce of at least 60 practicing paediatric clinicians.
Sub-specialty training
In order to improve the standard of clinical practice and in line with the continuous medical education
program the Paediatric division recognizes the need to support selected essential areas of sub-specialization.
Currently these areas are paediatric cardiology, neonatology, HIV medicine, and paediatric oncology. To
achieve the long term aims of the National Health Plan it will be necessary to also train for the following
areas: paediatric infectious diseases including malaria and tuberculosis, paediatric nutrition and malnutrition,
and paediatric intensive care. It will also be necessary to strengthen paediatric input into disability services,
child welfare services and adolescent health. It is important to ensure that there are positions established to
allow those with subspecialty expertise to function effectively and efficiently. Appendix 2 outlines a plan for
such training.
The training of Paediatricians in these areas should not detract from the primary aim of providing and
maintaining high quality general paediatric services at provincial level.
Key messages for Provincial Health Offices
Every province needs at least two paediatricians to provide clinical care and to work closely with the
provincial health office or Provincial Health Authority to implement the child health programs
If your province doesn’t have enough paediatricians, create these positions
Provide support for young medical officers entering the training programme in child health
(Diploma of Child Health) in your province
56
7.12 Child health nurses and midwives
Child health nursing need a major increase in resources. In the first five years of this plan (2009-2013) there
have been investments in midwifery training, with increased training places at School of Medicine and
Health Sciences (SMHS), University of Papua New Guinea, and other midwifery schools, heavily supported
by Australian Government, Department of Foreign Affairs and Trade (DFAT). However the same has not
occurred in child health / paediatric nursing. There were three post-graduate child health nursing courses in
PNG, now there is only one. This is based at the School of Medicine and Health Sciences, University of
Papua New Guinea, Taurama Campus. This school trains about 20 new midwives and 15 paediatric nurses
annually. Previous paediatric nursing programmes in Goroka and Pacific Adventist University in NCD are
no longer running such courses.
A review of PNG’s nursing workforce in 2002-3 estimated that there was a need for 435 more midwives and
200 more paediatric nurses. So more post-graduate programmes in child health nursing are needed; one in
each region. The establishment of these programmes will need considerable support in terms of suitably
qualified staff, infrastructure and resources. Selection processes, accreditation, recognition of skills and
remuneration issues need to be addressed if paediatric nurses, once trained, are to stay in the clinical
workforce.
Key messages for Provincial and District Health Staff
Each of the four regions in PNG should have a paediatric / child health nursing training course
There should be a child health nurse and a midwife in every health centre, and at least one on every
shift in hospitals
Send some of your nurses for paediatric nursing training
Ensure your province has positions at the appropriate level for your staff when they have completed
their training programs
57
Figure 4. Paediatric nurses are essential to running children’s wards, improving public child health
and implementing all aspects of this plan
58
7.13 Community Health Nurses
PNG is moving towards upgrading aid post to be community health posts. The intention is to have these
staffed by three officers; including at least one community health worker with training and skills in maternal
and child health care. The services that will be offered at community health posts for mothers and children
will include all essential MCH services: antenatal care, deliveries, basic newborn care, immunizations,
growth monitoring, and management of common childhood illnesses, and referral of very sick children. Staff
will also help encourage the Healthy Islands concept within communities.
Given the number of aid posts to be staffed, there will need to be marked increases in the number of CHWs
trained and major support given to CHW training schools.
7.14 Continuing professional development
A Continuing professional development (CPD) program is important for all child health workers in PNG.
Various CPD-related activities exist currently however there is no systematic program. A CPD program
needs to be developed for child health and general nurses, non-specialist doctors, HEOs and paediatricians.
Attendance and participation in annual medical and nursing symposiums, in-service training, clinical
attachments and postgraduate training for health workers should be supported. Health workers from rural and
remote areas should to be included in these CPD-related activities.
CPD for paediatricians
The Paediatric Society of Papua New Guinea is a professional body made up of all paediatricians working in
the country and membership is open to all child health workers. Members of the society must aim to be up to
date with new and emerging information on child health diseases and clinical practices around the world. A
CPD program for paediatricians should be developed with the support of the Paediatric Society, the NDoH
and the Medical Board of PNG. An accreditation process should be developed as part of the CPD program as
a measure of a paediatricians’ performance and professional standards. The CPD program should involve five
main areas of a paediatricians’ practice that contribute towards the accreditation process:
Involvement in teaching and training of doctors, nurses and community health workers in child
health
Involvement and participation in regular monthly auditing of clinical practice and outcomes
Involvement in research and access to relevant clinical journal
Attendance and participation at annual Medical Symposia and Paediatric Society meetings
Involvement as an active team member of either NDoH, Provincial DoH, non-government child
health organizations, hospital or clinical units
A successful CPD program requires funding to be sustainable as most paediatricians have limited access to
the internet and relevant medical journals. The program is to be supported with an accreditation process to be
developed by the Paediatric Society in collaboration with the Medical Board of PNG.
Activities for the CPD program:
CPD Scoring form incorporating
five
main areas of paediatricians practice to be sent out annually
Quarterly hard copies of journal articles on relevant topics and other relevant literature to be sent out
Annual CPD test/quiz Paediatric Society in collaboration with Medical Board to develop the
Accreditation process for paediatricians
Paediatric Society and Medical Board to issue Certificate of Accreditation for successful completion
of CPD program annually as a prerequisite for medical board registration
CPD for other health workers
CPD-related activities should be strengthened and supported for child health nurses, midwives, HEOs and
other doctors involved in child health by their respective professional organizations, Paediatric Society and
59
NDoH. In-service training, clinical attachments and postgraduate training for child health workers are some
of the activities that need to be supported. Access to relevant child health literature and training in usage of
clinical guidelines should be available to health workers involved in child health.
Key messages for Provincial Health Office
Support CPD activities for your midwives, child health nurses, HEOs, doctors and paediatricians in
your province
Support and strengthen networking and sharing of information among all child health workers in
your province
60
7.15 Adolescent Health
The WHO definition of an adolescent is an individual between the age of 10 and 19 years, an age group that
overlaps the paediatric with the early adult population. In Papua New Guinea, almost a quarter of the
population (22.5%) is made up of adolescents. The adolescent population in PNG are being marginalised as a
result of the lack of appropriate health and social services. Health programs and services targeting
adolescents require multi-sectoral approaches and should involve the NDoH, National Department of
Education, National Youth Commission and Department of Community Development.
The School Health Program jointly carried out by the Family Health Services in the National Department of
Health and the Department of Education aims to deliver immunization to school aged children, and
education on sexual and reproductive health (SRH). SRH problems are among the major health challenges
facing adolescents and there are many barriers in delivering an effective SRH education and services to
adolescents by the School Health Program. These barriers include lack of teacher training, lack of education
materials, low school attendance by girls and the very high school dropout rates. The NDoH has no existing
health program for adolescents in urban and rural areas of PNG.
Non-governmental organizations and churches deliver the bulk of services for the adolescent population in
PNG. The services provided include education and related SRH services such as STI and HIV prevention
and treatment, life skills training and involvement in activities that deter them from involving in social
problems such as smoking, alcohol and drug abuse. The lifestyle choices made by adolescents have a major
impact on the rate of non-communicable diseases in adulthood. The prevention of teenage and unwanted
pregnancies will contribute towards addressing population growth concerns. Therefore, the NDoH should
support these organizations in carrying out their programs with funding and technical resources.
The Paediatric Society should support the Adolescent Health section of NDoH in the development and
finalizing of the National Youth and Adolescent Health Policy. This policy aims to set guidelines for the
provision of health services targeting the adolescent population in the community. Paediatricians should
support and be involved with existing programs and activities of government and non-governmental
organizations that target adolescents in the community within the provinces they work in.
The care of sick adolescents admitted to hospitals in Papua New Guinea should be shared between the
paediatric and adult medical units. The current cut-off age for admission to a paediatric ward is 12 years old
while the adult wards admit 18 years and above. The management of chronic cases such as congenital or
acquired heart problems, epilepsy, cerebral palsy and multiple congenital abnormalities in this age gap is
also an issue. There is currently no allocated ward space and appropriate facilities for sick adolescents in
hospitals within PNG.
A model of adolescent services within a hospital
Hospitals in PNG should support appropriate clinical care of sick adolescents by the introduction of an
adolescent unit. The allocated ward space could be part of the children’s ward, with appropriate facilities that
contribute towards improved clinical outcomes. An adolescent unit could be made up of a paediatrician, an
adult physician, an obstetrician, a social worker and nurses who deliver non-judgemental clinical service and
education to adolescents. The continuity of care of adolescents with chronic clinical problems could be
coordinated between paediatricians, adult physicians and obstetricians within the adolescent unit. An
adolescent consultation clinic should be set up for follow up care. The unit should also work in collaboration
with other government and non-government organizations in the community that deliver preventative and
curative health services for adolescents and youths.
There is a need for interested paediatricians, adult physicians, obstetricians, social workers and nurses with
interests in adolescent health to receive appropriate training.
Key messages for Provincial Health Offices
Establish an adolescent centre in your province which can provide services to adolescents
Involve your hospital Paediatrician, obstetrician or physician in programs targeting adolescents and
youths in the community
Support school health programs including immunization activities
61
Support the training of health workers in adolescent health
In the life of this plan immunization against HPV, the cause of cervical cancer will be introduced
62
7.16 Childhood Cancer, Heart Disease and Paediatric
Surgery
Childhood cancer
The resources required for the management of paediatric cancer in PNG are inadequate. The priority of
resource allocation in child health is given to the prevention and management of acute infections and related
deaths. Childhood cancer, although not as common as infections, is not rare. Therefore adequate resources
need to be allocated to ensure the effective management of childhood malignancies. This should include the
availability of effective chemotherapy and appropriate supportive care for children with the intent to cure
and humane palliation for children with complicated or advanced cancers.
The true burden of paediatric malignancies in PNG is unknown; however, cancer is reported to be amongst
the top 10 causes of admissions in major hospitals in the country.
The following are common childhood malignancies among hospital admissions (in order of decreasing
prevalence):
1. Leukemia – AML, ALL, CML
2. Lymphomas (Burkitt Lymphoma, NHL- other than Burkitt, Hodgkin’s Disease)
3. Neuroblastoma
4. Retinoblastoma
5. Wilms Tumor
6. Brain tumors
There has been a notable difference in the pattern of clinical presentation compared to other parts of the
world, and a change in the incidence of leukaemia in the last three decades. Studies done in the 1970s
reported that leukaemia was not very common in PNG; however, more recent studies have shown that it has
become the commonest malignancy in children.
The barriers to adequate management of paediatric cancers in PNG include:
Late presentations and delayed diagnosis
Inadequate diagnostic facilities and manpower: pathology, medical imaging, timely surgical services
Unavailability of standardized cancer protocols
Unavailability of drugs for chemotherapy, supportive care, palliative care
Inadequate supportive care and facilities: nutrition, blood products, isolation areas
No central data base for cancer surveillance
Poor social support of patients and their families during treatment
Limited ward space for children needing radiotherapy referral
Future plans
Paediatricians to work with provincial health and NDOH to run community awareness programs that
encourage early health seeking behaviour.
To work in collaboration with CPHL and NDOH to improve diagnostic services:
Pathology: Haematology, Biochemistry, Histopathology
Medical Imaging: X-rays, Ultrasound, CT scan
Establishing an arrangement between provincial hospitals and CPHL to enable biological specimens to be
sent for analysis and results sent back to hospitals in a timely manner
Standardize paediatric cancer management by use of a standard cancer management manual for
paediatricians
To work with hospital pharmacies and the PNG Pharmaceutical Board to ensure the availability of drugs
required for chemotherapy, supportive care and palliative care
Encourage active involvement of hospital social workers department in the support of patients and families
during treatment
63
Establish a paediatric cancer unit (10 beds in PMGH and Lae), identify 2-4 beds in provincial hospitals for
use by cancer patients
Improve facilities for supportive care like nutrition, hand washing and hygiene, and blood products, and
child friendly facilities
Support central co-ordination and improve data collection and surveillance on pattern of childhood
malignancies and treatment outcomes
Establish a twinning relationship with an overseas paediatric oncology unit for specialist advice and opinion
Identify key nurses for skill development in childhood cancer especially in safe chemotherapy preparation,
administration and recognition and treatment of chemotherapy side effects ( possibly one in each major
hospital)
Continued support for paediatric oncology training for nurses
Paediatricians to train in oncology
Short courses for registrars and nurses on management of cancers and palliative care
Children with heart disease
The problem of heart diseases in PNG is relatively small compared to the other major infectious diseases and
nutritional health problems. However, they are an important cause of chronic disease in children, with poor
quality of life, high rates of morbidity and mortality and high costs to families if left untreated. Congenital
heart disease is the largest group. Although there are limited population-based data, congenital heart disease
affects 0.8% of infants born in most countries; therefore in PNG could be expected to affect 1,000 infants per
year. Rheumatic heart disease is also common. Cardiomyopathies are uncommon and lifestyle cardiac
diseases are seen in the adult population. Pericardial disease is mainly infective with tuberculosis the
predominant cause. Staphylcoccus aureus pericarditis is less common, but linked to more common skin
disease, impetigo and nutritional deficiencies.
Current situation of management of cardiac diseases
Management of cardiac disease has been a well established program with historically selected cases sent to
Australia for surgery and since 1993 annual visits by an Australian team of volunteers working together with
the local PNG team with both closed and open cases being performed at Port Moresby General Hospital.
Provincial paediatricians identify and manage cardiac patients who are then entered into regional cardiac
registries. Each year the two paediatricians with cardiology training then visit the regional and provincial
centres to review children on the registries. This screening process is to identify children who may benefit
optimally from cardiac surgery: those who require one procedure for a complete repair, and likely to
subsequently have a normal quality of life without significant complications.
Final selection takes place at PMGH by a paediatric cardiologist from Australia in consultation with the local
team and cardiac surgery team. Operations are done for the selected patients by the visiting team from
Australia. The results have been very good with a mortality rate of less than 2%, and good long-term quality
of life for the vast majority of children.
Over the last few years there has been an increasing amount of training and responsibility transferred to the
local PNG team, to the extent that in 2009 all closed heart operations and a number of open cases were
performed by the national team.
Funding for the operations comes from a number of sources including the Australian Government, NDoH,
fund raising by the public and volunteer services of the Australian volunteers.
Future plans in the management of cardiac disease
Cardiac surgery will continue to pose a significant problem for resource-poor countries like PNG. Despite
the increasing capability of PNG cardiac teams to manage these patients there is unlikely to be complete
transfer of the overall program to PNG.
There may some merit in initially establishing a basic local cardiothoracic unit which will be capable of
performing closed operations throughout the year whilst continuing to increase their participation with the
64
visiting teams in the open heart program. This will continue to require substantial training of selected
personnel in overseas units. Components in this plan should include:
Formation of cardiothoracic unit at PMGH
Continuing training for the paediatrician currently under cardiology training, and to identify a second
paediatrician for further training
Identification and training of at least two anaesthetists / intensivists
Identification of an additional surgeon for future training
Supporting training of two persons identified as perfusionists
Continuing training of operating theatre and intensive care unit staff
Key messages for Provincial Health Offices
Many children with cancer can be cured if they are diagnosed early and receive early treatment
All children with suspected cancer should be referred to the provincial paediatrician. We have a
paediatrician who has specialised in children’s cancer who can provide advice
All children with surgical problems should be referred to a provincial hospital and assessed by a
general surgeon or paediatric surgeon
The cardiac program (Operation Open Heart) in PNG has been running since 1994. Children with
heart disease can receive medical treatment, and some can receive surgery and be fully cured. Refer
early to your paediatrician
65
7.16 Child protection and social services
Child abuse and neglect
There is a need to support social services for children. In PNG some children are at higher risk of abuse or
neglect. These include orphans, adopted infants, displaced children, and those living in crowded conditions
in urban settlements. The number of orphans is increasing because of HIV and the breakdown of traditional
village structures. Natural disasters or civil conflict give rise to displaced children, unplanned urbanization is
increasing, all meaning the number of at risk children is increasing. The consequences are extreme, including
malnutrition, physical and emotional injury, preventable infection with HIV and other sexually transmitted
infections.
All paediatricians need to be advocates for marginalised and at risk children. More support is needed for
community groups working with at-risk children and their families. More social workers are needed. Having
a paediatrician within the National Department of Health who is trained in the area of child abuse and other
areas of child protection is an aim for the next five years.
Reducing domestic violence
Domestic violence against mothers and physical and sexual abuse against children destroy families and
destroy the psychological, emotional, spiritual and physical developments that are necessary in childhood
and adolescence. It is the responsibility of everyone to speak out against such violence, and to build
communities and families in which such violence is unacceptable. Health workers, teachers, community
groups and neighbours need to identify and report child abuse and domestic violence.
Universal education
In the longer term child survival and improved child health and development cannot be achieved without
concurrent increases in access to education. Achieving universal primary education, higher participation in
secondary and tertiary education and maintaining quality of education will be as important for child and
maternal health as any interventions within the health sector. There are several barriers, including school fees
and available places. These need to be addressed by advocacy and legislative change.
Birth registration
Vital registration of births and deaths is important for public and population health. Health workers can
promote vital registration when dealing with pregnant mothers, at delivery, and at times of infant
immunization. They should also register any death appropriately. Birth registration will be emphasised on
the Infant Record Book, and in health worker training in newborn care.
66
7.17 Children with disabilities
Our national disability policy emphasises the protection of human rights, inclusiveness, barrier free services
and partnerships for an estimated 1 million people with disabilities (PWD) living in PNG. An estimated 5%
of children in PNG have a disability (CWD) although there is little data on exact numbers. Most PWD and
CWD live in rural areas with ~2% being able to access support services such as community based
rehabilitation and special education resource centres.
In PNG illnesses causing disability are common and include meningitis, birth asphyxia, tuberculous
meningitis, trauma, and prematurity/low birth weight. These illnesses may result in cerebral palsy, the most
common physical disability in childhood, blindness, deafness, intellectual problems and epilepsy. Health
consequences include malnutrition, increased risk of pneumonia, skin problems and dental decay. In addition
to direct health consequences children with disabilities are vulnerable to socio-economic exclusion and
disadvantage. It has been estimated that more than 90% of children with disabilities in developing countries
do not attend school. Children with disabilities are also at increased risk of abuse and neglect. For example,
the annual incidence of violence experienced by children with disabilities in some countries is several times
greater than the rate experienced by children without disabilities. In spite of the extent of these problems,
research into the situation of children with disabilities in PNG is limited.
Prevention of disability
Up to two thirds of childhood disability is preventable and therefore a focus on disability will require
strategies for prevention, many of which are outlined in this Plan. These include:
Vaccines against meningitis, including Hib, S. pneumoniae, BCG
Strategies to improve newborn care: encouraging facility-based deliveries, skilled midwives,
neonatal resuscitation
Improving rates of exclusive breast feeding, reducing malnutrition, reducing anaemia and
micronutrient deficiencies
Strategies to improve child safety, such as car seat belt legislation, bicycle helmets, fire safety
Strategies to improve water and sanitation
Support services for children with disabilities
Many disabilities in children are not preventable, and children will continue to live with disability despite
optimal prevention strategies being in place. Improving support to services for children living with
disabilities is essential to improve their quality of life, health and development, and entails a cross-sector
approach as well as a multi-disciplinary approach in health.
Support services for CWD are mostly run by community-based organisations, with limited external funding.
These community organisations face many challenges, including lack of data on number and type of
disabilities in PNG or where and how CWD live; and poor infrastructure hindering access to CWD. There
are also challenges in terms of inclusive education and health for CWD which include accessibility to these
services as most live in rural areas, and there is a lack of local expertise. In regard to health, our lack of local
expertise in areas such as developmental screening, audiometry, speech therapy, Braille instruction,
occupational therapy, physiotherapy, optometry, orthopaedics and ENT remain some of our biggest
challenges.
Support services for CWD can be improved by:
Birth registration for all children, including babies born with disabilities
Registration of all children with disabilities seen by provincial and referral hospital paediatric teams
Strengthen referral pathways for CWD from all provincial peripheral health facilities to enable
registration
Strengthening or establishment of developmental screening programs for children at early education
centres and in major hospitals.
67
Increasing support to community organizations who work with disabled children.
Strengthening multi-disciplinary health services for children with disabilities
Training of nurses and paediatricians in supporting children with disabilities and their families
68
7.18 Urban and environmental health
The health of children in urban environments is of increasing concern. Well planned, child friendly and clean
urban and rural environments can contribute to child health and development, but unsafe environments lead
to transmission of infectious diseases, malnutrition, injuries, and psychological problems that can have
devastating consequences. Additional effort will be needed in the coming years to provide services that
address these needs. These require a multi-sector effort, involving health and education authorities, town
planning, other city or local government departments, and community organisations.
Features of healthy environments for children:
Lack of crowding in housing
Public safety measures (e.g. speed limits on roads, seat-belt legislation, smoke detectors in homes)
Sewage and sanitation
Hygienic waste disposal
Clean water
Healthy food, fresh fruits and vegetables
Access to preventative health care (vaccines, growth monitoring), primary health care and referral
level health services
Access to schools and education so children can reach their full potential
Parks and play-grounds, sporting ovals and sporting teams for children to join
Trees and gardens
Clean air, limiting pollution
Music
Books
Freedom from domestic violence and abuse of all kinds
Freedom from bullying and peer violence
Drug free environments
Paediatricians and other child health workers have a role in advocacy for healthy environments for children,
in both rural and urban areas.
NCD health is developing primary care services. In the life of this plan there may need to be better definition
of the role and credentialing of General Practitioners who look after children.
69
7.19 Child health research
The Child Health Policy and Plan strongly supports the further development of child health research and
research capacity in the country. All program areas mentioned in this Child Health Policy and Plan have
research needs, and priorities should be developed according to research that will best address high burdens
of morbidity and mortality. Some of the most useful research will be operational, to gain a better
understanding of how to implement effective programs and interventions in the PNG context. Other research
will be epidemiological or addressing key technical questions, such as the effectiveness of new preventative
or treatment strategies or the precision of new diagnostic technologies for common diseases. For program
areas that are relatively new in PNG, research may be required to develop and evaluate service delivery
models. Training paediatricians in research methodology is important sustain an evidence-based child health
service. In the last five years high quality research projects have been done by paediatric registrars in training
through the DCH and MMed, and this increases research capacity and addresses key issues in child health.
Some examples of such research are listed below:
Meningitis and encephalitis – aetiology and new diagnostics
Adoption practices and consequences
Rubella infection in newborn babies
Rotavirus diarrhoea – disease burden estimates
Sexual abuse of children
PPTCT and ART in children – descriptions of cohorts and outcomes
Malnutrition
Rheumatic Heart Disease
Dengue
Tuberculosis – new diagnostics
Oxygen therapy and pneumonia
Lung function in village and town children
Neonatal care – standards at district hospitals
Measles vaccine – the value of the six-month dose
70
71
CHAPTER 8. CHILD HEALTH ADVISORY
COMMITTEE
In line with the WHO Regional Child Survival Strategy recommendations a National Child Health Advisory
Committee was established in 2006. The Child Health Advisory Committee has a key role in co-ordinating
and supervising child health activities. This committee reviews all child health policy areas, new evidence
and information and provides recommendations to the National Department of Health (NDOH). The
committee has wide representation, including that from NDoH, the IMCI programme leader, UNICEF and
WHO, University of PNG, and a community breast feeding support group. It meets quarterly, overseeing
many child health activities. It is a vital link between child health workers, institutions and the NDoH. The
CHAC has made recommendations or resolutions concerning all the activities mentioned in this document. A
recent advance has been the appointment of an IMCI leader to be a member of the committee. General
support to the policy, coordinating, and monitoring roles of the CHAC will be very important to maintaining
a coordinated approach to child survival.
The CHAC comprises of:
Director, Family Health Services
EPI spokesperson
IMCI Paediatrician
Nutritionist
Chief Paediatrician
WHO representative
UNICEF representative
UPNG representative
Susu Mamas representative
Director, Office of Lukautim Pikinini, Department of Community Development
72
VOLUME II
SECTION II
STRATEGIC IMPLEMENTATION PLAN 2015-
2020
73
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: POLICY DEVELOPMENT IN CHILD HEALTH
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Policy development in child
health
Printing of Revised Child Health Policy and
Plan
X
X
X
Number of revised Child Health
Policy and Plan printed
NDoH
NDoH
Support the Paediatrics Mid-Year meeting
each June, and the Paediatric
Mini-Symposium in September as major
forums for child health policy development
advice to the Department
X
X
X
X
X
X
X
Meetings successfully conducted
twice a year
Meeting report and
recommendations completed and
submitted to CHAC
Recommendations considered by
CHAC
Number of recommendations
adopted and enacted
Family Health Services
Paediatric Society
GoPNG
DPs
Donor Agencies
Support the Child Health Advisory
Committee as the major technical advisory
body on child health
X
X
X
X
X
X
X
Meetings conducted quarterly
Meeting report with
recommendations completed and
distributed
Family Health Services
Chair, CHAC
NDoH
74
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources
required
2014
2015
2016
2017
2018
2019
2020
All health workers managing
sick children to be equipped with
skills and knowledge to
implement IMCI and Standard
Treatment
IMCI training modules completed for pre- and
post-service training. Trainings implemented in
provinces and districts
X
X
X
X
X
X
X
The number of institutions, provinces
and districts that have organized and
run trainings
Number of health workers trained in
IMCI Strategy
NDoH
Provincial and District Health
Offices
Development partners
WHO
UNICEF
GoPNG (NDoH,
PSIP, DSIP,
LLGSIP)
Development
partners and other
donor agencies
Establishment of training centres in provincial
hospitals
X
X
X
X
X
X
Number of Regional Centers of
Excellence for training established
NDoH
Provincial and District Health
Offices
IMCI coordinator
GoPNG (National,
Provincial and
District level)
Follow-up and supervision are implemented at
the provincial level
X
X
X
X
X
X
X
Follow-up and supervision are
incorporated into provincial annual
implementation plans
Provincial Health Offices
IMCI training, follow-up and supervision
included in provincial and district
implementation plans
X
X
X
Provincial and district plans that
include IMCI training
Provincial and District Health
Offices
Develop a database of all IMCI trainers and
trained health workers, including follow-up and
supervision
X
X
X
X
Database developed
National IMCI
coordinator
Infant and Young Child Feeding (IYCF) should
be incorporated into IMCI training
X
X
IYCF integrated with IMCI
National IMCI
coordinator
Coordination of IMCI
strengthened at all levels of the
health system
Advocate for Provincial and District IMCI
Coordinator positions to be created and filled
X
X
X
X
X
X
X
Number of Provinces and districts
with IMCI coordinators employed
NDoH
Provincial and District
Authorities
Development partners
Donor agencies
WHO
UNICEF
GoPNG
(Provincial and
District level)
Strengthen engagement at
community level and with GPs
and NGOs
Establish mechanisms for community
participation and ownership of the IMCI
Strategy
X
X
X
X
X
X
X
Number of communities actively
involved and participating in the
community IMCI activities
NDoH
IMCI Coordinators at all levels
VHV coordinators at all levels
Community Health Post
GoPNG (National,
PSIP,DSIP)
75
officers
76
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: EXPANDED PROGRAM OF IMMUNIZATION (EPI)
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
Refer to the Papua New Guinea Comprehensive Multi-Year Plan National Immunization Programme 2011-2015
77
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: STANDARD TREATMENT AND CLINICAL GUIDELINES
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
To have current evidence-based
clinical guidelines for diagnosis
and treatment of children
available to every health worker
Revise the Standard Treatment Manual 10th
edition (2016)
X
X
STM revised and submitted to
publisher
Dr Wendy Pameh
Prof Nakapi Tefuarani
Paediatric Society
NDoH
(FHS and
Office of Chief
Paediatrician)
Publish and distribute the 2016 Standard
Treatment Manual to all health workers in
the country
X
X
X
X
X
X
Approximately 30,000 copies
printed and appropriate numbers
distributed to every PHO and every
health facility in the country
Family Health Services
Provincial Health Offices
Technical Advisor Child
Health
Chief Paediatrician
GoPNG (National,
PSIP, DSIP)
Revision and reprinting of Paediatrics for
Doctors in PNG
X
X
X
X
X
X
Paediatrics for Doctors in PNG
revised and 10,000 copies printed
per year
Professor of Child Health
Chief Paediatrician
GoPNG (PSIP, DSIP)
Revision and reprinting of Child Health for
Nurses and HEOs in PNG (Green book)
X
X
X
X
X
Child Health for Nurses and HEOs
in PNG revised and 10,000 copies
printed per year
Professor of Child Health
Chief Paediatrician
GoPNG (National,
PSIP, DSIP)
Distribute WHO Pocketbook of Hospital
Care for Children
X
X
X
X
X
X
X
1,000 copies purchased per year
from WHO Geneva
Technical Advisor Child
Health
Chief Paediatrician
GoPNG (National,
PSIP,DSIP)
Distribute Shann’s Drug Doses
X
X
X
X
X
X
X
200 copies per year
Paediatric Society
DPs
78
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: NEONATAL CARE
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
To implement Minimal
Standards of Neonatal Care in
provincial and district hospitals
and health centers
Conduct needs assessments of what is
required for provincial and district hospitals,
and health centers to achieve minimal
standards of neonatal care (physical
facilities, basic equipment, essential drugs,
human resources, training, auditing,
infection control measures)
X
X
Number of hospitals in which needs
assessment conducted
Report produced
National Newborn Care
Coordinator, Dr Roland
Barnabas, Newborn Care
Specialist
Provincial paediatricians
GoPNG (National,
PSIP, DSIP)
Undertake a program to upgrade health
facilities neonatal and labour ward services
to achieve minimal standards
X
X
X
X
X
Number of hospitals in which
upgrading of neonatal and labour
ward facilities underway
NDoH
Provincial Health Offices
Responsibility for
funding will depend
on needs per health
facility – GoPNG
(PSIP, DSIP,
LLGSIP)
Promotion of breast feeding
Revitalization of the Baby Friendly Hospital
Initiative in all provincial hospitals
X
X
X
X
X
X
X
Number of hospitals accredited as
Baby Friendly
Paediatric Society
Family Health Services
Provincial Hospitals
SuSu-Mamas
GoPNG (National,
PHAs)
Making information available to
all mothers on newborn care
Publish the New Mothers brochure on
newborn care
X
X
Brochure reviewed and submitted to
printer
Dr Theresa Rhongap
Dr James Amini
Paediatric Society
Print and distribute Baby Book and New
Mothers Brochure to all health facilities
where babies are born or antenatal care is
given, and to community mothers groups:
200,000 deliveries per year
X
X
X
X
X
X
250,000 Copies printed per year and
appropriate numbers distributed to
every PHO and health facility in the
country
NDoH
GoPNG (National,
PSIP, DSIP, LLGSIP)
Support a program of neonatal
care and resuscitation training for
nurses, midwives and doctors
Print and distribute the neonatal
resuscitation poster to all hospitals and
health centers where babies are born
X
X
X
6, 000 copies of poster printed for
every health facility
Poster distributed
WHO
Family Health Services
Go PNG
DPs
Conduct neonatal training using the modules
in the WHO Pocketbook of Hospital Care
for Children and Early Essential Newborn
Care
X
X
X
X
X
X
X
Number of health workers trained in
neonatal resuscitation
National NBC coordinator
Provincial paediatricians
National IMCI coordinator
Go PNG (PHAs, PSIP,
DSIP)
Support neonatal clinical attachments (4-6
weeks) to level 1 and 2 hospitals for nursing
X
X
X
X
X
X
X
Number of health workers from
Level 3 and 4 hospitals completing
Provincial Health Offices
Provincial Hospitals
PHAs, PSIP
79
offices from level 4 and 3 hospitals
such attachments (at least 15 per
year)
Provincial paediatricians
Improved information on
neonates
Reporting through the PHR Program
X
X
X
X
X
X
X
Number of hospitals reporting
through the PHR program
Provincial paediatricians
Develop a centre of excellence
for neonatal care, for training and
good model for other provincial
hospitals
Build a new Special Care Nursery at
PMGH, as a centre of excellence in neonatal
care, emphasizing basic newborn care, low
cost technology and standard treatment
would provide a model for provincial
hospitals throughout the country
Achieved in 2013-2014
Funding achieved for new Special
Care Nursery
Building commenced
Building completed and new SCN
opened
NDoH
Other donor partners
80
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: BREAST FEEDING, NUTRITION AND MICRONUTRIENTS
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Increase human resource
capacity for child nutrition
Recruit a Senior National Nutritionist
X
X
Nutritionist recruited and working
within NDoH
NDoH
GoPNG
Create a nutritionist position in all
provincial hospitals
X
X
X
X
X
X
X
Positions created within new NDoH
structure
NDoH,
Provincial Hospitals
GoPNG
Develop a training program for local
nutritionists
X
X
X
X
X
X
X
Training program developed
Nutrition section, FHS
SMHS
Have a paediatrician trained in nutrition and
malnutrition to help provide national
leadership
X
X
X
X
X
X
Paediatrician identified and trained
Paediatric Society
Care of the child with severe
malnutrition
Roll out the multi-faceted approach to
improving severe malnutrition care in
hospitals
X
X
X
Evaluation of the pilot program at
PMGH done and the program rolled
out to number of hospitals
Dr Michael Landi
Dr Henry Welch
Prof Trevor Duke
Paediatric Society
GoPNG
DPs
Donor Agencies
Community promotion of breast
feeding and adequate
complementary feeding
Conduct IYCF training in all provinces
X
X
X
X
X
X
X
Number of provinces in which IYCF
training conducted
Nutrition section, FHS
WHO
GoPNG
DPs
Revise Infant and Young Child Feeding Act
(revised Baby Feeds Supply (Control) Act
1984)
X
X
X
X
X
X
X
IYCF Act endorsed and passed by
NEC and Parliament
Nutrition section, FHS
Paediatric Society
NDoH
SuSu Mamas
Community groups
GoPNG
DPs
Improve vitamin A coverage
Expansion of vitamin A supplementation
into the second year of life, by additional
doses at 18 and 24 months
Add dose of vitamin A for post-natal
mothers
X
X
X
X
X
X
X
Vitamin A supplementation
extended to 18 and 24 months olds
and also percentage of postnatal
mothers given vitamin A
Nutrition section, FHS
Paediatric Society
Child Health Advisory
Committee
NDoH
Achieve high coverage of
deworming
Albendazole for deworming, given with
vitamin A at 12 months, and at 6 monthly
intervals thereafter
X
X
X
X
X
X
X
Percentage of children receiving
Albendazole at 12 months of age
FHS
Child Health Advisory
Committee
Paediatric Society
81
Improve health facility and
community services for
management of malnutrition
Increase the availability of zinc sulphate as
treatment for children with diarrhoea and
with malnutrition
X
X
X
X
X
X
X
Evidence of widespread availability
of zinc in health facilities and
appropriate use of zinc by health
workers
NDoH
Provincial Health Offices
Incorporated within
normal operational
activities
Production of locally manufactured RUTF
Number of health facilities where
RUTF is available
DAL
NARI
UNITECH
SMHS
DOH – Nutrition and Food
Safety
Support improved nutrition in the
community
Encourage the fortification of staple foods,
such as rice and flour with multiple
micronutrients including iron, zinc, thiamin,
riboflavin and folate
Inter-sectoral collaboration to
encourage fortification
DAL
Provincial Health Offices
Nutrition section, FHS
82
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: QUALITY IMPROVEMENT OF HOSPITAL CARE
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Develop human resource
capacity for child health
Training in Hospital Care for Children in
every province
X
X
X
X
X
X
X
Training courses run in each
province
WHO
Family Health Services
PSPNG
Provincial hospitals
GoPNG
Provincial health
training funds
RE Ross Trust
BMGF
Improve oxygen systems and the
treatment of pneumonia
Expand the oxygen systems program to all
provincial and rural hospitals and major
district health centers in the country
X
X
X
X
Number of provincial and district
hospitals which have the oxygen
system
Provincial Health Offices
Provincial Hospitals
Family Health Services
Health Facility Branch
NDoH
PHAs
PHO
DHO
DPs, donor agencies
Maintain the oxygen program with review
visits and training
X
X
X
X
Number of hospitals in which
annual review visits conducted
NDoH (Family Health
Services, Clinical Services
and Health Facility
Branch)
GoPNG (PHA, PSIP,
DSIP)
DPs, donor agencies
Implementation trial of bubble-CPAP for
neonatal care and pneumonia treatment
X
X
X
X
X
X
X
Bubble-CPAP trialled and evaluated
Dr Francis Pulsan
Prof Trevor Duke
Provincial paediatricians
UPNG
Standardized hospital data
reporting and paediatric
surveillance
Extend the Paediatric Hospital Reporting
System to all provincial hospitals in the
country
X
X
X
Number of hospitals participating by
sending in data quarterly
Paediatric Disease
Surveillance Officer,
Edilson Yano
Provincial paediatricians
Dr James Amini
Prof Trevor Duke
GoPNG (NDoH,
PHA, PSIP)
Support human resource capacity and
logistics within Family Health Services and
provincial hospitals for Paediatric
Surveillance and Hospital Reporting
X
X
X
X
X
X
X
Position created within new
structure
Number of hospitals participating by
sending in data quarterly
Paediatric Disease
Surveillance Officer
Family Health Services
National position
created during
restructuring
Surveillance system for vaccine
preventable diseases
Funding for latex agglutination antigen
testing for CSF pathogens
X
X
X
X
X
X
X
Number of hospitals reporting use of
latex agglutination
National EPI Manager
TA Child Health
Medical Supply Branch
Go PNG (NDoH, PH)
83
Improved care for children with
chronic conditions
Implement models of care for children with
chronic conditions, including clear treatment
plans, clear communication between
primary and referral levels, parental
education and mechanisms for supply of less
common medicines at primary care level
X
X
X
X
X
X
Number of hospitals that have
adopted models for complex case
management
Paediatric Society
84
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: PNEUMONIA
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
See program areas: IMCI; EPI; Standard Treatment and Clinical Guidelines; Neonatal Care; Nutrition and Malnutrition; and Quality Improvement of Hospital Care
85
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: MALARIA
Improvements in the management and control of malaria in children will be closely aligned with the overall malaria control program
Strategic objectives
Activities
Timeframe
Responsible persons
Process indicators
Resources required
2014
2015
2016
2017
2018
2019
2020
Improve the prevention and
management of malaria among
mothers and children
Update malaria guidelines in the 10th
Edition of the Standard Treatment Manual.
Include artesunate suppositories for pre-
referral treatment in health centers
X
X
Revised treatment guidelines
included in STM
Evidence of availability and use
in
health centers
Paediatric focal person for
malaria
Prof Tefuarani and Dr
Wendy Pameh (as STM
Editors)
Support efforts to increase the use of rapid
diagnostic tests in clinical decision making
X
X
X
X
X
X
X
Evidence of increased use of
RDTs
Family Health Services
Global Fund for
Malaria
NDoH
Consider the implications of research on
intermittent chemoprophylaxis measures for
infants (IPTi)
X
X
Studies reviewed by Paediatric
Society and CHAC
Paediatric Society
Child Health Advisory
Committee
Improve the tendering process,
procurement and supply of all essential
drugs and supplies. Establish a
sustainable mechanism to deliver
antimalarial drugs and related supplies
to all levels of the health service
X
X
X
X
X
X
X
Antimalarials available at all levels
of the health system
Improved data and surveillance
for malaria
Improve reporting mechanisms from the
district to provincial health level and to
NHIS, and improving the reporting of
malaria cases and case fatality rates from
hospitals
X
X
Reports on malaria CFR from the
Paediatric Hospital Reporting
System
Number of hospitals providing
reports
Paediatric Disease
Surveillance Officer
Develop sentinal site surveillance for
malaria in 4 regions
X
X
X
X
X
X
X
Four regional sentinel sites
established (comprising of one
microscopist and one clerk)
National Malaria
Program
Paediatric focal person
for malaria
NDoH
PHAs
DPs
Donor Agencies
86
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: TUBERCULOSIS
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Improve the ability of health
workers to prevent, diagnose and
treat TB
Improve the availability of fixed-dose
combination (FDC) therapy for childhood
TB
X
X
X
FDC drugs distributed to all health
centers that are Basic Medical Units,
and hospitals
Dr Harry Poka (paediatric
TB focal person)
National TB Program
Provincial Health Offices
NTP
StopTB
Update Standard Treatment Manual to
include:
improved paediatric regimens for FDC
therapy;
indications for the use of GeneXpert MTB /
Rif; and
when to suspect MDR-TB
X
X
X
STM updated
Dr Harry Poka (paediatric
TB focal person)
Paediatric Society
NTP
StopTB
Provide training for health workers in the
use of fixed-dose combination therapy, child
TB detection, case management, and MDR-
TB using Hospital Care for Children
training and National TB program
guidelines
X
X
X
Number of provinces in which this
child TB training is done
Dr Harry Poka
National TB Program
NTP
StopTB
Ensure all children complete Intensive Phase
treatment under health supervision (in
hospitals or other facility supervised by TB
health workers), and ensure an effective
model of better follow-up at a district and
community level
X
X
X
X
Model of completion of IP in
hospital trialed and evaluated
National TB Program
Dr Harry Poka
Paediatric Society
NTP
StopTB
Implement preventive therapy for
asymptomatic contacts of adult TB cases
and HIV-infected children
Preventive therapy is available at all
levels of the health system
Dr Harry Poka (paediatric
TB focal person)
Paediatric Focal person for
HIV/AIDS
National TB Program
Provincial Health Offices
Improve coordination and
leadership of child TB
Create and fund a position of TB
Paediatrician, as the focal point for child TB
X
X
X
X
X
X
Position created within new NDoH
structure
National TB Program
87
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: HIV AND AIDS
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Improve the prevention of HIV
infection
Increase voluntary counseling and testing,
PPTCT and ART and ready-to-use
therapeutic feeds to 20 hospitals
X
X
Number of health facilities where
RUTF is available
Number of health facilities where
PPTCT and ART are available
Paediatric Focal person for
HIV/AIDS
Dr Mobumo Kiromat
CHAI PNG
NDoH
National HIV roll-out
program
Update to newer and more effective PPTCT
and ART regimens
X
X
X
Treatment guidelines updated to
include newer regimens
Paediatric Focal person for
HIV/AIDS
Paediatric Society
Dr Mobumo Kiromat
CHAI PNG
NDoH
National HIV roll-out
program
Establish adolescent services that include
primary prevention of HIV
X
X
X
X
X
X
X
Number of provinces in which
appropriate adolescent services
established
Dr Wendy Pameh (as
adolescent health focal
person)
NDoH TA - YAH
Provincial hospitals
Provincial paediatricians
Community groups /
NGOs
Improve the care of children with
HIV
Increase access to ART in all provincial
hospitals
X
X
X
X
X
X
X
Number of provincial hospitals
where ART is available
NDoH
National HIV roll-out
program
Ensure all affected children receive
cotrimoxazole and isoniazid prophylaxis
X
X
X
X
X
X
X
Number of health facilities where
preventive therapy is available
All health facilities
All paediatricians
Paediatric Society
NDoH
PSIP
DSIP
Provide nutritional support to children with
HIV, including ready-to-use therapeutic
feeds
X
X
X
X
X
X
X
Number of health facilities where
RUTF is available
Provincial and district
hospitals
CHAI PNG
UNICEF
Improve coordination and
leadership of child HIV
Create and fund a position of HIV
Paediatrician, as the focal point for child
HIV
X
X
X
X
X
X
Focal position created
Train a paediatric HIV nurse and PPTCT
trained midwife in each province
Number of provinces where HIV
nurse and PPTCT midwives are
88
trained
Inclusion of HIV in the IMCI checklist and
in Hospital Care for Children Training
HIV is inlcuded in the checklist and
training
89
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: PAEDIATRICIANS TRAINING
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Achieve the National Health
Minimum Standard on specialist
(Paediatrician) manpower: a
minimum of two Paediatricians
in all provinces and 5 in Level 1
hospital (PMGH)
Train new paediatricians to achieve the
minimal standards of two paediatricians in
each province by 2018
X
X
X
X
X
X
X
Number of new paediatricians
trained each year
SMHS
Chief Paediatrician
GoPNG
Donor partners
Increase Paediatric Training positions at
PMGH to six
X
X
X
X
X
X
X
Number of new trainees entering the
DCH and MMed programs
SMHS
Chief Paediatrician
GoPNG
Donor partners
Encourage provinces to create service
positions for registrar training
X
X
X
X
X
X
X
Number of provinces with registrar
positions
SMHS
Chief Paediatrician
GoPNG
Donor partners
Develop a paediatric workforce
with appropriate subspecialty
skills
Support training in cardiology, neonatology,
HIV medicine, adolescent health, oncology
and nutrition
X
X
X
X
X
X
X
Persons identified to receive training
in these specialty areas
Training organized and completed
Number of paediatricians fulfilling
these roles
SMHS
NDoH
Other educational
institution partners
GoPNG
Development partners
Donor partners
Develop an accreditation process for
paediatricians, supported by continuing
professional development activities
Number of CPD activities offered
Accreditation process developed
Paediatric Society
NDoH
Medical Board of Papua
New Guinea
Improving the evidence base for
child health
Research projects for MMed / DCH
X
X
X
X
X
X
Research projects completed
SMHS
GoPNG
Donor partners
90
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: CHILD HEALTH NURSES AND COMMUNITY HEALTH NURSES
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
To achieve the standard of one
child health nurse in every health
centre and at least one per shift in
every hospital
Establish a course in post-basic paediatric
nursing in each of 4 regions
X
X
X
X
X
X
X
Number of graduate child health
nurses
SMHS
Pacific Adventist
University
Goroka University
Other training colleges
GoPNG
DPs
Donor Agencies
Stregthen continuing
professional development for
child health nurses
In-service training, clinical attachments and
postgraduate training should be supported
CPD activities offered
91
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: ADOLESCENT HEALTH
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Provide appropriate facilities for
adolescent health services
Strengthen existing school clinics to provide
information to adolescents
X
X
X
X
X
X
X
Number of school clinics where
information is available
Department of Education
Establishment of adolescent drop-in centers
in provinces
X
X
X
X
X
X
X
Number of provinces in which
appropriate adolescent services
established
Dr Wendy Pameh (as
adolescent health focal
person)
NDoH TA - YAH
Provincial hospitals
Provincial paediatricians
Community groups /
NGOs
GoPNG (PSIP)
Create model of adolescent areas in
children’s wards in hospital
X
X
A model of adolsecent hospital care
is developed at PMGH
Dr Wendy Pameh
NDoH – TA YAH
PMGH
GoPNG
Improve human resources for
adolescent health
Provide training for a paediatrician in
adolescent health, to act as a national
resource-person for this area
X
X
Paediatrician having undergone
some training in this area
SMHS
Other educational
institution partners
GoPNG
DPs
Donor Agencies
Support immunization programs
for adolescents
Introduction of HPV vaccine
X
X
HPV vaccine successfully
introduced
TA – YAH
School Health and EPI
GoPNG
DPs
Donor Agencies
Strengthened national
coordination, technical assistance
and leadership
National Department of Health, leadership
in adolescent health
X
X
YAH Program and Coordination
mechanism already established at
NDoH level
TA – YAH Program
GoPNG
92
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: HEART DISEASE, CHILDHOOD CANCER
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Improve the management of
childhood cancer and ensure
wide access to services
Revise guidelines for managing paediatric
cancer. Develop referral guidelines
X
X
Completion of paediatric cancer
guidelines at
www.pngpaediatricsociety.org
Dr Gwenda Anga
Paediatric Society
GoPNG
DPs
Support central coordination and improve
data collection and surveillance on pattern
of childhood malignancies
X
X
X
X
X
X
X
Number of hospitals participating by
sending in data quarterly
Dr Gwenda Anga
Paediatric Society
See Paediatric Hospital
Reporting System
Improve diagnostic services, particularly
histopathology services
Provincial hospitals have in place
arrangements with CPHL for
specimen analysis
CPHL
Chief Pathologist
Dr Gwenda Anga
NDoH national function
Ensure appropriate drug regimes are
available, including drugs for effective
palliative care
X
X
X
X
X
X
X
Evidence of uninterrupted stocks of
essential chemotherapy and
analgesia
NDoH national function
Support a young paediatrician to train in
oncology (refer also to paediatricians
training)
Completed in 2013-2014
SMHS
Royal Children’s Hospital,
Melbourne
RE Ross Trust
Establish Paediatric Cancer Units (10 beds
ward) attached to PMGH and National
Cancer Unit in Lae
X
X
X
Evidence of improved services for
children with cancer
NDoH
PMGH Paediatric
Department
Angau Hospital
GoPNG
PMGH
ANGAU
Skill development for 5 nurses in childhood
cancer
X
X
X
X
X
Number of nurses trained in
childhood cancer management
PMGH
Other educational
institution partners
GoPNG
PMGH
Implement supportive care during treatment,
including social workers and nutritionists
Supportive care available at PMGH
and Lae
Develop a community awareness campaign
Community awareness campaign
Improve the management of
heart disease and support
surgical
Support the annual Operation Open Heart
X
X
X
X
X
X
X
Number of children having surgery
each year through OOH
Prof Nakapi Tefuarani
Dr Mathias Tovilu
Dr Cornelia Kilalang
GoPNG
DPs
Donor Agencies
Support the training of two paediatricians in
X
X
Paediatrician identified and training
SMHS
GoPNG
93
cardiology
completed
PMGH
Other educational
institution partners
Donor Agencies
94
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: CHILD PROTECTION AND SOCIAL SERVICES
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Improved reporting,
documentation and surveillance
systems for child abuse and
neglect
Improve child abuse reporting in all
provincial hospitals, through the PHR
(inpatients) and through the Family Support
Units
Ensure reporting of all cases of suspected
child abuse to police
X
X
X
X
X
X
X
Child abuse reporting systems in
place
Provincial health
authorities
Provincial hospitals
Provincial paediatricians
FHS
Chief Paediatrician
Improved preventative and
treatment services for children at
risk of physical and sexual abuse,
and neglect
Establish Family Support Units in all
Provincial hospitals. These will provide
medical, social, legal, and psychological
support services to child victims of sexual or
physical abuse, and to mothers suffering
from domestic violence
X
X
X
X
X
X
X
Number of provinces with
functioning Family Support Units,
staffed with social worker, nurses
trained n child abuse and access to
legal services and mental health
support services.
Number of cases managed by these
units annually.
Provincial health
authorities
Provincial hospitals
Provincial paediatricians
FHS
Chief Paediatrician
Health workers better prepared to
contribute to identifying and
managing at-risk, abused or
neglected children
Paediatrician trained in legislation, strategies
for protection, prevention and management
of child abuse and neglect
X
X
X
X
X
X
X
Paediatrician trained in child abuse
and child protection
Paediatric Society
Incorporation of training on child abuse and
child protection in MCH courses and post-
graduate child health nursing courses
X
X
X
X
X
X
X
Incorporation of training on child
abuse and child protection in MCH
courses and post-graduate child
health nursing courses
Paediatric Society
Strengthen leadership for child
health
National Department of Health leadership /
technical assistance in child protection
X
X
X
Evidence of coordination between
NDoH, police, legal and social
services and other stakeholders
NDoH
Paediatric Society
Go PNG
DPs
Donor Agencies
95
STRATEGIC IMPLEMENTATION PLAN: 2014-2020
PROGRAM AREA: CHILD DISABILITY
Strategic objectives
Activities
Timeframe
Process indicators
Responsible persons
Resources required
2014
2015
2016
2017
2018
2019
2020
Strengthened multi-disciplinary
health services for children with
disabilities
Establishment or strengthening of
developmental screening programs in early
education centres and major hospitals
X
X
X
X
Number of screening programs
available in EECs and health
facilities
Dr Beryl Vetuna
Dr James Amini
Paediatric Society
GoPNG
DPs
Donor Agencies
Improved referral pathways
X
X
X
X
Referral pathways in operation
Dr Beryl Vetuna
Dr James Amini
Paediatric Society
GoPNG
DPs
Donor Agencies
Increased support to community
organizations who work with disabled
children
X
X
X
X
Evdience of increased coordination
with community organizations
Dr Beryl Vetuna
Dr James Amini
Paediatric Society
GoPNG
DPs
Donor Agencies
Training of nurses and
paediatricians in supporting
children with disabilities
Incorporation of training on disability in
MCH courses and post-graduate child health
nursing courses
X
X
X
X
Disability included in MCH and
child health nursing courses
Paediatrician trained in child disability and
rehabilitation
X
X
X
X
Paediatrician trained in child
disability and rehabilitation
Dr Beryl Vetuna
Dr James Amini
Paediatric Society
GoPNG
DPs
Donor Agencies
Nurse trained in developmental screening of
children
X
X
X
X
Nurse trained in developmental
screening
Dr Beryl Vetuna
Dr James Amini
Paediatric Society
GoPNG
DPs
Donor Agencies
Improve awareness of child
safety in the community to
prevent disability
Advocacy for strategies to improve child
safety, such as car seat belt legislation,
bicycle helmets, fire safety
PHR program data to inform
advocacy for child safety legislation
Strengthen leadership to improve
support for children with
disability
National Department of Health leadership /
technical assistance in disability
Evidence of co-ordination between
NDoH and other stakeholders
NDoH
Paediatric Society
GoPNG
DPs
96
Appendix 1. Projection of paediatrician training 2015-2020
Hospital Classification
Current
(2015)
Projected
need by 2020
Additional
required by 2020
Level 1 Hospitals: National Referral Hospital
1. PMGH
5
7
3 *
2. UPNG (Lecturers)
2
3
2 *
Level 2 Hospitals: Regional Referral Hospitals
1. Angau, Lae - MOMASE
3
4
2 *
2. Mt. Hagen – Highlands Region
1
3
2
3. Nonga, Rabaul – Islands Region
1
3
2
4. PMGH - (Southern/Central/NCD)
1
2
1
Level 3 Hospitals: General Specialist Hospitals
1. Goroka
2 (+1)
3
0
2. Alotau
1
2
1
3. Madang
2
2
0
4. Wewak
1 (-1)
2
1
Level 4 Hospitals
1. Daru
1
1
2. Kerema
0
1
1
3. Popondetta
1
2
1
4. Kundiawa
1
2
1
5. Wabag
1
2
1
6. Mendi
1
2
1
7. Vanimo
1
2
1
8. Lorengau
0
1
1
9. Kavieng
1
2
1
10. Buka
1
2
1
11. Kimbe
1
2
1
Total
24 additional
paediatricians
required from
2015 to 2020
* Assumes attrition / retirement
97
Appendix 2. Paediatrician sub-specialty training 2015-2020
Sub-Specialty Areas
Current
In-Training
2015-2020
Paediatric Cardiology
1
1
5
Southern Region (Port Moresby)
1
1
2
Momase Region (Lae)
1
Highlands Region (Mt. Hagen)
1
New Guinea Islands
1
1
Paediatric Oncology
0
0
2
Port Moresby
1
1
1
Lae
1
Neonatology
0
1
2
Port Moresby
0
1
Lae
0
1
Goroka
0
1
Paediatric HIV Medicine
1
0
4
Southern Region (Port Moresby)
1
Momase Region (Lae)
1
Highlands Region (Mt. Hagen)
1
New Guinea Islands (Rabaul)
1
Respiratory Medicine and TB
0
0
4
Southern Region (Port Moresby)
1
Momase Region (Lae)
1
Highlands Region (Mt. Hagen)
1
New Guinea Islands (Rabaul)
1
Disability / Rehabilitation
0
0
2
Port Moresby
1
Lae
1
Nutrition / Malnutrition
0
0
4
Southern Region (Port Moresby)
1
Momase Region (Lae)
1
Highlands Region (Mt. Hagen)
1
New Guinea Islands (Rabaul)
1
The workforce plan does not mean an additional paediatrician should be trained in each of these sub-specialty
or program areas in addition to the general paediatrician workforce projections in Appendix 1. Rather the skills
in each of these areas should exist at a regional level. In most cases it is envisaged that general paediatricians
will be up-skilled in such areas to provide services in their regions.
98
Appendix 3. Child health contact addresses
Your provincial paediatrician will be able to guide you on all questions relating to child health and
paediatrics. The following are resource people for program areas. They may change contact details
during the life of this plan.
For updated information from the Paediatric Society of PNG, see www.pngpaediatricsociety.org
IMCI
Dr Gilchrist Oswyn, Paediatrician Milne Bay Province and IMCI National Coordinator
alotaugh@daltron.com.pg
Merolyn Jonathan, IMCI coordinator NDoH
Dr Patrick Kiromat, Paediatrician Alotau
EPI and vaccines
Dr William Lagani, Manager, Family Health Services william_lag[email protected]
Tel: 301 3706
Gerard Sui: EPI coordinator NDoH, gerard.sui2011@gmail.com
Dr Tarcisius Uluk, Paediatrician Kimbe tarcisiusuluk@yahoo.com
Dr Fiona Kupe, Paediatrician NCD Health dr_fkupe@yahoo.com
Standard Treatment Manual for Common Illnesses
Your provincial paediatrician or
Dr James Amini, Chief Paediatrician Port Moresby General Hospital jmamini9@gmail.com
Prof Nakapi Tefuarani, Professor of Child Health SMHS UPNG ntefuarani@datec.net.pg
Dr Wendy Pameh, Senior Lecturer Child Health UPNG wpameh@global.net.pg
Newborn Health
Dr Roland Barnabas, Paediatrician PMGH rabarnabas@yahoo.com
Frieda Sui, Neonatal coordinator NDoH freda_sui@health.gov.pg
Dr Gamini Vali, Paediatrician PMGH gvbom[email protected]
Dr Theresia Rongap, Paediatrician Lae
Nutrition, breast feeding and malnutrition
Dr Michael Landi, Paediatrician m[email protected]
Eileen Dogimab, Nutrition NDoH
Dr Theresia Rongap, Paediatrian Lae trongap@gmail.com
Dr Fiona Kupe, Paediatrician dr_fkupe@yahoo.com
Susu Mamas Toll Free Hotline 7200 MAMA (720 06262)
Hospital Care for Children training program
Dr Ilomo Hwaihwanje, Paediatrician Goroka: wohuiereke_i@hotmail.com
Dr Magdalynn Kaupa, Deputy Chief Paediatrician Highlands Region: magdalynnkp@yahoo.com
Dr Martin Sa’avu, Paediatrician Mendi: martinsaavu@yahoo.com.au
Dr Doreen Panauwe, Paediatrician Wabag dpanauwe@gmail.com
Malaria in children
Dr Jimmy Aipit, Paediatrician Madang jimmy[email protected].au
Dr Jason Vuvu, Paediatrician PMGH
Tuberculosis in children
Dr Harry Poka, Paediatrician Kundiawa harrywerakepoka@gmail.com
Dr Francesca Failing, Paediatrician Lae failingf@yahoo.com
99
Dr Angai Dama, Paediatrician Goroka
Dr Henry Welch, UPNG
HIV in children
Dr Mobumo Kiromat, Paediatrician PMGH
Dr Gamini Vali, Paediatrician PMGH
Paediatrician training
Dr James Amini, Chief Paediatrician PMGH jmamini9@gmail.com
Professor John Vince, Deputy Dean SMHS UPNG jvince@datec.net.pg
Dr Paulus Ripa, DMS Mt Hagen paulus.r[email protected]
Adolescent and School Health
Dr Wendy Pameh, SMHS, UPNG, wpameh@global.net.pg
Maluo Magaru, Coordinator School Health Program, NDoH
Dr Mary Paiva, Paediatrician Tabubil
Childhood cancer
Dr Gwenda Anga, Oncology Paediatrician, PMGH: gwendaanga@gmail.com
Dr Francesca Failing, Paediatrician Lae failingf@yahoo.com
Heart disease in children
Professor Nakapi Tefuarani, Professor of Paediatrics SMHS UPNG ntefuar[email protected]t.pg
Dr Cornelia Kilalang, Cardiology Paediatrician PMGH ckilalang@yahoo.com
Dr Mathias Tovilu, Cardiology Paediatrician mattovilu@gmail.com
Dr Tarcisius Uluk, Paediatrician Kimbe tarcisiusuluk@yahoo.com
Paediatric surgery
Dr MacLee Mathew, Paediatric Surgeon and DMS Kaviang Hospital
Child disability
Dr Beryl Vetuna, Paediatrician Rabaul bvetuna@gmail.com
Dr Kauve Pomat, Paediatrician Wewak
Continuing Professional Development
Dr Wendy Pameh wendy.pam[email protected]
Dr Paulus Ripa paulus.ripa@gmail.com
Professor Trevor Duke [email protected]rg.au
For general information about this Child Health Policy and Plan and information on the Child Health
Advisory Committee contact Dr William Lagani, Coordinator Child Health Advisory Committee.
william_lagani@health.gov.pg. Tel: 301 3706
100
Appendix 4. Core indicators and monitoring
There are several systems for data collection that are relevant to children:
The National Health Information System (NHIS)
Vaccine preventable disease surveillance
Acute flaccid paralysis surveillance
Acute Fever and Rash surveillance
Demographic and Health Survey (DHS)
Census
Paediatric Hospital Reporting System
EPI program data
National TB program
HIV program including Prevention of Parent to Child Transmission (PPTCT) data
This Plan would require the following information be collected, reported and published annually:
Statistic
Mechanism for data collection
Population based
Under-5 mortality rate
DHS / Census
Infant mortality rate
DHS / Census
Neonatal mortality rate
DHS / Census
Proportion of infants exclusively breast fed to 6 months of age
DHS / Census / National
Nutrition Surveys
Percentage of children who are <80% expected weight for age
(underweight or malnourished)
DHS / Census / National
Nutrition Surveys
Coverage rates for vaccines
EPI program
Vaccine preventable disease incidence
NHIS / Paediatric Reporting
System
Percentage of children who are fully immunized by age 1 year
EPI program vaccine coverage
surveys / DHS
Percentage of babies who receive Heb B vaccine in first 24
hours of life
EPI program vaccine
coverage surveys / NHIS /
DHS / Paediatric Reporting
System
101
Percentage of mothers attending 3 or more ANCs
NHIS / DHS / Census
census
Percentage of primiparous mothers receiving 2 doses of tetanus
toxoid
EPI program data DHS
Percentage of mothers receiving IPT
NHIS
Percentage of mothers having supervised health facility
deliveries
NHIS / DHS
Percentage of children who sleep under a bed-net
NHIS / DHS / Census
Health facility-based outcome data
Disease and age-specific case fatality rates for children
Paediatric Hospital Reporting
System
Case fatality rates for neonates
Case fatality rates for VLBW, birth asphyxia and neonatal
infections
Case fatality rates for severe pneumonia
Case fatality rates for diarrhoea
Case fatality rates for meningitis
Case fatality rates for malaria
Case fatality rates for severe malnutrition
New cases of paediatric HIV
Paediatric Reporting System /
HIV program data
Access to prevention of parent to child transmission (PPTCT)
prophylaxis
PPTCT program
New cases of meningitis due to Haemophilus influenzae type b
and Streptococcus pneumonia meningitis
Paediatric Hospital Reporting
System
Cases of childhood TB, TB treatment treatment completion rates
and hospital case fatality rates for childhood TB
National TB program DOTS data
system
Paediatric Hospital Reporting
System
Health facility-based program data
Number and distribution of health workers trained in IMCI
IMCI program data
Proportion of health facilities that have a trained midwife
Human resources mapping data
Proportion of health facilities that have a trained child health
nurse
Human resources mapping data
Proportion of health facilities with a microscopist or RDTs
Human resources mapping data
102
Number and distribution of health workers trained in Hospital
Care for Children
Hospital Care for Children
program data
Proportion of health facilities that have a nurse trained in IYCF
counselling
Human resources mapping data
IMCI program data
103
Acknowledgements
Many people contributed ideas and suggestions or reviewed various drafts. Substantial contributions
in specific areas to the writing of this plan were made by the following people.
The following people participated in meetings in 2008, 2009 and 2014 and 2015 where the Child
Health Plan was revised and the final version completed:
Dr David Mokela
Dr Jonah Kurubi
Dr James Amini
Dr Guapo Kiagi
Prof John Vince
Dr Francis Wandi
Prof Nakapi Tefuarani
Dr Mary Baki
Dr Mobumo Kiromat
Dr Roland Barnabas
Dr William Lagani
Dr Tarcisius Uluk
Dr Gilchrist Oswyn
Dr Michael Landi
Dr Hilda Polume
Dr Joe Kubu
Dr Job Hawap
Dr Jimmy Ipit
Dr Paulus Ripa
Dr Stella Jimmy
Prof Trevor Duke
Dr Jason Vuvu
Dr Benjamin Tahija
Dr Martin Sa'avu
Dr Tito Langas
Dr Stanley Hanap
Dr Patrick Kiromat
Dr Fiona Kupe
Dr Beryl Vetuna
Dr Gamini Vali
Dr Ilomo Hwaihwanje
Dr Mary Paiva
Dr Theresa Rongap
Dr Rosemary Kipalan
Dr Alphonse Rongap
Dr Sharon Kasa
Dr Magdalynn Kaupa
Dr Doreen Panauwe
Dr Naomi Pomat
Dr Louis Samiak
Dr Wendy Pameh
Dr Kauve Pomat
Dr Kone Sobi
Dr Dale Frank
Dr Harry Poka
Dr Jerry Tanumei
Dr Cornelia Kilalang
Dr Francesca Failing
Dr Angai Dama
Dr Paul Wari
104
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