Illuminating the local: can non-formal institutions be complementary to health system development in Papua New Guinea?

This paper offers a fresh insight into the performance and reform opportunities of the formal health system of Papua New Guinea. A central tenant of this paper is that the historically imposed and continuing top-down nature of the formal health system in PNG is not capitalizing on potentially positive incentives and motivations inherent in the broad range of non-formal institutions that frame the PNG health system. The paper suggests that an enhanced understanding of these non-formal institutions may provide clues for how the formal system could be reconfigured to better align with the non-formal. The opportunity offered by this approach is to leverage the energy, motivation and legitimacy inherent in non-formal institutions to better buttress or infuse the formal health system. The paper draws on an emerging body of development thinking that recognizes that development depends on institutions that are stable, fair, legitimate and flexible enough to reflect political pressures; and that in turn, these kinds of institutions are the product of the interplay of formal and informal institutions. In particular, this theory argues it is when informal institutions are 'complementary' to formal institutions that institutions are likely to be most effective. In these situations informal institutions support the formal institution through 'filling in gaps' either by addressing contingencies not dealt with in the formal rules and/or by facilitating or creating incentives for individuals to pursue the goals of formal institutions. The paper analyses the PNG health system through the lens of this non-formal institutional framework. This analysis, based on secondary data, suggests: Historically, the formal PNG health system was introduced as part of the broader process of colonial administration which, in combination with a number of contemporary ideological forces, allowed little or no space for indigenous negotiation, contestation, or engagement on the form of the PNG health system, or the nature of care within that system. This legacy of top-down planning and delivery in the formal health services of PNG continues, in a modified form, to the present. There is a rich, vibrant matrix of local, intersecting non-formal institutions of relevance to health in PNG – non-formal institutions that are characterized by strong and deep engagement and contestation around health and illness issues. The formal health system is not optimally leveraging the motivation, energy and legitimacy inherent in these non-formal institutions. Some elements of the non-formal institutions in PNG that, prima facie would appear to be potentially complementary to health service development include: Local leadership keen to capitalize on the perceived 'modernizing' political benefits of western health services; communities seeking to locate health workers, and health facilities more broadly, within local social relationships – relationships that coincide with understood social obligations; space for local negotiation around appropriate level/form of user fees – with a considerable degree of intra-family subsidization, group based risk sharing, and exemptions for the poor a high degree of patient autonomy – with health seeking behavior influenced by a social understanding of the cause and appropriate treatment of illness; a very strong tendency to locate ill-health in ruptured social relations - which require a range of collective actions to remedy; the potential for the associational value of provider associations to provide a source of constraint on health worker behavior that is not evident from government; a vibrant (if diverse) range of traditional health systems that remain common and valued healing resorts for many Papua New Guineans, and which have shown a relative degree of openness to western healing; a rich tapestry of community and clan based organizations that are actively engaged in solving local collective action problems, including health improvement activities. The paper argues there is no blueprint for how an awareness of non-formal institutions could be incorporated into possible institutional re-design/reform of the PNG health system. However it does conclude with a number of general pointers to guide possible action. These include: The critical importance of looking beyond the façade of the formal organizational and institutional arrangements of the health sector to make visible the non-formal institutions that surround and shape the formal. The need for deeper and more meaningful structures of engagement/ involvement of the PNG populace in the form, financing, delivery and performance of the PNG health system. The need to understand better the scale, motivation and practices of local, village based private health resources. The opportunity to build more dispersed mechanisms of sector regulation – including community monitoring of services, and competition between providers based on reputation and accreditation. A more concentrated focus on how traditional and formal health services can co-exist and, over time, integrate to create new or 'hybrid' institutions. A possible larger role for provider associations as organizational actors in the planning, development, management and regulation of PNG health services than is currently the case.