Graham Roberts

Strengthening Primary Health Care in Low- and Middle-Income Countries Generating Evidence Through Evaluation

Since the publication of the World Health Report 2008, there has been renewed interest in the potential of primary health care (PHC) to deliver global health policy agendas. The WHO Western Pacific Regional Strategy 2010 states that health systems in low- and middle-income countries (LMICs) can be strengthened using PHC values as core principles. This review article explores the development of an evidence-based approach for assessing the effectiveness of PHC programs and interventions in LMICs. A realist review method was used to investigate whether there is any internationally consistent approach to evaluating PHC. Studies from LMICs using an explicit methodology or framework for measuring PHC effectiveness were collated. Databases of published articles were searched, and a review of gray literature was undertaken to identify relevant reports. The review found no consistent approach for assessing the effectiveness of PHC interventions in LMICs. An innovative approach used in China, which developed a set of core community health facility indicators based on stakeholder input, does show some potential for use in other LMIC contexts.

Human resource challenges in scaling up the response to HIV in Papua New Guinea.

WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.006 www.wpro.who.int/wpsar 1 a Human Resources for Health Knowledge Hub, School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia. b School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia. Submitted: 1 May 2012; Published: 3 September 2012 doi: 10.5365/wpsar.2012.3.2.006 In Papua New Guinea, an estimated 0.9% of the adult population is infected with HIV, and the spread of the epidemic is geographically heterogeneous.1 The seriousness of the epidemic presents many issues for the government, donors and nongovernmental organizations. One of the greatest challenges of the HIV response is that of human resources. This article highlights human resource issues specific to HIV in Papua New Guinea and raises a series of questions that need to be addressed.

The History of Mental Health in Fiji

That cultural transition entailed risks of mental illness remained a favoured theory well into the twentieth century and effected the early development of mental health services across the Pacific. Fiji has a distinct form of Melanesian culture, although ontological beliefs are based on a similar integrative physical and metaphysical model of life where spirits and ancestors play an active part according to the conduct of the people. In the early years of British Administration Fijian secret societies and cannibalism were outlawed, but many still believe in and fear the sorcery of ‘drua ni kau’, which means ‘a leaf’ and refers metaphorically to personal items left behind that could be used in ritual sorcery to generate a curse to induce weakness, insanity, illness or death. The colonial administration sought to protect the indigenous population from the effects of cultural transition and brought indentured Indian labourers to Fiji’s sugar farms between 1879 and 1920. The plurality of Indian deities and cultural beliefs found resonance with i-Taukei beliefs of heath and illness, including the potential to incite malicious spirits. This highly exploitative labour scheme entailed profound disruption to the lives of people from disparate regions, castes and cultures. In 1890, suicide rates among indentured labourers were close to 16 times those in the Indian provinces from whence they had come. Now, after 100 years of cultural interaction, many folk beliefs are held in common. That the metaphysical world is potentially malevolent, all of the major communities of Fiji agree. During the colonial era, Fiji became a major regional hub as the headquarters of the British Western Pacific High Commission (1877–1953) and the major regional provider of health practitioner training. The introduction of psychiatric hospitalization in 1884 shaped Fiji’s mental health services during the entire colonial era and beyond. Fijian villagers had long experience of mental distress and had been unable or unwilling to cope with the severely mentally ill. Hospitalization provided a new alternative based on the authority of the administration and its legitimization of medical interventions. For the last 130 years, St. Giles Hospital has been the locus of changing psychiatric practice. There is little evidence of traditional concepts of aetiology having any influence on the application of psychiatry in Fiji; however, at the community level, ‘witchcraft’ is often the first-line treatment for mental disorders, while demonic possession, not fulfilling customary obligations or being cursed, is still thought to be the common causes of mental illness. Recent mental health policy favours the establishment of general hospital psychiatric units and community care, now articulated in the 2010 Fiji Mental Health Decree (MHD). Incrementally, Fiji is moving towards a more humane and integrative approach to treating the mentally ill. Recent legislative and reform developments have been supported by training and capacity building and active membership of international mental health advocacy groups, resulting in strengthened consumer and caregiver rights and the application of principles of international practice.

The History of Mental Health in Papua New Guinea

Papua New Guinea, with over 840 languages, presents the most complex of situations for transcultural understandings of what it means to be mentally ill. The earliest comments on a Papuan population suggest the possibility of a Rousseauian ideal of the natural human condition devoid of mental pathology, where psychoses occurred as a result of the stresses set up by white influence. The theme that the stresses associated with cultural transition were causative of acute psychosis recurs throughout the early PNG literature. The first government-initiated investigation into mental illness in 1957 produced a report that initiated much of the subsequent development in mental health in PNG. Soon after, an admission facility was established at Laloki 10 miles north of Port Moresby near the Bomana Correctional Facility, where psychiatric patients had previously been held in indefinite detention in an annex. Laloki continues to provide an inpatient service today. Subsequent policy has supported the development of general hospital psychiatry units in provincial hospitals, although staffing them with qualified mental health staff has not been achieved and several units have closed in recent years. In forecasting culturally relativist approaches, the report stated that ‘the mental health of an individual can be assessed only in relation to his culture and environment’. Dr. Burton-Bradley, appointed as the territory’s only psychiatrist, struggled with this concept over the next three decades. While modern anthropology argues for culturally relevant understanding of behaviour based on the social structures in which it occurs and the suspension of the explanations of an observer’s own culture, psychiatry found this difficult to achieve in Papua New Guinea. Burton-Bradley’s view of clinical psychiatry, his training of clinicians and his prolific writing and teaching shaped the development of psychiatry in PNG and established the medical model as the dominant explanatory paradigm. In 1975, PNG gained independence and many positions were nationalized. Dr. W. Moi was appointed as medical superintendent of the Laloki psychiatric centre and head of mental health services and stated that ‘culture and language represent a way of thinking and of understanding …and there are real advantages of being able to choose your frame of reference’ forecasting the accommodation of the culturally relevant diagnoses now in use in PNG. The 2010 mental health policy recognizes PNG’s cultural diversity and refers to a ‘home-grown policy’ to address the ‘complex cultural circumstances and other related factors which contribute to the origin of mental and neurological disorder unique to Papua New Guinea’, which confirms that European theories of aetiology and psychiatry’s medical nosology have not achieved complete acceptance, even at the policy level. Current traditional beliefs concerning both mental and physical illness are still widely centred on sorcery, witchcraft, spirit possession/supernatural agents and violations of social norms and taboos. But the inclusion into psychiatry of metaphysical conceptions, and beliefs and actions based on factors that are not empirically verifiable, calls into question psychiatry’s place within science. This perennial issue for psychiatry is brought into sharp focus in PNG.