Papua New Guinea, a large FCAS-classified SIDS, is the only ADB DMC assigned a threat level of 3 (moderate) by the United Nations Department of Safety and Security. 4 This elevated security risk creates challenges for ADB operations in Papua New Guinea, where project success ratings have lagged. In rural areas, a combination of tribal conflict and substandard infrastructure has made it difficult for ADB projects to deliver effective results.
The Rural Primary Health Services Delivery Project overcame security and access issues to achieve an overall project rating of successful—including achieving the highest possible ratings for relevance, effectiveness, and efficiency—in its project completion report. These results were validated in 2024 by ADB’s Independent Evaluation Department in its project valuation report. Although approval of this $96.6 million project predated the FSA by a decade, it offers lessons that are relevant today for ADB project officers working in challenging operating environments.
A factor of project success was the highly decentralized and localized approach, working closely with provincial governments and communities to deliver community health posts (CHPs) as the most peripheral health service. Various strategies were adopted to enable the effective delivery of results, including
- (i)
collaboration with local members of Parliament to secure land for the health facilities, ensuring political commitment to the project,
- (ii)
use of provincial government systems for contracting, enabling provincial ownership of the health facilities,
- (iii)
use of national contractors, with a stipulation to engage locals from the communities in roles where possible (e.g., security, transportation),
- (iv)
holding consultations with communities before and during construction.
In addition to financing civil works, the project financed
- (i)
the development of a digital public health surveillance system across the eight project provinces, to improve visibility between rural and central levels,
- (ii)
rigorous capacity development of the CHP health workers in emergency and obstetric care to improve the quality of care, and
- (iii)
improved national policies and standards of primary health care.
The project contributed to improved health indicators in Papua New Guinea, including a decline in the maternal mortality ratio from 733 to 171 per 100,000 during 2011–2020; a decline in the under-5 child mortality rate from 75 to 49 per 1,000 during 2007–2018; and a decline in the neonatal mortality rate from 29.1 to 20.0 per 1,000 in 2007–2018.
Principles of Tailored Approaches Exemplified: Rural Primary Health Services Delivery Project in Papua New Guinea
Be context-specific. Addressed a key country-specific driver of fragility: poor health infrastructure, including a high burden of communicable diseases and poor maternal and child health outcomes, contributing to high levels of poverty and inequity.
Pursue risk-informed solutions. Risk analysis of CHP sites were carried out to avoid sites adjacent to water courses and groundwater supply used for human consumption, and to steer clear of high rainfall areas with steep slopes to avert risk of contaminating water used downstream.
Ensure broad and enduring engagement. Included components to build community awareness of CHPs and engage village health volunteers and other community members in local health planning and implementation.
Develop capacity. Included context-specific capacity mapping and training needs assessments in developing programs to train community health workers and local management supervisors in all project provinces. Collectively, the project delivered more than 260 training courses reaching more than 8,500 participants, including nurses working in primary health care in emergency obstetrics and essential obstetrics care.
Adapt and respond to challenging or changing situations. Redirection of health system resources supported to overcome challenges arising from COVID-19.
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