Leadership, governance, and accountability are among the World Health Organization's core building blocks of the health system. They are foundational to strengthening the effectiveness and functionality of the system and improving people's access to health services.

Perceived as cross-cutting components, leadership and governance provide the basis for all other components of the health system, including financing, workforce, medicines and medical technologies, information, services, and infrastructure. They also involve coordination of all levels of the health system to ensure efficient management and improve their overall performance.

Despite ambitious policies and program reforms by previous governments to strengthen health systems in Papua New Guinea, significant challenges remain in governance, leadership, and accountability at the subnational level, particularly at the Provincial Health Authority (PHA) level. A particular area of concern is the funding of rural health services.

Our recent survey on the implementation of tuberculosis (TB) infection prevention and control policy in the Highlands and Momase regions of PNG found that although 80% of the district hospitals had developed TB infection prevention and control implementation plans, no specific budget was allocated to implement them. Our conversations with health workers, facility managers, and district health managers at the district hospitals also revealed that they lack funding for community awareness and health education programs focused on TB in surrounding communities.

Health workers with whom we spoke explained that funding for rural health services is disbursed from the national government through PHAs, so that funding for rural health services is subject to approval by PHA leadership. Our research found that the lack of solid governance, leadership, and management at the PHA level was responsible for the lack of funding to deliver healthcare services in rural and remote districts. It also found that the availability of funding at the district level is associated with strong leadership, governance, and accountability at the PHA level.

The delay in approving funding is an indication of lack of good management and leadership in the provincial health system. (TB Programme Officer)

Accountability, in particular, is pivotal in leadership as it promotes teamwork and the coordination of activities towards achieving a common goal, including effective management of TB. Our study not only highlights opportunities for stronger leadership but also identifies the importance of leader–worker relationships in healthcare facilities for maintaining cohesion among healthcare workers and achieving better service delivery. When leaders are held accountable for their actions and understand the impacts of failing to meet expectations, employees will trust their leadership more, leading to improved performance. Accountability can also accelerate innovation on the part of healthcare workers, which can lead to better TB infection prevention and control policy implementation outcomes in the long term.

The most important result of our study was that healthcare institutions in the districts simply could not roll out TB infection prevention and control programs. Our findings reveal that institutional capacities are limited by many factors, including the long-term shortage of healthcare workers, the lack of medical technologies and drugs, inadequate funding for TB infection prevention and control programs and poor healthcare infrastructure. Building and sustaining healthcare institutions’ capacity is complex and requires determined leadership, management support, and long-term planning and investments to implement key public health policies.

Our discussions with community members and patients corroborate healthcare workers' views that, over the past decades, community outreach programs have suffered significantly from funding and other resource constraints. Unfortunately, district hospitals responsible for providing comprehensive primary healthcare services to rural populations lack the necessary resources to provide these crucial services effectively.

TB is a complex public health issue. The development of partnerships between the PNG health authorities and other relevant actors, including development partners, non-government organizations and Christian Health Services, is critical to strengthening the long-term implementation of TB infection prevention and control policy in PNG.

TB is a complex health issue. We need support from the different tiers of the health sector and international partners to provide TB care. (Health facility manager)

In sum, the persistent lack of healthcare funding within rural primary healthcare settings in PNG is concerning, and PHA leadership, governance and accountability is part of the problem. This ongoing issue poses a significant obstacle to effectively implementing TB control policies and programs. A collaborative effort by all relevant actors is needed in order to support the objectives of PNG's TB control policies.

The authors would like to acknowledge the contributions of Peta-Anne Zimmerman and Neil Harris to this article.

This article appeared first on Devpolicy Blog (devpolicy.org), from the Development Policy Centre at The Australian National University. Gigil Marme is a lecturer in public health at Divine Word University, Papua New Guinea. He is currently studying for a PhD in Public Health Policy at Griffith University, Australia. Jerzy Kuzma is Professor of Surgery, and Head of the Department of Medicine at Divine Word University, Papua New Guinea. Shannon Rutherford is an associate professor of public health in the School of Medicine and Dentistry at Griffith University.