Public Expenditure, Decentralisation and Service Delivery in Papua New Guinea: Tracking Budgets to Health Clinics

Abstract

Forty years post-independence, Papua New Guinea’s (PNG) development aspirations remain unmet. Important social and human development indicators have stagnated, as has the delivery of basic public services, especially for PNG’s large rural populace. Over the last decade, PNG has experienced strong economic growth from an extended resource boom. Much of the increased revenues generated have been invested into public expenditure reforms aimed at improving service delivery through decentralised governance arrangements.

This thesis questions whether the significantly increased public expenditure commitments to service delivery have been translated into improved health services on the ground. A mixed methods approach was adopted that involved undertaking PNG’s largest and most comprehensive health expenditure tracking and facility survey, combined with in-depth case studies that mapped the implementation of national budgets to front-line service providers, and actual health delivery to communities. This thesis makes a significant contribution to research on the changing political economy of service delivery in PNG. It delivers a policy relevant and empirically grounded analysis of the state of health services and the politics that have driven decentralisation reforms. New findings are presented on the status of PNG’s health clinics, how they receive funding, raise revenue and the services that are delivered. Comparative survey data indicates that health service delivery has largely declined over the last decade, despite huge increases in recurrent and development health budgets. It is argued that the weak implementation of previous and current decentralisation reforms have contributed to widespread inefficiencies and inequalities in the delivery of health services across PNG.

The implications of these findings are analysed in the context of contemporary health expenditure reforms in PNG, which are increasingly politicised and appear destined to repeat past failures. This thesis finds that PNG’s major health policies are poorly targeted, misaligned with strengthening the health system, and do not address weaknesses in health financing. In particular, PNG members of parliament have directed ever-increasing constituency development funds to their electorates and have enacted legislative reforms that deliver greater control over the allocation of resources and service delivery priorities for their respective districts. This entrenches the de facto arrangements of the past, meaning that local politics, rather than national policy guidelines, increasingly determine how expenditure reforms are implemented on the ground. These changing governance arrangements have significant implications for the health sector, risking greater fragmentation of an already weak health system. More broadly, the research shows that the political context in which decentralisation reforms are implemented has important implications for service delivery. Show more