KNOWING THAT WE KNOW NOTHING: THE SOCRATIC PARADOX AND HEALTH SECTOR REFORM IN PNG LUKE ELICH & BENJAMIN DAY “As for me, all I know is that I know nothing…” (aphorism attributed to Socrates)

The PNG health sector, Conventional health system planning framework Planning & review in the PNG health sector Understanding the health system Simple, complicated & complex problems Complexity in PNG The Socratic paradox & its implications PRESENTATION OUTLINE

PNG experienced unprecedented economic growth and relative political stability PNG National Health Plan supported by numerous development partners via a ‘Sector Wide Approach’ (AusAID was dominant) Independent health monitoring and review group (IMRG) formed in 2006 to provide an objective assessment of overall sector performance & analyse causes of good/poor performance *** PNG health system, according to the PNG government, deteriorated by many measures during the decade PNG & ITS HEALTH SECTOR,

CONVENTIONAL HEALTH SYSTEM PLANNING FRAMEWORK Source: USAID Health Systems 20/20 (2012) The Health System Assessment Approach: A How-to Manual

PLANNING & REVIEW IN PNG HEALTH SECTOR Independent Monitoring & Review Group Report 1 (2007) # Recommendations:

WHO Framework for Action: “A health system consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health. It goals are improving health and health equity in ways that are responsive, financially fair, and make the best or most efficient, use of available resources.” *** UNDERSTANDING THE HEALTH SYSTEM A system is an interconnected set of elements that is coherently organized in a way that achieves something. The purpose of a system needs to be deduced from its behavior, not from rhetoric or stated goals. Source: Donella Meadows (2008) Thinking in Systems: A Primer

SIMPLE, COMPLICATED AND COMPLEX PROBLEMS Adapted from Glouberman and Zimmerman (2002 ) Following a RecipeSending a Rocket to the MoonRaising a Child The recipe is essentialFormulae are critical and necessaryFormulae have limited application Recipes are tested to assure easy replication Sending one rocket increases assurance that the next will be OK Raising one child provides experience but no assurance of success with the next No particular expertise is required. But cooking expertise increases success rate High levels of expertise in a variety of fields are necessary for success Expertise can contribute but is neither necessary nor sufficient to assure success Recipes produce standardized productsRockets are similar in critical ways Every child is unique and must be understood as an individual The best recipes give good results every time There is a high degree of certainty of outcome Uncertainty of outcome remains Linear Non-linear

COMPLEXITY IN PNG “where development is difficult” (Graeme Teskey, 2013) Extreme Social, cultural & geographic diversity Informal institutions prevail over formal institutions Winner takes all Weak national cohesion & sense of identity ‘Big man’ culture

Our collective understanding of how best to intervene to improve the PNG health system is exceedingly limited. Suggestions for Aid Programming Application of complexity science and systems thinking Stimulate innovation, context sensitive evaluation and research Long term focus – maintain relationships. Avoid changes to programming and support Identify and take advantage of ‘black swan’ opportunities THE SOCRATIC PARADOX & ITS IMPLICATIONS