Health service delivery in the Middle Ramu District, Madang, Papua New Guinea

Insert your name here

Dianne Kamong

RM610 Research Theory and Methods for Applied Research

Master of Research Methodology

Divine Word University

Table of Contents
1. Introduction......................................................................................................................................1
2. Research problem.............................................................................................................................2
2.1 Introduction................................................................................................................................2
2.2 Context of the problem...............................................................................................................2
2.3 Aim of the study..........................................................................................................................2
2.4 Research questions.....................................................................................................................2
2.5 Significance of the study.............................................................................................................2
2.6 Definition of key terms...............................................................................................................2
2.7 Summary.....................................................................................................................................2
3. Research design................................................................................................................................3
3.1 Introduction................................................................................................................................3
3.2 Research paradigms/philosophy................................................................................................3
3.2.1 Ontological context..............................................................................................................3
3.2.2 Epistemological context.......................................................................................................3
3.3 Research approach......................................................................................................................3
3.4 Summary.....................................................................................................................................3
3. Conclusion.........................................................................................................................................3
1. Introduction
In this section, introduce the main items you will discuss in this document.

This study examines the health service which is one of the many determinants faced by local people of
Middle Ramu District. Health service is a very essential basic care that individual people, despite the
races, ethnicity, gender and social status must acquire in life. Hence the services must be accessible,
acceptable, and affordable to the people. However in many studies done in PNG, they have exhibited
many economic and social determinants, which one of them is geographical terrain as a major
contributing factor to accessing health services and other basic services. According to (Witter, 2018)
states, “access to health services is particularly challenging in rural PNG. Majority of the population
(85% or more) live in rural villages which are often difficult to access”. In this segment, a group of
researchers have conducted an exploratory study and the main purpose of their research was to depict,
how the middle Ramu people were very much affected and isolated from outside world of social and
economic life, and went on to show why the middle Ramu district was ranked the 4 th district in the 89
districts of Papua New Guinea. The paper will be more focusing on health services as it narrows down to
illustrate the delivery of health care services in the middle Ramu district. However, included in this
section are the areas of discussion as follows; methods, Participants of the study, research findings, and
discussion as undertaken by four researchers who did their exploratory study, in the middle Ramu
district studying quality of life and development challenges. Furthermore in the next section of the
paper will discuss about research problem and final part of the paper will deliberate on the type of
research design taken.

Methods

The field data from this study was collected by four researchers, two males and two females on a week
fieldwork. The 4 researchers conducted an exploratory research which was overall a qualitative type of
research using observational tools questionnaires based on 2006 demographic and health survey and a
main welfare indicators developed by World Bank to conduct their research.

Participants

The study included local village counsellors, 18 households arranged for questionnaires. Eight people
were key informants with others participated in focus groups which included; adult man and women
and youth from each community of Djam and Jitibu using the quality life questionnaires.

Research Findings:

Following are the exploratory survey findings of the four researchers that were conducted during their
studies at the two communities Djam and Jitibu in the middle Ramu district. The research finding
highlighted, the communities asserts were actual a trade store, cocoa fermentary and a meeting house.
Looking at the learning side of education is very poor although there are primary schools and high
schools in situ. However, the health service facilities are very poor and are at deteriorating stage. There
are 5 local aid posts with no health workers were closed down, while there is only one health center
functioning with the other two health centers being closed. The Government services are at a very low
quality standard, because of poor government structured administration with the 9 hierarchy levels,
contributing to ineffective basic services within the district. Transportation is one of the major
determinants faced by local people of Ramu up to current time, hence distancing is making it a real
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problem and most dangerous route for people to take. In the meantime, betel nut selling is becoming a
main source of economic activity in middle Ramu district, which is the main route of their income
earning and finally, the land for growing commercial cash crops, and gardening are restricted to settlers
those came to reside at Annaberg station.

Discussion:

In this exploratory study, the four researchers’ had a week field study as their limitation to their
research study, in which they should have collected more information if they had stayed longer for
another week or so. Information such as shown on page 8, table 1. Items of income and expenses
listed has shown no figures but at least an estimated amount must be required to analyse the
problem more profound. The sample group should have included few school students for interview
and a few number of government personnel interview on middle Ramu district government
administration. However surprisingly, the study taken was a very challenging at this part of the
region with very informative data, too not only that but a very practical experienced life captured,
hence it is recommended that, length of study must be extended to capture incomplete data and a
full interview survey on school students and teachers and government administration should be
captured in the study.

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Research problem

2. Research problem
2.1 Introduction
In this section, state the main items you will discuss in this chapter.

In this part of the section, the paper will discuss the context of the problem, the aim of the study,
research question, significance of the study, definition of key terms, and finally the summary.

2.2 Context of the problem

In this section, discuss the background situation of the problem including the background of Middle
Ramu.

Middle Ramu District is one of the six district of Madang Province which is located in the middle of
upper and lower Ramu and is known to be the least developed district in the 89 districts of Papua
New Guinea (Seip, 2011). Due to its geographical location, and local government administration it
makes it so difficult to access proper and quality basic services such as health services delivery in the
district.

Local government: It is very significant to improve basic service delivery at the local levels where the
people’s needs are met. Looking back to MRD administration, the structure is too complex with all
official structures are centralized at the hierarchy level. In this important study of organizational
structure and impact on service delivery, Seip (cited Clayton et al. in 2005) found out,
“organizational structure should be designed in such that the organization can easily respond to the
factors in the business environment, respond to the competition, respond to technological
innovation and respond to the needs of customers”. Looking back to MRD Administration, has a
challenging structure that needs to be well rectified in its system in-order, to have a decentralized
system in governmental structure in the district.

Geographical terrain: According to (Witter, 2011, p.3) states, “Papua New Guinea (PNG) had a
population of just over 8 million in 2016, but faces particular geographical, with its Provinces being
mountainous and spread over more than 600 islands”. Furthermore, Witter (2011) explains, higher
cost for services and higher cost for outreach in remote areas are regarded as important factors in
the challenging geography of Papua New Guinea. Higher cost meaning, a local person coming from a
very poorly economical background such in MRD, could not afford to pay a boat fare at higher cost,
or paying for fuel at higher cost in providing health services such as MCH clinic visits, from village to
village in MRD geographical terrains is too expensive. This is a major issue and an expensive exercise
to be in such a place, where geographical landscapes are unpromising and basic services and
especially health care services are hardly accessible, and affordable in regions like MRD.

Health: Form the study conducted in the middle Ramu district has shown a very poor government
services outcome in the district, has placed the people of middle Ramu in desperate of essential
basic services and especially health services which are the biggest health priority concern for the
people of MRD in relation to mothers and children. According to WVI (June 26th, 2018) reports,
“receiving basic health services is another challenge, especially maternal and child health”. Women
who are pregnant residing in villages distance away from Kwanga health centre, would probably
have obstetric complications and may have lost their lives while seeking for medical assistance. For
other common illness, they go to the KHC if the illness is severe, but stay home with mild illness

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because, three health centres are not functioning anymore and only one at the Kwanga station is
providing the health care services to the majority of the population. Furthermore, “Father Daniel
Anmarin, the priest at Kwanga Catholic mission station said that, there are registered health centres
with registered positions but there seems to be no health workers to fill these positions” (WVI, June,
26th, 2018, p.2).

Historically, a German scientific expedition led by a German botanist explorer namely Carl
Lauterbach, first documented middle Ramu people in year 1896 and in 1933 Catholic mission started
at Annaberg middle Ramu and later shifted to Alexishafhen where is currently situated today in Sek
Madang Province. ………..

2.3 Aim of the study

In this section, discuss the aim of the study.

The aim of this study in this section, is to identify the factors that are key contributing sources to
ineffective health services delivery and how these major determinants can be addressed to improve
the health service delivery in middle Ramu district. Furthermore, in the process the research design
will answer the research questions being abstracted from the research problem explored in the
middle Ramu district, its importance in the study, definitions of key terms and a summary.

2.4 Research questions

In this section, present the research questions that must be answered to achieve the aim of the
study.

The research question can be in an interrogating format or declarative format.

Table 2.4.1 – Ref…………….

Interrogating format What are the key factors affecting health service delivery in Middle Ramu
District, Madang Province?
(In question forms) How can these key factors be addressed to improve the health service
delivery in Middle Ramu District, Madang Province?
Declarative format The key determinants affecting the health service delivery in middle Ramu
district, Madang Province.
(In statement forms) Health service delivery in middle Ramu district Madang Province can be
improved when the key determinants are addressed.

In the research question, we would like to see that the question/s must be clear and specific to the
situation affecting the health care deliveries explored in middle Ramu district as shown above in
table 2.4.1 only then we can correctly collect the data for analyzing to address the situation.

Therefore, the two major and key determinants that affected the health service deliveries in the
middle Ramu district are, MRD administration and geographical terrain in the Ramu district in
relation to transportation access.

2.5 Significance of the study

In this section, discuss the significance of the study; why this study is important.

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The importance of this study is, once the key determinants contributing to ineffective health services
in middle Ramu district are identified then, a better plan can be developed and implement to
improve better and effective health services in the district. Therefore the people can really benefit
from the basic services, including the health services that will improve the health of the middle
Ramu people. However to this time, the people of middle Ramu are still struggling for essential
services, and this has shown inequality and inequity government service in the region.

Middle Ramu District Administration (LLGC)

A study done by Seip (2011) stated that, “….the middle Ramu district Administration structure has a
high level of centralization with nine levels of hierarchy and has a high degree of formalization”. In
this chapter, the main important concept now is to look closely at the middle Ramu district
administration or LLGC structure, and reconstruct or rearrange the structure for the effectiveness of
the health services and other basic services. Seip (cited, Fayol in 1918) states, for an organization to
be effective, its structure must build on these four elements plan, organize, control and lead. These
facts shows that, the government is the source of all funds to pro-activate services accommodating
the four elements within its domain so that, the people are satisfied with good basic services.

Geographical location

On the other side, geographical terrain, is a major problem the people of MRD are facing. They have
poor access to transportation that could have brought economic activities into the communities, and
on the other hand, they have poor health service deliveries into the communities that has affected
them so much placing them in poor health status.

2.6 Definition of key terms

In this section, define key terms and acronyms.

Define key terms and acronyms.

MRDA Middle Ramu District Administration
LLGC Local level government council
Centralization Centralization means control of all activities are centralized under a
single authority.
Decentralization Decentralization means distribution of central control of all activities are
transferred and delegated to lower local authority offices than under a
single one.

2.7 Summary
In this section, summarize the main items you presented in this chapter.

To sum up this section, it is very essential to have a clear aim to research study so that, the
researcher can develop research questions and answer them accordingly to the problem explored. It
is also important to know the importance of the study, why the study was taken for or for what
purpose was the study conducted for. Furthermore, from the literatures reviewed, was the study
being captured within the discipline of the researcher’s area of interest or field, and were the
research questions derived from the explored situation and whether it is clear or broad in the study
process, these things must be clarified to the researcher before proceeding on with the research
design. Moreover, initial letters of unknown terms, and complicated words, should be simplified and
defined with clarified meanings for better understanding of the study.

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3. Research design
3.1 Introduction
In this section, state the main items you will discuss in this chapter.

In this part of the section, research design is conducted in-order to give detailed explanation of
the study, and what methods will carry out the study. While conducting the research design, the
paper will justify the philosophy of the study taken, explain the ontological and epistemology
context of the study, and will rationalize the research approach and finally will sum up with the
main items discussed in this section.

3.2 Research paradigms/philosophy

In this section, discuss the research philosophy/philosophies of your study and justify your decisions.

Simply philosophy in social science is a belief system of scientific knowledge of a phenomenon. In

the study of health service deliveries in the middle Ramu district has shown a biggest challenges
faced by people of middle Ramu, in which the middle Ramu local government district has a lot to
develop in its district. However, as a secondary researcher observed that, the study taken by four
researchers was a qualitative research design, and the nature of the study was an explorative and a
descriptive research. Now from the research philosophy of my study, the phenomena is illustrated
according to the research onion format below.

Research Onion

3.2.1 Research Philosophy: Critical realism (1st layer)

The concept of critical realism according to (Saunders, 2015) states,… the philosophy of critical
realism focuses on explaining what we see and experience, in terms of the underlying structures of
reality that shape the observed events”(p.138). “Father Daniel Anmarin, the priest at Kwanga
Catholic mission station said that, there are registered health centres with registered positions but
there seems to be no health workers to fill these positions” (WVI, June, 26th, 2018, p.2). Here we can
see from the subjectivist point of view that, “in the data collection, participants embedded in a social
phenomenon are interviewed to capture their subjective experiences and perspectives regarding the
phenomenon under investigation” (Bhattacherjee, 2012, P.109).

3.2.2 Research Approach: Inductive Approach (2nd layer)

With the inductive approach, the researchers collects data first and upon collecting the data they
develop theory. Survey such as that conducted by Gibbs et al. (2016) states, “we used questionnaires
based on those from the 2006 PNG demographic and health survey and a core welfare indicators
questionnaire developed by the World Bank”. This means that, after the survey questionnaires are
done, it will then be formulated into theory. According to Bhattacherjee (2012, p.109) explains, “in
inductive research the goal of a researcher is to infer theoretical concepts and patterns from
observed data.

3.2.3 Methodology: Mono method qualitative (3rd layer)

Another study by Saunders (2015) reports that, “in methodology it refers to the theory of how
research should be undertaken…methods refer to techniques and procedures used to obtain and
analyze data” (p.4). The research done by Gibbs and his team were questionnaires survey only, but
in three different questionnaire forms; Community questionnaire from 1996 PNG household Survey,
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Core welfare indicators questionnaire, and focus group using quality of life questions. According to
Saunders (2015) states, “A qualitative research design may use a single data collection technique,
such as semi-structured interviews, and corresponding qualitative analytical procedure. This is
known as mono method qualitative study” (p.168).

3.2.4 Research Strategies: Case study (4th layer)

Going through this research process, this study claims a case study as the research strategy. The
reason why it was chosen was a case study was, the study took place in the middle Ramu district
where people in that part of the region were interviewed, of how they felt, experienced and
behaved, seeing to that their health is muchly affected, deteriorating and is at high risk, where few
of the health facilities were closed down with only one functioning in the region, as well as other
essential basic services too were not provided. Furthermore it was reported that, people pay two
kina for regular treatment and a ten kina for every mother giving birth but, most of their babies are
born in the villages. These are the real life accounts from the people experiencing challenges in their
lives and are still expecting to see changes in near future. Therefore, Saunders (2015) explains a case
study as, “an in-depth inquiry into a topic or phenomenon within its real-life setting” (p.184).

3.2.5 Time zone: Cross-sectional (5th layer)

Furthermore the study has time limit as to when it should start and when it should end. This case
study survey is observed to be a cross-sectional study because it involves a particular phenomenon
at a particular time……for instance, case studies’ interviews occur in a short length of given time
frame (Saunders, 2015). Therefore it is clear from this survey that, according to (Gibbs, et al., 2016)
reports, “field data for this case study comes from one week of fieldwork……” This can justify what
cross-sectional means in time zone philosophy rather than longitudinal time zone which
accommodates longer time period to study change and development in a phenomenon.

3.2.6 Data collection and data analysis: Questionnaire Surveys and interview survey (6 Th layer)

In this part of data collection, the concept offers the type of tools used to collect data is expressed
here. The researchers Gibbs and the team used questionnaires to interview varies participants as
their sampling in their studies. According to (Saunders, 2015) states, “Questionnaire survey is a
research instrument consisting of a set of questions (items) intended to capture responses from
respondents in a standardized manner” (p.74). In addition, (Saunders 2015, p.78) presents, “A
variation of the personal interview is a group interview, also called focus group”. As the result, Gibbs
and the team used quality life questionnaires (61-63) of 1996 PNG household survey to interview
adult men, women, and youths in each community (Gibbs, et al., 2016). These were the techniques
used in collecting their data.

3.3 Ontological context

In this section, discuss the ontological context of your study and explain why.

In this context, it provides an important insights into research philosophy. The research philosophy
stands on two grounds of theory, and they are ontology and epistemology. According Neuman
(2011) explained that, “Ontology concerns the issue of what exists or the fundamental nature of
reality (p.94). More simple statement would be, our assumption about how we see the world. Hence
from the interpretivist point of view, the researchers collect views from the people in a specific
location or area about how they (social actors) see things in the social world they live in. For
instance, in regard to the health status in MRD, people of middle Ramu mentioned that they are still
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facing the biggest challenges in health services deliveries in the district, because of no district
governmental support. This can depict clearly that, the interpretivist is trying to understand this
human activities or social phenomenon in-order that, they will make assumption of what paradigms
fits the phenomenon.

3.4 Epistemological context

In this section, discuss your epistemological context and explain why.

Again epistemology is one part of philosophy concept that, assumes how best we can look at the
situation, reason around it and how to go about studying this phenomenon. As much have acquired
from the study of health service delivery with other essential basic services in MRD, this can give an
insight of what the study is about to look like. Epistemology “refers to our assumptions about the
best way to study the world”, (Bhattacherjee, 2012, p. 18). Looking at objectivist point of view it is
assumed that, there should be a radical structuralism in place. Overall view, the situation does not
allow people’s freedom to access good health services, better education and many more vital
services in their society. As an objectivist from my observation, there is unnecessary dominant and
unequal power distribution in the MRD administration down to the local leaders and the
communities, which has placed its own people in a very drastic situation. As noted by Seips (2011,
p.72), “the significance of studying the structure is that, structure determines the programs to
deliver, number of people to be employed, location of programs and staff, funds required etc.”
Therefore MRD administration should be now thinking of changing its structure in-order to bring
changes into its district.

3.5 Research approach

In this section, discuss your research approach and explain why.

In this section, the research approach that was used in this qualitative research done by Gibbs and
his team is inductive approach. Inductive approach simply is getting all the necessary information or
data to build theories. According to Sekaran and Bougie (2016) points out that, “….if your research
starts by collecting data to explore a phenomenon and you generate or build theory…..,then you are
using an inductive research”(p.145). Looking back to Gibbs and his research team, they first collected
their data from questionnaire surveys which they did in middle Ramu communities and started
building their theory framework. Therefore their research has produced a very challenging empirical
information for future academic research. On the other hand, a significant study on organizational
structure and impact on service delivery in MRD was conducted by Seip in 2011. He used a mix
method research design in which he took up abductive approach when he was collecting data using
Likert scale and analyzing the data on a Likert summative scaling method measuring its frequency,
distribution, rank and weight mean. According to (Sekaran & Bougie, 2015, p.170) states, “a mixed
methods research design may use a deductive, inductive or abductive approach to theory building”,
however for abductive approach, Sekaran and Bougie cited (Suddaby, in 2015 ) notes, abductive
approach tries to test a phenomena, why it occurs to discover more astonishing evidences. As we
can see from Seip’s study, that he came up with very interesting evidences showing MRD
Administration structure and concluded with a recommendation stating, “ this study therefore
recommends that a new organizational structure be designed in-order to promote efficient and
effective services delivery” (Seip, 2011, p.73).

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 3.6 Summary
In this section, summarize the main items presented in this chapter.

In this part of the section, research design is conducted in-order to give detailed explanation of
the study, and what methods will carry out the study. While conducting the research design, the
paper will justify the philosophy of the study taken, explain the ontological and epistemology
context of the study, and will rationalize the research approach and finally will sum up with the
main items discussed in this section.

3.7 Conclusion
In this section, conclude with main items presented in this document.

Reference

Bhattacherjee, A. (2012). Social Science Research: Principles, Methods, and Practices. (2 nd edition).
Florida, Scholar Commons.

Neuman, L. (2011). Social Research Methods: Qualitative and Qualitative Approaches. (7 th edition).
Pearson Education Limited, London.

Seip, K., B. (2011). Organizational structure and impact on service delivery: a case study of the Middle
Ramu District Administration in Papua New Guinea. DWU Research Journal.

Witter, S. (2018). Exploring factors driving the performance of rural health care in Papua New Guinea.
Research Gate. Date Accessed 2/12/2020 from https://www.researchgate.net/publication/326311323

WVI PNG. (2018). Woman farmer see promise in middle Ramu Cocoa project. Date accessed
11th/12/2020 from https://www.wvi.org/papua-new-guinea/article/woman-farmer-sees-promise-
middle-ramu-cocoa-project

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MRDA

Hence the MRD Local Level Government Council should revisit their administrative structure, modify
it to a simple and flexible structure, again capturing its land boundary in the district structure for
equal decentralization of power from the MRDA to the local leaders, to bring basic services and
changes into the communities. In addition, the MRD LLGC leaders must work closely with the
community leaders. It is more to do with leaders and power dissemination to bring these basic
essential services including health care services to all people in MRD.

Anyway, for a better plan to be effective to address the key factors, there must be a well-organized
and decentralized governmental structure and strategies in-placed in an administration of an
organization to fully function well.

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