DRAFT 12 April 1996
I. Basic Features of the Sector
A. Health Conditions of the Population
B. Environmental Risks to Health
C. The Health Care System
II. Policies of the Sector
A. Description of Past Policies
B. Description of Current Policies
III. Description of the Principal Issues and Constraints Facing the Sector
IV. Sectoral Objectives
V. Policy Recommendations and Their Technical Justifications
A. Institutional Policies
B. Policies for Financing Health Care
C. Policies Regarding the Availability of Pharmaceuticals and Medical Supplies
D. Community Participation
E. Policies by Stages of Health Care
VI. Recommended Legislative Changes
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One of the more unfortunate consequences of the well-documented decline of Guyana's economy over a period of two decades was that it led to deteriorated health conditions for a large part of the population. This was a result of many factors, primarily lower per capita income levels, the drop in educational levels, and the reduced capacity in the health sector to service the needs of the population. Government's recurrent allocations to the sector dropped sharply in real terms between 1986 and 1992, although subsequently that trend was reversed. While there has been success with immunisation programmes, the incidence of some diseases has increased precipitously in the last twenty to twenty-five years.
Comparative analysis shows that Guyana now fares poorly in comparison with neighbouring countries in regard to basic health indicators. Life expectancy declined from 70 years in 1985 to 64 years in 1992 (but it ceased to decline further in 1993 and 1994). Comparable figures for other countries in 1993 were Jamaica, 73 years; Barbados, 75 years; Surinam, 69.5 years; Venezuela, 70 years; and Trinidad and Tobago, 72 years. Guyana's infant mortality rate was measured at 49.0 (per 1,000 live births) in 1992 and 34.9 in 1993. In Venezuela, the infant mortality rate is 34, in Surinam 30, in Trinidad and Tobago 20, and in Jamaica 15.(1)
Maternal mortality also is relatively high. In 1990, the rates at the hospitals in Georgetown, Suddie and New Amsterdam were 231, 340 and 442, respectively, per 100,000 births. Comparable figures for the Caribbean were 35 in Barbados, 89 in Trinidad and Tobago and 115 in Jamaica, all data from 1988.
A health strategy has to be based on a determination of which are the leading health problems in the population, and what are the principal requirements to make the health care delivery system more effective. Health problems by age group are outlined in the following paragraphs of this Section, and then the structure of the health care system is presented. Issues and constraints affecting the availability and quality of health care are described in Section III.
The leading causes of mortality for young children aged 1 to 4 are:
Infectious intestinal diseases
Diseases of the respiratory system
Diseases of the blood and blood-forming organs
Diseases of the nervous system
Homicide and purposely inflicted injury
Malnutrition has been a product of the high rates of poverty (Chapter 17). It probably has decreased somewhat in the last three to four years, but as of 1993 the Living Standards Measurement Survey found that 2.2 percent of children suffered severe malnutrition and 16.1 percent experienced mild or moderate malnutrition. The prevalence of severe malnutrition was highest in Regions 2, 7 and 10.(2)
The rate of child mortality from diarrhoeal diseases has declined somewhat in very recent years, but the number of deaths from acute respiratory diseases is still too high. Hospitals have seen an increase in admittances due to accidents and violence.(3)
In 1992, the leading causes of mortality for all age groups in Guyana were:(4)
Cerebrovascular disease, ischaemic heart disease, hypertensive disorders and pulmonary circulation deficiencies, which may be grouped together as forms of heart disease.
Endocrine and metabolic diseases, particularly diabetes.
Conditions occurring in the perinatal period.
Other respiratory diseases.
Diseases of the digestive system, especially intestinal infections.
The picture is different in regard to morbidity. Overall, the ten health problems most often reported in 1993 were, in order of frequency, dental caries, malaria, acute respiratory infections, acute diarrhoeal disease, hypertension, worm infestation, diabetes mellitus, rheumatism and arthritis, accidents and injuries, and scabies. For purposes of policy planning, the significance of the morbidity profile is that it can be improved substantially through improved preventive health care, better education on health issues, more widespread access to potable water and sanitation services, and increased access to basic health care of good quality.
The high incidence of dental caries is no doubt influenced by the extremely low ratio of dentists to population, at 1:27,037.
As mentioned in Chapter 17, reported cases of malaria increased by 12-fold between 1984 and 1991. Cases of gastroenteritis and typhoid fever increases sharply as well. In general, diseases spread by vectors and those associated with environmental problems showed the most rapid rates of increase.
For the age group under 5, acute respiratory infections, worm infestation, scabies, malaria and acute diarrhoea are the most common afflictions. Malaria, hypertension and diabetes are the most frequent diseases for the 20 - 64 age group. Table 19-1 shows the incidence of these health problems by age group.
Morbidity Reported in Health Centres and Vector Control
and Dental Services by Age Group, 1993
|Cause of Morbidity||Age Group|
|0 - 4||5 - 44||45+||Total|
|Acute respiratory infections||6,110||4,325||1,639||13,052|
|Acute diarrhoeal disease||n.a.||n.a.||n.a.||11,354|
|Rheumatism and arthritis||7||766||2,152||3,922|
Note: Subtotals do not add to totals because the latter include cases in which the age was not stated.
Source: Ministry of Health, Draft National Health Plan of Guyana, 1995-2000, Georgetown, November, 1994.
There are significant differences in morbidity by region, owing in part to the geographical isolation of some communities and the attendant difficulties of delivering equipment and services to them. In 1993 the total number of cases of diseases and ailments per 1,000 population was 1,032 in Region 1 and 1,232 in Region 8, as compared to only 100 in Region 10, 110 in Region 6 and 154 in Region 3. Malaria is chiefly responsible for the high rates of morbidity in the hinterland, accounting for 709 cases per 1,000 population in Region 1 and an astonishing 975 cases per 1,000 population in Region 8. Even allowing for instances of repeated infection in the same year, it appears that most of the population of Region 8 has malaria. There also are more than 100 cases of malaria per 1,000 population in Regions 7 and 9. Malaria in the hinterland appears to be particularly associated with the influx of small-scale mining operators and timber workers. Indiscriminate use of antimalarial drugs in these areas has caused an increase in the drug-resistant strains of malaria.
In the 1940s Guyana's anti-malaria programme was one of the most successful in South America, and by 1950 the disease was virtually eliminated. This experience demonstrates what is possible. The resurgence of malaria began when anti-malaria measures were suspended between 1963 and 1974 owing to fiscal limitations.
It should be borne in mind that all the aforementioned data on morbidity refer to reported cases (for all diseases and ailments), so it is highly likely that actual levels of incidence are more elevated, perhaps significantly so for some diseases.
The Regions with the lowest overall morbidity rates (according to statistics on reported cases) are 10, 6, 3, 4 and 5, with 10 having the lowest and 5 the highest of that group. This finding undoubtedly reflects the relatively better quality of medical care that has characterised Region 10.
Regions 7, 8 and 9 also have a lower rate of vaccination than the rest of the country for the six diseases that can be prevented with vaccines, because of their lack of electricity and difficulties of access by river and air.
Apart from the major causes of morbidity reported in hospitals, health centres, vector control services and dental services, HIV/AIDS and other sexually transmitted diseases (STDs) are increasingly significant problems for Guyana. The number of AIDS cases increased from 10 in 1987 to 497 in 1993, and females accounted for 29 percent of the cases in the latter year. Among blood donors, 7.2 percent of the tests for STDs were positive and 1.45 percent of blood donors were HIV positive in 1992. Moreover, ante-natal monitoring of mothers indicates a 2 percent rate of HIV infection. Rates of use of contraceptive devices are relatively low (31 percent) and as a result abortion is a common practice for controlling family size. (It is estimated at 422 per 1,000 live births.) As in the case of the other syndromes mentioned above, increased efforts at education can play an important role in changing this profile. However, according to the Social Science Faculty at the St. Augustine Campus of the University of the West Indies (op. cit.), "If present trends continue, this disease [AIDS] will have major debilitating effects on production and productivity, and social services, by the end of the century, if not sooner."
Although there is very little statistical information on drug abuse, it appears to be increasing.
The nature of the most pressing health concerns varies by group in the population. For women, the principal concerns center around their childbearing role and include maternal mortality, anemia during pregnancy, teenage pregnancy(5), the prevalence of abortion, and complications arising during attempted abortions.(6) Cancer also figures among the leading causes of death of women.
The leading causes of morbidity for children have been mentioned. Low birth weights are an additional problem, characterising 19 percent of the live births. Coverage of immunisation programmes has been expanded considerably in recent years, specifically for BCG(7), DPT, OPV and measles vaccines. Rates of coverage for the first three, for the age group under 1 year, are now above 90 percent.
Malnutrition is seen as a serious problem among Amerindian children. For Amerindians in general, the main health problems include malaria, typhoid fever, dysentery, worm infestation, acute respiratory infections, cholera, malnutrition and, in the case of women, complications of childbirth. In the Western and Southwestern areas, snake bites are a problem and in the Southern areas the incidence of cutaneous leishmaniasis (bush yaws) appears to be increasing. Tuberculosis and eye infections have been mentioned as problems in Region 9.
Little information is available about disabled persons, and the care and facilities to help disabled children are very limited. There are no statistics on the number of persons with mental health problems, although schizophrenia is known to be the leading cause of admission for psychiatric patients. To date not much priority has been given to dealing with mental health issues.
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The geographical breadth of Guyana and the dispersed nature of part of the population has limited the extent of epidemics and the transmission of some diseases. The principal risks to health that arise from the environment were summarised in the Draft National Health Plan of Guyana (pp. 51-54), as follows:
"The quality of the water at source is generally acceptable, but water made available for human consumption is bacteriologically poor because contamination occurs in the distribution system. In areas where surface water is used without treatment -and some 169 of 171 systems are without disinfection facilities- the concentration of soluble organic matter originating from the decaying heavy vegetation in the water is high. In turn this encourages rapid growth of bacteria. Despite this . . . the reported incidence of gastroenteritis, infectious hepatitis, typhoid and cholera is relatively low. . . .
"Problems of basic sanitation, meanwhile, seem to be quite widespread. This is especially true of certain parts of Georgetown, where new housing schemes, factories, commercial institutions and industries have been developed without compliance to the existing land development plan . . . inadequate and poor quality water supply, stagnation of water in drainage canals, indiscriminate dumping of solid waste in canals and/or street parapets are all prevalent and create an unsanitary environment. . . . certain housing schemes have been developed without proper sewage systems, leaving individual septic tanks and pit latrines as the only means of sewage disposal. Unfortunately, the location of these tanks and latrines is not always in keeping with the recommended distance from the water supply, making water contamination a real possibility. Worse still is the situation of squatters, many of whom have no hygienic means of waste disposal. [Emphasis in original.]
". . . . overcrowded buildings encourage the transmission of obstructive pulmonary and other communicable diseases. . . . the current housing stock is deficient, and this has encouraged the expansion of squatting areas along the coast and along the embankment of the Lamaha canal in Georgetown. It also has made homelessness a reality for many people unable to afford anything better.
". . . . in 1992 there were a total of 14,355 [occupational] injuries. A substantial 13,905 of these occurred among those in agricultural occupations. . . .
". . . . a study on exposure of agricultural workers to pesticides conducted under the supervision of PAHO/WHO [demonstrated] that this health hazard is found in Guyana . . . in 1989 traces of organochlorine pesticides were found in water samples taken from artesian wells, fresh water canals and drainage canals in the agricultural fields of Mibicuri and Black Bush Polder in Region 6.
"Silicosis and bagassosis are also thought to exist among workers in the rice and sugar industries.
". . . . it is thought that domestic violence is a significant health problem in the country, impairing mental and social health, as well as causing physical harm.
"Despite Government regulations and food inspection programmes, chemical contamination of food continues to occur in the absence of real enforcement mechanisms."
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The health care system includes a variety of institutions, both public and private. These include Government Ministries (primarily the Ministries of Health, Labour, and Public Works, Communication and Regional Development); parastatals such as GUYSUCO, LINMINE and BERMINE; other governmental agencies such as the Guyana Agency for Health Sciences Education, Environment and Food Policy (GAHEF), the Social Impact Amelioration Programme (SIMAP), the Central Housing and Planning Authority (CH&PA), GUYWA, the Sewerage and Water Commissioners, and the National Nutrition Council; Regional authorities; the National Insurance Scheme; non-governmental organisations; the private sector; and international donor agencies.
Delivery of health services is provided at five different levels in the public sector:
Level I: Local Health Posts (39 in total) that provide preventive care and simple curative care for common diseases and attempt to promote proper health practices. They are staffed by community health workers.
Level II: Health Centres (194 in total) that provide preventive and rehabilitative care and promotion activities. Ideally they are staffed by a medical extension worker or public health nurse, along with a nursing assistant, a dental nurse and a midwife.
Level III: Eighteen District Hospitals (with 420 beds) that provide basic in-patient and out-patient care (although more the latter than the former) and selected diagnostic services. They should be equipped with also for simple radiological and laboratory services and be capable of providing preventive and curative dental care. They are designed to serve geographical areas with populations of 10,000 or more.
Level IV: Four Regional Hospitals (with 717 beds) that provide emergency services, routine surgery and obstetrical and gynaecological care, dental services, diagnostic services and specialist services in general medicine and paediatrics. They were designed to include the necessary support for this level of medical service in terms of laboratory and X-ray facilities, pharmacies and dietetic expertise. These hospitals are located in Regions 2, 3, 6 and 10.
Level V: National Referral Hospital (601 beds) in Georgetown that provides a wider range of diagnostic and specialist services, on both an in-patient and out-patient basis, and the Psychiatric Hospital in Canje, the Leprosarium in Mahaica and the Geriatric Hospital in Georgetown. There is also a children's rehabilitation centre.
This system is structured so that its proper functioning depends intimately on a process of referrals. Except for serious emergencies, patients are to be seen first at the lower levels, and those with problems that cannot be treated at those levels are referred to higher levels in the system. However, in practice, many patients by-pass the lower levels.
In addition to the facilities mentioned above, there are 10 hospitals belonging to the private sector and to public corporations, plus diagnostic facilities, clinics and dispensaries in those sectors. Between them these 10 hospitals account for 548 beds. While funding for the public health sector has declined, the private provision of health services has been expanding rapidly. The 19 clinics and dispensaries of GUYSUCO are especially noted for the high quality of their care.
The Ministry of Health is responsible for the funding and management of the National Referral Hospital in Georgetown but the facilities at the other levels receive their funding from the Ministry of Public Works, Communication and Regional Development. In each of the Regions there is a Regional Health Officer who reports to higher levels of the Ministry of Health on all professional and technical matters. However, in 1986 the Regions assumed responsibility for health care within their boundaries, and now administrative control over health resources in the region rests with the Regional Executive Officer, who is chief officer of the Regional Democratic Council. The possibilities of confusion and conflict between mandates are obvious, and have materialised. Recently the coordination between the Central Ministry and the Regional Governments has been improved, and the Ministry must approve all capital investments in health infrastructure.
Nevertheless, this divided mandate makes it difficult for the Ministry of Health to collect the necessary data on a regional level and hence to plan adequately for meeting the system's needs. Similarly, the fact that the Ministry of Health authorises purchases of equipment while the Regions are responsible for operating and maintaining it has resulted in instances of equipment being unused after installation, for lack of personnel trained in operating it or for lack of a sufficiently accurate diagnosis of needs before the equipment was purchased.
Under this system, Region 6 is responsible for the management of the National Psychiatric Hospital. The Ministry of Labour is responsible for the Geriatric Hospital and the Leprosarium.
The Ministry of Health also is responsible for establishing and implementing health policy and standards, accrediting facilities, and identifying the human resource needs of the sector. It has retained responsibility for the procurement and distribution of pharmaceuticals and medical supplies in all regions. It funds and manages in the entire country the vertical health programmes, including vector control, rehabilitation services and dental care and those programmes dealing with mental health, Hansen's disease, AIDS, and alcohol and drug abuse. The regulatory bodies for the health system include the Central Board of Health, the General Nursing Council, and the Pharmacy and Poisons Board. A Cabinet Subcommittee reviews developments in the health sector.
Currently the personnel in the system include 309 doctors (176 public and 133 private), 1218 public nurses (plus an unknown number in the private sector), 127 Medex personnel (medical extension workers who are qualified as nurses and have 18 months of clinical training), 133 community health workers, 80 pharmacists (3 public, 77 private), 24 environmental health officers and 27 dentists. There is heavy reliance on overseas personnel in some disciplines. For example, more than 90 percent of the specialist medical staff in the public sector are expatriates. Many medical personnel in the public sector also work in the private sector, and some observers have noted a neglect of the ir duties in the former, in favour of the latter.
In the public health sector the staff vacancy rates are in the range of 40 to 50 percent in most categories.(8) In rural areas and in the disciplines of pharmacy, laboratory technology, radiography and environmental health, the vacancy rates are higher.
The private sector provides about half of all curative services, while the public sector provides most of the preventive, secondary and tertiary services. In 1994, the public sector spent about 70 percent of total outlays in the health sector, and the private sector accounted for about 22 percent and the parastatals about 8 percent.
Almost 70 percent of the doctors are located in Georgetown, where one-quarter of the population lives. Out of total national health expenditure, the Georgetown Public Hospital (excluding drugs) accounted for 31.25 percent in 1994, and the regional public facilities, 21.43 percent. Only 1.4 percent was allocated to vector control.
The University of Guyana and GAHEF carries out almost all health-related training. The former offers curriculums in medicine, pharmacy, medical technology, radiography, environmental health, health sciences tutoring, and health service management. In collaboration with the Institute of Adult Learning and Continuing Education, evening classes for health professionals are offered in mental health, developmental psychology, care of the elderly, and child care.
NGOs have been very active in providing equipment and supplies, and many of them have provided health care in the deep hinterland areas. In recent years the coordination between Government and these NGOs has been strengthened.
Community involvement in health services has been weaker than desired to date. However, the community health workers, who are indigenous to the regions in which they work, represent a vital link between the public health system and the populations in remote areas. In addition, this programme has provided one of the few opportunities for Amerindians to improve their professional status, and it is generally considered a success from all perspectives.
GAHEF's programmes offer the necessary preparation for work as Medex personnel, nurses, X-ray technicians, dental auxiliaries, laboratory aides, community health workers, physiotherapy assistants, pharmacy assistants and nursing aides. There also is a public health nursing programme. GAHEF has two nursing schools attached to the public hospitals in Georgetown and New Amsterdam. Nursing schools also are operated by Mackenzie Hospital (run by LINMINE) and St. Joseph's Mercy Hospital (private).
GAHEF also has responsibility for developing and implementing policies on environmental health, food quality and nutrition, and for carrying out inspections of waste water, sewerage removal activities and disposal of hazardous waste.
In principle, the National Insurance Scheme (NIS) provides insurance for a portion of the cost of some classes of private medical expenses, but patients' dependents are not covered under the scheme. The Ministry of Health does not recover any costs from patients insured by NIS, although they use the public system. The NIS was not intended to serve primarily as a health insurance scheme, and in practice its claim processing procedures leave much to be desired. As it is presently constituted, there are serious concerns about the institution's long-run financial viability, having lost three-quarters of the real value of its assets between 1989 and 1992.
Private health insurance is an option utilised by some families. A survey in 1990 found that private health insurance policies covered some 45,000 persons. In cases of emergency treatment of indigent patients, the Ministry of Health reimburses private providers of medical care.
GUYSUCO provides diagnostic and outpatient services for some 24,000 employees and their dependents, and some of them have NIS coverage also. As noted, the quality of GUYSUCO's health services is generally high but there is little preventive health service and no family planning, and those facilities are not allowed to give immunisations by law. (Only the public sector's health facilities are authorised to provide immunisations.)
The MacKenzie Hospital of LINMINE (now scheduled for separation from the parent company) has provided service to employees of the mining corporation and to the general public, with proportionately more service given to the latter. A small portion of its costs is recovered through a company insurance programme, but the Ministry of Health covers the greatest share of those costs with a subvention.
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The past policies for the health sector have been characterised chiefly by a commitment to provide free health care to all citizens and by the structuring of the system in the above-mentioned manner, with five distinct levels and the expectation that patients would be handled in a referral process. Since the 1960s the role of the private sector in providing health care was severely restricted. However, in practice the fiscal allocations to health have not been sustained at a level which would be consistent with the provision of quality health care to all, and the consequence has been the documented deterioration in many principal indicators of the health of the population. In addition, the service is not free in reality, as most patients have to purchase essential medical supplies for hospital stays.
The administration of the health system of the public sector has been divided between three Ministries (Health, Labour, and Public Works, Communication and Regional Development), two public corporations, and the Regional Development Councils. The exception to this rule has been the "vertical programmes," such as vector control, maternal and child health, dental care and the AIDS programme, which fall entirely under the aegis of the Ministry of Health for all regions of the country.
The respective roles of the private and public sectors in the provision of health services have not been defined but the private sector has provided an increasing share of those services, especially in respect of curative care. Nevertheless, the most specialised procedures still are available only in the principal public hospital.
Considerable emphasis has been placed on immunisation programmes, with a high degree of success. Vector control and in general programmes for environmentally related maladies have not received the same degree of priority, nor has education on maternal health and sexually-transmitted diseases.
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In very recent years, the trend toward declining real budgetary allocation to the health sector has been arrested. Funding requirements, however, still exceed the availability of funds by a considerable margin, so the restrictions on private provision of health services have been relaxed. Now almost half the patients seek treatment in the private sector (and a small number use traditional healers).
Investments in facilities and equipment have been greatly increased, with donor assistance, and a clear priority has been given to rehabilitation of the Georgetown Hospital.
The Draft National Health Plan prepared by the Ministry of Health has identified and analysed many of the problems besetting the health care system, has identified priority areas of health care, and has raised significant questions about possible reforms in the institutional aspects of health care. In effect, it has raised issues that must be faced and resolved to satisfaction in the course of establishing national health policy. It also is a document rich in detail and insights about prevailing health standards and the health care system.
In terms of causes of morbidity and mortality, the most pressing priorities have been identified as malaria, sexually-transmitted diseases, acute respiratory infections, immunisable diseases, and perinatal problems. The plan points out that in these areas "the health gain for a given amount of money spent is estimated to be high" (p. 56).
The next set of priority problems includes malnutrition, diarrhoeal disease, abortions, maternal mortality, accidents and injuries, diabetes and hypertension, dental caries, mental ill health and drug abuse, and skin conditions (primarily scabies among children). Because of the importance of improving nutrition in general and maternal health in particular, programmes of nutritional fortification of wheat have been implemented.
For the health delivery system as a whole, the plan has defined objectives and targets for expanding primary health care, improving secondary and tertiary health care, and strengthening the management of the health sector, but new policies to achieve those objectives are not defined. Possibilities for restructuring the management of regional hospitals are mooted but no definitive stance is adopted in that document. Similarly, the option of instituting partial fees for selected services, in order to strengthen the system's finances, is raised but no policy decision is indicated.
The plan shows a willingness to come to grips with the main issues in health care, and many useful lines of action are set out. Building on that work, this Chapter of the National Development Strategy sets out the principal national health policies that will be necessary to facilitate the achievement of the plan's main objectives.
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1. All-Encompassing Issues
The fundamental issues that the health sector must confront on a continuing basis are the need to make effective the guarantee of access to health care on the part of all, and the need to improve the quality of the health care offered. In 1992, it was found that 12.5 percent of the population did not have access to health care. The situation is proportionately more difficult for the lower-income groups. In that same year a national survey found that in the lowest income quintile 24 percent of those who were ill or injured did not seek medical care "due to expense or distance factors." In the next-lowest quintile, the corresponding figure was 19 percent and in the highest quintile it was only 3 percent. Of the patients in the poorest quintile, 37 percent received medical attention from a doctor, whereas of those in the highest income quintile, 67 percent were seen by a doctor. These are clear indications of the length of the road yet to be travelled to make a reality of the goal of full access to health care.
It is important to recognise that making health care nominally free of charge (although in reality most patients pay) is not a guarantee of universal access to health care. International studies have shown that the most important factors determining access to health care are: distance and travel time to a health facility, the perceived quality of the care, the education level of the patient, and the type and severity of the illness. The price of the service plays a lesser role. Here it is worthwhile to note that there is a vital interaction between quality and access. When the quality of the care is perceived to be weak, the patient is more likely to defer treatment until the illness acquires greater severity, and then the consequences are that the illness becomes more debilitating or life-threatening and the cost of treatment is higher than it could have been otherwise. The patient suffers, and at the same time the financing problem for health care is aggravated.
The question of quality of health care is pervasive and also lies behind many of the statistics presented in the first section of this Chapter. During the long period of decline, many of the most qualified medical practitioners left the country, facilities deteriorated, many pieces of equipment lay inoperative, and pharmaceuticals and other medical supplies became scarce. Among other consequences, the poor quality of the care offered at the lower levels of the referral system has encouraged many patients to go directly to the higher levels, thus causing the system to break down.
In spite of some improvements in funding and management in the sector in recent years, the sector still has many vacancies of key personnel and quantities of nonfunctioning equipment. There is a lack of storage facilities for drugs and inadequate quality control over them. Patients still routinely purchase their own pharmaceuticals and medical supplies and have to spend excessive amounts of time in repeated visits to medical facilities. Hence, in overall terms, despite improvements in some staffing and in the area of immunisations, the overall quality of operations has not improved and in some respects continues to decline. In large part this is due to problems in the structure of organisation of the sector, in its management, and in the availability of financing.
Therefore in the most basic sense the sector today faces the twin challenges of widening the real access to medical care and improving the quality of its delivery. In the last two or three years the deterioration of the system has been arrested and considerable progress has been made in setting new priorities and directions for health care programmes. Nevertheless, the needs for continuing improvements are large indeed.
While all the stages of health care (primary, secondary, tertiary care plus vertical programmes) require strengthening, special priority has to be placed on improving primary health care, as that is where the greatest gains in the health of the population can be expected. It has not received sufficient emphasis, relative to its importance, in the past.
2. Basic Concept of Health and Its Determinants
The health status of the Guyanese people cannot be improved or sustained by medical services alone. In planning for improved health care, other factors that influence an individual's life should be taken into consideration, such as education and awareness of health issues, family and community supports, quality of the environment, economic stability and growth, and the health care system itself. Allocating tax dollars in a prevention approach among all the areas that affect health is wiser in the medium and long term, rather than to spend on health treatments that would be unaffordable eventually if treatment were relied on exclusively instead of a combination of treatment and prevention.
A health promotion strategy, as opposed to one that is purely curative, is more in keeping with the idea of the determinants of health, which go beyond purely medical considerations. It involves factors such as biological endowment (i.e., hereditary disorders), physical environment (i.e., air and water pollution, adequacy of housing), social environment (i.e., family relationship and social supports, employment status and income levels), individual behaviour (lifestyle factors such as diet, exercise and smoking), and health care itself (i.e., immunisation, physicians' services). From this concept stems the definition used by the Government in its proposed aim of primary health care and health for all: "health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." However, the tendency in the local health situation is to focus only on the approach of diagnosing and eliminating diseases. A shift is needed to the concept and strategy of health promotion and education.
3. Institutional Coordination in the Management of the Health Care System
As noted in the foregoing, institutional responsibility for the public sector's system of health care is dispersed among various Ministries and agencies. As noted by Homedes, "Under the present system, the operational responsibility for the implementation of the central programme is with the Regional Health Officer (RHO). The RHO reports to the Regional Executive Officer, who also has the financial authority and responsibility for programmes in all sectors. The REO, however, is not a public servant and is not accountable to the policy-making Ministries . . . The Ministry of Health, therefore, has virtually no downstream control on the implementation of its policies . . . there is no mechanism to hold the REO accountable for the delivery of the sectoral programme" (Nuria Homedes, Health Strategy Paper, 1994, p. 5). And "the lack of training and preparation of the RHOs [in management] constitutes a major constraint in the management of health services at the regional level" (Ibid).
Collaboration in the health planning process is nonexistent or ad hoc at best, both among these institutions and between the public health system and the other stakeholders. Substantially more effective collaboration among the health-related agencies, or a restructuring of institutional responsibilities, is essential in order to increase the efficacy of collective action aimed at minimising the causes of ill health. This collaboration or restructuring should involve agencies such as the Ministry of Education; Ministry of Labour and Human Services; Ministry of Public Works, Communication and Regional Development; Guyana Sugar Corporation; Ministry of Agriculture; and also non-governmental organisations in the health sector, associations such as the Guyana Association of Professional Social Workers, and other stakeholders in the social sector.
Although does exist minimal collaboration in some areas, better strategic planning is needed to improve the organisation and management of the intersectoral collaboration. Such planning will help maximise the quality of care and the efficiency in the collective use of the resources available. This Chapter of the National Development Strategy establishes the principal orientations which that strategy planning should follow for the next ten years.
Decentralisation of health planning and management functions has the potential of ensuring greater responsiveness to clients and increased timeliness and efficiency in the delivery of health services, as well as reducing the overlap of and conflicts between institutional responsibilities. However, this potential has not been realised under the present regionalised system of administration. There needs to be more collaboration between the Ministry of Health and the Ministries of Regional Development, Public Works and Communication, and the Regional Administrations in the management of the system, and a redefinition of their respective roles and responsibilities.
There is no single unit in the Ministry of Health responsible for the delivery of primary health care, and responsibility is divided between the Regional Health Director and other offices, such as the one for communicable diseases. Given the strategic importance of primary health care, this is an omission in the structure of the system that bears rethinking.
4. Financial Aspects of Health Care
Although Guyana's public expenditure on health increased significantly between 1992 and 1995, it still remains below the levels necessary to restore the system to the desired state. If national health priorities are to be properly addressed, adequate funding for these priorities is vital. In addition, there is considerable scope for improved financial management of the system so that the available funds are used more efficiently.
There are many sources of inefficiencies in the financial management of the sector. The format and structure of the annual budget estimate does not lend itself to a programme budgeting approach; the annual budget of the health sector is not based on projected programme outputs and objectives; managers are not often apprised of actual departmental budget allocation and there is minimal or non-existent financial autonomy at the departmental levels. There is difficulty in establishing the amount of resources needed; the Ministry of Health is not involved in setting the health budgets of the Regional administrations; budgets are not based on actual cost estimates or productivity criteria; and there is a lack of coordination of donor funding. Also, there is a scarcity of qualified and experienced professionals in health care accounting and there has not been a full exploration of alternative ways to finance health care. At the Regional level, a perceived crisis in another sector often means that budgeted funds are reallocated away from the health sector.
The lack of funding and inefficiencies in the ways that funds are budgeted and spent have been the major contributing factors to the flight of talented medical personnel. The reductions in funding for personnel costs were dramatic. From 1986 to 1991, a period when the total budget of the Ministry of Health was declining in real terms, the share of that financing devoted to salaries dropped from 38 percent to 11 percent. A similar phenomenon occurred in the Regional administrations over the same period, with the share of total spending devoted to salaries of health care personnel falling from 50 percent to 26 percent. Salary schedules for medical personnel have suffered the same erosion in real terms experienced by all salaries in the public service, so these reductions in funding led to both increased vacancies and reductions in real earnings of the personnel. In real terms, salaries for fully qualified physicians declined by almost half between 1985 and 1991.
In recognition of these problems, substantial increases in emoluments for medical personnel were decreed in 1992. However, salaries in the public health care sector are still well below what is offered in the private sector and abroad. Some of the newer benefits are not linked to levels of qualifications or to performance. Absenteeism of medical personnel is still a major concern in the public sector's health institutions.
While financing is still a limiting factor, it is important to recognise that social sector funding from the Central Government budget has increased in recent years, rising from 13.5 percent of total current expenditure in 1987 to 17.9 percent in 1994. Health care expenditure had risen to 5.6 percent of GDP in 1994, more than twice its share at the beginning of the decade. International donor agencies also play an important role in financing the sector. In 1994, the major sources of current financing for health care were, in order of magnitude, the Central Government budget, out-of-pocket expenditures by patients, PAHO, LINMINE, and GUYSUCO. For capital funding, the principal sources were, again in order, the IDB, the Central Government, the European Community, and SIMAP. CIDA has donated an intensive-care unit and an energy unit for one private facility, USAID and churches have assisted with other facilities, and many private physicians from abroad donate some of their time. Policies for increasing the sector's funding must take into account this diversity of sources. It is significant that approximately 20 percent of total funding, and 37 percent of current funding, come from out-of-pocket expenditures on the part of patients.
5. The Geographical Referral System
In principle, the referral system is well-suited to Guyana because of its geographic barriers to communications and transport. However, in practice it is not functioning well. The lower levels in the system are not well provisioned with adequately trained medical staff, supplies and equipment, so patients try to bypass them whenever possible. In a cruel irony, it is the poor who visit in disproportionate numbers the local facilities and endure the consequences of lower-quality care. A 1992 survey showed that of the poorest patients (those in the lowest income quintile), 16 percent used public health posts, while of the richest (those in the highest quintile) only 3 percent used the posts. The median-income group likewise avoided the posts, with only 1 percent of them having recourse to said facilities. Similarly, 21 percent of the poor used the public health centres while only 9 percent of the median-income and rich families visited them.
The principal reasons why the referral system is not working as planned appear to be the following:
i) The lack of sufficient administrative coordination between the Ministry of Health and the Regional authorities inhibits the planning and implementation of measures to upgrade the lower-level facilities and make the referral system function better.
ii) Shortages of funding also limit the possibilities for improving the quality of care at the lower levels.
iii) The ability of the Ministry of Health to provide leadership to the Regions is limited by its own shortages of skilled staff.
iv) Regional Health Officers usually are not trained in public health or in administration, and thus they are not properly equipped to be leaders of the health team in the Region.
v) Files and other information on patients are not systematically passed from one level to another, so valuable knowledge about the patient is lost and there is a costly duplication of examinations.
v) Needs assessments are conducted only rarely if at all in the Regions.
vi) In some parts of some Regions, it is easier to travel to Georgetown than to the appropriate health facility in the Region.
vii) The system appears to be over-designed in the sense that there are too many levels to be functional and too many hospitals in relation to the budgetary possibilities of equipping them all well.
viii) Mobile health units have not been sufficiently emphasised.
These considerations suggest that the referral system requires serious rethinking and a new design if it is to play an effective role in Guyana's health care in the next century.
A specific aspect of the referral system that merits comment is the spatial distribution of health centres. These centres are vital elements of the system as they provide a wide range of preventive services and some curative care, including maternal and child care, treatment of chronic diseases, health education, dental care, and environmental health services. However, the health centres in Regions 3, 4 and 6 cater to at least twice as many people as in the other regions. Homedes (1994, p.13) has commented "it is important to note that at least two RDCs believe that there are too many health centres in the coastal areas of their regions while there are shortages in the riverfront and hinterland areas."
6. The Procurement and Distribution of Pharmaceuticals and Medical Supplies
It is widely recognised that the supply and distribution of pharmaceuticals and medical supplies is a major bottleneck in the health care system. There are periodic shortages vis-a-vis needs, delivery is often not timely, and wastage occurs because of poor management. Issues affecting the procurement and distribution of drugs and medical supplies include:
Legislation in this area is out of date. The Food and Drug Act dates to 1971 and its supporting legislation to 1977.
The list of essential drugs, which should guide the priorities for making drugs available in hospitals and health centres, is scarcely utilised in drug procurement and distribution and in fact is little known outside central units. Also, it is much too long and urgently needs revision.
Testing for quality control is not carried out on a timely basis nor is its coverage sufficient. The Government Analysis Department of GAHEF has responsibility for quality control for all drugs produced, sold and used, in both private and public sectors, but it has no equipment, no qualified staff and only two field inspectors. While some inspection is carried out through a CARICOM-supported facility in Jamaica, this arrangement is not fully satisfactory. Recently some 13 percent of drug samples from Guyana failed quality assurance tests. Worldwide, quality assurance for drugs is becoming a major concern in developing countries; the prevalence of counterfeit or substandard drugs is reaching alarming proportions.
The Pharmacy Bond is responsible for all procurement of drugs but shortages are frequent so patients have to postpone treatment or purchase drugs through the private sector, which often means through unregistered traders with weak quality controls.
There are no adequate estimates for annual drug needs, to facilitate more efficient purchases through international tendering.
The annual budget for drugs is released in tranches, rather than at once, which further inhibits the possibility of purchasing through international tendering.
Hospitals do not have adequate management controls to prevent leakages of drugs and supplies to the private market, and the low salaries of staff encourage that kind of behaviour.
There is an absence of standard treatment protocols, for drug use in treatment common diseases. This is a serious gap.
In any case, the existing national drug policy is not fully implemented and existing legislation in this field is not enforced.
There is a gross insufficiency of pharmacy staff within the public system.
Storage facilities are inadequate both at central and regional levels. In addition, part of the space that is available is taken up by expired drugs or drugs in poor condition that should be destroyed, and by unused medical equipment.
The management information system for pharmaceuticals and other supplies does not function, although PAHO has provided assistance to the Pharmacy Bond in developing a computer system for inventory control.
The distribution system from the Pharmacy Bond to the Regions is inadequate and there are logistical difficulties in distribution of drugs and supplies in the interior.
There is inadequate consumer awareness about proper use of medications.
It is evident that the national drug policy also merits a fundamental review, above all with the aim of developing a system for supply and distribution that can be effectively implemented and that corresponds more closely to the needs of the population.
7. The Health Information System
A nation's health information system is the backbone of the delivery system as it is essential for monitoring health status, and for making informed decisions about programme planning, management and resource allocation at all levels of the delivery system. The major limitations that impede the effective functioning of the health information system are: inadequate and irregular supply and collection of data from the health units in the Regions; inappropriate reporting forms and procedures, inadequate and insufficiently trained staff to manage and analyse the information in a timely manner, and lack of a system of quality control for data and feedback to the health workers who are primarily responsible for collecting the data.
The practice of using data for decision-making by senior managers in the health system is not well developed. The pattern of decision making tends to be more reliant on precedent than on analysis. There is no management information system that would assist in analysing data and applying the findings to planning and evaluate purposes. Until there is a greater appreciation of the need for data in evaluating the quality of services and the demand for them, and in formulating policies, the prospects for improvement in data collection in the field will be dim.
8. Community Participation
In the past, attempts were made to involve communities in the planning and delivery of health services primarily at the regional level in certain health areas. However, these successful initiatives suffered from a lack of nurturing and so they were not sustained on a pervasive basis. Presently, there is inadequate community involvement in the planning, implementation, and evaluation of the health services. There are no incentives for sustaining the community participation process in the health sector or to establish these mechanisms anew.
9. Issues Related to the Stages of Health Care
Primary health care is the most vital link in the chain of health care. Improvements of primary health care are the most likely to contribute to the achievement of the goal of "attainment by all people . . . of a level of health that will allow them to lead a socially and economically productive life" that was established in the 1978 International Conference on Primary Health Care. Nevertheless, in Guyana primary care has received relatively less emphasis to date than secondary and tertiary care.
a. Primary Health Care
A comprehensive programme of primary health care would emphasise health promotion, and through it the themes of disease prevention, healthy lifestyles, and community participation. Greater awareness and activity in these areas will have the most significant impact on health status in the long term. However, as noted, there is currently no primary health care division within the Ministry of Health to ensure a clear focus and emphasis on primary health care and that primary health care activities are well integrated into other programmes and adequately funded. In addition, in the past, community participation, a foundation for primary health care activities, has been quite limited and has not been actively promoted by health authorities.
In the area of nutrition, in the past activities have been the prime responsibility of GAHEF and are currently being integrated into the Ministry of Health. There is a weak inter-sectoral approach to nutrition; limited emphasis on nutrition in training programmes; lack of nutritionists trained for regional level positions; and inadequate technical and material resources for public education programmes.
As for the environmental health services, they are in poor state despite an increased recognition over the past ten years of the importance of a healthy physical environment. Veterinary care, an integral component of primary health care, also is in a weakened state.
The maternal and child health programme is the largest vertical programme of the Ministry of Health and its services include ante- and post-natal checkups, immunisation through the Expanded Programme on Immunisation (EPI), education, nutritional advice and supplementation, and family planning. It is one of the most important priorities of the health care system.
b. Secondary and Tertiary Care
The quality of secondary and tertiary care has suffered from the deficiencies of management and financing of the system noted elsewhere in this Chapter. As a result, there are no strategic plans for hospitals. Poor hospital management, shortage of staff, and poor physical infrastructure are also prevalent as well as inadequate or nonexistent diagnostic facilities and an unreliable supply of adequate safe blood for transfusions, drugs and medical equipment.
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1. Inadequacy and Paucity of Leadership and Direction at the Central and Regional Levels
A serious constraint in this sector is the general insufficiency of trained, experienced and strong leadership to chart a clear future course for the health sector, more so as there are no strategic plans for health services development in the Regions. The health system in general is characterised by a lack of accountability for decisions and for implementation measures, an insufficient delegation of managerial authority, poor attitudes toward work and low morale, and an insufficient number of managers with training in health administration and financial management. Management of procurement and inventories has not been placed on a sufficiently professional basis, and assessments of needs in each component of the system are not made on a regularized, rigorous basis. There are no mechanisms through which data on the health status of the population and the incidence of particular diseases and syndromes can be channelled into the decision-making process.
2. Human Resources and Their Planning and Management
Lack of sufficient numbers, optimally distributed, and adequately trained human resources poses perhaps one of the greatest challenges to the health sector. While this is a general problem, it poses major problems in the delivery of certain key services such as pharmacy, laboratory, radiography and environmental health, as well as in management of the system. Moreover, the shortage of nurses, which form by far the largest percentage of the work force and are the backbone of the health sector, severely hampers the ability to delivery quality care.
The development and management of human resources is still not approached in a systematic and organised fashion due to several constraints and bottlenecks that plague the system, some of which are outside the control of the Ministry. Difficulties are experienced in recruitment, retention, training, deployment and utilisation of staff. There are especially severe shortages of staff in the fields of pharmacy, radiography, laboratory technology, physiotherapy, public health nursing an environmental health. There is also a shortage of medical specialist consultant staff and other technical health professionals. The major factors contributing to the public health sector's inability to attract, recruit and retain staff within the public health system are as follows: low salaries and related employment benefits, poor working conditions, little in-service training, the lack of opportunity for career or upward mobility, poor coordination of existing training, a general shortage of adequately trained teaching staff and teaching-related materials, and the absence of a comprehensive human resources development and management plan.
As a result of these constraints, the ratio of physicians to population still unacceptably low in some Regions, especially in Regions 5, 1, 9 and 6, in order of the seriousness of the shortage.
Programmes of recruitment and training of health care personnel have not given sufficient emphasis to persons from remote areas of the country. Also, distance education methods have not been stressed to be able to amplify the coverage of programmes of in-service training.
3. Buildings and Equipment
Guyana's health infrastructure is very old. Buildings are deteriorated and are in poor condition. The condition of equipment is also poor because of age and lack of maintenance. Currently, many donor agencies are involved in the rehabilitation of hospitals and health centres by providing the required financial resources. Utilisation rates in some of these facilities are very low, especially in public hospitals, due to several factors such as the shortage of supplies, equipment, health personnel, inaccessibility resulting in a lack of credibility in the system among its clients.
There is no recent assessment of what buildings and equipment are required, and there is only limited cooperation among the public, parastatal and private providers for more efficient use of facilities.
4. Transportation Equipment
The challenges facing the ability to provide transportation and communication include: inadequate supply and maintenance of vehicles, as well as bicycles, boats, and horses required to service the interior regions; limited budgetary allocations and insufficient supply of radio equipment to serve hard to reach areas.
Boats and vehicles that exist are often in poor working condition. Difficulties are also experienced in recruiting drivers due to the low and unattractive salaries and benefits.
5. Norms and Standards for the Delivery of Health Services
Currently, only a few documented standards exist. As to application, the few that exist are seldom effectively enforced or monitored. The major constraints affecting the development and application of standards are: inadequate definition of the role and functions of the Standards Unit, a lack of trained staff in the Unit, insufficient staff in the Unit to develop, carry out, monitor and enforce technical standards. Moreover, there is poor coordination among all stakeholders in standards development and enforcement.
A further difficulty arises from a decentralised health system. What is the ideal relationship of a staff service (the Standards Unit) to line agencies (field officers and health institutions) which are structurally in a different Ministry?
6. Health Information System
Major constraints hampering the effective functioning of the health information system include: inadequate collection of data; inappropriate reporting procedures; overly-complex reporting forms; lack of sufficient interest on the part of senior decision makers; and insufficient and inadequately trained staff. Further, there is no active and organized management and supervision of data collection, medical records are often incomplete and inaccessible, and the providers of data do not recognise its usefulness.
The lack of coordination between Regional authorities and the Ministry of Health in this area is a major hindrance to its improvement.
7. Primary Health Care
Specific constraints within several primary health care areas are:
a. Health education
Health education is delivered in Guyana by the Health Education Unit as well as a variety of agencies and organisations. However, it is affected by the following constraints:
it is not fully utilised by programme managers;
health personnel are not adequately oriented or trained to be health educators;
there are limited education support materials in health facilities; and
there is inadequate emphasis on health education in schools.
There is a limited nutritional surveillance system to monitor food and nutrition status on a continuous basis, as well as insufficient emphasis on nutrition within health institutions.
c. Environmental health services
Major constraints identified in this area include: lack of coordination among environmental health agencies; lack of a strong environmental health presence in the Ministry of Health; inappropriate lines of authority for field staff; an acute shortage of environmental health officers; and outdated environmental health legislation.
d. Maternal and child health
The constraints facing this programme include: shortage of staff; limited availability of pharmaceuticals and instruments; difficulty in reaching some remote regions; lack of data analysis, no explicit family planning programme or policy; and limited family life and reproductive health education in schools.
e. Veterinary public health
In order for the veterinary public health programme to be fully effective, the following constraints must be addressed: current food legislation needs to be amended; increased training and continuing education is needed for the veterinary public health staff; and the availability of transport needs to be increased, as the veterinary public health unit is very field oriented of necessity.
8. Secondary and Tertiary Care
Some principal constraints on this area include: lack of sufficient trained personnel; lack of sufficient autonomy in decision making in the hospitals; insufficient equipment; deteriorated facilities; inadequate information for informed decision-making; inadequate community involvement in hospital management; poor staff attitudes; lack of standards; and finally, high operating costs of the new ambulatory/diagnostic/surgical centre.
9. Vertical Programmes
Vertical programmes include maternal and child health, vector control, Hansen's disease, tuberculosis, dental services, rehabilitation, drug and alcohol abuse, and AIDS. Some are performing better than others, due to clearly defined goals and objectives, better funding, accountability to donors, and better training opportunities for staff.
The following constraints face all the vertical programmes: overstretched staff at the central level; insufficient support and field staff; inadequate inter-institutional coordination in programmes such as malaria control; and inadequate support services such as supplies of reagents, drugs and equipment.
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From the foregoing discussion, it is amply evident that health problems are a major national concern and that carrying out policies for improving the health status of the population must, of necessity, figure among the principal priorities of this National Development Strategy. In the broadest sense, the policy objectives of the sector are to increase the span of healthy life for all people in Guyana and to reduce health disparities between social groups. This is to ensure that increasingly most of Guyanese can enjoy a better quality of life and to minimise the incidence of illnesses and disabilities that cause premature death.
The overall operational objectives for achieving this goal are to improve population's access to health care, or its availability, and the quality of the care offered.
The access objective refers to ensuring universal access to a defined mix of basic services emphasizing above all the essential strategies of the primary health care notion. The purpose is to make health services more available and responsive to the needs and preferences of the clientele at all levels of the delivery system. The observations in section II of this Chapter demonstrate that we are still short of achieving this objective. Improving access to health care will mark a major step toward satisfying the equity or distributional objective of this National Development Strategy.
The quality objective refers to the pervasive need to restructure several key aspects of the system, seeking fundamental improvements in all areas, so that a patients visit to any unit of the system yields greater and more immediate health benefits. As noted in section II, there is an important interaction between quality and access, so that improvements in the former will also lead to improvements in the latter.
Supporting objectives, which require inter-sectoral collaboration for their attainment, are to create a healthier environment and inculcate a healthier lifestyle in Guyanese. Achieving these supporting objectives will reduce the population's need to have recourse to the health care system itself, which in turn will reduce human suffering and free up financial resources for uses in other sectors. Cooperation toward the fulfilment of these objectives will be required from the education sector, the environmental sector, the urban development and housing sector, and the poverty alleviation programmes, among others.
In working toward the achievement of these objectives, special emphasis will be placed on ensuring the survival and healthy development of children and adolescents, and on improving the health and well-being of target-priority population groups of all ages, in particular women and Amerindian communities.
The pursuit of the overall objectives will require policy actions in the following five fundamental areas:
The institutional structure of the health system.
The management of the system.
The financial basis of the system.
The primary health care area, including health promotion.
Secondary and tertiary health care.
Specific goals for each of these areas are presented in the context of the description of the sector's basic policies in the next section. Above all, it must be borne in mind that to improve the health care system, the most fundamental requirements are: leadership and effective management, and adequate financing and appropriate use of funds.
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There has been considerable progress in improving the health care system in recent years, so the base for achieving further advances is considerably more solid than it was previously. Allocations of the Government budget to the sector have increased, real salaries of health personnel have increased, although they still are not at the required levels, and the effort at rehabilitation of health infrastructure has been initiated with substantial investments. New financing-cum-management approaches have been reviewed, and at the local level one of them is being explored via the pilot implementation of the Bamako initiative.
For specific medical programmes, the draft National Health Plan provides useful priorities and guidelines for action. It was prepared through a carefully designed consultative process, and alternatives were considered before its guidelines were developed. It provides the basis for many of the thrusts of policy presented below. For the complete development of health policy which is set out in this Chapter the Health Plan has been complemented with further policy work in the broader areas of institutional structures and health care financing.
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1. Institutional Responsibilities
It is evident that part of the inefficiency of the system, as reflected in some expenditures that do not lead to better or more health care, arises from the fragmented authority that now characterises the management of health facilities. In particular, the fact that the Ministry of Health is responsible for capital investments, for personnel, and for the overall standards of health care, while Regional governments and other Ministries have authority over the operations and maintenance of facilities,
represents a continuing source of conflicts and inconsistencies among initiatives. As mentioned earlier in this document, there have been a number of instances of equipment that is purchased but not utilised, for lack of coordination between decisions on procurement and on training or assignment of staff, or for lack of maintenance of the equipment.
The problem was stated comprehensively and succinctly in the draft National Health Plan (p. 68): "the Ministry of Health has no authority to implement policies or to set the budgets of the Regional Administrations, making efficient and equitable planning of health sector resource use on a national basis very difficult; . . . the Regional Offices . . . have only limited expertise in both the health sector generally and planning specifically; there is a lack of clarity between the central Ministry of Health and the Regional Administrations over who is responsible for what and who should report to whom; . . . the division of functions between the Ministry of Health and the Regional Administrations does not make for a coherent decentralised system . . . lines of authority do not extend systematically from the central Ministry of Health to the field, but are severed at the Regional level. . . . "
It is a universal experience, in all countries and in all sectors, that an entity cannot function efficiently if different aspects of its operations lie under the authority of different institutions. In addition, it has been noted that many of the Regional personnel do not have the required training in health administration in order to be able to discharge their responsibilities effectively.
Many of the problems that afflict the sector can be resolved by unifying the management authority for it, and the logical entity to take on that expanded responsibility would be the Ministry of Health. For this reason, one of the fundamental policy reforms that will be carried out is to restructure institutional responsibilities for health care so that the Ministry of Health becomes the sole health authority in the public sector. After preparations for the transition have been completed, the Ministry of Health will, in the very short term, take on responsibility for operating and maintaining all public hospitals and other health facilities that now are under the aegis of Regional Administrations and the Ministry of Labour. Funding now channelled through the Ministry of Labour for this purpose, and given directly by the Ministry of Finance to the Regional Administrations, will be reallocated to the Ministry of Health. A management system will be established under which the Regional Health Officers report directly to an appropriate officer in the central units of the Ministry of Health, and they will be trained in health administration. The Ministry will carry out a programme of assessments of needs in all facilities and develop strengthened systems for in-service training of personnel and for inventory management of supplies. (See below for other management reforms.)
For the time being the hospitals operated by parastatal agencies will remain under their authority, for they have been operated to a high standard. As the quality of the national health system improves, and the parastatals focus increasingly on their own economic needs to remain competitive in production for export (see Chapters 32 and 33), a transfer of their hospitals to the national public system will be designed for implementation by the year 2005.
Within the restructured system, a division of primary health care will be established in the Ministry of Health, structured in a way so that it works in close cooperation with the Regional units, where most of the primary care is provided.
2. Operational Autonomy and Community Participation
Although regional officials no longer will have direct line authority for the operation of health facilities, they will participate via other mechanisms. For hospitals to operate effectively, they would require greater autonomy in day-to-day decisions. Accordingly, while the Ministry of Health will retain overall responsibility for the proper functioning of the health care system, and must approve all capital expenditures greater than a specified level, day-to-day operational decisions in all public hospitals in the country will be taken by the hospitals' managers, subject to the annual operating budgets provided by the Ministry. Hospital management also will be empowered to raise funds via other mechanisms (see below) and utilise them for their operations. This autonomous status will be confirmed in new legislation.
It is a rule of good management that operating decisions must be taken at the level of the operational entity, and this includes decisions on procurement of supplies, hiring and assignment of personnel and, within specified limits, provision of incentive allowances to staff. The Ministry of Health will approve annual staff training plans, but they will be drawn up at the level of individual hospitals (national, regional, and district). Similarly, the Ministry of Health will be responsible for undertaking annual needs assessments, but the management of each facility will participate in them and will have the option of writing a separate opinion to the Minister of Health.
The autonomous facilities will be supervised by non-profit Boards of Directors. As a first approximation to the composition of these Boards, each Board may contain one member appointed by each of the following entities:
The corresponding Regional Democratic Council
The Minister of Health
The Minister of Finance
The Minister of Public Works, Communications and Regional Development
The communities of the Region or District (acting in concert): 2 representatives
The principal employers of the Region or District (acting in concert)
The national health NGOs (acting in concert)
In the case of the Georgetown Public Hospital, the City Government will act as the community in appointing a Board member.
In all cases, the appointee of the Minister of Health will function as Chairman of the Board. The Ministry of Health would develop guidelines for the mechanisms through which the employers and NGOs may exercise their joint decisions in nominating members of the Boards.
The case of the Board members representing the local communities is rather special and merits separate treatment. In many kinds of public services, from agricultural research to education to health, it has been found useful to have a kind of community advisory-cum-supervisory board that helps define the expectations of the community, helps evaluate the extent to which the service meets those expectations, recommends continuing improvements in the way the service is provided, and assists in some maintenance or rehabilitation efforts for the facilities. In addition, these community entities often help raise funds for the service, and thus they become, in effect, partial "owners" of the service and accordingly acquire a deeper stake in its performance. This kind of local involvement is exceedingly salutary. It should be promoted for all the public hospitals by encouraging the formation of Community Hospital Associations affiliated with each of those facilities, much in the manner of parent-teacher associations. Those associations will meet regularly to review the plans, budgets and progress of the facility and to discuss operational and planning issues that have arisen. In each case, two of their members (selected on a rotating basis) will serve on the Board of Directors of the institution. The associations should be encouraged to raise funds locally for special programmes and equipment for the facilities. These associations will be one of the keys to better functioning of the health facilities in the country, and through them greater autonomy for the facilities will come to signify greater participation on the part of the communities. This is a concrete example of how the participatory thrust of this National Development Strategy can make significant contributions to the well-being of the citizenry.
After five years the experience of the Community Hospital Associations with the public hospitals should be reviewed to determine whether the model would be extended to health centres and health posts.
For each hospital facility, the primary roles of the Board of Directors include approving annual operating plans and requests for capital expenditures developed by the management of the facilities, and also reviewing and approving the needs assessments and training plans for staff. Another important role will be to raise supplementary funding equipment and other special needs indicated in the annual operating plan. (Funding options are reviewed further below.)
Conceived in this manner, the Boards will be integral elements for ensuring the requisite level of operational autonomy for hospitals and for involving the community more intimately in the planning and operation of those facilities.
This format will apply to National, Regional and District-level medical facilities. The situation of health centres and posts will be reviewed to provide them with as much operational autonomy as possible, subject to closer supervision by a district health officer, appointed by the Ministry of Health, than would be the case for hospitals.
3. The Geographical and Hierarchical Structure of the Health Care System
From the discussion in earlier sections of this Chapter, it is abundantly evident that the five-tiered referral system is not working as planned. One of the principal symptoms is the strong tendency for patients who can afford the travel to by-pass lower levels in the system, even though the nature their ailments may not always warrant doing so. Another symptom is the underutilisation of many of the facilities in place, particularly at the District level. An unfortunate consequence of the situation is inequity in the health care offered to different income groups. Statistical information cited above shows that the poorer families use health centres and posts in greater proportion, whereas better-off families have a much greater tendency to go directly to higher levels where they can receive more complete diagnosis and treatment. Another consequence is excessive strain on the facilities at the higher levels.
Clearly the lower levels of the system need to be strengthened over time, and this has been recognised. There will always be a need for localised medical services, and they should be made as good as possible. Nevertheless, it is important to ask the question whether the five-tiered structure is the most appropriate for Guyana's needs. Doubts emerge in that regard because it is likely that for many years, if not decades, there will be a perception, and perhaps a reality, of better care at the higher levels in the system. Hence the inherent inequity in medical care that has been remarked upon is likely to persist.
The observed underutilisation of most of the geographically dispersed facilities provides the clue that perhaps not all of them are needed, and that the funds might be better spent in equipping special aircraft and boats -air and water ambulances- and ensuring that radio communications networks are available in all localities, so that patients can be brought into Regional facilities, and a few selected District facilities. In addition, the programmes of rotating visits to remote facilities by physicians should be strengthened, so that villagers would know in advance that a doctor would be in the nearest health centre on specified days of the month. By closing some hospitals that are marginally used, funds could be made available to upgrade others as well as provide the flotilla of ambulances mentioned and finance an expansion of the programme of rotating visits. This is a prime illustration of how the existing financing available for the public health system could be used more effectively to enhance the functioning of the entire system.
It should be emphasised that the health posts are vital for the tasks of medical education, preventive care and arranging for medical transport to other facilities when it is needed, so they should be maintained and improved. The same reasoning applies to most of the health centres, for in addition they carry out rehabilitative care functions, but a careful review may indicate that a small number of them, especially those in coastal areas, could be closed in favour of strengthening selected District hospitals and placing more health posts in remote areas. It is the District hospitals whose role requires the most searching examination. Is it preferable to have eighteen District hospitals (in addition to Regional and National facilities), many of which have inoperative equipment and underutilised beds, or a lesser number in much improved conditions, accompanied by air and water ambulances? In which way will the rural patient ultimately receive better medical attention?
To answer this question requires a detailed review of all District facilities, so exact prescriptions cannot be set out in this Strategy, but it will be important to undertake such a review with a view to looking for opportunities to increase the effectiveness of the entire system in the manner indicated.
4. Health Management Policies
As a leader in the health sector, the Ministry will provide a national vision of the way forward and develop the ability to inspire the actors in the health sector responsible for delivering services. It must provide leadership in the areas of allocation of resources and innovation, and in the introduction of new methods.
Leaders that take overall responsibility for charting the future course of the health sector are required. The aims are to develop a shared vision among senior managers (public and private sectors) in relation to the future direction and destination of the health sector, a shared responsibility for achieving that vision, and to improve the leadership capacities of staff in senior positions through training and staff development. The style of leadership should be that of empowering and supporting other health sector stakeholders.
As stated in the Health Plan (p. 68), to achieve these aims for management of the sector the "culture of decision-making" needs to be reformed. In the words of the Plan, "Authority for decision-making in the public sector is centralised and is not delegated to the most appropriate decision-making level. Senior managers spend too much time on routine administrative tasks which could be dealt with at much lower levels. Many managers lack the clear authority to make decisions regarding their programmes and departments. . . . Decision-making [is] rarely based on data: Some data [do] exist but [are] rarely used as a basis for decision-making. Policy-makers and managers have become accustomed to making decisions on an ad hoc basis with insufficient information."
In addition to reforming management structures and procedures, salaries in the sector urgently need to be increased in real terms and better management training and tools need to be provided to administrators. Special attention should be paid to the need to place well-qualified medical personnel in the hinterland facilities.
To achieve these aims, and building on the indications in the Health Plan (pp. 125-28), a programme for implementing the following specific management policies for the public health sector will be embarked upon with a sense of urgency:
Develop workplans that delegate responsibility for decisions and tasks to the lowest level that can effectively handle them.
Require that all personnel in key management positions, e.g., programme managers, hospital administrators, district-level health officers, medical superintendents, and public health nurse supervisors, have received adequate training in health administration. Provide paid leaves of absence for the acquisition of the requisite training.
Develop new formats for the annual budgeting process which are based on the principles of programme budgeting, with annual objectives and expected annual outputs and a demonstration of how the levels of funding and effort will contribute to their achievement.
In addition, a policy of cost containment, efficiency, and effectiveness in the delivery of the services will be pursued.
Provide a greater degree of financial autonomy at the various departmental levels in the Ministry of Health, with the corresponding controls and monitoring mechanisms.
Develop guidelines for managers that require them to base strategic decisions on objective and relevant data.
Develop a comprehensive management information system that coverages all health care units and is applied to evaluating programmes and progress, monitoring performance, and planning improvements in the system.
Develop a programme for delinking the salary structures for health personnel from those of the public service or, in the absence of such a measure, developing a set of special categories for health personnel within the structure of the public service. It needs to be underscored that further improvement in salary conditions is a sine qua non for improving the quality of health care in the public sector.
Develop performance review procedures, grievance procedures and disciplinary measures which ensure that lines of authority are respected and used, and that by the same token adequate consideration is given to recommendations made by staff at all levels.
Institute mechanisms to ensure that progress of individuals, organisational units and programmes can be evaluated by --
clearly defining their respective roles at all levels, including job descriptions for all positions;
in consultation with staff, establishing objectives and related work programmes against which performance can be measured;
developing and implementing clear reporting relationships, supervision based on established guidelines, regular performance evaluation, and regular staff meetings.
These steps will also serve to enhance accountability within the system.
In the job descriptions emphasise flexibility, so that when a nurse is absent it does not become impossible to give immunisations even though a physician is present, and that qualified doctors are required to work X-ray machines when an X-ray technician is absent, rather than sending a patient to a higher-level facility, with the consequence cost in time and money.
Base promotions on performance rather than seniority.
Define a career structure for health workers, whose retention in the system has proven to be very difficult.
Provide supervisors with the authority to effectively discipline staff when work is unsatisfactory by ensuring that responsibility is matched with corresponding authority.
Develop and implement a supervision system in which supervisors at all levels institute minimum standards of performance and work to ensure that these are met.
Institute measures, including salary incentives, to recognise and reward initiative and superior performance, and to sanction laziness and poor performance.
Institute daily time-recording systems for medical personnel in hospitals and link incentives to the degree of presence in the facilities.
The shortage of qualified physicians and nurses is one of the most critical weaknesses of the public health care system today, especially in light of the burgeoning private medical practice. This shortage is especially acute in the hinterland areas. In this area the close collaboration of the public and private sectors will be critical to achieving a solution. Therefore, the following new policy will be implemented with respect to medical personnel in the private sector: As a condition of maintaining their licences to practice in Guyana, each doctor and nurse will be required to devote one month out of each 24 to 30 months (depending on the field of specialisation) to serving in residence in a health facility located outside Georgetown, as designated by the Ministry of Health. At least one in every two such "tours of duty" will take place in Region 1, 2, 6, 7, 8 or 9. Alternatively, they may participate for a month in the programme of rotating visits to remote health centres. The requirement will be fulfilled upon completing ten such tours of duty or reaching age 60, whichever comes first.
This will be a permanent form of national service in a critical field for the nation. While some medical personnel may resist the idea at first, the enriching experience in the field can be expected to convince many of the value of the service and to help them come to know more intimately their country.
For the management of programmes and facilities, the following policies will be put into effect:
Ensure that all facilities and programmes have clear and feasible goals, on a rolling five-year basis, by developing strategic plans for each of them. Develop annual operating plans within the framework of these five-year plans, including targets to be attained, projected current and capital expenditures, rehabilitation and maintenance plans and personnel requirements and responsibilities. Require that all such plans demonstrate how volunteers and community groups will be utilised.
Develop mechanisms to continuously monitor and evaluate progress in the implementation of policies and the operation of all programmes and facilities in the health service.
Organise all records of visits to health facilities by patient, so that a given patient does not have different records for visits arising from different ailments.
Develop a master plan for the rehabilitation and construction of facilities, including the acquisition and maintenance of an improved fleet of air and river ambulances.
In addition to the measures cited above, the following policies will be implemented in the area of developing and managing human resources:
Develop and implement a manpower plan for the health sector that specifies positive steps for overcoming the shortage of certain kinds of specialist personnel, such as pharmacists, dentists, radiographers and X-ray technicians, and also points the way to a general upgrading and improvement of the staffing.
Within the general framework of the manpower plan, specifically develop and implement a nursing action plan that addresses key issues such as salary levels, working conditions, organisation of the service, management and models for patient care. Nurses are poorly paid, have poor working conditions and receive little recognition, so it is not surprising that many of them migrate to other countries.
Develop and implement pre- and in-service recruitment and training plans to meet the manpower needs of the health system. At present there is no linkage between the needs of the sector and the structure of the training programmes.
Train management personnel in the Ministry of Health and all hospital managers in working with the Community Hospital Associations.
Ensure that physicians all have training regarding the role of medex (medical extension) personnel and primary health care. Provide this training on an in-service basis when it is not otherwise available.
Update standards and treatment protocols, to bring them abreast of current medical practices and the changing epidemiological profile of Guyana, and develop a system of monitoring the quality of treatment based on those standards and protocols. Strengthen the Ministry's Standards Unit for this purpose.
In the field of educating and training health professionals, evaluate existing curricula and course requirements for their appropriateness and update them, and require collaboration on the development of curriculums between GAHEF, the University of Guyana, and the Ministry of Health, in order to ensure their mutual consistency and relevance to the sector's needs.
Develop and maintain a comprehensive human resources data base with up-to-date information on the location of staff and their qualifications.
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1. General Orientations
The two fundamental points of departure in a review of financing options are that: i) it is urgent to mobilise more funding for health care, and ii) no one should be denied access to basic medical care because of lack of ability to pay. Sometimes it is felt that these two orientations are in conflict with each other, and that the adoption of one point of view necessarily means negating the other. In this section of the chapter, it is shown that they can indeed be compatible, and that realistic possibilities exist for fulfilling both conditions.
Another highly relevant facts are the following:
On average, patients in Guyana do pay for health care. Obviously they pay when using facilities and services of the private sector, through their insurance premiums in some cases, and through their contribution of taxes to the public budget, but they also pay for health services provided by the public sector i) by being obliged to procure their own medicines and supplies, ii) by incurring transport costs and suffering temporary loss of wages during treatment, iii) by spending time waiting for service, and iv) sometimes by undergoing unnecessarily repetitive visits and examinations, owing to the lack of coordination within the regional referral system discussed previously.
It is undeniable that some families who have the means to pay a greater share of the costs of medical services are receiving those services at highly subsidised rates. Therefore the large subsidy to the citizenry that is inherent in health care is not well targeted on the needy.
In reality, the public hospitals are subsidising private hospitals and clinics in three ways: i) because of the practice on the part of some patients of electing to undergo surgery in a private facility and then using the (much cheaper) public facility as a recovery ward; ii) because medical personnel who are supposed to be on duty in public facilities sometimes in fact use part of that time to engage in private practice; and iii) because supplies and drugs tend to leak out of public facilities into the private sector.
The Georgetown Public Hospital recovers through fees less than one-tenth of one percent of the cost of providing its services,(9) and it is not likely that other public facilities recover a higher share.
In addition, it should be underscored that patients often pay indirectly by receiving an inferior quality of health care, and by suffering environmentally-based diseases that could be controlled with improved preventive programmes. Additional financial resources properly spent on the health system --both for prevention and for treatment-- could alleviate this unfair burden on the population. Furthermore, it is a burden that falls disproportionately on the poor.
The growing emergence of a private health care sector represents a spontaneous response to the extended crisis of the public health care system. While it meets part of the medical needs of some segments of the population, it is not a complete answer for the population as a whole. It is a positive development in two important senses: i) it provides care of an improved quality to some citizens, and ii) it reduces the demand for services from the public sector, thereby permitting the resources of the latter to respond better to the patients that it retains. However, its very presence raises the issue of equity in access to medical care and is a tocsin insistently reminding one and all of the urgency of improving the public system.
These facts all point in the following directions: i) that there are possibilities for a partial recovery of costs through selective payments by patients, without prejudicing their access to health care, and ii) that the existing public funding of the health care system could be more effectively targeted on families of marginal economic means. Another important conclusion, amply illustrated in the earlier analysis in this chapter, is that there is considerable scope for improving the efficiency of the existing levels of budgetary resources in the sector. If priority in making such improvements were assigned to controlling vector-borne diseases and elevating the quality of the system of primary health care, the poorest families would benefit the most.
On the basis of the Government's continuing review of these and other issues of health care financing, complemented by studies of specialised researchers, the following policy guidelines are established in regard to the financing of the health sector:
a) The Central Government's budget will continue to be the principal source of funding for the public system of health care. Following the trends of recent years, that funding will continue to increase in real terms. Targets adopted for this purpose are that public health expenditure should reach 7.5 percent of GDP in the year 2000 and 10 percent in 2005.
b) No patient shall be refused service because of inability to pay any fee that is established. Every public health facility will have a Committee on Targeted Assistance to determine cases of both indigence and insufficient means in light of the cost of the treatment. Over time, a record-keeping system will be coordinated with SIMAP for this purpose. (See also Chapter 23 regarding the relevance of this system for determining eligibility for specified housing benefits.)
c) The extensive reforms described in this chapter with regard to institutional structures and management and related issues will be implemented to make expenditures on health care more effective in achieving the primary objective of better health for the population.
d) Community participation will be sought for mobilising funding to complement the public budget, through wider application of the Bamako initiative and, specifically in the case of hospitals in the public system, through the Community Hospital Associations described previously. Along with financial contributions, this approach will enable the communities to have a greater role in planning improvements in their local facilities and in monitoring the quality of their services.
e) A system of selective fees for public medical services will be implemented, always making the above-noted exceptions for those who are unable to pay. In the succeeding section a preliminary list of such fees is set out.
f) Diagnosis and treatment of tuberculosis, malaria, sexually transmitted diseases and the provision of maternal and child care will continue to be entirely subsidised, in light of health care priorities and in the interest of public health. Similarly, immunisations will continue to be provided free of charge at private facilities.
g) Hospitals and other facilities collecting fees will be allowed to retain a specified percentage of them to assist in meeting their operating expenses.
h) Hospitals' accounting procedures will be reformed on an urgent basis, so that all classes for fees are recorded in a central budgeting and accounting unit.
i) An extensive review of NIS and a corresponding reform programme will be developed, to improve its actuarial basis and strengthen its performance as a provider of health insurance.
j) The new structure of fees will be reimbursable by both NIS and private insurance schemes. Patients who are covered by private insurance policies will not be allowed to have recourse to NIS for expenses incurred in public health facilities.
k) The formation of private health-maintenance organisations will be encouraged.
l) Strict controls will be instituted on the time spent at post by medical personnel in the public system. Improved incentives will be offered, and by the same token pay will be withheld for missed time.
2. The System of Selective Fees
The final decision on the nature of fee structures will be made, within a very short time horizon, by a special Committee on Health Financing convened by the Minister of Health. The goals of the fee structure will be to recover 5 percent of facilities' operating costs in 1998, 10 percent by 2000, and 20 percent by 2002, thus permitting the additional expenditures that will contribute significantly to an improvement of the health care system.
A mixture of the following classes of fees will be used, all of which have been successfully implemented in at least one developing country. It bears repeating once again that those who truly are unable to pay will not be required to do so.
a) A modest registration fee can be introduced for all hospitals, lowest at the district level and highest at the Georgetown Public Hospital. This fee will be applied to both inpatients and outpatients, and it will be higher for the latter.
b) In addition to the registration fee, a bypass fee should be charged for all patients who completely bypass the lower-level facilities when seeking care that could have been provided by them.
c) The charges for private wards in the Georgetown Public Hospital should be increased substantially.
d) Private doctors could be allowed to use equipment in public hospitals on payment of a fee, subject to scheduling their use so that priority is given to the facilities' own physicians. (This measure also would help ensure more optimal utilisation of equipment and facilities.)
e) Patients admitted to public hospitals while under the care of private physicians should be subject to extra charges.
f) Fees set at part of costs can be levied for all laboratory procedures and for medications and bandages.
g) Partial fees can be charged for services of medical personnel and facility overheads for curative care but no such charges will be made for preventive care. This will encourage the population to give greater emphasis to seeking adequate preventive care.
h) Fees should be levied for dental care.
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It is clear that improvement of the availability of pharmaceuticals and medical supplies is one of the most urgent questions in the sector. In spite of various studies and extensive review at policy levels over the years, it remains a principal bottleneck to the provision of medical care of higher quality. The fundamental problem appears to be the role in which the Ministry of Health has been cast by previous policies. Its institutional strengths lie in the area of ensuring quality control, developing protocols for the use of drugs in treatments, implementing investments in improved facilities for storage of medicines at hospitals and clinics, carrying out educational programmes on the use of medication, and updating regulations and the essential drugs list. It does not have strengths in direct procurement and distribution, but these latter responsibilities have been emphasised rather than the former.
Therefore the following fundamental reform measures, which should deliver a quantum leap in the timeliness and availability of drugs are supplies, are adopted as part of the basic health sector policy:
a) Procurement of all pharmaceuticals and supplies for the public sector will be contracted out on the basis of three-year agreements, with a performance evaluation to be carried out in the final year of each contract. Each period's contract will be awarded on the basis of public bidding. The contractor will be required to carry out an assessment of needs for pharmaceuticals and supplies in the entire system, to procure them, to deliver them in required quantities to facilities in all regions of the country, and to assure their quality and their safe storage prior to delivery to the purchaser.
b) The budgets of all facilities will be adjusted to allow for them to make their own purchases of drugs and supplies from the contractor, and to negotiate prices taking into account transport costs.
c) Private physicians and facilities may make their own arrangements for the purchase of drugs and supplies, or purchase them from the contractor. However, when performance is evaluated the contractor will be judged primarily on meeting the needs of public facilities for these supplies, so any sales to the private sector should be anticipated in planning for each year's purchases from international sources.
d) The quality control function of the Government Analysis Department of GAHEF will be substantially strengthened, and donor assistance will be sought for that purpose.
e) The list of essential drugs will be updated and considerably shortened.
f) Investments will be made in improved storage facilities for pharmaceuticals in public hospitals, health centres and health posts. Donor assistance will be sought in this area as well.
g) The Ministry of Health will launch a campaign of public education on the proper use of medications, through schools and non-formal educational channels such as radio programmes.
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The community is an important resource that, to date in the health sector, has remained largely untapped and underutilised in the planning, implementation and evaluation of health programmes and projects. The experience of many countries has shown that greater community involvement is one of the keys to providing more effective health care.
The policy objective in this area is to ensure maximum community participation in health actions. The strategy is to empower the community to take responsibility for their own health by measures that include:
The formation of the Community Hospital Associations mentioned above, along with their active participation in the Boards of Directors of the hospitals.
The development by the Ministry of Health of a draft plan for community involvement in primary health care and the carrying out of consultations in all Regions for the purpose of soliciting comments on the draft and refining it. It then will be implemented fully. The consultations also will serve to better identify the communities' existing perceptions and understanding of health-related issues, so that health programmes can address them in an appropriate manner.
The development of a programme for sharing existing health information with the communities on an ongoing basis, and for meaningfully involving them to assist in finding solutions and also in planning and decision making for facilities and topics in health care outside the hospitals themselves.
The provision of training for health staff and individuals from the community in strategies for community and social participation.
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1. Primary Health Care
A well-designed primary health care service operated by a full complement of well-rewarded staff is the key to real improvement in the nation's health services. The policy objective is to ensure greater emphasis on primary health care activities and their coordination, utilising the strategy of health promotion, education, and the empowerment of the individual to take responsibility for his or her health. The primary health care philosophy adopts the holistic approach that encompasses a full range of services, including those that are preventive, curative, supportive and rehabilitative, and that utilises approaches which are founded on a thorough understanding of the broad determinants of health. It also incorporates services delivered at all levels of the health care system, including those at the secondary and tertiary care levels.
In the provision of these services, the following broad policy objectives will be pursued, in addition to the aforementioned emphasis on community involvement, drawing for the most part on the draft National Health Plan:
a) As noted above, the institutional structure for the provision of primary health care will be reorganised so that a single unit in the Ministry of Health has broad responsibility for this area.
b) Emphasis will be placed on improved delivery of primary health care in the hinterland areas.
c) Within population groups, priority will be given to children and adolescents and to pregnant and lactating women.
d) In disease control programmes, priority will be given to malaria, sexually-transmitted diseases, acute respiratory infections, immunisable diseases and perinatal problems. Close second priorities include malnutrition and diarrhoeal disease and the problems of maternal mortality. Improved primary health care will help greatly in reducing the incidence of all these syndromes. The already-strong immunisation programmes will be strengthened further and their coverage expanded.
e) Steps will be taken to ensure full integration of health education into the organisational structure of the Ministry of Health and to guarantee that health education is an integral part of day-to-day health services given to patients and the community. Special training will be given to managers and decision-makers in the health system regarding the importance of health education, and the curricula of schools will be reviewed to ensure that health education forms an integral part of them.
f) Through GAHEF nutritional surveillance and education will be strengthened. Improved nutritional care also will be sought in hospitals, through recruitment of dieticians and provision of diet counselling. Materials on nutrition and healthy lifestyles will be incorporated into health education programmes. Monitoring of the nutritional status of the population, especially the most vulnerable groups, will be carried out on a regular basis.
g) Greater priority will be given to questions of environmental health in the programmes of the Ministry of Health. The environmental health services of the Regions and the Ministry will be restructured to make them more effective and better coordinated. An environmental health information system will be developed to support programme planning, monitoring and evaluation in this area. The number of Environmental Health Officers will be increased, and training programmes on environmental health will be updated and improved. The Ministry of Health will review the pending environmental legislation and participate in the drafting of its regulations in regard to environmental health. The environmental health education programme will deal not only with issues such as contamination of food and water, vector control, and the role of diet, but also the need for behavioural change aimed at reducing traffic accident deaths and injuries, occupational accidents, other causes of violent injury and death.
h) A special action programme will be formulated and carried out as an urgent national priority. It will include measures to treat all the population in affected areas, widespread dissemination of impregnated mosquito nets, strengthening and enforcement of the regulations regarding standing water, coordination with city and local governments on improved programmes of drainage and spraying, and use of quarantine provisions as required. This programme will require substantially more resources than are presently allocated to this area and full inter-institutional coordination, including with the Regional and local governments, the school systems, water management authorities, immigration officials, and the GDF.
2. Secondary and Tertiary Health Care
Secondary and tertiary health care should benefit very substantially from the new policies outline above regarding the administration of Regional and district facilities, the greater autonomy for hospitals, the commitment to increased financing, the greater involvement of the communities, the extensive reforms in management practices, the bypass fees and other fees, the obligatory dedication of time to hinterland facilities on the part of private physicians, the emphasis on improving mobile medical units, the new modalities of supplying pharmaceuticals and other inputs, and other policy reforms.
To this it is only necessary to add that links with international and national NGOs should continue to be strengthened for securing participation in the visits to the hinterland of specialist doctors from abroad, for they have proven to be very valuable; and strong emphasis will be placed on ensuring that all facilities are staffed up to specifications and that essential supplies are always on hand, including safe blood supplies for transfusions.
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In general, health legislation is either nonexistent or outdated in some critical areas and thus, ineffective. In addition, the absence of legislation affects standards and norms with respect to the monitoring of health situations and activities.
The strategy action is to review, update and develop appropriate legal instruments to support the implementation of health policy and priority health issues. This exercise will be carried out in collaboration with other stakeholders in the health sector. It will be essential to draft new legislation to reform and strengthen the institutional aspects of the sector, following the policy guidelines in section V.1 of this Chapter; lay the juridical basis for greater autonomy on the part of hospitals and for the Community Hospital Associations; make the geographical referral system more flexible so that the necessary changes in the five-tiered structure can be made, as indicated; open the way for the selective fees; legislate the obligatory tours in Regional and local facilities for private physicians; carry out the sector's management reforms; make the indicated changes in the way that pharmaceuticals and supplies are procured and distributed; and in general pave the way for the implementation of the national health policies. In addition, specific legislation that requires updating includes the Food and Drugs Act, the Public Health Act, Mental Health Act, Hospital Administration Act, and special legislation related to HIV/AIDS to be drafted.
1. The source of these data is the Bureau of Statistics for Guyana and the UNDP's Human Development Indicators for other countries.
2. Inter-American Development Bank, Building Consensus for Social and Economic Reconstruction, Report of the IDB Pilot Mission on Socio-Economic Reform in the Cooperative Republic of Guyana, December, 1994.
3. Source: Staff of the Social Science Faculty, St. Augustine Campus, University of the West Indies, Trinidad and Tobago, "Report on Reform of the Health Sector and Monitoring of the Sectoral Reform Processes in Guyana," report prepared for the IDB and PAHO, 1995.
4. These data and other material in this Chapter are drawn from the Draft National Health Plan of Guyana, 1995-2000, produced by the Ministry of Health in collaboration with public and private health service providers and managers, Georgetown, November, 1994.
5. In 1990, women below the age of 20 accounted for 30 percent of all births.
6. In 1995, the Medical Termination of Pregnancy Bill was passed and is expected to reduce the incidence of unsafe abortions and the number of medical terminations, through provision of counselling.
7. BCG is the vaccine for tuberculosis.
8. However, with the improvement of the technology of delivery of health care over the years, some of these vacant posts may have become redundant since they were first created.
9. Thomas D. Murray, "Guyana Health Sector Analysis and Action Plans for Health Care Financing," June, 1993, p. 35.