19.I.1.1 One of the most unfortunate consequences of Guyana’s economic decline in the 1970s and 1980s was that it led to very poor health conditions for a large part of the population.

19.I.1.2 Compared to other neighbouring countries, Guyana ranks poorly in regard to basic health indicators. In 1998, life expectancy at birth was estimated at 66.0 for Guyana, 71.6 for Suriname, 72.9 for Venezuela; 73.8 for Trinidad and Tobago, 74.7 for Jamaica, and 76.5 for Barbados. In Guyana, the infant mortality rate in 1998 was 24.2, in Barbados 14.9; in Trinidad and Tobago 16.2; in Venezuela 22; in Jamaica 24.5; and in Suriname 25.1.

19.I.1.3 Maternal mortality rates in Guyana are also relatively high, being estimate at 124.6 for 1998. Comparable figures for other Caribbean countries are 50 for Barbados, 75 for Trinidad and 100 for Jamaica.

19.I.1.4 It must be emphasized, however, that although Guyana’s health profile still suffers in comparison with most of the Caribbean, there has been remarkable progress between 1988 and 1998

19.I.1.5 In Guyana the leading causes of mortality for children under the age of one are: certain conditions originating in the prenatal period (46.9%); intestinal infectious diseases (15.6%); congenital anomalies (10.4%); diseases of the respiratory system (6.7%); nutritional deficiencies 5.8%); bacterial diseases (4.0%); diseases of the blood and the blood-forming organs (2.0%); endocrine and metabolic disease immunity disorders (1.8%); accidents (1.6%); and diseases of the Nervous System (1.1%).

19.I.1.6 The leading causes of mortality for all age groups are cerebrovascular diseases (11.6%); ischemic heart disease (9.9%); immunity disorders (7.1%); diseases of the respiratory system (6.8%); diseases of pulmonary circulation and other forms of heart disease (6.6%); endocrine and metabolic diseases (5.5%); diseases of other parts of the Digestive System (5.2%); violence (5.1%); certain condition originating in the prenatal period (4.3%); and hypertensive diseases (3.9%).

19.I.1.7 The picture in regard to morbidity patterns differs. The ten leading causes of morbidity for all age groups are, in decreasing order: malaria; acute respiratory infections; symptoms, signs and ill defined or unknown conditions; hypertension; accident and injuries; acute diarrhoeal disease; diabetes mellitus; worm infestation; rheumatic arthritis; and mental and nervous disorders.

19.I.1.8 This morbidity profile indicates that it can be improved substantially through enhanced 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.

19.I.1.9 Poor environmental health is in part responsible for the seriousness of vector borne diseases, including malaria, filaria and dengue fever. Malaria is endemic and represents the major cause of morbidity in Regions 1, 7, 8, which are also among the poorest areas of Guyana. Filaria is endemic along the coastal strips, and dengue fever is prevalent especially also in the coastal area. In general, diseases spread by vectors and those associated with environmental problems show the most rapid rates of increase.

19.I.1.10 The high incidence of dental caries can be addressed through preventive and conservation care, including oral education. This incidence is influenced by the lack of qualified dentists. Moreover, public interventions have been confined to emergency care, especially to extractions, the state providing little or no curative and conservation treatments.

19.I.1.11 Although cancer is becoming an increasingly serious health issue for Guyanese, there is no system of diagnosis. This, of course, impedes a sensible appreciation of the magnitude of the problem. However, the incidence of cervical cancer appears to be rising among the female population, even though its impact could be reduced by preventive actions such as early detection. Smear tests are taken in Georgetown, Linden, and New Amsterdam. Most of the women whose test was positive could have reduced the severity of their condition through earlier detection and cure. At present there is no oncologist in Guyana, and the assessment of the urgency of each cancer case is very often not accurate. A Cancer Board, which is in the process of drafting a national cancer programme, was established in September 1998.

19.I.1.12 There are significant differences in the incidence and patterns of morbidity by Region. This is due in part to the geographical isolation of some communities and the attendant difficulties of delivering equipment and services to them, and in part to the fact that the deterioration of health infrastructure mainly affected the most remote communities. The Regions with the lowest overall morbidity rates are Regions 3, 4, 6 and 10. However, the reliability and completeness of the data are not uniform across regions, and are especially poor in areas where there are no health clinics, or where clinics are poorly staffed and statistics poorly reported. Hinterland areas are often the least accessible both by river and by air, and suffer from a lack of basic infrastructure and facilities, such as electricity and potable water, which makes the delivery of certain services a difficult task.

19.I.1.13 While malaria is mainly responsible for the high rates of morbidity in the hinterland, food accessibility and availability vary across regions. Moreover, the nature of the most pressing health concerns varies by population group. An analysis of disease patterns and other socio-economic variables has revealed particular groups and areas of vulnerability, namely: 1) women’s health; 2) children’s health; 3) people affected by STDs/AIDS; 4) people affected by mental health problems and drug abuse; 5) disabled people; 6) elderly people; and 7) the Amerindians.

19.I.1.14 The incidence of HIV/AIDS has grown almost exponentially in recent years. Indeed, the impact of this ailment could have extremely serious and deleterious effects on the individual, on the population as a whole, on the development of the economy, and on the social stability of the nation. Indeed, it is estimated that if the present trend is not reversed, life expectancy in Guyana could be reduced to 52 years by as early as 2010, and that 50% of the AIDS cases would be concentrated in the 10 to 24 age group.

19.I.1.15 Amerindians represent one of the most vulnerable groups to health issues. Their conditions are particularly difficult in respect of malaria, acute respiratory diseases^, water borne diseases, nutritional deficiencies, and access to health care.

19.I.2.1 Air pollution is mainly derived from the blowing of bauxite dust and the spraying of pesticides in the canefields, however their effects have not been investigated thoroughly.

19.I.2.2 Bacteriological contamination of water continues to occur in the distribution system and often surface water is used without treatment or disinfecting facilities. Moreover the high concentration of soluble organic matter encourages the rapid growth of bacteria.

19.I.2.3 Basic sanitation is poor. Sanitary conditions are dismal in squatter areas, many of which have no hygienic means of waste disposal. New housing schemes, factories, commercial institutions and industries have been developed without complying with the existing land development laws. In fact, individual septic tanks and pit latrines are often the only means of sewage disposal and are frequently not constructed at the recommended distance from the water supply.

19.I.2.4 The current housing stock is inadequate. Overcrowding in buildings is therefore common. This encourages the transmission of obstructive pulmonary and other communicable diseases. Furthermore, the lack of housing has encouraged the expansion of squatting areas.

19.I.2.5 In the work environment several health risks are prevalent. Most injuries occur in agricultural occupations, followed by the manufacturing and mining sectors. In the agricultural sector, the main risks to health are also derived from the use of pesticides. Moreover, workers in the rice and sugar industries have been recorded as sufferiing from silicosis and bagassosis. Silicosis, dermatitis, hearing loss, heat stress and diseases related to the absence of proper ventilation affect workers in the mining industry.

19.I.2.6 In the home, domestic violence represents a major health problem in Guyana, causing physical harm and damaging mental health.

19.I.2.7 Food contamination also constitutes an important health risk. Despite Government regulations and food inspection programmes, the chemical contamination of food continues to occur. Enforcement mechanisms are weak.

19.I.3.1 The delivery of health services is provided at five different levels in the public sector:

19.I.3.2 Level I: Local Health Posts (166 in total) that provide preventive and simple curative care for common diseases and attempt to promote proper health practices. Community health workers staff them.

19.I.3.3 Level II: Health Centres (109 in total) that provide preventive and rehabilitative care and promotion activities. These are ideally staffed with a medical extension worker or public health nurse, along with a nursing assistant, a dental nurse and a midwife.

19.I.3.4 Level III: Nineteen District Hospitals (with 473 beds) that provide basic in-patient and outpatient care (although more the latter than the former) and selected diagnostic services. They are also meant to be equipped to provide simple radiological and laboratory services, and to be capable of providing preventive and curative dental care. They are designed to serve geographical areas with populations of 10,000 or more.

19.I.3.5 Level IV: Four Regional Hospitals (with 620 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 are 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.

19.I.3.6 Level V: The National Referral Hospital (937 beds) in Georgetown that provides a wider range of diagnostic and specialist services, on both an in-patient and out-patient basis; the Psychiatric Hospital in Canje; and the Geriatric Hospital in Georgetown. There is also one children’s rehabilitation centre.

19.I.3.7 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.

19.I.3.8 The health sector is currently unable to offer certain sophisticated tertiary services and specialised medical services, the technology for which is unaffordable in Guyana, or for which the required medical specialists simply do not exist. Even with substantial improvements in the health sector, the need for overseas treatment for some services might remain. The Ministry of Health provides financial assistance to patients requiring such treatment, priority being given to children whose condition can be rehabilitated with significant improvements to their quality of life.

19.I.3.9 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. These 10 hospitals together, provide for 548 beds.

19.I.3.10 Eighteen clinics and dispensaries are owned by GUYSUCO.

19.I.3.11 The Ministry of Health and Labour is responsible for the funding of the National Referral Hospital in Georgetown, which has recently been made a public corporation managed by an independent Board. Region 6 is responsible for the management of the National Psychiatric Hospital. The Geriatric Hospital, previously administered by the Ministry of Labour, became the responsibility of the Ministry of Human Resources and Social Security in December 1997.

19.I.3.12 The facilities at the other levels receive their funding from the Ministry of Local Government. In each of the Regions there is a Regional Health Officer reporting to higher levels of the Ministry of Health on professional and technical matters. The Regional governments are responsible for health care within their boundaries, and administrative control over health resources rests with the Regional Executive Officer.

19.I.3.13 The Ministry of Health is responsible for establishing and implementing health policy and standards, accrediting facilities, and identifying the human resource requirements of the sector throughout the country. It has responsibility for the procurement and distribution of pharmaceuticals and medical supplies in all regions. It funds and manages the vertical health programmes, including vector control, rehabilitation services, dental care, mental health programmes, Hansen’s disease, AIDS, and alcohol and drug abuse.

19.I.3.14 The possibilities of confusion and overlapping among these agencies are obvious. Indeed they often occur.

19.I.3.15 Recent proposals for reforming the Regional system by creating Regional Health Authorities have been advanced and approved by Cabinet. However implementation modalities have not been thoroughly discussed. Under the new system, the Ministry of Health and Labour will not be responsible for day-to-day management and service delivery, but it will have responsibility only for policy formulation, regulation, planning, standard setting, monitoring and evaluation.

19.I.3.16 The personnel in the system include 336 doctors (190 within the public sector), 1597 registered nurses, 127 Medex officers (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 their duties in the former, in favour of the latter.

19.I.3.17 In the public health sector the staff vacancy rates range between 25 and 50 percent in most categories. Moreover, imbalances exist in terms of staff distribution: almost 70 percent of the doctors are located in Georgetown, where one-quarter of the population lives. In rural areas and in some specialisations such as pharmacy, laboratory technology, radiography and environmental health, the vacancy rates are at the higher levels.

19.I.3.18 Per capita Government spending was US$26 in 1997, which is well above the US$12 per capita assumed as the minimal threshold by international organisations for a basic primary health care package. However, biases occur in the allocation of resources, thus reducing the efficacy of Government expenditure, for example, the stated priority of Primary Health Care is under-funded, the major bias being towards hospital services all over the country. Indeed, in 1998, as much as 35 percent of total recurrent Government expenditures on health was allocated to the Public Hospital in Georgetown. The Regional budget for health was 25 percent.

19.I.3.19 The University of Guyana and the Liliendaal Annex of the MOH undertake almost all health-related training. UG offers curricula 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 childcare.

19.I.3.20 The Liliendaal Annex manages a variety of clinical and technical health education programmes, including professional education for those who intend to work as Medex personnel, nurses, X-ray technicians, dental auxiliaries, laboratory aides, community health workers, physiotherapy assistants, pharmacy assistants and nursing aides. It also offers a public health nursing programme. The Health Education programme of the Ministry of Health includes two nursing schools that are attached to the public hospitals of Georgetown and New Amsterdam. The Linden Hospital Complex operates a nursing school (Charles Rose Nursing School), and internal training is provided at the St. Joseph’s Mercy Hospital (private).

19.I.3.21 GUYSUCO provides diagnostic and outpatient services for their employees and their dependants, and some of them also have NIS coverage. GUYSUCO also carries out preventive activities through the annual screening of all employees, family planning, and immunisation through collaborative actions with the Ministry of Health. For example, GUYSUCO and the Ministry of Health joined their efforts for the implementation of the Yellow Fever and MMR Immunisation Campaign launched by the Ministry at the beginning of 1999. As noted, the quality of GUYSUCO’s health services is generally high.

19.II.1 Twelve and one-half percent of Guyana’s population does not have access to any health care. The situation is proportionally more severe for the lower-income groups. For example, among the lowest group twenty-four percent of the ill or injured does not seek medical care "due to expense or distance factors"; in the next lowest, the corresponding figure was nineteen percent; but in the highest it was only three percent.

19.II.2 The most important factors affecting the demand side of health care utilisation are the distance and travel time to a health facility, the perceived quality of the care, the education level of the patient, the type and severity of the illness and the out of pocket expenditures for health. The price of the service plays an important role, but is not the only determinant of health services demand.

19.II.3 The poor quality of the care offered at the lower levels has encouraged many patients to by-pass the referral system and seek care directly at the higher levels, thus causing the break-down of the referral system.

19.II.4 Overall, both structural and process quality is poor. In spite of recent increases in financing and improvements in management, the health sector still operates with vacancies in several key positions, and with malfunctioning and obsolescent equipment. Storage facilities for drugs are inadequate, as are quality control standards and implementation. Patients routinely purchase their own pharmaceuticals and medical supplies and are forced to spend excessively long time in repeated visits to medical facilities. Moreover, the overall quality of operations has not improved. Indeed, in some respects they continue to decline. In large part this is due to problems in the institutional structure of the sector, in its management practices, and in the unavailability of adequate financing.

19.II.5 Health services are not responsive to users, particularly those most in need, thus resulting in increased inequity. In addition, poor accountability to users undermines the responsiveness of the system.

19.II.6 Both allocative and technical inefficiencies plague the sector, particularly the public health sector. Allocative inefficiencies derive from the fact that resources are not allocated to the services that are most cost-effective. Technical inefficiencies result from an inefficient utilisation of those areas in which facilities are adequate. Unit costs of facilities at all levels are high.

19.II.7 Institutional responsibility for the public sector system of health care is dispersed among too many Ministries and agencies. Under the present system, the operational responsibility for the implementation of the Ministry of Health’s policy lies with the Regional Health Officer (RHO). The RHO reports to the Regional Executive Officer (REO), who also has the financial authority and responsibility for programmes in all sectors. The REO, however, 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 programmes. The restructuring of institutional responsibilities should therefore be a key component of the institutional reforms of the public health care system.

19.II.8 Although Guyana’s public expenditure on health has increased significantly during the 1990s, because the system had deteriorated resources remain below the levels necessary to restore it to the desired state. If national health priorities are to be properly addressed, adequate funding for them is vital. There is also a compelling need to improve financial management, so that the available funds are used more efficiently.

19.II.9 There is difficulty in establishing the overall resources needed in the public health sector because budgets are not based on actual cost estimates or productivity criteria.

19.II.10 There is a scarcity of qualified and experienced professionals in health care accounting and financial management.

19.II.11 Salaries in the public health care sector are still well below those that are offered in the private sector. Moreover, perhaps as a result, absenteeism of medical personnel is a major concern. Furthermore, those reforms that are intended, under the Highly Indebted Poor Countries Initiative, to upgrade salaries up to 80 per cent of private sector levels, have not yet been implemented. In addition, more flexible and efficient personnel policies are required.

19.II.12 In principle, the referral system is well-suited to Guyana because of the geographic barriers to communications and transport. However, in practice it is not functioning well. Technical inefficiencies, and the failure to provide adequately trained medical staff, supplies and equipment at the lower level induce patients to bypass the system and seek care in the National Public Hospital, or in private hospitals concentrated in the Georgetown area. In a cruel irony, it is the poor who visit in disproportionate numbers the local facilities and endure the consequences of lower-quality care.

19.II.13 The principal administrative and managerial reasons why the referral system is not working as planned appear to be the following: the lack of sufficient administrative co-ordination between the Ministry of Health and the Regional authorities; shortages of funding; technical and allocative inefficiencies; the inability of the Ministry of Health to provide leadership to the Regions; the lack of authority in the Ministry of Health to implement policies or to set the budgets of the Regional Administrations; the lack of training in public health or in administration of Regional Health Offices; the failure continues to pass on patients’ files to higher stages of the system. Indeed the failure to keep files on them; and the fact that in some parts of some Regions, it is easier to travel to Georgetown than to the appropriate health facility in the Region.

19.II.14 The spatial distribution of health centres is critical, for they provide a wide range of preventive services and some curative care. However, those in Regions 3, 4 and 6 cater to at least twice as many people as in the other regions. And yet, a distribution of health centres based on the population to be catered for would be highly inequitable. Inefficiencies in the spatial distribution of health centres are somehow inevitable given the geographical features of the Guyanese territory and the difficulties of travelling. A trade-off between equity and efficiency seems therefore to exist in that what is an equitable spatial distribution of health centres does not necessary constitute the most efficient solution. The proposals which have been put forward in the Chapter on the Transport sector would go a long way towards the resolution of this difficulty.

19.II.15 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-à-vis needs, delivery is often not timely, and wastage frequently occurs because of poor management. There is obviously a need to correlate estimates of annual drug requirements, procurement, distribution and the allocation of adequate financing. It is also necessary to provide adequate storage facilities, and effective security to prevent the leakage of drugs and other supplies to the private market. An increase of salaries might reduce this transfer of assets from the public to the private sector.

19.II.16 There is an absence of standard treatment protocols for drug use in treatment of common diseases.

19.II.17 There is a gross insufficiency of qualified pharmacists within the public system.

19.II.18 Storage facilities are inadequate and in many cases not suitable to the storage of drugs both at central and regional levels. In addition, part of the space that is available is taken up by expired drugs, drugs that should be destroyed because of their poor condition, and by unused medical equipment.

19.II.19 There is no comprehensive management information system for pharmaceuticals and other supplies in use at the Pharmacy Bond.

19.II.20 Planning is inadequate. In the Regions, planning for health services is often the responsibility of managers with no expertise in the health sector. Strategic plans for health services development in the Regions are not produced regularly and the planning of outreach activities is minimal. Decision-making is rarely based on supporting evidence. On the contrary, decisions are often made as a crisis response rather than as a result of a rational planning process. 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.

19.II.21 The unavailability of qualified personnel is one of the major weaknesses of the public health system. Moreover, the available staff is not optimally distributed. Major problems occur especially in certain key areas, such as pharmacy, laboratory technology, radiography and environmental health. In addition, the shortage of nurses, who form by far the largest percentage of the work force and are the backbone of the health sector, severely hampers the ability of the system to deliver quality care. There is also a dearth of medical specialist staff and other technical health professionals. As a result, the ratio of physicians and nurses to population is still unacceptably low in some Regions, especially in Regions 1, 5, 8, 9 and 10.

19.II.22 The management of the system is poor and most personnel in key positions lack managerial training and planning expertise. Difficulties are experienced in the recruitment, retention, training, deployment and utilisation of staff. The development and management of human resources is still not approached in a systematic and organised fashion. 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 incentives (salaries and employment benefits), unappealing working conditions, the lack of career development systems; limited opportunities for in-service 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.

19.II.23 The shortage of physicians is not necessarily a shortage in numbers. Rather, the problem is one of poor distribution since most physicians prefer to practise in Georgetown and surrounding areas. However there is a definite shortage of specialist physicians. Nursing shortages include both a dearth in absolute numbers and a lack of specialist such as anaesthetic, psychiatric and paediatric nurses. Services in health-related fields such as medical technologists, pharmacists and radiographers are most critical.

19.II.24 The lack of adequately designed rewarding systems for health care workers serving the interior mostly account for the inability to attract personnel to these areas. Hinterland conditions are poor, infrastructure and educational facilities for families inadequate, and the cost of living is generally higher than in Georgetown. Better incentives will need to be designed.

19.II.25 Health education and training systems for all types of health workers are inadequate and not always efficient. There is an absolute shortage of personnel in certain positions, which could be addressed through the enhancement of training activities. But there is an all-pervading absence of suitably trained educators and trainers.

19.II.26 Distance learning, which could amplify the coverage of programmes and of in-service training, has not been developed thoroughly. In the past, distance education was used for the continuous on-the-job training of medexes serving the interior, through weekly radio communication. The process was, however, discontinued because of the disrepair and poor maintenance of the radio equipment. Distance education would not only increase incentives for people to stay in the interior, but also would assist to retrain and upgrade staff’s skills. New health learning materials also need to be developed.

19.II.2.1 Guyana’s health infrastructure is very old and many buildings are in need of repair. The condition of the equipment is also poor because of its age and the lack of maintenance. The utilisation rate of the public facilities, especially at Health Centres and Health Posts, is very low. This is due mainly to the shortage of supplies, equipment, and health personnel; to the high hidden costs for the users (lengthy transportation, and waiting time); and to the relative inaccessibility of the Centres and Posts

19.II.2.2 The successful implementation of vertical programmes such as vector control, sexually transmitted diseases and HIV/AIDS, Hansen's disease, tuberculosis, dental services and veterinary public health is severely hampered in Guyana because of the institutional factors related to the existing Regional system. In addition the programmes are constrained by over-stretched staff at the central level; insufficient support and field staff; inadequate inter-institutional co-ordination in programmes such as malaria control; and inadequate supplies of reagents, drugs and equipment.

19.III.1 In the broadest sense, the objectives of the sector are to increase the length of healthy life for all people in Guyana, and to reduce health disparities among social groups. Put in another way, the objectives are to ensure that, increasingly, most Guyanese enjoy a better quality of life, and to minimise the incidence of illnesses and disabilities. To this end, the focus will be on primary health care and the promotion of preventive health measures.

19.III.2 The overall operational objectives for attaining these goals are to improve the population’s access to health care and the quality of the care that is offered, while ensuring that the health services are provided cost-effectively.

19.III.3 The question of access is double-sided. From the perspective of supply, improving access requires increasing the availability of health services and ensuring that these services are responsive to the needs and preferences of the clientele at all levels of the delivery system. From the perspective of demand, improved access requires the reduction in the household costs of accessing care (i.e. of reducing all direct and hidden costs).

Ministry of Health

19.IV.1.1 The Ministry of Health will be responsible for health policy formulation, health planning, and monitoring and regulating the health sector.

19.IV.1.2 The Ministry of Health will develop the capacity to prepare service agreements, monitor their implementation and assess the performance of devolved authorities.

19.IV.1.3 The Ministry of Health will be restructured to reflect the decentralisation of service delivery functions. It will operate in a regulatory capacity over the entire health sector, rather than in its traditional role as the centralised manager of the public health system. Service delivery and management responsibilities will be devolved to the health authorities and other agencies, which will report to the Ministry of Health. In the re-structured Ministry, the following functions will be retained and strengthened centrally: the development of policies and strategies; the allocation of resources; the establishment of objectives; the review of performance; regulation setting; and research and development.

19.IV.1.4 Legislation will be introduced to require allied-health-field personnel to register with a Paramedical Professional Council which will be established.

19.IV.1.5 Procurement of all pharmaceuticals and supplies for the public sector will be contracted out. A Procurement Board in charge of procurement and distribution of drugs and medical supplies will be established for this purpose.

19.IV.1.6 The Procurement Board will be autonomous and managed according to business principles. Private physicians and facilities would be able to purchase drugs and supplies from the Board. The Board 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.

19.IV.1.7 All devolved Authorities will arrange their own purchases of drugs and supplies from the Board, and will negotiate prices taking into account transport costs.

Regional Health Authorities

19.IV.1.8 Regional Health Authorities (RHAs) will be established. These will be decentralised public bodies with the responsibility for health service delivery. They will assume responsibilities for operating and maintaining those health facilities that are now under the aegis of the Regional Administrations.

19.IV.1.9 The Regional Health Authorities and hospitals will be operated by Boards.

19.IV.1.10 The Boards of the RHAs will be autonomous. They will comprise members of the Guyana Medical Association, ex officio representatives of the Ministry of Health, with a preponderance of representatives of the Regional government and local communities.

Human Resources

19.IV.1.11 The health personnel of the RHA’s will report to a Ministry Director or functionary: The Regional Authorities will account for their performance to an appropriate functionary at the central Ministry of Health.

19.IV.1.12 All Senior Regional Officers will be trained in health administration, by way of a structured training programme which the Ministry of Health will establish.

19.IV.1.13 Salaries in the sector will be increased. Special attention will be paid to the need to provide incentives for well-qualified medical and administrative personnel to serve in the hinterland facilities.

19.IV.1.14 In order to increase the flexibility of the public health system, the salary structures of health personnel will be de-linked from the public service. In addition, a set of special categories for health personnel will be developed.

19.IV.1.15 All personnel in key management positions, e.g., programme managers, hospital administrators, district-level health officers, medical superintendents, and public health nurse supervisors, will have adequate training in health administration.

19.IV.1.16 A manpower plan for the health sector that indicates ways to upgrade and improve staffing levels and analyses alternatives to overcome the shortage of specialist personnel such as medical technologists, pharmacists, dental technologists, radiographers and X-ray technicians will be developed.

19.IV.1.17 Adequate incentives will be developed in order to stimulate the service of health personnel in the hinterland. In order to overcome the problems of staffing, all persons trained by the Government in medical disciplines and allied fields will be asked to serve in an interior location for two years. Training local people, as in the case of the Community Health Workers, has already proved a successful strategy, and will be strengthened also in the case of extension personnel, such as Medex and Dentex. Outreach activities will be further expanded to increase access to health services in remote areas.

19.IV.1.18 Pre- and in-service recruitment and training plans will be developed and implemented in order 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.

19.IV.1.19 Physicians will be trained in the role of medical extension personnel and primary health care. Where such training is not otherwise available, it will be provided on an in-service basis.

19.IV.1.20 The education and training of health professionals will be updated and evaluated in order to assess the appropriateness of existing curricula and course requirements.

19.IV.1.21 Mechanisms will be put in place to ensure collaboration between the Liliendaal Annex, the University of Guyana, and the Ministry of Health on the development of curricula in order to guarantee consistency and relevance to the sector's needs.

Health programmes

19.IV.1.22 A division of primary health care will be established in the Ministry of Health, to work in close co-operation with the Regional units, where most of the primary care is provided.

19.IV.1.23 The Ministry will develop a strong Epidemiology department to undertake on-going health needs assessment, direct and assist health authorities and other devolved agencies to identify the health needs of their populations; and assess their effectiveness in satisfying these needs.

19.IV.1.24 The Ministry will institute a mechanism to monitor the quality of health care provided in both the public and private health sectors. Quality assurance programmes will be developed. This will include clinical and organisational audit, and the development of multidisciplinary quality assurance programmes and quality standards.

19.IV.1.25 Arms length and outreach activities will also be strengthened, including the use of mobile clinics.

19.IV.1.26 The institutional and functional capacity of the Government Analyst Department will be reorganised and strengthened so that the quality of drugs manufactured, imported and sold in Guyana might be ascertained.

Facilities and Services

19.IV.1.27 A detailed survey will be carried out to verify whether all the existing facilities of the five-tiered referral system are needed, and what is their current status.

19.IV.1.28 Hospitals, that are currently underutilised, will be closed. Funds could in this way be made available to upgrade other ‘strategic’ facilities, as well as to provide a fleet of ambulances and other transport facilities, to ensure that radio communication networks are available in all localities, and to finance an expansion of a programme of rotating visits.

19.IV.1.29 In addition, depending upon the results of the survey some of the health centers, especially those in coastal areas, might be closed. The funds released by this process will be utilised to strengthen selected District hospitals and establish more health posts in remote areas.

19.IV.1.30 Following the survey mentioned above, a master plan for the rehabilitation of facilities, including the acquisition and maintenance of an improved fleet of air and river ambulances, will be developed by the Ministry of Health.

19.IV.1.31 Every regional hospital and other district hospitals will have at least one ambulance for emergencies.

19.IV.1.32 All health centers will be equipped with a phone or radio for emergency calls.

19.IV.1.33 All hospitals will have adequate power generation supplies.

19.IV.1.34 Health posts will be maintained and improved, as they are vital for the tasks of medical education, preventive care and arranging for medical transport to other facilities.

19.IV.1.35 An essential Medical Supplies list will be formulated outlining types and specifications of supplies that will be stocked.

19.IV.1.36 Investments will be made to improve the storage facilities for pharmaceuticals in public hospitals, health centres and health posts.

19.IV.1.37 The programmes of rotating visits to the remotest facilities by physicians will be strengthened, so that villagers would know in advance when a doctor would be in the nearest health centre, for example on specified days of the month.

19.IV.1.38 Arrangements will be made for teams of foreign medical specialists, who are qualified in disciplines in which Guyana is in short supply, to visit the country in order to examine and treat patients.

19.IV.1.39 A Cancer Centre, headed by an oncologist, and provided with supporting staff, will be established.

19.IV.1.40 Dialysis equipment will be installed in order to provide assistance to patients suffering from relevant kidney disorders.

19.IV.1.41 The services of the Medical Faculty at the University of Guyana will be expanded and upgraded through the utilisation of Information Technology, and the linkages which will be established with a network of foreign universities both in the Caribbean and further afield. Through these Internet connections, Guyanese students will be able to undertake practical courses abroad.

19.IV.I.42 Information Technology will also be utilised extensively in the health sector, in administration, the procurement of medical supplies, in the co-ordination of the referral system, and in the rationalisation of the relationships between the central government and the region.

Financing

19.IV.I.43 Funding will be allocated to RHAs on the basis of service agreements negotiated with the Ministry of Health. Mechanisms to ensure financial accountability for public health will be put in place.

19.IV.1.44 Hospitals operated by parastatals which receive budgetary allocations willl operate under similar service agreements. As the quality of the national health system improves, and the parastatals focus increasingly on their own financial requirements, a transfer of their hospitals to the national public system will be undertaken.

19.IV.1.45 Financial reforms will proceed in parallel with institutional reforms, in order to make expenditure on health care more effective.

19.IV.1.46 The Central Government's budget will continue to be the principal source of funding for the public system of health care. Government health expenditure will reach 5 percent of GDP by the year 2002 and will increase progressively to 10 percent of GDP by the year 2010.

19.IV.1.47 General taxation will remain the main funding mechanism for health in Guyana. However, earmarked health taxes will be levied from the year 2003 when it is projected that the economy would be more robust.

19.IV.1.48 Resources will be allocated from the centre to devolved authorities on the basis of a funding formula. Public resources will be prioritised to highly cost effective services, such as primary health care (services like immunisation, sanitation, vector control, diagnosis and treatment of tuberculosis, malaria, sexually transmitted diseases, the provision of maternal and child care, health education, and public health interventions).

19.IV.1.49 Cost recovery mechanisms will not be directed to financing the health requirements of the vulnerable. Cost recovery will be utilised only for services for which public resources are inadequate, because they have been already allocated to other priority or essential health services. Indeed, user fees for well-defined services are currently charged at certain public care institutions. These include the Public Hospital Georgetown,(private rooms, pregnancy tests and physiotherapy services), at two Regional hospitals (X-rays mortuary service, laboratory tests), at the National Dental Care Centre (all treatments), at the Ptolomey Reid Rehabilitation Centre (for Orthotic and Prosthetic Appliances and hearing aids), at the National Blood Transfusion Centre, and at the Food and Drugs Administration. For other services, selective payments by patients will be imposed.

19.IV.1.50 Within a system of selective fees for medical services, cost recovery will never hinder access to health care and no patient will be refused service because of the inability to pay fees.

19.IV.1.51 Financial contributions to complement the public budget will be sought from communities, or through Community Hospital Associations. This approach will also enable the communities to have a greater role in planning health services and monitoring their quality.

19.IV.1.52 The government will develop further a health insurance scheme as a supplementary financing option.

19.IV.1.53 An extensive review of the NIS and a corresponding reform programme will be developed, in order to improve the NIS actuarial basis and strengthen its performance as a provider of social health benefits.

19.IV.1.54 A modest registration fee for both inpatients and outpatients will be charged at the Public Hospital Georgetown, and will be introduced in all district and regional hospitals from the year 2003, after the quality of service in these areas will have been improved.

19.IV.1.55 Fees for patients bypassing the referral system will also be charged from 2003, in order to avoid the overuse of upper-level facilities for care that could have been provided effectively at lower levels. Such a system of fees requires a definition of the rules governing the referral system and the establishment of adequate incentives and disincentives for providers of services at lower levels. These requirements will be met.

19.IV.1.56 At the Public Hospital Georgetown, already existing charges (e.g., physiotherapy, the use of private wards, the medical library, pregnancy tests) will be increased to reflect the real value of the resources necessary to provide the services.

19.IV.1.57 Fees will also be levied for other services, including laboratory procedures, X-Rays services, other specialised diagnostic services (e.g., CT), specialised surgery, medications. The application of some of these fees will be subject to a means test.

19.IV.1.58 The sale of services to the private sector will be extended. Existing charges for services sold to the private sector at the Food & Drug Administration and at the Blood Bank will be increased.

19.IV.1.59 The utilisation of equipment and facilities at the ACSD unit at the Public Hospital Georgetown will be optimised by allowing private doctors to use equipment in public hospitals on payment of a fee, subject to scheduling their use so that priority is given to the public physicians. Charges for patients admitted to public hospitals while under the care of private physicians will be imposed.

19.IV.1.60 Services for which excess capacity exists will be sold to the private sector. At the PHG these include, for example, non-clinical services such as the laundry, the kitchen, and the sterilisation unit.

19.IV.1.61 The tentative arrangements that have already been negotiated with CARICOM countries for the complementary utilisation of each other’s medical facilities and services will be finalised. To this end, a special fund will be established to expedite the evacuation of indigent patients to Caribbean countries for treatment in those ailments for which services are not available in Guyana.

19.IV.1.62 No charges will be made for preventive and primary health care at the commmunity level. This will encourage the population to give greater emphasis to seeking adequate preventive care.

19.IV.1.63 The establishment of cost recovery measures poses serious challenges in terms of public sector ‘capacity’. Several administrative and legal issues need to be resolved in order for the system described above to work effectively. The health sector will complete effectively a process of institutional strengthening in order to tackle these problems.

Health Promotion and Protection

19.IV.1.64 Programmes addressing gender specific health issues, for example, in the areas of reproductive health, the impact of STDs and HIV/AIDS, and cancer will be developed.

19.IV.1.65 Gender sensitivity analysis will also be included in the planning, implementation, monitoring and evaluation of all health programmes.

19.IV.1.66 Information systems will be designed to provide adequate gender-differentiated information in support of policy and decision making processes.

19.IV.1.67 The curricula of schools will be reviewed to ensure that health education forms an integral part.

19.IV.1.68 Adolescent health issues will be tackled through educational programmes within schools, in collaboration with school welfare departments and social workers.

19.IV.1.69 Public awareness programmes to sensitise people about the dangers of smoking will be strengthened.

19.IV.1.70 Education on nutrition and healthy lifestyles will be brought into schools. Campaigns to reach the entire population will also be strengthened.

19.IV.1.71 Improved nutritional care will be provided in hospitals, through the recruitment of dieticians and the provision of diet counselling.

19.IV.1.72 Monitoring of the nutritional status of the population, especially the most vulnerable groups, will be carried out on a regular basis.

19.IV.1.73 The vector control programme will be revised and modified to become a ‘National Advisory Board’, with the tasks of monitoring, research, emergency and crisis response, and the preparation of technical guidelines for guidance in the execution of programmes.

19.IV.1.74 Extensive inclusion of the community in the management of these diseases and vectors will form an Integral part of a national control policy to have effect. Such a policy will be prepared.

19.IV.1.75 STDs and HIV/AIDS constitute priority areas for health intervention in Guyana. The "National HIV/AIDS Prevention Plan, 1999-2001" recently prepared by the Ministry of Health will be thoroughly implemented, and rolled over, and funding from local and international organisations will be secured accordingly.

19.IV.1.76 Measures to treat all the population suffering from acute respiratory infections will be strengthened in all affected areas.

19.IV.1.77 Health education will become an integral part of the day-to-day health services given to patients and the community. These include the strengthening of counselling and informational services given to patients.

Vulnerable Groups

19.IV.1.78 A social assessment system to determine eligibility to exemptions will be established. Until such a system is in place, means assessments will be carried out at public health facility level.

19.IV.1.79 Inequalities in access to health care are of particular burden to the poorest categories. The Ministry of Health will examine ways to improve the provision and delivery, of services to these groups. The health needs of vulnerable groups are concentrated in the areas of nutritional problems, poor environmental health, vector-borne diseases and sexually transmitted diseases. Hence a health development strategy centered on the objectives of primary health care and health promotion will be designed and implemented to address the needs of the most vulnerable.

19.IV.1.80 While institutional reforms in the public health sector pursue objectives of equity, access and quality improvements of health services, an explicit stance will be taken to target the most needy.

19.IV.1.81 Policy documents addressing the health needs of each vulnerable group and detailing the action plans as well as institutional responsibilities will be prepared through processes of national consultation, involving all major social actors. This has been the case, for example, of the National Consultation on HIV/AIDS, which took place in November 1998 and was developed into a policy document and the National Plan for HIV/AIDS Prevention, 1999-2001.

19.IV.1.82 Besides the preparation of ‘basic package’ of services targeting Primary Health Care interventions, to be made accessible to the entire population, the Ministry of Health will design extra basic packages for needy groups. The institutional responsibilities for the delivery of such packages will be assigned through a process of consultation.

19.IV.1.83 Financing mechanisms, including those for cost recovery, will not be implemented unless they are accompanied by exemption policies and mechanisms targeting the most needy (the elderly, disabled, etc.), other categories of the medically indigent, and the poor (e.g.,: the employed poor, falling in the group of people at minimum wage; the unemployed; single-parent or single-earner households; the homeless; the youth with no formal education and no job).

19.IV.1.84 Special health needs of vulnerable groups will be identified and attributed adequate priority. For example the availability of drugs and access to physicians for the elderly, currently poor, is essential for the wellbeing of this vulnerable category.

19.IV.I.85 Targeting groups with certain well-identified health needs will help addressing their poverty status.