The Impact of Economic Reforms on Health Indicators in Guyana Caribbean Studies, Vol

Caribbean Studies ISSN: 0008-6533 [email protected] Instituto de Estudios del Caribe Puerto Rico

Gafar, John The impact of economic reforms on health indicators in Guyana Caribbean Studies, vol. 33, núm. 1, january-june, 2005, pp. 149-176 Instituto de Estudios del Caribe San Juan, Puerto Rico

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How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative THE IMPACT OF ECONOMIC REFORMS... 149 THE IMPACT OF ECONOMIC REFORMS ON HEALTH INDICATORS IN GUYANA

John Gafar

ABSTRACT This paper examines the performance of the health indicators in Guyana during the period of economic reforms. With economic reforms implemented in 1988 there have been impressive rates of economic growth. As a result, the health indicators in Guyana improved, immunization rates increased substantially, and malnutrition rates declined. There is a direct correlation between health outcomes and the level of education.

Keywords: economic reforms, health care system, health expenditures, immunization, malnutrition, health indicators and growth

RESUMEN Este trabajo examina el rendimiento de los indicadores de salud en Guyana durante el período de reformas económicas. Con las reformas económicas implementadas en 1988 se han logrado impresionantes tasas de desarrollo económico. Como resul- tado, los indicadores de salud en Guyana mejoraron, las tasas de vacunación aumentaron sustancialmente y la malnutrición disminuyó. Existe una correlación directa entre los resultados de salud y los niveles de educación.

Palabras clave: reformas económicas, sistema de salud, gastos de salud, inmunización, desnutrición, indicadores de salud y desarrollo

RÉSUMÉ Ce document examine le résultat des indicateurs de santé en Guyane pendant la période des réformes économiques. Suite à des réformes mises en vigueur en 1988, des taux impression- nants de croissance économique ont été remarqués, ce qui a permis l’augmentation considérable du taux d’immunisation, la baisse du taux de malnutrition et l’amélioration des indicateurs de santé en Guyane. Il existe une corrélation directe entre les

Vol. 33, No. 1 (January - June 2005), 149-176 Caribbean Studies 150 JOHN GAFAR

résultats de santé et l’éducation.

Mots-clés: réformes économiques, système de santé, dépenses de santé, immunisation, malnutrition, indicateurs de santé et de croissance.

Received: 19 April 2004. Revision received: 7 December 2004. Accepted: 9 December 2004.

uyana is a small, open, poor, heavily indebted, low-income country located on the northern coast Gof South America. It is the only English-speaking country in South America that has strong historical and cultural ties to the Anglophone Caribbean countries. The country is rich in mineral resources, biodiversity, and lands. However, the country remains one of the four poorest nations in the Western hemisphere because of past failed statist policies. Since independence in 1966, Guyana’s economy has gone through three main phases. The first phase lasted until 1988 as the country pursued a state interventionist socialist economic policy, which proved to be a disaster. State control of the economy was characterized with excessive controls, a bloated and cor- rupt bureaucracy, negative economic growth, falling standard of living, widespread poverty, declining health and social indicators, mounting foreign debt, reductions in social expenditures, massive emigration of skilled workers, unsustainable trade and fiscal deficits, inflation, human rights abuses, rigged elections, and autocratic and racist rule. (See Gafar 2003 and World Bank 1993b, 1994, 2002). Gross Domestic Product (GDP) declined in real terms at an annual average rate of 3 percent in the 1980s. The World Bank (2002: 37) reports that the “historically well- performing health system of Guyana saw substantial erosion in the 1980s” as a result of years of economic decline. The second phase started with the implementation of an IMF-World Bank economic recovery program (ERP) in 1988. The ERP included the elimination of price and quantitative controls, trade liberaliza- tion, competitive (flexible) exchange rates, reductions in public expenditures, downsizing of government, privatization of state

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 151 owned enterprises, and expanded spending for social services. The results of the ERP has been impressive: the economy grew at an annual rate of 7.1 percent during 1991-97, poverty fell from 43.2 percent in 1993 to 35 percent in 1999, per capita GDP increased from US$290 in 1990 to US$710 in 2001, and inflation has been reduced to single digit. However, per capita GDP is barely higher than the mid 1970s. Since the December 1997 general elections the country has entered the third phase characterized by economic stagnation, severe political disturbances, and exogenous shocks. These shocks include adverse weather conditions, falling export prices for rice, sugar, gold and bauxite, and deterioration in the terms of trade. As a result of these factors, economic growth stagnated, averaging 0.4 percent during 1998-2001. The purpose of this paper is to examine the performance of the health indicators during the period of economic reforms. World Health Organization (1998: 39) defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” There are no “suitable mea- surements” that are available to encompass WHO’s definition of health. Behrman (1996) argues that life expectancy at birth is often used as a “summary measure of health and nutrition status,” the better the health and nutrition are, the longer will be life expectancy. Infant and child mortality rates are also used as a summary indicator of health and nutrition in international com- parisons. This paper is organized as follows: Section II describes briefly the health care system. Section III examines the allocation of resources to the health sector. Section IV examines the immunization rates, and Section V deals with malnutrition rates, so that public health prevention practices can be related to health outcomes. Section VI examines the trend and determinants of the health indicators, to wit, crude birth weight, crude death rate, life expectancy, infant mortality rate, etc. And, finally, the paper ends with some broad conclusions.

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II: The Health Care System of Guyana The public sector is the major provider of health care services, although in recent years there has been an increase in private providers. The Ministry of Health is responsible for establishing regulations, determining national health policies, developing legislation, accreditation of health facilities, and enforcement of standards for the provision of health care services. Health services in the public sector are based on a five-tiered structure and an upward-moving referral system.1 Level I includes Health Posts (166 in total), and community health workers staff them. Level II comprises of Health Centers (149 in total). These are staffed with a public health nurse, a dental nurse, and a midwife. Levels I and II focus mainly on preventive care, and very little on curative care. Most of the health posts and health centers are located in the rural areas and serve primarily the poor. Level III consists of 19 district hospitals that provide basic in-patient and out-patient care, and simple radiological and laboratory services. Level IV includes four regional hospitals (located in urban areas) that provide general in- and out-patient services, diagnostic services, and specialist services in obstetrics and gynecology, general medicine, and surgery. Level V includes the National Referral Hospital (Georgetown Public Hospital), the Psychiatric Hospital in Canje, and the Geri- atric Hospital in Georgetown. The Georgetown Public Hospital is a teaching hospital that also trains doctors and nurses. A large share of the health budget is allocated for the operations of the Georgetown Public Hospital and the four regional hospitals that are urban based and are heavily involved in curative care. Services provided by the public hospitals are free of cost, but there are a few services and private room accommodations for which patients are required to pay. The World Bank (2002) points out that the extremely poor quality care (or, in many instances, no care) provided by the health clinics and health centers (Levels I-III) have forced patients to ignore these services, and seek care directly at the Georgetown Public Hospital or from private providers. Since many of the

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services provided at hospitals are ambulatory and could be provided less expensively at the lower levels, the World Bank (2002) notes that this “run to quality” increases the cost of providing public health. The generally poor quality of care at the health posts and health centers forces many people, including the poor, to travel long distances to seek medical care or pay high fees to private medical practitioners. One of the problems of the public health care system in Guyana is that funding is tied to consump- tion of resources rather than efficiency and quality (World Bank 2002). The World Bank (2002: 40) points out that statistics on basic performance variables (i.e. inputs, outputs, outcomes) are not “systematically” collected by the Ministry of Health, which means it is not possible to “calculate unit costs for health services, to know when a facility or region is using the resources more or less effectively or to know if spending is having an effect on people’s health.” According to the National Development Strategy, there are about ten hospitals, diagnostic facilities and clinics that belong to the private sector, and these are located in Georgetown and in other urban centers. Several NGOs, including religious orga- nizations (for example, the Catholic Church) provide health care services on a not-for-profit basis (which the poor find to be expen- sive). Fees from patients are the source of financing the private health care facilities, and these private facilities provide about half of all curative services in Guyana (PAHO 1999). Accord- ing to the National Development Strategy the health personnel in the entire system include the following: 336 doctors (190 in the public sector), 1597 registered nurses, 127 Medex officers (medical extension workers who are qualified as nurses and have 15 months of clinical training), 132 Community Health Workers, 80 pharmacists and 27 dentists. Many doctors in the public sector also work in the private sector, and some doctors neglect their public sector obligations for their renumerative private clinics. Staff vacancy rates are in the public health care sector range of 25 to 50 percent, and there are tremendous nursing shortages

Vol. 33, No. 1 (January - June 2005), 149-176 Caribbean Studies 154 JOHN GAFAR due in part to the emigration of skilled people from Guyana. The Ministry of Health has difficulties in recruiting and retaining staff because of very low salaries, and poor working conditions. In some of the usual specialist areas of medicine and surgery there are no doctors, and more than 90 percent of the specialist staff are expatriates (a large proportion from Cuba). Approximately 70 percent of the doctors practice in Georgetown, where a quar- ter of the population lives (National Development Strategy 2000). The ratio of health professionals to population has shown some improvement: in 1991 the ratio of physicians per 10,000 population was 2.0 but this increased to 3.8 in 2000; in 1991 the ratio of nurses per 10,000 population was 5.9 and this rose to 10.4 in 2000; and the number of hospital beds per 10,000 population increased from 28.8 in 1991 to 42.5 in 2000. However, Guyana’s health indicators compare poorly with the English-speaking Caribbean countries (Gafar 2003). The country has no dialysis units, there are only one CT scan and one MRI machine in Guyana, and both are in the private sector (PAHO 2001). Angioplasty procedures are not available. Recent press reports indicate that there is a huge backlog of patients (around 5,000) needing cataract surgery, with some on the waiting list for two years with no fixed date for their operation, since there are only two public facilities performing cataract surgeries at no cost (Seales 2004). The health sector in Guyana is unable to offer reliable quality care because the medical specialists do not exist, the medical equipment in the hospitals are obsolete and do malfunction, and the technology and supplies that are needed for diagnosis and treatment are unaffordable in Guyana. In the rural areas many communities have little or no access to physician services or hospital care.

III. Allocation of Resources The economic collapse of the 1980s resulted in a deterioration of the physical facilities, substantial reductions in the health care budget, medical shortages, emigration of health care work-

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 155 ers, and declining real wages. Data on health expenditures are not easily available and reliable. In 1980, expenditures on health accounted for 7.1 percent of the budget and 3.7 percent of GDP. However, during the 1980s public expenditures on health contin- ued to decline reaching 2.1 percent of GDP in 1985. Since 1990, the proportion of public resources allocated to the health and social sectors has increased. In 1990 public expenditures on health was G$0.4 billion (US$10.1 million), but this rose appreciably to G$2.88 billion (US$20.5 million) in 1996. Between 1992 and 1995, the increase in health expenditures was due to the substantial increase in capital expenditures for the health sector. Approxi- mately 30 percent of public spending on health is used to purchase drugs and medical supplies (PAHO 2001). Table 1 shows the trend on expenditures on health for 1990-2000.

Table 1: Expenditures on Health: 1990-2000

Public Private Total Health Health as % Total Health Spending on Spending on Expenditures Year of National Exp. Per capita Health as a Health as a as a Budget1 (current US$)2 % of GDP2 % of GDP2 % of GDP2 1990 3.7 2.6 0.93 3.53 19 1991 3.6 1.8 1.00 3.80 13 1992 6.5 3.4 0.90 4.30 22 1993 7.9 3.4 0.89 4.29 29 1994 9.0 3.6 0.89 4.49 34 1995 6.3 2.5 0.88 3.38 39 1996 6.8 2.7 0.93 3.63 43 1997 6.1 2.6 0.91 3.51 45 1998 6.8 2.7 0.94 3.64 45 1999 7.6 2.9 NA NA NA 2000 7.4 3.4 NA NA NA Sources: (1) World Bank (2002). (2) Pan American Health Organization, Statistical Database NA = not available The statistics in Table 1 show that in 1991 only 3.6 percent of the national budget was allocated to health, but this increased between 1992-2000 averaging 6.5 percent of the budget. Most of

Vol. 33, No. 1 (January - June 2005), 149-176 Caribbean Studies 156 JOHN GAFAR the increase in the budget allocation during 1992-98 was for the construction of the Georgetown Public Hospital (PAHO 1998). Available data indicate that in 1985 public spending on health, as a percent of GDP was 2.1 percent, and total expenditures on health as a percent of GDP was 2.7 percent. Public expenditures on health averaged 2.9 percent of GDP during 1990-2000, and private spending on health in Guyana is roughly one percent of GDP. Total health expenditures in Guyana averaged around 3.9 percent of GDP during 1990-1998. This is well below the Latin America and Caribbean regional averages of 6 percent of GDP (IDB 1996: 301). Private health expenditures account for nearly 20 percent of total health expenditures in Guyana; in the case of Barbados it is 47 percent, Jamaica 63 percent, and Trinidad and Tobago 41 percent (Gafar 2003). Cost recovery mechanisms are gradually being introduced in the public health sector. User fees for certain well defined services are currently being charged at the public health care facilities. However, the revenues generated from user fees, etc., accounted for only 0.3 percent of the public health budget in 1998. Financing of public spending on health in Guyana is done through the national budget. Public financing of health care can be justified on three considerations: firstly, the need to provide public goods (public health); secondly, to reduce poverty; and, thirdly, to correct for market failures (World Bank 1993a; Jack 1999). Many public health programs, such as spraying to control for malaria, are public goods that only the government can provide. The benefits associated with public health programs, such as immunizations and spraying to control for malaria, provide the rationale for public spending on health care. If the externality is not taken in consideration, the cost of treatment to the individual may be too prohibitive, thereby reducing overall treatment. For example, providing free vaccinations against tuberculosis protects not only the individual against the disease, but helps to limit the spread of the disease. Since the poor are unable to pay for medical services they may forego immunizations, unless they are provided free.

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An important policy question is: Do budgets, particularly primary health care spending, really matter in achieving better health outcomes? Filmer, Hammer and Pritchett (1997) examined this issue. These authors use child (under -5) mortality rates as a proxy for health status, and they find that GDP per capita explain 80 percent of cross-national variation in child mortality and by adding other variables (such as female education and a number of cultural factors) they explain 95 percent of the variation in mortality. These authors find that public spending on health has not had a substantial impact on health status. In a review of the impact of public health spending in developing countries Musgrove (1996) concludes: “multivariate estimates of the determinants of child mortality give much the same answer: income is always significant, but the share in GDP, the public share in health spending, and the share of public spending on health in GDP never are.” McCarthy and Wolf (2001) report that public health expenditure appears not to be a good predictor of health outcomes in Africa; and that access rates to health services, clean water, education and sanitation are associated with good health outcomes. In a recent paper, Gupta, Verhoeven and Tiongson (1999) find that health care spending (as a percent of GDP) is not significant in explain- ing infant and child (under 5) mortality, but that it may explain as much as 4 percent of cross-country variation in health status. Filmer, Hammer and Pritchett (1997) also find that child mortality is not significantly lower where more spending is directed at local health centers and where people have more access to local services. World Development Report 2000/2001 points out that higher public expenditures on health, education and infrastructure in developing countries have not resulted in more or better services for the poor for two reasons: firstly, many of these programs are of low quality and are not responsive to the needs of poor, and, moreover, the benefit-incidence tends to be regressive and, secondly, the poor may have to incur relatively high costs (such as transpor- tation) to benefit from these “free” social services. Hence, policies

Vol. 33, No. 1 (January - June 2005), 149-176 Caribbean Studies 158 JOHN GAFAR and public expenditures that lead to higher incomes for the poor may well lead to better health outcomes in the long-run.

IV. Immunization Bos and Batson (2000:7) point out that immunization is a health output with a strong impact on child morbidity, child mortality, and permanent disability, and that it is a “proxy for the performance of the health system.” Bos and Batson (2000:8) further point out that immunization coverage “provide timely evidence of improvement and deterioration in current services”, and that immunization against a number of childhood diseases is a “uni- versally recommended, cost effective public health priority.” Immunizations are at the top of the list of health interventions in terms of cost effectiveness. Spending on children’s immunizations yields the largest gains in reductions of morbidity and mortality per dollar spent of any health expenditure (World Bank 1993a). Immunization rates have increased significantly in Guyana in the 1990s due to economic growth that led to increased public health expenditures. Table 2 presents the details. The statistics in Table 2 show a remarkable achievement for a poor country: the percentage of under one-year olds immunized against DPT increased from 63.7 percent in 1986 to 90.0 percent in 1998; the one-year olds immunized against measles, mumps and rubella (MMR) increased from 42.3 percent in 1986 to 92.8 percent in 1998; the under one-year olds immunized against polio rose from 67 percent in 1986 to 90 percent in 1998; and the under one-year olds immunized against tuberculosis increased from 75.5 percent in 1986 to 93 percent in 2000. Research has shown that within countries, lower immunization coverage is associated with poverty (Bos and Batson 2000). While coverage rates by income quintiles show the inequity of health coverage, they are less useful for identifying and targeting poor areas. Table 3 shows the percentage of children aged 12-23 months

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Table 2: Immunization: Percentage By Vaccine: 1986-2000 Vaccine 1986 1988 1990 1992 1994 1998 2000 Under 1 year olds immunized against DPT (%) 63.7 64.3 83.2 79.3 89.7 90.0 88.0 One (1) year olds immunized against MMR (%)1 42.2 55.0 72.9 73.4 82.8 92.8 85.0 Under 1 year olds immunized against Polio (%) 67.0 69.4 79.0 86.3 90.1 90.0 78.0 Under 1 year olds immunized against BCG (TB) (%)2 75.5 64.0 85.2 87.2 93.5 92.3 93.0 Source: Bureau of Statistics, Guyana: Statistical Bulletin (various issues). 1. Children between (12-23) months old. Measles, Mumps and Rubella (MMR). 2. Bacilli Calmecte Gudrin (BCG) and Tuberculosis (TB).

Table 3: Percentage of children age 12-23 months currently vaccinated against childhood diseases, Guyana, 2000

BCG DPT Polio MMR ALL Male 98.5 95.7 94.5 91.6 83.4 Female 97.3 95.4 94.7 91.7 86.8

Interior (rural) 95.9 91.4 91.6 90.7 72.0

Coast (urban) 95.7 92.9 93.5 91.1 88.3 Coast (rural) 99.5 97.8 95.8 92.2 86.6

Urban 95.9 92.9 93.5 91.1 88.3 Rural 98.8 96.5 95.0 91.9 83.7

Mother’s education None 89.9 92.5 89.9 82.6 69.8 Secondary + 98.7 96.0 95.1 92.8 86.0

Total 97.9 95.5 94.6 91.7 85.0 Source: Taken from Bureau of Statistics (2001), “Guyana: Multiple Indicator Cluster Survey” report, Table 18. We only include the DPT and Polio first dose. We omitted the DPT and Polio second and third doses. There was a drop-off in the vaccination rates for the DPT and Polio second and third doses respectively.

Vol. 33, No. 1 (January - June 2005), 149-176 Caribbean Studies 160 JOHN GAFAR currently vaccinated against childhood diseases in 2000. The data in Table 3 indicate that the rates of vaccination for children aged 12 to 23 months were quite high for a developing country. DPT and Polio require three doses; and the statistics summarized in the Bureau of Statistics MICS report indicate a dropping off of the vaccination rates for the second and third doses for DPT and Polio. There is no significant difference in the vaccination rates for males and females, or between urban and rural areas. However, the interior had consistently lower vaccination rates compared with the urban and rural coast. The data in Table 3 show that vaccination coverage is highest among children whose mothers had a secondary or higher education, in short, children of educated mothers are more likely to be vaccinated against childhood diseases. The relationship between immunization rates (of under 1 year olds) and public spending on health as a percent of the budget is given by the regression equations summarized in Table 4. The estimated regression equations in this paper are all estimated by the method of Ordinary Least Squares. The estimated health budget coefficients presented in Table 4 are all positive, greater than one, and statistically significant at the 10 percent level (one tail) and beyond. The regression equations suggest that increases in the health budget would lead to increases in the immunization rates in Guyana. Is there any relationship between immunization rates and per capita GDP (a proxy for growth)? We ran several regressions of the logarithm (log) of the immunization rate on the log of per capita GDP for the period 1986-2000. The results obtained are as follows. In the case of DPT vaccination the elasticity with respect to per capita GDP is 0.42 (with a t statistics – 2.32) and R2 = 0.39; for MMR vaccination the elasticity is 0.95 (t = 3.16) and R2 = 0.44; for polio vaccination the elasticity is 0.26 (t = 1.75) and R2 = 0.29; and for tuberculosis vaccination the elasticity obtained is 0.46 (t = 2.69) and R2 = 0.58. These results are robust and statistically significant at the conventional levels. Moreover, the

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Table 4: Immunization and Health Budget, 1990 – 2000 Health Dependent Variable Constant Exp. as % R2 S.E. D.W. of Budget Immunization Against 76.53 1.43* 0.31 3.7 2.79 DPT (16.01) (2.01)

Measles, Mumps & 68.01 2.24* 0.27 6.3 1.68 Rubella (8.33) (1.83)

76.34 1.39 0.24 4.3 1.17 Polio (13.74) (1.68)

81.15 1.49* 0.55 2.3 3.02 Tuberculosis (27.07) (3.32) Notes: An asterisk denotes statistically significant at the 5 percent level (one-tail test). correlations between the immunization rates and per capita GDP are much stronger and more robust than the correlations between the immunization rates and public health expenditures. This suggests that economic growth (rising per capita GDP)—more than public spending on health—provides the stimulus and dynamic for improving children’s health.

V: Malnutrition Malnutrition—whether due to stunting, wasting or deficient in iodine, vitamin A, iron or other micronutrients—is one of the severe global public health problems. WHO and the World Bank (2002) report that in 2000, 60 percent of all childhood deaths were due to malnutrition and in 1998 more than one-third of young children worldwide were stunted. Moreover, the World Bank and WHO point out that children in poor families are more likely to be stunted. For example, in Brazil 23.2 percent of the children of the poor (bottom income quintile) were stunted compared to 5 percent for the 3rdquintile, 3.9 percent for the 4th quintile, and

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2 percent for the 5th quintile (WHO and the World Bank 2002). Malnutrition is a manifestation of poverty, deprivation, low incomes, and increased vulnerability to infection and disease. Malnutrition can lead to delayed motor development in a child, impaired cognition, poor school performance, and later problems in reproductive health (WHO and the World Bank 2002). World Development Report 1993 (at pages 77-78) concluded: Links between nutrition and growth in child-hood persist into adulthood. Both height and weight affect the risk of adult mortality. For men and women at all ages, greater height is associated with greater survival. Stunted adults are at particularly high risk of cardiovascular disease and obstructive lung disease. Statistics on nutritional status of children in Guyana are limited, and not readily available. The 1971 and 1981 National Food and Nutrition Surveys found that 17.7 percent and 15.4 percent of children under 5 years of age suffered from mild/moderate malnutrition in 1971 and 1981 (IFAD 1982:115).2 The IFAD report noted that in 1981 “almost 40% of all East Indian children” were malnourished, “as compared to only 13% of all African children.” The IFAD (1982:119) Report concluded that whatever data set is used “there remains a significant gap between the nutritional status of East Indian children and African children,” and there exists a “similarly significant gap” in the nutritional status of rural and urban children. This is not surprising since the poverty rate for East Indians exceeds that of the Blacks, and poverty is more pervasive in the rural areas. The Inter-American Development Bank (2002) reports that there are certain socioeconomic characteristics associated with malnutrition in Guyana. First, ethnicity appears to be a “decisive factor” with overall malnutrition being the great- est among Indo-Guyanese. Second, age is related to malnutrition with children from 6 to 23 months having the highest incidence rates. And, thirdly, chronic malnutrition is pervasive in the interior where the indigenous Amerindian populations live. Low birth weight is directly correlated with poor nutritional status. In 1982 and 1984, 18.4 percent and 19.5 percent of births

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 163 were of low birth weight (Government of Guyana and UNICEF 1989). Data for 1988 show that 23.2 percent of the children under 5 years were malnourished, and that malnutrition accounted for nearly 32.3 percent of all pediatric deaths between 1984-88 (Government of Guyana and UNICEF 1989). Moreover, over 60 percent of children under 5 years of age in 1988 suffered from protein energy malnutrition (Government of Guyana and UNICEF 1989, Table 1). World Development Report 1993 (at p. 75) notes that protein-energy malnutrition “raises the risk of death and may reduce physical and mental capacity.” The World Bank (1993b) noted that in 1988 nearly 30 percent of the children attending the health clinics suffered from mild/moderate malnutrition. In Trinidad and Tobago the malnutrition rate is 6.8 percent and 14.5 percent in Jamaica (World Bank 1993b). Malnutrition is not evenly distributed among the various socio-economic groups. The 1992/93 Household Income and Expenditure survey shows that 28.2 percent of the poorest 20 percent of infants were mildly malnourished compared to 10.1 percent of the richest infants. In the case of Jamaica 14.3 percent of the poorest infants were mildly malnourished, compared to 6.8 percent of the non-poor (World Bank 1996). World Development Report 2000/2001 (p. 27) notes that a study of 19 countries found that stunting, wasting and being underweight are “higher among poor people in almost all countries.” Data on the nutrition status for the period 1992-2000 are summarized in Table 5. Data on birth weight are a proxy of the mother and infant’s nutritional status. The data show that approximately 12.7 percent of infants were estimated to weigh less than 2500 grams in 2000. This statistic is higher than the 9 percent average for the Latin America and Caribbean region (Bureau of Statistics 2001). The statistics in Table 5 indicate that the percentage of births with low birth weight fell by 53 percent between 1992 and 2000, which clearly suggests an improvement in the nutritional status of mothers and infants in the 1990s. Nutritional deficiencies lead

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Table 5: Nutrition, 1992-2000 DESCRIPTION 1992 1994 1995 1997 1998 2000 Low Birthweight (<2500g), % 23.9 19.0 15.3 14.8 14.1 12.7

Underweight for children under 5 years: - Moderate & Severe, % 23.6 - 21.7 16.1 16.0 13.1 - Severe, % 3.0 - 1.1 0.9 1.0 0.5

Overweight for children under - - 5.6 4.5 4.0 4.3 5 years, %

Females with low hemoglobin < 10 grams, % - - 31.0 29.8 19.0 18.0 Source: Bureau of Statistics, Guyana: Statistical Bulletin (various issues). to anemia (a good measure of undernutrition). The World Bank (1993b) reports that in 1990 over 76 percent of pregnant women attending health clinics suffered from mild/moderate anemia and approximately 61 percent of children in 1986 suffered from anemia. PAHO (2001) reports that the 1997 micronutrient survey showed that about 52 percent of pregnant women were found to suffer from anemia (compared to 76 percent in 1990), and that 40-55% of children, adolescents and adults suffered from iron deficiency anemia. Compared to 1990, this is an improvement. The data in Table 5 also show that the percentages of females with low hemoglobin (anemia) fell from 31 percent in 1995 to 18 percent in 2000. The Inter-American Development Bank (2002) reports that almost half of all anemia cases are viewed as “severe”, and that anemia is one of the primary causes of maternal death and childhood mortality. Three surveys in the 1990s provide information on the malnutrition situation in Guyana, to wit, the National Household Income and Expenditure Survey of 1993 (HIES), the 1997 Micronutrient Survey (MRS) and the Multiple Indicator Cluster Survey of 2000-01 (MICS). These surveys provide estimates of overall (weight-for-age), chronic (height-for-age or stunting)

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 165 and acute (weight-for-height or wasting) malnutrition. Children whose weight or height is more than two standard deviations below the median of the reference population are considered malnourished. Table 6 presents estimates of the prevalence of malnutrition in children under 5 years of age in Guyana for 1993, 1997, and 2000. The data in Table 6 show that overall malnutrition declined between 1993 and 2000, during a period characterized with strong economic growth. However, between 1997 and 2000 (when economic growth stagnated) there has been no discernable improvement in nutritional status of children. We now examine the malnutrition rates by geography, sex, age, and education. Table 7 presents the percentage of under-five children who are severely or moderately malnourished in 2000. The data in Table 7 show that boys are more likely to be malnourished than girls, based on all three measures of malnutrition. Malnutri- tion rates are higher in rural areas than in the urban areas. Chronic malnutrition is high in the interior. This is not surprising since in 1999 the poverty rate in the interior was 80 percent, in the rural areas it was 39.8 percent and 16 percent in the urban areas. Age is also related to malnutrition. The highest evidence of malnutrition is concentrated in the 12 months to 35 months age group, perhaps due to the combined effects of early cessation of breastfeeding, inadequate feeding and infectious disease. The data show that there is a direct link between malnutrition of children and mother’s education, in short, better educated women (who may have higher incomes) tend to have less undernourished children. Table 6: Prevalence of malnutrition in children under 5 years of age in Guyana

Overall Malnutrition Chronic Malnutrition Acute Malnutrition Survey (Weight-for-age) (Height-for-age) (Weight-for-height) HIES, 1993 18.3 12.4 7.7 MRS, 1997 11.8 10.1 11.5 MICS, 2000 13.6 10.8 10.6 Source: IDB (2002), Basic Nutrition Program, Project No. GY-0068. Rates shown are percentage below 2 standard deviations of the age and sex specific reference median.

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Table 7: Percentage of children under 5 years of age who are malnourished, 2000

Overall Malnutrition Chronic Malnutrition Acute Malnutrition (Weight-for-age) (Height-for-age) (Weight-for-height) Male 14.4 11.6 11.4 Female 12.8 9.9 9.7

Interior (rural) 10.4 19.5 4.0

Coast (urban) 10.3 6.2 8.6 Coast (rural) 15.9 10.9 13.0

Urban 10.3 6.2 8.6 Rural 14.9 12.5 13.3

Age Less than 6 months 3.1 7.2 6.8 6 to 11 months 5.5 5.2 6.8 12 to 23 months 16.0 13.5 15.2 24 to 35 months 15.9 9.5 10.4 36 to 47 months 14.2 13.5 11.4 48 to 59 months 15.7 9.9 10.8

Mother’s Education None 33.9 32.0 19.6 Secondary + 13.8 10.6 10.9 Total 13.6 10.8 10.6 Source: Bureau of Statistics (2001), “Guyana: Multiple Cluster Survey” Report Table 14. Rates shown are percentage below 2 standard deviation of the specific reference median.

VI: Trend in Health Outcomes What determines health outcomes? The various factors that determine health outcomes are: biological or physiological, life- style, and environmental. The genetic makeup of people influ- ences how long they live, how healthy they are, and the probability of getting certain illnesses. Gender also plays a role. Men and

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 167 women get different kinds of illnesses and conditions at different ages. Income plays a role in determining health performance. The availability and quality of health services also determine the health and nutritional status of the people. Macro-economic policies that affect growth ultimately influence the supply of health services. The poor tend to have less control and fewer choices in their lives. Pritchett and Summers (1993) find that there is a structural relationship between income and health, and the direction of cau- sality flows from income to health. In an authoritative study, World Development Report 1993, at page 41, concluded that “income growth leads directly to better health:, and in a sample of fifty- eight developing countries, “a 10 percent increase in income per capita, all else being equal, reduced infant and child mortality rates by between 2.0 and 3.5 percent and increased life expectancy by a month.” Education also affects health outcomes since it gives the people the information and knowledge they need to make better choices. Culture, customs and traditions also affect people’s health, because these factors help shape what people think, feel and do. Clean air and water, improved sanitation, public health and public safety, safe work place, and law and order all contribute to good health. Table 8 presents some measures of health performance for Guyana for the period 1985-2000. Gafar (2003) reports that for every indicator summarized in Table 8, Barbados, Jamaica and Trinidad and Tobago out-perform Guyana. Haiti, followed by Guyana, has the worst health conditions in the Caribbean. One key indicator of a nation’s health status is life expectancy. Life expectancy at birth indicates the number of years a newborn baby would live if prevailing patterns of mortality at the time of birth were to remain the same throughout the child’s life (World Bank 1993a). Higher life expectancies can be achieved by either reductions in infant mortality rates or reductions in adult mortality rates, or a combination of both. Life expectancy, or survival rate, measures mortality rates rather than morbidity. The World Bank (1998) reports that life expectancy has increased worldwide since 1970, on average by 4 months each

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Table 8: Trend in Health Indicators, 1985-2000 Crude Crude Life Infant Daily Birth Death Expectancy Mortality Daily Calorie Protein Rate (per Rate (per at Birth Rate (per Intake2 Intake thousand)1 thousand) (years)1 thousand)1 (grams)2 1985 25.5 6.6 64.0 43.9 2426.4 38.1 1986 24.0 8.0 63.0 45.3 2304.0 34.7 1987 24.0 8.0 63.0 49.0 2124.0 36.3 1988 26.1 8.0 63.3 47.0 2088.1 34.0 1989 26.5 7.9 65.2 45.0 1920.0 29.3 1990 26.0 8.0 65.0 45.0 2271.9 28.7 1991 24.2 6.9 65.0 43.0 2277.6 30.8 1992 24.1 7.0 64.9 34.9 2339.3 37.8 1993 26.5 6.7 64.0 34.9 2409.7 43.2 1994 28.5 6.9 64.0 28.8 2369.4 43.4 1995 29.8 7.1 63.5 27.8 2454.4 47.9 1996 24.0 6.5 64.0 25.5 2401.4 46.6 1997 26.1 6.8 64.4 25.5 2466.0 50.8 1998 24.1 6.5 64.8 22.9 2475.8 51.7 1999 23.2 6.6 65.1 25.1 2569.0 53.6 2000 23.1 6.8 65.4 29.0 2582.0 53.9 Sources: 1. Taken from Bureau of Statistics, Guyana: Statistical Bulletin (various issues) 2. The data for the 1985-89 period are taken from Guyana: Statistical Bulletin (various issues) and for 1990-2000 period from Inter-American Develop- ment Bank, Guyana: Basic Socio-Economic Data; http://www.iadb.org. year. Second, infant mortality rates worldwide fell from 80 per 1,000 live births in 1980, to 54 per 1,000 in 1998. And, finally, women tend to outlive men by 5 to 8 years in the countries with the highest life expectancies, and by 0 to 3 years in the countries where life expectancy is low. In Guyana, there has been a steady increase in life expectancy during 1950 to 1980 (Gafar 2003). The Poverty Reduction Strategy Paper (PRSP) states that in 1980 life expectancy was 68 years, but this fell to 63 years in 1986, and it has increased gradually in the 1990s reaching 66 years in 2000. The gains in life expectancy since

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1950 are partly due to improvements in income and education, better nutrition, improvements in primary care (including safe water and better sanitation), advancements in medicine (anti- biotics and immunization), and treatment of disease. The life expectancy rates in Table 8 are national averages, and they do not necessarily reflect the comparable gains in all population groups by region (urban and rural), or by ethnicity. Female life expectancy in Guyana exceeds that of males by about 3 years. Ainsworth and Over (1997) report that the HIV/AIDS pandemic have reduced Guyana’s life expectancy considerably. According to these authors’ estimates Guyana’s life expectancy in 1996 was 5.2 years shorter than it would have been in the absence of AIDS, in the case of Haiti 5.7 years, and Brazil 5.3 years shorter. UNDP (1998:18) reports that life expectancy in Guyana in 1998 was 64 years and was projected to increase to 68 years (without AIDS) in 2010, but given the HIV/AIDS pandemic life expectancy in Guyana is now estimated to fall to 50 years in 2010. Life expectancy in the Caribbean is as follows: Barbados 76.6 years, Jamaica 75.1 years, Trinidad and Tobago 74.1 years, Dominican Republic 67.2 years, and Haiti 52.4 years (UNDP 1998). The crude birth rate has declined significantly since 1950 (Gafar 2003). Between 1985-1998, the crude birth rate has remained constant averaging 25.7 per 1,000. The crude death rate fell from 11.9 per 1,000 in 1950 to 8.8 in 1980. Between 1985-1998, the crude death rate averaged 7.2 per 1,000. This suggests that the natural rate of increase in the population was 1.85 percent per annum during 1985-1998, but the actual growth in the population was 0.6 percent per annum due to massive emigration. The data on infant mortality rates summarized in Table 8 show that infant mortality rates fell from 43.9 (per 1000 live births) in 1985 to 29.0 in 2000. The infant mortality rate in some Caribbean countries is as follows: Barbados 14, Jamaica 10, Trinidad and Tobago 17, and Haiti 83. The statistics in Table 8 do not tell us anything about infant mortality rates for the poor (the bottom 20 percent of the income distribution) compared to the wealthy

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(top 20 percent of the income distribution). World Development Report 2000/2001 states that in South Africa the under-five mortality rate for the poor is twice as high as the rate for the rich; and in Northeast and Southeast Brazil, three times as high. Gwatkin (2000) reports that for developing countries the infant mortality rate of the poor is roughly two to four times higher than that for the wealthy population. Maternal mortality rates in Guyana fell from 230 per 100,000 in 1985 to 125 in 1998 (PAHO 2001). The average daily per capita caloric intake fell below the benchmark of 2,400 calories in the 1980s, reaching a low of 1,920 calories in 1989. However, since 1990 there has been an increase in the average per capita caloric intake, reflecting the benefits of increased household incomes and economic growth. Guyana’s average daily supply of calories is below that of the English speaking Caribbean countries. In 1997 the average daily per capita supply of calories in Barbados was 3,176, Jamaica 2,553, Trinidad and Tobago 2,661, and Haiti 1,869 (Gafar 2003). The average daily protein intake fell from 38.1g (grams) in 1985 to 28.7g in 1990. However, by 1998 the average daily protein intake increased to 51.7g (for both sexes). World Health Organi- zation (1985) recommended the following daily protein requirements: 56g a day for men and 48g for women. This translates to approximately 52g for both sexes. The low level of protein intake in Guyana can be partly explained by the fact that East Indian diets consist primarily of pulses (peas, beans, and lentils) and lots of grains (rice) which are low in proteins. The low levels of protein intake are also a manifestation of low-income levels and poverty. The relationship between the health indicators and per capita GDP is given by the various regression equations summarized in Table 9. We also computed the correlations of the various health indicators with respect to the share of health expenditures of the national budget, but we found that the correlations with respect to per capita GDP were more robust, hence, only these results are reported. The regression equations in this paper are all estimated

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 171 by the method of Ordinary Least Squares (OLS). We now examine the results summarized in Table 9. The estimated regression coefficients may be biased because of endogeneity, measurement errors and omitted variables. There exists a robust statistically significant relationship between per capita GDP and the crude death rate, infant mortality rate, caloric intake and protein intake. In short, these results show that these health indicators improve with economic growth. The relationship between life expectancy and income is negative and not significant. Our results confirm those reported by Easterly (1999) who finds that infant mortality, calorie intake and protein intake are significantly related to income, and life expectancy’s relation to income is negative and not significant. The limited econometric evidence summarized in Table 9 suggests that a 10 percent increase in per capita GDP in Guyana will result in a 7 percent reduction in the crude death rate, 16.8 percent reduction in infant mortality rate, 3.7 percent increase in the average daily per capita caloric intake, and a 13.4 percent

Table 9: Health Indicators and Per Capita GDP, 1985-2000 Log of Per- 2 Log of Dependent Variable Constant capita R S.E. D.W. GDP 4.22 -0.01 Life-expectancy 0.01 0.02 1.38 (7.07) (0.15) 3.95 -0.07 Crude Birth Rate 0.02 0.07 1.22 (3.17) (0.58) 5.66 -0.37* Crude Death Rate 0.47 0.06 1.33 (5.36) (3.50) 20.48 -1.68* Infant Mortality Rate 0.85 0.11 1.74 (10.86) (8.99) Daily Per-capita caloric 3.99 0.37* 0.54 0.06 1.34 intake (4.28) (4.04) Daily Per-capita protein -9.89 1.34* 0.93 0.05 1.42 intake (9.80) (13.47) Notes: * denotes statistically significant at the 5 percent level and beyond. Absolute t values are denoted in parentheses.

Vol. 33, No. 1 (January - June 2005), 149-176 Caribbean Studies 172 JOHN GAFAR increase in the average daily per capita protein intake. There exists a weak and positive correlation (r = 0.25) between caloric intake and life expectancy, a significant negative correlation (r = -0.78) between caloric intake and the crude death rate, and a robust negative correlation (r = 0. 79) between caloric intake and infant mortality rate. In short, nutrition matters. Behrman (1996) examined the effects of caloric intake on life expectancy and other health indicators for Latin America and Caribbean countries. According to Behrman’s econometric results, an increase of 100 calories per day per capita is significantly associated with an increase in life expectancy at birth by 0.6 years and reductions in the following: infant mortality rate by 3.9 per 1,000; the risk of dying by age five by 4.6 per 1,000 live births; and the percentage of births with low birth weight by 1 percent.

V: Conclusion There are a number of findings that are worth re-stating. First, in the 1980s the health budget was significantly reduced because of the dismal economic performance. By 1991 only 1.9 percent of the budget was allocated for health expenditures, but, between 1992-98 public health spending averaged 6.8 percent of the national budget. In 1985 total health expenditures as a percent of GDP was 2.68 percent, but this increased in the 1990s averaging around 4.3 percent of GDP. However, this is well below the Latin America and Caribbean regional average of 6 percent of GDP. Second, there was a worsening of the health indicators for Guyana in the 1980s. However, since 1990, life expectancy has increased, and malnutrition and infant mortality rates have fallen. Third, the econometric results indicate a significant relationship between per capita GDP and the crude death rate, infant mortality rate, caloric and protein intake in Guyana. Hence, economic growth leads to improved health. Fourth, immunization rates increased significantly in Guyana in the 1990s and malnutrition rates of children have also declined in the 1990s. Fifth, there is a link between education and health outcomes. The data show

Caribbean Studies Vol. 33, No. 1 (January - June 2005), 149-176 THE IMPACT OF ECONOMIC REFORMS... 173 that malnutrition rates are lower, and the immunization rates are higher for children of educated women. Finally, the weight of the cumulative evidence suggests that there was a real improvement in the health indicators in Guyana during the period of economic reforms and economic growth in the 1990s.

Acknowledgement The author wishes to thank Dr. Roy and the two referees of this journal for their comments, and also Mr. Dharem Seelochan, Bureau of Statistics, Guyana for providing me the report on the Multiple Indicator Cluster Survey. The usual disclaimer applies.

References

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Gafar, J. 2003. Guyana: From State Control to Free Markets. New York: Nova Science Publishers. Government of Guyana. 2001. Poverty Reduction Strategy Paper, mimeo. Government of Guyana and United Nations Children’s Fund. 1989. An Analysis of the Situation of Children and Women in Guyana. George- town, Guyana: Department of International Economic Co-operation, Office of the President (mimeo). Gupta, S., M. Verhoeven and E. Tiongson. 1999. “Does Higher Govern- ment Spending Buy Better Results in Education and Health Care?” WP/99/21. Washington, D.C.: International Monetary Fund. Gwatkin, D. 2000. “Health Inequalities and the Health of the Poor: What do we Know? What can we Do?” Bulletin of the World Health Organization 78 (I): 3-18. Inter-American Development Bank. 1996. Economic and Social Progress in Latin America 1996 Report, distributed by The Johns Hopkins University Press for the Inter-American Development Bank, Wash- ington, D.C. Inter-American Development Bank. 2002. “Guyana: Basic Nutrition Program”, Project No. GY-0068, April 23, 2002. (http://www.iadb. org). IFAD (International Fund for Agricultural Development). 1982. A Food Sector Strategy For Guyana: Report of The Special Programming Mission. Rome, Italy: International Fund for Agricultural Develop- ment. Jack, W. 1999. Principles of Health Economics for Developing Countries. Washington, D.C.: The World Bank. McCarthy, F. and H. Wolf. 2001. “Comparative Life Expectancy in Africa.” Washington, D.C.: The World Bank. Musgrove, P. 1996. “Public and Private Roles in Health: Theory and Financing Patterns.” World Bank Discussion Paper No. 339. Wash- ington, D.C.: The World Bank. PAHO (Pan American Health Organization). 1993. Health Conditions in the Americas 1994: Guyana (draft), prepared by PAHO/WHO Guyana Office, April 1993, mimeo. . 1998. Health in the Americas: Guyana II (569). Washington, D.C.: Pan American Health Organization.

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. 1999. Guyana: Health Systems and Services Profile. (1st edition, February 25, 1999). (http://www.paho.org). . 2001. Health Systems and Services Profile of Guyana (2nd edition, December 14, 2001). (http://www.paho.org). Pritchett, L. and L. Summers. 1993. “Wealthier is Healthier.” Policy Research Working Paper. WPS 1150. Washington, D.C.: The World Bank. Seales, I. 2004. “Cataract Surgery Backlog at 5,000 – Some Waiting for Two Years.” Stabroek News, November 21. United Nations Development Programme (UNDP). 1998. Human Devel- opment Report 1998. New York: Oxford University Press for United Nations Development Programme. World Bank. 1993a. World Development Report 1993: Investing in Health. New York: Oxford University Press for the World Bank. . 1993b. Guyana: From Economic Recovery to Sustained Growth. Washington, D.C.: The World Bank. . 1994. Guyana: Strategies for Reducing Poverty. Report No. 12861-GUA. Washington, D.C.: The World Bank. . 1996. Caribbean Countries Poverty Reduction and Human Resource Development in the Caribbean. Report No. 15342-LAC. Washington, D.C.: The World Bank. . 1998. “Life Expectancy.” (http://www.org/depweb/social/ life). . 2001. World Development Report 2000/2001: Attacking Pov- erty. New York: Oxford University Press for the World Bank. . 2002. Guyana: Public Expenditure Review. Report No. 20151-GUA. Washington, D.C.: The World Bank. World Health Organization. 1985. “Energy and Protein Requirements.” WHO Technical Report Series 724. Geneva: World Health Organi- zation. . 1998. The World Health Report 1998: Life in the 21st Century: A Vision for All. Geneva: World Health Organization. and The World Bank. 2002. Better Health for Poor Children. (http://www.who.org).

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Notes

1 This section is based on the National Development Strategy 2000 and PAHO (1999). And this paper is based on Gafar (2003) Chapter 11. 2 The IFAD (International Fund For Agricultural Development) Report was prepared by a team of international experts led by Pro- fessor Eric Thorbecke.

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