PROGRESIVE REFORMS IN LATIN AMERICA Health Care in

Prem Misir, Ph.D., MPH, M.Phil, B.S.Sc.(Honours), FRSPH

Abstract antly asserted that the notion of universal health The paper is an overview of the Guyana healthcare coverage (UHC) is rooted in politics, ethics, and system, its outcomes, health planning, health re- international law.1 Sachs validated the roots of UHC forms, potential health reforms, and the govern- in Article 25 of the 1948 Universal Declaration of ment’s contribution to the development of an effi- Human Rights; this states that every person has a cient and equitable health system for the entire pop- fundamental right to a standard of living adequate ulation. The current institutional arrangements for for health2; Sachs also invoked the WHO Constitu- health system and service development in Guyana tion which states that: “The enjoyment of the high- pose significant challenges requiring significant est attainable standard of health is one of the funda- health planning to achieve meaningful health re- mental rights of every human being without distinc- forms. The Health Systems Assessment (HSA) re- tion of race, religion, political belief, economic, or viewed the Guyana healthcare system’s functioning social condition.”3 on six modules consistent with the WHO’s system The consensus that every human should have ad- building blocks - governance, health financing, ser- equate access to quality healthcare begins to unravel vice delivery, human resources for health (HRH), in many countries during the process of actually de- pharmaceutical management, and health information signing, managing, and financing healthcare. For systems (HIS); these are in synchrony with WHO’s instance, in the United States of America (U.S.), the concept of reform. The HSA review identified areas objectives of the 2010 Patient Protection and Af- for health reform through the WHO’s system build- fordable Care Act (ACA or Obamacare) were to ing blocks. The paper reviews the history of health reduce the number of uninsured, improve access to plans and reforms in Guyana to establish the influ- affordable healthcare, remove the concept of impos- ence of neoliberalism in the pathway toward univer- ing higher insurance premiums on people with pre- sal health coverage and equity. existing conditions, and reduce total healthcare costs through focusing on quality not quantity.4 U.S. con- Introduction servative stakeholders rejected Obamacare and uni- Health policy globally has endorsed the twin versal health coverage because they see health in- goals of universal health coverage and equity in surance as a commodity in a free market economy promoting better health for all. Jeffrey Sachs poign- where neoliberalism is the dominant ideology. The inefficiencies and inequities resulting from Prem Misir, Ph.D., MPH, M.Phil, neoliberal healthcare reforms imposed by the World B.S.Sc.(Honours), FRSPH Bank and the International Monetary Fund in the Executive Director 5 Health Sector Development Unit (HSDU) 1970’s and 1980’s have been well documented. Ministry of Health, Government of Guyana The fundamental principle governing neoliberal Georgetown Public Hospital Compound health reforms is the view that the private sector is East & Lamaha Streets, Georgetown, Guyana more efficient than the public sector. This implied Tel: (592) 225-9287 that the role of government should be minimal; the

Submitted: 3/12/2014 World Bank felt the neoliberal state should restrict Accepted: 6/18/2014 government’s role to regulating health while the Conflict of interest: None private sector should be the provider of healthcare Peer-reviewed: Yes services.6 These reforms were carried out by two

Social Medicine (www.socialmedicine.info) - 36 - Volume 9, Number 1, February 2015 key processes: decentralization and privatization. In The historical context of health reforms this way, governmental funds would be released to Guyana like many former British colonies expe- pay off the government’s huge public debt, the rea- rienced the full wrath of colonialism on the political, son the World Bank’s loan had been initially social, and economic fronts; the health sector also sought.5 Reducing the government’s commitment to was not spared this fury. For instance, Turshen8 provide health services was the quickest way to pay observed that pervasive ill health and chronic mal- off the public debt, and decentralizing healthcare to nutrition were not simply domestic problems (just as the regions was presented as a way of transferring poverty was not), but were the consequences of co- power away from an apathetic and inefficient central lonialism. Ramnath9 traced early health policy de- bureaucrats to the local people (as part of a process velopment in the colonial Commonwealth Caribbe- of improving democracy).7 These processes were an (which included Guyana, Jamaica, and Trinidad not primarily designed to provide universal health and Tobago) as follows: the planters’ and the colo- coverage and equity in healthcare. Rather, they ful- nial authorities’ first priority was the sustainability filled the World Bank’s self-interested mission in of the plantation economy, initially under slavery reducing the state’s public debt. and later under indentureship; the medical profes- The former WHO Director-General Dr. Gro Har- sion, through the presence of British physicians and lem Brundtland7 noted that health systems should surgeons, served to legitimize the plantation society; reduce inequalities and adopt approaches that im- two significant developments in Great Britain - the prove the health status of the worst-off; further, she British Public Health Act (1848) and the Sanitary indicated that in order to determine whether the Commission Report (1869) - impacted colonial goals of equity and equality were being met, coun- health services; when the planters expressed their tries should utilize WHO measures for the perfor- unwillingness to provide healthcare to the freed mance of health systems based on their four func- slaves, the colonial authorities with a new mandate tions: service provision; providing human and phys- in the crown colony system provided some sem- ical resources to ensure delivery of services; procur- blance of public health services to them; and in the ing and pooling the resources employed to finance post-emancipation era, the mushrooming colonial healthcare; and government’s fulfillment of its medical profession controlled the practice of medi- stewardship role. cine and management of early public health activi- This paper reviews the development of health ties that later evolved into local ministries of health. plans and reforms in Guyana to establish the influ- Major health reforms did not come until 1945 ence of neoliberalism on the pathway toward uni- when the Moyne Commission10 exposed significant versal health coverage and equity. This paper pre- health concerns related to poverty; these included sents the historical context of health reforms from high infant mortality and widespread morbidity, the colonial era through the post-Independence peri- poor housing, inadequate sanitation, and undernour- od. The paper then describes the current socioeco- ishment. The Commission also expressed concern nomic context of health reform focusing on Guy- that curative services were afforded higher priority ana’s geography, social demographics, and econom- than disease prevention. It recommended ameliora- ic indicators. In addition, this paper reviews the tive measures vis-à-vis improvements in health, ed- Guyana health system, health outcomes, health ucation, welfare, and housing. In 1947, rural health planning, and health reforms. Further, this paper received a boost through agricultural workers’ com- discusses potential health reforms and the role of the pensation and the organization of medical services government. In the final section, the paper examines on the sugar estates. Also in the late 1940’s, the co- the challenges of health reform within the neoliberal lonial government engaged in a malaria-control paradigm, and suggests that the health reform pro- campaign that practically wiped out malaria on the cess should be a political project to counter the neg- coastland. Malaria, however, remained a threat to ative aspects of neoliberalism.

Social Medicine (www.socialmedicine.info) - 37 - Volume 9, Number 1, February 2015 the people in both the hinterland and coastland areas central level should have jurisdiction over nurse in the 1990’s.11 workforce planning and training: it would provide guidance at the regional level. To ensure an ade- Health reforms in the post-Independence period quate supply of physicians, the Ministry of Health’s (1970-1980) core policy was overseas recruitment. A small num- In a study on health human resources policy and ber of medical students were trained at the Universi- policy reform in the Commonwealth Caribbean, ty of the West Indies, in North America, and the Ramnath9 reviewed policy reforms in planning, UK. Nonetheless, a shortage of physicians remained training, administration and management in Guyana a problem. between 1970 and 1980. Administration and Management Reform Plans The 1982 Neal Report examined the administra- The Ministry of Health in 1969 set up a planning tive failure of the previous decade, pointing to the unit that developed a 10-year plan called A Blue- failures of planning, production, and management print for Action in 1970. The plan employed region- /utilization. The end result was a system lacking the alization to address five levels of care, with levels ability to coordinate and properly staff the health one and two intended to provide primary care ser- service in the 1970s. In addition, bureaucratic politi- vices to the indigenous people in the hinterland and cization with its concomitant inefficiencies and in- levels three, four and five to provide secondary and competence, the devastating migration of health per- tertiary care services to the urban areas. Five health sonnel, and inadequate backing for public sector regions nationally were to be established to imple- non-People’s National Congress (PNC) party sup- ment these services; and two administrative levels – porters destroyed any hopes that the 1970 health regional and central - were set up. The Ministry of plan might actually be implemented. Health was the central body responsible for policy Summarizing Guyana’s experience with making and regulation. The proposed health reform healthcare reform in the 1970’s, Ramnath conclud- was expected to provide an equal focus on preven- ed: “The parlous state of the health system at all tive and curative aspects of diseases, with equal ac- levels - human, physical and material - by the end of cess to healthcare, and attribution of high priority to the 1970s therefore reflected not only economic cir- human resources development. These reforms had cumstances, but a clear case of neglect and lack of not been implemented by the close of the 1970s. commitment to policy implementation by the re- The Neal Report 1982 observed that human re- gime. This neglect was partly understandable given source development devoid of planning and man- the economic as well as political predicament facing power development persisted without any connec- the regime at that time. […] Attempts at developing tion to the needs of the healthcare system. and implementing a comprehensive human re- sources policy for the health sector under these con- Human Resources Development ditions were therefore limited and ad-hoc at best, The 1970 health plan indicated that appropriate and both negligible and negligent at worst.”9 training programs would support human resources During the 1980’s, the PNC Government tried to development. The Medex training program (to pre- implement its socialist philosophy through a pare local mid-level healthcare practitioners) was healthcare reform based on primary healthcare; the created in 1977, followed by the Community Health goal was to provide accessible care for all. But the Worker training program in 1979. Both programs 1980 budget allotted only 5% of funds to health, were weakened in the 1980s by reductions in with as much as 10% going to security. The Gov- healthcare spending driven by the Government’s ernment’s priorities were clearly oriented more to- concern for its political survival. The health plan ward political survival instead of health reform.12 had also indicated that the Ministry of Health at the The result was increased physician and nurse migra-

Social Medicine (www.socialmedicine.info) - 38 - Volume 9, Number 1, February 2015 tion. Undoubtedly, nurses and physicians experi- line.” Guyana’s land boundaries measure 2,949 kil- enced work turbulence during the 1980-1990 period; ometers, with land borders of 1,606 kilometers with Spinner12 notes that some doctors communicated Brazil, 743 kilometers with Venezuela; and 600 kil- with the Minister of Health about gross shortages of ometers with Suriname. everything that would make quality healthcare pos- People of diverse ethnic origins arrived in Guy- sible. In a context marked by worsening working ana to work on the sugar plantations, initially as conditions and inadequate emoluments, highly slaves and later as indentured laborers. Based on the skilled nurses migrated as soon they emerged from high variant assumption, Guyana’s population is nursing training programs.13 estimated at 808,309 for 201514 with the following Notwithstanding the undemocratic and resource- projected age distributions for 2015: 0-14 years: scarce environment, the Government was interested (male 102,438 (12.6%))/female 101,818 (12.5%)); in resolving the problem of physician shortage aris- 15-64 years: male 275,773 (34.1%)/female 271,094 ing from migration.9 Since 1973 the Guyanese Gov- (33.5%); and 65 years and over: male 25,461 ernment had sent only 5 students at full-cost schol- (3.1%)/female 31,724 (3.9%). Indeed, Guyana has a arships to the University of the West Indies Medical youthful, but ethnically diverse population. The School in Jamaica. This number was insufficient to population distribution in 2002 was as follows: East produce an adequate supply of physicians, and so Indian (43.46%); African (30.20%); Amerindian the Government decided to create a medical school (9.16%); Portuguese (0.20%); Chinese (0.19%); within the Faculty of Health Sciences by September White (0.08%); and Other (0.01%).15 1985. Today, the University of Guyana School of Guyana’s per capita income in 2012 was US$ Medicine has provisional CAAM-HP accreditation. 3,340. In that year the Gross Domestic Product Reflecting on the PNC record on health, several (GDP) grew 4.8%. The unemployment rate was of the PNC Government’s health reform policies 11% in 2007,16 and the literacy rate was 91%.17 In between 1970 and 1990 were laudable, but many of 2010, about 90% of the population had access to them also were not implemented. As a consequence, improved water and about 85% to improved sanita- health policy remained an ad-hoc affair as it had tion.18 been during the colonial period. The country’s stable macroeconomic fundamen- tals and improved sanitation are appropriate plat- The current socioeconomic context of health forms for the health sector’s take-off, the latter reforms largely as a result of Guyana’s gaining from En- A paradoxical feature of Guyana is that despite hanced-Highly Indebted Poor Countries (HIPC) ini- its huge land space of 83,000 square miles (approx- tiatives since 1997, producing a general decrease in imately 216,000 square kilometers), arable land is its external debt from 122% of the GDP in 2002 to scarce. Geographically, Guyana is situated on the 38% in 2008; the country’s HIPC status also ena- north-east coast of South America, with the Atlantic bled it to be the beneficiary of huge resources. How Ocean in the north, Suriname in the east, Brazil in much have these social and economic factors im- the south, and Venezuela in the west. pacted on the present health system? Guyana is positioned between 1 degree and 9 de- grees north latitude and 57 degrees and 61 degrees west longitude, and expands south to a depth of 450 The Guyana health system miles. Guyana has four natural regions: the low The public and private sectors are the main pro- coastal plain; the hilly sand and clay area; the high- viders of healthcare in Guyana. The Ministry of land region; and the interior savannahs. With about Health (MoH) is the major governmental provider 90 percent of its population on the coastland, it may and financier of healthcare. Guyana’s health system be accurate to not only see Guyana as the “land of is expected to be decentralized with the Ministry of many waters,” but also as the “land of the coast- Local Government and Regional Development man-

Social Medicine (www.socialmedicine.info) - 39 - Volume 9, Number 1, February 2015 aging, financing, and providing healthcare through Hospital, Dr. Balwant Singh’s Hospital, and Ana- the Regional Democratic Councils (RDC) and the mayah Memorial Hospital. Several non-govern- Regional Health Authorities (RHA) in 10 Adminis- mental organizations function within the private trative Regions. Currently, there is only one RHA in healthcare sector, but most tend to work within the country in Region 6. The MoH is expected to HIV/AIDS.18 The table shows the MoH and private provide guidance to the RDCs and RHAs. sector health facilities in the 10 Regions. Additional government agencies – the Ministries of Education, Agriculture, Local Government and Health outcomes Regional Development, and Amerindian Develop- Over the last 20 years, Guyana has enhanced the ment – support the MoH in healthcare provision. health status of its population improving the infant In 2009, there were 9 National Hospitals, 6 Pri- mortality rate (IMR) and life expectancy. World vate Hospitals, 21 District/Cottage Hospitals, 5 Re- Bank data suggest the following: life expectancy for gional Hospitals, 2 Specialist Hospitals, 1 Geriatric males at birth was 59 years in 1992 and 63 years in Hospital, 1 Rehabilitation Center, 211 Health Posts, 2011,19 for females it was 66 years in 1992 and 69 and 127 Health Centers.18 There is a private years in 201120; the crude death rate was 10 per healthcare sector operating under the jurisdiction of 1,000 persons in 1992 and 7 per 1,000 persons in the Health Facilities Licensing Regulation that de- 2011;21 infant mortality per 1,000 live births was 29 termines overall standards of care and practices. in 2011 and 44 in 199222; percentage of children Currently, there are seven private hospitals with aged 12-23 months receiving immunization against their associated clinics. The private hospitals are St. measles was 73 in 1992 and 99 in 201223; and the Joseph Mercy Hospital, Davis Memorial Hospital, percentage of children aged 12-23 months receiving Table: Health Facilities, 2010 Source: Inspectorate Department, Ministry of Finance Region 1 2 3 4 5 6 7 8 9 10 George- Total

town Health Post 43 19 29 8 1 3 24 16 51 18 0 212 Health 3 11 13 25 14 23 3 5 3 12 15 127 Center District 4 1 3 1 2 2 2 2 2 2 0 22 Hospital Private Hospital 0 0 0 0 0 2 0 0 0 0 6 7 National Referral Hospital 0 0 0 0 0 0 0 0 0 0 1 1 Regional Referral Hospital 0 0 0 0 0 2 0 0 0 0 0 2 Geriatric Hospital 0 0 0 0 0 0 0 0 0 0 1 1 Rehabilitation Center 0 0 0 0 0 0 0 0 0 0 1 1 Diagnostic Center (Hospital-based) 0 1 1 1 1 0 0 0 0 0 0 4 Total 50 33 47 36 18 33 29 23 56 33 24 382 Woodlands Hospital, Medical Arts Centre, Prasad’s immunization against DPT was 79 in 1992 and 97 in

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2012.24 There also is some control of the communi- Notwithstanding Guyana’s status as a low- cable diseases of Tuberculosis (TB), HIV, and Ma- middle income country with total expenditure on laria, but with disproportionate resources allocated health at 5.9% of GDP in 201127, the Guyanese to the HIV and AIDS programs. The health system healthcare system has had some vital upgrading. is still without a viable TB-HIV co-infection pro- Nonetheless, the current institutional structures of gram. the health system and services development in Guy- There were reductions in mortality from non- ana pose significant challenges requiring meaningful communicable diseases (NCD) between 2007 and health planning to achieve real health reforms. 2009,25 as NCDs not only accounted for most Several multilateral agencies are on board in deaths, but the rank ordering of NCDs as major Guyana to assist its health sector development re- causes of death remained practically unchanged dur- form; these are: Inter-American Development Bank ing this period. Compared with 2007, there were (IDB); World Bank (WB); Global Fund for AIDS, reductions in deaths in 2009 from Ischemic Heart TB, and Malaria (GFATM); Global Alliance for Diseases, Neoplasms, Diabetes Mellitus, and Heart Vaccines Initiative (GAVI); Canadian International Failure, and increases in deaths from Cerebrovascu- Development Agency (CIDA); China; ; Euro- lar Diseases and Hypertensive Diseases. pean Union (EU); United States Agency for Interna- Guyana’s control of TB, HIV, and Malaria does tional Development (USAID); Japan’s Development not compare well with the Caribbean region. In Cooperation Agency (JDCA); Presidential Emer- 201118, for instance, the prevalence of TB was 121 gency Program Fund for AIDS Relief (PEPFAR); per 100,000 population when the regional average US Centers for Disease Control and Prevention was 35; the prevalence of HIV was 814 per 100,000 (CDC); PAHO/WHO, UNICEF, UNDP, and population when the regional average was 319; and UNFPA. the incidence of malaria was 6049 per 100,000 pop- While the multilateral agencies provide support, ulation when the regional average was 194. Infor- it is the MoH which is the key player providing an mation from the World Bank showed that Guyana’s overall strategy and direction in the reform process. IMR as a health indicator was not as good as most The MoH had implemented two previous strategic of its CARICOM partners; for instance, in 2012, the plans between 2003 and 2012. These were the Na- IMR in Guyana was 29 per 1,000 live births while tional Health Plan (NHP) (2003-2007) and the Na- the IMRs for Barbados, Trinidad & Tobago, Jamai- tional Health Sector Strategy 2008 – 2012 (NHSS). ca, St. Lucia, Grenada, and St. Vincent & the Gren- These plans support the Poverty Reduction Strategy adines were 17, 18, 14, 15, 11, and 21, respective- (PRS), the National Development Strategy (NDS), ly.18 and the Millennium Development Goals (MDGs). A shortage of health professionals reduces access The NHP’s objectives28 were to reduce maternal to basic healthcare in the country. For instance, and infant mortality and morbidity rates; reduce WHO data18 suggest that in Guyana in 2005, there prevalence of HIV, TB, Malaria, and Dengue; limit were 2.1 physicians per 10,000 population; the re- non-communicable diseases such as Diabetes, Heart gional average was 20.4 physicians. There were 5.3 Disease, Cancer, and Accidents; manage mental nurses and midwives per 10,000 population; the re- disorders such as depression and substance abuse; gional average was 71.5. improve rehabilitation and intervention services for The Health Systems Assessment (HSA) found no the disabled; assure that the poor have equitable ac- comprehensive service provision assessment, result- cess to quality healthcare; foster intersectoral col- ing in incomplete information on the quality and laboration with the MoH; support healthy lifestyles; quantity of facilities and delivery of health services decrease risk factors contributing to poor health; and in Guyana.26 produce appropriate health systems to generate equi- table health outcomes.28 Health planning

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The vision of the NHSS was to enable “Guya- ratio was 250 per 100,000 live births.30 In 2009, pro- nese citizens [to] be among the healthiest in the Car- fessionally-trained attendants were present at 92% ibbean and South America.”28 The NHSS’s objec- of births.31 WHO data32 shows that other NHSS tives were to offer equitable access to quality con- health indicators were not met by 2011: Tuberculo- sumer-friendly health services. It focused on in- sis prevalence at 121 per 100,000, and incidence of creasing life expectancy to 68 years for both adult Malaria at 6049 per 100,000 population. By 2013, males and adult females; achieving the MDGs the NHSS exceeded its targets on immunization for through reducing maternal mortality to 80 per children aged 12-23 months for DPT (98%)33 and 100,000 live births, infant mortality to 16 per 1,000 Measles (99%).34 live births, child mortality to 25 per 1,000 live The many persisting challenges in Guyanese births; decreasing HIV prevalence to 1%, TB preva- healthcare underline the urgent need for health re- lence to 75 per 100,000, and Malaria incidence to form. Consumer demands and expectations for bet- 5,000 cases per year; providing better access to ter healthcare are increasing as a result of greater quality health services to reach 90% immunization health consciousness, unacceptable life expectancy, coverage of all antigens; assuring 95% access to and changing demographic patterns. Here are the healthcare within one hour from place of residence; challenges in the implementation of the NHSS having professionally-trained attendants at 95% of 2008-2012 that the Health Vision 2020 elucidates: births; satisfactory provision of medicines with 95% limited healthcare coordination failed to adequately availability of all items on the Essential Drug List; strengthen the health system; inappropriate selection and reducing disease burden from communicable of key interventions generated poor funding and and non-communicable diseases. The NHSS hoped inefficient usage of scarce human resources; lack of to achieve these targets through five strategies a management information system adversely affect- aimed at strengthening the health system. These in- ed health programming and strategic interventions; cluded decentralization, skilled workforce, leader- limited integration between the strategic plan, the ship and regulatory responsibilities of government, annual work plan, and lack of monitoring and evalu- sector management performance, and management ation resulted in a disconnect between the strategic information systems. objectives and their outcomes; and disproportionate The MoH’s current strategic plan is called financial resources were allocated to disease- Health Vision 2020, “Health for all in Guyana”: A focused programs to the disadvantage of capacity National Health Strategy for Guyana, 2013-2020.29 building. These challenges resonate with the prob- Health Vision 2020 will strive to advance the health lems of coordination in the 1970s, as indicated in of Guyanese, lessen health inequities, and develop the above section on “Health reforms in the post- the management and delivery of evidence-based, Independence period (1970-1980).” people-responsive quality healthcare. The MoH ex- Health planning since 1978 has targeted efforts pects to pursue these goals through universal health to increase equitable access to quality healthcare coverage and action on the social determinants of through its focus on primary healthcare and univer- health. sal health coverage.35 The Government’s policy on While Vision 2020 mentions some of the chal- health is guided by the Poverty Reduction Strategy lenges faced by prior plans, it fails to address sever- Paper with health outcomes from 28 core poverty al of NHSS 2008-2012 unmet key health indicators. indicators, sustaining total health expenditure at World Bank data demonstrate that several NHSS about 5.9% of GDP since 2011,36 as well as by the 2008-2012 key health indicators were not met: by Millennium Development Goals, CARICOM Nas- 2011, life expectancy at birth for adult male/female sau Declaration, the Port of Spain Declaration on was 63/69, infant mortality at 29 per 1,000 live Non-Communicable Diseases, Health initiatives of births, under-five mortality 35 per 1,000 live births; Union of South American Nations, and the WHO HIV prevalence was 1.3; and maternal mortality Constitution.

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available for HIV and AIDS. The HSA recommend-

Health reforms ed that: The WHO sees reform as raising the efficiency, Health financing could be strengthened in Guy- effectiveness, quality, equity, and financial strength ana by strengthening the existing need-based of health systems.37 In 2010, the HSA reviewed the budgeting system; empowering the new RHA Guyana healthcare system functions based on six structures by handing over control of health ex- modules consistent with WHO’s health system penditures to RHAs; strengthening the Financing building blocks: governance, health financing, ser- Technical Working Group (TWG) to coordinate vice delivery, human resources for health (HRH), improved resource allocation across the health pharmaceutical management, and health information sector, including between the MoF, MoH, and systems (HIS).38 These six modules are in syn- development partners; and ensuring data availa- chrony with the WHO’s concept of reform. The au- bility for decision-making, such as regular data thor uses the HSA report 2010 on these six modules from National Health Accounts estimations.38 to identify areas for health reform.

Service delivery Governance The health system with responsibility for service The National Health Sector Strategy 2008-2012 delivery has shown improvements in these areas: provided leadership in the growth of healthcare in equity in service delivery, attracting skilled human the six modules, all having aspects of governance. resources, and updating infrastructure and technolo- In the first module on Governance, the MoH is rec- gy. These improvements have occurred largely ognized as the central authority controlling the tech- through a network of laboratories, publicly guaran- nical facets of health, and where administrative au- teed services, and the strong response to HIV and thority resides at the regional level. The move in AIDS. Gaps in service provision are in the lower 2006 to integrate administrative authority with tech- levels of care and in the hinterland. nical oversight produced a pilot Regional Health

Authority in Region 6, which still does not have au- Human resources for health (HRH) thority over many aspects of health. Nonetheless, To counter high attrition rates in the health sec- the RHA brought some new components to the table tor, the Government has been increasing the number including the creation of regional health manage- of health workers. There are some successes in ment committees that provided citizen input on providing overseas education of doctors, and a simi- health delivery and service agreements. The HSA lar approach may be necessary to increase the nurs- recommended the assigning of RHAs to the Re- ing numbers and reduce the nurses’ attrition rate. gions. In 2015, Region 6 remains the sole region There is need to enhance worker retention and quali- with a health authority. ty through incentive systems, improving continuing

education programs, and formulating more efficient Health financing human resource management protocols. One of the- Governmental funding flows through the Minis- se protocols could be the availability of information try of Finance to the 10 Regions (via RDCs and re- on health worker movement, training, and salaries; gional health offices) and to the Georgetown Public such information would support evidence-based Hospital Corporation (GPHC). Other funding healthcare worker retention programs. sources are external donors, private expenditure through the National Insurance Scheme, and out-of- Pharmaceutical management pocket family spending. Government health expend- The Government’s engagement with external itures have doubled since 2005, with increased capi- donors such as The Global Fund and others has im- tal expenditures on new facilities and for rehabilitat- proved its capacity to procure, store, manage, and ing old facilities. Considerable funding flows are distribute medicines and medical supplies. The

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USAID-funded Supply Chain Management System The health system needs effective mechanisms to project has provided support to the MoH’s Materials monitor and coordinate drugs, facilities, dispensaries Management Unit. For instance, MoH now has pa- at regional storage outlets, donors’ pharmaceutical tient care protocols and a revised Essential Drugs management activities, and improved organization List. There are, however, challenges relating to of the Logistics Management Information Systems monitoring of drugs, facilities, and dispensaries at on requisitions, communications, and supply man- regional storage outlets, inappropriate coordination agement. of donors’ pharmaceutical management activities, The HSA report also alluded to the need to insti- and better streamlining of the Logistics Manage- tute RHAs with control over their own health ex- ment Information Systems on requisitions, commu- penditures and general autonomy for regional nications, and supply management. Resolution of healthcare in the 10 . For about these challenges would enhance quality assurance of eight years now, there has only been one RHA. drugs and provide timely delivery to health units. The Government’s contribution Health information systems (HIS) The Government of Guyana through Health Vi- The MoH has several Health Information Sys- sion 2020 has a pivotal responsibility to promote the tem-related initiatives such as the Guyana Health well-being of the Guyanese people, decrease health Information System (GHIS), Computerized Mainte- inequities, and upgrade the management and deliv- nance Management System, Warehouse Manage- ery of quality healthcare. Two strategic pillars - uni- ment System, HRH databases, and e-health initia- versal health coverage and the social determinants tives. The NHSS 2008-2012 propelled these initia- of health – speak to these responsibilities. The uni- tives. The new strategic plan in 2013 will need to versal health coverage pillar would facilitate a re- develop a monitoring and evaluation database. newal of primary healthcare while the social deter- minants of health pillar would focus on building Potential health reforms strategic partnerships and health promotion. The HSA report in 2010 outlined several chal- The World Health Report 200037 pointed out that lenges to delivery including the need to improve governmental stewardship of health involves: health coordination between programs, quality assurance policy formulation where the vision and policy di- monitoring, and client feedback; better management rection are defined; framing regulations to govern of health facilities and incorporation of standard the behaviors of employees within the health system operating procedures; and enhancement of the Na- and make sure that they are in compliance with the tional Referral System with the introduction of rules; and establishment of a strong information standard treatment guidelines. The need-based management system which would allow for better budgeting system could be improved and the Na- information and understanding of the total health tional Health Accounts could also provide regular system. In Guyana, the responsibilities of the gov- information to the health sector. In terms of the need ernment are in policy formulation, regulation, in- to reduce inequity in quality healthcare, there is formation management, financing, and the delivery growing urgency to provide better access to the poor of strategic public health. Health Vision 2020 notes and vulnerable and particularly to people in the hin- that strategic and policy formulation will be coordi- terland region where access and geographic mobility nated through a National Health Policy Committee, pose momentous challenges. The Government of and the implementation of the other four functions Guyana also faces enormous challenges in terms of through an Administration and Management Direc- human resources for health; there is a current con- torate and a Technical Health Directorate; and data cern over the shortage of nurses, analogous to the will be gathered largely through the Monitoring and 1980-1990 period. (see above). Evaluation (M&E) framework and an M&E plan.

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Conclusion privatization within a neoliberal framework. The Over the last decade, Guyana’s health policies health sector reform process in Guyana, thus, has to set forth in the National Health Plan (NHP) (2003- be a political project if it is to avoid the harmful ne- 2007) and the National Health Sector Strategy 2008 oliberal consequences because many people do not – 2012 (NHSS), and most recently Health Vision have health coverage and in some cases, limited real 2020, have supported the goals of universal health access to healthcare. The poor and vulnerable will coverage and equity. However, with no formal eval- become victims of privatization as they may not uation of these plans’ health outcomes, it is difficult have sufficient social assets, such as, education, in- to evaluate the reality of universal health coverage come, and health to compete in a privatized system and equity in the health sector. Without performance dominated by a neoliberal ideology which sees evaluations, even the potential and role of the lone 8 healthcare as a commodity in a free market and not year-old RHA as the overall driver of major trans- as a fundamental human right. formation of the Guyana health system remains in- determinate. References The underlying principle of the RHA approach 1. Sachs JD. Achieving universal health coverage was that decentralization would enable popular in- in low-income settings. Lancet. 2012;380:944-7. put to guide the healthcare system. However, if the doi: 10.1016/S0140-6736(12)61149-0. RHA approach is embodied within a neoliberal ide- 2. United Nations. The Universal Declaration of ology with the ultimate outcome of privatization, Human Rights: [Internet]; 1948 [cited 2012 May then the lessons of failure from Latin American ne- 1]. Available from: http://www.un.org/en/documents/udhr/. oliberal health reforms in the 1970s and 1980s will 3. WHO. Constitution. Geneva: WHO, 1989: have been lost to the Guyanese health planners. For [cited 2014 Mar 15] Available from: instance, Colombia which complied with the World http://apps.who.int/iris/handle/10665/36851. Bank neoliberal reform blueprints and even with its 4. Savel RH, Munro CL. Current state of health high health expenditures found that a huge part of its care reform: Dysfunctional government, divided population had no health coverage and the poor en- country. American Journal of Critical Care. dured enormous difficulties to access healthcare. 39 2014;23:100-2. In the neoliberal model, privatization emerges 5. Homedes N, Ugalde A. Why neoliberal health through government-sanctioned decentralization; reforms have failed in Latin America. Health but experience shows that privatization ends up Policy. 2005;71:83-96. doi: 10.1016/j.healthpol.2004.01.011. PubMed hurting historically disadvantaged groups. To be PMID: 15563995. effective the RHA approach would require direct 6. Ugalde A, Homedes N. La clase dominante government strategy and direction, particularly giv- transnacional: su rol en la inclusión y exclusión en the presence of a large number of neoliberal mul- de políticas en las reformas sanitarias de tilateral agencies in Guyana helping with health sec- América Latina. Cuad méd soc(Ros). 2002:95- tor development reform. 110. In addition, in the World Bank’s neoliberal mod- 7. The world health report 2000 - Health systems: el, the health sector attains maximum efficiency improving performance. [March 18, 2014]. through privatization under government regulation; Available from: but in many poor and even some advanced nations, http://www.who.int/whr/2000/en/. 8. Turshen M. The impact of colonialism on health governments may not have adequate regulatory ca- 39 and health services in Tanzania. International pacity. And so, privatization with a decentralized journal of health services : planning, framework (like the RHA) could be deleterious in administration, evaluation. 1977;7:7-35. the setting of inadequate state control. While decen- PubMed PMID: 319069. tralization is intended to mobilize the people’s input in healthcare, it could also be fully controlled by

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