Download - Hedwig Goede - Mapeo APS Guyana-Suriname
Mapping of PHC experiences in Guyana and Suriname
Hedwig Goede ISAGS consultant
Conferencia a linea Atención Primaria en Salud Rio de Janeiro 13-15 May, 2014
different health systems and different governance of health sector
Guyana and Suriname: Similarities -Shared geography,
shared colonial background,
some similarities of the population: small size, low population density
and specific geographic distribution, ethnic composition
Differences Suriname unique ethnic mix with population
from Java/Indonesia + Maroon population
Guyana considerable decentralized, Suriname centralized; in process of establishing local governance
Political development as independent state
Population at a glance GUYANA SURINAME
Population (source: nat. stats. Bureaus)
Total: less than 800,000 Total coastal: + 85% urban: + 28% rural coastal: + 62% Rural hinterland: + 9% Pop. density: 4/sq km (land mass: 215,000Km² )
Net migration: -32,770 (source: World Bank 2009-2013)
Total: more than 530,000 Total coastal: + 85% urban: + 67% rural coastal: + 20% rural hinterland: + 13% Pop. density: 3/sq km (land mass: 163,820 Km² )
Net migration: -5,000 (Source: World Bank 2009-2013)
Economic indicators
Lower middle income GDP: 3,584 US$/capita (Source: World Bank 2009-2013)
Higher middle income (as of 2010) GDP: 9,376 US$/capita (Source: World Bank 2009-2013)
Health situation at a glance GUYANA SURINAME
Health indicators (PAHO/WHO)
Life expectancy: 64/69 IMR/1,000: 22.0 under5MR/1,000: 36.0
Life expectancy: 68/72 IMR/1,000: 15.1 Under5MR/1,000: 30.0
PHC facilities (source: MOH)
Total: 321 Coastal: 173 Hinterland: 148 (12 health centers)
Total: 263 Coastal: 209 (private: 146/RHS 63)
Hinterland: 56
HRH (source: PAHO)
MDs: 0.69/1000 Nurses: 1.01/1000 70% of MDs in capital
MDs national.: 1.3/1000 Nurses national: 1.86/1000 75% nurses in hospitals
THE 5.9% of GDP (WB) 9.9% reported over 2009
6.6% of GDP (WB 2009-2013) 8.5% reported over 2006
Geographic Distribution physicians Suriname 2010
0
0.2
0.4
0.6
0.8
1
1.2
Paramaribo Kustgebied Binnenland
1.1
0.3 0.2
physicians/ 1000 pop
Rapid changes and transitional phase
GUYANA SURINAME
return of large numbers of Cuban trained physicians
introduction of a national basic care insurance system (compulsary)
Dramatic changes in Hinterland: From mostly traditional villages to a transnational context due to the goldmining industry with different nationalities, undocumented migrants, transnational health challenges involving mostly the three Guyana’s and Brazil.
GUYANA SURINAME
Concept in national health documents
comprehensive view, but often referred to as primary level of care, PHC as foundation of health system since Alma Ata and survived as such over time
in official documents as a comprehensive strategy short after Alma Ata, followed by decline of comprehensive view , concept replaced by first line care, Start of renewal process at subnational level by PHC organizations
Constitution and legal documents
Right to free medical care included in constitution + duties of citizen in protecting health and environment
right to health included in constitution + duties of government in addressing social determinants and educating citizen
PHC Concept
GUYANA SURINAME
Primarily public system; five levels of care from health posts to tertiary care hospitals PHC integrated in district health system with local governance responsible for services MOH in process of devolving authority to Regional Health Authority (autonomous health body established by MOH)
Fragmented, different schemes based on geographic area, income, occupation, MOH not any-longer a direct provider of PHC services (autonomous health institute established by MOH and service agreement with faith based NGO)
Both countries: extensive networks of PHC facilities in rural communities and hinterland
Health service delivery system
Most critical concern are the health human resources:
1. Numbers: shortages in most categories of workers
Emigration, especially of skilled persons
2. Distribution : Geographic imbalances in workforce
70 % of physicians in Guyana located in capital
Unique challenge: geography, uneven population distribution with extreme low population density in rural areas
About 80-90% of land mass with only about 10% of population in small scattered villages
River settlements
Essential pre-conditions for PHC
1. Expanding healthcare worker categories to meet the needs
2. Introducing midlevel workers with multipurpose skills
3. Producing necessary healthcare workers for PHC through short training programs
4. Policy and legislative backing of PHC workforce (Medex act 1978, Medex board, professional councils)
Seeking relevant solutions for PHC workforce challenges
MEDEX DEFINITION CHW DEFINITION
a midlevel healthcare worker who is: community-oriented Geared to provide a reasonable level of care Works primarily in remote areas Performs certain specific tasks that are normally performed by doctors
(Medex Act 1978)
A short-trained healthcare worker who is:
selected from and by the community Works primarily in remote areas from home or from a health hut or post Performs preventive services
Guyana Medex + CHW: description
MEDEX CHW
Training By MOH, dept. of Health Education Sciences Certification by University of Guyana
Legislation Medex Act 1978 Registration by medical board (can be removed from register in case of misconduct) Works formally under supervision of a registered physician Reports to Regional Health Officer, CMO, Director Regional Health Services
Duties -Defined in the Act
Conclusion: Medex protected by law
Training By MOH, dept. of Health Education Sciences Certificate by MOH
Legislation No specific act on CHW
Duties Defined as preventive and health promotive tasks
Medex and CHW: Policy and legislative backing
Tap into gains of investments in education Hinterland population
Reduce depletion of nursing workforce
Recruit from secondary school graduates with preferences for underserved areas
Four year training program, first phase nursing and midwifery skills
New Medex pathway (around 30 years commemoration of the medex program in 2007)
New developments
Key :
Indigenous and Maroon populations: rich knowledge of healing at risk to get lost
Trio population have preserved a formal ethno-medicine system
Amazon region source of large variety of therapeutic plants (as reported by studies)
Trio villages:
Kwamalasamutu: population + 1200, Located close to the Brazilian border) and Tepu: population + 500, located South-East
Collaboration between the Medical Mission, Conservation International and the Shamans in the Trio villages.
Partnerships with traditional healers in Suriname
Actions:
- Joint learning ‘formal’ healthcare workers and Trio Shamans
- Constructing a health post for the Shamans, close to the health center of the Medical Mission
Results:
- Adaptations of practices of both sides
- Respect , referral and counter referral of patients
- Improved treatment of Leishmaniasis since the Shamans do have a more effective treatment at lower costs
- Scaling up to Maroon villages where traditional healers are skilled in bone setting.
Partnerships with traditional healers in Suriname (cont)
1. Context extremely important when looking for strategies
2. Shared challenges (Sur + Guy) in health and in PHC
3. Different healthcare systems
GUY: unified state driven HS. Applies district health system approach with one PHC organization integrated in overall system
SUR: more fragmented HS, complex variety of payment schemes. Applies partially a district health system with two different PHC organizations for geographic regions
4. Development of PHC
SUR: Initiatives at level of PHC organizations
GUY: Initiatives at national level of state/MOH
Final remarks
4. Both countries face currently rapid changes
SUR: intro of national health insurance system, leading to more equity in access, but also risk to move towards a narrow medical model rather than a PHC model
GUY: rapid scale up of availability of physicians due to return of Cuban trained physicians, leading to improving medical skills in workforce, but also risk of weakening the outstanding Medex system, that provides an all round PHC worker
GUY + SUR: Changing socio-economic environment in Hinterlands due to gold-mining economy resulting in a multi-national population and transnational health challenges
Final remarks cont.