Health Sector Reform Health Sector Reform

GUYANA’S ExperienceGUYANA’S Experience

May 30May 30thth 2006 2006

Dr V MahadeoDr V Mahadeo

CEO, BRHACEO, BRHA

GUYANAGUYANA

• Located in South America with neighbours being Surinam, Brazil and Venezuela

• Area of 83,000 sq miles• Capital - Georgetown• English speaking• Independence since 1966• Republic since 1970• Subdivided into 10 Administrative Regions

Health CareHealth Care

• Public and Private• Public Health Care is free – funded by the Govt• All of the private hospitals are in the city• One medical school in Guyana (10 – 15

graduates per year)• Four Nursing Schools – Georgetown, New

Amsterdam, Linden and St Joseph’s

( private)

• Five levels of Health care in Guyana

Health Posts, Health Centres, District Hospital, Regional Hospital and National Referral Hospital.

• The National insurance scheme runs a social insurance for all employed persons with mandatory contributions

A thorough study done in 1993 A thorough study done in 1993 revealed the following weaknessesrevealed the following weaknesses

1.Structural weaknesses

2.Functional weaknesses

3.Cultural weaknesses

Structural ReasonsStructural Reasons

a.The Ministry of Health had no authority to implement policies or to set budgets of the regional administrations

b.Incomplete Regionalization c.The population density in regions

vary Region 8 approx 5,737 persons while Region 4 has

297,162 persons.

Functional ReasonsFunctional Reasons

1. Ministry of Health and the Regional Democratic Councils were service providers and the regulatory agencies.

2. Regional Health Officers had little experience in planning.

3. No clear lines of authority/responsibility between the MoH and the RDCs, in terms of who was responsible for what and who reported to whom.

4. Vertical programs

Functional Reasons cont.Functional Reasons cont.

1. Duplication of functions.

2. Procurement not structured

3. Mismatch between services and health needs in the various regions. [eg HIV]

4. Most investments were at hospitals and not at primary levels.

5. Human resource issues

Cultural ReasonsCultural Reasons

1. Decision-making was ad hoc.2. Attitudes to work and motivations were

weak.3. Decision makers at various levels were

not given autonomy and responsibility over management.

4. Leadership deficiencies. 5. Participation at the community level was

low.

What has happened/is happeningWhat has happened/is happening

• Strengthening of health sector management.• Modernizing and rationalizing health services• Establishing workforce development and

HRM systems• Implementing a national quality framework• Strengthening the Role of the Health Sector

Development Unit (HSDU)• M & E

Strengthening management control Strengthening management control and capacityand capacity

• Reorganization/Restructuring of Ministry of Health

• Georgetown Hospital has become a Corporation (GPHC) with a board

• Health Management Committees/Health Authorities -- semi- autonomous providers.

• Performance management systems will be introduced.

• Clinical targets established

Restructuring the Ministry of HealthRestructuring the Ministry of Health

HSDU has conducted several studies on the reorganization of MOH.

Implementation of some of recommendations have started, in 2003.

Intensification of these recommendations are being done ( 2004 –2006).

Service contracts between MoH and GPHC signed.

MoH and RHA pilot in 2005.

Getting our services better managedGetting our services better managed

Create 4 Regional Health Authorities (RHA’s) to cover the country

extensive control over resources

Similar to experience with GPHC except that the RHA’s will be accountable for the health of their whole communities (Regions)

Pilot RHA has started, and would continue to develop.

Getting our services better managedGetting our services better managed

• Phased in approach to the RHA’s starting with the Berbice RHA and to be followed by Linden RHA – Allow us to learn and adjust– Ensure that, from the next financial year; budgetary

flows and lines of responsibility have been agreed between MoF, MoLG, MoH and the RDCs

– RHAs will have boards and will receive technical assistance as they start up

– Management teams will be in place.– Transfer of employment to the RHAs, as was done for

GPHC (at time of corporitisation)

Targets for health improvementTargets for health improvement

Technical ProgramsTechnical Programs

The broad priority areas are:• Family Health• Non Communicable and Chronic Diseases• Communicable Diseases• HIV/AIDS/STI’s• Oral Health• Environmental Health• Special projects

Modernizing and rationalizing health Modernizing and rationalizing health servicesservices

• Infrastructure improvement at all levels • Decentralization of public health programs • Drug procurement and distribution systems will be

strengthened.• Clinical Services improvement• Improved referral services

2

Infrastructure RenewalInfrastructure Renewal

• GPHC phase III – Construction of 460 beds in patient facilities

• Hospital Prioritization and rationalization study completed. Based on this a capital works program was developed.

• Regional Hospitals• - New Amsterdam completed.• - Linden construction of a new hospital. Functional plans prepared. • - Lethem construction of a new hospital.• - West Demerara capital renovations.• - Mabaruma hospital – to be reconstructed.

• Convert some district hospitals into polyclinics• Construct new health centers based on established criteria.• Health Posts – construction • A computerized data base is being created for all health facilities.

This would assist in timely maintenance of the buildings.

Improve procurement/distribution of Improve procurement/distribution of DrugsDrugs

• Pharmaceutical Study – Prof. E. Seaone completed in 2004.

• Materials Management Unit established.• Development of management team• Restructure the procurement system• Restructure the storage and distribution

system. Additional work being done in 2005 – 2006. This includes construction of regional bonds.

• Development of information management system. Additional work is being done.

Establishing workforce development Establishing workforce development and HRM systemsand HRM systems

• Workforce planning will be developed in the Ministry of Health.

• Modern HRM systems is being established in RHA/Ministry of Health

• Training and recruitment will be modernized for various categories of staff.

• Staff appraisal systems will be streamlined in Health Management Committees and Ministry of Health.

• System on non financial benefits introduced.• All these activities would be funded by the IDB as of

2004 – 2008.

Implementing a national quality Implementing a national quality frameworkframework

• Standards of care is being set through regulation/policy.

• New legislation to be introduced[ Health Facilities Act, Public Health Act etc.]

• Systems for clinical governance will be established.

• Professional self regulation and Continuing Professional Development is being implemented. [ Programs to develop post graduate doctors training at GPHC, improvement in nurses training etc.

• Capacity to monitor and evaluate is being developed.

Directing $ to needs improving Directing $ to needs improving accountability and performance.accountability and performance.

• Finance will be allocated for needs and poverty.• Financial accountability and performance will be

linked.• Capacity to work with private sector will be

developed.• Regulation of private insurance to be improved.• Population Based Funding will be developed for

RHAs.

Other NHP strategiesOther NHP strategies

• Improving financial accountability• Cost accounting systems [ the systems would move to

assessing outputs rather than tracking line items inputs]• Developing partnerships with the private sector.

[technology assessment and cost effective mechanism will be developed]

• Focal point to develop strategies in working with the private sector.

• Development of options for regulating private health insurance

Managing the TransitionManaging the Transition

• The Health Sector Development Unit :1.1. Performance Management contractsPerformance Management contracts

2.2. Procurement of technical assistanceProcurement of technical assistance

3.3. Pilot the RHAPilot the RHA

4.4. Establish the HMISEstablish the HMIS

5.5. Strengthen Human Resource managementStrengthen Human Resource management

6.6. CommunicationCommunication

7.7. Capital Planning and oversee the construction of GPHC Capital Planning and oversee the construction of GPHC and Linden Hospitaland Linden Hospital

8.8. Coordination of technical program to ensure its adhering to Coordination of technical program to ensure its adhering to the goals of NHPthe goals of NHP

9.9. M and EM and E

Guyana Health Guyana Health Sector ReformSector Reform

Pilot RHAPilot RHABerbiceBerbice

Berbice Regional Health AuthorityBerbice Regional Health Authority

• From New Amsterdam to the Upper Corentyne River (including Orealla & Siparuta)

• Includes 1 National Hospital, 1 Regional Hospital, 3 District Hospitals and 26 Health Centres and Health Posts + (1 Nursing school)

• Caters for a population of over 120,000 persons

Pilot Health Authority Pilot Health Authority

Strengths

• Strong Support from the Minister of Health • Legislation passed Dec 2005 for establishment of

Regional Health Authority in Berbice• Groundwork done for 2 years (2004-2005) with an

Interim Management Committee• Board in Place• Management Team in Place (CEO & 4 Directors)• Ongoing Training (nurses, MPT’s, Doctors)

Minister of HealthMinister of Health

RHA Board

CEO

Management Team

Regional Hospital

D H

HC HC HP

Getting our services better managedGetting our services better managed

Uncoupling of functions• Ministry of Health responsible for STEERING functions

[policy]• Health Management Committee will be responsible for

ROWING functions [service delivery]

RHARHARHARHAMinistry of Health

WeaknessesWeaknesses

• Regional Authorities (Regional Democratic Council workers) still not very supportive

• Health budget still in the hands and under the control of the Regional Democratic Council

• Some officials at the Ministry of Health still do not understand their role in the new system

Weaknesses Cont’dWeaknesses Cont’d

• Present Severe shortage of staff – especially nurses, lab techs and junior doctors (primarily due to migration/active recruitment)

• Inadequate experience of board members in managing of a “corporate” entity

What is being Done?What is being Done?

• Regular meetings with the Regional Authorities to work out solutions

• Budget for the year 2007 is being prepared and will be managed by the board

• Training for Board Members• New nursing school and larger number of

students• Recruitment of foreign doctors – India, Cuba

(especially specialists)

Cont’dCont’d

• Meeting with NGO’s to support the Health System

• Community meetings started and to continue (to get feed back)

• Large number of medical students presently on GoG scholarships – to begin returning to Guyana in 2007/2008

• More attention being placed on Primary Health Care

THANK YOU !!!!