1. Health Sector Reform GUYANA’S Experience May 30 th 2006 Dr V Mahadeo CEO, BRHA

2. GUYANA 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

3. Health 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)

4. 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

5. A thorough study done in 1993 revealed the following weaknesses 1.Structural weaknesses 2.Functional weaknesses 3.Cultural weaknesses

6. Structural 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.

7. Functional 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

8. 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

9. Cultural 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.

10. What 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

11. Strengthening management control and 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

12. Restructuring 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.

13. Getting 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.

14. Getting 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)

15. Targets for health improvement Technical Programs Technical 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

16. Modernizing and rationalizing health services 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

17. Infrastructure 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.

18. Improve procurement/distribution of Drugs 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.

19. Establishing workforce development and 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.

20. Implementing a national quality framework 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.

21. Directing $ to needs improving 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.

22. Other 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

23. Managing the Transition The Health Sector Development Unit : 1.Performance Management contracts 2.Procurement of technical assistance 3.Pilot the RHA 4.Establish the HMIS 5.Strengthen Human Resource management 6.Communication 7.Capital Planning and oversee the construction of GPHC and Linden Hospital 8.Coordination of technical program to ensure its adhering to the goals of NHP 9.M and E

24. Guyana Health Sector Reform Pilot RHA Berbice

25. Berbice 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

26. 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)

27. Minister of Health RHA Board CEO Management Team Regional Hospital D H HC HP

28. Getting 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] RHA Ministry of Health

29. Weaknesses 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

30. Weaknesses 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

31. 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)

32. Cont’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

33. THANK YOU !!!!