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Health Reform in Guyana Ministry of Health PAHO Dr V Mahadeo

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Health Reform in Guyana Ministry of Health PAHO Dr V Mahadeo November 08-10, 2006 Tegucigalpa, Honduras Our Team Dr L Seoane PAHO/WHO Dr V Persaud Lecturer ... – PowerPoint PPT presentation

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Title: Health Reform in Guyana Ministry of Health PAHO Dr V Mahadeo


1
Health Reform in Guyana

Ministry of Health PAHO Dr V Mahadeo November
08-10, 2006
Tegucigalpa, Honduras
2
Our Team
  • Dr L Seoane PAHO/WHO
  • Dr V Persaud Lecturer, University of Guyana Med
    School
  • Dr G Krishendat Director, Chronic Diseases, MOH
  • Dr V Mahadeo CEO, Berbice Health Authority, MOH

3
  • Located in South America
  • neighbours- Surinam, Brazil and Venezuela
  • Area - 83,000 sq mls
  • Capital -Georgetown
  • English speaking
  • Independence - 1966
  • Republic - 1970
  • Subdivided into 10 Administrative Regions

4
GUYANA
Pomeroon-Supenaam
Barima-Waini
Essequibo Islands-West Demerara
Demerara-Mahaica

Mahaica-Berbice
Upper Demerara-Berbice
Cuyuni-Mazaruni
East Berbice-Corentyne
Potaro-Siparuni
Upper Takutu- Upper Essequibo
5
THE ECONOMY
  • The Economy is based on natural resources.
    Agriculture, forestry and fishing accounted for
    34.6 of GDP in 1998 and 35.1 in 1999, with
    sugar by far the main contributor

6
THE ECONOMY
  • Factors impacting the economy
  • Flooding (the Guyana Coastland is below sea
    level!)
  • Continued decline in export prices for bauxite,
    gold, timber and rice and sugar
  • Removal of preferential market for sugar in
    Europe
  • Rising oil prices
  • Civil unrest and public service strike
  • Remittances dry up with weaker U.S./Canada
    Economy
  • Massive Brain Drain especially in Public Sector

7
Levels of Primary Health Care System
  • The National insurance scheme runs a social
    insurance for all employed persons with mandatory
    contributions

8
Health Facilities in Guyana
  • Health Centres - 112 MCH
  • Health Posts -182 services
  • Specialized Institutions - 4
  • National Referral Hospital - 1
  • Regional Hospitals - 5
  • District Hospitals -18
  • Health facilities total - 321
  • Private Hospitals - 5
  • Private Doctors -115 (80 are in Region 4)

9
Health Care
  • Public and Private
  • Public Health Care is free Govt funded
  • All of the private hospitals in city
  • One medical school in Guyana (10 15 graduates
    per year)
  • Med students in Cuba - gt 300 to start returning
    to serve in 3 years time
  • Four Nursing Schools Georgetown, New Amsterdam,
    Linden and St Josephs ( private) Large intake
    of students starting 2006

10
  • MATERNAL MORTALITY
  • AN EXPRESSION OF INEQUITY AND INEQUALITY

Addressing the Unfinished Agenda
11
MATERNAL MORTALITY RATIOS in LAC (100,000 NV)
12
Under-ReportingNational Health Plan 2003-2007
Bureau of Statistics Sept 2001
Min/Max Estimates
MCH Report/Profile 2000
Draft CMO Report 2000
Estimate
MICS 2000
13
Maternal and Child Health Data
  • Annual Estimated births - 17,000.
  • Pregnant women attending ANC (Govt) - 15,000.
  • of women who receive ANC services - 90.
  • of women delivered by skilled attendant at
    birth - 95
  • Crude Birth Rate ( 2003) 23.1 per 1,000
  • DT Coverage for ANC mothers - 96 (2004).
  • Exclusive breastfeeding at 4 months ( 2003) 47
  • children malnourished 9.3
  • Maternal Anemia prevalence 54
  • Low Birth Weight (2003) 12.6
  • Source MOH, Statistical Unit, 2005

14
(No Transcript)
15
Comparison of Childhood Indicators ( based on
hospital estimates)
16
EXECUTIVE SUMMARY
  • The GPHC and the NAPH - principal maternity
    referral-hospitals in Guyana.
  • Both maternities are classified as health
    facilities that carry out comprehensive obstetric
    care (resolve obstetric and neonatal
    complications.)
  • The GPHC and the NAPH, have the capacity to
    manage PPH, eclampsia,
  • Laboratory Facilities available 24hrs/day
  • Have Blood Banking Facilities (resolve severe
    anemia,replenish the blood volume)
  • Theatre Facilities to do Caesarian Sections
    available

17
EXECUTIVE SUMMARY (contd.)
  • In Guyana, there is a general antibiotic protocol
    available, for the management of puerperal sepsis
  • there is no protocol available for the treatment
    of specific microorganisms.
  • Abortion Legislation exists in guyana - low
    level of maternal deaths by abortions -
    management of the same that are carried out in
    both maternities.
  • Voluntary abortion services only in a few
    institutions.
  • The other hospitals only look after patients that
    have incomplete abortion in progress

18
EXECUTIVE SUMMARY (contd.)
  • Most of the p/v bleeding patients coming to the
    hospitals would have self-medicated using
    prostaglandins (cytotec) - sold OTC in the
    private pharmacies. Some steps have been taken to
    resolve this.
  • The management of the newborn and the maneuvers
    of resuscitation, are carried out in both
    maternities, and they have the equipment and the
    necessary inputs for performing essential
    neonatal and emergency care.
  • Training done on Resusitation of the Newborn in
    2005

19
Neonatal Health Services Current Situation
  • However there is still a trend of an increase in
    the neonatal mortality.
  • Of the 18 hospitals, there is only the National
    Referral Hospital which has an Intensive Neonatal
    Care Unit.
  • Pediatricians are at the four regional hospitals.
  • All neonates from the district requiring
    specialized neonatal care are referred to the
    National Referral hospital in the capital city.
  • In the 5 private hospitals, there is no
    specialized neonatal services.

20
Neonatal Health Services Current Situation
(Contd)
  • All neonates delivered in hospitals are checked
    by the doctor before discharge.
  • After delivery, neonates are followed up in their
    Maternal and Child Health services in their
    district or attend private clinics.
  • Most of the private paediatric doctors follow the
    national MCH guidelines on immunization
    practices.
  • IMCI clinical course also caters to neonates of 1
    week.
  • IMCI has been introduced in 10 Regions in Guyana.
  • There are Community programmes that support IMCI
  • However C-IMCI still has to be introduced to the
    entire country

21
  • OUR PLANS

22
A thorough study done in 1993 revealed the
following weaknesses
  • Structural weaknesses
  • 2. Functional weaknesses
  • Cultural weaknesses
  • A national health plan was developed

23
The vision Guyanese citizens be among the
healthiest in the Caribbean and South America.
  • The Mission of MoH will create an enabling
    framework for the delivery of quality and
    responsive health services to improve the
    physical, mental and social well being of the
    Guyanese people. We will do this providing
    leadership, ensuring access to essential services
    particularly for the poor, and fostering enduring
    partnerships.

24
Purpose of the National health Plan 2003 2007
  • To improve the distribution of skilled and
    experienced staff (and other resources) so as to
    ensure an equitable access to quality care and
    strong health promotion and prevention strategies
    for all people of Guyana.

25
The Guiding Principles
  • Equity
  • Effectiveness and quality
  • Efficiency
  • Sustainable financing
  • Inter-sectoral collaboration and community
    participation.

26
The overall objectives of Our National Health
Plan 2003 2007
  • To improve the nations health
  • To support the Poverty Reduction Strategy, and
    the goals of the National Development Strategy.
  • To achieve good value for money in the sector
    public and private.

27
priority problems NHP aims to
  • Reduce the deaths (and illnesses) of mothers and
    infants vital indicators of performance.
  • Reduce communicable diseases these are leading
    causes of death, illness and loss of productivity
  • Contain chronic non-communicable diseases
    specifically diabetes, heart disease, cancers,
    accident and suicides

28
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

29
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

30
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 Regional Health Authority pilot started
    in 2005.

31
Minister of Health
RHA Board
CEO
Management Team
Regional Hospital
D H
HC
HC
HP
32
1. Getting services better managed
  • incentives to utilize available resources better
    including staff resources.
  • This means effective decentralization.
  • The NHP sees the creation of 4 to 5 Regional
    Health Authorities to cover the country
  • Each will have extensive control over resources
    including staff. The Public Corporation Act will
    be employed for this, as it was for Georgetown
    Public HospitalCorporation (GHPC).

33
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

Ministry of Health
RHA
RHA
RHA
RHA
34
2. Introducing proper governance
  • Annual service agreements with the RHAs which
    will ensure funding is allocated to priorities
    and that targets are set for RHAs spending.
  • MoH will develop a national advocacy role
  • More Community involvement
  • Better educated girls and mothers will reduce
    maternal and infant deaths and ill health
    youngsters of both sexes will reduce HIV
    transmission rates consumers will take some
    responsibility for their health (eat better, not
    smoke reducing diabetes, heart disease and
    cancer rate).
  • Much hospital expenditure and enable that money
    to be spent on unavoidable illnesses.

35
3. Moving money to where it buys the most
  • Getting services adequately staffed
  • Improving the quality and incentives of staff
  • Improving buildings, drugs and supplies
  • Getting more out of the private sector

36
In summary the National health Plan 2003 2007
aims to
  • Make the best use of the staff available by
    consolidating services and team building.
  • Create RHAs to manage services better and with
    more accountability.
  • Reform the role of the MoH for governance,
    advocacy and directing funding to needs.
  • Invest in improvements in those hospitals (and
    other units) that are really needed and are part
    of the national plan for services
  • Create more incentives and in-service training
    for staff including consumer relations
  • Modernize and create incentives for the MMU
  • Encourage development of the private sector and,
    in future, the purchasing of services form it.

37
Strategic Goals and the NHP objectives
  • Improving the health of women and children as
    indicated by reducing infant and child mortality
    rates by two thirds and maternal mortality rates
    by one thirds and sustaining vaccine coverage of
    gt 95
  • Improving access to quality health care,
    particularly for the poor, with an emphasis on
    prevention and promotion through strengthened
    primary care
  • Improving procurement and delivery of drugs and
    medical supplies
  • Improving the efficiency of health services
    through strategies of facility rationalization
    and strengthening of management capacity
  • Improve work terms and conditions for health
    personnel.

38
Priority Health Programmes
  • Maternal and Child Health (MCH) including
    Expanded Programme of Immunization (EPI), family
    planning and integrated Management of Childhood
    Illness (MCI)
  • HIV/AIDs including treatment of STIs and TB
  • Accidents and injuries including suicide
  • Chronic non communicable diseases including heart
    disease, hypertension, diabetes and nutritional
    deficiencies
  • Infectious diseases including malaria, diarrhoeal
    diseases, and respiratory infections which
    dominate the health profile of the hinterland
    regions.

39
STRATEGIC PLAN MATERNAL AND NEONATAL
MORTALITY REDUCTION IN GUYANAWORKING IN
PARTNERSHIP WITH AGENCIES2006-10

40
GOAL
  • To improve maternal and newborn health by
    promoting equity and thus Contributing to the
    well being of the families and communities in
    Guyana
  • Objective 1
  • To implement evidence-based standards and
    guidelines for effective maternal and neonatal
    health care

41
Result/Output 1.1.
  • By September 2007, policy, protocols and manuals
    developed and implemented for maternal and
    neonatal care in all regions.
  • 90 of health workers trained in protocols for
    normal care and can solve maternal and neonatal
    health complications and emergencies adequately
    in accordance with levels of care.
  • 40 of the health facilities would have basic
    neonatal resuscitation by 2006 and 80 of health
    facilities by 2008.
  • Over 90 of health facilities would have basic
    midwifery package /kits at the primary health
    care facilities by 2008.

42
Objective 2
  • To make available maternal and neonatal
    evidence-based interventions in the public health
    system

43
2. 1 Result/Output
  • Strengthen the capacity of skilled birth
    attendants to perform neonatal resuscitation.
  • By June 2009, 95 of all births attendants are
    competent in neonatal resuscitation.
  • Reduction in the number of neonatal deaths by 50
    from its present value
  • By end of 2008, all health trained in neonatal
    resuscitation.
  • By 2010, neonatal resuscitation implemented at
    health facilities.

44
Objective 3
  • To increase access to essential obstetric and
    neonatal care (EONC) and the use of quality
    maternal and neonatal health services and care

45
3.1 Results/Outputs
  • Increase awareness of regions to the value of
    essential obstetric and neonatal care.
  • Number of regional hospitals providing basic and
    comprehensive Essential Obstetric and Neonatal
    Care (EONC) by 2010.
  • Percentage of providers trained in EONC by 2010.
  • Number of community group meetings held in 4
    regions
  • Number of IEC/C materials developed, produced and
    distributed to 4 regions

46
Objective 4
  • To strengthen monitoring, surveillance and
    evaluation systems for maternal and neonatal
    health programmes

47
4. 1 Results/Outputs
  • Improve and standardize capacity of the MOH to
    undertake monitoring and surveillance of
    maternal, perinatal, neonatal programmes.
  • All health centres on coastal regions and main
    treatment facilities in the regions have
    installed and use Simplified Perinatal
    Information System (SIP)

48
Objective 5
  • To strengthen the management of maternal and
    neonatal health programmes.
  • 5.1 Results/Outputs
  • Revise and update the legal framework surrounding
    safe motherhood and neonatal care.
  • Increase of health personnel who knows of the
    legal framework of maternal and neonatal health.
  • Educate the Population on their rights

49
5.2 Results/Outputs
  • Ensure the availability of a skilled workface to
    provide maternal and neonatal health care.
  • Policy options and innovative models identified
    to address human resources

50
5.3 Results/Outputs
  • Strengthen the capacity of MOH to determine level
    of financing necessary to implement/improve basic
    maternal and neonatal package of services
  • Advocate for increased budgetary allocation for
    maternal and neonatal care
  • Request financial support from Donor agencies

51
CHALLENGES AND CRITICAL ISSUES
  • Creation and Use of protocols for Care.
  • Good team effort by all health workers.
  • Health workers including all doctors should
    uphold good practices and moral.
  • Prompt referral and management.
  • Appropriate management of the high risk
    pregnancy.
  • Promotion of institutional delivery.
  • Regional Plan of Actions

52
CHALLENGES AND CRITICAL ISSUES contd
  • Poor compensation of Health Care Professionals
  • Human resources issues Loss of skilled
    professionals
  • Poor coordination among donors
  • Inadequate number of Local Specialists
  • Expansion and use of services
  • Inequity and disparity between social, ethnic and
    geographic groups
  • Inadequate community involvement
  • Need for improved data collection quality of
    data

53
Challenges contd
  • Insufficient training of Birth Attendants, and
    families in neonatal resuscitation to improve
    quality of care.
  • High cost of procurement of neonatal equipment
    such as incubators and resuscitators.
  • More finance is needed to upgrade training of
    health workers and community volunteers in
    neonatal care..
  • Difficulties in accessing specialized emergency
    neonatal care.
  • It is difficult and expensive to travel in
    Guyana, -- large land mass small plpulation in
    the interior increasing risk of getting to help
    even when needed

54
  • A LOOK AT THE
  • MATERNITY PROGRAMME
  • IN REGION 6
  • Pilot Project

55
Statistics
  • Year 2003
  • 5 Deaths --- 2107 Deliveries
  • Year 2004
  • 4 Deaths --- 2046 Deliveries
  • Year 2005
  • 4 Deaths --- 2259 Deliveries
  • Year 2003
  • 48 Stillbirths
  • Year 2004
  • 49 Stillbirths
  • Year 2005
  • 24 Stillbirths

56
Year 2003
  • Maternal Mortality 5
  • Cause of Death PPH
  • 1 Septicemia
  • Note All Patients died at the Hospital and all
    died from causes directly related to Pregnancy

57
Year 2004
  • Maternal Mortality 4
  • Cause of Death PPH
  • Note All Patients died at the Hospital and all
    died from causes directly related to Pregnancy

58
Year 2005
  • Maternal Mortality 4
  • 2 died at the Hospital both from PPH
  • 2 came in Dead (before arrival)

59
What was done? In 2005
  • An appeal to do a review of all the charts of the
    Maternal Mortality was made This was done Dr
    Seoane (PAHO)
  • The main cause of Death was found to be PPH
  • All Maternal Deaths were investigated
    (There is a permanent investigating committee in
    Region 6 to investigate all Maternal Mortality
    and now also all Still Births)

60
Contd
  • From January 2005 at the monthly meetings with
    the MCH staff there were lectures done using the
    guidelines that were provided
  • A a 2 day seminar was organised to deal with APH
    and PPH involving the maternity and MCH staff
  • Sessions are being done on rounds and in the
    labour ward
  • The Lab Staff were spoken to on a few occasions
    as to the necessity to act speedily dealing with
    Maternity Cases

61
Contd
  • The Labour Ward Protocol used by GPHC was adapted
    and given to the Labour Ward Nurses
  • There was better Doctor Nurse response when
    called especially in cases of maternal/foetal
    distress resulting in an increase in of
    C-Sections and less Fresh SB

62
Onwards
  • Create a MASTER LIST of all Pregnant Women under
    our care
  • Give Mothers-to-be a choice of Institute for
    Delivery
  • Adequate info to be made available to all
    hospitals and MCH
  • Possibility for the Maternity Charts to be filled
    out at the H/Cs and H/Hs
  • Allow monitored home deliveries (Prepared Kits
    and inform the nearest hospital)

63
  • With a new Ob/Gyn Doctor we are able to do
    clinics at the District Hospitals and maybe even
    the major Health Centres
  • Mothers will be encouraged to begin attending
    clinics in the first trimester hopefully by the
    12th week Routine tests to be done
  • All Pregnant women will be assessed at least once
    by a medical physician and if they have a medical
    condition they will be referred to the Specialist
  • All Pregnant women will be seen and evaluated by
    the dentist

64
  • All Pregnant women will have an Ultrasound done
  • Evaluation of all Pregnant women will be done at
    least around the 12th week with a re-evaluation
    being done around the 22nd week
  • Evaluation for Risk will be ongoing but before
    28-32 weeks
  • TV Programmes will be organized to talk
    specifically about Maternity issues (this has
    already been arranged and to start in May)

65
  • All pregnant women with some risk involved will
    be monitored closely at the HRC
  • Early admission will be proposed for these
    clients if deemed necessary
  • Early referrals to the GPHC if necessary
  • Policy of the Health Authority If a Pregnant
    mother comes to the hospital with a live foetus
  • ( Foetal Heart Heard) a live baby must be
    delivered

66
  • Have 3 full time 1 Part- time Ob/Gyn Doctors
  • Have ultrasound facilities
  • Have Lab Facilities and there are plans to build
    a modern state of the art Blood bank
  • Have modern Theatre Facilities
  • Have modern Fetal Dopplers altho only 2
  • Have a few committed midwives

67
  • Have strong Administrative Support
  • (Board, CEO, Med Dir)
  • Have strong support and commitment from Minister
    of Health
  • Support from PAHO/WHO

68
  • If the Pilot Project in Region 6 is proven
    successful then it will be implemented across the
    country !
  • So far we have not had a single maternal death
    for the year although a transfer to the
    referral hospital died after 3 days in the
    hospital cause thrombo-embolism (?)

69
HIV/AIDS
70
AIDS Incidence 1989 to 2001 by Region
35 to 75 per 100,000
144 to 197 per 100,000
588 to 755 per 100,000
71
(No Transcript)
72
HIV Prevalence among TB patientsGuyana 1998 -
2002








73
Neonatal Health Services Current Situation
(Contd)
  • HIV exposed neonates are given specialized care
    of Nevirapine within 72 hours of birth.
  • Follow up of HIV exposed neonates are done at MCH
    clinics.
  • There is also the PMTCT plus program where HIV
    exposed neonates are followed after delivery.
  • Ministry of Health and Minister of Health has a
    special interest in this programme

74
MALARIA
75
MALARIA
  • Malaria incidence has increased from 1985 levels
    due many different
  • reasons but especially increased mining and
    logging activities.
  • Regions 1,7 and 8 (2003) contributed some 93
    of the total number of malaria cases recorded in
    Guyana
  • Broken/interrupted/incomplete treatments
    continues to be a problem
  • Self-medication with bush medicine, expired or
    wrong anti-malarial drugs and incomplete dosages
    of anti-malarial drugs is widespread.
  • Plasmodium falciparum infections, causing
    moderate to severe anaemia, increases
    vulnerability to other diseases
  • Malaria was responsible for 15 of all hospital
    admissions in 2003
  • ( Charity 13,4 , Port kaituma 27,3 ,
    Matthews Ridge 13,3 Bartica 7,8 New Amsterdam
    and Georgetown Public Hospital 5,6
    respectively, Mahdia 51,7 )

76
TUBERCULOSIS
77
TUBERCULOSIS IN GUYANANOTIFIED CASES 1980 - 2003
78
  • HIV AIDS contributes to increased Tbc
  • More active/aggressive searching/tracing of
    patients
  • DOTS programme that needs strengthening
  • Needs integrated DOTS/HIV management has started

79
NUTRITION
80
Nutritional Status of at Risk Groups in Guyana
  • Low income families
  • Indigent Homeless Persons
  • Young children -- 0-5 yrs old
  • Single parents
  • Elderly
  • Infected Affected Persons
  • Chronic Non-communicable diseases
  • Communicable disease

81
Nutritional Status Levels by Area and Gender --
FCS, Guyana, 2002
82
Ten Leading Causes of Death in Guyana, 1990,2000
83
GUYANA NOVEMBER 2006
84
  • A Special welcome to all of you to the worlds
    best waterfalls
  • Kaiteur Falls
  • In GUYANA
  • THE LAND OF MANY WATERS !

Thank you !!
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