Getting to the crux of health sector reform

Future Notes

Recently, the Parliamentary Secretary for Health, Mr Joseph Hamilton informed us that “a needful reform is required if the Ministry of Health is to better its current mode of operation.”  As reported, Mr. Hamilton’s intervention was quite general; most of what he said about the health sector could just as easily have been said about any other sector, but what struck me is what I perceived to be a genuine effort to come to grips with some of the difficulties facing the health sector. Quite apart from the fact that at some point in time, particularly as we get older, all of us interface with the health system, a weak health sector can contribute to lower workforce productivity, cause people to emigrate and not re-migrate, become an important personnel concern and cost for companies who may wish to establish locally, etc.

Table 1. Guyana

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World Health Organisation: Country Statistics. * 2008. **1995. 2009***

Our health institutions provide services to hundred of persons each day and one suspects that reports of individual cases, though justifiable and useful in improving the level of accountability, might not tell the full or even the true institutional story. If we are to gain sustained quality improvement, we need to go beyond these usually emotional stories to an institutional discussion about goals, priorities, capacities, constraints, and realistic outcomes. This and the following contribution are intended to facilitate just such a discourse.

future notesTalk of the need for fundamental health sector reform has been around for decades. Of course, the orientation of this kind of reform goes much beyond concerns about personnel and material management as expressed by the Parliamentary Secretary. Generally, it seeks to place the responsibility for health care in the hands of the individual, private organisations and local and central authorities. More specifically, central government’s role must become a steering one: responsible for health sector representation, policy formulation, monitoring and providing technical advice.  The provision of services should best be left to the private and non-governmental sectors and where the state is the provider, to local government and/or autonomous public authorities.

In my view, if the discussion is to proceed sensibly we must have some understanding of where the health sector is today. To help with this I provide the following two tables, which are by no means definitive but contain some relatively easily available date and also point to some of the health institutions that have been developed over the last two decades.

If the above figures are anything to go by, they indicate that nothing dramatic has taken place in the health sector over the last twenty years. With a few important exceptions, as the health budget has increased the health sector has been making slow but steady progress. Although it is pure political hyperbole to speak of Guyana as having or about to have the best health sector in the Caribbean, comparative to what other Caribbean countries are spending, outcomes in Guyana are quite good. Guyana was spending US$159 per capita in 2010 compared to some US$1,003 in Barbados and US$861 in Trinidad and Tobago, and has comparable and even better outcomes on some of the above indicators. The level of remuneration paid by the different systems, the fact that health care is comparatively more expensive as the tertiary level begins to dominate, national cultures, managerial focus, etc, are all important in explaining these outcomes.

On the negative side, maternal mortality, which has been rising consistently and today stands at some 280 per 100,000 live births compared to 46 in Trinidad and Tobago and 51 in Barbados, should be a major concern. The prevalence of tuberculosis is also high: higher than it was in 1990 with the highest year being 151 in 2007.

Table 2. Region Comparison (2010)

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World health Organisation: Country Statistics. *2008.**1995. 2009***

 

The Inter-American Development Bank health care projects, particularly Health Care 11 agreed to in 1988 – about the same year the Economic Recovery Programme began – started a system of institutional and structural development that has been ongoing. For example, beginning in the early mid 1990s, we have seen the establishment of the new Ambulatory Centre, Bartica Hospital, the Cheddi Jagan Dental Center, the new PHG Maternity Ward, the Tuberculosis Clinic, the National Blood Transfusion Centre, the Gynaecological Ward, the Commission for the Disabled, the Psychological Ward, the Cancer Center, the Caribbean Heart Institute, the New Amsterdam Hospital, and, with the help of the Cubans, Ophthalmological and Regional Diagnostic centres. So, quite apart from the public health figures given above, we cannot minimise the vital services these establishments have provided and are providing to thousands of individuals.

Nonetheless, Mr. Hamilton claimed that although the ministry has resources “we have had difficulties with how we manage the system and that is what we have to correct.” As an example: “We have had difficulty with how we procure and how we manage and distribute the resources and so it is useless in my view that we have all the monies and when I go to Paramakatoi and somebody says ‘we have a shortage of drugs’ when I know we have it in abundance in Georgetown…we have to do things differently,”

Among other things, procurement has been and remains a huge problem, both in terms of transparency, timeliness, storage and distribution of health materials. There have been numerous and perennial complaints of the substandard services provided throughout the system, but particularly in the hospitals and clinics, and comparative spending in the sector is very low. Thus, a reform agenda must seek to improve the general situation.
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