In `The Berbice Regional Health Authority is an Illegal… says Health Minister (KN 6/6/2015) the Minister of Public Health, Dr. George Norton, is reported as stating that the Berbice Regional Health Authority is illegal but receiving government funding. The board of the authority was established in 2005 and since the effort to regionalise the health system began as far back as 1997/1998, all of this is irregular and quite unfortunate. (Health Sector Reform, Ministry of Health Concept Paper, January, 1998. The Establishment of Regional Health Authorities in Guyana, Health Planning Unit, Ministry of Health, Guyana, April, 1998).
However, what is interesting to me is the minister’s commitment to look at the legislation again and his optimism that the body will function effectively once given legal authority and the necessary personnel. For, according to him, ‘you can have the best system in place, but if you don’t have the right personnel, it will continue to fail’.
In a general way, taken logically, the reverse of the last statement should not hold, for if you have the right personnel at various levels of the organisation, they should be able to identify and rectify a system that is deficient. But the minister, who I believe is quite sincere about achieving his goals for the health sector, should be somewhat cautious about conceptualising matters in this manner. The very notion of having ‘the right personnel’ is dubious, and in human resource conditions such as those existing in Guyana, even more tenuous. So below I proffer some background and advice to the minister.
As much time has passed since the present approach was devised, he might need to look at whether the model of managing the health sector as expressed in the establishment of regional health authorities is still the most appropriate way forward before giving the go-ahead. I would also suggest that even if the present arrangement is still considered the most efficacious, he will need much more than the changes he has proposed to achieve optimal results.
An October 1997 study, “Towards Integrated Health Systems Development”, done for the Ministry of Health claimed that, ‘To play its new role and carry out its responsibilities effectively and efficiently, the MoH must move expeditiously to divest itself of its current day-to-day responsibilities, including the Georgetown Public Hospital and as many of the vertical programmes (the services for integration include maternal and child health, vector control, environment health, Hansen’s disease, tuberculosis, veterinary public health, nutrition, dental services, mental health services, rehabilitation, drugs and alcohol abuse, and STD/HIV/AIDS) as is possible at this point of time.’
This approach was very much in keeping with the public management trend at the time, which sought clear demarcation between rowing and steering functions. For example, it does not take much to see that there is a major conflict of interest where the central ministry is responsible for the creation, implementation and monitoring policies, for in effect the ministry is monitoring itself. This is a particularly questionable practice in public management, where the financial sanction of failure – making a loss and ultimately going bankrupt – is largely absent. Thus the general idea was for the central ministry to establish policies and create those arrangements, goals and indicators that would allow it to properly monitor the authorities.
As a part of this process, the general health sector reform that actually began in early 1998 sought to decentralise the services of the Ministry of Health by creating four autonomous regional authorities (Berbice, Demerara (it was recognised at the time that given the size of Demerara it might require two authorities), Essequibo and the Hinterland) and to establish the Georgetown public hospital as a legally autonomous institution.
Health and health-related staff within each region were to form District Health Committees to plan for the districts and stakeholder representatives, Community Health Associations, should also have been members of these committees that were to manage the district/cottage hospitals. How much of this structure is in place and how it relates to the established regional health system should also be considered.
The role and functions of a Regional Health Authority were, inter alia, to: identify the health care needs in the geographic region and implement measures to address these within national policy guidelines; formulate plans and programmes for the development and implementation of a balanced and integrated health care system; coordinate all health planning and management activities within the region and facilitate the integration of health and social services development planning; determine the required resources (human, financial, material, etc.) and advise the ministry on their allocation; provide the interface between the ministry’s policy and the priorities and needs of the local communities and incorporate government’s policies into the planning process at the local, district and regional levels. (The Establishment of Regional Health Authorities, op. cit).
The reforms went furthest at the Public Hospital Georgetown, which by way of the Public Corporations Act (which allowed for an easier establishment of legally autonomous public utilities), was established in 1999 as the Georgetown Public Hospital Corporation to more-or-less continue with its usual functions.
In the process of incorporating these kinds of bodies a host of troublesome issues have to be addressed and this is perhaps why the process, at least in relation to the Berbice Regional Health Authority, was stalled.
Given the inauspicious labour relations environment of the time, in relation to the corporatisation of the Georgetown Public Hospital, the most problematical issue was the nature of union representation in the new body. Other concerns of primarily a personnel and financial management nature included the possible absorption of traditional public servants under the aegis of the new body without loss of service and other benefits, the establishment of a new pension scheme, the implementation of a new salary structure and other conditions of service for the employees of the new bodies, and the conditions under which budgetary subventions for the authorities were to be channeled through the Ministry of Health (Ibid.).
Indeed, it was in recognition of the time-consuming nature of putting in place arrangements such as those above for the entire country, that in the later months of 1998, a sector reform unit was established to drive the process on a day-to-day basis. If after consideration the minister decides to universalise the autonomous regional authority system, he might want to consider the reestablishment of such a body if one does not now exist.
In my view, and as I will argue next week, although legalisation, personnel and other institutional changes are important, the real value of arranging management in this manner is to be derived from properly setting and monitoring targets that are geared towards encouraging improvements in service delivery.
henryjeffrey@yahoo.com
