Based on an examination of the existing literature, a situational analysis and discussions with stakeholders, the 2010-2015 “Guyana: Country Cooperation Strategy” (CCS), constructed with the help of the Pan-American Health Organisation (PAHO/WHO), identified some twenty health challenges and seventeen health priorities.
Among the former are: sustainability issues regarding stewardship, leadership and regulation of the health sector at all levels; incomplete mechanisms to support decentralisation of health services and the stewardship role of the MOH (Ministry of Health); inadequate quality of health services and limited access, particularly in the hinterlands; insufficient human resources for health and absence of a human resource strategic plan; high burden of Chronic Non-Communicable Diseases; high maternal and infant mortality; high burden of mental health disorders and demand for improved services; increasing rate of violence and injuries, including domestic violence; high rates of suicide and substance abuse; low emphasis on sexual and reproductive health; vulnerability of the country to natural and man-made hazards; logistical and other difficulties in access to health care, especially in the hinterland; inadequate response to environmental health risks; little or no attention to the determinants of health.
The above is an obvious indication that the MOH does not have “all the monies” of which the Parliamentary Secretary, Mr. Joseph Hamilton spoke. It is in keeping with the generally negative health indicators I presented in the first article in this series on health, and while as a percentage of GDP, the regime’s commitment can be deemed admirable there is definitely a limit to what US$160 per capita spending on health could do.
Further, I have argued that although nothing spectacular has happened in the health sector over the last twenty years, with increasing resources, health provisions have incrementally improved. The fact is that Guyana is a very poor country: one important reason why we need to better manage our resources.
Both the CCS and the Parliamentary Secretary observed that the management of the sector remains weak and indeed, PAHO/WHO identified as its first cooperation priority “Strengthening health systems governance, organization and management based on primary health care approach.” The CCS also claimed to recognise a “…. recent major paradigm-shift in the traditional role and function of the MOH from that of being the main provider of health care to that of a regulator. In this new arrangement, the Regional Health Authorities (RHAs) are responsible for the provision of health care services.”
This latter statement is both historically and factually incorrect and, more importantly, if left as it is, could also limit the scope of what in my opinion should be a more far reaching reform agenda.
In January 1998, explaining as Minister of Health and Labour, why the MOH intended to relinquish day-to-day control of the PHG, I stated: “Governments, through their ministries, etc., perform four basic functions. They make policy, deliver services and create and enforce rules and regulations. In modern times the policy making function is usually referred to as the ‘steering’ function and the others as ‘rowing’ functions.
Traditionally … in Guyana these two functions have been in the hands of the same public servants. … The result has been generally poor performance. … Steer and rowing functions must be uncoupled and separate autonomous agencies created to deliver services and perform other rowing activities. … Finally, rowing agencies are made accountable to policy makers: they must meet specific performance guidelines and be responsible for the consequences of their performances.” Thus, in my 1998 budget presentation I promised to “totally transform the way labour and health services are delivered in Guyana. Put simply, our goal is to create a small central ministry which sets and monitors policy and helps to garner resources for the sector.”
By April 1998 the MOH produced a paper “The Establishment of Regional Health Authorities in Guyana”, which stated the intention to establish four legally semi-autonomous Regional Health Authorities to replace the ten regional health departments. “These authorities will be responsible and accountable for the planning, management, coordination and the delivery of the health services in the particular geographical area. … A Regional Health Authority will not be a mere quasi-administrative arm or branch of the Ministry or an extension of it, although it has the responsibility to carry out central government policy.”
The historical error aside, at this stage it is to the scope of the then envisaged reforms that I wish to draw attention. The paper indicated that they were not limited to the creation of RHAs but that similar type semi-autonomous boards would be established to manage vector control, health education, materials management, food and drugs administration, dental services and the “corporatisation of the National Referral Hospital (The Public Hospital Georgetown) is expected in the last quarter of 1998” (this process was completed by the first half of 1999). Also, in November 2008, Michael Khan, then the Director of Procurement/Materials Management at the MOH wrote: “The Government proposes (draft legislation is already in place) to establish a Medical Procurement Board.”
It took about six years after the corporatisation of the PHG for the regime to pass the Regional Health Authorities Act 2005, and to this day, as the CCS observed, the process has not moved much further. This must leave the distinct impression that those involved are only paying lip-service to the reform process. Why is this so?
Quite apart from wanting more-or-less direct access to the cookie jar so as to be able to dip into it as one pleases, there is sometimes a genuine primordial management instinctive feeling that an organisation is best managed if one is in total control of it, and to disguise these deleterious propensities, those of a contrary disposition are usually presented to the undiscerning as lazy or shirkers of responsibilities!
Thus, in 2007 Kenwyn Nicholls (“Towards Integrated Health Systems Development”, Ministry of Health) begged that decentralisation be seen as: “a genuine interest on the part of the Government in providing more efficient and effective service … It should not be seen as a move by the decision-makers to shift the problem to another body.” In April 2008 another consultant, Dr. Jean Griffith pleaded “…. The management and leadership of the Ministry must wean itself off from these entities and allow the management and leadership capabilities of these institutions to evolve. … These de-linked organisations should be made accountable for the effective management of their organisation” (“Draft Reorganisation/ Restructuring Plan,” Ministry of Health).
Mr. Parliamentary Secretary, the ball is now in your Ministry’s court to begin a national discourse to move this process forward and perhaps add more value to the very limited resources at your disposal.
