Mapping of PHC experiences in Guyana and Suriname

Hedwig Goede ISAGS consultant

Conferencia a linea Atención Primaria en Salud Rio de Janeiro 13-15 May, 2014

different health systems and different governance of health sector

Guyana and Suriname: Similarities -Shared geography,

shared colonial background,

some similarities of the population: small size, low population density

and specific geographic distribution, ethnic composition

Differences Suriname unique ethnic mix with population

from Java/Indonesia + Maroon population

Guyana considerable decentralized, Suriname centralized; in process of establishing local governance

Political development as independent state

Population at a glance GUYANA SURINAME

Population (source: nat. stats. Bureaus)

Total: less than 800,000 Total coastal: + 85% urban: + 28% rural coastal: + 62% Rural hinterland: + 9% Pop. density: 4/sq km (land mass: 215,000Km² )

Net migration: -32,770 (source: World Bank 2009-2013)

Total: more than 530,000 Total coastal: + 85% urban: + 67% rural coastal: + 20% rural hinterland: + 13% Pop. density: 3/sq km (land mass: 163,820 Km² )

Net migration: -5,000 (Source: World Bank 2009-2013)

Economic indicators

Lower middle income GDP: 3,584 US$/capita (Source: World Bank 2009-2013)

Higher middle income (as of 2010) GDP: 9,376 US$/capita (Source: World Bank 2009-2013)

Health situation at a glance GUYANA SURINAME

Health indicators (PAHO/WHO)

Life expectancy: 64/69 IMR/1,000: 22.0 under5MR/1,000: 36.0

Life expectancy: 68/72 IMR/1,000: 15.1 Under5MR/1,000: 30.0

PHC facilities (source: MOH)

Total: 321 Coastal: 173 Hinterland: 148 (12 health centers)

Total: 263 Coastal: 209 (private: 146/RHS 63)

Hinterland: 56

HRH (source: PAHO)

MDs: 0.69/1000 Nurses: 1.01/1000 70% of MDs in capital

MDs national.: 1.3/1000 Nurses national: 1.86/1000 75% nurses in hospitals

THE 5.9% of GDP (WB) 9.9% reported over 2009

6.6% of GDP (WB 2009-2013) 8.5% reported over 2006

Geographic Distribution physicians Suriname 2010

0

0.2

0.4

0.6

0.8

1

1.2

Paramaribo Kustgebied Binnenland

1.1

0.3 0.2

physicians/ 1000 pop

Rapid changes and transitional phase

GUYANA SURINAME

return of large numbers of Cuban trained physicians

introduction of a national basic care insurance system (compulsary)

Dramatic changes in Hinterland: From mostly traditional villages to a transnational context due to the goldmining industry with different nationalities, undocumented migrants, transnational health challenges involving mostly the three Guyana’s and Brazil.

GUYANA SURINAME

Concept in national health documents

comprehensive view, but often referred to as primary level of care, PHC as foundation of health system since Alma Ata and survived as such over time

in official documents as a comprehensive strategy short after Alma Ata, followed by decline of comprehensive view , concept replaced by first line care, Start of renewal process at subnational level by PHC organizations

Constitution and legal documents

Right to free medical care included in constitution + duties of citizen in protecting health and environment

right to health included in constitution + duties of government in addressing social determinants and educating citizen

PHC Concept

GUYANA SURINAME

Primarily public system; five levels of care from health posts to tertiary care hospitals PHC integrated in district health system with local governance responsible for services MOH in process of devolving authority to Regional Health Authority (autonomous health body established by MOH)

Fragmented, different schemes based on geographic area, income, occupation, MOH not any-longer a direct provider of PHC services (autonomous health institute established by MOH and service agreement with faith based NGO)

Both countries: extensive networks of PHC facilities in rural communities and hinterland

Health service delivery system

Most critical concern are the health human resources:

1. Numbers: shortages in most categories of workers

Emigration, especially of skilled persons

2. Distribution : Geographic imbalances in workforce

70 % of physicians in Guyana located in capital

Unique challenge: geography, uneven population distribution with extreme low population density in rural areas

About 80-90% of land mass with only about 10% of population in small scattered villages

River settlements

Essential pre-conditions for PHC

1. Expanding healthcare worker categories to meet the needs

2. Introducing midlevel workers with multipurpose skills

3. Producing necessary healthcare workers for PHC through short training programs

4. Policy and legislative backing of PHC workforce (Medex act 1978, Medex board, professional councils)

Seeking relevant solutions for PHC workforce challenges

MEDEX DEFINITION CHW DEFINITION

a midlevel healthcare worker who is: community-oriented Geared to provide a reasonable level of care Works primarily in remote areas Performs certain specific tasks that are normally performed by doctors

(Medex Act 1978)

A short-trained healthcare worker who is:

selected from and by the community Works primarily in remote areas from home or from a health hut or post Performs preventive services

Guyana Medex + CHW: description

MEDEX CHW

Training By MOH, dept. of Health Education Sciences Certification by University of Guyana

Legislation Medex Act 1978 Registration by medical board (can be removed from register in case of misconduct) Works formally under supervision of a registered physician Reports to Regional Health Officer, CMO, Director Regional Health Services

Duties -Defined in the Act

Conclusion: Medex protected by law

Training By MOH, dept. of Health Education Sciences Certificate by MOH

Legislation No specific act on CHW

Duties Defined as preventive and health promotive tasks

Medex and CHW: Policy and legislative backing

Tap into gains of investments in education Hinterland population

Reduce depletion of nursing workforce

Recruit from secondary school graduates with preferences for underserved areas

Four year training program, first phase nursing and midwifery skills

New Medex pathway (around 30 years commemoration of the medex program in 2007)

New developments

Key :

Indigenous and Maroon populations: rich knowledge of healing at risk to get lost

Trio population have preserved a formal ethno-medicine system

Amazon region source of large variety of therapeutic plants (as reported by studies)

Trio villages:

Kwamalasamutu: population + 1200, Located close to the Brazilian border) and Tepu: population + 500, located South-East

Collaboration between the Medical Mission, Conservation International and the Shamans in the Trio villages.

Partnerships with traditional healers in Suriname

Actions:

- Joint learning ‘formal’ healthcare workers and Trio Shamans

- Constructing a health post for the Shamans, close to the health center of the Medical Mission

Results:

- Adaptations of practices of both sides

- Respect , referral and counter referral of patients

- Improved treatment of Leishmaniasis since the Shamans do have a more effective treatment at lower costs

- Scaling up to Maroon villages where traditional healers are skilled in bone setting.

Partnerships with traditional healers in Suriname (cont)

1. Context extremely important when looking for strategies

2. Shared challenges (Sur + Guy) in health and in PHC

3. Different healthcare systems

GUY: unified state driven HS. Applies district health system approach with one PHC organization integrated in overall system

SUR: more fragmented HS, complex variety of payment schemes. Applies partially a district health system with two different PHC organizations for geographic regions

4. Development of PHC

SUR: Initiatives at level of PHC organizations

GUY: Initiatives at national level of state/MOH

Final remarks

4. Both countries face currently rapid changes

SUR: intro of national health insurance system, leading to more equity in access, but also risk to move towards a narrow medical model rather than a PHC model

GUY: rapid scale up of availability of physicians due to return of Cuban trained physicians, leading to improving medical skills in workforce, but also risk of weakening the outstanding Medex system, that provides an all round PHC worker

GUY + SUR: Changing socio-economic environment in Hinterlands due to gold-mining economy resulting in a multi-national population and transnational health challenges

Final remarks cont.