PRIMARY HEALTH CARE APPROACHES

AND STRATEGIES FOR THE RETENTION

OF HEALTH WORKERS IN REMOTE AND

UNDERSERVED AREAS IN GUYANA Dr. Monica Odwin

Rio de Janeiro, 2014

OUTLINE

Background on Guyana

Health system and Primary Health Care Service

Guyana Human Resource for Health

Situation Analysis of HR retention in remote and

underserved areas

GUYANA COUNTRY DEMOGRAPHICS

Population: 751,223(2002)

Urban:28.4% Rural 71.6%

Area size: 215,000 Sq.km (83,000 Sq. Miles)

Coastal Regions 85% population (2,3,4,5,6)

Rural 9.4% population (1,7,8,9)

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CULTURAL AND ETHNIC DIVERSITY

Multi- Racial Population

Indo-Guyanese 43%

Afro-Guyanese 30%

Mixed 16.7%

Amerindians 9.2% (9 tribes,9 languages)

Portuguese and Chinese 1%

Regions 1,7,8,9 mainly Amerindians

Regions 2,3,5,6 Indo-Guyanese

,

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POLICY: HEALTH VISION 2020

2013-2020

Primary Health Care

Universal Access

Financial Protection

Social Determinants

Health as a Human Right

Health Equity

Solidarity

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GUYANA HEALTH SYSTEM

Health Governance

Financing

Human resource

Service delivery

Medicines and equipment

Health information systems

Partnerships

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GUYANA HEALTH SYSTEM

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Ministry of Health

Ministry of Local Government

Regional Democratic councils

Regional Health Authorities

Georgetown Hospital

Corporation

Private

Private hospitals

Municipality-Georgetown

• PAHO, WHO, UNICEF,

UNFPA,

• PEPFAR, Global Funds to fight

AIDS,TB,Malaria, GAVI

• Public Private partnerships-

Heart surgery, cancer and

dialysis

• NGOs

• FBOs

• Community based

Organizations

Public Partnerships

HEALTH FINANCING

In 2008, public expenditure accounted for 54%, while donor and private were 34% and 12 % respectively.

2013- 10% of GDP

National Insurance Scheme-all employees including self employed are required to join the NIS, although membership -45% of the labor force. Benefits for loss of pay, private medical care

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SERVICE DELIVERY-PHC

Integrated health service networks

Levels of care

Referral System

Orientation and Standard T. Guidelines

Service Agreements

Quality assurance measures: Standards

and Technical Services

PHC attributes

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LEVELS OF CARE

Level 5

Central Hospital-1

Level 4

Regional hospitals-4

Level 3

District hospitals-20

Level 2

Health centers-133

Level 1

Health Posts- 210

PRIMARY HEALTH CARE

Health Promotion- , disease prevention, treatment

and Rehabilitation.

Attributes: access, affordable, acceptable,

appropriate, quality, safety, integrated

Inter sectoral collaboration, Community

participation, close to client care.

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PRIMARY HEALTH CARE

Family Health across the life cycle

Family planning

Antenatal, delivery and post natal care

Child health, nutrition, vaccination

Adolescent, womens and men health

Elderly care

Water and sanitation

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Referral System

GUYANA: HEALTH HUMAN RESOURCE

Inadequate capacity for HR management,

development and information systems. (fires)

Supply, local and overseas training programs

Recruitment and deployment

Performance management

Out migration, high attrition, vacancies.

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TRAINING OF HEALTH CARE

PROFESSIONALS IN GUYANA

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EXTERNAL HEALTH WORKFORCE SUPPLY

Cuban trained Guyanese doctors-400 not reflected

in last available proportions. When the new census

results are out the ratio would increase.

Cuban medical specialist and other skills mix.

Chinese medical specialists.

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DISTRIBUTION OF HUMAN RESOURCES

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GEOGRAPHIC DISTRIBUTION OF

HEALTH WORKERS BY REGION

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MIGRATION 2010

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Poor salary

Increades workload

Job related stress

Poor physiacl facilites,

equipment and

supplies.

Better working and living

conditions in the USA,

Canada, UK, Caribbean.

Better salary

Better living conditions

Social safety and security

Professional development

Push factors Pull factors

REGULATION, LEGISLATION

Guyana Medical Council (doctors, medics,

opticians)

General Nursing Council (midwives, nurses,NA)

Dental Council

Allied Health Professional Council ( technicians)

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TYPES OF HEALTH WORKERS

Community Health Workers

Medex

Doctors

Nurses including midwives

Malaria,TB and HIV workers

Dental

Environmental health

Family health

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CHARACTERISTICS OF REMOTE AREAS

Located in regions 1,7,8,9 and small pockets in

other regions.

Terrain-access barrier-river, mountains,

Communication barriers

Transportation barriers, roads, rivers, air

Language barriers

Cultural sensitivities to indigenous Amerindians-

Hinterland Health

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GEOGRAPHICAL AREAS COVERED

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KEY OBJECTIVES OF RHS

To oversee and coordinate the functioning of the

Regional Health Officers.,

To Provide direct supervisory support and adequate

staffing to Georgetown Health Centers.

To provide capacity building and institutional

strengthening of human resources to the regional

health facilities primarily thru the Cuban Medical Brigade

and the Guyanese Cuban trained medical doctors.

Emergency Medical Evacuations from the hinterland

locations to the regional or central hospitals

Assist in the provision of specialist health care outreach

services to regional facilities as deemed necessary.

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RURAL RETENTION STRATEGIES

Education

Regulation

Financial incentives

Personal & professional

support

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EDUCATION STRATEGIES

Personnel from the rural and remote areas are targeted for admission into health training programs, ej doctors, nurses, medexs, Community Health Workers and technician courses. Upon successful completion of training, they are then deployed to their regions of origins to serve

The CHW program have been conducted in Lethem, Charity, and West Demerara, outside of the capital to increase their likelihood to remain in the rural districts.

Most of the locally trained health personnel from various disciplines so as to so as to encourage retention in the rural areas.

The curriculum of the CHW and Medex was tailored, reviewed and revised to address competencies and cultural sensitivity for rural settings

Planned strategy to develop continued medical education for the health workers.

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REGULATION STRATEGIES

Task shifting is done in some of the rural areas in various skills mix, however this leads to a quality concern as well as the difficulty to monitor the scope of practice.

Health care workers who are sponsored by the government or are on scholarships through the Ministry of Health or the Regional Administration for training programs are placed on bond or contractual obligation to serve the government for a specify : number of years in any of the administrative regions. This guarantees their return to serve in their communities.

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REGULATION STRATEGIES

Health personnel who are placed in the remote areas are given rural, riverain and hinterland incentives, however this may not be uniform across the skills mix. This helps to increase recruitment and subsequent retention of health professionals in these areas.

Health workers who are embarking on post graduate training programs are paid their salaries during the period of training which serves as an incentive

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FINANCIAL INCENTIVES

STRATEGIES FOR RETENTION

Station allowances/riverain/

Accommodation or housing allowance

Duty free transportation concession for some

workers

Paid vacations allowance

Uniform allowance

( to be reviewed and revised)

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PERSONAL AND PROFESSIONAL SUPPORT

STRATEGIES FOR RETENTION

Before some workers are deployed or actually travel to rural areas to take up their post, RHS would ensure that the living conditions ie water, security, electricity are in place so as to influence on a health worker’s decision to remain in rural areas.

RHS arranges training in ALARM, BLS, IT, CMEs

Surgical and medical outreaches to Bartica, Mabaruma,

Lethem, where multidisciplinary teams visit to support the local health workers and allow opportunity for professional support.

As part of the emergency medical evacuation, a conversation takes place between the rural doctor /medex and acentral doctor as to initial management and stabilization of the patient.

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PERSONAL AND PROFESSIONAL SUPPORT

STRATEGIES FOR RETENTION

The University in collaboration with the MOH has developed an 2 years part time MPH program intended for the RHOs. This would be an area for upward mobility without the need for leaving the work place except for short periods.

RHS provides transportation for health workers to come to central locations for CME or short training.

Internal rotations within regions.

Public award ceremonies for nurses , midwives, TB award ceremony.

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FACTORS FOR NON-PLACEMENT OF

WORKERS IN AREAS WITH FEWER

WORKERS?

Economic : High cost of living.

High cost for basic food items

Lack of suitable Accommodation

High cost of transportation and communication

Limited financial incentives

Social

Disruption of families especially if it involves relocation of spouse who is employed either in an unrelated field or by a different organization or children in Secondary School

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WHAT ARE THE TYPES OF HEALTH WORKERS

THAT ARE MORE DIFFICULT TO PLACE IN

REMOTE AND UNDERSERVED AREAS? Level of training and competencies: The higher

trained workers: specialist nurses and doctors because the level of health infrastructure and service provision at levels 1 and 2 dose not support such workers.

Doctors not under governmental contractual obligation: The locally trained doctors from the University of Guyana have no contractual obligation to serve in remote areas .

Registered Nurses, pharmacists, Lab and X-Ray technicians. 35

WHAT ARE THE FORMS OF

CONTRACTING WORKERS AND WHO

ARE THE EMPLOYERS? Workers are contracted on a contract gratuity system.

Employers are the state through the MOH or the RDC.

Professional remuneration for state employee are a

monthly salary and a performance based gratuity.

Contract obligation for government sponsored

workers influence their placement as they have no

choice.

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MAIN STRATEGIES FOR THE PLACEMENT OF

WORKERS IN REMOTE AND UNDERSERVED

AREAS According to the health needs of the community According to the level of service delivery.

Return of health personnel from the specific region who were trained for that region.

There is no specific strategy with respect to placement of human resources. Placement of workers in remote and underserved areas is based on the needs of the areas and the availability of their relevant staff.

It should be noted however that the Ministry of health in

collaboration with PAHO/WHO has recently developed a human resource action plan, the implementation of which should commence shortly. This is in addition to Ministry of Health, Health Sector Strategy 2013-2020.

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IS THIS STRATEGY PART OF A NATIONAL

POLICY?

PPHGS-Health Vision 2020

The Package of Publicly Guaranteed Health

Services are a menu of services that the

government commits to the population

Universal Health Coverage is a principal pillar of

Health Vision 2020 which strategically protects

from financial risk, improves access to all and

improves outcomes.

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WHO ARE THOSE RESPONSIBLE FOR THEIR

ELABORATION, EXECUTION, FINANCING?

RHS/ MOLGRD

Who finances the strategy? MOF National

consolidated funds, thru MOH and Regional health

budgets. Ministry of Finance, Ministry of Health and Ministry of Local Government and Regional Development.

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WHICH PROFESSIONALS ARE INCLUDED

IN THIS POLICY/STRATEGY?

Low level prof on a day to day basis

Specialist on outreach

General outreaches by NGOS, FBOs supported

facilitated by the MOH

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DO THE STRATEGIES INCLUDE THE

ENHANCEMENT OF THE HEALTH

INFRASTRUCTURE AND EQUIPMENT?

Regions 1 and 7 are examples for rehabilitation services, maternity waiting home

Region 8and 9 are examples for TB, HIV, Malaria, where room space with diagnostic capabilities for health workers were upgraded.

Vaccine programs require vaccine carrier, cold chain, solar refrigeration is functional in some remote areas.

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WHICH INTERVENTIONS IN THE CONDITIONS OF

LOCAL/WORK INFRASTRUCTURE HAVE BEEN CARRIED

OUT IN ORDER TO INCREASE THE PLACEMENT OF

WORKERS IN THE REGION?

Renovation: Living conditions available, region 9 have renovated a building to function as apartments and comfortable accommodation. Construction of a nursing hostel at Kamarang-7 Construction of doctors quarters at Mahdia -8.

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STRATEGIES TO FACILITATE THE INTERACTION

BETWEEN WORKERS IN RUA AND OTHER

WORKERS

The referral system is supported by a communication network including telephones consultations, texting, radio sets communication for the management of emergencies to take appropriate action during pre-

referral and transfer.

CHWs meeting by radio in the past and needs to

be restarted.

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WHAT STRATEGIES ARE USED TO

SENSITIZE THE STUDENTS TO WORKING

IN RUAS

Exposure to the challenges and working conditions in the rural areas during internship, or soon after completing the training program

CHWs were trained in rural areas such as region 1,

9 and 3, close to where they are expected to work. Medical interns are required to do compulsory

stints at level 2 and 3 facilities, health centers. They also gain experience at level 1 facilities during outreaches clinics.

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REGULATION INSTRUMENTS FOR THE

SUPPLY/AVAILABILITY OF HEALTH

WORKERS

Regulate supply: based on the needs assessment and gap analysis. Which would inform the numbers to train.

Service delivery

Regulatory bodies ensure that the health workers have the levelof competence and registration and license to operate within the scope of practice. Ej doctors without full registration to practice are not permitted to practice independently within a remote setting. Similarly for the nursing personnel as well . Medex are required to register however recent … CHW sare not regulated but work under the supervision of the senior health personel ej, medex or midwife by indirect supervision.Government strategies for regulating supply

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STRATEGIES OF SOCIAL

ACKNOWLEDGEMENT OF

PROFESSIONAL WORKING WITH PHC

Midwives: every year selected midwives from all the 10 administrative regions are given awards in a national forum during international midwives day celebrations.

The same type of social recognition is done for nurses of all categories during international nurse day at both regional and central levels.

EPI evaluations

The awardees are publicly acknowledged in the local media

The tools for recognition are monetary prizes, trophies or other tokens of appreciation 46

INCENTIVES FOR RESEARCH AND KNOWLEDGE

EXCHANGE

Lacking. Isolated cases- one nurse through the

midwives association, Tracy had presented a paper in Ecuador at midwives forum, study on the use of contraceptives. This led to further collaboration with the Caribbean midwives association, where 4 participants attended a competency based trainer of trainers workshop for midwives, tutors and PHC workers.

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TOOLS FOR MONITORING AND

EVALUATION

OF PLACEMENT/RETENTION STRATEGIES The are no formal tools available, however a

survey is currently being piloted.

SARA- The Service Availability and Readiness Assessment tool. It is a survey in the form of a questionnaire to determine whether the resources including HR are available or not in keeping with the PPGHS.

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THANK YOU 54