The problems of the health sector in Guyana National Development Strategy

By Kenneth King
Stabroek News
September 23, 2001

Among the most unfortunate consequences of Guyana's economic decline between 1976/77 and 1990 are the relatively poor health conditions which now prevail in our country. Indeed, despite the progress which has taken place in the sector since 1991, persons born in Guyana can still expect to have shorter life-spans than if they were born in any other Caribbean country, except Haiti. Perhaps not surprisingly, both the infant mortality rate and the mortality rate of children under five years old in our country are inordinately high for the region. Moreover, the statistics reveal that a significantly high proportion of our people suffer, almost continuously, from a range of illnesses; malaria, acute respiratory infections, hypertension, acute diarrhoreal diseases, diabetes, worm infestation, rheumatic arthritis, and mental and nervous disorders. On top of all this, the incidence of HIV/AIDS in Guyana has attained frightening proportions in recent years. Furthermore, Guyanese who are afflicted with certain types of illnesses are obliged to travel overseas for treatment, either because no specialists in these disciplines are available and/or because the relevant medical facilities simply do not exist. Almost inevitably, therefore, many of our poorer citizens either continue to suffer or die from ailments which are routinely cured or alleviated in other parts of the Caribbean.

The National Development Strategy (NDS) lists several reasons for this state of affairs.

First are the horrid conditions of our environment. Bacteriological contamination of water continues to pervade the distribution system and, often, surface water is used without treatment.

Moreover, basic sanitation facilities in many areas either do not exist, or are at best most rudimentary. For example, in many squatter areas there are no acceptable means to dispose of waste, of any sort. In addition, frequently when new housing schemes, factories, and industries are developed the existing environmental laws are ignored with impunity. And, as we have already pointed out in this series, because the current housing stock is inadequate, overcrowding is common in our tenement yards. This aids, of course the transmission of obstructive pulmonary and other communicable diseases.

Second is the poor quality of the country's health infrastructure and delivery systems: many of the buildings are very old and in dire need of repair; the condition of much of the equipment in our medical centres is poor; there are frequent shortages of medical supplies and equipment; and all too often health facilities are not optimally sited. As a result, especially in hinterland districts, the mere act of going to a health centre is onerous, costly and time-consuming. It is small wonder, therefore, that many of these hospitals remain underutilised particularly in districts with the highest proportions of potential patients.

Third is the shortage of trained health personnel. Indeed, in some areas, even though there may be buildings and equipment, there are few or no staff. This is especially true in hinterland districts, and in the public health-care sector in which salaries are still well below those that are offered in the private sector. Perhaps as a result, there are significantly high rates of absenteeism among medical personnel.

It cannot be too strongly emphasized that more important than the relative shortage of physicians is their inequitable distribution throughout Guyana, because most of them appear to prefer to practise in Georgetown and in its surroundings. There is, however, a definite shortage of specialist physicians.

Guyana does not have a sufficient number of general nurses, and it is woefully deficient in specialist anesthetic, psychiatric, and paediatric nurses. This shortage of nurses, who form by far the largest percentage of the workforce and are the backbone of the health sector, severely inhibits the system's capacity to deliver quality care.

There is also a critical dearth of personnel trained in such health-related fields as medical technology, pharmacy and radiography.

Fourth is a set of factors which singly and together adversely affects the quality of our health services: an absence of standard protocols for drug use in the treatment of common diseases; inadequate storage facilities at both the regional and central levels, often leading to the deterioration of scarce medicines; inefficient health education and training systems for all types of health workers; and ineffective systems of pharmaceutical and drug distribution which result in local shortages even when the medicaments are available.

The basic cause of the generally poor quality of health in Guyana, however, is the structure and organization of the health care system. Health services are delivered at five different levels in the public sector: at Level I there are 166 Local Health Posts which provide preventive and simple curative care for common diseases. These are staffed by community workers. Level II comprises 109 Health Centres which provide preventive and rehabilitative care. These are supposed to be staffed with a medical extension worker or public health nurse, along with a nursing assistant, a dental nurse, and a midwife. There are 19 District Hospitals at Level III. They are designed to serve geographical areas with populations of 10,000 or more, and are intended to provide basic in-patient and outpatient care, and selected diagnostic services. They are also meant to be equipped to provide simple radiological and laboratory services, and to be capable of providing preventive and curative dental care. Level IV encompasses four Regional Hospitals that provide emergency services, routine surgery and obstetrical and gynaecological care, dental services and specialist services in general medicine and paediatrics. The intention is for these hospitals to possess laboratory and X-ray facilities, pharmacies and dietetic expertise. These hospitals are located in Regions 2,3,6 and 10. And finally at Level V, there are the National Referral Hospital in Georgetown that provides a wider range of diagnostic and specialist services, the Psychiatric Hospital in Canje, and the Geriatric Hospital in Georgetown. There is also one children's rehabilitation centre.

The system is so structured that its proper functioning absolutely depends on a process of referrals. Except for serious emergencies, patients are to be seen first at the lower levels, and those with problems that cannot be treated at those levels are referred to higher echelons in the system.

In principle, the referral system is well-suited to Guyana because of the difficulties which the country experiences in communications and transport. However, it does not function well in practice. Technical inefficiencies and the failure to provide adequately trained medical staff, supplies and equipment at the lower levels induce patients to by-pass the various stages of the

system and seek care in the National Public Hospital or in the private hospitals concentrated in the Georgetown area.

In a cruel irony, it is the poor who visit the local facilities in disproportionate numbers, and endure the consequences of lower quality care.

The referral system also does not work well because there is little or no administrative co-ordination between the Centre and the Regions; inadequate funding; a virtual absence of

training in public health or in administration in Regional Health Offices; the failure to pass on patients' files to higher stages of the system, or even to keep records on patients; and the fact that in some parts of some districts it is easier to travel to Georgetown than to the appropriate health facility in the Region.

I shall, in the next article in this series, outline the strategy which the authors of the NDS have formulated to ensure that all the people of Guyana would be in a position to enjoy long healthy lives.