PRIMARY HEALTH CARE APPROACHES
AND STRATEGIES FOR THE RETENTION
OF HEALTH WORKERS IN REMOTE AND
UNDERSERVED AREAS IN GUYAN...
OUTLINE
 Background on Guyana
 Health system and Primary Health Care Service
 Guyana Human Resource for Health
 Situat...
GUYANA COUNTRY DEMOGRAPHICS
 Population: 751,223(2002)
 Urban:28.4% Rural 71.6%
 Area size: 215,000 Sq.km (83,000 Sq. M...
CULTURAL AND ETHNIC DIVERSITY
 Multi- Racial Population
 Indo-Guyanese 43%
 Afro-Guyanese 30%
 Mixed 16.7%
 Amerindia...
POLICY: HEALTH VISION 2020
2013-2020
 Primary Health Care
 Universal Access
 Financial Protection
 Social Determinants...
GUYANA HEALTH SYSTEM
 Health Governance
 Financing
 Human resource
 Service delivery
 Medicines and equipment
 Healt...
GUYANA HEALTH SYSTEM
9
 Ministry of Health
 Ministry of Local Government
 Regional Democratic councils
 Regional Healt...
HEALTH FINANCING
 In 2008, public expenditure accounted for 54%,
while donor and private were 34% and 12 %
respectively.
...
SERVICE DELIVERY-PHC
Integrated health service networks
Levels of care
Referral System
Orientation and Standard T. Gui...
LEVELS OF CARE
Level 5
Central
Hospital-1
Level 4
Regional
hospitals-4
Level 3
District hospitals-20
Level 2
Health center...
PRIMARY HEALTH CARE
 Health Promotion- , disease prevention, treatment
and Rehabilitation.
 Attributes: access, affordab...
PRIMARY HEALTH CARE
 Family Health across the life cycle
 Family planning
 Antenatal, delivery and post natal care
 Ch...
Referral System
GUYANA: HEALTH HUMAN RESOURCE
 Inadequate capacity for HR management,
development and information systems. (fires)
 Supp...
TRAINING OF HEALTH CARE
PROFESSIONALS IN GUYANA
17
EXTERNAL HEALTH WORKFORCE SUPPLY
 Cuban trained Guyanese doctors-400 not reflected
in last available proportions. When th...
DISTRIBUTION OF HUMAN RESOURCES
19
GEOGRAPHIC DISTRIBUTION OF
HEALTH WORKERS BY REGION
20
MIGRATION 2010
21
 Poor salary
 Increades workload
 Job related stress
 Poor physiacl facilites,
equipment and
supplie...
REGULATION, LEGISLATION
 Guyana Medical Council (doctors, medics,
opticians)
 General Nursing Council (midwives, nurses,...
TYPES OF HEALTH WORKERS
 Community Health Workers
 Medex
 Doctors
 Nurses including midwives
 Malaria,TB and HIV work...
CHARACTERISTICS OF REMOTE AREAS
 Located in regions 1,7,8,9 and small pockets in
other regions.
 Terrain-access barrier-...
GEOGRAPHICAL AREAS COVERED
25
KEY OBJECTIVES OF RHS
 To oversee and coordinate the functioning of the
Regional Health Officers.,
 To Provide direct su...
RURAL RETENTION STRATEGIES
Education
Regulation
Financial incentives
Personal & professional
support
27
EDUCATION STRATEGIES
 Personnel from the rural and remote areas are targeted for
admission into health training programs,...
REGULATION STRATEGIES
 Task shifting is done in some of the rural areas in
various skills mix, however this leads to a qu...
REGULATION STRATEGIES
 Health personnel who are placed in the remote
areas are given rural, riverain and hinterland
incen...
FINANCIAL INCENTIVES
STRATEGIES FOR RETENTION
 Station allowances/riverain/
 Accommodation or housing allowance
 Duty f...
PERSONAL AND PROFESSIONAL SUPPORT
STRATEGIES FOR RETENTION
 Before some workers are deployed or actually travel to
rural ...
PERSONAL AND PROFESSIONAL SUPPORT
STRATEGIES FOR RETENTION
 The University in collaboration with the MOH has
developed an...
FACTORS FOR NON-PLACEMENT OF
WORKERS IN AREAS WITH FEWER
WORKERS?
Economic : High cost of living.
 High cost for basic fo...
WHAT ARE THE TYPES OF HEALTH WORKERS
THAT ARE MORE DIFFICULT TO PLACE IN
REMOTE AND UNDERSERVED AREAS?
 Level of training...
WHAT ARE THE FORMS OF
CONTRACTING WORKERS AND WHO
ARE THE EMPLOYERS?
 Workers are contracted on a contract gratuity syste...
MAIN STRATEGIES FOR THE PLACEMENT OF
WORKERS IN REMOTE AND UNDERSERVED
AREAS
 According to the health needs of the commun...
IS THIS STRATEGY PART OF A NATIONAL
POLICY?
 PPHGS-Health Vision 2020
 The Package of Publicly Guaranteed Health
Service...
WHO ARE THOSE RESPONSIBLE FOR THEIR
ELABORATION, EXECUTION, FINANCING?
 RHS/ MOLGRD
 Who finances the strategy? MOF Nati...
WHICH PROFESSIONALS ARE INCLUDED
IN THIS POLICY/STRATEGY?
 Low level prof on a day to day basis
 Specialist on outreach
...
DO THE STRATEGIES INCLUDE THE
ENHANCEMENT OF THE HEALTH
INFRASTRUCTURE AND EQUIPMENT?
 Regions 1 and 7 are examples for r...
WHICH INTERVENTIONS IN THE CONDITIONS OF
LOCAL/WORK INFRASTRUCTURE HAVE BEEN CARRIED
OUT IN ORDER TO INCREASE THE PLACEMEN...
STRATEGIES TO FACILITATE THE INTERACTION
BETWEEN WORKERS IN RUA AND OTHER
WORKERS
 The referral system is supported by a ...
WHAT STRATEGIES ARE USED TO
SENSITIZE THE STUDENTS TO WORKING
IN RUAS
 Exposure to the challenges and working
conditions ...
REGULATION INSTRUMENTS FOR THE
SUPPLY/AVAILABILITY OF HEALTH
WORKERS
 Regulate supply: based on the needs assessment and ...
STRATEGIES OF SOCIAL
ACKNOWLEDGEMENT OF
PROFESSIONAL WORKING WITH PHC
 Midwives: every year selected midwives from all th...
INCENTIVES FOR RESEARCH AND KNOWLEDGE
EXCHANGE
 Lacking.
Isolated cases- one nurse through the
midwives association, Trac...
TOOLS FOR MONITORING AND
EVALUATION
OF PLACEMENT/RETENTION STRATEGIES
 The are no formal tools available, however a
surve...
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50
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52
53
THANK YOU 54
Monica Odwin - PHC approaches and strategies for the retention of health workers in remote an underserved areas/Guyana
Monica Odwin - PHC approaches and strategies for the retention of health workers in remote an underserved areas/Guyana
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Monica Odwin - PHC approaches and strategies for the retention of health workers in remote an underserved areas/Guyana

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Presentación de Monica Odwin/Guyana hecha por ocasión del Taller “Abordajes de Atención Primaria a la Salud y estrategias para permanencia de profesionales en zonas alejadas y desfavorecidas en los países de Suramérica”, que se realizó en el ISAGS los días 13, 14 y 15 de mayo de 2014.

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Monica Odwin - PHC approaches and strategies for the retention of health workers in remote an underserved areas/Guyana

  1. 1. 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
  2. 2. 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
  3. 3. 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) 3
  4. 4. 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  , 4
  5. 5. POLICY: HEALTH VISION 2020 2013-2020  Primary Health Care  Universal Access  Financial Protection  Social Determinants  Health as a Human Right  Health Equity  Solidarity 7
  6. 6. GUYANA HEALTH SYSTEM  Health Governance  Financing  Human resource  Service delivery  Medicines and equipment  Health information systems  Partnerships 8
  7. 7. GUYANA HEALTH SYSTEM 9  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
  8. 8. 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 10
  9. 9. 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 11
  10. 10. 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
  11. 11. 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. 13
  12. 12. 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 14
  13. 13. Referral System
  14. 14. 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. 16
  15. 15. TRAINING OF HEALTH CARE PROFESSIONALS IN GUYANA 17
  16. 16. 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. 18
  17. 17. DISTRIBUTION OF HUMAN RESOURCES 19
  18. 18. GEOGRAPHIC DISTRIBUTION OF HEALTH WORKERS BY REGION 20
  19. 19. MIGRATION 2010 21  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
  20. 20. REGULATION, LEGISLATION  Guyana Medical Council (doctors, medics, opticians)  General Nursing Council (midwives, nurses,NA)  Dental Council  Allied Health Professional Council ( technicians) 22
  21. 21. TYPES OF HEALTH WORKERS  Community Health Workers  Medex  Doctors  Nurses including midwives  Malaria,TB and HIV workers  Dental  Environmental health  Family health 23
  22. 22. 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 24
  23. 23. GEOGRAPHICAL AREAS COVERED 25
  24. 24. 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. 26
  25. 25. RURAL RETENTION STRATEGIES Education Regulation Financial incentives Personal & professional support 27
  26. 26. 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. 28
  27. 27. 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. 29
  28. 28. 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 30
  29. 29. 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) 31
  30. 30. 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. 32
  31. 31. 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. 33
  32. 32. 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 34
  33. 33. 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
  34. 34. 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. 36
  35. 35. 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. 37
  36. 36. 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. 38
  37. 37. 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. 39
  38. 38. 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 40
  39. 39. 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. 41
  40. 40. 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. 42
  41. 41. 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. 43
  42. 42. 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. 44
  43. 43. 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 45
  44. 44. 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
  45. 45. 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. 47
  46. 46. 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. 48
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  52. 52. THANK YOU 54

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