The document outlines primary health care approaches and strategies for retaining health workers in remote and underserved areas of Guyana. It discusses Guyana's demographics, cultural diversity, health system structure, human resource challenges, and strategies used to improve retention in remote areas. These include educational preferences for local residents, contracts tying training costs to service, increased pay and housing in remote areas, and ensuring access to professional support and development opportunities for rural health workers.

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. 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. 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. 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

7. POLICY: HEALTH VISION 2020
2013-2020
 Primary Health Care
 Universal Access
 Financial Protection
 Social Determinants
 Health as a Human Right
 Health Equity
 Solidarity
7

8. GUYANA HEALTH SYSTEM
 Health Governance
 Financing
 Human resource
 Service delivery
 Medicines and equipment
 Health information systems
 Partnerships
8

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Referral System

16. 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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17. TRAINING OF HEALTH CARE
PROFESSIONALS IN GUYANA
17

18. 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

19. DISTRIBUTION OF HUMAN RESOURCES
19

20. GEOGRAPHIC DISTRIBUTION OF
HEALTH WORKERS BY REGION
20

21. 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

22. 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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23. TYPES OF HEALTH WORKERS
 Community Health Workers
 Medex
 Doctors
 Nurses including midwives
 Malaria,TB and HIV workers
 Dental
 Environmental health
 Family health
23

24. 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

25. GEOGRAPHICAL AREAS COVERED
25

26. 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

27. RURAL RETENTION STRATEGIES
Education
Regulation
Financial incentives
Personal & professional
support
27

28. 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

29. 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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30. 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

31. 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

32. 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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33. 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

34. 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

35. 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

36. 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

37. 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

38. 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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39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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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48. 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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54. THANK YOU 54