SECTION 3: Health and Human Development in Guyana

Introduction

In this Section we focus on the second of three sets of variables which are measured in the calculation of the HDI. We look at human development concerns pertaining to health status, the health care system, access and equity in health care delivery and health policies in Guyana. By its very nature however, health cannot be separated from other national sectors, therefore the health status presented in this sub-Section cannot be adequately evaluated outside of the performance of these other sectors. Among the more important related sectors are: nutrition, education, housing, sanitation, water supply, the availability of basic services, food availability, recreation, cultural attitudes and life styles. Several of these sectors will be considered later in this Report.

i) Health Status

Life Expectancy, Fertility and Mortality Rates

Life expectancy, fertility and mortality rates are the foundation statistics in describing the health status of a population. In Guyana, life expectancy is presently 64 years. For females it is 69 years, and males 63 years. The crude birth rate is 29.8 and the crude death rate 7.1. The latter compares to 6.9 in 1960.

Fertility rates have declined over the past three decades; from a high of 6.1 in 1960, it is presently estimated at 2.6 children per woman of child-bearing age. Although the prime child bearing age is still the 20-24 age group, early (teenage) pregnancies have been recording the fastest increases in recent times.

The ten leading causes of death for the population as a whole as given in the National Health Plan are in descending order:

• cerebro-vascular disease;
• ischaemic heart disease;
• diseases of pulmonary circulation and other types of heart diseases;
• diseases of the digestive system;
• endocrine and metabolic diseases including immunity disorders;
• other diseases of the respiratory system;
• hypertensive disease;
• conditions originating in the perinatal period;
• intestinal infectious diseases;
• accidents.

As reported in the national budget (1996), in 1995 the infant and children (under-five) mortality rates were 32 and 65 respectively. The four leading causes of infant mortality, which together account for 78 percent of all infant deaths at the time of the most recent MOH survey (1992), were:

• conditions originating in the perinatal period (35 percent)
• intestinal infectious diseases (25 percent)
• other diseases of the respiratory system (12 percent)
• nutritional deficiencies (6 percent)

The leading causes of death among children aged 1-4 in the same survey overlapped with those indicated above. These are: intestinal infectious diseases, other diseases of the respiratory system and nutritional deficiencies.

The particularly tragic aspect of these circumstances is that all these diseases fall in the class of "preventable" diseases.

Maternal mortality rates were found to be high in the survey, reaching 213,340 and 443 per 100,000 in the three major hospitals in the country. The Georgetown hospital, which is the leading hospital, and is at the top of the national referral system, recorded the rate of 213 per 100,000 cited above. These rates are more than treble some of those obtained elsewhere in the CARICOM region.

Morbidity and Risk Factors

Data on morbidity and risk factors are sparse. Even the latest available draft of the Guyana National Health Plan (1995) reported difficulties in accurately determining the leading causes of morbidity. It nevertheless produced a list based on data from a variety of sources in the health care system, which show the leading causes of morbidity to be:

• Dental caries
• Malaria
• STDs excluding HIV/AIDS
• Hypertension
• Abortion
• Diabetes
• Acute Respiratory Infections (ARI)
• Malnutrition
• Acute Diarrhoeal Diseases
• Accidents and Injuries
• Worm Infestations

The draft Plan also identified the major risk factors for the population and located these in the physical environment, the work place and the home. The following were identified as the key elements of each:

i) Physical Environment

• Air-pollution, especially in the bauxite belts and pesticides in agricultural areas.
• Bacterial contamination of water supply.
• Basic sanitation deficiencies, especially waste disposal.
• Insufficient and poor quality housing.
• Flooding.

ii) Work Place

• Accidents and injuries.
• Pesticide contamination of the irrigation and drinking water supply system at workplaces.

iii) Home

Adequate data were not available as children and women abuse is often not reported. Women advocacy groups though claim that the incidences of this violence are high and rising.

 Linked to these high risk factors is the question of the identification of particularly vulnerable population groups. The data available to us suggest that these special population groups are to be found in the following areas:

• Infant and child health (already revealed in the data cited above).
• Reproductive health (also indicated in the fertility data and reference to early (teenage) pregnancies) and the increasing incidences of breast and cervical cancers. Data presented later on nutrition will also support this identification.
• The Amerindian population (already identified in Section I as a group, which is the poorest of the poor).
• People with disabilities, who form a significant minority (discussed later).
• Mental health problems, which frequently go undiagnosed and untreated and more often than not are shrouded in traditional beliefs and superstitions).
• Drugs and Substance abuse (discussed later).

HIV/AIDS

The world-wide epidemic of HIV/AIDS, and the concomitant problems it poses for health care systems, apply equally to Guyana. Our discussions with health care personnel in the preparation of this Report lead us to believe that in Guyana, the incidence of HIV/AIDS is much higher than the official statistics suggest. We therefore report the information which we have gathered below:

• While reported data show the AIDS curve to be rising, of great significance, the majority of cases are found in the 20 to 34 years age group which constituted 67 percent of all HIV positive cases seen at the Genito-Urinary Clinic (GUM) in Georgetown up to 1995, with the male/female ratio being 1.7:1 (see Table 3.1). This clinic is charged with the clinical aspect of HIV/AIDS testing in Guyana.
• Since 1987 more than a thousand Guyanese have shown positive results to official HIV testing. According to the Division of Communicable Diseases, Ministry of Health, there were 1,241 such persons of whom 1,173 were reported through the GUM Clinic.

Table 3.1: HIV-positive by Age Group

Source: Information collected from MOH 1996.

• However, the GUM Clinic acknowledges that only a fraction of HIV cases comes to its attention, so that the incidence of HIV positive cases may be in fact many times higher. One difficulty the clinic faces is the stigma attached to it among the urban populace who sees it principally as a place "which looks after sexual diseases contracted by socially undesirable elements of society."
• Available information also suggests that the private hospitals and laboratories are not routinely reporting the incidence of HIV cases to the National AIDS Programme Secretariat.
• Another indication of the size of the HIV/AIDS problem is provided by the percentage of blood donors who are identified by the National Blood Bank officials as being HIV positive when they show up to donate blood for sick relatives or friends. In what is generally considered a low-risk, healthy section of the population - blood donors who are self-selected and unaware of the personal risk of HIV - 1.5 percent annually test HIV positive. Extrapolating this rate of HIV positives among voluntary blood donor samples - the highest rate in the Caribbean -one highly placed Health official has estimated that there may be about 7,000 new HIV cases in Guyana each year.
• In response to the situation a National AIDS Programme Secretariat was set up to deal with the administrative and educational aspects of the problem in Guyana as well as to keep national statistics on the situation. However, as Table 3.2 below shows, there is a discrepancy in the reported figures on HIV/AIDS held by the GUM Clinic and the National AIDS Programme Secretariat, with higher annual figures recorded by the GUM Clinic in the 1993-95 period, than by the National AIDS Programme Secretariat.

Table 3.2: HIV/AIDS

Source: Information collected from MOH.

• Data on ethnicity are not kept by the GUM Clinic because of the observation that its services are used mostly by urban poor African Guyanese and by sex workers, while persons of other ethnicities generally go to the private hospitals and laboratories for blood tests. Keeping a record of ethnicity therefore, in the absence of parallel record keeping at private hospitals and laboratories, would result in the data being heavily skewed, likely leading to the unfair and inaccurate stigmatising of one ethnic group.

Recent information from the Caribbean Epidemiological Centre (CAREC) has placed Guyana as having the highest AIDS rating in the Caribbean. Its 1996 statistics also showed that Guyana has the most living persons with AIDS per 100,000 persons of the population. This figure is approximately 67 for every 100,000 persons.

It is obvious that in light of these circumstances public education has to be a major plank of health policy. Contraceptive prevalence in Guyana is very low, reported at 28 percent in the LSMS survey. With this in mind, regional AIDS Committees have been set up in Guyana's 10 administrative regions, charged with promoting AIDS awareness throughout the country.

Health officials however, admit little success. They are particularly concerned about the 15-29 age group, where they believe that information on the imperative and methods of practising safe sex is not reaching those most at risk. Given the long incubation period of the AIDS virus, health workers suggest that sex education should even begin in the pre-teenager years.

The Health Ministry has allocated only US$75,000 to the education programme managed by the AIDS Secretariat, which is intended to cover hinterland and riverain areas also. Two World Bank consultants at the Ministry of Health - one in management and control - have been assigned to examine the current structure for information and education, and the functioning of the Regional AIDS Committees (RACs). A national AIDS hotline was started in August 1995 but to date, this have not been much used by the public, leading to the curtailment of its service hours.

ii) Health and Nutrition Status

LSMS Survey Results

Concerns over poor health status in Guyana are also reflected in the health and nutrition status of the population. The 1992 HIES/LSMS survey reported that nationally, 2.2 percent of the children in Guyana were severely malnourished and 16.1 percent mildly malnourished. Malnutrition, as would be expected, was highest among the poor, and in turn these were found to be heavily concentrated in the interior, parts of the rural areas and in urban slums. One-third of the children living in households which fell within the poorest quintile were malnourished.

Anthropometric Data

In 1994, the Guyana Agency for Health Education, Environment and Food Policy (GAHEF) conducted a survey of weight-for-height and height-for-age among school children as proxy indicators of their nutritional status. Children were classified as malnourished or of low anthropometry when they were below two standard deviations of the median of the reference population. Criteria were also pro-vided for measuring the degree of severity of under-nutrition in the sample population. While there is an increasing consensus among specialists that it is misleading to use WHO anthropometric indices as a measure against which to evaluate widely varying human populations - in which short stature, for example, is often an adaptive strategy of forest peoples - existing data on Guyana is presented below.

The results show that 13.7 percent of the sample population were low height-for-age, and 8.1 percent were low weight-for-height.

In the first category, height-for-age, the national average (13.7 percent) was classified as falling in the low range of severity, which was put at the level of less than 20 percent of the sample population. There were wide regional differences in the results. Region 9, an interior Region, recorded a level of 73.2 percent! Region 1 was the only other Region above the national average. Its percentage was 17.9

In the second category, weight-for-height, the national average of 8.1 percent was classified as a medium level of sever-ity, because this result fell between 5 and 10 percent of the sample population. There were also regional differences in this category, but not as striking as the other variable. Regions 3 (14.6 percent), 6 (12.1 percent) and 5 (10.3 percent) were above the national average and were classed in the high degree of severity range.

When classified by ethnicity, the Amerindian population fared the worst in height-for-age (61.7 percent), and the best in the weight-for-height measure, (1.5 percent). The worst placed ethnic

group based on this latter measure was the East Indian population (14.3 percent).

In summary therefore, the data show strong regional and ethnic imbalances in the nutritional status of children in Guyana. In instances, where regions or ethnic groups performed worse than the national average, it should be noted also that these levels fell in the high degree of severity category, and must therefore be a matter for urgent national attention (See Box 3.1).

Anaemia and Pregnant Women

GAHEF also gathered data on anaemia among pregnant women attending clinics. These provide useful insights into the nutritional status of this population group. Measuring anaemia as when the Hb level in the blood was <10g/dL, the data showed that in 1993, 32.7 percent of the pregnant mothers attending clinics were suffering from anaemia.

These results can be related to the data on still-births and low birth weight among infants. For 1994, it was estimated that the still-birth rate was 23.9 per 1,000 births. This was up from 18.2 in 1991 when a similar survey was conducted. In 1994, 19 percent of the total of live births was infants with low birth-weight (i.e., below 2.5 kg).

The results above showed marked regional variations. Thus in Region 2 the highest anaemia count was obtained, 96.3 percent of clinic attendees, and the lowest was in Region 8 (8.3 percent). In the area of low birth-weights, 33 percent of infants from Region 10 were in this category, while in Region 9 it was 8 percent.

Food Availability

The data on national food availability complete the picture of nutritional status in Guyana. In 1994, the per capita food avail-ability yielded a diet equivalent to 2,356 kilocalories. The overall per capita availability of calories was on average sufficient for most categories of the population, and only slightly below that recommended for young male adults (2400 kilocalories).

This per capita food availability contains 71 grams which came from protein and 43 grams from fat. The per capita availability of protein at 71 grams, exceeded the recommended norm for young male adults.

Food available from plant sources was 89 percent of the total. In the non-plant food sources, fish and shrimp supplied the bulk (60 percent) of this category of food.

These data however, refer to the national average availability and do not reflect the significant variations in the access to food among different sections of the population, as the malnutrition and anaemia and other data above indicate (See Box 3.2).

iii) The Health Care System

Institutional Structure

Given the picture we have drawn of the health and nutrition status of the population and the threat posed by HIV/AIDS, how does the health care system stand in relation to these challenges. Clearly the answer would determine the state of SHD in Guyana. At present health care in Guyana is provided through a mix of Government, parastatal, private and non-governmental institutions with the international donor community playing a very important role.

There are three Government Ministries linked to the health care system: the Ministry of Health (MOH); the Ministry of Regional Development, Public Works and Communication, through which the Regional Authorities service the public provision of health services in the regions, following on the decision to regionalize public administration in the 1980s; and the Ministry of Labour, with responsibility for the geriatric hospital and the leprosarium. These three Government ministries account for about two-thirds of total health expenditure in Guyana. A number of other Government agencies are also responsible for health care related matters, e.g., national insurance, nutrition, water and sewerage.

Parastatal enterprises control the bauxite and sugar industries, (which form the two leading sectors of the economy), and these have traditionally provided health care to their employees and dependants, until very recently when it was announced that the bauxite industry's health services would be henceforth, provided by the Government.

The independent private business sector provides health insurance, sells pharmaceuticals, as well as offers private medical services in six private hospitals and a large number of individual and group practices. Traditional healers also operate.

The international community offers services through a variety of health missions to Guyana, and plays the dominant role in financing new health facilities in the country, as well as contributes substantially to the formulation of local health policies and programmes: for example, PAHO/WHO has an office in Guyana.

The health services in the public sector are based on a five tiered structure and an upward moving referral system. There are 256 public health facilities, including the national referral hospital in Georgetown. The structure of the public health system and the numbers in each category are presented in Table 3.3 below.

Thomas (1996) reported that the general view among health care providers is that as described, the health care system is considered to be well designed. Given the topography of the country and its population distribution, the system aims to have health care delivered as close to the population as possible, regardless of location, income or wealth, while simultaneously seeking to balance appropriateness with need, in a cost effective manner.

Table 3.3: Public Sector Health Services

Source: Information supplied by the MOH, 1996.

However, as the indicators presented in the next sub-section indicate, in practice the referral system has virtually collapsed. And, although its financing has improved in recent years, public health care is so badly under-financed that it has become extremely inefficient, contributing to the reversals in health indicators noted above.

This position has been also acknowledged in the draft National Health Plan which states: "in practice, however, (the health care system) is not working as originally intended" (MOH, National Health Plan, p.2). Indeed, the situation is so serious that as the IADB notes: "the health situation in Guyana is probably the worst in the Commonwealth Caribbean" (IADB, 1994), an observation which is in keeping with the health indicators we have reported above.

In addition to the public sector, there are 10 hospitals owned by parastatals and private companies, but information on these is not reported regularly.

The MOF in the National Budget for 1997 reports the number of physicians, nurses and hospital beds per 10,000 of the population as 3.8, 8.0, 35.9 respectively. The trend since 1991 is shown in Table 3.4.

Table 3.4: Health Ratios

Source: Ministry of Finance, National Budget, various years.

At present we have estimated that about one-quarter of the hospital beds are in private institutions, and of the 80 registered and practising pharmacists, 77 were working in the private sector. The distribution of doctors was 176 and 133 respectively in the public and private sectors, with several working in both.

Expenditure Patterns

The MOH estimated that the private sector spent about US$8-10 million on drugs and health facilities in 1995. Expenditure by parastatals was about US$3 million. In 1995 the National Budget provided for US$21 million in total health expenditure, of which about US$15 million was on capital expenditure and US$6 million on current expenditure in the sector. Total Government expenditures represented about two-thirds of all expenditure on health.

There has been a significant increase in public spending on health in recent years. A significant proportion of this is due to expenditures on the IADB Health Care Project II financing of the upgrading of the National Referral Hospital's Ambulatory, Diagnostic and Surgical units (See Box 3.3).

In real terms, (i.e., adjusting for inflation), total health expenditures declined by about 46 percent between 1988 and 1991. Since then the increase has doubled in real terms. Capital spending on the IADB Health Project alone accounted for 46 percent of total health expenditure in 1995. With the recent completion of this project, the 1996 Budget provides for only 17 percent of its expenditure to be on this line item.

Per capita Government spending on health has also shown significant increases since 1991. In the 1996 Budget, this is projected at US$27, which is well above the US$12 per capita considered as minimal for a basic primary health care package.

Given this pattern of spending in recent times, that the health status of the population remains so poor, indicates complex problems of size, and "lumpiness" of investments scale and population distribution, as well as an historical bias towards hospital services, in preference to primary health care. It also indicates what we noted in the discussion of the SHD indicators: the health measures used do not respond rapidly to changes in priority, as a general rule.

In terms of fiscal effort, Government spending on health as a percentage of the national budget was 6.3 percent in 1996, up from less than 3 percent in 1991 (Table 3.5). In terms of national effort spending in 1996 was 3.0 percent of GDP.

Table 3.5: Public Expenditure on Health (% of National Budget)

Source: Ministry of Finance, National Budget, 1997.

iv) Access and Equity

Of crucial importance to SHD is the level of access and equity in the health care delivery system. In this regard the LSMS survey data indicate that even though in general, access to health services in Guyana is high, nevertheless the poorest sections of the population do not fare very well. While 93.4 percent of the population made their first visit to the formal medical sector, transport, waiting time and the cost of medicines were significant impediments in accessing health care. In practice the "free system" is hardly free and these hidden costs largely disadvantaged the poorest sections of the population, (which were also in many instances those living in isolated hinterland/interior communities). The survey data showed that 43 percent of the population purchased their own medication. For the poorest quintile of the population, who could not afford to do this, the percentage purchasing its own medication, was less than one-half of the national figure - 20 percent.

Perhaps the most apt commentary on the "free" public health care system comes from the survey data which showed that 31 percent of the population seeking treatment went to the public hospitals, 12 percent to health centres and 5 percent to health posts. But as many as 21 percent visited a private doctor, 11 percent a private hospital and 5 percent a private clinic, despite health being "free" in the public health care delivery system. This occurred in a situation where 80 percent of the population has no health insurance. The IICA/IFAD data also showed that rural households consider the district hospitals and local centres to be sub-standard, and preferred to travel to the capital city if they could afford it and had the time. Only 46 percent of households surveyed used the rural clinics and health centres. The result of such circumstances is that public health care has become by default, not by preference and choice, the major supplier of health care to the poor. Persons by-pass this system when they can afford it.

In light of the perceived quality of the "free" public health care system, it is significant from the point of view of equity, that the poorest quintile relied more heavily on it (60 percent) than the top quintile (41 percent). If we exclude the public hospitals, over one-third of the poorest quintile relied on the health centres and health posts. This ratio was more than twice that of any other quintile (see Table 3.6).

Table 3.6: Type of Health Facility Used, by Quintile

*Other includes traditional medicine and to a lesser extent dispenser's home/office, patient's home, or private drugstore.

Source: World Bank (1994)

While nationally about two-thirds of the population received health care from a doctor, followed by one-sixth from the medex, the figures for the poorest quintile were 37 and 22 percent respectively. The corresponding figures for the top quintile were 67 and 13 percent respectively (Table 3.7).

The data also show that access to preventative care (immunization, medical check-ups, pre- and post-natal care) was 43 percent nationally. But the poorest quintile of the population only recorded an access rate of 34 percent (Table 3.8).

Table 3.7: Type of Health Care Worker Delivering Treatment, by Quintile

*Other includes midwife and healer.

Source: World Bank (1994)

Table 3.8: Access to Health Services by Welfare Group

Source: World Bank (1994).

Based on the information provided in the draft National Health Plan, Thomas (1996) provides a schedule of the major constraints identified in the whole gamut of delivery services, based on the 11 heads, 9 sub-heads and further sub-divisions in the draft Plan. This is reproduced in Table 3.9.

Table 3.9: Schedule of Health Delivery Constraints

Source: Thomas (1996).

v) Policy Interventions in Health

Introduction

Interviews with health care providers indicate that there is a strong belief that a number of well-intentioned and well-conceived initiatives already exist. The issue that is crucial, is how to get these put in place and moving. It would seem, therefore, that the best way to commence our discussion would be with a brief review of these proposals, which together focus on seven major initiatives in health. All of these appear to us to be consistent with the strategic interventions required to promote SHD. These initiatives are:

• The draft National Health Plan, which has been in draft form for two years or more.
• Various nutrition programmes, some of which were to have commenced several years ago.
• Initiatives by the private business sector and Government corporations.
• The activities of NGOs and the Government's poverty alleviation agency (SIMAP).
• The National Plan of Action for Children
• The activities of the international donor community.

The National Health Plan

Concurring with the observations made earlier in this Report on the critical situation in the health sector, the draft Plan justifies itself by stating that "the health sector is having to face up to problems of large and growing magnitude" (National Health Plan, p.6). Its vision and mission statements declare that:

"It is the aim of the Government that Guyanese citizens be among the healthiest people in South America and the Caribbean" and that "our mission is to improve the physical, social, and mental health status of all Guyanese".

The Plan then proceeds in two stages, first, in identifying the main health problems in the country (and from this establishes its priorities) and then assesses the health delivery system (and from this identifies critical areas for improvement and reform).

The indicators used to determine the major health problems are similar to those used in this Report, e.g., the leading causes of mortality; the leading causes of morbidity; specific health issues affecting critical population groups; and risk factors in the physical, workplace and home environment.

The Plan sets the following four objectives for Year 2000.

a) Strengthening and expanding primary health care with the emphasis on health education, nutrition, environmental health, maternal and child health, prevention and control of endemic health problems.

b) Improving secondary health care services at the regional and district hospitals.

c) Improving tertiary health care at the Georgetown public hospital which is already in train with the IADB's Health Care II project (see Box 3.3).

d) Strengthening general management of the health sector.

Nutrition Programmes

Initiatives have been underway for some time now in three broad areas of nutrition, namely, assessment, education and surveillance and further interventions. The proposals are that:

• The maternal, child and health care programme of the MOH which provides ante-natal care, as well as iron and vitamin supplementation, will be expanded.
• Health centres which offer check-ups to infants and children under 5 will have their coverage improved.
• Immunization programmes will be expanded to full national coverage.
• Pilot projects which are jointly operated by the MOH, PAHO and the Caribbean Food and Nutrition Institute (CFNI) in areas of high malnutrition, will be intensified.
• PL480 wheat imports which are fortified with iron in the flour distributed nationally under this USAID programme will be continued.
• The programme for pregnant women to receive iron tablets to prevent anaemia will be expanded.
• The World Food Programme which started a school feeding programme as far back as 1983 which provides mid-morning biscuit and milk snacks to 75,000 primary school children and 25,000 nursery school children, will be continued and if possible, expanded.
• SIMAP's programme of food supplementation through day care centres and in the form of take home supplements will be encouraged.
• Breast feeding promotion through the Baby Friendly Hospital Initiative which aims at making breast feeding universal for all children up to four months will be continued. At present 97 percent of infants are breast fed for the first month, dropping to 33 percent in the second. The mean period of breastfeeding is 1.2 months.

From interviews and discussions with those involved, certain problems seem to have already emerged with these programmes. Thus:

• nutrition monitoring and surveillance have been found to be far too intermittent to be satisfactory;
• frequently, data acquired are not analysed so as to guide these programmes;
• many of the programmes which exist also do not seem to be well targeted and reflect inadequate community involvement in their design, implementation and processing.
• in the interior areas, with their high concentration of Amerindian peoples, the coverage of these programmes is poor;
• finally, programmes such as the food supplementation ones are felt by many recipients to be unreliable and irregular.

As a result of these considerations some have called for existing programmes to be evaluated and their results publicly disseminated as the first step in a major drive aimed at nutrition promotion and education. As Mehrota states:

"The policy conclusion is, therefore, that child malnutrition continues to exist not because of lack of a program to remedy the problem, but because most are ineffective" (Mehrota, UNDP Report, 1994).

Public Corporations and Private Business Initiatives

Traditionally the bauxite and sugar companies, the two largest employers of labour, have played major roles in health care delivery in Guyana. Because of the sustained economic reverses in the late 1970s and 1980s, delivery of these services has come under severe stress. So much so that the state owned bauxite company has shed its responsibility for health, transferring these to the Government.

In sugar, the situation is somewhat different. Since 1991 when the management was privatized, it has made rehabilitation of its community support functions, including health, a priority. As a result, its medical facilities have been improved, with the provision of ambulances, preventative health care measures, additional doctors and para-medical personnel, drugs, and so forth. In keeping with this emphasis, the occupational health and safety aspects of the company's welfare work has also received considerable attention, as safety equipment and protective gear have become more available and their use by the workers better ensured. Underlining this development has been the promotion of the safe use of chemicals in the industry. The industry's health services programme now emphasises health promotion and is centred on 7 areas: evaluative/preventative; health education; treatment; training; employee assistance; statistics; and research administration.

The breakdown of the health referral system in the public sector and the poor quality of public health care have resulted in the growth of the private health care business. At present, about 50 percent of health care is provided in the private sector. With the recent robust growth of the economy, expectations are that if the public health sector is not turned around quickly, more and more recourse will be made to the private health system.

In the latter sector the crucial bottleneck seems to be the supply of medical doctors. If market incentives get better, then one might also anticipate a greater marketing of private health insurance and group health programmes for employees. At present no organized private sector grouping of health care providers exists, in a manner similar to that in the public sector. There are however, discussions about private health insurance from local and overseas insurance enterprises.

One can also reasonably anticipate that a profit driven health care system will improve access for those who can afford it. It will not deal directly with the problems of the many poor in Guyana. For those who therefore, see access to health care as a basic human right and a necessary element of SHD, this would not be an immediate solution to Guyana's health care woes.

SIMAP and NGOs

These health care providers are elements of a wider system of safety nets in Guyana which will be discussed separately in Section 7, where the management of poverty alleviation programmes is considered. It is important to stress however, that these institutions will be expected to play a significant part in an improved health care system. Much of this may well be through accessing external financing, as well as human and technical support for the design of primary health care programmes. To be effective these latter programmes would have to be more performance oriented and targeted to the neediest sections of the population than existing ones.

National Plan of Action For Children

Under the impetus of the World Summit for Children (1990), a National Commission for the Survival, Protection and Development of Children was appointed in 1993 to prepare a National Plan of Action for Children to the Year 2000. The report has not yet been finalized and accepted although it is based on a "two-cycle phasing", the first of which should last from approval of the Plan to 1997, and the second from 1997 to completion of the Plan in the Year 2000. The objective of the Plan is to ensure that the issues of children and women are kept on the political-social agenda for a long enough period to secure real progress.

The plan has three major goals for children under 5 years old by the Year 2000.

• To decrease the existing mortality by at least one-third.
• To reduce the maternal mortality rate by the same percentage.
• To reduce severe malnutrition also by one-third and moderate malnutrition by one-half of the prevailing rates.

These goals are to be achieved through 10 clusters of interventions namely:

1. Rehabilitation of primary health facilities.
2. Increased immunization coverage.
3. A reduction in the incidence of diarrhoeal diseases and an improvement in its treatment through wide dissemination of oral rehydration therapy.
4. More effective treatment of acute respiratory disorders.
5. Reduction of malaria among children through improved preventative measures.
6. Improved antenatal care at the primary and referral levels, and better health promotion for pregnant women.
7. Increased birth attendance by properly trained health personnel.
8. Reduced abortions and improved contraceptive education.
9. Improved nutrition for mothers and children.
10. Concentrated attention among the Amerindian population.

Donor Recommendations

The donor community as we saw is a major source of finance for health care investments in Guyana and their views will have an important bearing on the outcomes. The IADB which has financed the Health care Project II, has in its Socioeconomic Mission Report (1994) identified five priority areas of policy reform:

• Strengthening the primary health care system.
• Introducing user charges in a judicious manner.
• Developing a national health insurance scheme.
• Developing programmes by applying the principles of the BAMAKO Initiative in Guyana.
• Engaging in health promotion.

The BAMAKO Initiative is based on the partnership of the health centres and the communities which they serve. The objective is to ensure that the community creates and controls its own revolving fund to be used to secure inputs for the health centres as well as to encourage local communities to play an influential role in the design, implementation, monitoring and evaluation of community health programmes.

The World Bank which has financed the LSMS Survey has, in its analysis and reporting on the data, accepted the premise of strengthening the health delivery system as well as the broad objectives stated in the National Health Plan. It stresses, however, the importance of putting in place certain key measures if these results are to be achieved. These are:

First, to clarify the role of the public sector in health and to make a determination of what essential services the Government should reasonably aspire to provide. In this regard, the Bank recommends its own minimal package which includes: vector borne disease control, illness of young children and mothers, family planning and sexually transmitted diseases.

Second, it advocates that health care spending needs to be made far more efficient and equitable.

Third, it recommends that there should be the speedy overhaul of the administrative system in the MOH and the regions in order to strengthen institutional capacities.

Fourth, better health promotion is advocated as a priority.

Fifth, associated improvements in nutrition programmes and other basic services like housing, water and sanitation have also been advanced as crucial elements of its package.

Inter-governmental agencies such as WHO/PAHO, UNICEF and UNDP have also been involved in the formulation of the National Health Plan, various nutrition programmes, and the National Plan of Action for Children. Their proposals have been captured in the various documents we have referred to, and so do not require separate presentation here. The point should be made however, that because of local shortages of human resources, technical inputs of staff and consultants from these agencies have played a significant role in the development of proposals for improving health care in Guyana.

vi) Recommendations

What recommendations do we make about advancing the role of health in promoting SHD in Guyana? The above policy review seems to us to confirm the view that the health sector is not short on good proposals which can improve the health of the Guyanese population and therefore enhance SHD. This seems all the more plausible because these proposals which have been put forward by a wide range of institutions still substantially overlap, confirming our view that the problems and solutions are strikingly self-evident. We therefore emphasize four priorities:

First the need for prompt decision-making about the status of existing proposals.

Second, putting in place systematic procedures to ensure speedy but effective consultation with all the principal stake-holders providing health care in Guyana and its major beneficiaries.

Third, securing the necessary political commitment to pursue the task identified.

Fourth, ensuring that effective implementation capacity exists in the public sector, so that it can fulfil its share of the responsibilities.

The National Health Plan is a good example of the situation as it now exists. This Plan was drafted three years ago, with subsequent revisions. The changes however, have not been substantial and therefore raise the question as to whether the continuing delay is justified. It seems to us that the loss of timelessness may not be justified when one considers that the principal weakness of the original draft remains.

It is almost exclusively pre-occupied with public sector issues, although being presented as a national plan. Most of the members of the National Committee who drafted the plan were:

"confined to public sector participants with only nominal representation from the Public Service Union, and the doctors, as a professional body. The parastatal, private business and NGO communities were not adequately involved" (Thomas, 1996, p.51).

Another example is dental health, which tops the list of major causes of morbidity in Guyana. Our review of this area found that at the official level, the state of dental health tends to get subsumed under the press of other health concerns, even though Guyana's status as a significant sugar-producing and consuming nation may be contributory to the high caries rate. The Guyana Oral Health Survey of School Children 1995, carried out under the auspices of the Guyana Dental Association (GDA), confirmed an earlier survey done in 1984 that Guyana has a very high dental caries prevalence in children as determined by the DMFS classifications (Decayed Missing Filled Surfaces) established by the World Health Organisation. The GDA also sponsored a short-term consultancy in November 1995 which made recommendations for dentistry in Guyana and advised on ways to ensure mass exposure to systemic fluoridation (Report from CESO Project No. 17650 of Dr David Johnson, Nov. 4-11, 1995).

The 1995 studies found that dental treatment needs in Guyanese children are currently unmet. There is virtually no treatment of caries in the six year old age group, for example, and little treatment at other ages. The earlier 1984 survey had put the DMFS index at about 2.3 to 3, which means that almost every child has as many as 3 cavities.

Other notable findings in the Oral Health Survey of Guyana School Children 1995 are:

• About 80 percent of the DMF (Decayed Missing Filled) index corresponded to decayed teeth.
• Children of African ancestry had a higher severity of caries experience as compared with East Indian and Amerindian children.
• 62 percent of all children (n. =3,156) required some type of dental treatment. In 15 percent of all children the need was immediate due to pain or infection. Amerindian children had the highest proportion of urgent treatment needs (32 percent).

In the national health structure, dental health is only one of the areas which fall under the purview of one of the four Medical Directors who reports in turn to the Chief Medical Officer. This director is a medical officer who also oversees all Pharmaceuticals, Standard and Technical Services, Radiology, etc. It is not surprising then that the state of dental health is accorded low priority both at this and higher levels.

An advance in promoting dental health - salt fluoridation-introduced and promoted at a Caribbean regional level since 1977, has not been taken up since then, even though it involves no outlay of funding by the State - an important oversight as Guyana's dental budget is so small that it allows almost no preventive dental care. Training at the dental school only offers an 18-month auxiliary dental training programme for dental nurses. Dental technicians are also trained. The dentist-to-population ratio in Guyana is very low - roughly 1 dentist for every 30,000 people. Most dentists, however, practice in the capital city; all practice on the coastal plain where the majority of the Guyanese population is concentrated. Consequently, there is no dentist practising in the interior regions of Guyana where most of the indigenous populations live. There are 18 dentists in Government service, an estimated 10 dentists in full time private practice.

Poor as this dentist-patient ratio is, the reality is that the majority of Guyanese cannot afford to pay for dental services. Because of the chronic lack of supplies, most of the State dentists can only perform extractions since no amalgam, hand pieces or drills are available to save teeth with minor cavities. Most of the dental units are in a state of disrepair.

In this situation it has long been recognized that the dental nurses training programme located at the National Dental Centre in Georgetown has potential to help resolve the personnel problem. Yet in 1995, although the training programme could accommodate at least 12 students, only 6 were enrolled. One reason is that the present pay and conditions of service of employment do not make this occupation an attractive career.

The European Community has approved funding for the construction and equipping of a new National Dental Centre, schedule for completion by July 1997.

Salt Fluoridation

Although salt fluoridation was introduced in the Caribbean in 1977, no national effort has ever been expended on its introduction in Guyana. In contrast, this was introduced in Jamaica in 1987 and in less than 8 years had taken the DMFS index from 6.7 to 1.08.

The fluoride ion, in recommended amounts, has been proven to be a safe and effective preventative dental agent which can be delivered to the teeth systemically to reduce dental caries (by as much as 50 to 60 percent) among populations, particularly children. In developed countries, the fluoride ion is efficiently delivered via water fluoridation. Water fluoridation is not recommended at this time for Guyana for technical and economic reasons (poor community water supply in both urban and rural areas as well as the existence of over 270 wells means that delivery of the fluoride ion at optimal level by this mechanism to consumers cannot be guaranteed).

Salt fluoridation appears therefore, as an alternative, affordable recommendation which reaches the entire population quickly. In Jamaica, fluoridation of salt was found to be at least 500 times less costly than fluoridation of water, in a country with so many water supplies. At present, Guyana imports roughly half of its salt from Cuba, with most of the remaining coming from Trinidad and Jamaica. But only Jamaica supplies fluoridised salt and at no extra cost to the Guyanese consumer. This is an example of a low cost solution, which has been overlooked. In conclusion we may note that several recommendations, including salt fluoridation, were recently made by the Guyana Dental Association to the Chief Medical Officer (June, 1996). Others include:

• The implementation of preventative dentistry programmes for school children, in particular Amerindian schoolchildren, combined with a traumatic Dental Restoration and pit and fissure sealant programmes.
• Exemption from all taxes of fluoridated toothpaste, brushes and dental floss.