As we saw in the last article of this series, the health situation in Guyana is parlous. Indeed, because of the inadequacy of existing facilities, and the unavailability of essential health practitioners at all levels, many of our citizens suffer unnecessarily, and die earlier than they would, if they were living in any other CARICOM state.

The poverty of our nation is, of course, the basic cause of this sorry state of affairs. The authors of the NDS therefore emphasise the imperative of formulating and implementing macroeconomic policies which would lead to a rapid expansion of our economy, and to significant increases in the amounts of revenue available to the government for spending on this important social sector.

They stress that the central Government's budget should continue to be the principal source of funding for the public system of health care, and recommend that Government's expenditure on health should be raised to 5 percent of GDP by the year 2002, and should be progressively increased to 10 percent of GDP by the year 2010. In addition, they strongly suggest that earmarked health taxes should be levied from the year 2003, when it is projected that the economy would be more robust. Furthermore, they urge that cost-recovery mechanisms be put in place for certain services. They are adamant, however, that these mechanisms should not be directed to the vulnerable, and assert that "within a system of selected fees for medical services, cost-recovery should never hinder access to health care, and no patient should be refused service because of the inability to pay fees."

The NDS also recommends that a health insurance scheme should be developed as a supplementary financing option, and that an extensive review of the NIS be undertaken, in order to improve its actuarial basis and to strengthen its performance as a provider of social health benefits.

A not insignificant proportion of the increased resources available to the health sector, the NDS suggests, should be spent on increasing salaries, and on providing incentives for well-qualified medical and administrative personnel to serve in the hinterland. In addition, the NDS puts forward the view that, in order to increase the flexibility of the public health system, the salary structure of health personnel be delinked from that of the public service and, in doing so, a set of special categories for health personnel should be developed.

Further, it is adamant that in order to overcome the problems of staffing away from the towns all persons who have been trained by the government in medical disciplines and allied fields should be required to serve in a rural or interior location for at least two years.

The authors of the NDS are fully cognizant of the fact that in addition to the perennial shortage of money, there are certain systemic and organizational factors which militate against the effective delivery of health care in Guyana. Accordingly, they recommend that the health service should be radically decentralised and that the Ministry of Health should be restructured to reflect this decentralisation. They argue that the Ministry should operate in a regulatory capacity for the entire health sector, rather than in its traditional role as the centralised manager of the public health system, and that service delivery and management responsibilities be devolved to Regional Health Authorities (RHA) which should be established for these specific purposes. These RHAs should be governed by autonomous Boards comprising a preponderance of representatives from the regional administrations and local communities.

They should report to the Ministry of Health which should concentrate on the establishment of sectoral objectives, the formulation of policies and strategies, the allocation of resources, the review of performance in the regions, the promulgation of regulations, and research and development.

The NDS also recommends that the procurement of all pharmaceuticals and medical supplies for the public health sector should be contracted out, and that an autonomous Procurement Board, which should be managed according to business principles, should be responsible both for the contracting out process, and the distribution of drugs and supplies.

The NDS urges that a Division of Primary Health Care should be established in the Ministry, to work in close collaboration with the Regional Units; and that the Ministry should develop a strong Epidemiology department to undertake health needs assessments, direct and assist health authorities to identify the health needs of their populations, and assess their effectiveness in satisfying these needs.

The NDS recommends that a comprehensive survey of all existing health facilities in Guyana be undertaken and that, depending on the results of this survey, hospitals and health centres that are currently underutilised should be closed. The funds released by this process should be used to strengthen district hospitals and establish more health posts in remote areas. The important point, the NDS argues, is that that there should be a rational distribution of health facilities, and that these facilities should be well equipped and staffed with adequate numbers of trained personnel. To this end, for example, it suggests that each district hospital should have at least one ambulance and adequate power generation supplies; and that all health centres would be equipped with a phone or radio for emergency calls.

It also argues that there should be established a programme for rotating visits to health facilities throughout the country so that villagers would know in advance when a doctor would be in the nearest health centre; that arrangements should be made for teams of foreign medical specialists who are qualified in disciplines in which Guyana is in short supply to visit the country on a regular basis; that a sufficient amount of money be budgeted for sending patients abroad when necessary; that a Cancer Centre headed by an oncologist be established, and provided with supporting staff and that dialysis equipment be installed.

And finally, it urges that the Medical Faculty at UG be expanded and upgraded through the utilisation of Information Technology, and the establishment of linkages with a network of foreign universities.

The authors of the NDS are convinced that the strategy which they have recommended for the development of the health sector is relatively easy to implement, and is cost-effective. They are also positive that if the strategy is followed the population's access to health care would be considerably enhanced, the quality of the care that is offered would be impressively improved and, more important, most Guyanese would live much longer and enjoy a much better quality of life than they now do.