During FY07 PAHO provided key technical support to Guyana's National TB Program (NTP) including

revision of of the National TB Strategic Plan to incorporate the components of the new "Stop TB" strategy

and adaptation of generic WHO Integrated Management of Adult Illness (IMAI) materials for the Guyana

context. During FY08, PAHO will continue to work with national counterparts to implement the new STOP

TB Strategy, expand quality DOTS services, and use the new IMAI materials to roll out the strategy in all 10

regions. PAHO will update the TB Program guidelines and provide technical assistance to implement further

plans for decentralization of TB program into Primary Health Care facilities through the IMAI. PAHO will

seek opportunities to improve the management skills and capabilities of the national TB leadership team as

well services at the Chest Clinic in Georgetown. Technical assistance will be provided to improve the patient

care flows and the information flows between the TB care sites and HIV clinics, to implement VCT in TB

clinics and to strengthen the M&E (forms, data collection, reporting and analysis) for decision making.

PAHO will provide assistance to the NTP to make efficient use of resources from the Global Fund project in

the implementation of planned activities.

PAHO will continue to strengthen TB/HIV collaborative activities within the National Tuberculosis Program.

As a part of its regional health model, which decentralizes health services to the regional level, tuberculosis

nurses at all MOH regional hospitals and health centers with outpatient TB clinics will be trained in TB/HIV

co-management.

TB nurses will be trained to offer HIV testing to all TB patients and suspected patients, offer cotrimoxazole

prophylaxis, counsel patients on prevention, assess clinical stages for TB/HIV co-infected patients, and

refer patients for ART when necessary. Regional TB coordinators will be included in IMAI training for

regional HIV coordinators and will receive training and funding for site visits to facilities with out-patient TB

clinics. During these visits, regional TB coordinators will offer support to TB nurses, monitor progress, and

assess the need for supplementary trainings. These activities will strengthen linkages between TB and HIV

treatment systems, enhance co-infection services in outer regions, and help integrate TB/HIV management

into the greater healthcare system for maximum sustainability. PAHO will coordinate closely with PEPFAR

Guyana partners and other stakeholders to ensure efficient, synergistic activities.

Preparations are underway to train clinical teams and supervisors from 3 of the 10 regions of the country as

a pilot exercise for the implementation of the IMAI. After the pilot phase, the IMAI strategy will be rolled out

in remaining regions taking into account learned lessons from the pilot. The roll out of the IMAI strategy will

compensate for health workers turnover and expand the number of facilities providing integrated HIV

services. Limited human resources in the health sector is the greatest threat to sustainable HIV services in

Guyana. The regional health model and IMAI initiative will shift tasks involved in HIV care into the overall

health care system. This shift will better integrate HIV care into primary care and ease the need for

specialists physicians who are in critically short supply in Guyana. Formative and integrated supervision of

HIV program activities will continue to be a priority as HIV services are decentralized. In the regional health

model, the regional coordinator has a crucial role in ensuring smooth functioning of public health programs

such as HIV and TB. The regional HIV coordinator is most often an administrator with previous clinical

training (as a doctor, clinical officer or nurse) who has the responsibility of coordinating all HIV program

activities in the region. A regional HIV coordinator with clinical training is necessary to supervise HIV clinical

services at health facilities in the region All regional HIV coordinators will be trained for 1 week in HIV

program management to include: planning for scale-up, coordinating region-level training, recording and

reporting using the national patient monitoring system, performing site visits and identifying/solving facility-

level problems. This training will precede IMAI clinical training for clinical teams in the region. PEPFAR-

supported clinicians providing treatment services will also serve as a support system to mentor the MOH

regional coordinators in the field. Regional coordinators will be expected to participate in the 2-week basic

IMAI clinical course in order to become completely familiar with the clinical and operational protocols used

at regional hospital and health centre level. Supervisory site visits will start immediately after IMAI clinical

training, and will continue monthly for 3-6 months, after which the frequency will shift to quarterly. This

activity covers funds for transportation to health facilities within the region and communication via phone,

radio or mobile phone with facilities and regional offices. The IMAI tools for regional HIV coordination

include standardized case management observation and exit interviews that will be included as part of the

routine reports submitted by regional HIV coordinators to regional and national offices. Quantification of this

data in a subset of regions will be done as part of an evaluation of the quality of care during scale-up of

integrated HIV services in those regions. At the regional level, the HIV management team should be

strengthened by additional staff whose major responsibility will be coordinating support supervision activities

at the regional level: communicating with region HIV coordinators, reviewing reports, solving regional-level

problems, and coordinating support for regional coordinators. Coordinators at all levels will be trained in

reporting via the standardized patient monitoring system (covered in the Patient Monitoring concept paper).

This activity also covers the cost of meetings that will be held quarterly in each region, to allow regional

coordinators to exchange experiences with each other.

In FY07, PAHO served as lead technical agency to assist the Ministry of Health to adapt the WHO format

national patient tracking and monitoring system to the Guyana context. The system is being rolled out in all

existing ARV treatment sites. The system is now the national monitoring system for all HIV/AIDS care in

country. As part of the IMAI initiative, PAHO will provide support to the roll out of the system in all district

hospitals (19) and a limited number of health centers meeting criteria to provide ARV. PAHO will also

support the WHO HIV Drug Resistance (HIV-DR) tracking initiative. This includes Early Warning Indicators

to be obtained from the Patient Monitoring System and cohort analysis. PAHO will continue to support and

supervise the work provided by contract data entry clerks and clinic staff working on the roll out of the

Patient Monitoring System.

The PAHO Surveillance Officer will continue to work closely with CDC (the SI technical lead for the USG

team), USAID, and other partners to coordinate activities in support of the MOH Surveillance Unit including

funding and training for backfilling of registries, mentorship for Surveillance Unit staff and technical

assistance for data analysis and reporting. Site visits for ongoing monitoring will coincide with visits for

monitoring other programs such as the malaria initiative. This coordination will assist in the integration of

HIV care into the overall health system.

Continuing Activity

In FY06 and FY07 PAHO focused on strengthening the capacity of the National AIDS Program Secretariat

since a 2004 assessment conducted by the Caribbean Health Research Council (CHRC) noted that

insufficient human and technical ability as well as inadequate emphasis on its mandate of coordination and

management weakened the national response to HIV/AIDS. Currently, PAHO continues to assist the

Ministry of Health in strengthening NAPS to take the lead in implementing all health-related aspects of the

National HIV/AIDS Strategic Plan, including the implementation of the GFATM project. Also, in FY07 PAHO

has been able to make significant strides in the development of a human resource unit within the Ministry of

Health, including staffing and initial work on strategy documents and policy positions.

A considerable amount of work was undertaken in the past to analyze workforce issues and develop a

National Health Plan 2003-2007. This plan, released in March 2003, contains important recommendations

on Health Services and Workforce Development Strategies. In FY07, PAHO will dedicate more effort to the

MOH and its human resource unit with a primary focus on fields most relied upon by the HIV/AIDS program.

PAHO will support the MOH to establish a Human Resources Planning and Development Unit (HRDU) with

the following functions:

• Steer the development of an integrated Human Resources for Health Plan which matches population

health needs and service delivery mandates with skills needed and appropriate budget levels for supplies,

equipment and pharmaceuticals

• Provide directions to the existing training department (Dept of Health Sciences Education) with the aim to

achieve synchrony between the identified service needs and the training activities

• Collect and systematize a database of stock, trends, and qualitative data on human resources that allows

forecasting needs and tracking the impact of interventions

• Build a consensus mechanism involving education, finance, donors, public service and local governments

in order to address this issue through a comprehensive and coordinated approach

Given the environment of out-migration and internal migration, PAHO will play a proactive role in defining

and responding to the main contributing factors by:

• Conducting studies on the main flows of different types of professionals and the consequences of these

flows in the health services and in the priority programs

• Implement and reinforce an "exit interview" procedure

• Facilitate international dialogues between major partner recipient countries of Guyana health staff and the

Guyana health services to provide more specific support to Guyana service needs development based on

staff losses

• Develop and pass regulation of contracting policies in the health sector as a way of balancing the

availability of critical human resources in the MoH and the other health providers and programs

• Determine critical path to scale up the main training programs and the establishment of an inter-sectoral

task force to devise a short term plan to address the ill effects of the identified bottlenecks. This will be done

in collaboration with the CDC ITECH activities for health sector training coordination and planning as well as

information system platform being developed currently

• Achieve consensus among development partners on incentive structures across the various priority health

and education programs they support. To date, a pilot performance-based incentive program is being

implemented and continuously evaluated and assessed for opportunities for strengthening the system as

well as expanding it

The main issue of concern for the MOH with recruitment and retention is the inefficient procedure for filling

new and vacant positions. It is too time-consuming and inefficient to guarantee adequate levels of staffing

and leads to the loss of good candidates. Other concerns include the lack of career prospects (flat pay

structure, poor working conditions), insufficient incentives through the current pay system, and insufficient

access to continuing and post-graduate education. PAHO will develop a coherent set of interventions

addressing the main factors identified:

• Design alternatives to build career paths adapted to the public health sector, rewarding performance,

acquired skills and experience

• Strengthen the continuing education system so it is linked to opportunities for career advancement

• Establish a dialogue with Ministry of Finance and Public Service Ministry to discuss ways for appropriate

salary grid and/or benefits packages and streamlining the appointment process

• Consult with partner community for staff, category-specific, needs, particularly in the area of incentives

which do not demand immediate remuneration issues

• Promote a cabinet approved Human Resources for Health Plan as the basis for staffing needs and

authorization to fill positions to avoid delays

• Determine staffing levels through workload indicators of staffing needs which should form an integral part

of the Human Resources for Health Plan