Transcript Karam Ramotar The Ottawa Hospital Mar 2 2009

Karam Ramotar
The Ottawa Hospital
Mar 2 2009
GUYANA
Not Ghana
Mar 2 2009
Where is it?
.
Mar 2 2009
.
215,000 KM2
Mar 2 2009
History
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“Guiana”: “land of many waters”
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1498: Columbus arrives
1616 - 1814: Dutch/British/French
1831: British Guiana created
1834/38: Emancipation of slaves
1846-1917: Arrival of Portuguese,
Indians then Chinese
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Mar 2 2009
History
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1951: Limited self
government
1966:
Independence
1970: Republic
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Member of the
Commonwealth
Parliamentary
government
President and
Prime Minister
10 Administrative
regions
The People
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Population (2002): 751, 223
People: 6 ethnic groups
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East Indians (44%); African (38%);
Chinese; Portuguese, Amerindian (7%);
Mixed
Religion: Christian (50%); Hindu (35%);
Muslim (10%); Other (5%)
Language: English; Creole; Amerindian
dialects; Hindi; Urdu
Mar 2 2009
Economy
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GDP (2005):
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Agriculture – 28%
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Industry – 27%
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Sugar – 50%; Rice – 11%; fish – 10%
Mining (bauxite;gold) – 29%; Timber –
13%
Services – 43%
Tourism – 1% (e.g., Kaieteur Falls, Orinduik
Falls, Shell Beach)
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EXPORTS
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Export Partners: Canada (23%); US (19%); UK (11%)
Economy
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US$ = G$161; Can$ = G$ 125
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Exports: $587.2 M; Imports: $681.6 M
Debt external: $1.2 Billion
Economic aid-recipient
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$253 M (1997)
Other: trans-shipment point for narcotics
from SA to Europe and US
Mar 2 2009
People
Mar 2 2009
Places
Kaieteur falls
Mar 2 2009
Flora
Mar 2 2009
Fauna
Mar 2 2009
Contrasts
Mar 2 2009
Demographics
Indicator
Guyana
Canada
62.9/68.3
81.5/76.1
98%
99%
18.45
11.21
8.32
7.47
33.3
5.5
125.7
3.8
Sex Ratio (Males/Female)
1.01
0.98
Adult Unemployment Rate
12%
6.8%
2.1
1.6
Life Expectancy at Birth
(female/male)
Literacy
Birth Rate (per 1000 pop)
Death Rate (per 1000 pop)
Infant Mortality (per 1000 live
births)
Maternal Mortality (per 100,000 live
births)
Fertility Rate (# children/woman)
Mar 2 2009
UNAIDS, WHO, PAHO, BoS
Health Care System
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Guyana's health care system is
well designed and structured to
emphasize primary health care.

However, due to the rising
incidence of both HIV/AIDS and
tuberculosis, Guyana is now
facing a major health crisis,
owing to:
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Poor organization and management
Limited financial resources
Shortage of health care
professionals
Skewed distribution of health care
professionals
Inadequate social services
Absence of economic management
Weak capacities to collect, analyze,
and utilize health indicator data at
both the local and national level.
Mar 2 2009
Disease
Infections/yr (M) Deaths (M)
HIV (PLWA)
AIDS
TB
NG
CT
Syphilis
Malaria
34.2
1.3
1.2
6.2
7.2
1.5
67.6
Mar 2 2009
http://www.poodwaddle.com/
0.5
0.2
0.1
HIV Prevalence in Guyana
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Seroprevalence 2.5% (UNAIDS 2004)
 20,000
persons are believed to be
HIV infected
 Miners
and loggers: 6.3%
 CSW: 45%
 Pregnant women attending ANCs: 3.8%
 STI patients: 12 to 15%.
 TB Patients: 33 – 40 %
Mar 2 2009
HIV Prevalence in
America and the Caribbean
Haiti
Bahamas
Guyana
Dominican Rep.
Trinidad & Tobago
Belize
Honduras
Panama
Surinam
Jamaica
Barbados
Guatemala
Argentina
Brazil
El Salvador
United States
Costa Rica
Venezuela
Colombia
Peru
Paraguay
Uruguay
Canada
Mexico
Ecuador
Chile
Nicaragua
Bolivia
Cuba
5.6
3.0
2.5
1.7
3.2
2.4
1.8
0.9
1.7
1.2
1.5
1.1
0.7
0.7
0.7
0.6
0.6
0.7
0.7
0.5
0.5
0.3
0.3
0.3
0,3
0.3
0.2
<0.1
0.1
Source: UNAIDS. AIDS world epidemic report / 2004
HIV/AIDS 2
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Females now make up 38% of all AIDS cases
and significantly more females than males
aged 15-24.
800 HIV infected children.
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1100 children under 15 had lost at least one
parent to the disease
AIDS is the leading cause of death in 25-49
year olds and the second overall cause of
death.
Mar 2 2009
INCIDENCE OF HIV IN GUYANA
Annual incidence of AIDS is estimated at 56 per 100,000 population
= 420 new cases per year
Males
Females
300
250
200
150
100
50
Mar 2 2009
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
0
CDC Data
HIV
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HIV transmission predominantly heterosexual with
increasing reports of homosexual transmission
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75% of Guyanese HIV cases were transmitted
heterosexually
13% of cases were transmitted via men who have sex with
men (MSM)
2.3% were transmitted from mother to child
0.4% were infected through intravenous drug use
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Note: many believe that homosexual transmission is
underreported, while heterosexual transmission might be over
reported
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Note: Along with The Bahamas, Barbados, the Dominican
Republic and Haiti, Guyana is one of the few Caribbean/Latin
American countries whose HIV/AIDS epidemic has spread
beyond specific high risk groups into the general population.
Mar 2 2009
HIV/AIDS 4
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Guyana’s development indicators may
be reversed, as the active productive
age groups are affected.
With a high emigration rate and a HIV
negative sero-status a condition for
emigration, disproportionately more
HIV positive persons are left in the
country.
Mar 2 2009
WHY THE HIV EPIDEMIC IN
GUYANA?
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Mobile population
Migrant labour system and Internal Migration
Single motherhood (~60-80%)
Intergenerational and transactional sex
Lack of routine male circumcision
Alcohol intake and “Condom Confusion”
Drugs
Poverty and Inequity
Stigma and Discrimination
Rape
Mar 2 2009
STIs in Guyana
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According to a 1998 University of Miami
study, one third of sex workers in
Georgetown are infected with Syphilis
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According to PAHO, in 1995 the following
cases were diagnosed at the GUM Clinic:
625 cases of gonorrhea
 325 cases of syphilis
 856 cases of nongonococcal infection
 ?? Cases of genital herpes
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Mar 2 2009
TB in Guyana (2006)
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4th highest estimated rate of TB in the
Americas.
Incidence rate (2006)
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164/100,000/yr
1230 new cases per year
Prevalence (2006)
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Current prevalence = 0.2%
16,125 cases(2,400 active cases)
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Co-infected with HIV = 35%
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Mortality Rate = 215/100,000/yr
Mar 2 2009
WHO data
TB in Guyana: Case
Notifications
Mar 2 2009
WHO Data
TB Risk Factors
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TB Infection
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TB Disease
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Mar 2 2009
Socio economic factors(housing,
overcrowding, ventilation)
Nutrition (under-10 % less than optimum
weight, overweight?)
Behaviors (knowledge, attitudes and
practices)
HIV – increases 300 times when HIV+
Diabetes – 9 % of adult cases
Alcohol/drug abuse,
Other - steroid treatment, cancers, previous
TB
PUBLIC HEALTH
STRENGTHENING IN GUYANA
a 4-year
CIDA funded Project
Designed and Implemented by
CSIH in Partnership with the
Guyana Ministry of Health
CAN $5.6 M
Project Goal
To improve and maintain the health of Guyana’s
population, by supporting an integrated approach to
disease, prevention, diagnosis, management and
care at the national and regional levels
Project Objectives
Better manage, deliver and monitor disease prevention
and control programs in the areas of
STI/HIV/AIDS/TB
Key Components
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Expanding and Strengthening the
prevention, Management and Care of
STIs/HIV/AIDS:
Improving National Tuberculosis
Prevention and Control Program:
Strengthening the Health Information
System
Community Health Development and
Care
Mar 2 2009
The key components of the
Project - 1
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Expanding and Strengthening the
Prevention Management and Care of
STIs/HIV/AIDS:
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Mar 2 2009
Provide technical support for the National Aids
Secretariat (NAPS)
Develop and implementing national guidelines
for STIs and HIV/AIDS
Strengthen the local capacity to deliver and
sustain the Prevention and Management of
STI/HIV/TB
Strengthen laboratory ability to support
diagnosis and treatment of STIs/HIV.
The key components of the
Project - 2
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Improving National Tuberculosis
Prevention and Control Program:
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Mar 2 2009
Provide technical and administrative support
for the NTP Unit
Developing and implementing national
technical and operational diagnosis and
treatment guidelines
Develop implementation strategies for directly
observed therapy short-course (DOTS) for
tuberculosis using WHO standard treatment
Strengthen laboratory abilitiy to support
diagnosis of TB
Anticipated Outcomes
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An improved national program for the
prevention and control of STIs and
HIV/AIDS
An improved national program for the
prevention and control of Tuberculosis
An improved capacity to collect health
data
An improved awareness of communitybased approaches for disease
prevention and control
Strengthened human resources
capacity to sustain project gains
Mar 2 2009
The Canadian Society for
International Health (CSIH)
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National non-governmental organization with
members committed to the promotion of
international health and development
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Mandate
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Advocate for international health and development
Mobilize Canadian resources to advocate and facilitate
research, education and service activities in international
health
Promote progressive health policies and programming in
Canada and around the world
Mar 2 2009
Chronicle – Monday, July 12, 2004
$5.6M public health project launched
on Friday at the Emba-Sea Courtyard (formerly Cara Inn) in Pere Street, Kitty.
Mar 2 2009
Minister of Health Dr. Leslie Ramsammy
addresses the launching ceremony of the
public health project
Project Focus
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Region 4: GPHC
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Region 3: WDPH
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Region 6: NAPH
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Region 10: UDHC
Mar 2 2009
Overview of PHSG Project Objectives and
Outcomes
Better
management,
delivery and
monitoring of
disease
prevention and
control programs
in the areas of
STI/HIV/AIDS/TB.
Effective
planning,
management,
and evaluation of
health care
services
Mar 2 2009
Improved national
program for the
prevention and control
of STIs and HIV/AIDS
Improved national
program for the
prevention and control
of Tuberculosis
Improved capacities to
collect health data,
process it into
information, and
communicate data and
information from
sources to points of use
Improved awareness of
community-based
approaches for disease
prevention and control
Improved Canadian
public awareness of
Guyana-Canada
collaboration
Activity Group A:
HR Development
Activity Group B:
Capacity Building
Activity Group C:
Guidelines, Manuals,
and Strategies
Activity Group D:
Procurement and
Refurbishment
Activity Group E:
Research
Activity Group F:
Public Engagement
Project Management Structure
CIDA
Government of
Guyana –
Ministry of
Health
Project Steering
Committee
Canadian Society for
International Health
Canadian
Technical
Assistance
Mar 2 2009
CSIH Field Office
Project
Implementat
ion
Committee
HOW/Process: responsive to local
needs & participatory
•Project Implementation Committee (PIC)
meets every 3 months
•Every year a detailed Work plan is
developed with local partners and submitted
for approval to CIDA and MOH at PSC
meetings
Where was Guyana when
PHSG STI project started
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GUM clinic was the only specialist STI
clinic in Guyana
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Management of STI regionally was
mainly through outpatient and
antenatal clinics by physicians and
Medex
Mar 2 2009
Where we started
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With the exception of the GUM clinic
treatment was not standardized
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Written treatment guidelines not
readily available
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Efficacy of treatment regimen???
Laboratory diagnosis of STI country
wide was dormant
Mar 2 2009
What did we have to do?
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Develop written guidelines that are
evidence based
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STI baseline study
Write preliminary guidelines
Train health workers
Decentralize STI service from GUM
clinic only to include regional services
Develop and Implement laboratory
diagnostic services
Mar 2 2009
STI Baseline study
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Study to acquire baseline “prevalence” rates
for the following infections:
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CT; NG; Syphilis; Chancroid; HSV; Trich; HIV; Hep
B and Hep C
Enrol 250 patients in 6 centres:
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GT (2: GUM & GRPA), NA, Linden (2 McKenzie &
Wismar), West Dem
200 with “discharge”
50 with Lesions
Look for NG/CT/Syphilis/HSV/Chancroid/Trich
Mar 2 2009
STI “Baseline” Study
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Conducted at 4 STI clinics
November 2004-2006
Patient enrolment
Voluntary participation
 Informed consent
 Questionnaire
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Ethics review
Mar 2 2009
STI “Baseline” Study
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333 patients enrolled
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M/F: 88/245
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Clinical Syndromes
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Mar 2 2009
Genital Discharge
Genital discharge and Ulcer
Genital Ulcer
300
28
5
STI “Baseline” Study
No. of
Patients
Gram/wet
prep
Culture
PCR
PCR or
Culture
NG
293
56 (23.7)
46 (15.7)
16 (7.4)
53 (18.1)
CT
216
NG or CT
293
T. Vag
220
RPR
252
Pathogen
25 (11.6)
74 (25.3)
43 (19.5)
3 (1.3)
Syphilis
30
0
HSV
29
13 (44.8)
H. Ducreyi
30
0
Mar 2 2009
Other
Testing
STI “Baseline” Study
No. of
Patients
Other
testing
HIV
293
30 (10.2)
HepB sAg
290
5 (1.7)
HCv
289
14 (4.8)
RPR
252
3 (1.3
Pathogen
Mar 2 2009
Where did we end up?
Decentralization of STI service
 3 nurse driven STI clinics
established
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Providing STI management +
HIV counselling and testing
Patients being managed
according to standardized
syndromic treatment protocols
Training of primary care
health workers
Mar 2 2009
Where did we end up?
Evidence based guidelines
 National STI guidelines developed
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> 100 health workers trained
STI/HIV training instituted at UG & MOH
Standardization of STI training-base on
guidelines
STI baseline study
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Mar 2 2009
200 patients recruited
Early evidence of inadequacy of current
treatment regimen a resistance of
N.gonorrhoeae to 1st line drugs
Retreat for TB and HIV health
workers
Mar 2 2009
3rd National Tuberculosis
Conference of Guyana, 2006
“Consolidating gains and expanding successes in
the fight against Tuberculosis”
November 17-18, 2006
Sea Breeze Hotel, Georgetown Guyana
Mar 2 2009
PUBLIC HEALTH
STRENGTHENING IN GUYANA
Diagnostic Laboratory
Development and Support
Where we started with lab
support
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Practically no lab diagnosis for STI
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None or minimal lab diagnosis for STI
For TB?
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Mar 2 2009
Limited capacity for direct smear of
specimens
No cultures
Goal: Build Lab Capacity
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STI
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Establish STI diagnostic services at the
existing GPHC Lab (region 4)
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Develop the same in regions 3, 6, & 10
TB
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Mar 2 2009
Improve & Expand Service at GPHC
Develop same in NA, Linden & West Dem
Infrastructure and Supplies
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Outfit all the labs
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Build, modify,
renovate physical
plant where
necessary
Provide
equipment
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Procure supplies
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Mar 2 2009
Fridges, freezers,
centrifuges, BSCs
Reagents etc.
Training & Education
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Train technologists working in
targeted labs
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Technical procedures
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Education
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Mar 2 2009
Workshops - Wet labs: group and
individualized
Continuing Education lectures for techs
Review of UG’s medical technology
microbiology module
Manuals
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Develop Lab Manuals
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Mar 2 2009
STI Lab manual
TB Lab manual
STI Training manual
TB QA and proficiency testing manual
Gram stain proficiency testing manual
Gaps
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Constant supply of lab reagents?
Logistics to move samples from regions
difficult
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Reference lab services
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? Procurement of dedicated vehicles for regions
Public health lab?
Additional lab services
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STI lab support limited…..tests for other STI
pathogens unavailable
Mar 2 2009
Sustainability
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Infrastructure
Resources
Technical know how
Human resources
Improved education
Mar 2 2009
GPHC TB Lab
Mar 2 2009
Challenges
Mar 2 2009
Shipping
Mar 2 2009
Challenges
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High staff turn over due mainly to migration
Logistics to move samples from regions
difficult
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Supply of lab reagents continues to be
problematic
Need for continuing support for all STI sites
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Re-training of staff
Regular visits from the centre MOH/CSIH
STI lab support limited…..tests for other
STI pathogens unavailable
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? Procurement of dedicated vehicles for
regions
? Reference public health lab
Turn around time for lab results too long
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Mar 2 2009
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Understaffing and/or high staff turnover
Resources e.g. reagents
Summary of Achievements
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Local capacity built to manage STI
according to national guidelines
Local capacity built to manage
HIV/AIDS according to national
guidelines
Local capacity built to manage TB
according to national and international
guidelines
Diagnostic/ Laboratory Capacity
strengthened
Mar 2 2009
Summary of Achievements
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Health Information System created and
installed
Establishment of a home and
community-based training program for
the care and support of HIV/AIDS and
TB clients
Capacity of educational institutions
built
Mar 2 2009
Project: Lessons Learned
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Engage the staff and patients in
evaluating services---They have valuable
information
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Ask WHY
Talk about their goals and expectations
Listen to ALL staff needs to improve
system
Training and implementing changes
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Give the staff responsibility
Small steps
Explore the staff’s ideas
Project: Lessons Learned
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Must have sufficient time to fully and
appropriately design a project - this
may ultimately determine level of
success
A Good work plan is often essential in
the securing of partners' commitment
Reporting templates do not always
recognize the importance or value of
“process”
Mar 2 2009
Project: Lessons Learned
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Complex projects with significant
procurement require increased
management/staffing time
Project evaluation processes can be
effective and beneficial when undertaken in
a participatory manner.
Incorporating in-kind technical assistance
from Canadians of Guyanese origin
Human resource constraints need to be
continually addressed
Mar 2 2009
Project: Lessons Learned
In order to contribute to long-term change,
multi-component projects should be seen as
long term/multi-phase projects
 The choice of consultants is very important
and should be made carefully
 It is critical that all parties to a bilateral
project fully understand their roles and
responsibilities
 Coordination with other donors and
agencies is a continuous and time
consuming activity
Mar 2 2009
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Project: Lessons Learned
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The identification of adequate supplies
and suppliers for Guyana is a
challenge
Recognizing the capacity that already
exists, and building upon it, is the key
to long term sustainability
Mar 2 2009
Team Guyana
Mar 2 2009
Canadian Award for
International Cooperation
Mar 2 2009
PHSG Project Handover
Events
Mar 2 2009
Family
Name
Family
HIV/STI
Laboratory
Farley
John
Ramotar
Karam
Bowie
William
Deokharan
Diaram
Ramotar
Karam
Chedore
Pam
Balfour
Louise
Trajtman
Adriana
Cameron
William
Chehil
Sonia
Hershfield
Earl
Conway
Brian
Jones
Arlene
Fritzler
Evelyn
Martin
Axel
Harrison
Ray
McMorran
Joann
Jain
Suchita
Seemangal
Julie
Lucki
Beverly
MacPherson
Paul A.
Fisher
Paul
Pancham
Sonilal
Walters
Gavin
Rodger
Deborah
Khan
Alam
Stephens
Gwen
Da Costa
Laura
Taylor
Marliss
Tosca
George
Toye
Baldwin
Other
Mar 2 2009
Name
TB
GHIS
Gender
Hinds
Cora
HBC
Porter
Faye
Deonandan
Raywat
Courville
Jean
Tota
G. P.
Lesmond
Joan
Lachapelle
Mary
Hanczaryk
Donna
Mar 2 2009
HOME & COMMUNITY BASED
CARE PROGRAM

Elements of the Program
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Lessons Learned
Background
Aim of the MOH to institutionalize HBC as
an extension of its service
 The establishment of HBC service with
resources from the Global Fund is part of
the expansion of the range of services
already offered by the MOH
 HBC is relatively new and there is a need
for a guiding strategy on HBC.
 MOH has asked the CSIH to assist in
crafting such a strategy and a draft policy
will be drawn up for further discussion
Mar 2 2009

Organizational structure of MOH
HBC program
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Director of NAPS
Home Based Care Coordinator
Nursing Supervisors: stationed in the
administrative regions:
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professionals have already been
recruited for three Administrative
Regions - Regions Two, Three and Four.
Volunteers who will be working with
the Nursing Supervisors
Mar 2 2009
Challenges
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Lack of human resources
Incorporate informal and community care
givers in an organized system
Maintain socially acceptable quality
services based on global best practices
Improve access especially in rural and
hinterland areas to HBC (In the rural
communities, in particular, PLWHA must be
reached, but that is challenging because of,
at times, politics and the physical
structures of the community)
Establish and maintain standards through
supervision and monitoring of the process
Mar 2 2009
Elements of the
Program
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Nursing Guidelines approved by the
Ministry of Health
Foundation Modules:
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Principles of Adult Learning
Gender Equity
Key Modules for Community Education:
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Infection Control
Tuberculosis Care
HIV/AIDS Care
Home Care Delivery
Palliative and End-of-Life Care
Lessons Learned
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Train the Trainers based on nursing model,
with migration, had to rethink
Building local capacity through Guyana
Nurses Association, but greater
development and resources required
Hospice initially thought to be viable
delivery model; feasibility study showed
otherwise
Introduction of home-based care and
orientation expanded as need is greater
Lessons Learned cont
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Greater flexibility when planning
events in the country required
Knowledge of structure and
process to engage volunteers
formally is limited
Bilateral agreement means
operating in a political environment
Home base care
Mar 2 2009
Health Service Delivery
Suchita Jain
Capacity Building in
Service Delivery Improvement
Introduction
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Evaluation health service delivery in
the GUM clinic
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Patient exit interviews
Staff interviews
Make recommendations
Staff Retreat I
Staff Retreat II
Summary of lessons learned
Background and
Challenges
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Efficiency of services
Physical environment
Staff support
Staff morale
Human resources and training
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Evaluation of health service
delivery
Patient exit interviews:
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Patient’s perceptions of staff attitude and
behaviour
Prevention advice and education
Rating quality of services, what changes
they would like to see and the strengths
and weaknesses of the clinic
Staff interviews
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Definition of quality of care
The strengths and weaknesses in the clinic
Changes needed for improvement
Major themes emerged from these
discussions: a) physical environment; b)
quality of care; c) team building; d)
advocacy in the community and e)