Pan American Health Organization

Guyana

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of GuyanaGuyana is located on the northeastern coast of South America, occupying 215,000 km2. It is bordered by Suriname to the east, Venezuela to the west, and Brazil to the south and southwest. A former British territory, it is the only English-speaking country on the South American continent.

The country gained its independence from the United Kingdom in 1966. Guyana is a democratic republic functioning under a Westminster system of government. The legislative branch is represented by a unicameral National Assembly comprising 12 nonelected members and 53 members who are elected under a system of proportional representation. The Executive President serves both as the Head of State and of the Government. The last election was held in May 2015 and the ruling coalition party won 50.3% of the votes. In that year, 31.9% of the seats in Parliament were occupied by women.

The country is divided into 10 administrative regions: the coastal area is included in Regions 2, 3, 4, 5, and 6; the hinterland, or rural interior, is included in Regions 1, 7, 8, 9, and 10. Local government structure consists of 10 regional democratic councils, 65 neighborhood democratic councils, 6 municipalities, and 76 Amerindian village councils. Guyana’s multiethnic population includes Indo-Guyanese (40% of the total population), Afro-Guyanese (26%), Amerindians (11%), and persons of mixed ethnicity (20%). The Chinese, Portuguese, and white population together account for less than 1% of the total. Although the official language is English, there are at least eight different languages and dialects spoken in the country.

Demographics

The most recent Population and Housing Census was conducted in 2012. It determined Guyana’s population to be 747,884 persons, with 49.8% males and 50.2% females. This represents a decline from 751,223 recorded in the 2002 census, which showed a nearly equal proportion of males and females. Guyana had a negative population growth rate of -0.44 over the intercensal period 2002-2012 ().

In 2012, 88.2% of the population was under the age of 55 years compared to 91.3% in 2002. The 2012 census showed that 41.9% of the population resided in the capital city of Georgetown, located in Region 4; 47.2% lived in the coastal region (excluding Georgetown); and 10.9% lived in the hinterland. In 2012, Guyana’s population structure for the 10-14- and 15-19-year-old age groups shows the impact of the high number of registered live births from 1993-2002. In 2012, the population structure also reflects a shrinking of age groups in their prime working years (20-39 years) due to continuous, outward migration (). Changes in the structure of the population between 1990 and 2015 are shown in Figure 1.

Figure 1. Population structure, by age and sex, Guyana, 1990 and 2015

The population increased 6.5% between 1990 and 2015. In 1990, the population structure had an expansive structure. By 2015, the structure became irregular, with an expansive shape in the groups older than 45 years of age and in those 15 and 30 years of age; a regressive shape manifested itself in the remaining groups, as a result of changes driven by migration, birth rate, and mortality at different periods.

Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015

Life expectancy at birth was 67 years in 2010 but decreased by one year in 2014 (66 years). Information for 2012 showed life expectancy for males was 63.5 years and 68.7 years for females. The crude birth rate was 20 per 1,000 population in 2012 and 19 in 2014. The rate remained constant at around 8 per 1,000 population in the years 2012 through 2015. Infant mortality rates fluctuated in the period 2010-2013 and peaked at 23.9 per 1,000 live births in 2014. Total fertility rate in 2012 was 2.6 children per woman in the 15-49-year age group. The 2014 Guyana Multiple Indicator Cluster Survey (MICS) revealed differences based on location of residence with fertility rates of 2.3, 2.7, 2.4, and 4.3 children per woman for urban, rural, coastal, and interior areas, respectively ().

From 2008 to 2012, the total adult literacy rate remained at 85% (82% for males and 87% for females). Education is free and compulsory for ages 5-16 years.

The Economy

The economy depends heavily on Guyana’s abundant natural resources, particularly bauxite, gold, diamonds, and lumber. The country has fertile and productive soils, abundant water resources, a continental shelf off the Atlantic Coast, and, most recently, oil. In 2015, agriculture, forestry, fishing, and mining industries accounted for 28% of total GDP; bauxite, sugar, rice, gold, and timber made up 83% of exports.

During the years of extremely low GDP, Guyana was classified as a highly indebted poor country. However, per capita GDP at basic prices increased from US$ 2,514 in 2010 to US$ 3,724 in 2015 (). GDP at current basic prices rose from US$ 1.97 billion in 2010 to US$ 2.76 billion in 2015. In mid-2016, owing to the discovery of additional oil in Guyana, the World Bank classified Guyana as an upper-middle-income country. Guyana’s basic minimum wage was US$ 3,000 per year.

The legal age for employment in Guyana is 16 years. In 2015, the overall adult unemployment rate was 6.9% (5.3% for males and 9.3% for females). The youth unemployment rate was 25.1% (20.6% for males and 34.0% for females).

Violence and Security

Criminal activities continued to be a major threat to well-being in Guyana. The most recent information from the United Nations Office on Drugs and Crime lists Guyana’s 2012 death rate due to homicide as 17 per 100,000 people (). The Guyana Police Force is committed to reducing crime and violence and has outlined priorities in its Strategic Plan for 2013-2017, one of which is to advance modernization of the police force. Its operational priorities are to address drugs, domestic violence, youth crime, and human trafficking ().

Data were not available to substantiate and analyze the extent, economic impact, and health consequences of drug trafficking in Guyana. However, a 2016 U.S. narcotics control strategy report concluded that drug traffickers are attracted to Guyana because of the country’s poorly monitored ports, remote airstrips, intricate river networks, porous land borders, and weak security sector capacity. The Government of Guyana has legislation in place that could enable a more effective response to the threat of drug trafficking and money laundering. In 2014, the government started to draft anti-gang legislation, but this process remained incomplete. A new drug strategy plan for 2015-2020 was launched in January 2015. In addition, a special organized crime unit, established in 2014, became operational in 2015 ().

The U.S. Department of State 2015 Trafficking in Persons Report indicated that Guyana is a source and destination country for men, women, and children who are subjected to sex trafficking and forced labor, with children being particularly vulnerable. Victims are subjected to forced labor in the mining, agriculture, and forestry sectors. The government is making significant efforts to fully comply with the minimum standards for the elimination of trafficking, and an anti-trafficking action plan was released in June 2014 ().

Health Policies, Plans, and Programs

The National Health Sector Strategy for 2008-2012 set out a broad plan for providing equitable access to quality and consumer-friendly health services based on the principles of equity in distribution of health knowledge, opportunity, and service; consumer-oriented services that are people-focused and user-friendly; quality services that represent good value for money; and accountable provider and government. Subsequently, the health strategy, “Health Vision 2020,” was developed in 2013. Its strategic goals are to advance the well-being of all the people of Guyana, reduce health inequities, and improve management and provision of evidence-based, people-responsive, and quality health services ().

In terms of policy and planning options, a report by Dubois & Ingabire (2009) suggests that given the limited size of Guyana’s health workforce, its disease profile, the rural distribution of its population, and the public health focus of many of Guyana’s external partners, expanding the primary health care (PHC) delivery system would greatly improve the population’s access to cost-effective health services. The report also indicated that the successful implementation of the PHC programs will depend upon Guyana having a workforce with the appropriate skills, competencies, and motivation, buoyed by a health management system that provides supportive work environments with the proper incentives and accountability ().

Vulnerable Populations

Marked disparities continue to exist between coastal communities and the hinterland, especially relating to poverty levels. Amerindians, the predominant population group throughout most of the country’s interior, are the poorest social group and exhibit some of the lowest health indicators in Guyana. The last Poverty Reduction Strategy Paper was presented in 2002; it promoted a path toward growth in job creation, led by the private sector.

In 2014, the Government of Guyana indicated that it had met the internally established targets in the fight against hunger by halving the proportion of people who suffered from hunger; reducing the prevalence of underourished persons from 19.1% (1990-1992) to 5.1% (2010-2012); reducing the absolute number of undernourished persons; and decreasing malnutrition in children under 5 years old.

In May 2010, the Government of Guyana launched the world’s first national-scale model for a low-carbon economy-Guyana’s Low-Carbon Development Strategy (LCDS). This strategy uses an innovative approach to ensure low rates of deforestation and to stimulate the creation of a low-carbon, climate-resilient economy. The National Health Sector Strategy for 2008-2012 included activities that should improve Guyana’s capacity to respond to climate change and other environmental health risks (). According to the 2014 MICS, an estimated 7% of households use solid fuels (wood, charcoal, crops, straw, etc.) for cooking. Use of solid fuels was lowest in urban areas (2%) and highest (31%) in the interior. Use of these fuels increases the risk of acute respiratory illness, chronic obstructive lung disease, asthma, and other respiratory-related morbidities ().

The Health System

Health governance is characterized by centralized authority over technical aspects of health, with administrative authority decentralized to the regional level. In the administrative regions, the regional democratic councils have control of the health budget, but the Ministry of Public Health is responsible for the provision of services. Financing for health in Guyana includes public funding from the Ministry of Finance, from the treasury, including tax revenue, and resources from external partners. Donor funding for health decreased from 35.5% in 2008 to 7.2% in 2014. Public sector health services are free in Guyana and the private sector operates on a fee-for-service basis. The Georgetown Public Hospital Corporation (GPHC) receives and manages its own funding for all hospital services. There is also significant external donor funding and private spending through the National Insurance Scheme and out-of-pocket household expenditures (). Table 1 shows the key health financing indicators for Guyana from 2008 to 2012.

Table 1. Key health financing indicators, Guyana, 2008- 2012

Health financing indicator 2008 2009 2010 2011 2012
Total expenditure on health as % of GDP 6.6% 6.6% 5.7% 5.3% 5.4%
Per capita total expenditure on health (US$ at average exchange rate) 147.0 150.7 145.1 152.5 159.1
Government expenditure on health as % of total health expenditure 47.9% 56.1% 57.8% 60.1% 64.5%
Government expenditure on health as % of total government expenditure 9.4% 10.3% 9.5% 9.6% 8.7%
External (donor) expenditure on health as % of total expenditure on health 35.5% 27.4% 24.8% 22.5% 18.4%
Out-of-pocket expenditure as % of private expenditure on health 48.6% 49.3% 50.1% 48.5% 48.1%

Source: Guyana, Ministry of Public Health, Planning and Expenditure Analysis Department, 2016.

According to Guyana’s estimates of public expenditure, total health expenditure averaged above 9% for the period 2010-2015. The health expenditure as a total of government expenditure remained consistently above 9% for the period 2010-2014 with the highest percentage of 9.5% in 2014, with the exception of 8.2% in 2013.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

Malaria is a disease of major concern in Guyana. Malaria transmission has always been linked to the movement of persons from the coast to hinterland regions to engage in economic activity associated with the extractive industries (mining and lumber). Whenever there is an increase in the price of gold on the world market, there is a concomitant increase in the number of malaria cases. The majority of cases of malaria occur in males in the 15-49-year age group (which is the profile of gold and diamond miners) and among the Amerindian population.

In 2014 there were 12,353 reported cases-a sharp decrease compared with 30,542 in 2013. During an external evaluation of the malaria data information system carried out in August 2015 by the Pan American Health Organization/World Health Organization (PAHO/WHO), only 57.8% of the information coming from health facilities reached at the national level. After adjusting for this underreporting at the health facility level, the number of cases in 2014 could be higher (about 19,005) but still below the 2013 levels. In 2015, the number of cases was 13,096. The incidence rate is highest in Regions 1, 7, and 8. The decrease in cases in 2014 may be due to reduced exposure of those working in mining and logging activities, as mining activity decreased with lower gold prices.

The geography of endemic areas continued to be a challenge for the prevention, early diagnosis, and treatment of malaria. According to PAHO/WHO’s August 2015 rapid assessment of the malaria situation in the country, there was a 42% underreporting of cases nationally in 2013 and 44% in 2014 (). The proportion of confirmed cases of malaria, by age and ethnic group, is shown in Figure 2.

Figure 2. Confirmed cases of malaria, by age group and ethnicity, Guyana, 2014


Source: Guyana “Concept Note” for Malaria and the Global Fund, April 2015.

New and emerging diseases of public health significance include infection with the chikungunya and Zika viruses. Chikungunya was first detected in Guyana in May 2014; data from health facilities at both public and private institutions estimated that by the end of 2014 there were more than 5,000 suspected cases. The Ministry of Public Health’s response included increased vector control efforts, mainly through fogging and health promotion campaigns. The first case of the Zika virus was detected in Guyana in 2016. As of August 2016, of the 127 persons tested for the Zika virus, 26 (5 males and 21 females) were positive. The confirmed cases were in the following age groups: 5-14 years (2 cases), 15-24 years (9 cases), 25-44 years (11 cases), and 45-64 years (4 cases). The Ministry has applied experience gained from its response to the chikungunya virus to strengthen its surveillance capabilities and vector management activities.

Tuberculosis

Tuberculosis (TB) is a major public health threat in Guyana. From 1993, the number of new cases detected annually increased progressively, reaching a peak of 712 cases in 2012. Thereafter, there was a steady decline, with 508 cases in 2015. In that same year, 56 old cases re-entered treatment ().

An upsurge in TB cases was detected in the prison population in 2012; the annual number of new cases fluctuated in the period 2002-2009 and peaked at 42 new cases in 2012. In 2015, there were nine new cases, the lowest in the past 15 years. This reduction was due to intensive screening and more than 90% treatment success with directly observed treatment, short course (DOTS) in the prisons. Of the nine new cases in the prison population, three were coinfected with HIV. The TB/HIV coinfection rate in that population declined from 29% in 2012 to 20% in 2015.

HIV/AIDS

HIV/AIDS was first reported in Guyana in 1987. Incidence peaked in 2006 with 1,614 reported cases; thereafter the number of cases fluctuated, declining to 915 in 2015 (). In the early stages of the epidemic in Guyana, males were more affected than females, with ratios as high as 4:1. However, from the late 1990s, females accounted for a higher rate of infection than their male counterparts. From 2004 onwards, HIV/AIDS cases were equally distributed in males and females. Figure 3 shows the annual combined number of HIV/AIDS cases in the period 1989-2015 ().

Figure 3. HIV/AIDS cases (combined,) Guyana, 1989-2015


Source: Guyana, Ministry of Public Health database, 2016.

Guyana implemented the program for Prevention of Mother-to-Child Transmission of HIV (PMTCT) in 2001. Babies born to infected women in the PMTCT program are tested for HIV within the first 6 months using DNA polymerase chain reaction (PCR) and at 18 months with the enzyme-linked immunosorbent assay (ELISA). Antiretrovirals are given to women infected with HIV during labor and delivery and to newborns within 48 hours of birth. In 2002, the prevalence of HIV among pregnant women was 3.5%; in both 2013 and 2014 prevalence was 1.9% ().

Leprosy

One new case of leprosy was reported in 2012, 20 new cases in 2013 (including two children under 15 years old), and 29 cases in 2015. Cases with multibacillary (MB) leprosy occurred three times more frequently than cases of paucibacillary (PB) leprosy. More cases of MB and PB have been diagnosed in males than in females. Males with MP leprosy comprise close to 40% of all recorded cases ().

Chronic Conditions

The Government of Guyana has given priority to addressing the incidence of noncommunicable diseases (NCDs). The Ministry of Public Health’s “Health Vision 2020” incorporates strategic objectives and interventions to respond to the burden of disease in three categories: chronic diseases; accidents, injuries, and violence; and mental health. Because most behavioral and lifestyle factors are amenable to modification through education and sensitization, the government continued to work with various stakeholders to educate the general public. The initiatives addressed three major risk factors for chronic diseases: unhealthy diets, tobacco use, and physical inactivity ().

NCDs ranked among the 10 leading causes of death in Guyana for the period 2010-2012. Although there were no available national prevalence data on hypertension, surveillance data estimated that there were 81,608 patients with hypertension enrolled in the public health care system in 2014. A cost analysis of diabetes and hypertension for 2013 and 2014 showed a high cost for treating patients with these conditions. At the outpatient level, the estimated annual cost was US$ 17.0 million for diabetes and US$ 17.9 million for hypertension. The total annual cost accruing from NCDs was estimated at US$ 221.5 million.

From 2003 to 2012, 6,518 cases of cancer were recorded for an average incidence of 86.7 cases per 100,000 population. During that period, 52.4% of all persons with cancer died, with females having twice the mortality of males. Afro-Guyanese accounted for 44.4% (2,892) of cancer deaths in that period, the highest among all ethnic groups.

Breast cancer ranked the highest among malignant neoplasms during the period 2003-2012, with 1,074 cases reported for females and 16 for males. Indo-Guyanese women comprised 44.9% of total cases followed by Afro-Guyanese women with 42.3%. In the same period, cancer of the cervix was the second most common, with 1,014 cases. Afro-Guyanese and Indo-Guyanese women accounted for 384 and 383 cases, respectively. However, Guyanese women of Chinese descent had the highest average annual rate of cervical cancer (56.1 per 100,000), followed by Afro-Guyanese women (33.9 per 100,000) and women of mixed ethnicity (15.1 per 100,000).

Cancer of the prostate gland was the third most common in the period 2003-2012. There were 865 cases for an annual incidence of 11.5 per 100,000 population. Sixty-six percent of all cases occurred in Afro-Guyanese males and 19% in Indo-Guyanese males ().

Mental Health

The current mental health system in Guyana is fragmented, poorly resourced, and not integrated into the general health care system. Care of the mentally ill continues to be provided under the outmoded legislative framework of the Mental Health Ordinance of 1930. Lack of updated legal provisions to protect the civil and human rights of people with mental disorders has contributed to the current inequity in the financing, organization, and provision of mental health care services compared to general health care services in Guyana. Financing for mental health was secured from three sources: Ministry of Public Health, Georgetown Public Hospital Corperation (Mental Health Unit), and Region 6 Mental Health Program. Because of the lack of staffing at the Ministry’s central level, appropriated funds have remained unspent.

As of 2016, the Ministry changed the paradigm to community-based mental health and increased expenditure for human resources in mental health accordingly. The Government of Guyana is committed to addressing many of the challenges to reduce the inequities prevalent in this vulnerable population, mainly those residing in the hinterland. In the absence of national data, global estimates project that up to 10% of adults in Guyana may experience clinical depression and up to 2% of the Guyanese population may develop an anxiety disorder at some point in their lives. A national mental health strategy for 2015-2020 is being implemented.

Human Resources

The ratio of physicians rose from 6.8/10,000 population in 2010 to 8.2/10,000 in 2013. Similarly, the ratio of nurses increased from 10.1/10,000 population in 2010 to 15.3/10,000 in 2013. In total, 2,069 nurses and nursing assistants were registered to work in Guyana in 2013. In 2014, there were 13.3 physicians and 30.5 nurses and midwives per 10,000 population. The Ministry of Public Health strategy, “Strengthening the Foundation: A Health Human Resource Action Plan for Guyana 2011-2016,” presents a comprehensive plan for addressing the challenges and gaps in human resources. Training and human resource development in the health sector takes place in two main venues: the University of Guyana offers degrees in medicine, nursing, pharmacy, medical technology, and radiography, and the Division of Health Sciences Education within the Ministry of Public Health trains mid-level health workers and PHC workers.

In 2009, an analysis of the human resources for health gap was conducted to assess the feasibility of applying a standard “Package of Publicly Guaranteed Health Services” (now called the “Package of Essential Health Services”) in light of current staff availability and to make projections on the growth of the health workforce. According to the analysis, some of the key challenges facing Guyana included: poor progress toward achieving its Millennium Development Goal on reducing infant, child, and maternal mortality; health workforce vacancy rates of 25%-50%; and declining quality of the health training program because of over-subscription. The analysis noted that 57% of physicians work in the private sector and 90% of specialists are from other countries. Another challenge highlighted was that support from external development partners is program-focused and not well coordinated ().

Health Knowledge, Technology, and Information

Guyana’s health sector has many fragmented and compartmentalized information systems with little or no interoperability and communication; data are captured and generated through routine, paper-based information systems at the facility level. Initiatives are under way to develop an electronic medical records registry; to build and sustain robust, coordinated, and relevant data systems; to conduct formative research; and to access and develop annually updated geographic information system maps. Political, technical, and financial support are needed to develop the infrastructure, recruit qualified human resources, and support the sustainability of these technologies ().

The Environment and Human Security

Guyana is a vulnerable country due to the dependence of its population on the coastal plain, which, according to projections, will be affected by sea-level rise, storm surges, increased flooding due to greater precipitation, and other climate-related events. The key impacts of climate change relate to an increase in vector-borne, waterborne, and foodborne illnesses. Other effects include higher temperatures, food insecurity, and increased pressure on environmental, economic, and social factors that sustain health and are already under stress. Finally, climate change will pose threats to infrastructure and health systems due to projected sea-level rise and the current vulnerability of the coastal zone.

Drinking Water and Sanitation

Guyana is referred to as the “land of many waters” because it has sufficient water to support the needs of the population. According to the 2014 MICS, 83% of households had access to both an improved source of drinking water and improved sanitation facilities (90% for urban populations, 81% rural, 88% coastal, and 55% interior). An estimated 87% of households used a sanitation facility that was not shared (). Notably, water contamination in the distribution system in Guyana remained a significant problem.

National consultations were conducted in 2014 and resulted in the development of a Ministry of Public Health Action Plan for 2015-2025. The objective of the plan is to stratify and improve coverage and quality of waste management. In the area of food safety, the Veterinary Public Health Unit and the Food and Drug Department of the Ministry of Public Health are the responsible agencies. An important challenge related to food safety is that the Food and Drug Act of 1971 and the Food and Drug Regulations have not been updated.

Migration

Foreign-born residents represented 1.26% (9,321) of the population in 2002, decreasing to 1.10% (7,927) in 2012. Of this group, 45.8% were concentrated in the 20-49-year age group, the prime working-age group. The 2012 census also showed that persons from CARICOM Member States accounted for 41.1% of the foreign-born residents, a decline from 44.9% in 2002. In 2012, neighboring Suriname (17.8% of the foreign-born population), Brazil (12.2%), and Venezuela (10.3%) ranked highest in the number of their citizens residing in Guyana. Residents from the United States made up nearly 8.9% of the foreign-born population, and those from the United Kingdom and Canada together accounted for 4.8%. The 2012 census also revealed that there was a positive net inflow of persons from abroad who returned to the hinterland regions and a negative net outflow of persons residing in the coastland regions who left the country for overseas destinations.

Monitoring the Health System’s Organization, Provision of Care, and Performance

Some legislation pertaining to Guyana’s health system requires revising and updating. The provision of health services in the private sector is mainly confined to Georgetown. The health service delivery is based on a five-tier referral system. Level I includes 214 health posts; level II, 136 polyclinics and health centers; level III, 21 district or community hospitals; level IV, 5 regional hospitals and diagnostic centers; and level V, the Georgetown Public Hospital Corporation (GPHC). This facility has 502 beds distributed as follows: 406 for adults, 59 for infants, 7 for intensive care, 10 for cardiac intensive care, and 20 for pediatrics. Mental health services are provided at two health facilities: the Georgetown Public Hospital Corporation (Psychiatry Department) and the National Psychiatric Hospital, located in Berbice.

Significant strides were made to provide equitable services, skilled human resources, and infrastructure and technology. These are being achieved through the strengthened network of laboratories, and the implementation of the Package of Essential Health Services.

Gaps in quality of service provision exist, particularly at the more basic levels of care. Such issues are evident in certain geographic areas, especially in the difficult to reach hinterland areas. Challenges persist in the improvement of the national referral system and the development and implementation of standard treatment guidelines for service delivery at levels I and II (health posts and centers) ().

Prospects

The national health strategy “Health Vision 2020” and various national operational plans for specific diseases have outlined Guyana’s forward-looking strategies for immediate-, medium-, and long-term objectives. This strategy targets three goals: 1) advance the well-being of the people of Guyana; 2) reduce health inequities; and 3) improve the management and provision of evidence-based, people-responsive, quality health services.

In 2016, opportunities were created to discuss and prioritize national health challenges and constraints facing Guyana in the context of inequities and multisectoral participation. The main problems facing Guyana are NCDs, mental health (suicide), HIV and TB, vector-borne diseases, and insufficient numbers of skilled health workers. Key elements for short-, medium-, and long-term strategies include:

  • Expand access to equitable, quality, comprehensive health services;
  • Reorient health financing modalities to increase efficiency and increase public and multisectoral investments in health;
  • Strengthen stewardship and governance to redefine the functions and structure of the Ministry of Public Health to better address health inequities;
  • Enhance intersectoral collaboration (strategic partnerships) by formalizing the Health Commissions within the Cabinet and establishing inter-ministerial technical groups, including participation from the administrative regions.

These strategies will facilitate a dynamic transformation of Guyana’s health system in achieving universal health and reducing health inequities.

References

1. Ministry of Public Health, Bureau of Statistics (Guyana). 2012 Population & Housing Census: final report. Georgetown: MPH; 2012. Available from: https://www.statisticsguyana.gov.gy/pubs/Final_2012_Census_Count.pdf.

2. Ministry of Public Health, Bureau of Statistics (Guyana); United Nations Children’s Fund. Guyana Multiple Indicator Cluster Survey 2014: final report. Georgetown: MPH/UNICEF; 2015. Available from: https://www.statisticsguyana.gov.gy/pubs/MICS5_Final_Report.pdf.

3. Ministry of Public Health (Guyana); Pan American Health Organization. Health @ 50 in Guyana: progress health report 1966 – 2016. Georgetown: MPH/PAHO; 2016. Available from: https://www.paho.org/guy/index.php?option=com_docman&view=download&category_slug=publications&alias=173-health-at-50-in-guyana-progress-health-report-3&Itemid=291.

4. United Nations Office on Drugs and Crime. Global study on homicide 2013: trends, contexts, data. Vienna: UNODC; 2013. Available from: https://www.unodc.org/documents/data-and-analysis/statistics/GSH2013/2014_GLOBAL_HOMICIDE_BOOK_web.pdf.

5. Capita Symonds Limited. Institutional modernisation of Guyana Police Force: final report. Georgetown (Guyana): Ministry of Home Affairs, Citizen Security Programme; 2011. Available from: http://mops.gov.gy/wp-content/uploads/2017/05/institutional-modernisation-of-guyana-police-force.pdf.

6. Department of State Bureau of International Narcotics and Law Enforcement Affairs (United States). 2016 International Narcotics Control Strategy Report (INCSR): Guyana. Washington, D.C.: DoS; 2016. Available from: https://www.state.gov/j/inl/rls/nrcrpt/2016/vol1/253269.htm.

7. Department of State Office to Monitor and Combat Trafficking in Persons (United States). Trafficking in persons report: July 2015. Washington, D.C.: DoS; 2015. Available from: https://www.state.gov/documents/organization/245365.pdf.

8. Ministry of Public Health (Guyana). Health Vision 2020: a national health strategy for Guyana 2013–2020. Georgetown: MPH; 2013. Available from: https://www.paho.org/guy/index.php?option=com_docman&view=download&category_slug=health-systems-and-services&alias=123-guy-healthvision-2013-2020&Itemid=291.

9. Dubois CA, Ingabire MG. Implementing Guyana’s package of publicly guaranteed health services: bridging health human resources gaps. Georgetown (Guyana): Ministry of Public Health/Pan American Health Organization; 2009.

10. Government of Guyana. Guyana Second National Communication to the United Nations Framework Convention on Climate Change. Georgetown: GoG; 2012. Available from: http://unfccc.int/resource/docs/natc/guync2.pdf.

11. Health Systems 20/20; Ministry of Health (Guyana). Guyana health system assessment 2010. Bethesda, MD: Health Systems 20/20 / Abt Associates Inc.; 2011. Available from: https://www.hfgproject.org/wp-content/uploads/2015/02/Guyana-Health-System-Assessment-2010.pdf.

12. Ministry of Public Health, Bureau of Statistics (Guyana); ICF Macro. Guyana Demographic and Health Survey 2009. Georgetown: MPH/ICF Macro; 2010. Available from: https://dhsprogram.com/pubs/pdf/FR232/FR232.pdf.

13. Ministry of Public Health (Guyana). Guyana MDG acceleration framework: improve maternal health. Georgetown: MPH; 2014. Available from: http://www.un.org.gy/index.php?option=com_k2&view=item&id=192:mdg-acceleration-framework-improve-maternal-health&Itemid=740.

14. Ministry of Public Health (Guyana). Guyana dental health services oral health report 2013. Georgetown: MPH; 2014. Available from: http://www.cohipr.com/wp-content/uploads/2014/07/GUYANA.pdf.

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