Mapping and Analysis of Primary Health Care Models in South American Countries

Transcription

1 Mapping and Analysis of Primary Health Care Models in South American Countries Mapping of PHC in Suriname Consultant: Hedwig Goede Auctorial document on PHC in South American countries

2 MAPPING AND ANALYSIS OF PRIMARY HEALTH CARE MODELS IN SOUTH AMERICAN COUNTRIES Mapping of PHC in Suriname Consultant: Hedwig Goede Auctorial document on PHC in South American countries Rio de Janeiro June 2014

3 South American Institute of Government in Health Executive Director: José Gomes Temporão Technical Coordinator: Henri Jouval South American Health Council June 2014 Juan Luis Manzur Argentina Bheri Ramsaran Guyana Juan Carlos Calvimontes Bolivia Arthur Chioro Brazil Helia Molina Chile Alejandro Gaviria Colombia Carina Vance Mafla Ecuador Antonio Carlos Barrios Paraguay Midori Musme De Habich Rospigliosi Peru María Susana Muñiz Jiménez Uruguay Michel Blokland Suriname Francisco Armada Venezuela Text and Images: Hedwig Goede Graphic Project: Humponto Design e Comunicação Mapping of Primary Health Care Models in South American Countries Coordination: Ligia Giovanella Assistant Researcher: Suelen Oliveira Hedwig Goede Public Health Consultant Hedwig Goede is a physician, with a master s degree in Public Health by the University of Michigan, Unites States. She is a consultant for public health issues, with experience in strengthening institutional capacity and enabling the exchange of processes and innovation in primary health care organizations, community health programs, development and organization of health systems, human resources formation, among others. The opinions expressed in this document are those of the author and do not necessarily reflect the official policy or position of the Organization

4 Table of Contents Mapping of PHC in Suriname Introduction Objectives and Methodology Background Republic of Suriname Health System Suriname Primary Health Care Conduction Concept of Primary Healthcare Attributions of subnational governmental spheres Other relevant actors in PHC policies PHC Funding Funding sources and expenditures PHC and Health Insurances Co-payments in PHC Characteristics of PHC Organization and Provision Characteristics of PHC organization Coastal area: Regional Health Service Foundation and private general practice Interior area (Amazon rainforest), Medical Mission PHC Suriname foundation Access to services for populations through publicly funded services Addressing malaria in the gold-mining communities Characteristics of PHC Provision Coordination of care and Integration of PHC in the service network Referral and counter-referral system PHC Workforce Coastal area Interior area Intersectoral collaboration, social participation, and inter-culturality in PHC Conclusions References Annex 1: Table of demographics and Socio-economic indicators, Suriname, 2012 Annex 2: Selected Health Indicators, Suriname, 2000, 2005, 2010 and latest Annex 3: Human Resources and Facility capacity, Suriname List of Acronyms List of Figures Acknowledgments

5 Mapping of PHC in Suriname Mapping of PHC in Suriname Introduction 5 Mapping of PHC in Suriname 1 INTRODUCTION Objectives and Methodology This document reports on the mapping of Primary Health Care (PHC) in Suriname. It is part of the work of ISAGS to build knowledge in PHC models and experiences among the South American countries. It is expected that the mapping will contribute to useful information that will support governments in identifying strategic policies and facilitate political decision-making related to the construction of universal health systems in the South American region. The mapping took place during period February- May 2014 and was based on the analytical framework developed by ISAGS. The framework was presented in a matrix with various dimensions of Primary Health Care that included PHC conduction, funding, service provision, organization, coordination and integration, workforce, intersectoral actions, interculturality, social participation in PHC as well as planning, information systems and quality monitoring. The activities for the mapping included a review of secondary resources, discussions with key actors from the policy - and management level of PHC and review of author s informal notes from participatory observations of recent national and subnational stakeholders situation analysis of PHC in the country (table 1). It should be noted that documentation of PHC in Suriname is scarce (Laryea, Barten, & Goede, 2013). Table 1: Sources for the Mapping of PHC in Suriname Documents Meetings (notes from observations of elaborations during participatory stakeholders meetings) Interviews National development Plans, Health Policies and Health Plans, Published academic articles Published and unpublished reports on studies, assessments, analysis related to PHC Consultation meetings on the strategic policy plan for the sub national restructuring of the Regional Health Services (April-August 2013) national Stakeholders consultations and working group meetings on the strategic planning of the Renewal and strengthening of Primary Health Care (July 2012 September 2013) Dr. Michel Blokland, Minister of Health Dr. Edward van Eer, Director Medical Mission, Primary Health Care Dr.Maaltie Sardjoe, Medical Director Regional Health Services Mr. Ronald Ritfeld, responsible for community participation in PHC of Regional Health Services Mr.Melvin Uiterloo, focal point for collaboration with traditional healers, Medical Mission, Primary Health Care 1 This document was prepared by a consultant. The opinions expressed here in are the responsibility of the authors and don t express the position of ISAGS or the Ministry of Health of the country or the professionals interviewed

6 Mapping of PHC in Suriname Introduction 6 Background Republic of Suriname Table 2: General information, Suriname Location Land mass Administrative division North-east of the South American continent, bordering Guyana, French Guyana, Brazil and the Atlantic Ocean Land mass: 163,820 Km² Ten administrative districts Total size population 541,638 Population settlements and density Ethnic groups, % population Language Economy 1. Urban coastal: 66.3% 2. Rural coastal: 20.5% 3. Rural interior: 13.2 % 4. Total population density: 3.3/ Km² a. Coastal density: 17.2/ Km² b. Interior density: 2.9/ Km² Hindustani/Indian descendants (27.4%), Maroon/descendants of slavery escaped African slaves (21.7%), Creole/mixed African descendants (15.7), Javanese/Indonesian descendants (13.7), Mixed (13.4). The remaining 8% consist of other groups such as Indigenous/Carib, Arawak, Trio, Wayana and other first inhabitants, Chinese and Dutch descendants, Lebanese descendants. Official language: Dutch, many other languages spoken Classification: upper middle income (World Bank as of 2010) GDP: 9,376 US$/capita (World Bank) Main economy: Mining (Gold, Oil, Bauxite) Sources: (Central Bureau of Statistics Suriname, 2012) (World Bank, 2014) Geographically defined disparities Three different geographic regions can be distinguished in the country; urban coastal, rural coastal and rural interior. Close to 90 percent of Surinamers live on the Northern coastal plains of which two thirds (66.3%) in the greater Paramaribo urban area and one third in the rural coastal districts. The Amazon rainforest (Interior) covers close to 90 percent of the country and is traditionally sparsely populated (13.2% of total population) by Indigenous Peoples and Maroons. There are marked differences in social determinants and poverty levels among the urban, rural coastal and rural interior populations 2. However, there is a recent trend of reducing some of the gaps between the interior population and the coastal population as is demonstrated by the improvement of access to safe drinking water for the rural interior population. 2 Gold-mining populations not included in the analysis.

7 Mapping of PHC in Suriname Introduction 7 Figure 1: % of population using improved sources of drinking water by geographic area, Suriname, 2006, 2010 Source: (Government of Suriname and Unicef, 2006) (Government of Suriname and Unicef, 2010) Figure 2: % of population using improved sanitation by geographic area, Suriname, 2006, 2010 Source: (Government of Suriname and Unicef, 2006) (Government of Suriname and Unicef, 2010)

8 Mapping of PHC in Suriname Introduction 8 Figure 3: % of population with access to electricity by geographic area, Suriname, 2009 Source: (UNDP, 2009) Figure 4: % population (15+) with tertiary Education by geographic area, Suriname, 2009 Source: (UNDP, 2009)

9 Mapping of PHC in Suriname Introduction 9 Ongoing rapid changes of health determinants in the Interior Dramatic socioeconomic and environmental changes are ongoing in the Interior due to the gold-mining boom in the past two decades. Artisanal gold-mining is the largest sub-sector in the gold sector. Those involved in small scale mining are mostly Garimpeiros from Brazil (estimated 70-80% of total) and Maroons from the Interior, but also other nationalities are directly or indirectly involved in the goldmining economy in the Interior (de Theije & Heemskerk, 2009). It is difficult to obtain a reliable number of gold-miners. One reported estimate is that of 14,000 persons that includes miners and shop- and bar owners, all-terrain vehicles drivers, operators and sex workers (C., 2009). More recent estimates from the Government s Commission Ordening Gold Sector mentioned an estimate of 20,000 miners (of which only slightly more than 100 are officially registered) with a turnover of more than 1 billion US$ a year (Cairo, 2011). Therefore the interior has changed from a setting of solely traditional Indigenous and Maroon villages, with some small eco-tourism resorts, to a transnational context with different nationalities involving mainly the three Guyana s and Brazil; including documented and undocumented migrants. Gold-mining communities are established outside the traditional villages and lack health services, especially when at greater distance of the traditional villages where the Medical Mission provides comprehensive PHC. This is in contrast with the health needs arising from an environment with excess health risks (Heemskerk, 2004). Another trend is the remarkable growth of the Maroon population; both in the Interior and among those living in the urban areas of the country. The Maroon population has the highest fertility rate and mortality rates have decreased probably due to control of malaria and other improvements in health status. The growth rate of the Maroon population from 2004 to 2012 is 62% (Central Bureau of Statistics Suriname, 2012) Health System Suriname The Ministry of Health (MOH) is the national health authority with the responsibility for safeguarding health of the public and more specifically with the supervision over public health. Tasks include; warranting quality, availability and accessibility of health care in the entire country, guaranteeing infrastructure and human resources for health, managing the supervision of health institutions, pharmaceuticals and other supplies, surveillance and port health, oversight on medical practice and on investigation of food products and food handling and monitoring compliance with legislation related to optimal external living environment. In addition the Ministry is also tasked with health education and health promotion and with healthcare of those population groups and individuals who would otherwise lack healthcare (Government of Suriname, 2002) The country has a public-private mix of health system and provision and financing of health services are separated. The health system is highly segmented into subsystems through different financing modalities and different service providing institutes.

10 Mapping of PHC in Suriname Introduction 10 Segmentation of the population is based on geographic location, employment status and income level. The Ministry of Finance (the largest financer of health services) is allocating funds to not less than four ministries with health on their annual budgets. These include the Ministry of Social Affairs and Housing, who finances healthcare for the poor and near poor, the Ministry of Justice and Police, who finances healthcare for the Police servants, the Ministry of Defense, financing health services for the members of the national army and their families and the Ministry of Health. The ministry of health is in turn allocating funds to a number of health service providers; both semi-autonomous state institutions as well as NGOs in health. This high level of segmentation contributes to inequity in access to health and a fragmented system where available resources are not optimal utilized. This complexity of the health system forms a challenge to the governing and coordinating role of the Ministry of Health (MOH) as national health authority. Main institutions of the MOH to exercise its role as health authority are: 1. The central office with among others the medical, nursing and pharmaceutical inspectorates, the department of planning and the health information system. 2. The Bureau of Public Health, responsible for prevention and protection of health of the public (surveillance, environmental health, national referral laboratory, disease- and population specific programs) 3. The Drugs Supply Company, a state-owned company responsible for import of drugs (90%) and produces in addition a small part of essential medicines. The MOH has also a number of commissions and councils that assist in the oversight of the health system or provide coordination.

11 Mapping of PHC in Suriname Primary Health Care Conduction 11 PRIMARY HEALTH CARE CONDUCTION The Alma Ata conference on Primary Health Care (1978) came short after independence of Suriname (1975). In this period the country was considerable isolated from the region; there were limited formal networks within the region and for example membership of the Caribbean Community (Caricom) took place much later (1995). The country s reference was primarily the Netherlands. The Alma Ata strategy and concept of health matched well with the post-independence calls for own reliance, belief in own capacity of the country and the search for new pathways in national development. Previous health officials mentioned that there was a breakthrough in the isolation from the region and by visiting nearby countries they were exposed to diverse healthcare models (Goede, 2014). Concept of Primary Healthcare The comprehensive view of the PHC strategy was politically adopted in the early Eighties and followed by amending the constitution to include health as a right, and by taking measures to develop the organization, workforce and facilities network for the provision of PHC services. Three institutions were established in this period: The State Healthcare Fund covering public servants and their families (1980), the Central School of Nursing and Allied Occupations (1983), and the Regional Health Services providing healthcare primarily to the poor covered in the social healthcare system through the Ministry of Social Affairs. It was anticipated that the State Health Insurance Fund would be transformed to a General Healthcare Fund, but despite preliminary work at several moments in time, this has never been materialized. This first period of efforts to develop PHC in Suriname was followed by a period of narrowing down on the comprehensive view of PHC and replacing this with the concept of selective PHC. After the early Eighties the concept of PHC was slowly demolished, even before it was fully institutionalized and this lasted more than two decades. A historical review of PHC found that, with the exception of the national health plan ( ), all national policy documents refer mostly to PHC as level of care (basic healthcare, first line care) with limited attention to critical components of comprehensive PHC (Goede, 2014).The national health plan , developed as first plan after Alma Ata, adopted the comprehensive view of the Alma Ata declaration and included pillars of PHC such as affordable healthcare services, community participation and intersectoral collaboration. These can be found only in a fragmented manner in later policy documents and national plans. The context of the country in the late and post Eighties was characterized by economic crisis, structural adjustment (Nineties) and recovery from an internal war. In the late Nineties a National Health Reform program was prepared with the IADB that was implemented in the early till mid-twenties. Assessments conducted in the framework of the Health Reform pointed to the need of strengthening first

12 Mapping of PHC in Suriname Primary Health Care Conduction 12 line care from a health finance point of view (Hindori, M and Ministry of Health, 2001). It was further observed that Suriname is ambiguous between the general practice model and the Primary Health Care strategy of Alma Ata (Royal Insitute for Tropical Medicine, 2001). Recently a third wave in the development of PHC occurred. Around the commemoration of 30 years Primary Health Care (2008), a slow return of interest in PHC as a comprehensive strategy could be noticed in the country and several activities led to policy documents and measures at the level of PHC service delivery institutions and to the development of the national strategic PHC plan Series of awareness raising and planning meetings have been taken place after 30 years Alma Ata at the national level as well at the level of the PHC organizations. The Medical Mission started in 2009 a program of strengthening integrated PHC for the population of the Interior (Medical Mission, 2009). The program is aiming for the reorientation of the organization towards a more comprehensive PHC model with the emphasis on strengthening community participation, health education and inter-sectoral actions as the weakest components. The Regional Health Services developed in 2013 a five years strategic plan for the restructuring of the Regional Health Services in Suriname that is also aiming for the reorientation towards comprehensive PHC as well as strengthening the internal organizational and management structure (Regional Health Services, 2013). The Ministry of Health started in 2012 the process of developing a national strategic plan for the renewal of Primary Health Care. This plan is now approved for the period The plan refers to the Alma Ata definition of PHC and conceptualizes PHC in a comprehensive manner and states that PHC is beyond merely the first level of care. According to the plan PHC as a strategy is placing human beings central and is viewing them in her/his environment. Further, PHC brings healthcare close to homes and utilizes scientifically sound and socially accepted technologies and essential medicines and extends to addressing health risks with social participation and intersectoral collaboration (Ministry of Health Suriname, 2014). Currently fundamental changes are made in the health system. Reform of the national social security system has been put in process by the government and this includes the development of a national basic healthcare insurance system compulsory to all residents of productive age will be required to close a basic healthcare insurance at the insurance market. The government through public funds will cover the insurance costs of those not working; children 0-16 years of age and persons of 60 years of age and above. The two decades of silence on PHC at the policy level, now broken, and the development of the national strategic plan for the renewal of Primary Health Care (PHC) was not directly linked to the reform of the national social security system, but the reform will impact on the entire health system including on PHC. There is no legal definition of PHC in the country and PHC is not mentioned in the articles and policy documents of national health insurance schemes.

13 Mapping of PHC in Suriname Primary Health Care Conduction 13 The government s development plan Suriname in Transformation ( ) assigned PHC a central role in achieving the goal of equity in health for Surinamese citizens (Government of Suriname, 2012). Although not defining PHC this national development plan contains statements on key pillars of PHC such as the importance of addressing social determinants of health, the role of non-health sectors and community development and social participation as a strategic approach in health. (Government of Suriname, 2012). The right to health is enshrined in the constitution. Article 36 of the constitution states that everyone has the right to health and that the state promotes healthcare through systematically improving the living- and work conditions and providing education for the protection of health. (Government of Suriname, 1987). Attributions of subnational governmental spheres Suriname has no local government and therefore sub national levels of the government have no specific duties in PHC. However, the development of local government at the district level is ongoing. Other relevant actors in PHC policies There are many actors influencing the development of PHC. These include regional bodies such as the Caricom and Unasur, several bilateral partners, funding agencies (Inter-American Bank, Islamic Bank, Global Fund) the UN agencies, especially, PAHO/WHO, Unicef and UNFPA. The Netherlands health system remains influential through different channels. Important actors are Dutch health institutions, universities and occupational associations cooperating with counterparts in Suriname. Medical missions from medical specialists in the Netherlands are often organized and/or undertaken by specialists in the Netherlands from Surinamese origin. At the level of PHC a recent initiative is the collaboration on establishing a family practice specialist training program that taps to a great extent into the Dutch family practice model. The Caricom has importance in PHC through the Caribbean Cooperation in Health (CCH) III that serves as the Caribbean Regional Framework in Health (Caricom Secretariat). Among the expected outcomes is the re-orientation of healthcare to PHC-based systems in countries (Caricom Secretariat, CCH III). CCH III is signed by Suriname as a member state. The Inter-American Development Bank (IADB) is an actor influencing the country through funding (grants and loans); previous the health sector reform program, HIV grants and currently the national NCD plan. The Islamic Bank is funding infrastructural strengthening (rehabilitation and construction of PHC facilities). France with its border of French Guyana in the East of Suriname has several cooperative actions with Suriname. Unasur through its work on health systems is a new actor to the country with attention to PHC and universal health systems.

14 Mapping of PHC in Suriname PHC Funding 14 PHC FUNDING Funding sources and expenditures Public funding of health is overall 37.5%, while private funding from private insurance companies and company health plan is 34.1%. About twenty percent of the population is not covered for health costs and therefore about 20% of households in Suriname need to cover costs of healthcare out-of-pocket. (Ministry of Health Suriname, 2006) In the absence of local governance public resources are all from the national government. The Ministry of Finance collects taxes, allocates funds for healthcare to four different ministries (Ministry of Health, Ministry of Social Affairs and Housing, Ministry of Defense and the Ministry of Justice and Police). The Ministry of Finance is also managing the contributions of the State Health Fund Foundation. The contributions are a combination of the employees share in the premium and of that of the government as employer. The Ministry of Health, in turn, allocates funds to a number of non-governmental as well as semi-autonomous state foundations involved in PHC these are: 1. Institutions providing integrated PHC services a. Regional Health Services Foundation b. Medical Mission Primary Health Care Foundation Suriname 2. Other institutions involved in preventive and/or first level care a. Youth Dental Healthcare Foundation b. Bureau Alcohol and Drugs 3. Training institutions a. Central School of Nursing and Allied Professionals. In addition, the Bureau of Public Health as part of the Ministry of Health is on the budget with PHC related activities, especially in the area of family health and child development. Health Expenditure per capita rose sharply from USD in 2000 to USD in 2006 and 521 USD in 2012 (Ministry of Health Suriname, 2006) (World Health Organization, 2014). However, Primary Health Care continues to receive the lowest allocation and spending on PHC and prevention even declined in 2006 with 19.3% in comparison with the year The percentage spent on PHC and preventive services 3 was 27.2% of the total health expenditure in (Ministry of Health Suriname, 2006) 3 In estimating PHC expenditure first line care of general practitioners + PHC of the Regional Health Services and Medical Mission are brought together. The latter two provide integrated services and therefore the NHA reports on PHC and prevention as one entity.

15 Mapping of PHC in Suriname PHC Funding 15 PHC and Health Insurances As of 2013, the government embarked on the reform of the social security system. As part of this reform a national basic care system will be introduced as a market oriented model that includes competition among insurance companies. The new system must, among others, reduce the 20% out-of-pocket expenditure of households on healthcare and ensure a basic care package to all. The government has submitted a draft law to parliament for the introduction of a compulsory health insurance. The process is ongoing and the shift in health financing was not known while this document was prepared. Until the introduction of the new social security system the Ministry of Finance is providing funds for health in a fragmented manner; to the Ministry of Health, and to the three other Ministries that have healthcare on their budgets. This is a reflection of the segmentation of the healthcare system where segments of the population are covered with healthcare services by different providers. This situation will drastically change with the new national basic care system. The national basic care system will introduce compulsory health insurance through a market mechanism and the proposal is that the government will cover the premium costs of the non-working citizens: those of 0-16 years and 60+ of age. The working population will need to cover their own healthcare premium costs. For those with disabilities or an income below the poverty line, the government will guarantee financing of the insurance. Figure 5 shows the situation, now under change, where the Ministry of Social Affairs and Housing is covering the largest group, 24% of the total population. The medical card assigned by this Ministry to the poor and a different card to the near poor guarantees access to comprehensive care at all levels: PHC of the Regional Health Services and referrals to specialist care and hospitalization. It should be noted that individuals who do not meet the Ministry of Social Affairs criteria for a longer term medical card, can be granted a temporary card when they risk excess out-of-pocket payments that they cannot bear. These temporary cards are usually granted for only a short period when hospitalization is necessary. Another social protection mechanism is maintaining a lower barrier to entry for individuals with chronic diseases for whom the continuous care and medication would be a financial burden if financed by out-of-pocket expenses. The government anticipates reducing segmentation and gaining greater equity in healthcare with the new basic care system, because individuals will not any-longer be identifiable based on their economic- or employment status or geographic location. All enrolled, whether contributing or not, will have the same card. This is an important step forward, because it was found that at the policlinics of the Regional Health Services those with a Social Affairs card (the poor) receive less attention, are less often referred to laboratory services and have often longer waiting hours than private patients or those otherwise insured (Royal Insitute for Tropical Medicine, 2001).

16 Mapping of PHC in Suriname PHC Funding 16 Figure 5: Percentage of population insured by plan, Suriname, 2009 Source: (National Health Information System, Ministry of Health Suriname, 2009) Co-payments in PHC There are limited co-payments in PHC and these are linked to drug dispensing. A contribution of one Surinamese dollar (0.33 US$) per prescribed drug is required at the pharmacies for those covered by the State Health Fund. For those with a Social Affairs card of the near poor this is half the amount (0.165 US$) and for holders of a card for the poor this is further reduced to US$. Persons in the Hinterlands, registered at the Medical Mission, do have no co-payments for any of the services, including for specialist care or diagnostic services. But, hidden informal costs can be substantial; especially transport costs can be high for those individuals from remote areas referred to secondary care in the capital Paramaribo. Only medical emergency evacuation is provided free of costs to the population in the Interior.

17 Mapping of PHC in Suriname Characteristics of PHC Organization and Provision 17 CHARACTERISTICS OF PHC ORGANIZATION AND PROVISION Characteristics of PHC organization In Suriname the organization of PHC is geographically divided into two subnational networks: one for the coastal area and one for the interior; the Amazon rainforest. Two different organizations are responsible for the subnational PHC service networks and they share some similarities in the organization of services, but have also differences. In the coastal area the Regional Health Service Foundation has the responsibility for PHC and in the interior this is the Medical Mission, PHC-Suriname Foundation. In addition, private practices of general physicians are an additional important point of first contact with the health system for those covered by the State Health Insurance, private health insurances or out-of-pocket payers. The private practices are only found in the coastal belt and mostly in the more populated urban areas (Paramaribo, district of Wanica and Nickerie). Table 3: Number of nationwide PHC facilities by category of providers (including first line), Suriname, 2012 Category of providers Number Regional Health Services 63 Medical Mission 54 Private polyclinics 146 Company polyclinics 11 TOTAL 274 Source: (Ministry of Health, 2012) Coastal area: Regional Health Service Foundation and private general practice The Regional Health Service (RHS) is an autonomous institution, founded by the government as an executive body of the Ministry of Health. The legal status is that of a foundation and the governing board is appointed by the minister of Health. The RHS originated from the MOH Medical Service department and its development is to a great extent inspired by the Alma Ata PHC strategy. The Regional Health Service serves the population along the country s Northern coastline which covers not much more than 10 percent of the land mass, but offers residency to about 85 percent of the total Surinamese population. This includes the urban- and the rural coastal populations. Private general practitioners offer a more limited package of first line care while the services of the Regional Health Service are more comprehensive. Interior area (Amazon rainforest), Medical Mission PHC Suriname foundation The Medical Mission PHC Suriname is a foundation established by religious organizations. Its work area is the Interior. The Interior covers close to 90 percent of the country s land mass and is part of the Amazon rainforest. It is sparsely populated by various Indigenous and Maroon populations who live mainly at traditional villages along the large Rivers.

18 Mapping of PHC in Suriname Characteristics of PHC Organization and Provision 18 The government was not involved in healthcare services in the Interior. Short after independence the government and the Medical Mission closed a formal agreement on healthcare in the Interior. This agreement stipulated that the Medical Mission would provide services free of charge to the Interior populations and that the Ministry of Health would provide the funds to the Medical Mission. Access to services for populations through publicly funded services Progress has been made slowly in closing the gap in access to basic services for the populations in disadvantaged geographic regions and socioeconomic positions. The number of PHC facilities in the Interior increased from 17 short before Alma Ata to 54 in For the coastal area a similar trend took place for the Regional Health Service. Both organizations serve the poor and close-by-home facilities providing services without direct financial barriers are an essential first step. Map 1: Distribution of publicly funded PHC facilities Regional Health Services (coastal) and Medical Mission (Interior), Suriname, 2014 Source: (van Eer & Sardjoe, May 2014) Among the progress made in closing the gaps is the close to equal proportion of skilled birth attendance in a period of ten years (figure 6 and tables 3, 4 and 5).

19 Mapping of PHC in Suriname Characteristics of PHC Organization and Provision 19 Figure 6: % of skilled attendance births by geographic region, Suriname, 2000, 2006, 2010 Source: Figure produced by author based on data from MICS 2000, 2006, 2010 Table 4: Proportion of personnel type assisting at delivery by region, Suriname, 2000 Personnel type Urban Rural Costal Rural Interior Total Doctor 31.10% 32.50% 7.10% 24.00% Midwife 49.50% 49.20% 11.20% 37.60% Nurse 12.10% 8.30% 6.10% 9.30% Health assistant 0.00% 0.00% 43.90% 13.60% Traditional birth attendant 0.00% 1.70% 25.50% 8.30% Missing 6.30% 7.50% 6.10% 6.60% No assistance received 1.10% 0.80% 0.00% 0.70% Any skilled personnel 92.70% 90.00% 68.30% 84.50% Source: (Government of Suriname and Unicef, 2000) Table 5: Proportion of personnel type assisting at delivery by region, Suriname, 2006 Personnel type Urban Rural Coastal Rural Interior Total Doctor 28.50% 23.70% 18.60% 25.80% Nurse/Midwife 62.60% 64.00% 50.60% 60.70% Auxiliary midwife 3.70% 3.20% 2.30% 3.30% Health assistant 0.20% 0.00% 19.10% 3.60% Traditional birth attendant 0.00% 0.00% 6.70% 1.20% Relative /friend 1.30% 2.70% 2.20% 1.70% Missing 3.20% 5.10% 0.00% 3.00% No assistance received 0.40% 1.20% 0.60% 0.60% Any skilled personnel 95.0% 90.90% 90.60% 93.40% Source: (Government of Suriname and Unicef, 2006)

20 Mapping of PHC in Suriname Characteristics of PHC Organization and Provision 20 Table 6: Proportion of personnel type assisting at delivery by region, Suriname, 2010 Personnel type Urban Rural Coastal Rural Interior Total Doctor 37.2% 36.7% 33.3% 36.4 % Nurse/Midwife 56.1% 56.5% 42.6% 53.6 % Auxiliary midwife 1.2% 1.6% 0.6% 1.2 % Health Assistant 0.5% 0.3% 14.6% 3.1 % Traditional birth attendant 0.7% 0% 4.5% 1.3 % Relative /friend 0.2% 2.9% 1.6% 1.0 % Missing No assistance received 0% 0% 0.2% 0.0 % Any skilled personnel 95.0% 95.1% 91.1% 94.3% Source: (Government of Suriname and Unicef, 2010) The figure 7 below shows a trend of closing the gap on contraceptive use between the Interior population and the coastal population. Figure 7: Contraceptive Prevalence Rate, Suriname, 1992, 2000, 2006 and 2010 Source: (Jagdeo, 1992), (Government of Suriname and Unicef, 2000) (Government of Suriname and Unicef, 2006) (Government of Suriname and Unicef, 2010) Addressing malaria in the gold-mining communities The gold-mining communities are transnational, high health risks environments in the Interior mostly without PHC facilities. The most important health problem in this setting was malaria and this was fuelling malaria in the other parts of the Interior. The malaria program of the Bureau of Public Health, MOH with support of the Global Fund applied an innovative public health approach that led to a dramatic reduction of