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Country Health Profile.
Data updated for 2001Puerto Rico Health Situation Analysis and Trends Summary Country Chapter Summary from Health in the Americas, 1998.
PUERTO RICOGENERAL SITUATION AND TRENDSSocioeconomic, Political, and Demographic Overview Puerto Rico is a commonwealth associated with the United States of America. Since 1992, the Government of Puerto Rico has established a new public policy and strategies relating to health. The highest rate of real economic growth during 1990–1995 was registered in 1995. The gross product that year rose 3.4%, compared to increases of 3.3% in 1993 and 2.5% in 1994. The Government of Puerto Rico continued to apply its New Economic Development Model, whose economic, social, financial, regulatory, institutional, and human resource strategies were determining factors in the economic recovery. The Government played a significant role in the growth of the construction industry, particularly through investments in infrastructure works such as roads, electricity and telephone lines, and prison facilities. In fiscal year 1995, the gross domestic product (GDP), in current prices, rose to US$ 42,363,700, an increase of 7.2% from 1994. Personal income increased 5.5% in 1995, surpassing the 4.1% in 1994. At current prices, per capita personal income was US$ 7,296 in 1994–1995, higher than the previous year, of US$ 7,009. In fiscal year 1995, the total number of employed persons, according to a survey of the Department of Labor and Human Resources, averaged 1,051,000, an increase of 40,000 jobs from 1994. Employment measured by this survey excludes agricultural workers and self-employed persons, who total 896,000. The number of unemployed people was 168,000. That year the unemployment rate was 13.8%. The U.S. Federal Government participates actively in the island’s economy through net disbursements. These consist of net federal transfers to individuals and to the public sector, as well as the net operating expenditures of the federal agencies that are active in Puerto Rico. In fiscal year 1995, they totaled US$ 6,367,100, representing an increase of US$ 430.8 million (7.3%) from 1993–1994. These disbursements account for 22.4% of the island’s gross domestic product. The increase registered in 1994–1995 exceeded the average rate of growth of 5.4 % over 1990–1995. Puerto Rico is made up of municipios, or counties (the island is divided into 78 municipios), with each municipio having an urban or semiurban nucleus (city, town, or village) and may include both urban and rural areas. The population density has been increasing: in 1990 it was 396.9 inhabitants per km2, but by 1995 it was 416.0 inhabitants per km2; it is estimated that by 2000 the figure will be 432.7 inhabitants per km2. The population of the municipio of San Juan accounted for 12.2% of the island’s population in 1995 (3,643.7 inhabitants per km2). As of 1 July 1995, an estimate of the population of Puerto Rico was 3,720,018, (1,801,519 males, 1,918,499 females), an increase of 34,288 (0.9%) from July 1994. The population growth rate was 17.9 % (1.7% per year) in the 1970s and 9.9% (1.0% per year) in the 1980s. In the 1990–1995 period, the annual average growth rate was 1.1%. For many years, migration has most affected Puerto Rico’s population. The bulk of the migration is between Puerto Rico and the United States. Net migration in fiscal year 1980, was -16,101 persons, but in 1994 it was +26,853. Preliminary data for 1995 show a negative net balance of 1,326 people, the lowest since fiscal year 1971, when the figure was –2,525 people. The birth rate, which was 24.8 per 1,000 population in 1970, dropped to 18.8 in 1985 and to 17.5 in 1994. Available data reveal a falling trend in the specific fertility rate during recent decades in all age groups of mothers, except the 15–19 age group. In the group 20–24 years, the specific fertility rate in 1970 was 187.7 births per 1,000 women, but fell to 138.0 in 1992; in the group 25–29 years, the corresponding rates were 179.4 and 122.0, respectively. In the group aged 15–19, birth rates have fluctuated with specific fertility rates of 71.9 births per 1,000 women in 1970, 76.3 in 1980, 63.5 in 1985, and 73.3 in 1992. Mortality and Morbidity Profile The Ongoing Health Study is a field study that gathers statistical data on hospitalization, physician and dentist visits, acute and chronic morbidity, and days of restricted activity. The sample of dwellings used is a subsample of the group of workers of the Statistics Division of the Department of Labor and Human Resources. The population under study consists of noninstitutionalized civilians in Puerto Rico. Data from the survey show a total of 5.5 million chronic disorders in 1992. This figure indicates a rate of 154.4 chronic disorders per 100 population, or 1.5 disorders per person per year. The rate begins to increase at 6 years of age and reaches a peak of 429.4 disorders per 100 people in the group 65 years and over. In 1992, as in previous years, diseases of the circulatory system were the leading cause of morbidity, with rates of 25.6 per 100 population; next were diseases of the respiratory system (20.7), diseases of the musculoskeletal system and connective tissue and endocrine diseases (both with rates of 12.5), and diseases of the digestive system (10.6). The rate of chronic disorders in women was higher than that in men; 174.0 per 100 women versus 133.6 per 100 men. All births, deaths, marriages, and fetal deaths that occur in Puerto Rico are registered at local offices of the Population Registry located throughout the island. Death registries are very complete, and causes of death are certified by physicians: 52% by family doctors, 37% by physicians who base their certification on the results of autopsies and medical records or other tests, and the remaining 11% by physicians who utilize other sources of information. Mortality has remained relatively stable: in 1970 (6.6 per 1,000 population); in 1980, it declined to 6.4 and remained at 6.5 during 1981-1984; subsequently it rose to 7.0 in 1987 and continued to increase until reaching levels of 7.9 in 1993 and 7.7 in 1994. The increase in this rate is attributed to the natural aging of the population and the rapid growth of older age groups, as well as to an increased mortality in the diseases that are the leading causes of death. In 1994, 28,444 people died from all causes (16,707 men and 11,737 women). Heart disease (157.7 per 100,000 population) and malignant neoplasms (116.6) were the two leading causes of death, together accounting for 35.6% of all deaths. Some 5,814 people died from diseases of the heart in 1994 (3,169 men and 2,645 women), while 4,298 died from malignant neoplasms (2,516 men and 1,782 women). Breast cancer as the leading cause of death from malignant neoplasms among women with 294 deaths (6.8%), followed by colon cancer, 153 deaths (3.6%). Among men, prostate cancer was the most frequent, causing 505 deaths (11.7%), followed by cancer of the trachea, bronchus, and lung, with 386 deaths (9.0%). As in previous years, diabetes mellitus ranked third as a cause of death, accounting for 1,868 deaths, or 6.6% of all deaths in 1994; of these, 1,028 were women. In 1993 diabetes mellitus caused 1,876 deaths. The fourth leading cause of death was AIDS with 1,549 deaths: 1,210 (78.1%) males and 339 (21.9%) females. Cerebrovascular disease was the fifth leading cause with 1,428 (5.0%) deaths. This cause ranked fourth in 1993, with 1,443 deaths (5.1%).
SPECIFIC HEALTH PROBLEMS Analysis by Population Group In 1992, children under age 6 had the highest rates of acute illness (229.1 per 100 population per year), and the incidence was highest among the youngest in this age group. The patterns are similar in males and females. Children under age 6 also had the highest incidence of common cold and influenza (83.5 per 100 children per year) and other infections of the respiratory system (37.2 per 100 per year). This age group also experienced a greater number of episodes of dysentery and gastroenteritis, 24.9 per 100 population. In 1994, there were 738 deaths in this age group, 11.5 per 1,000 live births (557 neonatal and 181 postneonatal). The leading causes of infant mortality were conditions related to prematurity and low birthweight (215 deaths), congenital anomalies (142 deaths), respiratory distress syndrome (92 deaths), conditions originating in the perinatal period (24 deaths), and accidents and injuries (18 deaths). In the under-1 age group, 30 deaths occurred, and the leading cause was accidents (9 deaths). Among 2 year-olds, 16 children died, and the principal cause was heart disease. Among 3-year-olds, 21 children died, and malignant neoplasms were the leading cause, and among 4-year-olds, 9 children died, and the leading cause of death was accidents. In 1994, 53 children 5–9 years old died (16.0 per 100,000). The leading causes of death were accidents (13 deaths, rate of 3.9), and AIDS and diseases of the nervous system, which caused 8 deaths each (rate of 2.4). Among males, the leading causes of death were accidents, (11 deaths, 6.5 per 100,000), and diseases of the nervous system and sensory organs, (6 deaths, rate of 3.6). Among females, the leading causes of death were AIDS, (5 deaths, rate of 3.1), and congenital anomalies, (3 deaths, rate of 3.1). Abuse and neglect of minors are critical issues in Puerto Rico. During 1994–1995, the Department of Family Services reported a total of 48,705 cases of child abuse, 30,388 due to some type of neglect and the other 18,317 to some type of mistreatment (this includes exploitation; institutional, emotional, physical, or multiple types of abuse; and sexual harassment). Of all the cases reported, 11 children died. In 1995, 49,913 cases of neglect and abuse were reported. In 1994 there were an estimated 355,400 adolescents aged 10–14 years and 341,900 aged 15–19 years. For both age groups, the principal health problems were accidents, homicide (especially drug-related homicide), and pregnancy. In 1994, 452 adolescents in those age groups died. The death rate was 29.0 per 100,000 in 10–14 year olds and 102.1 in 15–19 year olds. The leading causes of death in 10-14 year olds were accidents, (37 deaths, rate of 10.4), and homicide, (14 deaths, rate of 3.9). Among 15–19 year olds, the leading causes of death were also homicide, (187 deaths, rate of 54.7), and accidents, (83 deaths, rate of 24.3). In 1994, 2,195,594 people (59% of the population) were 15-59 years of age; 1,050,395 were male and 1,145,199, female. A steady rise in the birth rate among mothers under 20 years of age has been noted since 1988. In 1994, of 64,325 births, 12,779 (20%) were to mothers under the age of 20 (444 to mothers under 15 and 12,335 to mothers 15–19 years old). Of these, 8,165 were to unwed mothers (64%). Of the children of adolescent mothers, 1,215 (9.5%) had low birthweight (< 2,500 g) and 204 (1.6%) had very low birthweight (< 1,500 g). Of the total births in 1994, 63,854 were to mothers 15-49 years of age, with most births registered to those aged 20–24 (20,469 births, a specific fertility rate of 133.8). In 1994, one out of every four pregnant women did not receive prenatal care until the third trimester and 1.2 % (764) of women did not receive any prenatal care. The maternal mortality rate was 7.8 per 100,000 live births, the lowest since 1990. In 1994, of the 28,444 deaths registered, 7,981 (28%) occurred in the population aged 15–59 years. In the group aged 15–24, there were 862 deaths (729 men, 133 women), 3.0% of all deaths. Of these, 435 (51%) were due to homicide and 199 (23%) were the result of accidents. Among those aged 25–49 years, 4,598 people died (17% of the total), 3,439 men and 1,159 women. Slight variations were noted between the sexes with regard to the leading causes of death. Among men aged 25–29, the leading causes of death were homicide (156) and AIDS (111), while among women, AIDS (56) was the leading cause, then accidents (16). Among men aged 30–39 years, the leading causes were AIDS (507) and accidents (195); while among women, the leading causes were AIDS (156) and malignant neoplasms (53). In the group aged 40–44, the leading cause among men continued to be AIDS (238), and diseases of the digestive system (72); while among women, it was malignant neoplasms (69) and AIDS (46). The leading causes of death among men aged 45–49 years were AIDS (159) and heart disease (85) and among women, malignant neoplasms (86) and heart disease (48). In the 50–59 age group, 2,521 people died (1,682 men and 839 women). The two principal causes of death for both sexes were heart disease and malignant neoplasms. In 1994, the Planning Board estimated that 13.2% of the population was 60 or more years of age; 487,381 people, 224,055 men and 263,326 women. In 1992, 19,493 people died in that age group. Diseases of the circulatory system, diseases of the musculoskeletal system and connective tissue, endocrine diseases, and diseases of nutrition and metabolism were the chronic disorders that prevailed. The leading causes of death were diseases of the heart, malignant neoplasms, and diabetes mellitus. Other important causes of death included chronic liver disease and cirrhosis, hypertensive disease, cerebrovascular disease, and chronic obstructive pulmonary disease and related disorders. The Census of 1990 found that 66,187 elderly people lived alone, 19.4% of this age group. In almost all the municipios, a higher percentage of women than men lived alone. The principal sources of income for the elderly population are social security, pensions, and public assistance. The Department of Family Services indicated that 18,202 elderly people participated in the Economic Assistance Program during fiscal year 1990, and 22,432 during fiscal year 1993–1994. The Office for the Protection of Persons with Impediments (OPPI) in a 1993 report indicated that there were 704,407 people in Puerto Rico in 1990 with some type of disability, including 140,881 with visual impairments and 176,102 with developmental problems. Data of the Maternal and Child Health Program from pediatric centers serving children with special health needs indicate that the number of persons under 21 seen in these centers has increased. In 1993–1994, 15,363 people received care, while in 1994–1995, the number was 21,335. Of these 21,335 children, 11,620 were 6 years of age or under, 8,864 were between 6-17, and 851 were 18 or over. According to data from the last census, these pediatric centers cover 1.5% of the children in Puerto Rico and 27% of the children who need services. The most frequent problems treated in the centers are delayed psychomotor development, cerebral palsy, neural tube defects, speech and language disorders, and cleft palate. The Office of the Undersecretary for Family Services within the Department of Family Services administers a program to help blind, disabled, and elderly adults achieve greater well-being. In 1993–1994, of the 70,261 people served, 3,163 (4.5%) were disabled. Analysis by Type of Disease Communicable Diseases In 1993, the Dengue Control Program established an active surveillance system. In a 1994 epidemic outbreak of dengue, 24,252 suspected cases were reported and 5,390 cases were laboratory confirmed, 3 of them fatal. In 1995, 2,046 cases of dengue were confirmed by laboratory testing; in 1996, 1,804 cases were confirmed. The presence of dengue-3 virus has not been detected since 1977. In recent outbreaks, serotypes 1, 2, and 4 have been identified. Measles re-emerged in 1990 when 1,805 cases (51.3 per 100,000 population) and 12 deaths were reported. In 1993, 355 cases were reported (10.1 per 100,000 population), of which 254 (72%) occurred in preschoolers (0–5 years) and 116 (33%) in infants (under 12 months of age). A mass vaccination campaign in 1994 succeeded in covering 77% of the target population (children aged 6 months to 5 years). In May of that year, a national coverage study (estimated population based on 64,336 births), achieved 87% coverage (four doses of DTP, three doses OPV, and one dose of MMR). In 1994, 2 cases of tetanus were reported, 3 of whooping cough, 2 of mumps, 3 of meningitis (due to Haemophylus influenzae type B), 415 of hepatitis B, and 46 of measles. That same year, two deaths from tetanus, both males, were reported. No deaths from diphtheria, pertussis, or measles were reported. As of 30 June 1995, 110,224 doses of hepatitis B vaccine had been administered in the public sector and 17,681 in the private sector. In 1993 the hepatitis B vaccine was included in the vaccination series for children under age 1. The objective is to cover the entire population aged 0–18 by the year 2000. Puerto Rico has had no reported cases of cholera in the twentieth century. The incidence of tuberculosis has shown slight variations over the years: 312 cases were reported in 1992 (8.9 per 100,000 population), 257 cases in 1993 (7.3), 274 cases in 1994 (7.8), 263 cases in 1995 (7.5), and 222 cases in 1996 (6.3). The distribution by sex was as follows: in 1994, 73 % of the cases were males and 27% females; in 1995, 65% males and 35% females; and in 1996, 72% of the cases males and 28 % females. In 1996, 90% of the cases were the pulmonary form of the disease. During that same year, the distribution of cases by age group was: 6.3%, 0–14 years, 1.4%, 15–19 years, 39.2%, 20–44 years, 15.3%, 45–54 years, and 33.8%, 55 and over. Mortality from tuberculosis was 1.7 per 100,000 population in 1994, 1.6 in 1995, and 1.7 in 1996. Multidrug resistance was reported cases in 11 cases in 1994, 8 in 1995, and 4 in 1996. From 1994-1995, an increase was seen in the percentage of tuberculosis cases in people who were also infected with the human immunodeficiency virus (HIV). In 1993, 72 of 257 tuberculosis patients had AIDS (28%). In 1994, 81 of 274 tuberculosis patients had AIDS (30%); in 1995, 57 of 263 (18%); and in 1996, 60 of 222 cases (27%). The Ongoing Health Study estimated that the incidence of acute morbidity in 1992 was 4.5 million episodes with the highest numbers in diseases of the respiratory system (55.8 episodes per 100 population). The most frequent respiratory disorders were the common cold and influenza (39.7 per 100 people), other diseases of the respiratory system (10.7), and acute bronchitis (3.2). A study of the prevalence of chronic disorders found 737,435 episodes of acute respiratory disease (20.7 per 100 people) in 1992. The most frequent were asthma (309,403 episodes) and respiratory allergies (234,596 episodes). During fiscal year 1994–1995, 5,908 animals were vaccinated against rabies, a figure that surpassed the number programmed by 11%. In that same period, 211 suspected cases of animal rabies were investigated and 51 animals tested positive. As a result, rabies treatment was administered to 51 people. In 1994, AIDS was the fourth leading cause of death with 1,549 deaths (42.0 per 100,000 population). Of these deaths, 1,210 (78.1%) were males and 339 (21.9%) females. However, AIDS is the leading cause of death for both men and women in the 25–49 age group. As of December 1994, 16,109 cases of AIDS had been confirmed; of that number, 11,400 patients (71%) had died. As of 30 April 1997 there were 19,625 confirmed cases, with 12,752 (65%) deaths. Of the total number of diagnosed cases, 19,261 occurred in adults and adolescents and 364 in the pediatric population. Forty-five percent of those affected were 30-39 years of age and 23 % were 40-49. The primary risk factors were drug use in males (56%) and heterosexual relations with an HIV-infected partner in women (57%). The incidence of AIDS declined 27% from 1993 (89) to 1994 (65). The incidence of primary and secondary syphilis declined from 1993 to 1994 (13 and 9 cases per 100,000 population, respectively). The incidence of gonorrhea declined from 1993 to 1994 (15 and 14 cases per 100,000 population, respectively). In contrast, five times more Chlamydia infections were reported in women in 1994 than in 1993 (109 and 19 cases per 100,000 population, respectively). Noncommunicable Diseases and Other Health-Related Problems In 1994, diabetes mellitus was the third leading cause of death, outranked only by heart disease and malignant neoplasms, when 1,868 people died (1,028 females and 840 males). The disease ranked among the first five causes of death of males aged 55–59, with 60 deaths (87.3 per 100,000 population), and accounted for the greatest number of deaths (139) in the group aged 70–74, (329.4 per 100,000 population). Among women, it was among the first five causes of death in the 45–49 age group, with 19 deaths (17.7 per 100,000 population), and its importance is increasing. In the group aged 85 and over, diabetes caused 211 deaths, (1,060.7 per 100,000 population). In 1983, the rate was 31.0 per 100,000 population; but in 1994, the rate was 50.7 —an increase of 63.5% in 10 years. The group of diseases comprising endocrine, nutritional, and metabolic disorders ranked fourth in the Ongoing Health Study on chronic conditions in 1992, affecting 443,452 persons. A total of 206,644 people suffered from diabetes mellitus. Most diabetics were aged 45–64 (91,763) and 65 years and over (77,152). Among males, 86,592 had diabetes with 45–64 years old (41,269) most affected. Among females, 120,052 were diabetics and those aged 45–64 (50,494) and 65 and over (47,882) most affected. The prevalence of diabetes, including both diagnosed and undiagnosed cases, in adults is 14%. The same study found that diseases of the circulatory system were the most frequent disorders in 1992, affecting 909,409 persons. Of these, hypertensive disease (400,293 cases) and heart disease (160,807 cases) were most prevalent. The 45–64 age group had the highest number of cases of hypertensive disease (192,103), while those 65 years and over had the greatest number of cases of heart disease (72,188). In 1994, cardiovascular diseases, including heart disease, cerebrovascular disease, hypertensive disease, and atherosclerosis, caused 8,663 deaths (4,589 males, 4,074 females), 30.4% of all deaths, (235.0 per 100,000 population). Mortality from heart disease was the highest (157.7 per 100,000 population) with 5,811 deaths (3,169 males, 2,642 females). For both sexes, ischemic heart disease caused the most deaths (3,372: 1,895 males, 1,477 females). Among men, heart disease was the leading cause of death in the 50–54 age group and among women, in the group aged 65 and over. The same study reported a total of 14,982 cases of malignant neoplasms in 1992. Most affected was the group 45 years old and over, for both males and females. Of the 6,652 cases of malignant neoplasms in males, 5,425 occurred in that age group. Among women, 8,330 cases were reported, 7,693 in the group 45 years and older. Malignant neoplasms were the second leading cause of death in Puerto Rico in 1994 (4,298 deaths). The most frequent cancer sites were the digestive organs and the peritoneum (1,426 deaths), the genitourinary organs (866: 623 males, 243 females), and the respiratory and intrathoracic organs (657). The most frequent cancer site in men was the prostate and in women, the placenta and uterus (64 deaths) and the ovaries (54 deaths). Among women aged 35–64, malignant neoplasms were the leading cause of death. After age 65 they dropped to second place, while among men they became the second leading cause of death after 50 years of age. In 1994, accidents were the sixth leading cause of death, with 1,313 deaths (1,006 males and 307 females). Of all deaths due to accidents, 48.1% are attributed to motor vehicle accidents (631); of these, 144 were aged 15–24 and 117 aged 25–34 years. Homicides were the ninth leading cause of death in 1994 with 1,017 deaths (27.6 per 100,000 population; 931 males, 86 females). Homicide is among the first three causes of death in 10–14 years old and in those aged 35–39. Of the 1,017 deaths, 816 (65.6%) were aged 10-39 and of this group, 759 were males. Of 355 suicide deaths in 1994, 320 were males and 35 were females. Suicide is among the first five causes of death in men aged 10–39 (141 deaths). In 1994, the Program for Treatment of Alcohol Abuse within the Substance Abuse and Mental Health Services Administration (ASSMCA) treated 7,391 people. Of these, 7,042 were males (95%) and 349 were females (5%). The largest percentage of males treated fell into the 35–44 age group (32%) and the groups aged 45–54 (24%) and 25–34 (23%). These age groups accounted for 83% of the cases treated (79% males, 4% females). The 35–44 age group was most likely to be treated repeatedly for excessive consumption of alcohol (34%). In 1994, a total of 36,604 people were treated in ASSMCA facilities for drug addiction (88% males, 12 % females). Seven mental health institutions and 12 outpatient care centers operate on the island. In 1994, of those treated in mental health facilities (102,117), 96% received outpatient care. Of these, 54,937 were male (54%) and 47,108 were female (46%). According to the study on chronic morbidity, 264,798 of the individuals interviewed (128,481 men, 136,317 women) had some form of mental illness in 1992. Neurosis was the most frequent disorder (193,383 cases). The largest number of cases of mental illness was among those aged 45–64 (106,255) and 25–44 (77,285). In recent years the fluoridation of water has been stopped due to a lack of funding. But, studies are being conducted with a view to reinstating it. In 1994, 68 people died from malignant neoplasms of the oral cavity. The Ongoing Health Study indicated 3.5 million dental visits in the country in 1992 (1.0 visits per person), the same rate as that recorded in 1989. The rate of visits per person per year was 1.2 for females and 0.8 for males. The group aged 45–64 had the highest rate of dental visits (1.3 per person per year), and the group aged 6–24 (1.1). There was a correlation between income level and number of visits per person.
RESPONSE OF THE HEALTH SYSTEM National Health Plans and Policies In recent years, health care costs in Puerto Rico have skyrocketed. Curbing this increase and ensuring that every Puerto Rican receives good and reasonably priced health care are at the core of current health reforms. The model now in effect also seeks to have the Department of Health delegate responsibility for the delivery of services to the private sector—the aim is to have a single health care system—while maintaining responsibility for ensuring that the population receives appropriate health services. The model emphasizes a preventive approach, including education and promotion of healthy lifestyles, in order to minimize long-term costs for hospitalization and treatment of catastrophic illness. The Government has made it a top priority to restructure the health regions and their levels of care, as a way to avoid duplication. The new model for health service delivery to the indigent seeks to improve the accessibility and quality of services in a framework of equity and social justice. As of October 1997, 61 of Puerto Rico’s 78 municipios in Puerto Rico (78%) had been brought into the health sector reform process, and health insurance coverage had been extended to more than 1 million indigent persons. It is expected that another 14 municipios will have been included by the end of fiscal year 1997–1998. The government insurance plan covers services that are necessary to maintain good physical and mental health. Insurance cost and the deductible amounts are determined according to the beneficiaries’ ability to pay. Beneficiaries are entitled to select a health care provider from a network of providers in their area of residence. The incorporation of the new public policies on health into the operations of the Department of Health and its Health Facilities and Services Administration is considered a priority. Among activities under way are the identification of volunteer organizations and their guidance services, and the identification of barriers that impede access to Health Department’s services. Another high priority is the strengthening of technical and administrative capabilities for the delivery of optimal services for the prevention and treatment of AIDS. Priority is also assigned to the strengthening of health services to ensure that people age 65 and older receive regular health care services and to improving the availability and quality of mental health services at the primary care level. Organization of the Health Sector The Department of Health has the sole public authority responsible for planning health services. To fulfill this responsibility, the Department designed a regionalization scheme, which it began to implement in 1958. The first region to be designated was the area served by the Bayamón District Hospital, which included the San Juan metropolitan area and 16 municipios. In 1960, the rest of island was divided into five regions. The three levels of care included in this scheme were the local health centers (primary care), the regional hospitals (secondary and tertiary care), and the Río Piedras Medical Center in the metropolitan area (specialized care). In 1970, that system was restructured and the island was divided into three regions: northeast, south, and west. The medical centers in Río Piedras, Ponce, and Mayagüez were designated as base hospitals for each of these regions, respectively. In 1977, the geographic and functional aspects of the regionalization scheme were again modified. The new system, which remains in effect today, comprises seven regions (Metropolitan Area, Bayamón, Arecibo, Mayagüez, Ponce, Caguas, and Fajardo) and two subregions (Aguadilla, in the region of Mayagüez, and Humacao, in the region of Caguas), which in turn have been subdivided into 16 areas. Various linked levels of care have been established, which makes it possible for users to receive the care they need as quickly and effectively as possible. The primary level is the gateway into the health system, to which every person has direct access and from which referrals are made to higher levels. The primary level has emergency and ambulatory services, as well as facilities and equipment for the treatment of disease in diagnostic and treatment centers, family health centers, and public health clinics and units. Health promotion and protection and disease prevention activities are stressed. The secondary level is responsible for treating health problems that occur relatively infrequently in isolated individuals but whose prevalence is significant in population groups of more than 25,000 people. Early detection of disease is emphasized. Secondary level services are provided in subregional and area hospitals. The tertiary level concentrates on infrequent diseases, the prevalence of which can only be predicted in populations across several municipios. This level requires costly specialized services, complex technology, and highly skilled professionals. The regional specialized and semi-specialized hospitals provide services at this level. Under the new model, the regional offices have been maintained but their functions have changed radically in order to focus more on health promotion and protection. Rather than operational functions relating to direct provision of health care, the offices are now carrying out normative functions, and the strategy of healthy communities and "total wellness centers" are being applied as instruments of social participation. Health sector reform requires changes in the existing legal framework. At the central level, committees have been created expressly to advance decentralization and to eliminate obsolete regulations. The new approach to privatization also has required that the law on privatization of health care facilities be amended, in order to permit the sale of such facilities to the private sector and to incorporate other privatization models. The Office of the Undersecretary for Regulation and Accreditation of Health Facilities (SARAFS) is the agency within the Department of Health responsible for the regulation and quality control of health services and the operation of health facilities. It includes the Office of Administration, the Division for Certification of Need and Suitability, the Drug and Pharmacy Division, the Laboratory Division, the Division of Health Institutions, the Medicare Coordination Division, and the Division of Medical Emergencies. The Drug Bioequivalence Board also comes under this Office. Various federal and state agencies of the United States are responsible for the regulation and control of activities relating to environmental protection. At the federal level, the main agency is the United States Environmental Protection Agency (EPA). At the local level, primary responsibility rests with the Environmental Quality Board, an agency under the Office of the Governor. Other public corporations and agencies in Puerto Rico that play an important role are the Department of Health, the Department of Natural and Environmental Resources, the Solid Waste Authority, and the Aqueduct and Sewer Authority. Functions of the Environmental Quality Board are to adopt rules and prepare regulations, carry out investigations, impose sanctions, initiate legal and administrative actions, and establish requirements for the issuance of permits related to its programs for the control of ground and surface water contamination and air, soil, and noise pollution. It administers funds provided in the Environmental Emergency Fund. The Solid Waste Authority, a public corporation, is empowered to provide technical and economic assistance to the municipal governments for the management and proper disposal of solid waste. The Department of Natural and Environmental Resources is responsible for the enforcement of laws concerning forests, water, mines, caves, caverns and sink holes, sand, stone, and gravel. In addition, it has primary responsibility for the management of coastal resources and wildlife conservation. The Aqueduct and Sewer Authority is a public corporation responsible for drinking water supply to communities and administration of sanitary sewerage systems. In addition, it controls the discharge of water to public treatment systems. The Department of Health maintains active monitoring of drinking water quality in public water systems. In coordination with the Environmental Quality Board, the EPA administers the National System for the Elimination of Contaminant Residues in Puerto Rico. The EPA also plays an important role in monitoring the management and disposal of hazardous solid waste, as well as in the investigation of sites that are contaminated with hazardous substances. The Department of Health has delegated responsibility for food quality control to the Office of the Undersecretary for Environmental Health. Weekly reports of the numbers of cases of communicable diseases are submitted from the primary and secondary care levels in each municipio to the regional level. The data are then processed and communicated to the Epidemiology Division at the central level. The Division, in turn, coordinates the collection of all epidemiological information, which is then transmitted by modem from regional computers to be analyzed, interpreted, and redisseminated to each of the lower levels. The CDC provides the Program with advisory and support services and it establishes standards for the disease prevention and control methods used in Puerto Rico. In a dengue outbreak, the Epidemiology Program collaborates with the CDC Dengue Laboratory located in San Juan. The Institute of Health Laboratories has five operational programs: the Program for Proficiency Testing of Clinical Laboratories, Program on Alcohol Toxicology, the Program for Certification of Health Laboratories, the Program for Epidemiological Support Laboratories, and the Program for Environmental Health Laboratories. The Aqueduct and Sewer Authority administers 208 water systems that supply approximately 97% of the island’s population. Seventy-four percent of the urban population is connected to sewer systems (26% have septic tanks), and 80 % of the rural population has basic sanitation services, including latrines. The Solid Waste Authority estimated that in 1994, 2 million tons of solid waste was generated on the island. The vast majority of this waste was disposed of in municipal dumps. Only 7% of the total were recovered for recycling. The Department of Family Services carries out the Program for Nutritional Assistance, which offers economic assistance to low-income families for food supplements and emergencies. During fiscal year 1993–1994, the program served an average of 490,813 families monthly. The total amount of funds distributed was US$ 1 billion (US$ 2,043 per family). The health care delivery system includes public, private, and privatized public institutions. Facilities that provide primary care services must be accredited. According to SARAFS, in 1997 Puerto Rico had 68 hospitals, 24 of them public (including privatized public hospitals) and 44 private hospitals. Of the public hospitals, 16 are general hospitals, 3 are specialized, 4 are psychiatric hospitals, and 1 is a federal hospital. Of the private facilities, 38 are general hospitals, 4 are specialized, and 2 are psychiatric. The 24 public hospitals have a total of 5,464 beds, of which 3,930 are available beds; 3,811 of these are in use. The private hospitals have a total of 6,614 beds, of which 6,239 are available beds and 5,818 are in use. In fiscal year 1993–1994 the public sector registered, at its three levels of service delivery, a total of 3 million visits to outpatient clinics, 2.1 million visits to emergency rooms, an average hospital stay of 5.33 days, and a bed occupancy rate of 67.2%. At the tertiary level, the average stay was 5.83 days and the bed occupancy rate was 70.3%. Professionals who provide health services in public and private institutions must have completed a formal course of study in a school or university recognized by the Government and must meet the requirements for continuing education. Of the 6,269 physicians practicing in 1989–1992, 3,377 worked in the public sector and 1,283 in the private sector, 1,601 had their own private practices, and 8 worked on a volunteer basis. There were 6,707 general nurses in the public sector and 5,252 in the private sector. Of the 7,394 licensed practical nurses, 4,406 worked in the public sector and 2,807 in the private sector, 175 were self-employed, and 6 worked on a volunteer basis. The island currently has schools of medicine, nursing, pharmacy, medical technology, and allied health professions, as well as internships in nutrition and dietetics, a graduate school of public health, and graduate programs in psychology and other areas. Traditionally, the public sector has provided most employment opportunities for health professionals. The private sector is recruiting more professionals as it gradually takes over health care delivery to the indigent. Research and technology activities are carried out by university centers in coordination with the Department of Health. Research projects are conducted under agreements with the CDC and others are subsidized with federal funds from the United States Government, especially in the area of treatment of patients with HIV and AIDS. Between 1986-1995, health care expenditures grew at an annual rate of 6.0%. Although annual growth rates appear to have declined (7.1% in 1992, 5.6% in 1993, 2.9% in 1994, and 5.0 % in 1995), health care spending has nevertheless increased at a faster rate than inflation in almost every year of this decade. In 1995–1996 the operating budget of the Department of Health and the Health Facilities and Services Administration totaled US$ 1 billion. As of December 1996, 1,033,777 people had purchased health insurance plans at a total cost of US$ 608 million.
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