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—from Epidemiological Bulletin, Vol. 24 No. 1, March 2003—
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Figure 1: Population structure, by age and sex, Honduras,
2000
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The economy was characterized by a GDP depending on exports of
goods and services, with low development of domestic consumption. In 1999, the
GDP fell 1.9% from 1998. In 1999, hurricane Mitch had a negative effect on the
economy, although the impact was partially diminished by international collaboration.
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Figure 2: Gross domestic product, annual growth (%),
Honduras, 1991-2000
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In 2000, the school coverage was 96% for the primary level, but
52.6% of the elderly population was illiterate.
According to estimates of the Secretariat of Planning, the crude
death rate in 1996 was 5.8 deaths per 1,000 population, (32,666 deaths; 18,510
male); 15% of deaths were reported through hospital discharges. According to
the General Bureau of Statistics and Censuses, the estimated underregistration
of mortality was 47% in 1999.
Specific health problems
By population group
Children (0-4 years): According to the National Survey of Epidemiology
and Family Health of 1996, the infant mortality rate was estimated at 36 per
1,000 live births (53% neonatal), between 1991 and 1995. Acute respiratory infections
and acute diarrhea with dehydration were the leading causes of death in children
under 5.
Schoolchildren (5 to 9 years): In 1994, among children 5-9 years of age there
were 375 deaths, 2.3% of the total deaths.
Adolescents (10 -14 and 15-19 years): In 1999, 17% of hospital
discharges were adolescents: 47.8% due to the female reproductive process and
care related to pregnancy, childbirth and puerperium. Violence (mainly injury
and poisoning) accounted for 27% of hospitalizations. Survey data in this period
indicated that the fertility rate of females 15-19 years of age was 136 births
per 1,000 women. The survey also showed that the first sexual experience occurred
before 15 years of age among 20% of women. The maternal mortality rate among
those 12-14 years of age (391 per 100,000 live births) was almost four times
that of the total maternal mortality rate (108).
Adults (20-59 years): Normal delivery and the reproductive
process accounted for 43% of hospital discharges in this population group. This
age group of women represented 66% of the total female hospitalizations. The
use of contraceptive methods among women 20-24 years was 39% and among those
35-39 years it was 58%. The group 15-59 years of age comprised 90% of AIDS cases,
of which 61% were males.
The elderly (60 years and older): In 1999, 59% of this
population lived in rural areas. Elderly adults generated 10.2% of all public
health outpatient consultations.
The disabled: It is estimated that more than half a million
inhabitants of the country display some degree of physical or mental disability.
Indigenous groups: More than half a million Hondurans are
indigenous and/or of Afro descent; they are distributed among 9 culturally distinct
groups: Lencas, Chortis, Tolupanes, Tawahkas, Garífunas, Afro English-speaking,
Pech, Nahualt, and Miskitos. Their health status reflects their marginalized
situation, including lack of access to basic health services and limited social
participation.
By type of health problem
Natural disasters: In 1998, the country was affected by Hurricane Mitch
in 1998 and in 2000, a great drought affected more than 85,000 people of the
southern region of the country. Hurricane Mitch brought torrential rains, and
floods that affected 11 of 18 departments of the country, resulting in 1.5 million
victims; 5,657 dead; 8,058 missing; and 12,272 injured. Losses due to Hurricane
Mitch were estimated by the Economic Commission for Latin-America and the Caribbean
(ECLAC) at almost 3.8 billion dollars (70% of GDP) and nearly 100% of foreign
debt.
Vector-borne diseases: Malaria has been endemic since the
1950s. The Northern coastal area of the country (Department of Colón)
recorded the greatest number of cases, reporting 36% of cases in 1999. At the
end of 2000 there were 35,122 registered cases of malaria. Dengue has been endemic
in Honduras since 1998, when 28,064 cases were reported and 77 cases of dengue
hemorrhagic fever were confirmed. In 2000, the country reported an epidemic
concentrated in Tegucigalpa, with 13,795 cases. In 1999 dengue hemorrhagic fever
caused 8 deaths with a case-fatality rate of 20% and in 2000, 10 deaths with
a case-fatality rate of 3%.
Diseases preventable by immunization: No cases of poliomyelitis have been reported since 1989, and vaccination in children under 2 years of age had a coverage over 90% in 1998-2000. The last case of measles was reported in 1996; vaccination coverage of children under two was 98% from 1998-2000. The coverage with DTP vaccine in the population under 2 has been 94% or higher since 1997. The country has not reported cases of diphtheria since 1981. Several whooping cough outbreaks have occurred in recent years, with more than 648 cases and 28 deaths in 1996-2000. In 2000, no case of neonatal tetanus had been reported. The coverage with BCG vaccine has been higher than 97%. In 2000, only 4 cases of tuberculosis meningitis were reported in children under 5. Rubella has been controlled with the pentavalent vaccine (MMR, plus anti Haemophilus Influenzae and anti Hepatitis B) since 2000.
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Figure 3: Vacination coverage among the population
under 1 year of age, by vaccine, Honduras, 2000
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Intestinal infectious diseases: In 1997, 90 cases of cholera
were reported. In 1998 there was an outbreak in Mosquitia (Department of Gracias
a Dios) with 289 cases and a 3.9% case-fatality rate. In 1999, 57 cases and
3 deaths were reported. In 2000, 15 cases of cholera were reported and 3 died.
The annual average number of cases of diarrhea for this period fluctuated around
200,000, 85% in children under 15.
Communicable chronic diseases: There was an average of
4,700 cases of TB reported between 1997 and 1999. The association between TB
and HIV/AIDS increased in the period 1996-2000. In 1998, the National Program
of Leprosy was reinitiated after being discontinued for almost two years (1996-1998).
At the end of 1998, the program had followed up on 78 cases, of which 13% remained
on multiple drug therapy. In 1999, cases declined to 72.
Acute respiratory infections (ARI): The general trend of
ARI in the country has been increasing constantly, with an annual average rate
of 5%. In 1996, about 90,000 infections were reported; in 1998, reported cases
reached 98,790.
Zoonoses: In 1998 and 1999, there were 7 and 5 cases of
canine rabies and no case of human rabies reported. In 2000, 1 case of human
rabies and 15 cases of canine rabies were reported.
HIV/AIDS: In the Department of Cortés, the metropolitan areas of San Pedro Sula and Francisco Morazán (Tegucigalpa) accounted for 60% of the 11,789 confirmed cases of HIV in 2000. The pattern of predominant transmission was sexual (85% heterosexual, 3% homosexual and 5% bisexual), blood transfusions (1%) and vertical transmission (6.1%). In 2000 the Male-Female ratio was 1.2.
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Figure 4: AIDS incidence, by sex, with male-female
ratio, Honduras, 1994-2000
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Nutritional and metabolic diseases: In 1996, The Micronutrient
Survey found that 26% of non-pregnant women and 32% of pregnant women were anemic.
The prevalence of malnutrition in 1997 was 40.6%, 26% moderate and 14% severe.
Malignant neoplasms: In 1998, 456 cases of malignant neoplasms
were reported, of which 67.8% were females. The most frequent sites of primary
cancer in women were cervix (34%) and breast (17%). In men the most frequent
site was the eye, brain and central nervous system (16%), followed by the hematopoietic
and reticuloendothelial system (15%) and genitalia (4%).
Emerging and re-emerging diseases: Between 1998 and 1999,
a laboratory diagnostic capability was developed for leptospirosis, and in 1998,
the first diagnosis was made 4 days after the occurrence of Hurricane Mitch.
In 1999, 39 cases of leptospirosis were diagnosed.
The response of the health system
National health policies and plans
The reform process has undergone several stages: modernization of the State
(1990), National Initiative Emphasizing Access to health Services (1996), New
Agenda in Health (1998) and Transformation of the Health Sector (2000). In 1996-98,
the Ministry of Public Health established access to health services as the central
policy for reform of health services. In 1998, after the worst disaster in the
history of the country, Hurricane Mitch, the Ministry of Public Health issued
policy guidelines for 1999-2001 that considered the need to promote health sector
reform in the national reconstruction process. The objective was to strengthen
the health care networkand expand coverage.
Health sector reform
The Strategy of Health Sector Reform was based on the principles of universality,
solidarity, equity, efficiency, participation, quality, and transparency (guidelines
of policy 1999-2001). For the achievement of its objectives, four basic lines
of action were designed: institutional development of the Ministry of Public
Health; decentralization and local development; health promotion and reorganization
of the health care model and strengthening of management. One of the pillars
of sectoral reform is strengthening of the steering role of the Ministry of
Public Health. To improve the institutional management at different levels,
the Coordinating Council of the Ministry and the Technical Council for Institutional
Management were integrated. To improve and strengthen the information system,
a Management and Financial Information System was introduced in 1999, and a
Management Information System was introduced in 2001, both of which were designed
to serve as managerial support tools for the information system as a whole.
The health system
The health system is made up of public and private subsectors; the public sector
consists of the Ministry of Public Health and the Honduran Social Security Institute
(IHSS), the National Water Supply and Sewerage Service and the National Institute
for the Prevention of Alcoholism, Drug Addiction, and Drug Dependence. In the
review period, the estimated coverage for the Ministry of Public Health was
60%; Social security covered between 10-12% and the private services covered
10% of the population. The Ministry of Public Health is organized into 9 Health
Regions and 42 Areas.
Organization of regulatory actions
The Ministry of Health’s Department of Pharmacy is responsible for the
regulation of medical drugs and concentrated efforts on the Public Health Registry,
with 8.725 drugs, 83.4% proprietary and the rest generic. Water and sewerage
services and sanitation in general have shown limited progress in the last five
years. Investment over the last two years in this sector has focused on repairing
infrastructure damaged by Hurricane Mitch. In 1999, access to potable water
at the national level was 80.9%; 71.1% of the population was served with some
form of excreta disposal. Since 1995, regular monitoring of air quality has
been carried out in Tegucigalpa and intermittently in the cities of San Pedro
Sula and La Ceiba. The results of monitoring indicate that concentrations of
suspended particulates are continuously outside standard limits.
Organization of public health care services
The Ministry of Education coordinates activities related to sports and for the
improvement and promotion of healthy lifestyles. The National Congress has worked
on a new code for protection of children as well as various laws to combat alcoholism
and drug addiction; a new penal code; a law creating the Children and Family
Institute; and a special law on family violence. The Office of the National
Commissioner for the Protection of Human Rights has also been strengthened with
special attention given to minor offenders, battered women and abused minors.
The Ministry of Public Health’s Bureau on Population Risks carried out
normative functions for health programs. Up until 2000, epidemiological surveillance
was based on a network comprised of 1,190 reporting units that constituted an
“Action Alert” system. Technical and financial resources obtained
following Hurricane Mitch strengthened the network of public health laboratories.
Organization of individual health care services
In 1996, Ministry of Public Health care facilities provided 5.8 million outpatient
consultations and 372,000 hospital discharges. There is a National Blood Reference
Center, 26 blood banks and 29 blood collection centers. Mental health care was
mainly concentrated in hospital services, including 2 psychiatric hospitals.
Health supplies
Total spending on drugs amounted to 1.9% of the GDP in 1997 and 1.7% in 1998.
There are no programs to control the price of drugs. The Ministry of Public
Health has a Basic List of Drugs including 271 active ingredients. Public spending
on health allocated to drugs was 13.8% in 1996, 14.6% in 1997, 12% in 1998 and
8.3% in 1999.
Human resources
In 2000, there were 5,287 registered physicians, 37.8% working in the public
subsector (8.8 physicians per 10,000 population). There were 1,957 registered
professional nurses (3 per 10,000), 45.3% of them working in the public subsector.
Health Research and Technology
The Honduran Science and Technology Council is responsible for coordinating
the sector’s science and technology. In 2000, the Ibero-American Program
of Science and Technology for Development was launched to train human resources
in areas of scientific and technological research, to help solve specific problems
and implement projects of social interest.
Health Sector Expenditure and Financing
The sources of health sector financing in 1999 were: families (53.7% of national
spending on health); Government (32.9%); IHSS (7.8%); and non profit organizations
and private insurers (4.3% and 1.3%, respectively). Between 1993 and 1999, the
financing of the Ministry of Public Health increased by 91.6%, mainly due to
external financing that reached 117%. The financing of the IHSS, sustained through
member contributions, was insufficient to cover expenses. Public spending on
health in relation to public spending as a whole decreased from 7.2% to 6.7%
between 1993 and 1998. The total per capita health expenditure showed a decline
of 24.1% between 1995 and 1999.
External technical cooperation and financing
After Hurricane Mitch, the flow of technical and financial cooperation increased
considerably. Bilateral international cooperation for all sectors amounted to
US$ 1,113.2 million; increasing non-reimbursable funds to US$ 945.8 million.
Multilateral Cooperation amounted to US$ 1,099.3 million; the non-reimbursable
funds reached US$ 298.8 million. The total of non-reimbursable funds was US$
1,244.6 million and the total of the reimbursable funds was US$ 967.9 million.
Return to Index
Epidemiological Bulletin, Vol. 24 No. 1, March
2003