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—from Epidemiological Bulletin , Vol. 25 No. 2, June 2004—
Country Profiles: Guatemala
General situation and trends
Its land area of 108,889 km2 is divided administratively into 22 departments
and 331 municipalities, which in turn have a total of 20,485 communities. In
2000, the country had an estimated population of 11,433,694; 65% lived in rural
area. The average density was 102 inhabitants per km2. The indigenous population
represents 48% of the total. In 2000, the annual population growth rate was 2.9%.
In terms of age distribution, 44% of the total population was children and adolescents
under 15 years old and 5.3% were 60 or older (Figure 1). Life expectancy was
67.2 years (64.7 years for men and 69.8 years for women).
Figure 1: Population structure, by age and sex, Guatemala, 2000.
Agricultural activity accounted for 26% of GDP and generated 60% of employment.
In 1998, the Guatemalan economy grew 5%. In 1999 and 2000, GDP grew 3.6% and
3.3%, respectively, and per capita GDP at 1995 prices was 0.9% and 0.8%, respectively.
The growth of GDP is shown in Figure 2. In 1998, the net tax burden (not including
returned tax credit) came to 8.9% of GDP. The internal debt as a proportion
of GDP was reduced from 10.6% in 1990 to 5.2% in 1998, and the foreign debt
went from 18% in 1990 to 10% in 1998. In 1998, 91.3% of the indigenous population
was living below the poverty line. Open unemployment rose from 3.7% in 1995
to 5.6% in 1999. In 1999, the illiteracy rate was 31.7% (39.2% for women and
26.3% for men). In 1999, the birth rate was 34 per 1,000 population.
Figure 2: Gross domestic product, annual growth (%), Guatemala, 1990-2000.
A total of 53,486 deaths were registered in 1999, for a mortality
rate of 4.8 per 1,000 population. For both sexes, the leading causes of mortality
were pneumonia and diarrhea, which in 1999 represented 22.3% and 6.0% of all
deaths, respectively. According to data from the National Statistical Institute,
the distribution of proportional mortality for the six broad groups of causes
in 1997 was as follows: communicable diseases, 13%; external causes, 13%; diseases
of the circulatory system, 12%; certain conditions originating in the perinatal
period, 8%; tumors, 7%; and all other causes, 47%. Physicians certified 59.8%
of all deaths. The underregistration is around 56%.
Specific health problems
Analysis by population group
Health of the children (0-4 years) and schoolchildren
(5-9 years): In 1997
and 1999, the infant mortality rate was 37.7 per 1,000 live births, and 40.5
per 1,000 live births (Figure 3). The rates for neonatal and postneonatal mortality
were 15.4 and 22.3 per 1,000 live births, respectively. The National Maternal
and Child Health Survey conducted in 1998-1999 (ENSMI 98-99) estimated infant
mortality at 45 per 1,000 live births. In 1999, acute respiratory infections
accounted for 40% of all deaths in children under 1 year, acute diarrheal disease
claimed 12%, and perinatal causes, 11%. The mortality rate in children 1-4
years old was 14 per 1,000; 9 per 1,000 in the cities and 20 per 1,000 in rural
areas. In 1999, a total of 1,027 deaths were registered in the 5-9 years age
group, for a rate of 0.6 per 1,000. Cases of acute diarrheal disease rose from
16,015 in 1997 to 43,119 in 1998 and 50,799 in 1999.
Figure 3: Infant mortality trend, Guatemala, 1986-2000.
Health of the Adolescents (10-14 years
and 15-19 years): In
2000, Guatemala had a population of 2,752,924 adolescents, who comprised 24%
of the national population. In rural areas adolescents comprised 51% of the
population. The fertility rate in girls aged 15-19 was 123 per 1,000. According
to data from the National Statistical Institute, in 1998 the leading cause
of death in youths aged 15-19 was gunshot wounds, followed by pneumonia and
influenza and intestinal infections.
Health of the adults (20-59) and elderly (60 years and
older): In 1999, the
population of adults between the ages of 20 and 59 numbered 4,116,147 and corresponded
to 39.3% of the total. According to the findings of ENSMI 95, maternal mortality
during 1990-1995 was estimated at 190 per 100,000 live births. The Ministry's
Health Management Information System gives maternal mortality rates of 98 per
100,000 live births in 1997, 100.2 in 1998, and 94.9 in 1999. The use of family
planning has been on the rise, from 31.4% in 1995 to 38.2% in 1998 and 1999.
In 1999, the proportion of the population aged 60 and older was estimated at
5.3%.
Health of the workers: National Statistical Institute data for the period
1989-1999 indicate that women constitute 24% of the economically active. In
the group of children and adolescents 7-14 years old, 34.1% were working. The
Guatemalan Social Security Institute (IGSS) covers only 17% of the national
population. In 1998, there were 1,131 cases of pesticide poisoning in six departments
in the country, and in 1999 there were 754.
Health of the indigenous Groups: Guatemala is one of the Latin American countries
with a high percentage of indigenous population (48%). In 1998, illiteracy
in the departments with 75% to 100 % indigenous population was 52.2%. Of the
indigenous population 67.8% suffered from chronic malnutrition.
Analysis by type of health problem
Natural Disasters: In 1999 and 2000, a series of tremors caused damage in 12
departments. In November 1998, Hurricane Mitch caused heavy damage in 14
of the country's 22 departments, causing 106,000 people to be evacuated and
taking the lives of 268. Heavy rainfall in 2000, double the level in the
winter of 1999, caused rivers to rise and cause damage along the southern
coast and in the west.
Vector-borne Diseases: In 1999, a total of 101,326 cases of malaria were reported
and the annual parasite index was 12.2 per 1,000 population. Of the confirmed
cases, 92% were attributed to Plasmodium vivax, 3.2% to P. falciparum , and
5.3% to 12 associated cases. In 2000, there were 109,874 reported cases of
malaria (95.9%, P. vivax ; 4%, P. falciparum; 0.1%, mixed). In 1999, a total
of 3,617 cases of dengue were reported (incidence: 931.7 per 100,000 population,
recorded two cases of hemorrhagic dengue and one death. In 2000, there were
10,083 reported cases, 9,006 of which were clinically diagnosed as classical
dengue (1,035 of them confirmed) and 42 were hemorrhagic dengue, leading to
9 deaths (case-fatality rate was 21.4%).
Diseases preventable by immunization: The last case of poliomyelitis was reported
in 1991. Epidemiological surveillance for the occurrence of acute flaccid paralysis
continued during 1996-2000, when the system reported 49, 77, 51, 56, and 87
cases in those five years; none of them was confirmed to be polio. In 2000,
the overall rate of acute flaccid paralysis was 1.7 per 100,000 in the population
under 15 years. In 1996, there were no reported cases of measles; one isolated
case occurred in 1997, but since then there have been no further cases. In
the five years 1996-2000 there were reports of 128, 303, 171, 291, and 904
cases, respectively, of unconfirmed measles. The numbers of reported cases
of neonatal tetanus in the four years 1996-1999 were 17, 7, 5, and 2, respectively.
In 2000, there were 6 cases and 3 deaths. Cases of pertussis increased during
the period 1996-1999: 40 in 1996, 131 in 1997, 441 in 1998, and 268 in 1999.
The 194 reported cases in 2000 represented 28 % fewer than the year before.
The last case of diphtheria was recorded in 1997. In 2000, there were five
reported cases of tuberculous meningitis, with four deaths. All areas had over
90% BCG coverage (Figure 4).
Figure 4: Vaccination coverage among the population under 1 year of age, by vaccine,
and tetanus toxoid coverage for women of childbearing age, Guatemala, 2000.
Intestinal infectious diseases: In 1999, there were a total
of 385,633 cases of acute diarrheal disease (incidence: 3,470 per 100,000 population)
and 3,244 deaths from this cause (29.2 per 100,000). In 2000, morbidity was
up 21.6% from that in 1999, with 468,981 reported cases (4,220 per 100,000).
In 1999, children under 5 years old were most affected, with 238,434 cases,
or 61.8% of the total. Cholera cases doubled from 1,008 in 1997 to 2,077 in
1999. In 2000 the number dropped to 790. The case-fatality rate has been declining:
in 1999 there were 18 reported deaths, and in 2000 there were 6, with corresponding
fatality rates of 0.9 and 0.8.
Chronic communicable diseases: In 1999, a total of 2,820 cases of tuberculosis
were reported, 2,597 (87.1%) of them pulmonary; of the latter number 2,264
were diagnosed by positive sputum smear. Adults 25-34 years old were the group
most affected, representing 21% of all cases in 1999. In 2000, there were 2,274
registered cases of tuberculosis, 46.6% in women, and 324 of them in children
under 10 years of age. In 2001, only 27 cases of leprosy were registered at
the national level, and the patients were undergoing treatment.
Acute respiratory infections (ARIs): ARI's are the leading cause of morbidity
and mortality in the country. In 1999, a total of 1,019,247 cases of ARI and
228,762 cases of pneumonia were reported, with 11,082 deaths. Pneumonia was
the leading cause of mortality in infants under 1 year (10.6 per 1,000 population),
while 63% of the cases and 50% of the deaths were in children under 5 years
old.
Zoonoses: Two cases of human rabies were reported in 1999 and six in 2000.
A total of 13,207 persons were bitten by suspected rabid animals in 1999, and
in 2000 the number was 15,053.
HIV/AIDS: The epidemic has been concentrated in urban populations and groups
traditionally regarded as being at high risk. As of 30 June 2001, a total of
4,197 cases had been reported officially (35.9 per 100,000 population), and
underregistration is believed to be as high as 50%. Seventy-four percent of
the affected individuals are males; the 15-49 years age group is most vulnerable,
accounting for 87% of the cases. In 2000, the male-female ratio was 2.1:1 (Figure
5). As of 1999, there were 141 known cases of mother-to-child transmission.
A total of 266 cases of AIDS were reported in 1999 and 316 in 2000.
Figure 5: AIDS incidence, by sex, with male-female ratio, Guatemala, 1994-2000.
Nutritional diseases: Forty-six percent of children under
5 years old have some degree of chronic protein-energy malnutrition. The prevalence
of global malnutrition (as measured by weight-for-age) is 24% in children under
5 years of age. The vitamin A deficiency (serum retinol = 20 µ/dL) affected
15% of preschool children. Iron deficiency (Hb =12 g/dL) affected 35.4% of
women of reproductive age, 39.1% of pregnant women, and 34.9% of non-pregnant
women. The prevalence of anemia (Hb = 11 g/dL) in children 1-5 years old was
26%.
Malignant neoplasms: Cancers of the reproductive system account for 42% of
all neoplasms in both sexes. In 1999 there were 452 cases of cervical cancer
and 240 deaths. Breast cancer is the third leading cancer and the second most
frequent site for women.
Accidents and violence: In 1999, a total of 2,741 deaths were caused by accidents
(5.1% of all deaths), with a rate of 16 per 100,000 population. There were
384 suicides (0.7% of all deaths) and 1,774 homicides (3.3%).
Response of the health system
National health policies and plans
The Constitution of the Republic recognizes health as a fundamental right.
The Peace Agreement constitutes another public policy instrument that supports
health sector reform and extended coverage. The Health Code approved in November
1997 stipulates that the Ministry of Public Health and Social Welfare (MSPAS)
is formally responsible for leadership of the health sector. As defined in
the Code, leadership includes the guidance, regulation, surveillance, coordination,
and evaluation of health actions and institutions at the national level. This
definition constitutes the legal basis for a sectoral reform that has the capacity
to transcend the public institutions. The Code also obligates the Ministry
to provide free health care to persons without means. The instrument Health
Policies 2000-2004 calls for development of the following: (a) integrated health
care for families; (b) health care for the Mayan, Garifuna, and Xinka peoples,
with emphasis on women; (c) health care for the migrant population and strengthening
of integrated health care for other groups; (d) broader basic health service
coverage with quality and sustainability; (e) basic and environmental sanitation;
(f) access to essential drugs and traditional medicine; (g) strategic distribution
of human resources; (h) institutional development, deconcentration, and decentralization;
(i) intra- and intersectoral coordination; (j) improvement and optimization
of external cooperation; and (k) expansion of health sector financing.
Health sector reform strategies and programs
The objective of health sector reform is comprehensive transformation of the
social health production model, including improvement of the efficiency and
equity of service delivery. In addition, it has the following specific objectives:
(a) extension of basic health service coverage with emphasis on the poorest
segments of the population; (b) increased public expenditure on health and
mobilization of financial resources to ensure sustainability of the sector;
(c) redirection of resource allocation; (d) increased efficiency of the public
sector in the performance of its functions and the production of services;
and (e) generation of an organized social response, with a broad base of
social and community participation. Emphasis is placed on the organization
of publicly financed services to extend coverage to the rural population
that currently has no access to health care. In 1996, the population without
health service coverage was estimated at 46%; between 1997 and 2000, coverage
was increased to include an additional 35% of the total population. The strategy
used was based on a partnership between the Government, represented by the
Ministry, and nongovernmental organizations.
Organization of public health services
The health system is composed of three large sectors: private for-profit, private
nonprofit, and public, which in the past have functioned independently. Heading
up the public sector is the MSPAS, which, as pointed out earlier, is responsible
for leadership of the sector and is also one of the main direct providers
of services to the open population. Other public providers take care of specific
groups that serve the State, including the health services of the armed forces
and the national police. IGSS has its own service network, which covers workers
affiliated with its regime. The private nonprofit sector consists of some
1,100 nongovernmental organizations, 82% of them national; of those, 18%
carry out preventive health activities (80%) and provide clinical services
(20%). The private for-profit sector provides services through insurance
programs, prepaid medical services, medical centers or hospitals.
Organization of regulatory actions
The regulatory role of the Ministry in the private sector is especially important
in ensuring the quality control, efficacy, and safety of drugs and related
products. The Department for the Regulation and Control of Drugs and Related
Products was created within the Ministry to enable it to exercise control
in this area, and the Department is supported, in turn, by the National Health
Laboratory, where physical, chemical, and microbiological analyses are performed.
The water supply coverage reached 92% of the population in urban areas and
54% in rural areas, while sanitation coverage was 72% and 52%, respectively.
In urban areas, 47% of the population disposes of solid waste through collection
services.
Organization of individual health care services
In 1999, the Ministry of Public Health and Social Welfare had 1,352 health
establishments, 43 of which were hospitals (17 at the department level, 10
at the district level, 7 regional, 6 specialized and 3 general hospitals
that receive referrals). There were 29 type A health centers, 234 type B
health centers, 973 health posts, 48 peripheral emergency centers, and 15
maternity centers at the canton level. The bed-population ratio was 1.0 per
1,000 in the country. IGSS has 24 hospitals, 30 consultation offices, 18
primary care posts, and 5 services attached to national hospitals; 6 of the
hospitals and 11 of the consultation offices are located in the department
of Guatemala. There are 2,447 available beds, for a ratio of 1.4 per 1,000
beneficiaries. There is a 360-bed Public Psychiatric Hospital in Guatemala
City, and six other national hospitals have mental health units. IGSS has
a 30-bed psychiatric unit and is working on creating a mental health program.
Health supplies
Drugs are sold through a network of public and private pharmacies. There are
85 national and 2 foreign laboratories that manufacture drugs. In 1999, the
Ministry spent US$ 17,073,649 on drugs, IGSS spent US$ 24,000,000, and the
private sector spent US$ 129,803,326. In 1997, a system was established for
the joint negotiation of drug purchase prices with participation by the Ministry,
IGSS, and the Military Medical Center.
Human resources
The ratio of physicians to total population is 9 per 10,000. For every 3 physicians
there is only 1 professional nurse; for each professional nurse there are
14 nursing auxiliaries. Health human resources tend to be concentrated in
urban areas: the ratio of urban to rural physicians is 4:1, and for professional
nurses it is 3:2. Guatemala has 80 specialists in public health with a master’s
degree.
Health sector expenditure and financing
In 1999, health expenditure represented 2.8% of GDP. Households were the most
important source of health financing (42.9%), followed by the Government
(27.3%), businesses (22%), and external cooperation (7.8%). The annual amount
spent on health came to US$ 630 million.
External technical cooperation and financing
In the last five years, Guatemala’s technical and financial cooperation
amounted to US$ 2,386.6 million. Of this total, 37.3% corresponded to nonreimbursable
cooperation and 62.7% of it was reimbursable. 75.2% was intended to support
the peace process, 21.7% was for other programs, and 3.1% was allocated for
the Hurricane Mitch Reconstruction and Transformation Program. The total amount
disbursed during the five years came to more than US$ 1,600 million, of which
55.3% corresponded to reimbursable and 44.7% to nonreimbursable cooperation.
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Epidemiological
Bulletin , Vol. 25 No. 2, June 2004
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