Socioeconomic, Political, and Demographic Overview
The Republic of Guatemala has a land area covering 108,889 km2, bordered on the north and northeast by Mexico, on the east by Honduras and El Salvador, on the northeast by Belize, and on the south by the Pacific Ocean. It is divided politically and administratively into 22 departments, which include 330 municipios. The departments are grouped into eight regions. In 1995 the population was estimated at 9.98 million, with an annual growth rate of 2.8%. Sixty-five percent of the population lives in rural areas, where 80% of the people live in settlements of fewer than 500 inhabitants.
During the present decade Guatemala has been slowly resuming its economic growth rate. Between 1990 and 1996 the gross domestic product (GDP), adjusted for inflation, increased at rates of 3% to 5%, and the GDP per capita grew only 0.1% to 1.9%. In 1994 the per capita gross national product (GNP) was US$ 1,190.
Total unemployment has remained steady at around 37%. Open unemployment, which was 6.5% in 1990, dropped to 2.5% in 1993 and then rose again to 5% in 1996. Inflation fell considerably during 19901996, as evidenced by the fact that the annual variation in the consumer price index went from nearly 60% to between 8% and 14%.
The fiscal policy succeeded in keeping the public sector deficit under control: in 1990 it was 4% of GDP, whereas by 1996 it was only 1.2%. This reduction was due more to austerity in spending than to an increase in revenue from taxes, despite the reforms that have been made in this area, including an increase in the value-added tax from 7% to 10%. However, these favorable macroeconomic indicators are not matched by a decline in poverty, which afflicts three of every four Guatemalans.
According to data from 1989, the proportion of the population living in conditions of poverty was 75% for the country as a whole, with 58% living in extreme poverty. Both poverty and extreme poverty are higher in rural areas and among the indigenous population, 93% of whom were living in poverty and 91% in extreme poverty in 1989. By contrast, among the nonindigenous population the proportions were only 66% and 45%, respectively.
In 1994 the literacy rate was 71% in men and 57% in women, with an overall national rate of 64%. The total rate of enrollment in primary school was 79% in 1991, 83% in 1992, and 85% in 1995.
The northern, northeastern, and southeastern regions are relatively less developed than the rest of the country. Almost half the population lives in these regions, and the population is largely indigenous. Twenty-two percent of the people live in the national capital.
The birth rate was 37.3 per 1,000 population in 1995, and total fertility was 5.1 children per woman (6.2 in rural areas and 3.8 in the urban population). The fertility rate in the indigenous population remained steady between 1986 and 1995, whereas in the nonindigenous group it dropped from 5.0 children per woman in 1987 to 4.3 in 1995. In 1994 underregistration of births was estimated at 3%.
In 1992 life expectancy at birth was 62.4 years for men and 67.3 years for women; by 1995 it was 64.7 for men, 69.8 for women, and 67.1 for the population as a whole. In 1995 females represented 49.5% of the population and women of reproductive age, 22%. The Guatemalan population is very young: 45% are under 15 years of age and only 3% are older than 60.
Indigenous peoples, classified linguistically into more than 21 different groups, represent 43% of the countrys population. Speakers of Quiché represent 29% of the total indigenous population; Kakchiquel, 25%; Kekchí, 14%; Mam, 4%; Pocomchi, Pocomam, and Tzutuhil, 24%; and other languages, 4%. About 32% of the indigenous population speaks only a Mayan language.
Since 1987, when the process of voluntary individual repatriation began, there has been a steadily increasing return of Guatemalans who had been living for years in neighboring countries, especially Mexico. It is estimated that some 20,000 people returned between 1993 and 1995 and since 1996, after the Peace Accords were signed, people have been returning in much larger numbers. For the most part, those who have come back have made their homes in remote jungle areas, where they are living in precarious conditions without basic services.
In 1995 the crude death rate was 7.4 per 1,000 population. During the period 19851995 infant mortality was 51.0 per 1,000 live births (neonatal mortality, 26.0 per 1,000; postneonatal mortality, 25.0 per 1,000).
In 1994 a total of 65,535 deaths were reported, for a crude death rate of 6.8 per 1,000 population. Of all deaths, 27.3 % were in infants under 1 year old; 3.9% in children 1 to 4 years of age; 2.7% in the population aged 5 to 14; 21.8 % among those aged 15 to 59; and 36% in the 60 and over bracket.
Of all the deaths reported in 1994, 58% were males and 42 % were females; 24% occurred in hospitals, 66% at home, 8% in public places, and 2% in nursing homes. The leading causes of death were pneumonia and influenza (16.5%), conditions arising in the perinatal period (13.8%), intestinal infectious diseases (8.9%), and nutritional deficiencies (5.7%). Infectious diseases, deficiency diseases, and conditions related to pregnancy and delivery accounted for about 45% of the deaths.
In 1994, 57% of the deaths were reported or registered by physicians, 28% by other health personnel, and 10% by persons outside the health sector; in 4.5% of cases it was unknown who certified the death. Underreporting of death was estimated at 2.8% in 1993.
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
Health of Children
In 1994 the perinatal mortality rate was 14.2 per 1,000 live births, and that same year a total of 17,907 deaths were reported in infants under 1 year of age (27.3% of all deaths). Infant mortality was 48.3 per 1,000 live births, and the leading causes were conditions in the perinatal period (50.5%), pneumonia (17.0%), intestinal infections (8.8%), and malnutrition (2.3%). The percentage of low-weight newborns (less than 2,500 g) was 7.8% in 1993. In 1995, 50.5% of infants breast-fed exclusively until 4 months of age and 32 % did so until the age of 6 months.
Mortality in children 1 to 4 years of age was 2.3 per 1,000 in 1995. The leading causes of mortality in this group, according to 1994 data, were pneumonia (26.0%), intestinal infections (24.3%), and nutritional deficiencies (10.0%).
Health of Adolescents
In an estimated population of 2.4 million adolescents aged 10 to 19, a total of 2,148 deaths were reported in 1994, corresponding to a mortality rate of 88 per 100,000. The leading cause in this group was external causes, with a rate of 20.4 per 100,000. Within this category, firearms were the leading cause (8.9 per 100,000). Bronchopneumonia (7.0 per 100,000) and intestinal infections (4.6 per 100,000) came next. In this age group mortality was much higher among males (60.5% of all deaths as opposed to 39.5% for females, corresponding to rates of 104.6 and 70.8 per 100,000, respectively). The leading cause of death in male adolescents was injuries from firearms and other types of injuries; in female adolescents the most frequent causes were bronchopneumonia and intestinal infections.
Health of Adults
In the group aged 20 to 24 years the mortality rate was 177 per 100,000 in 1994. The leading cause of death was external causes, including injury inflicted by firearms, followed by other injuries and unintentional deaths, and attacks with sharp instruments, with rates of 30.7, 23.3, and 8.4 per 100,000, respectively. Bronchopneumonia came next, with a rate of 7.4 per 100,000. Of the total deaths in this age group, 72% were in males, for whom the most frequent cause was injury inflicted by firearms or other means. In women the leading causes of death were bronchopneumonia and intestinal infections.
According to a 1994 estimate of years of potential life lost (YPLL) in adolescents and young adults (10 to 24 years old), if deaths due to violent causes were eliminated, YPLL would be reduced by 21% in the group aged 10 to 14, by 50% in the group aged 15 to 19, and by 49% in the group aged 20 to 24.
During 19901995 maternal mortality was estimated at 190 per 100,000 live births, based on data from the second national maternal and child health survey (1995), which used the sisterhood method of collecting information. The latest year for which routine information is available is 1994, when maternal mortality was reported at 96 per 100,000. Underreporting is estimated at approximately 60%. The five leading causes of maternal mortality were complications of delivery (30%), retention of the placenta (14%), puerperal sepsis (11%), eclampsia (11%), and abortion (7%).
The percentage of pregnant women who received prenatal care given by trained personnel rose from 34% in 1992 to 54% in 1995, when 45% of all prenatal monitoring was done by physicians, 8% by nurses, and 26% by midwives. Among indigenous women and in rural areas, prenatal care was more frequently given by midwives and nurses. Physician care was most frequent among nonindigenous and urban women.
In the country as a whole, 37.8% of all deliveries were attended by trained personnel (physicians, 34.1%; nurses, 3.7%). As with prenatal care, physician-attended deliveries were much more frequent in urban areas (60% of all deliveries) than in rural areas (18%). By contrast, midwives attended 53% of the rural deliveries and only 31% of urban deliveries.
The proportion of women who received at least one dose of tetanus toxoid during pregnancy was 55% in the country as a whole (49% among indigenous women and 60% among nonindigenous women).
In 1995 it was estimated that in the total population of women of reproductive age 5% used traditional contraceptive methods and 26% used modern methods such as female sterilization (14.5%), contraceptive pills (3.5%), intrauterine devices (2.4%), hormone injections (2.3%), condoms (2.2%), or male sterilization (1.5%). It is estimated that currently, of all women living in sexual unions, 69% do not use any contraceptive method. In the indigenous group only 9.6% of the women use any family planning method; in the nonindigenous group the proportion is 43.3%.
According to the 1994 census, 0.7% of the Guatemalan population had some form of disabilityphysical in 60 % of the cases, sensory in 36%, and mental in 3.1%. By sex, 58 % of the disabled were males and 42% were females.
Analysis by Type of Disease
Vector-Borne Diseases. The malarious area covers 80% of the national territory (20 of the 22 departments). In 1994 there were 21,996 reported cases of malaria and 90 deaths, and in 1995 there were 23,608 reported cases and 108 deaths. In 1996 there were 21,556 cases of clinical malaria, of which 7,795 were confirmed. The annual parasite index in the endemic area was 2.4 per 1,000. Of the confirmed cases in 1996, 86% corresponded to Plasmodium vivax and 0.7% corresponded to P. falciparum.
In 1994 there were 2,384 reported cases of classical dengue and in 1995 there were 3,886. In 1995 there was one reported case of hemorrhagic dengue in Escuintla. By 1996 the numbers had risen to 3,704 cases of classical dengue and 19 cases of the hemorrhagic type, with no deaths. That year the Guatemalan Social Security Institute (IGSS) reported 500 cases of classical dengue.
Vaccine-Preventable Diseases. In 1994 there were 68 reported cases of measles and 34 deaths from this cause, 28 of which were in children under 5 years old. In 1995 there were 64 reported cases, and by 1996 there was only 1 confirmed case. In 1994 there were 74 reported cases of whooping cough, with 73 deaths; there were 62 cases in 1995 and 66 in 1996. There were no reported cases of diphtheria in 1994 and there were 2 cases in 1995. With regard to neonatal tetanus, 18 cases were reported in 1994, with 7 deaths; there were 8 cases in 1995 and 12 in 1996. No cases of wild poliovirus have been reported since 1990. The Expanded Program on Immunization was established in the country in 1982. By 1996, vaccination coverage of infants under 1 year old was 73% for the three doses of oral polio vaccine, 73 % for the three doses of DTP, 70% for measles vaccine, and 77 % for BCG; coverage was 8% for tetanus toxoid in women of reproductive age.
Cholera and Other Intestinal Infectious Diseases. In 1994 a total of 84,932 cases of acute diarrheal disease were reported, with 5,842 deaths from this cause; in 1995 there were 83,643 cases and 6,784 deaths. There has been a decline since 1992, when 99,737 cases were reported, which can be attributed to preventive measures and investments in resources to increase coverage and to water quality surveillance, which started in 1991 in response to the cholera epidemic.
Intestinal parasitic diseases are one of the leading causes of morbidity nationwide. In 1994 there were 154,911 reported cases, for a rate of 15.1 per 1,000 population, and 442 deaths attributed to this cause. No data are available that distinguish among the different causes of parasitic disease.
In 1994 there were 16,779 reported cases of cholera, but this number dropped to 8,280 in 1995 and to 1,572 (106 confirmed) in 1996. The respective case fatality rates were 0.9%, 1.2%, and 0.9%. The department that had the highest morbidity in 1995 was El Progreso, with 276 cases per 100,000 population.
Chronic Communicable Diseases. In 1994 there were 3,365 reported cases of tuberculosis, for an incidence of 33 per 100,000. By 1995 the incidence had fallen to 17.3 per 100,000. There were 523 deaths that year. During the 19911997 period there were 77 reported cases of leprosy, all of them in adults.
Acute Respiratory Infections. Acute respiratory infections continue to be one of the leading causes of morbidity and mortality in the country. In 1994 there were 138,550 reported cases, and in 1995, 178,355 (which represents an incidence of 18 per 1,000). In 1994, 10,846 reported deaths were attributed to pneumonia and influenza, which were the leading causes of total mortality and the second-ranking cause of hospital mortality that year. Pneumonia was the second leading cause of mortality in children under 1 year old (17% of deaths) and the leading cause in the group aged 1 to 4 years (26%). It was also the leading cause of death in women aged 15 to 49 (12% of all deaths in that age group).
Rabies and Other Zoonoses. In 1994 there were 13 reported cases of human rabies, and in 1995 there were only 9. In 1996 some 8,000 people were bitten by animals suspected of having rabies, 8 persons died, and 178 cases were reported of rabies in animals. The zoonosis section conducted nationwide rabies vaccination campaigns.
AIDS and Other STDs. As of 30 September 1996 the Ministry of Public Health and Social Assistance had reported a cumulative total of 1,371 cases of AIDS in Guatemala since 1984. Of this total, there were three times more cases in men than in women, which have also been on the increase. Sexual transmission was responsible for 93% of the cases, 67% of which were due to heterosexual transmission. Given the serious reporting difficulties, it would be risky to estimate the incidence of AIDS and the mortality from this disease in Guatemala. The data available indicate that the annual incidence is on the order of 5 cases per 100,000 population.
Diagnosed cases of syphilis in 1994 came to a total of 308. No information is available on other STDs.
Foodborne Diseases. In 1994 there were a total of 257,680 reported cases of foodborne disease, with a morbidity rate of 2,580 per 100,000 population and a mortality rate of 25 per 100,000. In most cases the etiologic agents and foods involved were unknown.
Noncommunicable Diseases and Other Health-Related Problems
Nutritional Diseases and Diseases of Metabolism. In 1994 mortality from malnutrition was 45 per 100,000 population nationwide. In the Sentinel School Program, initiated in 1994, low height for age in children under 6 years of age was found in 64% of the girls and 75% of the boys; low weight for height was found in 11% of the girls and 17% of the boys; and low weight for age was found in 45 % of the girls and 54% of the boys. According to the same study, in 1994, 84% of the girls and 83% of the boys under 9 years old were suffering from malnutrition.
In the 1995 National Survey of Micronutrients the excretion of urinary iodine in schoolchildren, both girls and boys, was used to measure possible dietary deficiency of this micronutrient. The results showed that the situation is good, with an average iodine excretion of 211 µg/ml in rural areas and 248 µg/ml in the urban population (normal excretion was considered to be 100 µg/ml).
In 1995 the prevalence of anemia was 35.4% in women of reproductive age, 39.1% in pregnant women, and 26.0% in children from 1 to 5 years old. The prevalence of vitamin A deficiency in children aged 1 to 5 was estimated at 15 % nationwide.
Malignant Tumors. In 1994 there were 2,329 reported deaths from malignant tumors (3.6% of all deaths). The most frequent sites of origin were the stomach (36%), liver or bile duct (36%), and bronchus or lung (10.5%). In women aged 15 to 49, the most frequent sites were the uterine cervix (40%), stomach (27.5%), liver (14.0%), breast (10.9%), and bronchus (3.7%). In men the five leading sites were the stomach (41.3%), liver (31.5%), bronchus and lung (10.5%), pancreas (6.9%), and prostate (3.5%). In 1994 mortality from cancer of the uterine cervix in women over 15 years of age was 4.4 per 100,000.
Accidents and Violence. In 1994 there were 1,720 reported deaths caused by trauma, poisoning, and other injuries and external causes; 85% of these deaths were in men and 15% were in women. The mortality rate from injuries caused by motor vehicles was 0.92 per 100,000 population.
In 1996 the IGSS reported that it had attended a total of 37,676 accidents85% of them non-work-related and 15 % work-related accidents. The most common sites of these accidents were places of business (67%), public thoroughfares (23%), and the home (9%).
Estimated mortality from homicide in the population over 15 years of age was 47 per 100,000 population in 1994.
Oral Health. In 1991 the Department of Oral Health in the Ministry of Public Health and Social Assistance studied a sampling of 11,000 schoolchildren and youths aged 2 to 18 from 157 randomly selected educational centers. The average index of decayed, missing, or filled teeth (DMFT) was 7, and 80% of the students said that they had a toothbrush or something similar.
Behavioral Disorders. There are no nationwide data for psychiatric morbidity. It is estimated that one-fourth of the population may have some kind of emotional disorder, and this proportion may be as high as 35 % in areas of armed conflict.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
In 1994 a formal negotiation process got under way following the agreement to reinitiate the peace talks. The Peace Accord was signed on 29 December 1996 by representatives of the Government and the guerrilla forces. This new state of peace led to a thorough institutional modernization of the State with a view to substantially improving efficiency and management capacity, addressing the delicate question of public finances, and effectively implementing social programs that would support the processes of peace and economic development.
Health policies come under the program for economic modernization of the Government, which includes reforms aimed at increasing State income, controlling the national debt, and raising expenditure in the social sectors. An important complement to these policies has been the reforms in the allocation of funds to the municipios. Of the amounts that the Government gives to the municipalitiesnamely, 8% of the national budgetat least 90% is supposed to go for programs in education, preventive health, infrastructure, and public services to improve the quality of life.
The 19962000 Social Development Plan reviews and examines the goals and objectives set forth in previous development plans and incorporates the commitments assumed at the recent Central American presidential summits, especially with regard to sustainable development and social integration.
The Government has formulated a set of health policies for 19962000, which incorporate, orient, and support various aspects of the reform and the peace accords. These policies address seven areas: (a) reorganization, integration, and modernization of the health sector; (b) increased coverage and improved quality of basic health services, with emphasis on the prevention and control of priority problems; (c) improved management of hospitals; (d) promotion of health and a healthy environment; (e) increased coverage and improved quality of drinking water and extended coverage of basic environmental sanitation in rural areas; (f) social participation and oversight as part of public management of the services; and (g) coordination of international technical cooperation to support the activities determined to have priority in the health policies and in the sectoral reform process.
The overall framework of State reform includes reform of the health sector, with the political aim of bringing about a comprehensive transformation in the social production model for health. Above all, it undertakes to achieve an organized social response so that the sectors interventions will have an effect on the fundamental causes of disease and not merely their effects on health.
The health sector reform that got under way in 1994 has the following specific objectives: (a) to increase the coverage of basic health services, focusing on the poorest segment of the population; (b) to increase public spending and expand the sources of financing for the sector to ensure its sustainability; (c) to rechannel the allocation of resources; (d) to increase the efficiency of the public sectors performance of its duties and the production of its services; and (e) to generate an organized social response founded on a broad base of participation.
Along with this process a financial reform is also taking place that envisages economic modernization of the State, maintenance of a stable macroeconomic situation, and creation of the fiscal capacity necessary to increase social spending.
Organization of the Health Sector
The health sector is made up of both public and private institutions, nongovernmental organizations, and a large sector of traditional medicine surviving from the Mayan culture, which is found mainly in rural areas among the indigenous population.
At the national level, institutional coverage of the population is as follows: Ministry of Public Health and Social Assistance, 25%; IGSS, 17%; Military Health Service, 2.5%; nongovernmental organizations, 4%; and the private sector, 10%. Less than 60% of the population has the benefit of some form of health service coverage, and this coverage has not increased substantially since 1990, when it was 54%. This was one of the reasons why the Government decided to change the traditional care model by reforming the sector. A Comprehensive Health Care System (SIAS) was designed, which is now being implemented and intends to provide basic health care to the entire population that currently is without access to health services. Existing resources will be used for this purpose within a context of community organization and participation that will generate and bring about changes in the health situation.
The SIAS concept is based on the delivery of specific, simplified, and ongoing health services provided by volunteers with the support and supervision of institutional personnel. These community participants are expected to work closely with a health team that provides them with technical, logistic, and decision-making support and whose members, unlike traditional health personnel, work in close contact with the community.
With regard to health care for individuals, specifics have been formulated for minimum health services and national coverage according to the communities epidemiological profile. The following activities are included: (1) care of pregnant women through prenatal monitoring, administration of tetanus toxoid, provision of ferrous sulfate, and care during delivery and the puerperium; (2) child health care, vaccination, control of acute respiratory infections and diarrheal diseases, and nutritional evaluation and care of children under 2 years of age; (3) emergency and acute disease care (diarrhea, cholera, respiratory infections, malaria, dengue, tuberculosis, rabies, STDs, and others, depending on the local epidemiological profile).
The expanded health services are directed toward the 58% of the population already covered by health services and are provided by institutional personnel who, in addition to the minimum services listed above, offer care for women of reproductive age, early detection of cancer, and family planning; care for infants and preschoolers under the age of 5; emergency care and treatment of illnesses; and environmental protection, sanitation standards, and project development and management.
Development of Health-Related Legislation
The purpose of the new Health Code is to ensure viability and implementation of the changes that have been ushered in with health sector reform. It incorporates innovative aspects, including the definition and concept itself of "health sector," and it creates the National Health Council, an entity that advises the Government and the Ministry of Public Health and Social Assistance on regulating the development and infrastructure of health services with regard to formation and utilization of human resources and the health care service network. The Code specifically includes and gives priority to health promotion and protection.
Health Services and Resources
Organization of Services for Care of the Population
Water Supply, Sewerage Systems, and Solid Waste Disposal. In 1994 water supply systems reached 92% of the urban population and 54% in rural areas. Sanitation coverage (sewerage systems) in urban areas was 72% (65% with drainage or a septic system and 33% with latrines), whereas in rural areas it was only 52%. This means that 3.7 million people had no supply of drinking water and 4.2 million did not have adequate sanitation services.
There are 16 wastewater treatment plants in the metropolitan area, but only 4 of them are in operation. Of the 329 municipalities in the rest of the country, 286 have a sewerage system, but only 15 have a wastewater treatment plant. The rest of them dispose of wastewater without treating it.
Nowhere in Guatemala is there a system for the final disposal of solid waste. In the urban areas it is estimated that 47 % of the population has the benefit of solid waste collection. The rest of the people burn, bury, or toss out their trash. In rural areas only 4% of the population has the benefit of trash collection services. The waste that is collected, in both urban and rural areas, is deposited in dumps with no further treatment.
Environmental Protection. Air pollution in Guatemala is mainly from motor vehicles, which increase in number each year. A 19951996 study conducted in Guatemala City by the San Carlos University and the Central American Ecological Program showed that atmospheric concentrations of particulate matter, nitrogen dioxide, and ozone all exceeded WHO standards.
A standard for leaded gasoline was issued in 1991 by the Ministry of Energy and Mines, which regulates gasoline imports to ensure that lead concentrations do not exceed 130 mg/l.
Guatemala is an agricultural country, with 32% of its territory devoted to farming. Almost 2 million people live in direct contact with pesticides. In 1994 a total of 5.7 million kg (0.5 kg per capita) of pesticides were imported. The Ministry of Public Health and Social Assistance periodically checks for traces of pesticides in food for human consumption. Of 72 samples analyzed in 1995, only 2 had levels exceeding the limits set by FAO/WHO.
The use of pesticides results in a sizable number of accidental work-related poisoning cases each year. Although the exact number of acute cases of pesticide poisoning is unknown, according to IGSS reports there were 282 cases in 1993, 237 in 1994, and 80 in 1996.
Food Poisoning. Food poisoning continues to be a frequent cause of morbidity and mortality. Adulteration is one of the main problems, especially in dairy products. In 1993, 53% of the dairy product samples collected met established standards. In 1993 in microbiological tests of food sold by street vendors, the quality was satisfactory in 60% of the samples taken in the capital and in 52% of those taken in the interior.
The System for the Epidemiological Surveillance of Foodborne Diseases is currently being revamped, because there is considerable underregistration due to insufficient reporting. Moreover, diseases such as cholera and others that can be transmitted by food are not reported as foodborne diseases.
Public Health Information and Statistics. The System for Epidemiological Surveillance of Maternal Deaths began to be implemented in the metropolitan region of Guatemala City in 1991, and in 1995 it was also introduced in the departments of Huehuetenango and Baja Verapaz. The data are gathered by health workers who have been briefly trained for the purpose, and the resulting information has provided useful support for the decision-making process.
In 1996 the Ministry of Public Health and Social Assistance decided to implement the Health Information Management System (SIGSA), which is based on the policy of expanded coverage and incorporates information as part of the Comprehensive Health Care System. An integrated information system, SIGSA includes modules on health statistics, finance, planning, supplies, human resources, and hospital management. Its aim is to give added analytical capacity to personnel at various levels so that their decisions will be based on timely and pertinent information.
Organization and Operation of Personal Health Care Services
In 1993 the Ministry of Public Health and Social Assistance had 19,385 employees and a network of some 3,861 health establishments, including 35 hospitals, 32 type A health centers, 188 type B health centers, 785 health posts under the Ministry of Health, 24 health posts under the Military Health Service, and 2,642 establishments, including State pharmacies, municipal drug dispensaries, etc. The private sector has some 2,000 establishments, but they cover only 10 % of the population.
According to 1995 data, there are 12,725 hospital beds in the country as a whole, or 1.1 per 1,000 population.
The IGSS has 24 hospitals, 4 of them specialized. IGSS coverage is limited at the national level, because it has health posts and first aid stations in only 9 departments and offices for consultation in 10. Its hospitals are mainly located in Guatemala City, but it has also opened hospitals in Escuintla and Suchitepéquez in recent years.
The health posts of the Ministry and the IGSS are covered by auxiliary personnel. The Ministrys health centers have permanent medical staff but are open for only eight hours per day. The health posts and centers have very limited decision-making capacity and there is no effective system in place for referrals and counterreferrals.
The hospitals of the Ministry and the IGSS have specialists on contract who work four hours per day. The national specialized reference hospitals are located in Guatemala City.
Health of Former Combatants. Some 3,400 former guerrilla combatants (URNG) have been resettled in seven encampments in the interior in the departments of Quiché, Alta Verapaz, Escuintla, and Quetzaltenango. They are mostly adults under 30 years of age; 15% to 20% are women, and there are also some children. A bimonthly program was started on 3 March 1997 that will carry on the process of social reintegration through training and vocational programs. There are also programs for comprehensive medical care and oral health. The health teams comprise a URNG physician, who heads up the team; a physician from Médicos del Mundo, a nongovernmental organization, four dentistry students, a health promoter from the Universidad Misionero de los Pobres, a health promoter from the URNG, and a dental health promoter, also from the URNG.
Mental Health. Mental health has not been given high priority in Guatemala, but for the past two years a group of governmental and nongovernmental agencies has called attention to the problem and to promotion of development of a national mental health program.
The Ministry has a 350-bed national psychiatric reference hospital that offers outpatient consultation as well as daytime hospitalization. The IGSS has a 25-bed psychiatric unit to which cases from its affiliates are referred, and it also offers outpatient consultation. The Ministry has outpatient psychiatric clinics in three of its national-level hospitals located in Guatemala City. There are 10 Ministry psychologists and 10 IGSS psychologists in the metropolitan area who provide services in health centers and peripheral polyclinics. The IGSS has a community psychology program in the department of Escuintla.
Inputs for Health
Essential Drugs and Medications. Drugs are marketed through a network of 52 public pharmacies, 80 municipal drug dispensaries, and 1,920 privately owned pharmacies. There are 900 pharmacists and 1,100 pharmacy technicians. A total of 8,172 pharmaceutical products are registered, of which only 12% are in circulation. There are 81 national and 9 foreign laboratories that manufacture drugs. There is one official laboratory for drug quality control and there are four private ones.
In 1995 a total of US$ 159 million was spent on drugs, of which $13 million (8%) corresponded to the Ministry of Public Health and Social Assistance, $19 million (12%) to the IGSS, and $127 million (80%) to the private sector.
The most widely used therapeutic groups of drugs are anti-infectives, anti-inflammatories, and drugs for gastritis and peptic ulcers. Since 1996 there has been a multisectoral committee on drug policies that includes participants from the Ministry of Public Health and Social Assistance, the IGSS, the Ministry of Economy, the association of drug manufacturers and importers, and PAHO.
The Ministry of Public Health and Social Assistance has a Division of Food and Drug Registration and Control, which registers drugs; grants licenses to pharmaceutical establishments; performs physical and chemical analyses; monitors the production, marketing, and dispensing of narcotics; and authorizes advertising related to drugs.
In 1993 there were some 51,000 persons working in the health sector, of whom 26% were community volunteers, 17% were in the private sector, and 57% were in the public sector. The Ministry of Public Health and Social Assistance had 19,385 employees, distributed as follows: 12.4% professionals, 8.8 % technicians, 26.5% auxiliaries, and 52.3% administrative and general service staff. The IGSS had approximately 8,000 regular employees and 1,300 supernumeraries. Of this total, 50.5% had administrative and miscellaneous duties.
According to 1993 data, for every 10,000 Guatemalans there are 9 physicians, 3 professional nurses, 11 nursing aides, 20 midwives, and 1.3 dentists.
Approximately 80% of physicians, 56% of professional nurses, and 50% of nursing aides are located in the metropolitan region, where there are 28 physicians and 4.9 professional nurses per 10,000 population. The rural areas, where 65% of the population lives and where the high-risk groups are concentrated, are largely covered by nursing aides, rural health technicians, midwives, and volunteer community health promoters.
Nearly 80% of IGSS health personnel are found in the metropolitan region. The concentration of human resources in the metropolitan area and the shortage in the hospitals of physicians with the basic specialties seriously undermines decision-making capacity at the rural outpatient and hospital levels. The current distribution of human resources is a reflection of a centralized health care model that is heavily inclined toward curative medical care.
With regard to administrative training, institutional staff are trained for specific operational processes, but they are not trained in managerial aspects of the health system.
In the field of public health, all the countrys departments have epidemiologists with varying levels of training. There is a shortage of sanitary engineers and specialists in health economics, even at the central level of the Ministry. Education for the health professions is given at the University of San Carlos (USAC), Francisco Marroquín University, and the University of Valle. The latter two institutions are private, while the USAC belongs to the State. In 1995 a masters degree program in public health was introduced at USAC that will train staff from various government institutions in management, environmental studies, research, and epidemiology.
Expenditures and Sectoral Financing
Public spending on health in 1995 was equivalent to 1.2% of the GDP. The percentage of the Governments general budget devoted to health in 19911994 came to 18.1%. In 1996 public spending on health amounted to 13% of total public spending, whereas in 1992 it had been 6.6%.
The budgetary allocation for the Ministry of Public Health and Social Assistance in 1996 equaled US$ 195.98 million, and in 1997 the figure was US$ 203.57 million. The IGSS allocation in 1994 amounted to US$ 199.27 million, and in 1995 it was US$ 227.23 million (exchange rate for 1996 and 1997: 6 quetzals = US$ 1).
In 1996, unlike other years, public spending on health was redirected and a large proportion (43.8%) was allocated for primary health care, or local health services, while 24.6 % was designated for the hospital network.
The Ministrys Sectoral Planning Unit currently has a set of peace-related proposals, of which the following are of interest:
Comprehensive Health Care System for Critical Departments and Municipios in the Peace Zone, for which the Ministry has a budgetary allocation equivalent to US$ 13.81 million and a supplementary foreign investment of US$ 26.3 million.
Drinking Water and Sanitation for Rural Areas of Priority Municipios in the Peace Zone, which envisages a government investment of US$ 12.65 million, a community contribution of US$ 5.06 million, and a foreign investment of US$ 12.65 million.
24-hour First-Level Medical Emergency Units in the metropolitan area of Guatemala City, with a Ministry expenditure of US$ 232,000 and a foreign investment of US$ 659,000.
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