Socioeconomic, Political, and Demographic Overview
Honduras has a surface area of 112,492 km2 and a population density of 46 inhabitants per km2. In urban areas, the population density is 184 inhabitants per km2. The terrain is predominantly mountainous, with 19 watersheds. The countrys principal environmental problem is deforestation. Between 1964 and 1990, forests were reduced by some 25,899 km2 (34%). It is estimated that between 1992 and 1993, as much as 7% of the forest cover reported in 1990 was lost, which indicates a deforestation rate of more than 1,000 km2. The country is divided into 18 departments and 297 municipios with 3,730 towns and 27,764 small rural communities. With the adoption of the Municipal Government Law (1990), decentralization was strengthened and 5% of Government revenues were transferred to the municipal governments.
In 1990 a program for structural adjustment of the economy was established and policies and incentives were gradually put in place to promote the most efficient use of resources, coupled with social compensation programs, such as the Honduran Social Investment Fund, the Family Allocation Program, and the Social Housing Fund. These programs are designed to relieve the effects of the adjustment in the poorest segments of the population. The share of these three programs in social spending increased from 3.6% in 1990 to 13.6% in 1995.
The per capita gross domestic product (GDP) was US$ 702.7 in 1990 and US$ 722.0 in 1995, with an average annual growth rate of 0.58%. In the same period, the countrys total foreign debt increased 23.5%, climbing from US$ 3,517.8 million in 1990 to US$ 4,343.5 million in 1995; public debt accounted for 90% of this amount.
The predominant economic activities continue to be agriculture, forestry, hunting, and fishing, Honduras experienced sustained growth in the manufacturing industry (export processing and assembly) in the 1990s; this economic activity generated some 44,000 jobs as of 1994. The economically active population (EAP) makes up 35% of the total population. In 1995 the underemployment rates were 34 % in rural areas and 17% in urban areas. In 1993 women made up 31% of the EAP: 40% of the urban EAP and 22% of the rural EAP. Twenty-four percent of households are headed by women and 65% of those are poor. In 1994, unemployment and underemployment affected 73% of young men and 69% of young women aged 1519 years. Among those aged 2029, in contrast, the percentages were 43% among males and 45% among females; in the group aged 3044 years 29% of males and 40% of females were unemployed or underemployed.
Inflation rose from 21.7% in 1994 to 29.5% in 1995. The impact of this increase was felt especially in the cost of the basic market basket of food, which jumped 144% between 1990 and 1995. It is estimated that the national population consumes, on average, only 77% of the required daily caloric intake. During the 19801994 period, per capita availability of food fell 10% because production grew at a slower rate than the population. In March 1994, revealed the percentage of households that fell below the poverty line was 75.6% (54.5% of households were indigent).
During the 19901994 period, illiteracy declined from 31.3% to 22.8% in 1994; illiteracy in rural areas remained 49% higher than in urban areas. The average level of educational attainment for the total population in 1994 was 4.2 years; it is estimated that 60% of the EAP has fewer than three years of schooling.
The housing shortage in 1995 totaled 700,000 dwellings. Of urban dwellings, 64% are overcrowded, 33% do not have a regular supply of drinking water, and 41% lack sanitation systems. In rural areas, only 16% of dwellings are considered adequate; more than 81% have no access to drinking water, excreta disposal services, and electricity.
Based on the last population census, carried out in 1988, the estimated population in 1996 was 5.6 million, with a growth rate of 2.8%. In 1996 the population aged 04 years made up 15.7% of the total; the population aged 59 years, 14.2%; the population aged 1014 years, 12.9%; the population aged 1519 years, 11.5%; and the population aged 60 and over, 5.1%.
It is estimated that in 1995 urban dwellers made up 43% of the total population. Most of the urban population is concentrated in two cities: Tegucigalpa and San Pedro Sula (32.9% and 16.2% of the total urban population, respectively). There is a significant geographic/sex differential in this migration: females tend to migrate primarily to the major urban centers, whereas males migrate mainly to agricultural areas. In 1995, the total estimated net rate of internal migration was 1.6% (1.7% for males and 1.4% for females). Most migrants are between 15 and 44 years of age, and the largest proportion are in the 2029 age group. Emigration also has been increasing: in 1989 the net emigration rate was 1.1% (1.3% for males and 1.0% for females).
Life expectancy at birth, which was 64 years for the total population in the period 19851990, was estimated at 71 years for women and 66 years for men in 1996. The estimated total fertility rate, according to the 19951996 National Epidemiology and Family Health Survey (ENESF), was 4.9, 6.3 in rural areas, and 3.9 in urban areas. The birth rate per 1,000 population was 33.4 in 1996.
There are eight culturally differentiated ethnic groups in Honduras: the Lencas, the Pech, the Garifunas, the Chortis, the Tawahkas, the Tolupanes or Xicaques, the Miskitos, and the English-speaking black population. In 1993 it was estimated the size of this population at 253,790 (5.97% of the total population). The areas inhabited by the indigenous populations are among the most severely underserved.
In 1990, the last year for which information is available, an estimated 44.2% of deaths went unreported. According to estimates of the Secretariat for Planning, the crude death rate in 1996 was 5.8 per 1,000 population; a total of 32,666 deaths occurred, of which 18,510 were males and 14,156 were females. Of the total number of deaths, 15% (5,355) were reported in connection with hospital discharge figures.
In 1990, the five leading causes of death in the general population were ischemic and hypertensive diseases, diseases of pulmonary circulation, and other forms of heart disease (19.0%); accidents and violence (13.0%); diseases of the respiratory system (9.5%); intestinal infectious diseases (9.0%); and malignant neoplasms (8.2%). The leading causes of infant mortality in 1990 (1,624 registered deaths with 638 attributed to ill-defined conditions) were intestinal infectious diseases (28.2%); diseases of the respiratory system (21.8%); and certain disorders originating in the perinatal period (20.6%).
Because of the aforementioned problems with the registration of deaths, the country relies on other sources to calculate mortality figures. These include national surveys conducted on specific subjects and population censuses carried out in certain geographical areas, which provide mortality data based on various methodologies. The data on maternal mortality are considered reliable and are based on prospective studies carried out in 1990, which indicate a rate of 221 maternal deaths per 100,000 live births. The infant mortality rate decreased from 50 per 1,000 live births in 1990 to 42 per 1,000 in 1994.
Hospital deaths increased in absolute numbers from 4,433 in 1993 to 5,355 in 1996 and from 10% to 16% with respect to total deaths for those years, which were estimated at 33,300, and 32,666, respectively. The leading causes of hospital death between 1993 and 1996, based on ICD-9 classification, were diseases of the respiratory system (11.8%); ischemic and hypertensive diseases, diseases of pulmonary circulation, and other forms of heart disease (9.1%); and accidents and violence (8.2%). These three leading causes are the same (although not in the same order) as those reported in 1990. Other important causes of death were malignant neoplasms (5.7%), viral diseases (5.4%), and AIDS (5.4%).
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
During the 1980s, the percentage of children with low birthweight who were delivered in health facilities of the Ministry of Public Health and the IHSS ranged from 7.0% to 8.7%. The figure increased to 9.2% in 1992. The percentage of malnutrition in children under 5 increased from 48.6% in 1987 to 52.5% in 1991.
The percentage of exclusively breast-fed infants (in the 0- to 3-month age group) increased from 36.7% in 1991 to 42.4 % in 1995. The proportion of children aged 69 months who were being breast-fed with supplementary feeding was 69.2%, and the proportion who continued to be breast-fed into the second year of life (2023 months) was 45.4%. The average duration of exclusive breast-feeding is 2.1 months.
A comparison of the leading causes of death in children under 5, based on the last two epidemiological surveys, reveals that acute respiratory infections continue to be in the forefront, accounting for 22% of deaths in 19911992 and 23% in 1996. The next leading cause is diarrheal diseases, which increased from 19% to 21% during the same interval.
In 1994, an estimated 73.1% of children aged 59 years were enrolled in school. Several height censuses of schoolchildren aged 69 carried out between 1986 and 1996. In 1996, the proportion of malnourished children remained at 39%, (33.3% of girls and 42.2% of boys suffered from chronic malnutrition).
According to the Ministry of Public Health, in 1995, 16.3% of AIDS cases in the country occurred in the group aged 1024. According to the 19951996 ENESF, almost 45 % of 18-year-old women are sexually active and one-half of them have been pregnant; 8.5% of 15-year-olds and about 40% of 18-year-olds are married; by age 20, 50% of women are mothers. Among women aged 1519 years who live with a male partner, 27.6% use some method of contraception; the most frequently used method is oral contraception. In the group 1619 years old, illiteracy declined from 11.9% in 1990 to 8.2% in 1994. Among males, this proportion dropped from 14.4% to 10.1%, and among females, from 9.4% to 6.2% in the same period.
There is no comprehensive information on the health status of the elderly population. Hospital discharge data from 1996 reveal that 17.9% of discharges in the group aged 50 and over were associated with alcohol dependency syndrome and 16.6 % were associated with diarrheal diseases.
In 1992, the national plan on workers health found six major health problems: accidents in the workplace, pesticide poisoning, noise pollution in the manufacturing sector, reproductive health of workers, widespread use of chemical products, and mental health problems (such as depression and alcoholism). Little information is available on these problems.
In Honduras, 4.5% of the population has some disability requiring rehabilitation services. Although the age and sex distribution of the disabled population is unknown. Fundación Teletón has three centers (in Tegucigalpa, San Pedro Sula, and Santa Rosa de Copán), which served 26,139 patients between 1990 and 1995.
Malnutrition is widespread, affecting 95% of the indigenous population under the age of 14. Of every 100 indigenous people born, 68 die of infectious diseases. In 1993, estimated life expectancy in this group was 36 years for males and 43 years for females. Immunization coverage in 12 border municipios averages 60.3%.
Analysis by Type of Disease
The number of cases of malaria increased from 70,838 in 1992 to 74,487 in 1996 (API 18 and 16.5, respectively.) The disease mainly struck the countrys northern and southern areas, which together accounted for 52% of the cases reported in 1996. The highest incidence rates per 1,000 population (46.4 in 1994 and 74.3 in 1995) occurred in the swampy region on the east. In 1996, 98.9% of all cases were due to Plasmodium vivax and 1.1% (1,003 cases) to Plasmodium falciparum. In the period between 1993 and 1995, the largest proportion of malaria cases occurred in females aged 1549 years (51% in 1993, 62% in 1994, and 53% in 1995).
In 1993, 2,687 clinical cases of dengue were reported. In 1994, the number was 4,687; in 1995, 28,064; and in 1996, 7,564. In 1995, almost 50% of dengue cases (16 were cases of dengue hemorrhagic fever) were diagnosed in the central and northern areas of the country. Between August and November 86% of the cases for the year were reported. In 19931994, most cases occurred in women and more than half were in the population over 15 years of age.
Fourteen clinical cases of Chagas disease were reported in 1994, 94 in 1995, and 66 as of October 1996. A study conducted in 1996 in the municipio of San Francisco de Opalaca, located in the department of Intibucá (where Chagas disease is highly prevalent), found that 17.7 % of children under 5 were infected.
In 1992, 992 cases of cutaneous leishmaniasis were reported, and in 1994, 1,083. The number increased 13% in 1995, when 1,230 cases were reported, 70% of which occurred in the department of Olancho.
No cases of poliomyelitis have been reported since 1989. There was one reported case of measles in 1995 and four in 1996; since 1991, no measles deaths have been registered. Immunization coverage among children under 1 year old was 91 % in 1996. The rate among children under 5 increased with respect to earlier years, and in 1996 it was 97.3% for the oral polio vaccine, 96.5% for DTP, 98.7% for measles, and 100% for BCG. By 1995, coverage with two doses of tetanus toxoid in women of childbearing age was 93%. Only three and four cases of neonatal tetanus were reported in 1995 and 1996, respectively, which represents a reduction of 50% with respect to 1994. In the 19901994 period, 63% of the cases were reported in urban areas. A campaign to vaccinate all health workers against hepatitis B was launched in 1994. By 1995, 50% had been vaccinated and by 1996, 67.8%. In 1996, 200 cases of whooping cough were reported. There have been no cases of diphtheria since 1981.
The prevalence of diarrheal diseases in children under 5 in Tegucigalpa and San Pedro Sula decreased from 25.5% in 1987 to 18.8% in 1991 and 14.8% in 1996. In rural areas, the prevalence has been variable (31.9% in 1987, 19.1% in 1991, and 21.1% in 1996). Cholera re-emerged in the country in October 1991, causing a hospital case fatality rate in children under 5 of 4.2% in 1992 and 2.0% in 1996. In 1995 there were 4,748 cases of cholera nationwide, with a case fatality rate of 1.6% (77 deaths); 56% of the cases were in males and 76% of those occurred in persons aged 15 and over. In 1996 there were 708 cases and 14 deaths, with a case fatality rate of 1.9%; 53.2% of the cases occurred in men and, of these, 40% were aged 15 and over.
There were 45 cases of tuberculous meningitis in 1992, 23 in 1993, and 15 in 1994, with 6, 5, and 11 cases, respectively, in children under 5. The number of cases of tuberculosis reported from 1992 to 1996 was 4,267. In the period 19931995, tuberculosis was associated with an annual average of 1,289 hospital discharges, with a predominance of cases in males (60%). The central and northeastern regions of the country have the greatest number of cases. Extrapulmonary tuberculosis occured at a rate of 5.2 cases per 100,000 population in 1989 and 2.0 cases in 1996. All detected cases of pulmonary tuberculosis have been treated; only one drug-resistant case has been identified. Of the 416 patients who received the directly observed treatment, short-course, 380 were cured and 36 abandoned treatment.
The prevalence of leprosy remained constant at 0.1 (84 cases) per 10,000 population from 1992 to 1995; an average of 3 new cases per year were diagnosed between 1992 and 1995.
In 1992, two cases of human rabies were reported from the metropolitan area; in 1993, no cases were reported; in 1994, one case was reported from the countrys southern area; and in 1995, two cases were reported, both from the Tegucijalpa metropolitan area. In 1996, no cases were reported. The number of cases of canine rabies decreased from 14 in 1995 to 9 in 1996. With respect to cysticercosis, a study carried out in 1995 in animals slaughtered in metropolitan meat-packing plants showed that 3% of the pigs analyzed were infected with cysticerci.
In 1993 a rate of 19.0 AIDS cases per 100,000 population was reported. In 1995, the rate was 17.7. The predominant route of transmission is through heterosexual contact (82.9%). The male-female ratio of 4:1 registered at the beginning of the epidemic has shifted steadily over the years and is now approaching parity (38% of women in 1996). The 2529 age group is most affected (21.8%), although the number of cases diagnosed in children under 5 has been increasing (from 1.9 % in 1987 to 4.8% in 1996). Geographically, the largest proportion of AIDS cases are in the northern region of the country (47.6%), followed by the central region (20.4%). Of the cumulative total of 6,005 cases registered up to 1996, 1,041 have died. The percentage of infected women also has risen: from 30.3% of 752 cases in 1992 to 38% of 734 in 1996. In 1991, in San Pedro Sula the prevalence of HIV infection was 3.6% among pregnant women and 14% among prostitutes. This association between tuberculosis and AIDS has shown a rising trend, with the rate increasing from 0.11 per 100,000 population in 1986 to 1.4 in 1996. The incidence of other STDs continues to be higher in the metropolitan region and in the northern part of the country. In the 19921995 period, the number of cases of these diseases dropped gradually from 2,004 to 1,026. In 1996, 1,112 cases were reported. The number of reported cases fell from 5,952 in 1992 to 2,146 in 1996.
Subclinical vitamin A deficiency affects 13% of the population aged 13 years. The problem is most severe in rural areas in the western and northern regions and in several urban areas. There are no current data on the prevalence of goiter due to iodine deficiency in schoolchildren (in 1987 the rate was 8.8%); however, iodine level studies conducted in 1995 in sentinel sites suggest that it is not a major problem. Iron deficiency is prevalent and in 1996 affected 30.2% of children aged 13; 0.5% of these children were severely anemic. The problem occurs throughout the country. Twenty-six percent of women of childbearing age and 32% of pregnant women with deficient levels of hemoglobin were found to be anemic.
The only available information on cardiovascular disease is from hospital discharge and mortality records: discharge rates per 100,000 population were 99.0 in 1993 (2,030 patients), 116.6 in 1994 (4,768 patients), and 126.3 in 1995 (6,189 patients); hospital mortality rates per 100,000 population were 11.7, 14.8, and 13.6, respectively, for the same years. Women over the age of 50 made up the largest proportion of patients with cardiovascular disease discharged from hospitals. The largest proportion of deaths (38%) were due to cerebrovascular diseases.
Of the 173,961 cytology exams carried out in 1995 in the country as a whole (34.8% coverage of women aged 3059 years), 0.4% of the samples were found to be abnormal. Since 1990 there has been a cancer registry in the San Felipe General Hospital (Tegucigalpa), which is the national cancer referral center and the only hospital with a cobalt-60 unit. In 1990 and 1995, 389 and 870 new cases of cancer were treated, respectively. In 1994, 60% of the cases were uterine cancer; 8% were breast cancer; 4% were cancer of trachea, bronchus, and lung; 4% were skin cancer; and 3.6% were stomach cancer. The hospital mortality from malignant neoplasms was 60 per 100,000 population in 1993, 51 per 100,000 in 1994, and 43 per 100,000 in 1995. The principal cancer sites are the digestive system, the genitourinary system, the respiratory system, and bones and tissue.
The Public Security Force reports that the homicide rate increased from 20.7 per 100,000 population in 1989 to 40.0 per 100,000 in 1995. Firearms were used in most homicides (69.6%). The age at which criminal activities begin has fallen (10 years).
Mortality from traffic accidents increased from 7.6 per 1,000 population in 1989 to 13.8 in 1994; the rate of domestic violence was 65.5 per 100,000 population in 1996 when records on this type of violence began to be kept. Crimes against minors (between 1 and 18 years of age) reached a rate of 66.0 per 100,000 population in 1996. In that same year, the reported incidence of rape was 3.0 per 100,000 women and 5.3 per 100,000 girls.
The age at which young people begin to use alcohol and tobacco has dropped. A study on children and alcohol carried out in eight marginal neighborhoods in the Tegucigalpa metropolitan area in 1992 revealed that the age at which alcohol was consumed for the first time ranges from 10 to 16 years. Forty-two percent of traffic accidents are associated with alcohol consumption by the driver, and 61% of occupational accidents (injuries and mutilations) occur among workers who consumed excess alcohol the previous day.
In a study conducted by the Honduran Institute for the Prevention of Alcoholism, Drug Addiction, and Drug Dependency on the use of alcohol and drugs among students in teachers schools in Honduras in 1996, four of every five students reported that children and adolescents could easily obtain alcohol in their neighborhoods or communities, and approximately half the respondents (47%) reported the same about tobacco. With regard to illegal drugs, fewer than 17% said that marijuana could be easily obtained in their communities.
In 1993, tropical storms Bert and Gert affected 4,000 households, 30,000 people, and 2,000 km2 of agricultural land in the northern region of Honduras. In November 1996 there were floods due to heavy rainfall in the Chamelecón, Ulúa, Luán, and Aguán river basins, which affected an estimated 80,840 people. Corn, beans, sorghum, rice, and banana crops worth approximately US$ 7.7 million were also lost, and several roads and about 10 bridges were damaged.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
Between 1994 and 1997 the Ministry of Public Health stepped up the process of decentralizing functions to health areas and to municipal government agencies. The Ministry also enlisted other key players in the promotion of the process of increasing access to health services as a fundamental aspect of health reform.
The national access initiative, which seeks to address these problems by extending service coverage and transforming the countrys basic health institutionsunder the leadership and regulation of the Ministry of Public Healthencompasses three basic strategies: adaptation of local health systems, with an emphasis on health areas; social control of the management of health systems; and development and improvement of human resources.
The Ministry of Public Health has promoted specific policies, such as rapid extension of services through universal access to basic health packages; coordination of international cooperation; reorganization of the health system, with an emphasis on the local levels; environmental and health protection; health financing; food security; development of institutional and community human resources; and shortages of drugs and medical supplies.
Organization of the Health Sector
The health services are provided mainly by the Ministry of Public Health, which functions as both a service provider and a regulatory agency, the Honduran Social Security Institute, and to a lesser extent, the Armed Forces Health System; the National Social Welfare Agency; and the Department of Occupational Medicine, Hygiene, and Safety within the Ministry of Labor. The public health subsystem also oversees the National Autonomous Water Supply and Sewerage Service (SANAA). The private subsystem provides care to 10% of the total population.
The services provided by the Ministry of Public Health are organized in six levels of care, linked in a weak referral system. The Ministry has organized nine health regions, which, in turn, are divided into 41 health areas; this division does not mirror the countrys political-administrative division. In 1994 the Ministrys network of services consisted of 978 establishments, including 28 hospitals, 214 physician-staffed health centers, 727 rural health centers, and 9 maternal and child clinics. Of the 28 hospitals, 6 are considered national reference hospitals, 6 are regional hospitals, and 16 are area hospitals.
The public subsector has 4,803 hospital beds, 4,141 of which are in Ministry of Public Health establishments and 662 are in IHSS establishments (a rate of 0.8 public-sector beds per 1,000 population). In 1995 the Ministry of Public Health recorded 35.1 hospital discharges per 1,000 population, of which 40% were patients admitted for childbirth. The private subsector accounts for some 30% of all hospital discharges in the country. The average occupancy rate in hospitals of the Ministry of Public Health was 73%. In rural areas, the vast majority of deliveries are attended by traditional birth attendants. Agreements for shared services have been established between the Medical-Surgical Hospital of the IHSS and the national hospitals of the Ministry of Public Health in the areas of psychiatry, ophthalmology, oncology, nephrology, intensive care, and cardiology.
The current Health Code was approved in 1991. Through the Law on Municipal Government (Decree No.134-40, October 1990) progress has been made in decentralizing the health sector. The General Law on the Environment, enacted in 1993 to encourage environmental protection, established the Office of the Environment, the National Environmental Advisory Board, and the Technical Advisory Committee to support the Ministry of the Environment and the Office of Environmental Law. The Law on Modernization and Development of the Agricultural Sector, enacted in 1992, regulates the registration of agrochemical and biological products for agricultural or veterinary use as a way to prevent environmental risks. In 1993, regulations were adopted on the sanitary control of food sold in public places. In 1993 a procedural law was adopted that provides special benefits for the elderly, retirees, and pensioners, including discounts on recreational activities, travel, hospitalization, and other services. There is a health commission within the National Congress, which is responsible for studying and issuing opinions on proposed legislation to be submitted to the legislature for approval; this commission also participates in the Central American Parliament (PARLACEN) and the Latin American Parliament (PARLATINO).
Between 7,000 and 9,000 drugs are marketed in Honduras. Of these, the Ministry of Public Health has granted marketing authorization for 5,071 products4,011 brand-name and 1,060 generic products. The drugs consumed in the country are marketed through a network of distributors consisting of 115 wholesale dealers, 620 pharmacies, and 215 drug retail outlets. The Ministry of Finance controls the price and markup of imported drugs. The price of domestic pharmaceutical products is not subject to any controls.
The Ministry of the Environment was created in 1993 to oversee enforcement of the General Law on the Environment, formulate policies, and coordinate actions with other institutions. During 1996 the establishment of environmental quality indices was initiated in 45 cities, with a view to assessing and controlling various environmental risks through low-cost technology.
Honduras has no programs for protecting food quality. Regulations establish fortification of foods with micronutrients (addition of vitamin A to sugar and iodine to salt) and enrichment of wheat flour.
The Honduran Congress has drafted a new code on child health and welfare, various laws aimed at controlling alcoholism and drug addiction, a law creating an institute for childhood and family issues and a special law on domestic violence. The National Commission for the Protection of Human Rights also has been strengthened, with special attention to provisions relating to juvenile offenders, abused children, and battered women. In June 1994 an agreement on support for child protection activities was signed.
Health services and resources
The Ministry of Public Health oversees various disease prevention and control programs, among them the programs for control of cancer, STDs and AIDS, rabies, vector-borne diseases, tuberculosis, and leprosy.
The epidemiological surveillance system has maintained coverage levels of under 60% for weekly national reporting of diseases, although there are significant differences among the various health regions of the country. The system encompasses diseases under international surveillance (cholera, plague, smallpox, yellow fever, influenza, and malaria), as well as diseases under surveillance by the national disease alert system and the Expanded Program on Immunization: typhoid fever, dengue, meningitis, and encephalitis. Most of the control programs have established their own information systems, but they are not linked together. Honduras participates in epidemiological monitoring of diarrheal diseases, amebiasis, tuberculosis, rabies, leishmaniasis, and AIDS.
The laboratory network is made up of 28 hospital laboratories, 8 regional laboratories, and 1 central reference laboratory.
Drinking water and sewerage are under control of the National Drinking Water and Sewerage Commission (CONAPA), a decentralized technical agency of the Ministry of Public Health that has considerable operational and financial independence. Some services are in the process of decentralization, to transfer SANAA-operated systems to the municipios.
The two principal service providers in the countrys two major cities (SANAA in Tegucigalpa and the Municipal Water Department in San Pedro Sula) suffer from relatively high rates of water losses, lack of up-to-date records of users, and lack of water meters. The rural systems constructed by SANAA include an important community participation component, and their management is delegated to administrative boards made up of users.
The most common method of treating household solid waste is open-air burning, which causes air pollution. Communities with greater managerial capacity and larger populations generally have systems for waste management, with a coverage level that ranges from 20% to 50% in medium-sized communities and from 50% to 80% in larger cities (Tegucigalpa and San Pedro Sula).
Honduras has four food aid programs: the maternal and child supplementary feeding program (PAMI), the program of food and nutritional assistance for at-risk groups and promotion of food production for personal consumption, the school lunch program (PME), and the "food for work" program (PAT). These programs were incorporated in 1995 as strategies under the national food security plan. During the 19901993 period, PAMI served 220,907 people, distributing food through 1,153 food and nutrition centers. During the same period, PME served an annual average of 434,939 schoolchildren and in 19931994 covered nearly 50% of the public schools.
There are a total of 25 blood banks and transfusion services. Of the six national hospitals, only three have blood banks and transfusion services; regional and area hospitals have their own blood banks. In the Ministry of Public Health, a unit has been created to structure the organization and operation of the blood bank network. This unit and the network of blood banks are overseen by microbiologists. As of 1997 operation of the blood banks was not subject to established technical standards and procedures.
The Ministry of Public Health provides dental services through 34 local oral health clinics in schools and 84 health centers and hospitals. There are four high-productivity centers. The services provided are basically curative and the vast majority are extractions. The ratio of 1.68 dentists per 10,000 population is insufficient to meet the oral health care needs of the Honduran population.
Two national psychiatric hospitals are located in Tegucigalpa. In San Pedro Sula, there is a psychiatric care clinic that refers patients to one of the two hospitals in Tegucigalpa. Each general hospital has two or three beds available for psychiatric patients.
IHSS provides services to 14,680 pensioners and retirees throughout the country. The Retirees and Pensioners Unit of the IHSS offers seminars on preparing for retirement and courses in handicrafts, and it provides support for project management. There are two homes for the elderly, which are financed by voluntary contributions and offer basic inpatient services.
The total supply of drugs in the Honduran pharmaceuticals market during the 19921995 period increased 26%. Imported drugs account for a high percentage of the national market (54.8% in 1990 and 60.7% in 1994) and represented 23 % of Honduras total imports in the period 19931995; their value rose from US$ 24 million in 1990 to US$ 40 million in 1996. The public sector (Ministry of Public Health and IHSS) accounted for 27.2% of the total supply of drugs on the market in 1993 and 29.0% in 1994. The Ministry of Public Health accounted for 24.8% of the total in the network of services in 1994, and the IHSS 4.2%.
On average, there are 6.5 physicians per 10,000 population (33% in the public sector); 2.4 professional nurses (48% in the public sector); 8.4 auxiliary nurses (87% in the public sector), and 0.2 dentists (18% in the public sector). There are insufficient numbers of human resources in the public sector for the majority of the professions. The situation is exacerbated by the unequal geographical distribution of resources; in some communities in the country, the job market for health personnel is saturated, whereas in othersgenerally those that are most inaccessiblemany positions are vacant. The public sector, including IHSS, employs 69% of all health workers in the country.
The education of health professionals is the responsibility of the National Autonomous University of Honduras (UNAH). In the period 19921996, an average of 272 physicians, 19 nurses, and 41 dentists were graduated each year. The education of auxiliary and mid-level technicians is the responsibility of educational establishments administered by the Division of Human Resources of the Ministry of Public Health. In 1990, several new categories of health workers were recognized: environmental health technician, teacher in public health, and nurse specialist in maternal and perinatal health.
There is little applied research in health and most studies are conducted by the United States Agency for International Development (USAID), the Japanese International Cooperation Agency (JICA), PAHO/WHO, the World Bank, and the Governments of the United Kingdom and Sweden.
Health expenditures, as a proportion of GDP, increased from 2.7% in 1990 to 3.0% in 1995 and, as a proportion of total public spending, health expenditure has shown an erratic pattern: from 8.1% in 1990 to 6% in 1993 and to 9.2% in 1995. Similar fluctuations were observed in health spending as a percentage of total central government expenditures (10.4% in 1990, 9.0% in 1993, 13.4% in 1995). Health expenditure per capita increased from US$ 18.9 in 1990 to US$ 21.5 in 1995. Current spending decreased from 70.9% in 1990 to 61.4% in 1995; the greatest decline occurred in the category of compensation (40.5% in 1990 and 31.0% in 1995), and the category of goods and services expenditures increased more than the inflation rate. Capital spending has increased significantly: from US$ 26.0 million in 1990 to US$ 41.2 million in 1995, representing 29.1% in 1990 to 38.6% in 1995. Hospital service expenditures dropped from 40.1% in 1990 to 28.5% in 1995, while the share of spending on the communicable disease control program increased from 18.9% in 1990 to 22.4% in 1995.
Of the total resources available for the health sector during the period 19901995, 78% were public funds and 22 % foreign. Bilateral cooperation accounts for 53.3% of international cooperation for health, and the United States is the largest donor (45.2%); however, since 1990 there has been a decline in the amount of bilateral assistance, which has been replaced by cooperation from agencies of the United Nations system and financial institutions such as the Inter-American Development Bank and the World Bank. In 1992, the three largest bilateral donors were the United States (US$ 38.4 million), Italy (US$ 37.4 million), and Japan (US$ 19.4 million).
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