Pan American Health Organization

Guatemala

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of GuatemalaThe Republic of Guatemala extends for 108,928 km2. In 2015, the country was divided politically and administratively into 22 departments and 340 municipalities.

In 2016, it had a population of 16,672,956 (), with a density of 153 inhabitants per km2. The under-15 population accounted for 36%, and the population aged 65 and over, 5%. Guatemala’s largest departments are Petén, Izabal, Alta Verapaz, El Quiché, and Huehuetenango, which cover 33.9%, 8.3%, 8.0%, 7.7%, and 6.8% of the nation’s territory, respectively. Its smallest departments (less than 1% each of the nation’s territory) are Sacatepéquez, Totonicapán, and Sololá. These latter three, located in the mountainous Northwest Altiplano region, have the greatest population densities—681, 449, and 412 inhabitants per km2, respectively—that is, three to five times the national average. These three departments are territorially fragmented into several municipalities, and their population is primarily rural and indigenous (41% of the population).

In the groups aged 15 and older, the percentages grew; for example, the population over 64 years of age rose from 4.1% in 1990 to 5.3% in 2015. The departments in the north and west reported higher percentages of people under 18, while those in the east and south had relatively lower percentages of people under 18. Figure 1 shows Guatemala’s population structure in 1990 and 2011.

Figure 1. Population structure, by age and sex, Guatemala, 1990 and 2015

Between 1990 and 2015, Guatemala’s population grew by 78.4%. In 1990, its population structure displayed a rapidly expanding pyramidal shape, with a predominance of age groups under the age of 20. This growth continued in 2015, although with a widespread slowdown in the under-20 age groups, related to the decline in fertility and mortality, especially in the past two decades.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs, Population Division. Review 2015. New York 2015.

Life expectancy at birth in 2012 was 68 years for men and 75 for women ().

With respect to social assistance, social security coverage was low. The Guatemalan Social Security Institute (IGSS) reported barely 22.1% coverage of the economically active population (EAP) in 2012, since 74.5% of the EAP worked in the informal sector (); thus, the percentage of older persons with pensions was low. It was estimated that in 2016, annual per capita alcohol consumption among adults and older persons was 5 liters for men and 1.7 liters for women. Furthermore, 13.3% of adults were not physically active enough ().

According to the National Maternal and Child Health Survey (ENSMI for its Spanish acronym) for 2008–2009, 36% of men and almost half of women of reproductive age were overweight or obese, with weight increasing with age ().

Guatemala’s Constitution recognizes that the country is inhabited by four ethnic groups: the Garifuna, the Maya, mestizos, and the Xinca. Although Spanish is the official language, 22 languages and their various dialects are spoken by ethnic Mayans, and the Garifuna and Xinca speak their own languages. Most of the indigenous population is monolingual. This is particularly true in the case of women. In 2014, the National Survey of Living Conditions (ENCOVI, for its Spanish acronym) () reported a literacy rate of 79.1% in the population aged 15 and over (84.8% in men and 74.0% in women; 86.1% in urban dwellers and 71.4% in rural dwellers). Literacy among rural women was 64.7%. Indigenous women, with a literacy rate of 57.6%, were the most disadvantaged in terms of access to education.

The National Employment and Income Survey of 2014 found that 65.8% of people were working in the informal sector (). This percentage was 80.3% for indigenous people, in contrast to just 57.7% for nonindigenous people. The main activities are farming (43.7%), commerce (27.9%), manufacturing (11.2%), and other service activities (8.7%), which together employ 91.5% of the population in the informal sector. The economically active population numbers 6.2 million, 65% of it men and 35% of it women; 26.7% of the EAP is between the ages of 15 and 24. Moreover, according to the 2014 ENCOVI (), 59.3% of the population was living in poverty (consumption of less than Q 10,218 per year), an increase of 2.9 percentage points over the 2006 survey.

The incidence of poverty is systematically higher in indigenous populations. The ENCOVI 2014 found that the poverty rate in the indigenous population (79.2%) was 1.7 times higher than that of the nonindigenous population (46.6%). Poverty has likewise been historically higher in rural areas than in urban areas, although the gap has been narrowing: in 2000, the rural poverty rate was 74.5%, or 2.7 times higher than the urban rate, while in 2014, the rate (76.1%) was 1.8 times higher than the urban rate (42.1%). Most of the departments with a poverty level above the national average are in the northwest; those with largely indigenous, rural, and denser populations are in the east (Figure 2) (). In 2014, the extreme poverty rate in the general population was 23.4%; in other words, there was an increase of 8.1 percentage points over 2006, when the rate was 15.3%. The extreme poverty rate in the indigenous population was 39.8% in 2014, versus 12.8% in the nonindigenous population, and 35.3% in the rural population, versus 11.2% in the urban population.

Figure 2. Poverty incidence, by department, Guatemala, 2014

Source: National Statistics Institute of Guatemala. National Survey of Living Conditions 2014. Guatemala; 2015.

In recent years, Guatemala has been hit by volcanic eruptions, droughts, and storms. In 2016, it ranked 89th out of 180 countries on the global Environmental Performance Index (EPI), which measures a country’s policies with respect to two variables: environmental health and the vitality of its ecosystems. Of the 18 Latin American countries evaluated, Guatemala ranked 14th ().

Furthermore, urbanization is rapidly growing, largely due to migration to existing urban centers, especially Guatemala City (the nation’s capital) or certain departmental capitals. Guatemala City is increasingly unable to provide goods and services to the burgeoning population on its outskirts and in highly vulnerable areas. Is estimated that in 2014, 49.5% of the Guatemalan population was living in urban areas located mainly in the metropolitan area of the Department of Guatemala, as well as Escuintla, Quetzaltenango, and other departments in the center of the country ().

Guatemala’s major cities, as well as those in areas bordering neighboring countries, are increasingly exposed to the global phenomena of insecurity and violence stemming from drug trafficking, prostitution, human trafficking, etc.

Leading Health Challenges

Critical Health Problems

In 1987, the base year for the commitments of the Millennium Development Goals (MDGs), mortality in children under 5 was 110 per 1,000 live births. In light of this, the target of reducing the rate to 37 per 1,000 live births was set for 2015. The progress reports were yielding encouraging data, and the ENSMI for 2014–2015 (), which estimates the rate for the last five-year period, ultimately showed that the rate (in children under 5) had fallen to 35 per 1,000 live births, exceeding the target for 2015. It should be noted that the estimated infant mortality (in children under 1 year) for the same five-year period was 28 per 1,000 live births; in other words, 80% of the mortality in children under 5 occurred during the first year of life.

The most frequent causes of death in children under 5 continue to be infectious and deficiency diseases (flu and pneumonia, intestinal infections, and malnutrition and nutritional anemias) (2014) (). Reducing the burden of these diseases will require tackling social and environmental determinants, such as environmental sanitation and access to safe water, and improving knowledge and practices related to personal hygiene and the necessary care for children through access to prevention and treatment services and greater coverage (). Meeting these objectives will undoubtedly lower mortality rates in infants (children under 1 year) and children under 5, especially in the historically most marginalized populations ().

According to the website of the National Food and Nutrition Security Information System (SIINSAN for its Spanish acronym) (), 14,657 cases of acute malnutrition were reported in the country in 2015, for a rate of 64.5 cases per 10,000 children under 5, with 183 deaths.

In 1989, the base year for monitoring the MDGs, the maternal mortality ratio (MMR) was 219 deaths per 100,000 live births. Progress in this indicator has been slow, reflected in the fact that in 2013, the MMR was 113.4 per 100,000 live births ().

As for communicable diseases, dengue remains a health concern, with 12,622 reported cases in 2013 (). Other concerns in recent years have been the chikungunya virus and, since 2015, the Zika virus.

Chronic Conditions

Chronic noncommunicable diseases (NCDs) are a becoming an important issue due to their growing prevalence in a population with a higher proportion of adults and older persons: in 2000, the population aged 45 and over was 14.5% and, in 2016, 16.5% (). In 2010, the leading causes of morbidity from chronic diseases reported by the Health Information Management System (SIGSA) of the Ministry of Public Health and Social Welfare (MSPAS) () were diabetes, hypertension, cerebrovascular disease, and tumors.

According to the 2012 national publication on core health indicators, mortality from diabetes mellitus in the country was 33.5 per 100,000 population, and mortality from diseases of the circulatory system, 77.2 per 100,000 population ().

Guatemala suffers from an environment of insecurity and violence, as well as social and economic conflicts, all of which are a source of mental health problems. A 2011 report indicated that the institutional response to these problems () is inadequate: less than 1% of the health budget is devoted to mental health, which is why mental health care is provided by the private sector. In 2012, suicide and homicide and conflict were the third leading cause of years of life lost due to premature mortality (YLL) and years of healthy life lost due to disability (YLD), with neuropsychiatric diseases coming in fourth ().

Human Resources

The 2016 core indicators publication () showed that in 2014 the country had 7.5 physicians per 10,000 population; however, a review of the 2012 national core indicators document () shows unequal distribution. For example, physician density in the MSPAS network in the Department of Guatemala was 8.1 per 10,000 population, while in rural departments with extensive territories and high population density, the figures were much lower. In Alta Verapaz and Huehuetenango, for example, the figures were 1.5 and 1.6 per 10,000 population, respectively.

According to the 2016 core indicators, the proportion of professional nurses was even lower, with 6 per 100,000 population (). These metrics do not include midwives, because there are no formal training programs for this specialty in the country; in 2013, the MSPAS began putting together a training program, using the maternal mortality ratio to prioritize the geographic areas for its initial implementation. Physicians receive their training at the public university and six private universities, which have branches headquartered in the departments and Guatemala City. Cuba’s Latin American School of Medicine also provides training for Guatemalan students, who subsequently enter Guatemala’s medical profession through the state university. In 2015, the MSPAS had 53,068 employees, and 54% of health services personnel (physicians, nurses, and auxiliaries) were hired through a modality that does not guarantee job security. Specialized training is available, especially in clinical disciplines, and two graduate schools have public health programs and focus on health administration and epidemiology. Around 40% of general physicians and specialists are concentrated in the six departments with the country’s major cities; the State’s limited finances preclude hiring larger numbers of professionals to meet the needs of the system.

Health Knowledge, Technology, and Information

Although the MSPAS has made real efforts to improve both the technology infrastructure and the Health Information Management System, and has managed to achieve an advanced level of technological development and resources, many areas require strengthening. For example, in terms of the approaches used by the human resources charged with the entry, processing, and use of data, there need to be improvements in the application of the ICD-10, in the definition of indicators included in the system, in the consistency and periodicity of the information disseminated, in preventing duplication of data in the different programs in reducing or eliminating underreporting in vital statistics and epidemiological data, and in reducing the number of reported deaths from ill-defined causes.

In 2014, mortality underreporting was estimated at 16.1%, while 6.4% of deaths were reported with an ill-defined or unknown cause ().

The production of scientific and technical literature is still subject to many constraints, and much of the country’s health research comes from university theses. The Institute of National Problems at the University of San Carlos (IPNUSAC), part of the state university, occasionally publishes reports on health topics.

Recently, the National Statistics Institute (INE), with the backing of international organizations, created the Health Statistics Sectoral Coordinating Office (OCSES), which compiles, organizes, and standardizes the most important health data from the institutions involved (MSPAS, Guatemalan Social Security Institute [IGSS], and Institute of Oncology, to name but a few) for its publication of core health indicators, both in print and online through the INE website. The MSPAS website also disseminates health information, but not systematically, and the information is not current.

The Environment and Human Security

Although forums are held on preparedness to deal with the effects of climate change, and information is disseminated, there has been little progress in policy-making and program operations. Unbridled and unplanned urban growth has created unsafe areas in the country’s major cities where the population is highly vulnerable. The urban area of metropolitan Guatemala City grew by more than 150% between 1975 and 2014 (). In the rainy season, frequent mudslides and floods occur in peri-urban areas and the country’s interior.

Furthermore, according to the Vehicle Tax Registration System, cited by the Banking Association of Guatemala (), the number of vehicles in the country rose from 1.1 million in 2005 to 2.7 million in 2014. This increase, moreover, entailed an increase in imports of used vehicles with high pollutant emissions.

Furthermore, pollution of water sources is on the rise, and regulations governing the use and conservation of surface- and groundwater are insufficiently enforced (). Large-scale farming of export products has occasionally polluted the environment with waste products and pesticides. The country is experiencing rapid deforestation, and firewood remains the fuel of choice in rural households. In Central America, Guatemala is country that consumes the most firewood (19,505 m3 in 2014, or 46% of the firewood used by all households in Central America that year) (). Environmental pollution has a heavy impact on the respiratory disease profile, food security, and drinking water.

Aging

According to the ENCOVI 2014, there were significant changes in the age distribution of the population between 2000 and 2014; for example, the under-15 population fell from 44.3% to 35.7%.

Migration

The greatest migration is outward, especially to the United States and border areas (primarily Mexico) in search of seasonal farm work. According to the ENCOVI 2014 (), in 2.6% of the households surveyed, at least one member had been a migrant in the past 5 years. In rural households, this figure was 3.6%, due to the limited work opportunities. A 2012 report by the International Organization for Migration (IOM) cites a 2010 survey on remittances indicating that the Guatemalan departments that produced the most migrants to the United States were Guatemala, Huehuetenango, San Marcos, and Quetzaltenango (). These migrants had mainly a primary and middle school education, and only 1% of them were university-trained professionals. The people who migrate are usually men, leaving women behind as the head of household to care and provide for the family. The departments with the highest internal immigration are Petén, Santa Rosa, and Guatemala ().

Monitoring the Health System’s Organization, Provision of Care, and Performance

Although the Health Code designates the MSPAS as the national regulatory agency, the legal instruments for it to perform its functions are inadequate. In the period 2010–2015, the Ministry’s political and financial crisis grew, reflected in the high turnover of senior administrative staff and the preparation of two Strategic Health Plans that were not implemented. Between 2012 and 2016, the Ministry had seven different administrators at its helm that were unable to implement these plans. In response to the crisis in the health system, and to ensure the system’s sustainability, a health sector reform proposal was drafted within the framework of the government’s priorities. This proposal indicated the action that should be taken in the short, medium, and long term to achieve universal health coverage in the population, and was aligned with the strategy for universal access to health and health coverage approved by the Directing Council of the Pan American Health Organization (PAHO) in 2014.

The IGSS covers approximately 18% of the population, and around 8% of the population has access to private health insurance. The MSPAS has an assigned coverage of 70% and provides services at the three levels of care; however, access indicators are low, primarily for the indigenous population, and have not improved since 2000 (). In 2006, the health services network consisted of 43 hospitals, 279 health centers, 903 health posts, and 46 enhanced health posts. As of 2014, such health service infrastructure had not significantly increased; these health servicces were generally in poor condition and concentrated mostly in urban areas with lower poverty indexes ().

In 2014, the MSPAS began cancelling agreements with private health service providers that had provided first-level services and a basic package of maternal and child health care to some four million people in remote rural areas. Although initially the MPSAS lacked a mechanism to gradually provide coverage for the population that had been left without services, by 2015 it had a model of care at the first level (). Under this model, health services were institutionalized to guarantee preventive care and health promotion for individuals, families, and communities. The model also prioritized the rural communities left in the lurch by the cancellation of the agreements with service providers, assigning specific health territories of 5,000 people to health posts staffed by health teams consisting of nursing auxiliaries, educators, and community facilitators, and also coordinating with midwives.

Furthermore, to improve coordination between the different levels of care, and to promote the continuity of care, the integrated health services network strategy was implemented that year in priority departments (). The second level of care (health centers, permanent care centers, and comprehensive maternal and child health centers) began providing emergency services and care on demand by general practitioners and—in a few centers—by specialists. Third-level services are provided by 44 district, departmental, and regional hospitals and two national referral hospitals (), which handle most of the care provided by the service network, although they lack adequate referral and back-referral to the second and first level of care.

In 2014, Guatemala’s average fiscal and tax revenues represented 11.6% of its gross domestic product (GDP), putting the country in last place in Latin America—an important fact for the analysis of investment for the execution of public and social investment policies. According to 2014 estimates, national public health expenditure represented 2.3% of GDP, and private sector expenditure, 3.9% (). In 2015, health financing (including the public and private sectors) represented 6.3% of GDP.

Private expenditure continues to be the main source of health service financing in the country. In 2014, out-of-pocket spending on health services accounted for 52.2% of the total financing, followed by the IGSS, with 18.7%, and the MSPAS, with 15.6%. In the distribution of financing for production functions, financing for human resources accounted for 38.1% of the total, and pharmaceutical products, 25.8%. The percentage of expenditure on medicines remained constant at 1.7% of GDP from 2005 to 2014.

Prospects

In addition to the demographic and epidemiological changes in Guatemala over the past five years, political and social transformations since 2015 will affect the State’s ability to address the health situation of the population. It has been recognized that the health sector is both fragmented and segmented, with leadership problems and funding gaps. The country’s health indicators reveal inequalities and gaps that will be difficult to overcome. Policies are needed that focus on modifying the health determinants of the population and not just on health outcomes, if progress is to be made and achievements sustained in the long term. Moreover, active social engagement in planning, management, and reporting should be encouraged, from the local to the national level.

Progress toward a healthier citizenry will require strengthening MSPAS capacity as a regulatory entity so that it can exercise leadership in the regulation of the sector and governance mechanisms at the local and national level.

As a way to attain universal access to comprehensive and inclusive health care, the MSPAS has launched the Inclusive Health Model (MIS) as a mechanism for reorganizing and strengthening the public health services network. The MIS promotes intersectoral action and recognizes interculturalism and the role of social determinants in local spaces. The challenges facing the MSPAS in implementing the MIS throughout the nation include ensuring the financing needed to strengthen its different levels of management, designing governance mechanisms, and guaranteeing the necessary infrastructure and human resources (in terms of numbers and skill sets). Furthermore, from the sector standpoint, it is important to begin considering what steps to take next to make the MIS a sustained and sustainable national model; these will include academic training for health professionals, coordination with the different service providers (Guatemalan Social Security Institute, Ministry of Defense, NGOs), and the engagement of key stakeholders, including municipal governments, civil society, and academia.

The country needs to develop mechanisms for including tools in its health policies that address health determinants in a multisectoral manner and link the sector with the social and economic agenda and the Development Board System (SISCODE). This requires creating opportunities for information, dialogue, and coordination with not only the general public but politicians, private sector chambers and associations, organized civil society, universities and collegiate bodies, and professional societies. Implementing the country’s strategies designed to meet the Sustainable Development Goals provides an opportunity to create synergies with other sectors that are able to influence the reduction of inequalities and the social, economic, and environmental determinants of health. Under the approach of the regional Plan of Action on Health in All Policies, the MSPAS can set priorities and develop these synergies.

In order to tackle these challenges, political support at the highest level is needed, through the allocation of budgetary resources and a review and updating of the current legal framework, to ensure that the changes introduced have a legal foundation. Box 1 highlights Guatemala’s achievements and challenges in health between 2007 and 2011.

Box 1. Achievements and Challenges in Health

In the period 2007-2011, the country successfully eliminated the last foci of onchocerciasis transmission. In September 2016, at the opening of the 55th Directing Council of PAHO, it was announced that Guatemala had become the fourth country in the world to be declared free of the disease (noting that it was a Guatemalan physician, Rodolfo Robles, who was the first to discover its presence in the Americas and to associate it with “river blindness”). Guatemala was also one of the first countries in the Region to conduct studies on the efficacy and effectiveness of administering ivermectin to control the disease.

In the case of communicable diseases, the country has made significant progress in malaria control (only two departments, Escuintla and Alta Verapaz, persist as major foci of transmission) and trachoma elimination will soon be a reality.

A major challenge for the country is the implementation of a model that permits universal access and universal health coverage, with special care in addressing the social, economic, and environmental determinants of health. Similarly, appropriate intersectoral coordination is needed to conduct the activities to meet the Sustainable Development Goals.

References

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31. Institute for Health Metrics and Evaluation. Guatemala: leading causes of DALYs in 2013 and percent change, 1990–2013 [Internet]. Seattle: IHME; 2013. Available from: http://www.healthdata.org/guatemala. Accessed on 30 August 2016.

32. Instituto Nacional de Estadística; Secretaría de Bienestar Social (Guatemala). Hallazgos de la Primera Encuesta Nacional de Discapacidad 2005. Guatemala City: INE; 2005. Available from: https://www.ine.gob.gt/sistema/uploads/2014/01/16/U3l8MepiRtatBurbPSoTVxo56SY9pqs0.pdf.

33. Ministerio de Salud Pública y Asistencia Social, Departamento de Epidemiología (Guatemala). Estadísticasdel VIH [Internet]. Guatemala City: MSPAS; 2015. Available from: http://epidemiologia.mspas.gob.gt/files/Publicaciones%202016/Salas%20Situacionales/Estadisticas%20VIH%20a%20octubre%202016%20JG.pdf.

34. Ministerio de Salud Pública y Asistencia Social (Guatemala). Sistema de Información Gerencial en Salud: semana epidemiológica 46. Guatemala City: MSPAS; 2016.

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Reference/Note:

1. Guatemalan quetzals (7.46 Q = 1 dollar).

2. International Classification of Diseases and Related Health Problems, 10th Revision.

3. http://ipn.usac.edu.gt/

4. https://www.ine.gob.gt/index.php/estadisticas/tema-indicadores

5. Health posts are staffed by nursing auxiliaries and rural health technicians. Due to the special needs of the jurisdictions they serve, “enhanced” health posts also have a physician and professional nurse on staff.

6. Both indigenous and non-indigenous residents live in rural areas.

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