Guatemala

Overall Context

The 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 (1), 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 (2).

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 (3); 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 (4).

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 (5).

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) (6) 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 (7). 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 (8), 59.3% of the population was living in poverty (consumption of less than Q 10,218¹ 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) (8). 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 ((9, 10)).

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 (6).

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.

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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 (11), 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) (12). 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 (13, 14). 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 (13).

According to the website of the National Food and Nutrition Security Information System (SIINSAN for its Spanish acronym) (15), 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 (16).

As for communicable diseases, dengue remains a health concern, with 12,622 reported cases in 2013 (17). 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% (1). 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) (18) 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 (19).

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 (20) 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 (21).

Human Resources

The 2016 core indicators publication (22) showed that in 2014 the country had 7.5 physicians per 10,000 population; however, a review of the 2012 national core indicators document (19) 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 (4). 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-10,² 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 (4).

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),³ 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.⁴ 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 (22). 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 (23), 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 (22). 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) (22). 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 (8), 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 (24). 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 (8).

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 (25). In 2006, the health services network consisted of 43 hospitals, 279 health centers, 903 health posts, and 46 enhanced health posts.⁵ 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 (26).

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 (27). 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 (28). 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 (29), 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% (4). 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.

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

The total fertility rate (TFR) trended downward, from 3.6 children per woman in 2008 to 3.1 in 2014 (22). The TFR was 3.6 among indigenous women versus 2.8 among nonindigenous women, and 3.7 in rural areas versus 2.5 in urban areas. The rate was 2.9 times higher in woman with no schooling (4.6) versus woman with a higher education (1.6); the same proportion is found between the rates of the lowest and highest socioeconomic quintiles. Reflecting these inequalities, the highest TFR values were in the country’s north and northwest. Some 60.6% of sexually active women of reproductive age (married, in a stable relationship, or unattached) interviewed in the 2014 ENSMI (11) reported using some form of contraception (48.9% modern methods). According to that same survey, the disparities in the use of the different methods followed the pattern of lower use in rural, indigenous, and poor populations with little or no education. Some 91.3% of the pregnant women had received some prenatal monitoring by skilled personnel, although disparities associated with educational and socioeconomic level and, to a lesser extent, area of residence, were still observed. Nationally, however, only 65.5% of births were attended by skilled personnel; among indigenous women the figure was 50.3%, versus 82.1% among nonindigenous women. In the rest of the population, care in childbirth was provided mainly by traditional midwives, although this group was not part of the health services network. The disparities were clearly associated with rurality, socioeconomic level, ethnicity, and schooling. Overall, 63.7% of infants under 2 months and 43.5% of infants aged 4–5 months were exclusively breastfed.

Maternal mortality has remained high, although it has fallen in recent years. In 2013 (16), the MMR was 113.4 per 100,000 live births, derived from 452 deaths, leaving 1,394 orphans. Of these deaths, 68.4% of the women were indigenous, 42% were illiterate, 41% had had some degree of primary education, and 43% had died at home or on the way to some health care facility. Rural departments inaccessible to the health services and with larger indigenous populations have the highest MMR values. The country did not reach the MDG target of an MMR of 55 per 100,000 live births.

Child Health

According to the 2014–2015 ENSMI (11), a comparison of the principal neonatal, infant, and child mortality indicators in survey time series shows differences in the behavior of the indicators: mortality in children under 5 clearly declined, with respective rates (per 1,000 live births) for the periods 2000–2005, 2005–2010, and 2010–2015 of 48, 42, and 35. Infant mortality (children under 1 year) declined to a lesser extent (11, 10, and 8 in the respective periods), while neonatal mortality was 19, 18, and 17. In the most recent five-year period, 80% of deaths in children under 5 occurred before the age of 1 year, and 40.5%, during the neonatal period. Table 1 shows the inequalities in childhood mortality rates by socioeconomic strata based on the 2014–2015 ENSMI.

Table 1. Neonatal, infant, and under-5 mortality,a Guatemala, 2014-2015

With regard to vaccination, according to the 2014–2015 ENSMI, 98% of children aged 12–23 months received the BCG vaccine, 84.6% a third dose of the pentavalent vaccine, 82.5% a third dose of the polio vaccine, and 63% one dose of the measles vaccine. Only 59% had received all the vaccines (BCG, measles, three doses of the pentavalent vaccine, and three doses of the polio vaccine). As with other indicators, there are significant inequalities associated with area of residence, ethnicity, education, and socioeconomic level. The regions with the lowest complete vaccination coverage were the southwest, north, and northwest, at 46.8%, 52.5%, and 57.0%, respectively.

Health of Adolescents (10 to 19 Years Old)

According to the INE, adolescents aged 10–19 account for 23.4% of the country’s total population. The 2014–2015 ENSMI (11) found that 20.7% of females in this age group had already had one pregnancy and 16.2% were already mothers. Although no differences related to ethnicity were found, there were differences related to education, area of residence,⁶ and socioeconomic level.

Adolescent pregnancy is higher in the northern and northwestern regions. Some 88% of sexually active adolescents aged 15–19 with more than one sexual partner had not used a condom in their most recent sexual encounter. Given the high adolescent pregnancy index and the increased health risk factors for girls, in late 2015, Guatemalan legislation raised both the minimum age for marriage and the age for declaring common-law relationships to 18 (30)—up from the prior minimum age of 14 for women and 16 for men.

Health of Adults and the Elderly

According to the 2008–2009 ENSMI (5), 21.7% of men and 1.5% of women were smokers at the time of the survey, while 23.7% of men and 5.4% of women were drinkers. Insufficient physical activity was reported in 11.5% of men and 15% of women (4). Cardiovascular disease, diabetes, suicide, homicide, and injuries and other violence, as well as different types of cancer, respiratory diseases, and chronic kidney disease, all contribute to an increase in years of life lost (YLL), placing a heavy burden on the Guatemalan population. Data from the World Health Organization (WHO) show that these diseases are among the 12 that contribute most to disability-adjusted life years (DALYs) (21). An estimate of the change in DALYs between the 1990s and 2013 conducted by the Institute for Health Metrics and Evaluation (IHME) (31), with no adjustment for age, revealed that the highest contribution to DALYs was from diabetes, which had increased by 158%, followed by cardiovascular disease and injuries caused by interpersonal violence. Table 2 presents the 20 leading causes of death in 2014 (12).

Table 2. Leading causes of deatha in the general population, Guatemala, 2014

Health of Ethnic and Racial Groups

One of the major challenges for health service delivery in Guatemala—particularly for health promotion—is monolingualism, especially among Mayan women, who speak their Mayan mother tongue but not Spanish, the official language. This is a real challenge, because most service providers are also monolingual and speak only Spanish. The MSPAS is currently distributing a self-identification guide for people who visit the health services to facilitate the collection of data on the group and linguistic community to which they belong (Garifuna, Maya, mestizo, or Xinca). Furthermore, the government has also approved a National Midwives Policy, which it is publicizing and promoting in all health services, especially in locations where most of the indigenous population resides. In addition, in July 2016 the new ministerial administration took office and declared its support for health centers nationwide that incorporated traditional and complementary medicine into their practice and added traditional healers to their staff. This resolution, which heightens recognition of Guatemala’s significant ethnic, cultural, and linguistic diversity, is based on the constitutional framework and other domestic law, as well as mechanisms such as the International Labour Organization (ILO) Convention 169 on Indigenous and Tribal Populations in Independent Countries, and the Health of the Indigenous Peoples Initiative of the Americas (SAPIA).

Health of the Disabled

Although there is no information on people with disabilities for 2010–2015, during the second half of 2016, the second National Survey of Persons with Disabilities (ENDI) was conducted, with results expected in 2017. According to the first survey (2005)(32), disability prevalence was 37.4 per 1,000 population, with visual (27% of the total) and musculoskeletal (21%) disabilities being the most important. Some 57% of the persons with disabilities had received specialized care at some point, and the leading cause of this low percentage was lack of money (66.6%). At the time of the survey, only 22% of persons with disabilities were in treatment. It was found that 57% of these individuals were army officers, workmen, or artisans; 17% were farmers or farm laborers; and 47% were self-employed.

Mortality

Table 2 shows the 10 leading causes of death in the general population for 2014. However, disaggregating by specific population groups, it is observed that the five leading causes of death in infants under 1 year were: 1) disorders originating in the perinatal period; 2) congenital malformations and chromosomal abnormalities; 3) influenza and pneumonia; 4) intestinal infectious diseases; and 5) septicemia. In children aged 1–4, the leading causes of death were pneumonia (34 per 100,000 population); intestinal infectious diseases (31.8 per 100,000); malnutrition and nutritional anemias (8 per 100,000); congenital malformations, deformities, and chromosomal abnormalities (7.5 per 100,000); and septicemia (7 per 100,000 population) (12). The direct causes of maternal mortality were hemorrhage, hypertension, infection, and abortion (16). According to the core indicators for 2016 (4), the national age-adjusted mortality rate per 100,000 population from diabetes mellitus was 69.9, with a higher rate in women (75.)) than men (62.)), while mortality from ischemic heart disease was 65.7–77.3 in men and 56.1 in women.

Breast cancer was the cause of death in 6 out of every 100,000 women. For prostate cancer, the age-adjusted death rate was 17.1 deaths per 100,000 men. Mortality from motor vehicle accidents was 18.8 per 100,000 population in men and 3.8 per 100,000 population in women. The homicide rate was significantly higher in men (62.3 per 100,000) than in women (9.6 per 100,000). According to the national publication on core indicators of 2012 (19), mortality from tuberculosis, malaria, and HIV/AIDS was 1.5, 0.1, and 3.2 per 100,000 population, respectively.

Morbidity

Communicable Diseases

Among vector-borne diseases, malaria is endemic in roughly 70% of Guatemala’s territory, although in recent years the highest incidences have tended to be concentrated in two departments, Escuintla and Alta Verapaz. The country met target 6C of the MDGs, reducing malaria by more than 75% with respect to 2000. The core indicators of 2012 (19) also reported a total of 7,022 cases—6,967 from P. vivax and 55 from P. falciparum. In 2015, the MSPAS reported 5,437 cases; control efforts are under way in Escuintla (2,155 cases) and Alta Verapaz (218 cases), while the rest of the country is achieving elimination of the disease.

Dengue is hyperendemic in several regions of the country, where circulation of the four serotypes of the virus has been confirmed. The most affected areas are the northwest, central Guatemala, Baja Verapaz, Santa Rosa, and Sacatepéquez. According to data from the Health Information Management System, 50 cases of severe dengue were reported in 2015, with 9 deaths. That same year 30,716 cases of chikungunya virus were reported, 13% more than in the same period in 2014, with 5 deaths; the most affected areas were Petén Sur Oriente, Zacapa, and Santa Rosa. The country began reporting cases of Zika virus in epidemiological week 46 of 2015. As of epidemiological week 25 of 2016, 1,852 cases had been reported, for a rate of 11.4 per 100,000 population; the most affected areas were Chiquimula, Quetzaltenango, Santa Rosa, and Zacapa. A total of 361 pregnant women with presumptive cases of Zika virus have been reported, 107 of which have been confirmed. In August 2016, one case of Zika-associated microcephaly was reported.

In 2010, the population exposed to Chagas disease totaled around 1.4 million, with 166,667 infected individuals, 32,759 of whom were women. The annual figure for new cases of vector-borne transmission was 1,275. The two most important vectors reported were Triatoma dimidiata (present in 21 of the 22 departments) and Rhodnius prolixus in a locality in the Department of Chiquimula, which is in the elimination phase.

The last foci of onchocerciasis (Robles disease) transmission in the country were eliminated in the period 2007–2011 and, in September 2016, after international verification, WHO declared Guatemala the fourth disease-free country.

The most frequently reported form of leishmaniasis is cutaneous (95% of cases). In the period 2010–2014, 2,600 cases were reported, with an incidence of 20 per 100,000 population. The most affected areas were Petén Norte, Petén Sur Oriente, Petén Sur Occidente, and Alta Verapaz.

In the period 2010–2015, the tuberculosis (TB) incidence rate fell from 23 to 21 per 100,000 population. The success rate (patients cured with treatment completed) for new cases of drug-susceptible mycobacterium tuberculosis was 86% for 2010 and 2011 and 87% for 2014. In contrast, dropout rates in the same period ranged from 5% to 8%. In 2013, the success rate (patients cured with treatment completed) in cases of multidrug-resistant (MDR) TB was 78%. However, 11% of the cases in that cohort died and 7.4% dropped out of treatment. In 2015, 63 people were diagnosed with MDR TB and 40 began treatment.

According to 2015 estimates, there were 55,000 (38,000–80,000) individuals in Guatemala with HIV and 3,700 (1,800–6,400) new infections annually. That same year, 1,580 new cases were reported. The epidemic is concentrated in certain key populations, such as men who have sex with men, trans women, and sex workers. Seroprevalence figures suggest that distribution of the HIV epidemic in the country is not uniform, since the cases are located primarily in urban areas along major commercial routes in the east and south, as well as in the key ports for national economic activity (33). The most common mode of transmission is sexual (93%), followed by mother-to-child transmission (4%). Of the cases reported in 2015, 68% were men and 32% women (male:female ratio of 2:1), with the highest number of cases among people aged 20–39 (64%). Of the total HIV cases reported in 2015, 78% of the individuals self-identified as Ladino or mestizo, 18% as Mayan, and 0.4% as Garifuna; 3% did not report their ethnicity. It is estimated that 9% of new TB cases were coinfected with HIV.

In the past 5 years, 6 cases of human rabies were reported (34) in western and southwestern departments (2 cases in 2011 and 1 in 2016 in Huehuetenango; 1 in 2014 in Suchitepéquez; 1 in 2014 in San Marcos, and 1 in 2016 in Quetzaltenango).

Vaccine-preventable Diseases

In regards to vaccine-preventable diseases, Guatemala continues to be free of wild poliovirus circulation. Progress has been made in the elimination of measles, rubella, and congenital rubella syndrome, and neonatal tetanus elimination has been maintained. Efforts are under way to control diphtheria, hepatitis B, invasive Haemophilus influenzae type b, tubercular meningitis, and whooping cough.

After reporting very low vaccination coverage in 2014, the MSPAS reported that coverage had been restored in 2015, reaching 90% for the vaccines administered to children under 2, in accordance with the national vaccination schedule. In 2010, the rotavirus vaccine was added to the schedule, and more than 1.2 million doses of the pandemic influenza A(H1N1) vaccine were administered. In 2016, the second dose of measles vaccine was introduced. Furthermore, as part of the final polio eradication phase, the first dose of inactivated vaccine was introduced and, for the subsequent doses in the schedule, the switch was made from the trivalent oral vaccine to the bivalent oral vaccine.

Nutritional Diseases

The 2014–2015 ENSMI (11) showed that 46.5% of children under 5 had stunting (less than –2 standard deviations from the median of a standard normal population distribution). Such prevalence in this age group reflects a failure to meet basic dietary and health needs due to deficient social, economic, and environmental conditions. Prevalence rates are higher in indigenous (58%) than nonindigenous groups (34.2%), in the children of mothers with no schooling (67%) than in those whose mothers have a higher education (19.1%), in children in the lowest socioeconomic quintile (65.9%) than in those in the highest quintile (17.4%), and in rural children (53%) than in urban children (34.6%).

Furthermore, stunting (height of less than 145 cm) is found in 35% of women of reproductive age in rural areas (versus 25% in urban areas) (5), 48.3% of indigenous women (versus 19% of nonindigenous women), and 48.8% of women with no schooling (versus 4.6% of those with a higher education).

The other extreme of nutritional status is also present in the country: 56.2% of women and 47.6% of men are overweight or obese (4). Added to this are problems associated with deficient consumption or utilization of micronutrients—for example, anemia, with a 25% prevalence in children under 5 and a 10% prevalence in mothers (11).

Accidents and Violence

Guatemala is located in a migration corridor where human and drug trafficking are prevalent, exposing the country to violence and insecurity that increase mental health problems. According to the State of the Region Report for Central America (22), Guatemala’s homicide rate in 2014 was 31 per 100,000 population. The most violent regions, with rates approaching 60 homicides per 100,000 population, are the eastern, northern, and southern regions, while, in the Western Altiplano, where the population is largely indigenous, the rates range from 9 to 15 per 100,000 population. To put this into perspective, according to that same source, the traffic accident rate in 2012 was 7.8 per 100,000 population.

The 2014–2015 ENSMI (11) reported that 20.4% of the women aged 15–49 that were interviewed—either married or in a stable relationship at some point—had experienced some type of physical violence at the hands of their partner; in 7.9%, the event had occurred within the past 12 months, and 7.1% had at some time experienced sexual violence. Furthermore, 9.4% of men said that they experienced physical violence at some point at the hands of their wife/partner—4.3% of them in the 12 months prior to the survey. The highest rates of violence against women were found in urban areas, in the highest socioeconomic quintile, and in the nonindigenous group. Gender violence against both men and women occurs more frequently in the central, southeastern, and metropolitan regions.

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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.

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References

1. Pan American Health Organization. PLISA: Health Information Platform for the Americas. Demographic-socioeconomic indicators: population national level, Guatemala, 2016 [Internet]. Washington, D.C.: PAHO; 2016. Available from: https://www.paho.org/data/index.php/en/indicators/demographics-core/308-poblacion-nac-en.html Accessed on 25 August 2016.

2. World Health Organization. Countries: Guatemala: statistics [Internet]. Geneva: WHO; 2016. Available from: http://www.who.int/countries/gtm/en/ Accessed on 29 August 2016.

3. Instituto Guatemalteco de Seguridad Social (Guatemala). Plan operativo anual institucional y presupuesto 2014. Guatemala City: IGSS; 2014. Available from: http://www.igssgt.org/ley_acceso_info/pdf/pdf2014/inciso5/POA_2014.pdf.

4. Pan American Health Organization. Core indicators 2016: health situation in the Americas. Washington, D.C.: PAHO; 2016. Available from: http://iris.paho.org/xmlui/handle/123456789/31289.

5. Ministerio de Salud Pública y Asistencia Social; Instituto Nacional de Estadística (Guatemala). Guatemala, V Encuesta Nacional de Salud Materno Infantil, ENSMI 2008–2009: informe final. Guatemala City: MSPAS; 2011. Available from: https://www.ine.gob.gt/sistema/uploads/2014/01/22/LYk4A1kGJAO7lvfS0Aq6tezcUa9tQh35.pdf.

6. Instituto Nacional de Estadística (Guatemala). Encuesta Nacional de Condiciones de Vida 2014, tomo I. Guatemala City: INE; 2016. Available from: https://www.ine.gob.gt/sistema/uploads/2016/02/03/bWC7f6t7aSbEI4wmuExoNR0oScpSHKyB.pdf Accessed on 25 August 2016.

7. Instituto Nacional de Estadística (Guatemala). Encuesta Nacional de Empleos e Ingresos, tomo II, 2014. Guatemala City: INE; 2015. Available from: https://www.ine.gob.gt/sistema/uploads/2015/05/14/zbOswAbS8BYJ2Ruv7RoRRiZp0uVGAXZZ.pdf Accessed on 25 August 2016.

8. Instituto Nacional de Estadística (Guatemala). Encuesta Nacional de Condiciones de Vida, 2014: principales resultados. Guatemala City: INE; 2015. Available from: https://www.ine.gob.gt/index.php/encuestas-de-hogares-y-personas/condiciones-de-vida Accessed on 25 August 2016.

9. Fundación para el Desarrollo de Guatemala. Índice de desempeño ambiental 2016. Boletín ’76. Guatemala City: FUNDESA; 2016. Available from: http://fundesa.org.gt/content/files/publicaciones/76_-_Indice_de_Desempeno_Ambiental_2016.pdf Accessed on 26 August 2016.

10. Hsu A, Alexandre N, Cohen S, Jao P, Khusainova E, Mosteller D. Environmental Performance Index 2016: country ranking—Guatemala [Internet]. New Haven: Yale University; 2016. Available from: http://epi.yale.edu/country-rankings Accessed on 26 August 2016.

11. Ministerio de Salud Pública y Asistencia Social; Instituto Nacional de Estadística (Guatemala). Guatemala: VI Encuesta Nacional de Salud Materno Infantil, ENSMI 2014–2015: informe de indicadores básicos. Guatemala City: MSPAS/INE; 2015. Available from: http://pdf.usaid.gov/pdf_docs/PBAAD728.pdf.

12. Pan American Health Organization. PLISA: Health Information Platform for the Americas. Mortality data: leading causes of death, Guatemala, 2014 [Internet]. Washington, D.C.: PAHO; 2016. Available from: https://hiss.paho.org/pahosys/lcd.php Accessed on 26 August 2016.

13. United Nations Children’s Fund. Pneumonia and diarrhoea: tackling the deadliest diseases for the world’s poorest children. New York: UNICEF; 2012. Available from: https://www.unicef.de/blob/8760/3341eb79ccd721c9d1842ed2fbdd3e98/ar035-unicef-report-on-diarrhoea-and-pneumonia-2012-pdf-data.pdf.

14. United Nations Children’s Fund; World Health Organization. Diarrhoea: why children are still dying and what can be done. Geneva: UNICEF/WHO; 2009. Available from: http://apps.who.int/iris/bitstream/10665/44174/1/9789241598415_eng.pdf Accessed on 30 September 2016.

15. Sistema de Información Nacional de Seguridad Alimentaria y Nutricional (Guatemala). Sala situacional desnutrición aguda [Internet]. Guatemala City: SIINSAN; 2016. Available from: http://www.siinsan.gob.gt/SemanasSalaSituacional Accessed on 29 August 2016.

16. Ministerio de Salud Pública y Asistencia Social (Guatemala). Situación de la mortalidad materna: informe de país 2013. Guatemala City: MSPAS; 2015. Available from: http://www.osarguatemala.org/Archivos/PDF/201510/255_3.pdf.

17. Sistema de Información Gerencial en Salud (Guatemala). Enfermedades por causa, transmisibles: morbilidad por dengue, 2009–2014 [Internet]. Guatemala City: SIGSA; 2016. Available from: http://sigsa.mspas.gob.gt/enfermedades-por-causa.html. Accessed on 29 August 2016.

18. Sistema de Información Gerencial en Salud (Guatemala). Enfermedades por causa, crónicas no transmisibles y cáncer: casos de enfermedades crónicas 2010 (nacional) [Internet]. Guatemala City: SIGSA; 2016. Available from: http://sigsa.mspas.gob.gt/enfermedades-por-causa.html. Accessed on 29 August 2016.

19. Ministerio de Salud Pública y Asistencia Social; Instituto Nacional de Estadística (Guatemala). Indicadores básicos de salud 2012: Guatemala. Guatemala City: MSPAS/INE; 2015. Available from: https://www.ine.gob.gt/sistema/uploads/2015/10/12/9d7Lu5VW9AJqkLm9wDxvdT4P6jqTtJS6.pdf.

20. Pan American Health Organization/World Health Organization. Informe sobre el sistema de salud mental en Guatemala, 2011. Geneva: WHO/PAHO; 2011. Available from: http://www.who.int/mental_health/who_aims_country_reports/guatemala_who_aims_report_spanish.pdf.

21. World Health Organization. Guatemala: WHO statistical profile. Geneva: WHO; 2015. Available from: http://www.who.int/gho/countries/gtm.pdf?ua=1. Accessed on 30 August 2016.

22. Programa Estado de la Nación (Costa Rica). Fifth State of the Region report on sustainable human development: summary [Internet]. San Jose, CR: PEN, 2017. Available from: http://estadonacion.or.cr/files/engdocs/ERCA5-BookSummary.pdf.

23. Asociación Bancaria de Guatemala. Análisis económico ECO-ABG: informes 2014, Diciembre—sector automóviles. Guatemala City: ABG; 2014. Available from: http://abg.org.gt/web2014/wp-content/uploads/2014/09/SECTOR-3-AUTOMOVILES-DICIEMBRE-2014.pdf.

24. International Organization for Migration. Perfil migratorio de Guatemala 2012. Guatemala City: IOM; 2013. Available from: http://publications.iom.int/es/system/files/pdf/mpguatemala_11july2013.pdf.

25. Ministerio de Salud Pública y Asistencia Social (Guatemala); World Health Organization. Perfil de salud de los pueblos indígenas de Guatemala. Guatemala City: MSPAS/WHO; 2015. Available from: https://www.paho.org/gut/index.php?option=com_docman&view=download&category_slug=publications&alias=792-perfil-de-salud-de-los-pueblos-indigenas-de-guatemala&Itemid=518.

26. Ministerio de Salud Pública y Asistencia Social (Guatemala); Pan American Health Organization/World Health Organization. Desigualdades en salud en Guatemala. Guatemala City: MSPAS/WHO/PAHO; 2015. Available from: https://www.paho.org/gut/index.php?option=com_docman&view=download&category_slug=publications&alias=793-desigualdades-en-salud-en-guatemala&Itemid=518.

27. Ministerio de Salud Pública y Asistencia Social (Guatemala). Modelo de atención de primer nivel. Guatemala City: MSPAS; 2016.

28. Ministerio de Salud Pública y Asistencia Social (Guatemala); Pan American Health Organization. Manual metodológico: implementación de la estrategia de redes integradas de servicios de salud (RISS) en Guatemala. Guatemala City: MSPAS/PAHO; 2015.

29. Ministerio de Salud Pública y Asistencia Social (Guatemala). Ministerio de Salud Pública y Asistencia Social: Red de servicios, tercer nivel de atención [Internet]. Guatemala City: MSPAS; 2016. Available from: http://www.mspas.gob.gt/ Accessed on 30 September 2016.

30. El Periodico (Guatemala). Edad de matrimonio infantil se eleva a 18 años con salvedades [news release]. 6 Nov. Guatemala City: Aldea Global; 2015. Available from: https://elperiodico.com.gt/nacion/2015/11/06/edad-de-matrimonio-infantil-se-eleva-a-18-anos-con-salvedades/.

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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