Pan American Health Organization

Honduras

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

Flag of HondurasThe Constitution of Honduras defines the country’s government as republican, democratic, and representative with three complementary and mutually independent powers: the executive, legislative, and judicial branches.

The country extends for 112 492 km2 and has a coastline along the Caribbean Sea and the Pacific Ocean; it is divided into 18 departments and 298 municipalities.

Demographics

In 2016, Honduras had an estimated population of 8,189,501 (51.19% women and 54.7% urban) (); 31.0% of its population was under 15 years of age and 7.4% was 60 years old or older. By 2016, the aging of the population had causes the population pyramid to shift from a progressive to a regressive pattern, placing the country in a position to benefit from the demographic bonus (). Figure 1 shows the evolution of Honduras’ population structure between 1990 and 2015.

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

Between 1990 and 2015, the population increased by 64.7%. In 1990 the population has a rapidly expansive structure, with the under-25 age group predominating. By 2015 the pyramid’s structure had become more regressive, with a larger aging population and a reduction in the under-20 age group, due a marked decline in fertility and mortality rates over the intervening decades.

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

The Economy

Honduras, which is considered to be a lower middle-income country, has worked to transform and modernize its economy; the country is transitioning from an economy driven by agriculture to an industrial economy, especially maquiladoras, which now represents 20% of the gross domestic product (GDP). The country has recovered from the 2008/2009 political and economic crisis to achieve a growth rate of 3.5% in 2015, thanks to public investments, exports, and a high level of remittances.

Violence and Security

According to a 2015 survey, one in five people had been a victim of crime. Respondents also felt that they could not rely on the institutions directly or indirectly responsible for their safety (). In 2014, the country had one of the highest homicide rates in the world, with 67 murders per 100,000 population Crime curtails competitiveness and discourages investment; the World Bank estimates that it is responsible for the country losing 10% of GDP ().

Leading Environmental Problems

The country’s diverse territory includes several of different ecosystems. Approximately 27% of its total land encompass areas that have been set aside to preserve biodiversity or as aquifer recharging areas along the main river basins. These areas are threatened by deforestation from intensive livestock raising, land clearing, and expansion of the area under human use (). Although the country has an overall water supply of 87,000 hm3/year, infrastructure conditions limit the amount actually consumed by households, commercial and industrial applications, agriculture, hydroelectric generation, and tourism to only 9%.

The country’s northern portion has an abundant water supply in both rainy and dry seasons, but in the south, water supply is much lower during the dry season, reduces the yield of wells. The overexploitation of groundwater has given rise to problems, particularly in the south, where much of the land is devoted to intensive agriculture for export. Pollution and salinization are the main threats to the water supply ().

Health Policies, Plans, and Programs

Country Vision 2010-2038 sets goals, targets, and guidelines designed to achieve equity based on “solidarity and equity as criteria for State intervention” and “gender equity as a cross-cutting axis;” since this strategy came into effect in 2010, seven administradiont have adopted it The ultimate goal of Country Vision 2010-2038 is to reduce inequality so that, by 2038, all Hondurans will be able to have equal access to quality education, health care, vocational training, social security, and basic services ().

Social Determinants of Health

The government’s 2014-2018 Strategic Plan sets forth objectives aimed at increasing employment and reducing poverty, stabilizing the economy, shoring up the country’s infrastructure and logistic development, strengthening democratic governance, and protecting citizen safety (). Within this framework, the government has created the Better Life program, which is designed to provide a safety net for those living in extreme poverty through such projects as Healthy Housing, Creating Jobs and Opportunities, Let’s Develop Honduras, and the Better Life bond. By 2015, these projects had benefited 150,000 persons through conditional monetary transfers and improvements to their homes.

Environmental regulations include the National Policy for the Drinking Water and Sanitation Sector (), the Policy on the Rational Management of Chemicals, and its accompanying National Commission (), and the Climate Change Act (), which is linked to the National Climate Change Strategy 2010 (). The country’s environmental policy is being updated; other mechanisms, such as the National Policy and the Law on the Comprehensive Management of Solid Waste, are under preparation ().

Vulnerable Populations

The country’s authorities have defined vulnerable populations as those for whom there is little or no presence of the State and its services, especially groups living in extreme poverty, children, adolescents, pregnant women, older persons, and indigenous peoples. According to the Unmet Basic Needs (UBN) calculation, in 2013, 15.9% of Hondurans were living in extreme poverty or had more than one unmet basic need, most often a lack of basic services and overcrowding (). Among the population older than15 years old, 88% had an average of 7.5 years of schooling, while fewer than 30% had a secondary education. The average proficiency was 48% for mathematics and 43% for language skills. Spending on education was 7% of GDP ().

In 2012, one in five Hondurans lived on less than US$ 1.90 a day, and in 2013, almost 65% of households lived in poverty, 43% of them in extreme poverty. These conditions have come about due to a slow per capita growth and a high degree of inequality (Gini coefficient of 0.54 in 2013), perpetuated by the country’s vulnerability to external shocks ().

The Health System

The country has a dual health system, with public and private sectors. The Ministry of Health and the Honduran Social Security Institute (IHSS) are the two main institutions in the public sector. While the Ministry of Health serves the entire population in its own facilities with its own physicians and nurses, it is estimated that only 50%-60% of Hondurans use its services regularly. IHSS covers 40% of actively employed individuals and their dependents, 18% of the total population, through its own and contracted facilities. The private sector serves those who can afford to pay out-of-pocket or who are covered by private insurers (between 10% and 15% of the population), providing care in private physician’s offices and nonprofit and for-profit private hospitals. It is estimated that 17% of Hondurans have no regular access to health services ().

The National Health Model, based on primary health care, was approved in 2013. One of its strategies calls for the deployment of 500 primary health care (PHC) teams to rural and isolated areas within two years. The teams, consisting of a physician, a nurse, and a health promoter, give priority to communities living in extreme poverty, environmentally vulnerable conditions, or violent situations. By mid-2015, 367 teams were already working in the field, serving 1,400,000 persons and promoting in their attitudes and habits ().

The new classification of health facilities recognizes three types of first-level care units (the PHC unit, the comprehensive health care center, and the polyclinic) and four second-level establishments (the basic hospital, the general hospital, the specialty hospital, and the health institute).

In 2015, the decentralized health services provided care in 82 municipalities in 15 departments, covering a population of 1,337,874 (); by the first half of 2016 the decentralized management model had been adopted by 16 municipal governments, 11 intermunicipal communities, 5 nongovernmental organizations, and 6 grassroots community organizations.

Leading Health Challenges

Chronic Conditions

Surveys of risk factors found that 34% of those older thaan 20 years were overweight and 21% were obese to some degree (); among adolescents 13-15 years old, 18.7% were overweight and 5.4% were obese ().

The national prevalence of diabetes among 20-79-year olds is 7.4% (), although this figure varies depending on the source (). The prevalence of hypertension is 22.6% in the adult population (23.2% in men and 22.1% in women) ().

Human Resources

The Directorate-General of Human Resources, created in 2013, is responsible for the professional development of health workers; it has formalized the Honduras Human Resources for Health Observatory.

According to the Central American Human Resources Observatory, in 2015 the country had not met the targets established in 2007 for the density of physicians and nurses. In 2013, the country had 10 physicians, 3.8 nurses, and 0.3 dentists per 1,000 population. The country also did not meet targets for the competencies of primary care personnel, retention of the country’s trained health workers, or promotion of healthy working environments (). While numbers are imprecise, there is a growing trend of of physicians and nurses emigrating to the United States, Spain, and elsewhere in search of better social and economic conditions. As part of a subregional effort, a strategic framework has been proposed to encourage the formulation of policies aimed at retaining skilled human resources and forestalling a deterioration of quality in the health services ().

Health Knowledge, Technology, and Information

A year after the enactment of the 2013 Law on Promotion of the Development of Science, Technology, and Innovation, the National System of Science, Technology, and Innovation was created, composed of the National Secretariat for Science, Technology, and Innovation and the Honduras Institute of Science, Technology, and Innovation. The law is intended to promote and consolidate scientific and technological development in Honduras’ private research centers and groups, as well as in public and private institutions of higher learning that focus on science and technology.

Also in 2014, the Ministry of Health created its Information Management Unit, which is responsible for ensuring that health information is accurate, timely, and useful to health planning, organization, direction, control, and evaluation. In 2016, the unit began to implement the electronic family health record to be used by family health teams nationwide.

As of 2016, 28 hospitals in the country had access to the FarmaTools system, which offers better management of medications and the capability to issue prescriptions electronically.

Although the 2015 Third Global Survey on eHealth did not show progress, it did identify some successful pilot experiments, including a health surveillance application and the use of smartphones for reporting outbreaks. Based on these initial successes, additional eHealth strategies that will contribute to universal health coverage are being planned.

In terms of research, in 2015 the Ministry of Health published the Health Research Agenda 2015-2018. In addition, the 2012 Network of Ethics and Research Committees was expanded to include 12 additional ethics committees in various parts of the country. The network uses the ProEthos platform, which facilitates the review of research protocols and guides researchers and committees in meeting the requirements for the ethical stages of scientific studies.

Honduras does not have a national dialysis and kidney transplant registry, but in 2014 the Ministry of Health introduced a dialysis registration and billing system (Control Dialisis) which has made it possible to gather epidemiological data and information on costs, helping to improve patient care and reduce the cost of services. The IHSS has a separate dialysis and transplant registry that is not integrated with the Ministry of Health system.

The Environment and Human Security

Air Pollution

The country’s efforts to manage air quality focus]on Tegucigalpa, concentrations of suspended particulates and particulate matter exceeded the reference values at the locations selected (), according to a study. Other initiatives for addressing air quality in the interior () have been developed according to World Health Organization (WHO) guidelines ().

Use of Solid Fuels

Approximately 1,000,000 Honduran households depend on firewood and other organic matter for cooking and heating. Such use constitute risk factors for health, as well as a major environmental hazard (). Since 2014, the Better Life program has been fulfilling its commitment to distribute 100,000 efficient firewood stoves each year. Beneficiaries are selected by the National Social Sector Information Center. Government oversight of the operation is handled the Healthy Housing Technical Unit within the Ministry of Social Development and Inclusion.

Persistent Organic Pollutants

Honduras imports chemicals for agricultural, industrial, domestic, and public health use. Even though these are regulated by various government agencies, it has not been possible to assess the volume of production or the flow of chemical waste. In 2012, the Persistent Organic Pollutants Project (COPs2) eliminated 60 tons of products and materials contaminated with persistent organic pesticides (POPs) and obsolete or banned pesticides, including 500 kg of endosulfan. Surveillance of acute pesticide poisoning disclosed a rate of 14 poisonings per 100,000 population in 2012, while an analysis of over 300,000 hospital discharges showed that 4.4% of the hospitalizations were for poisonings, 42.6% of them due to pesticides ().

Natural and Manmade Disasters

Data gathered for the Global Climate Risk Index 2016 shows that Honduras was one of the three countries in the world most affected by extreme weather events during the 20-year period from 1995 through 2014 (). Public expenditure on risk management has not been sufficiently proactive, which has undermined the country’s resiliency in facing disasters (). In 2014-2015, farmers in Honduras’ “dry corridor” suffered heavy crop losses and water shortages, leading to a drop in food production and, as a result, lost income. During this period, the government declared an international drought emergency ().

An important milestone in disaster preparedness was approval of the 2013 Honduras National Policy on Comprehensive Risk Management. This policy calls on government agencies to adopt ongoing and concrete measures to reduce vulnerability and risk in the event of disasters, as well as to cultivate a culture of citizen and institutional preparedness, responsibility, and resilience. The effects of this policy will contribute to fulfillment of the government’s international commitments, but implementing it will be a challenge ().

Water and Sanitation

The population with access to improved drinking water sources increased from 80.0% in 2000 to 91.2% in 2015, while the population with access to improved sanitation facilities increased from 63.3% to 82.6% during the same period. In urban areas, 97.4% of residents had access to water and 86.7% to sanitation, but in rural areas these figures were 83.8% and 77.7%, respectively (). Real access to drinking water is much lower, however, because 90% of the supply is intermittent and only 44% of the water systems purify it effectively. Of the 54 sewer systems registered with the Regulatory Entity of the Drinking Water Services and Sanitation (ERSAPS), only 52% have a purification system; the others pour wastewater directly into the final receiving body ().

The level of investment in urban water supply has been insufficient to maintain coverage and extend service to the low-income population. ERSAPS does not have information on the application of water quality standards by service providers in the municipalities. The recovery of service costs is highly inefficient: on average, about 60% of the cost of supplying the services is offset by tariffs collected.

Solid Waste

The main institutions responsible for regulating solid waste management are the Ministry of Health and the Ministry of Energy, Natural Resources, the Environment, and Mines, but only the latter has a department for solid waste management with responsibility for institutional coordination, planning, promotion, and training, among other functions. At the local level, the municipal governments are directly responsible for solid waste management, but only 23% of them have a department specifically devoted to the collection, transportation, and final disposal of solid waste, and they usually have to deal with multiple administrative, technical, and operational challenges. There is no information system, nor are there any indicators for solid waste management, but according to estimates from 2014, a total of 4,575 tons of household waste were being generated in a day, while reports published in 2002 and 2010 showed collection levels of 68% and 64.6%, respectively. It has been calculated that no more than 5.7% of the country’s solid waste receives proper final disposal. Seventeen municipalities have a facility like a mechanized or semi-mechanized landfill or use trenching. Unfortunately, most of the municipalities have open-air dumps that pollute the soil, air, and water ().

Aging

The country is at the start of a demographic transition, with 7.4% of its population being over 60 years of age. However, a longer life is not matched by an improvement in quality of life. Furthermore, the over-60 age group is particularly vulnerable for many reasons, including the facts that 46.6% of them had no schooling and 79.7% did not have any Social Security coverage (). Of the population 60-69 years old, 44.5% live in extreme poverty; for those aged 70-79 years, the proportion rises to 51.2%.

Migration

The country’s economic and social situation is one of the factors that motivate Hondurans to emigrate. They mainly go to the United States, but other destinations include Canada, Italy, and Spain. Since 2000, the annual emigration from Honduras to the United States is estimated at 80,000 undocumented individuals, who risk illness and death from disease or violence. Of this total, about 70,000 are repatriated. Those who manage to stay generate annual remittances amounting to more than US$ 2,500 billion, or 15%-20% of the national GDP ().

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

Total per capita spending on health increased from US$ 178 in 2010 to US$ 212 in 2014, though as a proportion of GDP the level remained unchanged at 8.72%. That same year, public spending (Ministry of Health plus IHSS) came to US$ 107 per capita, or 4.4% of GDP. Out-of-pocket spending in 2011 represented 50% of total health sector expenditure.

In 2014, the Ministry of Health established a Master Insurance Plan for Medicines and Health Supplies. A review of the National List of Essential Medicines covering 495 and 349 active ingredients was conducted in 2014-2015. The country has increased its level of withdrawal from the PAHO Strategic Fund to US$ 2.9 million, which is used for the purchase of medicines, equipment, reagents and supplies.

The Government has identified the following list of health challenges: (i) restructuring the Ministry of Health to strengthen its stewardship role and implement the separation of functions; (ii) strengthening the Integrated Health Information System through development of a results-based system for the monitoring and evaluation of management; (iii) developing public policies that promote healthy habits and healthy lifestyles; (iv) implementing the International Health Regulations; (v) monitoring compliance with the Framework Convention on Tobacco Control; (vi) retrofitting infrastructure with a view to achieving optimal operation of the health services network; (vii) conducting research on indigenous and African descent populations to learn about evidence-based interventions; (viii) building the quantity, quality, and relevance of human talent, especially to strengthen the first level of care and ensure continuity of the model; and (ix) strengthen actions aimed at ensuring quality patient care and safety in health establishments ().

Prospects

The country needs to design strategies to strengthen the stewardship roles of the national health authority, including evaluation and strengthening of essential public health functions under Ministry of Health leadership (SESAL). Furthermore, a reliable integrated health information system is needed. It is imperative to develop and strengthen national capacity and dialogue on the adoption of financing strategies aimed at increasing and optimizing public investment in the health sector. Box 1 summarizes Honduras’ leading achievements and challenges in health.

It is also essential to update national policy on medicines and develop an action plan to facilitate its execution, along with legal and regulatory frameworks that take health needs into account as well as the life course of the medicine. In addition, a regulatory framework is needed for implementing the new model of the national medicines and supplies management system. The national regulatory authority for medicines and other supplies should also strengthened by implementing a quality management system, updating the regulatory framework, and developing human resources capacity.

In order to meet the Sustainable Development Goals (SDGs), technical cooperation will be needed to support the definition, and the later the measurement, of national targets under SDG 3 and other health-related goals. It is essential to promote and strengthen multisectoral partnerships and the generation of evidence for the Health in All Policies approach, especially for noncommunicable diseases and injuries due to external causes. It is also pertinent and necessary to develop national capacity and competency in measuring equity and inequalities in health, as well as in applying the human rights and gender and ethnic equality approaches.

The current delivery model is based on quality health services offered with compassion, based on primary health care throughout the life course, integrated into people- and community-centered networks, and coordinated with actions aimed at strengthening and implementing the National Health Model (MNS). The management of public health services and human resources development needs to be improved. It is important to design strategies that will make it possible to have skilled, culturally appropriate, well regulated, and equitably distributed health personnel.

Basic skills need to be strengthened so that it will be possible to detect, assess, and report events in accordance with International Health Regulations; prepare for risks; and respond rapidly and effectively to public health emergencies. It is also urgent to strengthen epidemiological surveillance and the integrated management of vectors and risks in order to provide a systematic and strategic response to situations involving communicable and vector-borne diseases.

BOX 1. Leading Achievements and Challenges in Health

Prior to 2015, there was no law enshrining the national health care model or mechanisms for regulating it. Mindful of this lacuna, during that year the National Congress approved the Framework Law on Social Protection, which establishes a new modality for social protection. The Framework Law envisages a unified, universal system of public health insurance that allows for the articulated coexistence of benefits and services provided by both the contributory and subsidized systems (Art. 21). The model is aimed at achieving a pluralism in which separation of the system’s functions is clearly delineated. This will require a new organizational structure in which the stewardship role of the Ministry of Health is strengthened, a structure for health oversight is established, and the role of the IHSS as insurer of the National Health System is recognized.

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Reference/Note:

1. In-bond assembly plants.

2. The United Nations considers any rate above 10 per 100,000 population as an epidemic.

3. Strategy and Plan of Action on eHealth: Midterm Review. 158th Session of the Executive Committee of PAHO/WHO, Washington, D.C., 20-24 June 2016. Available from: https://www.paho.org/hq/index.php?option=com_content&view=article&id=11901&Itemid=41978&lang=en.

4. Underreporting is calculated by comparing reported deaths (6,477 in 2013) against expected deaths for the same period (40,490 in 2013), the latter figure based on the crude mortality rate and the country’s total population.

5. Stewardship functions: leadership, oversight of the normative framework, guarantee of insurance and equitable access to health care, modulation of health financing, harmonization of health services delivery, surveillance of health, and monitoring and evaluation of the performance of national health services.

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