Country Report: Guatemala
Guatemala is located in Central America and borders Mexico, Honduras, El Salvador, and Belize. With a territory of 108,928 km2, it is divided politically and administratively into 22 departments and 340 municipalities. The main ethnic groups are the Garifuna, the Maya, the Xinca and mixed race, or mestizo.
Although Spanish is the official language, 22 languages with their different dialects are spoken by ethnic Mayans, and the Garifuna and Xinca also speak their own languages.
Between 1990 and 2015, the population grew by 78.4%. The population structure remains expansive, totaling 16.3 million inhabitants in 2015 and 16.7 million in 2016, although the population is steadily aging. In 2015, people aged 65 and over made up 5.3% of the population.
In 2012, life expectancy at birth was 68 years for men and 75 for women.
- The last foci of onchocerciasis (Robles disease) transmission were eliminated in the period 2007-2011. In September 2016, after international verification, the World Health Organization declared Guatemala the fourth disease-free country.
- 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). Trachoma elimination will soon be a reality.
- The country met target 6C of the Millennium Development Goals, reducing malaria by more than 75% over 1990.
- 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 influenza type b, TB meningitis, and whooping cough.
Figure 1. Distribution of the population by age and sex, Guatemala, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan-American Health Organization, World Health Organization, and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: División de Población y División de Estadísticas de las Naciones Unidas 1990; Organización Panamericana de la Salud. Plataforma de Información de Salud (PLISA) 2013, 2014 y 2015.
SOCIAL DETERMINANTS OF HEALTH
- In 2014, 23.4% of the population was living in extreme poverty, with a higher figure in indigenous groups (39.8%) and rural dwellers (35.3%). The informal economy employed 65.8% of workers: 80.3% among the indigenous population versus only 57.7% in the non-indigenous population.
- In 2014, the literacy rate for people 15 years or older was 79.1% (84.8% in men, and 74% in women; 86.1% in urban areas, and 71.4% in rural areas). Among rural women, the literacy rate was 64.7%, although this figure was 57.6% among indigenous women, since they are the most disadvantaged group in terms of access to education.
- Departments with a higher percentage of indigenous and rural populations with less access to health services had the highest maternal mortality.
- The population periodically suffers the effects of natural disasters, particularly volcanic eruptions, droughts, and storms.
- Urbanization is growing, largely due to internal migration toward urban centers. Major cities and surrounding areas are marked by insecurity and violence stemming from drug trafficking, prostitution, human trafficking, etc.
- There is a significant amount of emigration, mainly in the direction of the United States and Mexico. Guatemala's geographic location puts it in a migration corridor where human and drug trafficking are prevalent, exposing the country to violence and insecurity.
- 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.
HEALTH SITUATION AND THE HEALTH SYSTEM
- In 2013, maternal mortality was 113.4 deaths per 100,000 live births. Of these deaths, 68.4% were indigenous women and 42% were illiterate women. The leading causes of death were hemorrhage, hypertension, infection, and abortion.
- It has been estimated that 20.7% of women aged 10-19 had already had one pregnancy and 16.2% were already mothers.
- From 2010 to 2015, mortality in children under 5 was 35 deaths a year per 1,000 live births. In this period, 40.5% of deaths occurred in the neonatal period and 80% in the first year of life.
- The leading causes of death in infants under 1 year were disorders originating in the perinatal period and congenital malformations.
- In the period 2014-2015, 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 all their vaccinations. Progress has been made in the elimination of measles, rubella, and congenital rubella syndrome, and neonatal tetanus elimination has been maintained.
- In 2010, the rotavirus vaccine was added to the national vaccination schedule and in 2016, the second dose of measles vaccine was introduced. 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.
- One of the major challenges for health service delivery is monolingualism, especially among Mayan women, who speak their Mayan mother tongue but not Spanish, the country's official language.
- The estimated disability prevalence was 37.4 cases per 1,000 population. At the time of the survey, in early 2017, only 22% of persons with disabilities were receiving care.
- In 2014, 17% of deaths were from circulatory system diseases, 16% from external causes, and 12% from respiratory system diseases.
- In 2016, diabetes mellitus caused 69.9 deaths per 100,000 population (62.0 in men and 75.0 in women), while ischemic heart disease caused 65.7 deaths per 100,000 population (77.3 in men and 56.1 in women).
- Breast cancer was the cause of death in 6 out of every 100,000 women, and prostate cancer, the cause in 17.1 out of every 100,000 men.
- The homicide rate was higher in men than in women (62.3 and 9.6 per 100,000 population, respectively).
- Dengue is hyperendemic in several regions of the country, where circulation of the four serotypes of the virus has been confirmed. In 2015, 50 severe cases of dengue were reported, with nine deaths. That same year, 30,716 cases of chikungunya virus were reported.
- In 2006, there were 11.4 cases of Zika virus per 100,000 population. In 2010, 166,000 people had Chagas disease, and in the past five years, 6 cases of human rabies were reported.
- In 2016, the country was declared free of onchocerciasis. In the period 2010-2014, 2,600 cases of leishmaniasis were reported, with an incidence of 20 per 100,000 population.
- In 2012, mortality from tuberculosis (TB), malaria, and HIV/AIDS was 1.5, 0.1, and 3.2 deaths per 100,000 population, respectively.
- In 2015, there were 55,000 people with HIV and an estimated 3,700 new infections annually.
- In the period 2010-2015, the TB incidence rate fell from 23 to 21 per 100,000 population. In 2015, 63 persons were diagnosed with multidrug resistant (MDR) TB, and 40 began treatment. In 2010, the leading causes of morbidity from chronic diseases were diabetes mellitus, hypertension, cerebrovascular disease, and tumors.
- An estimated 46.5% of children under 5 had stunting, a major problem in indigenous populations (58%), children whose mothers had no schooling (67%), and in rural areas (53%). Some 56.2% of women and 47.6% of men are overweight or obese.
- Chronic non-communicable diseases are a heavy burden on the population, especially cardiovascular disease, diabetes, various types of cancer, respiratory diseases, and chronic kidney disease.
- The national regulatory agency is the Ministry of Public Health and Social Welfare. It covers 70% of the population and provides services at the three levels of care; however, access indicators are low, primarily for the indigenous population.
- The Guatemalan Social Security Institute covers approximately 18% of the population, and around 8% of the population has access to private health insurance.
- The Ministry of Public Health and Social Welfare has launched the Inclusive Health Model (MIS) as a mechanism for restructuring and strengthening the public health services network.
- In 2014, Guatemala's average fiscal and tax revenues represented 11.6% of its Gross Domestic Product (GDP). That year, health financing represented 6.3% of GDP, including the public and private sectors.
- In 2014, the country had 7.5 physicians per 10,000 population. However, distribution was unequal, as some departments only had 1.5 physicians per 10,000 population.
- As of 2015, the Ministry of Health had a primary health care-based model. Under this model, health services were institutionalized to guarantee preventive care and health promotion for individuals, families, and communities.
- Priority is given to rural communities, assigning specific health territories of 5,000 people to rural health posts staffed by health teams consisting of nursing auxiliaries, educators, and community facilitators. The health teams also coordinate with midwives.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- The Ministry of Health and Social Welfare is responsible for overseeing the health sector, but it has political and financial limitations that impede more effective management of a segmented and fragmented health system. The relatively low and unequal social and health indicators pose complex challenges that are hard to resolve with the system's current structure and performance.
- The main challenge for the health system is to draft feasible policies and plans that can be implemented gradually and consider the real development potential, given the available resources, national context, and the country's financial constraints.
- The country needs to implement a model that promotes universal access to health and universal health coverage, with special attention to the social, economic, and environmental determinants of health.
- A main concern is resolving language access barriers, since most of the indigenous population is monolingual.
- Health policies should include mechanisms and tools that address health determinants in a multisectoral manner, link the sector with the social and economic agenda, and improve the oversight capacity of the health authority.
- Similarly, appropriate intersectoral coordination is needed to take the action necessary to meet the Sustainable Development Goals.
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