- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Puerto Rico, officially known as the Commonwealth of Puerto Rico, is an archipelago in the Greater Antilles located in the northeastern Caribbean Sea; it comprises a principal island with 78 municipalities, 8 senatorial districts, and a number of smaller islands (the largest of which are Mona, Vieques, and Culebra). The total area of the main island, measuring 170 km by 60 km, is 9,105 km2. The Puerto Rican climate is tropical, with varied ecosystems: coastal and marine, dry forests and rainforests, the karst region, and mountainous areas. The capital is San Juan, located on the northern coast of the main island.
According to the 2010 census, Puerto Rico’s population was 3,721,526 people; in 2015, it had fallen 6.6%, to 3,474,182 (Figure 1). During that same period, the proportion of the population 65 years old or older rose from 14.5% to 18.0%. The median age also rose, from 37 in 2010 (35.2 in men and 38.7 in women) to 40 in 2015 (38 in men and 41.8 in women). Moreover, the 0–19-year age group shrank 17.3%, from 1,010,741 in 2010 to 835,602 in 2015, and the 30–39 group also dropped during that period, from 488,064 to 430,172 (11.9%). The greatest increase was in the subgroup of women and girls aged 5 years or more, from 308,404 in 2010 to 355,631 in 2015 (15.3%). Between July 2010 and July 2015, nearly all of Puerto Rico’s municipalities, except for Gurabo and Toa Alta, lost population. The general fertility rate was 52.2 per live births per 1,000 women of reproductive age in 2012, dropping to 48.2 in 2014.
Figure 1. Population structure, by age and sex, Puerto Rico, 1990 and 2015
Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.
Life expectancy rose from 78.8 to 79.5 years between 2010 and 2013; for men, the increase was from 74.8 to 75.8 years, whereas for women it was from 82.7 to 83.1 (). The economic dependency ratio rose from 52.3% in 2010 to 53.9% in 2015 (). The replacement rate has remained constant at 1.7 between 2010 and 2015 ().
According to the World Bank, Puerto Rico is a high-income economy, since between 2010 and 2015 its average annual per capita income was US $12,476 (). Nevertheless, the recession that began in 2006 worsened during that period: the economy, including the banking industry and housing sales, slumped; oil prices rose; and there were persistent deficits, leading the bond markets to lose confidence (). Consequently, in 2016 the U.S. government passed the Puerto Rico Oversight, Management, and Economic Stability Act (PROMISE), which established a Financial Oversight and Management Board, a process for restructuring debt, and expedited procedures for approving critical infrastructure projects ().
The gross national product (GNP), at current prices, grew between fiscal years 2014 and 2015 (Table 1). However, at constant prices, GNP fell by US$ 6.347 billion in fiscal year 2014, and by US$ 6.312 billion in 2015. Medical and funeral services, one of the components of personal consumption expenditure?the principal component of internal demand, at current prices?totaled US$ 11.497 billion in 2014, rising to US$ 12.54 billion in 2015 (an increase of US$ 1.043 billion (Table 2) ().
Table 1. Gross national product in current and constant prices, Puerto Rico, fiscal years 2012-2015 (in million U.S. dollars)
Source: Commonwealth of Puerto Rico, Office of the Governor, Planning Board, Economic Report to the Governor, 2015.
Table 2. Spending on personal consumption, including medical and funeral services, Puerto Rico, fiscal years 2014 and 2015 (in million U.S. dollars)
|Medical and funeral services||11,497.2||12,540.6|
Source: Commonwealth of Puerto Rico, Office of the Governor, Planning Board, Economic Report to the Governor, 2015.
The Gini economic inequality index showed a slight increase, from 0.537 in 2010 to 0.559 in 2015. The rates of poverty and extreme poverty, likewise, rose by an average of 1% for all age groups, although the most affected population group was those under 18, whose poverty rate grew from 56.3% in 2010 to 58.3% in 2015 (). On the other hand, the unemployment rate dropped 3.4 percentage points (from 16.3% in 2010 to 12.9% in 2015), and the gross domestic product (GDP) saw a slight uptick, from US$ 98.381 billion in 2010 to US$ 102.906 billion in 2015. Furthermore, GDP per capita grew from US$ 26,369 in 2010 to US$ 29,360 in 2015 (). The inflation rate fell from 2% in 2010 to 0.3% in 2015 (). Gross public debt stood at US$ 66.182 billion in 2015 (). In May 2017, Puerto Rico sought a form of bankruptcy relief in U.S. federal court for its debt and pension obligations of US$ 123 billion ().
Violence and Security
The annual homicide rate dropped from of 31.6 per 100,000 inhabitants in 2011 to 16.8 in 2015. The homicide rate for August 2011 was 26.7 per 100,000, falling to 15.9 homicides for August 2016.
As to the increase or decrease in the rates for other crimes per 100,000 inhabitants from 2013 to 2015: rape increased from 0.47 in 2013 to 3.1 in 2015, which can be attributed to public awareness campaigns on the importance of reporting sexual assault; robbery dropped from 111.9 to 78.6; aggravated assault rose from 43.8 to 57.6; and in the case of property crime, burglaries fell from 257.7 in 2013 to 184.5 in 2015 (). In 2016, the police force had approximately 382 officers per 100,000 inhabitants.
The first case of human trafficking was reported in 2015. Although Puerto Rico’s overall figures for homicide and other violent crime have fallen, these problems still persist (Table 3) (); therefore, a Violent Deaths Surveillance System was launched, which began compiling data in January 2017.
Table 3. Number of homicides, number of inhabitants, and annual homicide rate, Puerto Rico, 2011-2015
|Rate (per 100,000 inhab.)||31.6||27.6||25.1||19.8||16.8|
Source: Police of Puerto Rico, Report of Type I Crimes (2011-2015). Available at: http://estadisticas.pr/iepr/Estadisticas/InventariodeEstadisticas/tabid/186/ctl/view_detail/mid/775/report_id/00975852-e14a-4339-a6c8-ab23fd36d2a1/Default.aspx.
Leading Environmental Problems
The Environmental Protection Agency (EPA) of the United States, along with the U.S. Department of Agriculture, are responsible for adopting corrective measures, with fines ranging from US$ 200 to US $1,000, and prison sentences from 30 days to a maximum of six months for the use of dangerous pesticides ().
In Puerto Rico, the principal sources of toxic emissions are electric power plants, which contribute approximately 75% of the total. The release of toxic chemicals has trended steadily downward from 1990 to 2013: in 1990, 18.7 million pounds of toxic chemicals were released, compared with 2.3 million pounds in 2014 and 2 million in 2015. A breakdown for 2015 toxic chemical releases estimates that 1.8 million pounds went into the air, 390 pounds into the water, and 22,800 pounds into the soil ().
There was an intense drought in 2015, and the U.S. Department of Agriculture declared 17 municipalities (including Bayamón, Guaynabo, and San Juan) as primary natural disaster areas (). The decline in precipitation levels caused the Puerto Rico Aqueduct and Sewer Authority to impose rationing in order to control water consumption. Service was available on certain days at certain times, which enabled the public to save water. Rationing was mainly limited to the reservoirs of La Plata and Carraízo, which supply the Metropolitan Area; specifically, the municipalities of San Juan, Bayamón, Guaynabo, and Carolina, where 23% of the population lives.
Measured in million gallons per day (Mgal/day), instream water withdrawals in 2010 totaled 2,817.55 Mgal/day, of which 677.21 Mgal/day were public-supply water withdrawals; another 38.16 Mgal/day were used for crop irrigation (). The damage caused by the drought was not only environmental, harming flora and fauna, and causing millions of dollars of losses in agriculture and livestock; water shortages also affected service in hospitals, health care centers, schools, and homes.
Social Determinants of Health
The percentage of the population under the Federal Poverty Level (FPL) rose slightly, from 45% in 2010 to 46.1% in 2015. The rate was higher among the unemployed, those 25 years or older without higher education, women, and children (). The population 25 years or older with an intermediate or lower level of education dropped by 16.1% between 2010 and 2014 (). The general literacy rate was 92% in 2010 (). For the period between 2011 and 2014, an estimated 43,197 adults (1.6% of this population group) were part of the community of lesbians, gays, bisexuals, and transsexuals (LGBT) ().
The Health System
The delivery of health services to individuals, families, and communities is usually organized by the level of delivery of these services. This includes signing up for a coverage plan under an administrator (insurer); primary services, secondary services, and tertiary services accessed through referral to a specialist; and utilization and review mechanisms, such as prior authorization. The integration of the services is carried out through screening and disease prevention in doctors’ offices, and coordination with the administrators of mental health benefits and the insurers.
Puerto Rico’s PSG covers those with limited resources, but there is no universal plan. The PSG offers primary care and mental health services, access to specialists, medicines, clinical laboratories, specialized diagnostic tests, X-rays, and hospitals. Patients can access service providers by freely choosing them, or by going to an assigned physician, according to what kind of coverage they have. Puerto Rico also has several patients’ rights charters aimed at different groups. In each one of these cases, a regulatory entity is specified.
The laboratory network falls under the coverage of the health providers, whether public or private. Some samples collected in clinical laboratories (for example, arboviral samples) are sent to reference laboratories in the United States. The Laboratory of the Puerto Rico Medical Services Administration covers all of Puerto Rico as well as the Caribbean, offering clinical and anatomic pathology services.
The community network features different nonprofit entities that provide health services to the vulnerable and disadvantaged. In the fiscal year 2014–2015, the hospital network totaled 67 public and private hospitals, with a ratio of 285.5 beds per every 100,000 inhabitants ()(Departamento de Salud, 2016).
The population of 65 years or older is eligible for Medicare Part A, Medicare Part B, or both ()(Medicare.gov, 2016). Furthermore, the elderly can be covered under traditional Medicare, Medicare Advantage, or Medicare with private supplemental insurance. The services includes free choice of doctors, or managed care. According to estimates from Medicaid and Medicare Service Centers, in Puerto Rico there was a reduction of 11% in 2016 funds from Medicare Advantage. This will have an impact on the capacity of this kind of insurance to assume responsibility for its 250,000 beneficiaries, possibly increasing its operating costs, which varied from US$ 20-30 million a year to US$ 120-150 million annually ()(Gil-Fournier, 2014).
The health system is financed by federal contributions, employer contributions, contributions from the Puerto Rican government, and direct payment by individuals. Approximately 45% of Government Health Plan (PSG) funding comes from the federal government, with 10% from municipal funds and 45% from Puerto Rican government funds.
The health system is organized into two components: one private and one public, organized under a coordinated care model (). The Puerto Rico Health Insurance Administration (PRHIA) and the Department of Health offer health services to the general population; the Puerto Rico State Insurance Fund Corporation provides workers compensation; and the Mental Health and Addiction Services Administration (ASSMCA) assists those with mental health or addiction problems. Other government entities offer services such as managing health facilities or medical services, defending patients’ rights, and addressing the needs of specific populations. The health care plans follow the relevant regulations of the Patient Protection and Affordable Care Act, and the Health Care and Education Reconciliation Act.
Leading Health Challenges
Critical Health Problems
In recent years, Puerto Rico has seen three epidemics that involved emerging diseases: dengue in 2010, with 33 deaths and 22,000 reported cases; chikungunya in 2014, with 10 deaths and 4,278 confirmed cases; and Zika, with five deaths and 32,070 confirmed cases as of November 2016. The Department of Health, together with the Centers for Disease Control and Prevention (CDC), are in charge of the diagnostic tests for the control and prevention of diseases transmitted by arboviruses, as well as weekly reporting. A passive surveillance system is used for these diseases, which means that diagnosed cases could be underreported. In total, 61,677 presumed cases of these diseases had been reported as of 3 November 2016 ().
Dengue is an endemic disease in Puerto Rico, and during 2014 there were 8,664 presumed cases recorded, with 473 laboratory-confirmed cases, along with two confirmed cases of dengue hemorrhagic fever. In 2015, there were 1,866 presumed cases and 57 laboratory-confirmed cases, with no confirmed case of dengue hemorrhagic fever nor any death caused by the virus (). At the beginning of November 2016, 151 confirmed cases of dengue had been reported for the year, mostly subtype 2 ().
Chikungunya is a new disease in Puerto Rico. The first case was reported on 5 May 2014 (), with a total of 25,796 presumed cases that year and 31 cases associated with recent trips (). In 2015, there were 1,043 presumed cases reported, 216 confirmed cases, and one case in which a person infected with the virus died. At the beginning of November 2016, 171 confirmed cases of the virus had been reported for the year ().
The first case of Zika was recorded on 31 December 2015 (). As of 3 November 2016, 34,060 confirmed cases had been reported, of which 2,631 were pregnant women; of these, 63% were symptomatic. Of all these cases, 279 patients were hospitalized, and five people died who tested positive for the virus. There were also reports of 46 cases of Guillain-Barré syndrome caused by the Zika virus, two deaths associated with that syndrome, and four newborns with Zika-related birth defects ().
Maternal deaths fell from six in 2010 to three in 2014, according to data from death certificates. In 2007, the Maternal Mortality Epidemiological Surveillance System (SiVEMMa)—a program complementing data from death certificates, birth certificates, and medical records—was discontinued. During 2016, the SiVEMMa Act was drafted to create a formal system to compile, analyze and disseminate reliable maternal mortality data.
In 2010, there were 26.8 live births per 1,000 female adolescents—a figure that fell to 20.4 in 2014. In that year, 38% of deliveries in adolescents were cesarean sections; 96.3% of teenage mothers were on the PSG, indicating that they were low-income women. Also in 2014, 31% of births in this group corresponded to women between 15 and 17 years old. For mothers in each age subgroup, more than 10% of their babies had low birth weights; the same percentage were premature. The fertility rate for women between 15 and 19 years old fell from 51.3 per 1,000 in 2010 to 40.4 per 1,000 in 2014 ().
The prevalence of overweight and obesity declined from 66.1% in 2011 to 65.6% in 2014. In 2011, the prevalence of obesity was higher in men (27%) that in the women (25.8%), and also higher in the 45–54-year age group (31.3). However, in 2014 the prevalence of obesity in men fell to 26.8%, while increasing in women to 29.6%; the age group with the highest percentage of obesity was 55–64 years (35.2%) ().
In 2012, it was estimated that between five and seven out of 10 adults had at least one chronic disease. The Department of Health has a 2014–2020 action plan to control chronic diseases, with an emphasis on prevention (). Prevalence data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) telephone survey, targeting households, which interviewed adults over the age of 18 (). Beginning in 2011, a cell phone sample was included, and therefore these data are not comparable with those from previous years.
The prevalence of hypertension in adults fell from 36.8% in 2011 to 42.3% in 2013. In that year, prevalence was higher in women (43.9%) than in men (40.5%), and highest in those 65 years or older (72.0%) ().
The life prevalence of depression in adults was 18.5% (). It was higher in women (20.4%) than in men (16.4%), and highest in the 55–64-year age group (31.4%). Furthermore, it was estimated that 14% of adults had anxiety disorders, and 5.5% of children between 4 and 17 years old presented oppositional defiant disorder ().
The prevalence of diabetes mellitus in adults rose from 13.5% in 2011 to 15.7% in 2014. It was higher among women (16.4%) than men (14.8%). This increase was related to a rise in the prevalence of risk factors, and the aging population ().
With regard to cardiovascular diseases, the prevalence of heart disease rose from 7.2% in 2011 to 8.5% in 2014. This occurred in both sexes, but was slightly higher in women (9%) than in men (8%), and was highest among those aged 65 and older (15.6%). The prevalence of myocardial infarction was 4.8% in 2011, rising to 5.3% in 2014, being higher in men (6.4%) than in women (4.3%), and highest among the population aged 65 and older (12.2%) (). Finally, the prevalence of stroke in 2011 was 1.7%, being higher in women (2.0%) than in men (1.4%); in 2014, this prevalence increased to 2.2%, with the highest rate for those 65 years or older (5.2%) ().
Chronic Obstructive Pulmonary Disease (COPD) was present in 3.8% of the population in 2014; prevalence was higher in women (4.9%) than in men (2.6%), and especially affected the population of 65 years or older (6.8%) ().
As to suicide, the Puerto Rico Poison Control Center’s help line registered 1,642 calls stemming from suicide attempts in 2015, 59.4% of them from women (). The ASSMCA’s Psychosocial First Aid (PAS) hotline answered 17,091 calls from people with suicidal ideation and suicidal attempts in the 2014-2015 fiscal year; of these callers, 56.5% were women and 4.4% were children. Of the adults who sought assistance, 69.7% were between 21 and 59 years old. Suicidal ideation was the reason for 83.2% of the calls ().
In the three-year period from 2010 to 2012, there were 55,000 health professionals active in Puerto Rico, of whom the majority were between 40 and 54 years old, with a predominance of women. Their principal employer was the private sector, with the majority of the workforce being nursing staff; of these, 17,740 were university graduates, 4,780 were licensed practical and vocational nurses, 1,570 were medical nurses and 310 were nurse anesthetists (). Between 2013 and 2015, there were 9,616 active physicians, the majority working in private practice; among them were 3,151 generalists, mainly 40 to 44 years old. Specialists, however, tended to be aged 55 to 59, with few specialists younger than 40 (); this is important, due to the shortage of professionals passing the medical licensing examination (reválida médica), meaning that they can neither practice professionally nor emigrate to the United States.
In 2012, the number of professionals graduating from academic and educational institutions reached six physicians per 100,000 inhabitants (excluding psychiatrists), 190.1 nursing staff at a level lower than a master’s, 12.9 psychologists with master’s or doctoral studies, 22.1 social workers, and 1.5 occupational therapists ().
Puerto Rican law requires that all physicians have a currently valid license and be recertified every three years; some other health professionals are also required to periodically renew their certification in order to practice professionally ().
From 2010 to 2013, 30% of psychologists, nursing staff, and occupational therapists worked in the public sector, whereas 55% worked at both public and private companies ().
Between 2010 and 2014, figures for emigration to the United States totaled approximately 2,665 nursing professionals; 1,735 nursing assistants, psychiatric aides, and nursing home assistants; 987 physicians; 709 clinical laboratory technicians and technologists; 354 respiratory therapists; and 305 pharmacists ().
Health Knowledge, Technology, and Information
The Department of Health has a Virtual Learning Center for public health training (). Some hospitals have an internal electronic records system, enabling patients to access their clinical history at that hospital. Among the hospitals with this service are the Mennonite General Hospital and Pavía Hospital.
Data on health facilities were included in the survey on adopting broadband technology (as part of the general survey of commercial establishments). In 2010, 85% of health establishments reported being broadband internet subscribers; by 2015 this figure had risen to 89%. That same year, 21% of health establishments reported using mobile internet services ().
Looking at Puerto Rico’s scientific output, there are local research projects in different health care areas, and collaborations with other entities. Moreover, there are university-affiliated organizations carrying out research in these areas, some receiving federal funds. There are eight Puerto Rican journals in the health field, aimed at reporting on subjects related to health and to promoting healthier lifestyles. Furthermore, there are 54 libraries at different universities that serve as sources of peer-reviewed information. The Virtual Health Library (VHL) continues to operate in collaboration with the Latin American and Caribbean Center on Health Sciences (BIREME) and the Pan American Health Organization (PAHO) ().
The Demographic Registry compiles vital statistics in Puerto Rico. Since 1996, the BRFSS has also collected adult behavioral health risk data. There also are surveillance systems for chronic, infectious, and reportable diseases.
The Environment and Human Security
The increase in the average temperature across land and ocean surface areas, in addition to rising sea levels, has had an effect on Puerto Rican ecosystems and biodiversity. This poses a security issue, since 56% of the population resides in municipalities with coastal areas, where there are also hotels and power plants (). The consulting firm Desarrollo Integral del Sur reported finding oil, heavy metal, organic, and other kinds of waste in the petrochemical corridor between Peñuelas and Guayanilla ().
Life expectancy at birth was 79.3 years in 2012, but for those aged 65 to 69, it was 20.4 years, meaning that they could live to an average age of 85.4 to 89.4 years. Whereas in 2010, there were 546,885 people over 65, in 2015 there were 626,962; women represented 56.7% of this group, with an increase of 14.6% compared to 2010 (). Among the elderly residing in a family home, 23.9% were women living alone without a husband, and 2% were responsible for a grandchild under 18. In the elderly group, 26.2% had not finished high school, and 49.7% had at least one disability, especially difficulty walking ().
The total number of elderly Puerto Ricans insured under the PSG’s Medicare Platinum stood at 248,306 in December 2015, compared with 195,200 in December 2012 (). In 2014, 59% of beneficiaries aged 65 and over were women.
Of the 65-or-over group, 6.9% worked during 2014 (). In December of the same year, it was reported that 435,569 people were beneficiaries of U.S. Social Security retirement plan; 292,975 of these beneficiaries were women aged 65 and over (). Furthermore, according to the Puerto Rico Community Survey, 81.9% of this population received Social Security income; 22.7% had a retirement income fund, and 5.9% received public assistance ().
There are a number of health risk factors for the over-65 population; these include tobacco use—with 5.4% of this population being active smokers, according to a 2014 estimate—and alcohol, with 12.5% of this population consuming alcohol, 3% being acute alcohol consumers, and 2.2% being chronic alcohol consumers. Overweight and obesity are other health hazards for the elderly: in 2014, 41.8% of this population was overweight, and 23.2% had obesity; in 2013 it was reported that 51.6% of this population consumed at least one serving of fruit per day, and 80.1% had at least one vegetable serving per day. According to data from 2013, 42.2% of this population had some kind of physical activity; only 2.2% of these did aerobic and stretching exercises, thus meeting the recommended guidelines, and 3.1% did muscle strengthening exercises at least twice a week ().
According to the Puerto Rico Community Survey, emigration to the United States is considerable. Between 2010 and 2015, an estimated 457,000 people left Puerto Rico, and 144,000 entered the island. The net balance in these five years resulted in 313,000 fewer people, whose principal destinations were the southern and northeastern United States; 82% of Puerto Rico’s emigrants went to these regions (). A factor driving migration is the economic instability that the archipelago is experiencing ().
Monitoring the Health System’s Organization, Provision of Care, and Performance
In Puerto Rico, the management and governance of the health system is fragmented. The principal health-related laws are Act No. 81 of 14 May 1912, as amended, known as the Health Department Act; and Act No. 72 of 7 September 1993, as amended, called the Health Insurance Administration Act. In addition to these, Puerto Rico has enacted several more recent health-related laws; taken together, they constitute the legal framework on which the system is based (Lexjuris, 2016).
The Department of Health forged partnerships with different sectors to implement the Chronic Disease Plan () and organize meetings for developing a 10-year health plan. Collaborative agreements and special projects were set up between the Department of Health and the Department of Education for the School Health Program (). Together with different organizations, the Department of Health created the Suicide Prevention Commission (). Furthermore, the ASSMCA signed, with the Department of Family Affairs and other nonprofit entities, the Cooperative Agreements to Benefit Homeless Individuals (CABHI) in order to provide recovery and treatment services to homeless people with severe mental illness or concurrent substance use disorders ().
In 2014, health expenditure totaled US$ 10.877 billion, or 10.5% of GDP. Per capita health expenditure was approximately US $3,065 ().
The Department of Health is divided into six regions, and the PRHIA into eight regions. PRHIA formalizes contracts with private health insurers to provide services through its provider network, under the PSG.
Beneficiaries qualify for the PSG after an assessment of their poverty level by the Department of Health’s Medicaid program. After analyzing their revenue and individual and family resources, it is determined which program or type of program corresponds to the patient’s situation. Some people are eligible for federal Medicaid programs or the State Children’s Health Insurance Program (SCHIP). This is the case for those who exceed the FPL or who do not fall under the previously mentioned categories; the public system also provides Medicare Part A coverage for those under a certain income threshold, and covers their Medicare Part B so that they can benefit from Medicare Advantage coverage. In these programs there are co-payments which depend on an individual’s income level.
In 2014, PRHIA had a deficit of US$ 230 million and a working capital deficit of US$ 26 million, without considering lines of credit with the Government Development Bank, totaling US$ 183 million, set to mature between 2015 and 2023. Puerto Rican government credit accounts for 36.2% of PRHIA’s operating revenue and 10% of the Puerto Rican government budget (), which could have a negative impact on access to services of the medically poor.
There are several types of medical coverage available. One involves free selection, under which individuals can choose their health provider from those listed in a contracted provider network. Another variant is coverage coordinated with specialized health facilities, where primary care physicians coordinate patients’ services through a system of referral clinics. A third type of coverage is the point-of-service plan, which combines elements of free selection and coordinated care coverage; this form has the advantage that those who receive services through their primary care physician or health service facility pay less than if they had received the services through a contracted provider network. Finally, there is fee-for-service: individuals can receive the services of any health provider, and their employer reimburses the provider ().
Some provisions of the US Patient Protection and Affordable Care Act (PPCA), together with the Health Insurance Code of Puerto Rico, guarantee 10 essential health benefits (): 1) outpatient and medical-surgical services; 2) hospitalization; 3) emergency services ; 4) maternity services and neonatal care; 5) mental health services and treatment for controlled substance use disorders; 6) laboratory services, X-rays, and diagnostic tests; 7) pediatric services, including vision and dental health; 8) drug coverage; 9) habilitation and rehabilitation services; and 10) preventive and wellness services.
Moreover, all of these medical plans must provide coverage for different preventive health benefits, without deductibles or copayments. Another provision of the PPCA is that private medical plans cannot deny health coverage due to preexisting health conditions, and certain essential health benefits are guaranteed ().
In 2013, a disbursement of US$ 1 million from the Emergency Fund was authorized to control the flu epidemic. In 2014, the Department of Health presented a protocol for chikungunya control. In 2016, Zika virus disease was declared a public health emergency, and a comprehensive national plan for the prevention and treatment of arboviral diseases was developed. In July 2016, due to the pressure from environmental groups, farmers, scientists, and health professionals, the Puerto Rican government ruled out spraying the organophosphorus insecticide Naled as an option for combating the spread of the mosquito that transmits the Zika virus.
Starting in 2010, several executive orders were issued to safeguard the rights of patients seeking care at hospitals and clinics. A number of health-related laws were passed, including measures on compliance with health protocols, and requirements for agencies to create surveillance systems and keep them up to date, helping to ensure a reliable set of statistics on the incidence and prevalence of diseases in Puerto Rico.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
In 2012, 45.4% of the women participating in a reproductive health survey reported not using a contraceptive method. Of these, 34.7% wished to become pregnant at another time, and 5.6% did not want to become pregnant. In 2014, although 83.4% of pregnant women began prenatal care in the first trimester and 35.7% had adequate weight gain, 47.2% of them had cesarean deliveries ().
In 2011 and 2014, the leading causes of fetal death were disorders related to short gestation, low birth weight, and complications of the placenta or of the umbilical cord. In all of these cases, deaths were concentrated in fetuses weighing less than 500 grams ().
The leading cause of infant mortality (children under 1 year) in 2011 was congenital malformation, at 18.3%; this fell to 13.1% in 2014. In 2011, the second leading cause was respiratory difficulty in the newborn (12.1%), which was similar in 2014. The third leading cause of death in 2011 was bacterial sepsis, at 10.7%; in 2014, this had fallen to 5.7%. The leading causes of neonatal mortality in 2011 were respiratory difficulty; congenital malformations, deformations, and chromosomal abnormalities; and bacterial sepsis of the newborn. In 2014, the figures for all of these causes of death had fallen. The leading two causes of post-neonatal death in 2011 were congenital malformations and septicemia. During this period, congenital malformations and septicemia were among the leading causes of infant, neonatal, and post-neonatal mortality ().
Vaccination is a requirement for children going to school. In 2012, it was confirmed that 3,895 35-month-old children (85%) were vaccinated. In 2015, vaccination coverage for this group fell to 77.3% (3,007 children). In the years 2012 and 2015, few 35-month-old children were immunized against the flu (156 in 2012, and 202 in 2015). In these same years, 90% of the children from 6 to 10 years received flu vaccinations ().
Health of Schoolchildren
According to Puerto Rico’s Substance Use and Abuse Observatory, in 2012 it was estimated that 8.4% of seventh- to ninth-grade students had behavioral disorders; 13.8% presented attention deficit and hyperactivity disorders; 11.6% showed symptoms of major depression; and 16.3% had seriously considered committing suicide. Of students in this age group, 30% reported having drunk alcohol in the previous year, and 6.4% had used illicit drugs ().
Health of Adolescents
According to Puerto Rico’s Substance Use and Abuse Observatory, 9.1% of tenth- to twelfth-grade students had behavioral disorders; 21.4% presented attention deficit and hyperactivity disorders; 18.6% showed symptoms of major depression; and 24.4% had seriously considered committing suicide. Of students in this age group, 60.4% reported having drunk alcohol in the previous year, and 17.0% had used illicit drugs ().
The Youth Behavioral Risk Surveillance System (YBRSS) reported that in 2015, 10% of ninth- to twelfth-grade students had experienced bullying, and 6.7% had experienced cyberbullying. Of these, 15.9% had attempted suicide, with 4.3% presenting an injury, poisoning, or overdose as a consequence of the attempt. Of students in this age group, 12.7% used some tobacco product, 6% consumed marijuana, and 8.1% used inhalants ().
Health of Adults
In 2014, an estimated 44.5% of the population 16 years or older more was in the work force, and 36.3% was employed. The highest number of workers were in office and administrative support occupations (170,639), sales and related occupations (129,688), and government (120,326) ().
This population’s risk factors include the use of tobacco and alcohol, excess weight, eating problems, and physical inactivity. According to the BRFSS, the percentage of active smokers in the adult population fell from 14.8% in 2011 to 11.3% in 2014, with a higher proportion of men (20.8% in 2011, and 16.4% in 2014) than women (9.4% and 6.8%) (). In 2011, 34.1% of the population reported consuming alcohol, a figure that fell to 29.3% in 2014. In the years 2011 and 2014, men registered a higher prevalence of alcohol consumption (46.5% in 2011, and 39.1% in 2014) than women (23.2% and 20.8%). In 2014, it was reported that 13.2% of those who consumed alcohol were acute drinkers, with men presenting higher prevalence rates than women (19.8% and 8.5%, respectively); 3.8% were chronic drinkers (5.2% for men, 2.7% for women). These percentages were higher in 2011 ().
Regarding prevalence of overweight, in 2011 this affected 44.1% of men and 35.9% of women. The highest rates for excess weight were found in the 45–54 year-old group in 2011 (46.2%) and 2014 (42.7%). In 2014, prevalence declined, to 41.6% in men, and 34% in women ().
In 2013, according to BRFSS data, 48.7% of adults consumed at least one serving of fruit daily. This percentage was greater in women (50.5%) than in men (46.7%). As to vegetables, 75.5% of adults had at least one serving a day (79.1% of men and 72.4% of women) (). In 2014, a figure of 59.4% adults reported exercising; this was greater than the percentage in 2011 (52.7%). In both 2011 and 2014, a higher percentage of men (60.4% and 65.8%, respectively) than women (45.8% and 53.7%) engaged in physical activity ().
Health of the Elderly
Principal disorders of the elderly were hypertension (72.0%), arthritis (54.2%), high cholesterol (53.3%), and diabetes mellitus (36.7%) ().
According to the Behavioral Risk Factor Surveillance System (BRFSS), 39.7% of adults aged 65 years or more were vaccinated against the flu in 2014 (43.4% of men and 36.8% of women in this group) ()(Centers for Disease Control and Prevention, 2017).
Health of Workers
The rate of occupational injuries and diseases among government employees was 5 cases per every 100 full-time employees during 2010 and 2011; these figures dropped steadily over the next three years, to 4.4 (2012), 4.2 (2013), and 4.1 cases (2014). In the private sector, the rate was 4.1 cases per every 100 full-time employees in 2010; between 2011 and 2014, these figures dropped, as well, to 4.0 (2011), 3.6 (2012), 3.7 (2013) and 3.4 (2014). During this four-year period, men showed a higher percentage of occupational injuries and diseases resulting in missed work days, compared with women. The principal occupational injuries and diseases for every year were pulled or torn muscles, sprains, contusions, and bruises (). As to cases treated under the Puerto Rico State Insurance Fund (CFSE), in the 2014–2015 fiscal year the main occupational injuries were fractures or sprains (30.8%), and disorders of the musculoskeletal system (17.0% affecting the lumbar spine and 13.6% the cervical column) ().
Health of the Disabled
In 2014 it was estimated that 18% of the population from 18 to 64 years old had at least one disability, the most prominent being difficulty walking (9.3%) and cognitive difficulty (8.4%). In the population of 65 years or older, the rate of persons with a disability rose to 49.7%; the main disabilities in this group were problems walking (34.9%), followed by the inability to live independently (29.5%) ().
The crude death rate was 813.8 per 100,000 inhabitants in 2011, rising to 854.8 in 2014. For men, the crude death rate was 928.3 in 2011 and 964.9 in 2014; it was lower for women: 708.6 in 2011 and 753.5 in 2014. As to age-adjusted rates per 100,000 inhabitants, in 2011, malignant neoplasms became the leading cause of death, displacing deaths from heart disease. For 2014, the leading causes of death were malignant tumors (119.2), heart disease (116.1), and diabetes mellitus (71.9). Alzheimer’s disease was the fourth leading cause of death, although it surpassed diabetes mellitus for third place in two municipalities: Cidra (63.2) and Manatí (68.4). In 2014, age- and gender-specific mortality was higher in men (). Between the ages of 15 and 39, between 20 and 69.8 per 100,000 men died from homicide (). Annually, the total number of deaths by suicide averages 311. In 2015, 9 out of 10 suicides were men. The highest rates per 100,000 were reported in the 80–84 year-old group (17.9), followed by 55–59-year-olds (13.4). In 74% of the cases, death was by hanging ().
The rate of tuberculosis (TB) rose slightly between 2011 (50 cases) and 2015 (52 cases); the adjusted rate for 2011 was 1.4 per 100,000 inhabitants, and 1.5 in 2015. The San Juan region saw the highest rate of reported cases, with 3.1 per every 100,000 inhabitants in 2011, falling to 2.0 in 2015. That same year, 37% of cases corresponded to the 45–64 age group ().
During 2010 and 2012, there were no recorded cases of rubella. In 2015, 24 cases of hepatitis B were reported, and 10 cases in 2016 through the end of October; 10 cases of whooping cough were reported in 2015, and 9 until the end of October 2016; 1 case of tetanus was reported in 2015 (). Only 39 cases of rabies were reported in 2014, with the number dropping even further, to 12 cases, in 2015 ().
Chronic, Noncommunicable Diseases
In 2012, the age-adjusted rate for uterine and cervical cancer was 11.6 per every 100,000 women; in 2013 it was 26.3. As to breast cancer, in 2012 the age-adjusted rate in women was 93.5 per 100,000, rising to 95.8 in 2013. In the case of lung and bronchial cancer, the age-adjusted rate was 17.9 per every 100,000 inhabitants in 2012, and 22 in 2013 (). The age-adjusted rate for thyroid cancer was 25.5 per every 100,000 inhabitants in 2012 ().
Of the adult population, 42.3% presented hypertension in 2013, with women having a higher prevalence than men (43.9% compared with 40.5%). The prevalence of hypertension rose with age, reaching 72% in those 65 years or older ().
Accidents and Violence
The number of incidents of domestic violence reported between January and November 2015 was 8,222; during that same period, 9,999 protection orders were issued. Approximately 80% of the victims were women, with slightly more than 70% suffering physical abuse. Domestic violence resulted in nine murders, with eight of the victims being women ().
In 2015 there were 297 traffic accidents that caused 310 deaths, 6 more than in 2014. Of these deaths, 23.5% were people between 20 and 29 years old, and 81% of them were men. Moreover, it was found that 62% of fatal accidents occurred from Friday to Sunday; of these, 56.5% were between 6 p.m. and 3 a.m. ().
Other Health Problems
In 2011, 19.7% of the adult population suffered from arthritis; this percentage rose to 24.6% in 2014. By sex, prevalence was higher among women than men (31.0% compared with 17.3%) ().
Regarding oral health, An estimated 67.9% of adults visited the dentist in 2012, a figure which rose to 68.8% in 2014. That year, these indicators were higher in women (69.4%) than in men (61.6%). The percentage of people going to the dentist trends downward with age: in 2014, 76.6% of the people who visited a dentist were 18 to 24 years old, whereas in the group of 65 years or older, only 54.9% went.
In 2012, 19.9% of adults reported that all of their teeth had been removed, whereas in 2014 this figure had fallen to 16.7% (). Figures on tooth extraction are important, since having teeth—or lacking them—can affect the type of food that an older person can eat, with a possible adverse impact on nutrition.
The prevalence of vision problems in the adult population was 32.1% in 2012, with 6 of every 10 patients being women. The prevalence of people with cataracts for that year was 7.2%, while 3.1% presented glaucoma. Furthermore, 15.4% of adults had myopia, and 15.1% had astigmatism ().
Puerto Rico has striven to meet the targets related to Sustainable Development Goal (SDG) 3: “Ensure healthy lives and promote wellbeing for all at all ages” (). At present, this has been achieved by reducing the maternal mortality ratio and preventable deaths of newborns and children under 5 years of age.
Another step is the Chronic Disease Action Plan for 2014-2020. These strategies arose from the fact that 52.7% of deaths in 2014 were due to heart disease, cancer, diabetes, Alzheimer’s disease, and stroke. Chronic diseases are expensive to treat and they have a heavy socio-economic impact. The Chronic Disease Action Plan’s approach is to promote health and prevent disease through strategies aimed at supporting healthy lifestyles. Prevention is a vital tool for the health situation that faces Puerto Rico, because health costs are high and poverty indices are steadily rising. Total health expenditure in 2010 was US$ 12.058 billion, falling to US$ 10.877 billion in 2014. However, when health expenditure is analyzed in comparison with the public’s spending on health, it can be observed that these figures have been rising. In 2011, per capita expenditure on health was US$ 3,301, whereas in 2014 it was US$ 3,065. One of the reasons for this reduction is that these federal funds were allocated to Medicare Advantage.
Furthermore, in 2016 the Obesity Prevention Action Plan was launched, using a PAHO model and under its auspices, with the Food and Nutrition Commission as the regulatory body. Obesity is an epidemic that costs Puerto Rico US$ 76 million annually, growing worse every year; research indicates that an obese child will become an obese adult. The plan hopes to raise awareness about the diseases that obesity causes in young people, and promote healthy eating habits and physical activity.
With CDC funds, the Institute of Statistics established a Violent Deaths Surveillance System to collate data on homicides and murders reported by the Department of Health, the Puerto Rican police force, and the Institute of Forensic Sciences. The purpose of this program is to reduce the number of violent deaths through a surveillance system providing accurate, timely, and complete data in order to develop strategies for controlling and preventing violent deaths. Data provided by the Institute of Forensic Sciences show that in 2011 there were 1,181 homicides and 325 suicides, compared with 2015, when there were 614 homicides and 227 suicides. This database will enable the creation of new policies to tackle the problem of violence that Puerto Rico is experiencing. Finally, during this period the Department of Health launched its Tobacco Control Plan (2016), Strategic Asthma Plan (2016) and Alzheimer’s Action Plan (2015)—the latter especially important due to Puerto Rico’s aging population.
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1. The FPL is set by the U.S. Department of Health and Human Services, and used to determine eligibility for a variety of state and federal programs and benefits, based on a combination of income and family size.
2. Oppositional defiant disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association as a “pattern of negativistic, hostile, and defiant behavior” that is excessive for the child’s sociocultural context and level of development, resulting in significant impairment in functioning.
3. The toll-free Poison Help Line is a national telephone number for assistance in poisoning emergencies. Callers are connected with the nearest local Poison Control Center. Calls can be made from anywhere in the United States, including Puerto Rico, and are answered by specially trained toxicologists, nurses, pharmacists or physicians. The service is free and confidential, and available in Spanish for those who so desire.
4. Suicidal ideation includes thinking about suicide, death wishes, and planning the act of taking one’s life ().
5. For more information, see the work of María Levis at http://planinnosalud.org/webinar/ and http://planinnosalud.org/es/wp-content/uploads/2016/10/04-CARE_MODELS_TRAINING_MODULE_FINAL.pdf.
6. Medicare Part A is hospital insurance, and covers most medically necessary hospital, skilled nursing facility, home health, and hospice care; Medicare Part B is medical insurance, covering doctors’ services and preventive care.
7. Along with the Health Care and Education Affordability Reconciliation Act of 2010, this law came out of the health care reform program enacted by the US Congress, with a Democratic majority, and the Obama Administration. The PPACA (called Obamacare in the US media) required the majority of adults not covered by any health plan – whether provided by their employers or subsidized by the government – to obtain coverage, risking a fine if they did not.
8. Rates adjusted according to the 2000 standard US population.