INTRODUCTION AND BACKGROUND
The strengthening of health systems in developing countries is considered a priority for the World Health Organization (WHO). The WHO Framework for Action, published in 2007 at the midpoint of the Millennium Development Goals (MDGs) countdown to 2015, is a call to action to strengthen what it has identified as the six building blocks of health systems worldwide. These building blocks include the following broad sectors: (1) Leadership and governance; (2) Health care financing; (3) Health workforce; (4) Medical products and technologies; (5) Information and research; and (6) service delivery (WHO 2007a). Each building block is interrelated with the others, making health systems strengthening in developing countries a complex challenge requiring a coordinated global effort.
The aim of this paper is to examine the components of the health system in Guatemala. First, I will outline the structure of the Guatemalan health system using the six WHO building blocks as a foundation. Second, I will examine the key challenges to the country’s health system with regard to the national response to HIV/AIDS. Lastly, I will present recommendations which could be taken to improve Guatemala’s health system response to HIV/AIDS.
Guatemala: A Health System in Transition
Guatemala is a lower-middle income country in Central America with a population of 14.38 million (World Bank 2013). An examination of its health system is of interest for several reasons. First, a high proportion of its population lives in poverty. Fifty-four percent live under the poverty line (Central Intelligence Agency 2013) and 37% of the population lives under $2 per day (World Bank 2006). This means that a high percentage of its population is vulnerable to economic shocks due to catastrophic health spending
NOTE: This post is an adaptation of a paper written at the University of Sydney. If you wish to use this content, you must include a citation. Cite as follows: Counts Tanner, Amanda. (2013, July 19). Health Systems Strengthening in Guatemala: A Case Study of HIV/AIDs. [Web log comment]. Retrieved from https://amandactanner.wordpress.com
Guatemala is also one of the most unequal societies in the world, with a Gini index of 55.1 (CIA 2013). Forty-percent of the population identifies as indigenous Mayan (World Health Organization 2007), and health disparities between the indigenous and the Spanish-speaking ladino majority (of mixed European descent) are among the highest in Latin America (Ishida et al. 2012). The Mayans experienced brutal violence at the hands of government forces during the 36-year Guatemalan Civil War (1960-1996), which left a legacy of displacement and exclusion. Continued discrimination and mistreatment by the government has reinforced a tendency among Mayans to avoid institutionalized health care facilities (Ishida et. al 2012). The civil war is only the most recent prolonged conflict in Guatemala. In many ways, the country is still recovering from hundreds of years of Spanish conquest and the consequences of colonialism.
Guatemala has a human development index of .561 (ranking number 133 among 187 countries) and an inequality-adjusted index (IHDI) of .389 (United Nations Development Program 2013). These development indicators, in addition to the historical context of social inequality in Guatemala, provide important context to discussing the country’s challenges in dealing with the health of its population.
The Building Blocks of Guatemala’s Health System
In light of Guatemala’s history, it is unsurprising that the country’s health system is largely described as inequitable. There is a high degree of segmentation with regard to health service delivery. According to data from the Global Fund, higher-income sectors of the population – predominately ladinos – use private healthcare institutions, while over half the population depends on the lower-quality public health system. The 2012 budget of the Guatemalan Ministry of Public Health and Social Welfare (MSPAS) was only 1.08% of the GDP, a level which is considered insufficient to over the national priorities for health (Global Fund 2013). Lack of public-sector funding translates into insufficient access to health services among indigenous and rural populations, who rely on the public system.
Soon after the end of the civil war in 1996, the Ministry of Health (MOH) implemented a range of health system reforms in order to address problems of access, including the Extension of Coverage program (Global Health Initiative 2010). The Extension of Coverage program contracted with non-governmental NGOs (NGOs) to provide basic health care services in rural areas of the country. This program has largely been considered a success for service delivery. By the year 2000, 89 NGOs were providing health care to 3.7 million people (Hecht and Shah 2006). The services provided include basic primary care services, maternal and child health services, and immunizations.
According to the most recent data available from the Pan American Health Organization (PAHO), there are 51,000 people working in the health sector in Guatemala. Fifty-seven percent work in the public health sector, 17% work in the private sector, and 26% are volunteers (PAHO 2001). The ratio of physicians to the total population is 9 per 10,000. A disproportionate percentage of these physicians are concentrated in urban areas (80%), where the ratio is 28 doctors per 10,000. Additionally, there are 3 professional nurses, 11 nursing aids, and 20 midwives per 10,000 people. The WHO suggests that countries with fewer than 23 healthcare professionals (physicians, nurses and midwives) per 10,000 people are unlikely to achieve adequate coverage rates necessary for the primary health interventions prioritized by the Millennium Development Goals (WHO 2009).
Inadequate pay, lack of job security, and political discontinuity is a major challenge among Guatemala’s health workforce. As in other Latin American countries, there is no civil service career ladder (GHI 2010). The majority of MSPAS public health staff earn less than USD 2,000 per year and work on a contract-only basis, making them ineligible for employment benefits (Magaña-Valladeres et al. 2009). The national political system of Guatemala allows only one term of service, meaning that the regime changes every four years. This disrupts long-term health projects and causes a high degree of MOH staff turnover (Institute for Health Promotion and Disease Prevention Research 2009).
The health information system in Guatemala, as in many developing countries, is underdeveloped. The national health information system is fragmented among the different levels of the health system. The Health Management Information System (SIGSA), used by public-sector physicians, is not coordinated with other important networks including the network for HIV/TB/malaria workers, the epidemiology monitoring system, and the warning system of the National Epidemiology Center (Global Fund Office of the Inspector General 2013). Due to a lack of human resources, epidemiological surveillance is limited, and the scope of many health problems remain poorly understood. This problem is currently being addressed by new university training programs in epidemiology and public health within the country (Magaña-Valladeres et al. 2009)
The supply chain for medicines and other health supplies is frequently disrupted (GFOIG 2013). The Guatemalan MSPAS often underestimates the country’s requirements for supplies, and not all relevant parties has been involve in the process of these estimations (GFOIG 2013). The Global Fund suggests that this process be made more participatory, using a bottom-up approach among health workers providing direct services (GFOIG 2013).
Guatemala’s status as a middle-income country makes it ineligible for non-reimbursable financial cooperation; however, external financial investment is still plays a vital role in the country’s development (WHO 2007b). Countries who have invested in Guatemala’s health include USAID/USA, AECI/Spain, SIDA/Sweden, JICA/Japan, GTZ/Germany, MINSAP/Cuba, and others, as well as major UN agencies including UNDP, UNICEF, UNAIDS, and the World Bank. The Government of Guatemala experienced a severe budget crisis in 2010, which squeezed the already tight budget of the MOH. In 2011, the MOH budget was US$425 million, instead of a requested $687.5 million (GHI 2010). This created a squeeze on resources for service delivery in the public health sector.
With regard to health leadership and governance, the MOH prepared a National Health Plan (NHP) in 2008 to support the health-related components of the 1996 Peace Accords and the achievement of the MDGs (GHI 2010). The development of human resources, decentralization of health services and increased funding for health are among the listed priorities. The NHP also recognizes the need to address health inequities among rural and indigenous populations and states that it seeks to improve access among these communities.
With this background information, I now turn to a discussion of Guatemala’s health system response to the HIV/AIDS epidemic among its own population.
HIV/AIDS IN GUATEMALA
Guatemala has a concentrated yet growing epidemic of HIV/AIDS. Current estimates of the adult HIV prevalence are stated at 0.8% (USAID 2010). The contribution of HIV/AIDS to the total number of disability-adjusted life years (DALYs) in Guatemala rose 3133% between the years 1990-2010 (Institute of Health Metrics 2013). Infections occur primarily among men who have sex with men (MSM) and commercial sex workers (CSWs) (USAID 2010). According to a 2002 study by UNAIDS, infection levels among MSM were 10 times higher than the general population (UNAIDS 2008). Transmission is predominately sexual. Sexual transmission accounted for 94% of all new HIV cases reported from 1984 to 2005 (World Bank 2006). To date, there have been no reported transmissions from intravenous drug use.
The HIV prevalence rates in Guatemala are likely to be grossly underestimated. Underreporting due to stigmatization is a prominent concern in a cultural environment ripe with conservative Roman Catholic beliefs and prejudice toward people with HIV/AIDS (Mendoza 2007). In addition, little data exists about the scope of the problem among indigenous communities. Preliminary data suggest that Mayans could be experiencing increasing HIV infections (USAID 2010), though little has been done to monitor HIV spread among these communities (Cohen 2006).
Guatemala’s Health System Response to HIV/AIDS
Nine years after the first reported case of HIV in 1984, the Guatemalan government declared HIV/AIDS a national emergency in 1995 (World Bank 2006). This was solidified into the HIV/AIDS law in 2000. The law declared HIV/AIDS and other sexually transmitted infections to be a problem of national urgency and outlined the guidelines for protecting human rights in the face of the epidemic (WHO 2005). The national law provided the foundation for the establishment of the National Program for the Prevention and Control of HIV/AIDS and STIs (PNS) within the MSPAS (World Bank 2006). During 2006-2007, Guatemala implemented a strategy focused on scaling-up coverage of HIV treatment to increase access among the population (UNAIDS 2008). The government has begun working with public-private partners such as the Global Fund and NGOs in order to decentralize HIV services from national to regional hospitals. Decentralization can lead to improved responsiveness in addition to access.
As with other health services in Guatemala, the service delivery of HIV treatment has been significantly facilitated by NGOs. The government began providing antiretroviral treatment (ART) in 2001; however, until 2004, few people with HIV were provided ART by MSPAS (World Bank 2006). Only individuals covered by social security were eligible to receive treatment free of charge from the national hospital in Guatemala City. Between 2001-2004, Doctors Without Borders (MSF) facilitated a significant increase in the number of people receiving treatment for HIV (World Bank 2006). As a result, people receiving antiretroviral treatment went from 6647 in 2006 to 8000 in 2007 (UNAIDS 2008). After years of capacity building, MSF officially handed over service delivery of ART treatment to the MOH in 2007 and assumed a monitoring role in the provision of treatment (MSF 2007).
Cooperation by the Global Fund has allowed at least 30 NGOs and community-based organizations to be subsidized for providing HIV health services, including testing, diagnosis, and treatment (Humanist Institute for Development Cooperation 2013). As a primary recipient of Global Fund grants, the international development agency Humanist Institute for Development Cooperation (HIVOS) has coordinated programs to reach priority at-risk populations including MSM, SCWs, prison inmates, and at-risk youth. To date, 10,124 people have received treatment from HIVOS-facilitated programs (HIVOS 2013).
In 2007, the MOH established the National Monitoring and Evaluation Plan for Preventing STIs and HIV/AIDS. The information system is still weak, however, with only 60% of health centers reporting data (UNGASS 2008). Nunez, an epidemiologist in Guatemala City, has stated that, “Epidemiology is not seen as important. Countries and ministries of health are concerned that they have treatment for people in these countries. But we can’t forget about prevention either” (as cited in Cohen 2006:480). More work needs to be done to map the current HIV situation and increase surveillance – particularly among indigenous communities.
Guatemala has invested in local hiring and training of human resources for its HIV national program (GFOIG 2013), which is a practice recommended by the WHO for the retention of human resources in rural areas (WHO 2010). There have been more training programs targeted at health workers for the treatment and prevention of HIV, and uptake has been considered a success (WHO 2006).
Since 2004, Global Fund has made significant investment investments in HIV prevention in Guatemala. In the years 2004-2008, the Global Fund invested US $42 million for HIV care and prevention (USAID 2010). The MSPAS has been the principle recipient of three grants from the Global Fund, one each for HIV, TB and malaria. USAID, UNICEF, and PEPFAR have also contributed significantly to the country and the region. Between 2004-2011, PEPFAR distributed US $54.4 million to HIV support in the Central America region (U.S. President’s Emergency Plan for AIDS Relief 2012). These funds have not always been handled with care, however. The Government of Guatemala gave its approval for MSPAS’s Global Fund grants to be exempt from taxation, yet the responsible united have not yet obtained an except Tax Identification Number (NIT) (GFOIG 2013). In 2012 alone, an estimated US $272,032 taxes were needlessly paid with Global Fund resources. Alternatively, these resources could have gone to the provision of services.
As of 2007, an estimated 37% of people with HIV are receiving antiretroviral treatment (USAID 2010); however, there is less than 25% coverage of antiretrovirals for the prevention of mother-to-child transmission in Guatemala (UNAIDS 2008). The Essential Medications Campaign – an initiative by MSF – made generic ARV drugs available for use, which dramatically lowered the cost of ARV treatment per person. Due to this push, the annual cost of triple therapy treatment for HIV went down from US $10,439 for brand names to $201 for generics (World Bank 2006). The MSPAS has experienced challenges with managing the procurement process, however. Procurement for drugs takes at least 130 days and includes 52 steps, often involving a number of administrative authorizations before purchasing can take place (GFOID 2013).
RECOMMENDATIONS AND CONCLUSION
The health system of Guatemala faces several challenges due to social inequalities, lack of financial resources, and the distribution of the rural population. The following recommendations, each aimed a building block of the health system, could be taken to improve Guatemala’s response to HIV/AIDs:
- Recommendation 1: Design targeted programs administered in native languages for HIV prevention, treatment, and epidemiological surveillance among indigenous communities. It is very possible that the epidemic could spread to this population due to lack of awareness.
- Recommendation 2: Secure tax-exempt status for bilateral grants for HIV. Global Fund grants should not be used to pay when these funds could go directly to services.
- Recommendation 3: Partner with capacity-building organizations such as the Supply Chain Management Assistance (SCMA) in order to strengthen the supply-chain management of medicines for HIV (Global Fund 2013).
- Recommendation 4: The MSPAS should create coordination between health information systems of SIGSA and the other important health networks identified in this paper. It should also implement training programs for health workers to ensure that each worker is aware of how to use the system in order to increase participation in data reporting.
- Recommendation 5: The MOH should create a policy of long-term job appointments for MOH staff. The contract-only basis upon which most staff work creates staff turnover and disincentives for highly trained and educated staff, who may prefer to work elsewhere for increased job security and pay.
- Recommendation 6: The National Program for the Prevention and Control of HIV/AIDS (PNS) should continue its activities, but create more quantified targets for the prevention of HIV within Guatemala. It is not enough to rely on Millennium Development Goals for targets and indicators. Guatemala should create country-specific targets in reduction and ARV coverage that reflect its own cultural situation – particularly with regard to social inequities.
 Catastrophic health spending is defined as 40% or more of a household’s income being spent on healthcare (Bowser and Mahal 2010).
 The Gini coefficient is a measure of in the distribution of family income in a country, based on statistical measures of dispersion.
 The Human Development Index (HDI) is an overall development indicator that measures life expectancy, education, and income.
 The Inequality-adjusted Human Development Index (IHDI) is a measure of the average level of human development in a country once social and economic inequality is taken into account.
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