Assessing the performance of the health system in Guatemala

San Gabriel and Metropolitan Service Planning Area Health Office (SPA Research 3 & 4) Institute forValley Health Promotion and Disease Prevention

CASE STUDY

ASSESSING THE PERFORMANCE OF THE HEALTH SYSTEM IN GUATEMALA Volume I: Narrative Edition

GLOBAL HEALTH LEADERSHIP REPORTS BEST PRACTICE SOLUTIONS TO ENHANCE THE PERFORMANCE OF HEALTH SYSTEMS

M. RICARDO CALDERÓN, SERIES EDITOR

June 2008 Institute for Health Promotion and Disease Prevention

INSTITUTE FOR HEALTH PROMOTION & DISEASE PREVENTION RESEARCH Keck School of Medicine University of Southern California (USC) 1000 South Freemont Avenue, Unit 8 Alhambra, California 91803

The Global Health Leadership Reports is a publication of the USC Institute for Health Promotion and Disease Prevention Research (IPR). The opinions expressed herein are those of the editor and author(s) and do not necessarily reflect the views of the University of Southern California. Excerpts from these publications may be freely reproduced acknowledging Global Health Leadership Reports as the source.

Internet: http://mph.usc.edu/ipr/ http://www.mrcalderon.com

GLOBAL HEALTH LEADERSHIP TEAM SERIES EDITOR: M. Ricardo Calderón, M.D., M.P.H. Senior Administrative Director, International Training Programs; Associate Professor, Preventive Medicine; Founding Director, Master of Public Health (MPH) in Global Health Leadership Track; and Regional Director, Latin America and the Caribbean, USC-IPR, and Area Director & Health Officer County of Los Angeles Department of Public Health MANUSCRIPT AUTHORS Andrea Cooper, Pharm.D., M.P.H. Robyn Eakle, B.A., M.P.H. Nik Gorman, B.A., M.P.H. Lawrence Ham, B.S., M.P.H. Jae Hyun, B.S., M.P.H. Katrina Kane, B.A., M.P.H. Saieh Khademi, B.A., M.P.H. Liyan Moghadam, B.S., M.P.H. Wilson Ong, B.S., M.P.H. Mana Pirnia, B.A., M.P.H. Brian Sandoval, B.S., M.P.H. Amy Yeh, B.S., M.A., M.P.H. ENGLISH/SPANISH TRANSLATORS Roberto D. Valladares, B.S., B.S. Cándida E. Valladares, B.S., B.A. INFORMATION DISSEMINATION INITIATIVE Carina Lopez, M.P.H. Program Manager

At a Glance The GLOBAL HEALTH LEADERSHIP REPORTS series was created by Professor M. Ricardo Calderón during his tenure at the Institute for Health Promotion and Disease Prevention Research (IPR) of the University of Southern California’s Keck School of Medicine (USC). It was designed to provide a forum for faculty and students of the USC Master of Public Health (MPH) Program to share lessons learned and best practice solutions to enhance the performance of health systems around the world. Traditionally and due to scholarly purposes, the research, training and service of university faculty and students is published in a variety of peer reviewed and professional journals. While this is the acceptable professional and academic manner to contribute with original unpublished research, social science analyses, scholarly essays, critical commentaries and letters to the editors, there is an extensive body of practical information and valuable knowledge that is either not submitted for publication or that takes too long to be published. This lack of information exchange reflects a missed opportunity to strengthen, expand and diversify knowledge learning and capacity development in order to trouble-shoot, problem-solve, make informed choices, prioritize investments, implement evidence-based practices or lead innovation and change in the healthcare and public health industries.

The Global Health Leadership Reports series was created to fill some of these gaps in information dissemination and exchange. More importantly, it was designed for the timely integration of research findings and best practice solutions into program development, implementation and evaluation. It was also created to continue to enhance the performance of health systems and population health outcomes. This is accomplished through electronic publications that can be easily distributed by e-mail, posted on websites, or transmitted via internet around the world. This is also done by capitalizing upon the research efforts and practical solutions developed by faculty and graduate students during their teaching and learning experience, graduate education, classroom debates, and group discussions, including a variety of projects that are implemented by talented, creative and innovative faculty and students.

We trust that the reader will be open to our publication rationale and approach, and will contribute to further disseminate reliable information for the effective development of community and global health programs, plans and policies. We hope that the Global Health Leadership Reports will stimulate discussion and reflection, propel continued dialogue, and encourage the pioneering of new combinations of innovative approaches and practical solutions to enhance the performance of health systems and improve the health status and wellbeing of individuals, families and communities worldwide. We also hope to contribute to fulfill the vision to create healthy people living in healthy environments locally and globally. People living longer, quality lives in a world with less pain and suffering, less injuries and disease, less health inequities and disparities, and a world where our minds and bodies perform at optimum levels.

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ASSESSING THE PERFORMANCE OF THE HEALTH SYSTEM IN GUATEMALA

TABLE OF CONTENTS I. EXECUTIVE SUMMARY

A. Acknowledgements

II. THE GUATEMALA SUMMER PRACTICUM

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A. Introduction B. Purpose, Goals, Objectives and Learning Outcomes C. Guatemala Practicum Description D. Partner and Host Institution in Guatemala

III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM AND COUNTRY IN TRANSITION: PART 1

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A. Introduction B. Historical Background C. Demographic Indicators D. Economic Indicators E. Health Needs F. Organization and Management of the Health Care System G. Health System Resources H. The Key Stakeholders I. Future Implications J. References

IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM AND COUNTRY IN TRANSITION: PART 2 27

A. Introduction B. The Stakeholders C. Stakeholder Analysis D. Areas of Consensus E. Areas of Discord F. Resource Commitment G. Conflicting Interests H. Stakeholders Summary I. The SWOT Analysis

1. Strengths

2. Weaknesses

3. Opportunities

4. Threats J. Proposed Goals to Restructure and Revitalize the Guatemalan Health System

Goal #1: Community Empowerment and Raising Awareness

Goal #2: Increase and Improve Cooperation, Communication and Accountability

Goal #3: Increase and Improve Capacity and Resources

K. References

V. OVERALL CONCLUSIONS AND RECOMMENDATIONS

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A. Introduction B. The Challenges that Health Systems Face Today C. How to Improve Health System Performance

1. Stewardship

2. Service Provision

3. Resource Generation

4. Health System Financing

VI. BIBLIOGRAPHY

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EXECUTIVE SUMMARY

EXECUTIVE SUMMARY A twelve-member team of Master of Public Health (MPH) students of the University of Southern California (USC), along with two pre-medical students and English/Spanish translators from Westmont College, conducted an assessment of the health system in Guatemala during summer 2007. The assessment was designed, organized and directed by the USC Founding Director of the MPH Global Health Leadership Track. It was created as the culminating USC MPH Public Health Practicum, a field internship experience aimed to apply the scientific intelligence and leadership skills acquired by students in the MPH program to a real life setting.

It was also developed in preparation for the work that students will perform in institutions, communities and countries when they graduate and join the public health workforce at local, national or international level.

The practicum placed special emphasis on teamwork, collaboration, partnerships and leading change efforts to improve institutional performance and population health outcomes. The total internship program lasted ten weeks –Literature Review: 5 weeks; Guatemala Site Visit: 3 weeks; Report Writing: 2 weeks—and students played roles as USC “interns and researchers” as well as “evaluators and consultants” in Guatemala. The host institution in Guatemala was the MPH program at the Universidad de San Carlos de Guatemala (USAC) whose faculty and students contributed considerably to the development of the practicum and resulting health system assessment. The design of this “real life experience” was based on the Strategic and Implementation Planning Approach conducted by Family Health International (FHI) in the 1990s during the implementation of the largest HIV/AIDS Prevention and Control Project in the world –The United States Agency for International Development (USAID) AIDSCAP Project, 1992 - 1997. That is, a 3-week field assignment to develop a strategic or an implementation plan ending with a formal presentation to the respective USAID Mission and country counterparts including a written, draft document left in-country. This was preceded by preparation time and was followed by final report writing time along with respective FHI, USAID and country approvals.

The USC MPH students conducted an extensive literature review to become knowledgeable about the society and health system of Guatemala. Upon arrival on-site, a powerpoint presentation was given to the USC Internship Program Director and MPH professors at USAC. This was followed by an intensive 3-week period comprising indepth interviews with country counterparts from the public, private and non-profit sectors as well as representatives from international technical cooperation and donor agencies. Opportunities were also provided for cultural immersion to understand the social, cultural, political and economic environments in Guatemala. At the end of the field experience, a USAC/USC Technical and Scientific Session was convened at the Metropolitan University Center. This two-hour session was attended by close to 100 national and international stakeholders. The presentation discussed the Guatemalan Health System and the Critical Importance of Global Health Training. A question and answer period followed the presentation acknowledging the outstanding work and contributions of the USC students and enriching the technical content of the discussion.

The purpose of this publication is to make available to students and faculty in the U.S. and Guatemala, and to the local and international population, health and development community, the practicum rationale and strategic approach and findings and recommendations of the assessment. This was done through a SWOT Analysis resulting in the following thematic and topical issues: STRENGTHS: capacity to identify health problems and solutions, work efforts to improve health, awareness of the need for education, availability of traditional healers, WEAKNESSES: systemic ideologies, data management, lack of resources, stewardship and political insecurity, education implementation, population disparities,

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EXECUTIVE SUMMARY

OPPORTUNITIES: form stakeholder coalitions, integrate traditional healers, change provider paradigms, bridge alliances, invest in human potential, develop a sound health policy, and THREATS: organizational issues, integration issues, human resources issues, communication challenges, investment issues, and lack of enforcement of health related laws.

In addition to this publication, readers are referred to two companion “Slide Edition” publications, “Assessing the Performance of the Health System in Guatemala, Volume II.I: Guatemala, A Health System in Transition, Part I, PreTrip Report, and Volume II.2: Guatemala, a Health System in Transition, Part II, Post-Trip Report.

We trust that the reader, including local and international public, private and non-profit organizations working to improve the health status and well-being of individuals, families and communities in Guatemala, will benefit from the strengths and accomplishments and the concerns and recommendations outlined in this report.

We acknowledge the contributions of the USAC faculty and students and all stakeholders interviewed, and congratulate and thank the USC students for their interest and willingness to contribute to the Guatemalan society with this report. We also hope that global health leadership training continues to expand the opportunities to engage faculty and students and population health and development practitioners from industrialized and developing countries to enhance the performance of health systems and improve population health outcomes around the world.

M. RICARDO CALDERÓN, M.D., M.P.H. Los Angeles, CA, USA June 2008

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ACKNOWLEDGEMENTS

Andrea Cooper, PharmD, University of Southern California, Los Angeles, CA & BCPS.

Katrina Kane, B.A. Kinesiology and Applied Physiology, University of Colorado, Boulder, CO. MPH, Global Health Leadership, University of Southern California, Los Angeles, CA.

Nik Gorman, B.A. Psychology, Lewis and Clark College, Portland, OR. MPH, Biostatistics and Epidemiology, University of Southern California , Los Angeles, CA.

Saieh Khademi, B.A. Political Science, University of California, Los Angeles. MPH, Health Promotion, University of Southern California, Los Angeles, CA.

Jae Hyun, B.S. Physiology, University of California, Los Angeles. MPH, Biostatistics and Epidemiology, University of Southern California, Los Angeles, CA.

Liyan Moghadam, B.S. Physiological Sciences, B.S. Biochemistry, University of Arizona, Tucson, AZ. MPH Global Health Leadership, University of Southern California, Los Angeles, CA.

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ACKNOWLEDGEMENTS

Wilson Ong, B.S. Biological Science, University of Southern California, Los Angeles, CA. MPH, Global Health Leadership, University of Southern California, Los Angeles, CA.

Robyn Eakle, B.A. French Literature and Comparative Literature, University of Washington, Seattle, WA. MPH, Global Health Leadership, University of Southern California, Los Angeles, CA

Lawrence Ham, B.S. Biology, University of California, Riverside, Riverside, CA. MPH, Global Health Leadership, University of Southern California, Los Angeles, CA.

Amy Yeh, B.S., Biological Sciences & B.A. Political Science, University of California, Irvine & M.A., Medical Sciences, Boston University & MPH, Global Health Leadership, University of Southern California, Los Angeles, CA

C谩ndida Elisabeth Valladares Calder贸n, B.S. Chemistry & B.A. Biology, Westmont College, Santa Barbara, CA.

Brian Sandoval, B.S. Physiology, California State University, Long Beach & MPH, Global Health Leadership, University of Southern California in Los Angeles, CA

Roberto Daniel Valladares Calder贸n, B.S.Chemistry & B.S. Biology, Westmont College, Santa Barbara, CA.

Mana Pirnia, B.A. Psychology University of California, Los Angeles. MPH, Global Health Leadership, University of Southern California, Los Angeles, CA.

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II. THE GUATEMALA SUMMER PRACTICUM INTRODUCTION, GOALS, OBJECTIVES AND LEARNING OUTCOMES

II. THE GUATEMALA SUMMER PRACTICUM A. INTRODUCTION The Master of Public Health (MPH) in Global Health Leadership (GHL) of the Institute for Health Promotion and Disease Prevention Research (IPR) at the Keck School of Medicine, University of Southern California (USC), equips students and develops leaders with worldclass knowledge and technology in population-based disease prevention and control and public health leadership and management principles for the 21st century.

MPH-GHL graduates are expected to work with local, national and international organizations and partners to strengthen regional public health systems, enhance public health preparedness and emergency response, and protect and improve global health as a whole. They are equipped with knowledge, skills and abilities to lead multi-disciplinary, multi-sectoral and multi-national initiatives to enhance the health status and wellbeing of individuals, families, and communities around the world.

In order to strengthen, expand and diversify the learning experience and teaching approach of the MPH program, USC-IPR offers a variety of Summer Internship Programs.

An internship program, called Practicum at USC-IPR, provides local, national and international field experience based on the principle that adult students learn by doing. It is developed to help students apply the scientific intelligence and leadership skills acquired through the MPH program to a real life setting in preparation to the work they will perform

in institutions, communities and countries when they join the public health workforce. Special emphasis is placed on teamwork, collaboration, partnerships, and leading change efforts to improve institutional performance and community health.

The MPH Guatemala Summer Practicum is an applied learning experience that takes place in the context of a foreign country instead of a student’s personal and local environment. Students are expected to work on a public health issue, challenge or opportunity using an Action Learning Approach. In Action Learning, students try to deeply understand a real problem, take wise actions, and reflect on what they have learned. It is done in a group so students can learn from one another and collaborate. Consequently, the Guatemala Summer Practicum is an opportunity for students to practice being a collaborative leader of change networking with and working in concert with foreign MPH students and faculty, as well as a variety of public health experts and counterparts from pubic, private and non-profits institutions.

B. PURPOSE, GOALS, OBJECTIVES AND LEARNING OUTCOMES The main PURPOSE of the MPH Summer Practicum is to strengthen, expand and diversify the USC-IPR curricula through the development and implementation of value-added study, practice and research abroad/ field experiences. The key GOALS of the Practicum are to: • Create an assignment/consultancy that stimulates and reflects what students will be doing in their future careers as public health practitioners and leaders.

• Enhance the students’ public health knowledge and leadership skills to better equip them to protect, maintain, and advance the health status and wellbeing of populations at local, national and/or international levels.

The specific OBJECTIVES of Practicum are, but will not be limited to, the following: • Provide students with a field experience to fulfill the MPH program practicum requirements • Expose students to a real life health system including its challenges, constraints and problems • Facilitate information exchange between USC-IPR and local MPH students • Provide students with an intense cultural immersion experience • Provide students with an opportunity to practice collaborative and shared leadership skills • Strengthen students’ interpersonal and teamwork skills including peer education and support • Link students to key stakeholders in Guatemala, particularly public, private and non-profit organizations, academic institutions, international health and technical cooperation organizations, bilateral and multilateral donor agencies, etc.

• Help students integrate overseas studies and thinking into their academic and professional careers.

In terms of LEARNING OUTCOMES, at the completion of the Practicum, students will be able to: • Describe the social, economic and political environment of the Guatemalan society • Describe the key features of the

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II. THE GUATEMALA SUMMER PRACTICUM GUATEMALA PRACTICUM DESCRIPTION

Guatemalan Health System and its capacity and effectiveness to provide health promotion and disease prevention and control services to the entire population

to an Assessment of the Guatemalan Health Sector as follows:

• Assess the strengths, weaknesses, opportunities and threats (SWOT Analysis) of the health system

A 4-week, 140-hour program of self-directed study and team research that takes place in Los Angeles, California during the period 06/18/07 through 07/13/07.

In this Phase, students conduct an extensive literature review to prepare a Pre-Trip Written Report and PowerPoint Presentation on the Guatemalan Health System based on the following guidelines and outline:

• Explain the critical importance of the private and voluntary sectors, in addition to government, in achieving better levels of health system performance • Describe the defining purpose, goals and key functions of the Guatemalan Health System in comparison to WHO’s recommended goals and vital functions • Develop health system change or reform recommendations based on the knowledge and skills gained through MPH courses, self-directed study, team research, and in- country consultations with key experts and stakeholders • Develop on-site, in-country rapid research, report writing and presentation skills • Contribute to teamwork assignments either as a team leader, advisor or member • Utilize Action Learning and Delphi Technique concepts and approaches to assess public health challenges, issues and problems • Develop networks of professional contacts in foreign settings

C. GUATEMALA PRACTICUM DESCRIPTION The Guatemala Practicum is a 3-month (June, July & August) program of study based on 3 mutually reinforcing phases leading

PHASE I

• PRE-TRIP WRITTEN REPORT & POWERPOINT PRESENTATION (DUE 07/13/07): This reports comprises, among other topics, a description of the population, key health status indicators, health system characteristics, and an appraisal of social and political trends and their implications for the health system.

This will include basic information about disease patterns and health system financing, as well as the history, present status and future challenges of the system. This report and a corresponding PowerPoint presentation will be organized according to the following seven thematic areas: 1. BACKGROUND INFORMATION: government, the economy: employment and economic dimensions, demographics and education, health system history, geographic location, etc.

2. CONTEXT: HEALTH NEEDS: health status, major health problems, leading causes

4. HEALTH SYSTEM FINANCING: financing structures (hospital care, ambulatory care, preventive care) and reimbursement mechanisms (cost-sharing, cost-containment, etc.)

5. HEALTH RESOURCES: Healthcare Professionals (physicians, public health professionals, pharmacists, nurses and nursing aides, allied health professionals) and Health Services Facilities: hospitals, clinics, public health facilities, medical equipment and commodities, drugs, etc.

6. SERVICE DELIVERY: nature and distribution of primary, secondary and tertiary care; availability, access, equity and quality; urban versus rural contrast, etc.

7. PROSPECTS FOR THE FUTURE: strengths, constraints, options, challenges, opportunities.

PHASE II This is a 3-week (07/23/07 – 08/10/07), 180-hour field experience in Guatemala, Central America.

Phase II will start on Monday July 23rd with a Morning Workshop at the MPH Program of the Universidad de San Carlos de Guatemala (USAC) to review the Pre-Trip Written Report and the PowerPoint Presentation. A presentation will be given to the faculty and students

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of morbidity and mortality, demographic patterns and trends of disease.

3. ORGANIZATION AND MANAGEMENTN OF THE HEALTH SYSTEM: public, private and nonprofit health programs and services.

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II. GUATEMALA SUMMER PRACTICUM GUATEMALA PRACTICUM DESCRIPTION

of the USAC MPH program. They will provide technical input and expert advice regarding the local health system, complement pre-trip research and report findings, and make recommendations regarding additional data, information, and features and characteristics of the health system, including referrals to key local and expatriate experts.

The afternoon of Monday, July 23th, will be spent reviewing in detail the components and logistics of the 3-week agenda including the information gathering approach (i.e., individual and group interviews).

In addition, a presentation will be made by INGUAT (Guatemalan Tourism Institute) staff about the Guatemalan history, politics, economy, geography, culture, demographics, languages, religion, education, and biodiversity and ecology to familiarize students with the local context.

The Guatemala Summer Practicum Coordinator (Dr. M. Ricardo Calderón, USC-IPR Senior Administrative Director for International Programs, Associate Professor in Preventive Medicine, Founding Director, MPH Global Health Leadership Track, and Regional Director, Latin America & the Caribbean) will develop a detailed 3-week agenda during June and July. The Practicum will expose students to medical, public health, population and social science experts, and local and international stakeholders from three different sectors of the Guatemalan society – public, private for profit and nonprofit sectors--, critical to assure the population’s health.

While in-country, the main method

to gather information and data about the Guatemalan Health System will be the adaptation and application of the Delphi Technique in addition to the Action Learning Approach previously described. The purpose of the Delphi Technique will be to elicit information and judgments from local experts and stakeholders to facilitate problem solving, facts finding, report writing, health system assessment, and health sector planning and decision-making. Responses will be collected and analyzed; then, common and conflicting viewpoints will be identified. If consensus among students regarding critical issues of the system is not reached, the process continues through thesis and antithesis discussions to gradually work toward synthesis and consensus building. This technique will be utilized to take advantage of the experts’ and stakeholders’ knowledge, experience, creativity and resourcefulness as well as the facilitating effects of group involvement and interaction. It will be applied to capitalize on the merits of both individual and group-problem solving. Crucial to this Phase will be in-depth and keyinformant interviews, and meetings and discussions with individual and group representatives from the following six sub-sectors connected directly or indirectly to health promotion, wellness and disease prevention and control: While in-country also, students will prepare a draft country report of their findings that will be discussed at the end of the practicum at a Stakeholders Meeting. This report will be a critical analysis and assessment of the health system

leading to recommendations to strengthen the system according to the World Health Organization’s (WHO) three Goals –improve health, enhance responsiveness to the expectations of the population, and fairness of financial contribution— and four Vital Functions of a health system –service provision (delivering services), resource generation (investment and training), financing (collecting, pooling and purchasing), and stewardship (management, oversight). At the Stakeholders Meeting, key people from the public, private for profit and non-profit sectors of Guatemala, particularly faculty from the USAC MPH Program, will serve as local Practicum Outcome Evaluators. They will assess the performance of the USC-IPR team through a PowerPoint Presentation that students will make and will contribute with critical input and insights to clarify issues and strengthen recommendations.

This presentation will be made in one of the Virtual Classrooms of the School of Medical Sciences. The expected audience will be faculty and students from the USAC MPH program, experts and stakeholders interviewed, invited guests from the public, private and non-profit sectors, and representatives from USC-IPR.

PHASE III This is a 2-week, 80-hour phase of the Practicum that takes place back in Los Angeles, California during the last two weeks of August for a total of 400 hours of practicum experience. Students will review, edit, refine and strengthen their draft country report and PowerPoint

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III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I INTRODUCTION presentation with the suggestions and recommendations provided by the evaluators and participating audience at the Stakeholders Meeting. Students will submit as practicum deliverables two documents –An Assessment of the Guatemalan Health Sector merging the pre-trip report with the draft incountry report, and a corresponding PowerPoint presentation. The due date for these deliverables will be August 27, 2007.

D. PARTNER AND HOST INSTITUTION IN GUATEMALA USC-IPR has developed a strategic partnership and agreement of technical cooperation with the host institution in Guatemala, the MPH Program at the Universidad de San Carlos De Guatemala (USAC). The USC-IPR Practicum Coordinator will ensure concurrence by USAC-MPH with all practicum activities, i.e., goals and objectives, strategic approach, research methodology, selection of experts, stakeholders and practicum evaluators. USC-IPR students will have an opportunity to participate in several USAC-MPH classes. USACMPH faculty will also lecture USC-IPR students on select healthcare issues, public health topics, and emerging trends in medicine and public health in Guatemala. Also, USC-IPR students will be paired with USAC-MPH students to conduct visits to their places of employment including their programs and services at local, departmental, regional and national level.

The USAC-MPH is a 2-year, 4-semester program aimed to (1) develop professionals with scientific, technical, epidemiological, humanistic, ethical, moral and environmental capacities in public

health, (2) promote health at a community, national and regional levels focusing on gender and intercultural studies, and (3) develop agents of social change with skills in research, social administration and leadership. The program is delivered 2 days a week (Fridays and Saturdays) from February through November.

It is intended primarily for working professionals expected to connect and apply the curricular content to their work environments and institutions through a research and intervention project.

The MPH program, housed at the USAC School of Medicine, comprises 6 Curricular (Thematic) Areas – Research, Epidemiology, Health Promotion, Environmental Health, Health Services Management & Graduate Thesis, each of which is divided into 3 modules corresponding directly to Semesters 1 through 3.

Students are expected to select one of seven MPH Tracks and undertake specialized coursework in Semester 4 in Epidemiology, Chronic Disease Epidemiology, Promotion of Food Security and Nutrition, Addictions, Environmental Health, Disaster Management, or Health Services Management.

The key faculty of the USAC-MPH program and counterparts for the implementation of the USC-IPR Guatemala Summer Practicum are the following: • Mario Rodolfo Salazar Morales, MD, MPH, MS, Professor, Epidemiology, and MPH Program Director • Cizel Zea Iriarte, MD, MPA, SSD, Professor, Administration and Social Health •

Giovani Salazar Moreno, MD,

• Joel Sical Flores, MD, MPH, Professor, Research • Jorge Bolivar Dias Carranza, MD, MPH, Professor, Environmental Health and Epidemiology • Otto Hugo Velasquez, MD, MPH, Professor, Epidemiology • Alfredo Moreno Quiñonez, MD, MPH, Professor, Research

III. PRE-TRIP REPORT, GUATEMALA: A HEALTH SYSTEM AND COUNTRY IN TRANSITION PART 1: A. INTRODUCTION Guatemala is a culturally diverse nation that is known as the “Soul of the Earth”. It is a colorful nation where Spanish is the official language, but an additional 23 indigenous languages are also spoken. In an attempt to catch up with the rest of Central and South America, this Central American country is working to define itself as it transitions from an impoverished developing country into a more developed, middle income nation.

From a public health standpoint, Guatemala is challenged with the dual burden of chronic and infectious disease. Limited health resources place constraints on the country’s ability to effectively manage this dual burden. This is exacerbated by poor stewardship, lack of infrastructure, and a diverse, disaggregate population with many cultural barriers. In order to assist Guatemala’s transition into a developed nation, we must first examine and evaluate the current health care system and attempt to diagnose its numerous health 11

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MPH, Professor, Health Promotion

June 2008

III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I HISTORICAL BACKGROUND

issues. In preparation for an intense, three week in-country health system assessment, the purpose of this paper will be to present an overview of the current Guatemalan Health Care System set within the context of the country’s history, political structure, and existing infrastructure.

Key priorities for preliminary recommendations and interventions will also be identified. Preliminary recommendations for the future will capitalize on existing resources that are not currently being utilized to their full potential and innovative new approaches to meeting the health needs of the people of Guatemala.

This pre-trip report will be followed up with a post-trip report comprising final recommendations based on the integration of data gathered during pre-trip and in-country research.

B. HISTORICAL BACKGROUND In investigating Guatemala’s current state, it is vital to first consider the county’s historical origins. Certainly not the only defining element in the country’s history, one important recurring theme has been that of political regime change. Throughout its history, the country has been subject to a number of political turnovers culminating in its current condition, with entirely new and disparate political entities coming into power every four years. For the earliest documentation of this, one can look to the shift in power from the Mayan civilization, which began its decline in 900 A.D., to the Spanish Empire that took control of the area shortly after arriving in 1523.

Following the Mayan civilization, the Spanish Empire maintained the second longest period of political stability, one that lasted for 300 years.

It is important to note that each successive reigning power has left

an impact on the country. Indeed, hundreds of years later, the country’s Mayan roots are still apparent through the indigenous cultures that inhabit various regions around Guatemala. Today, the Spanish culture also remains in the Ladino and Mestizo people, which comprise over half of the nation’s population.

Since this initial transition of power, Guatemala has seen a series of progressively more rapid political changes. Between 1821 and 1840, Guatemala experienced a series of regime changes, declaring its independence from Spain, Mexico, and the United Provinces of Central America (“Timeline: Guatemala,” 2007). Following this turbulent period, Guatemala was governed by a series of liberal dictators who introduced a number of social reforms. The end of these dictators came as a result of one significant, albeit short-lived, reform. In an effort to address high rates of poverty and homelessness, the country’s leaders, Colonel Jacobo Arbenz Guzmán and Juan José Arévalo, began redistributing land to homeless peasants. However, shortly after seizing land from the United Fruit Company, a powerful, tax-exempt industry leader in Guatemala with heavy U.S. investment, Guzmán’s successor, Colonel Carlos Castillo, was assassinated in a U.S. affiliated coup (Derek, 2004; “Timeline: Guatemala,” 2007). In the following years, the U.S. withdrew its presence and the political void was filled with military powers that continued to vie for control of the country through violence and fear tactics during the early 1990s. During this time, there was systematic persecution of the indigenous populations, resulting in widespread fear, distrust, and censorship.

In 1996, after years of instability,

the United Nations sponsored the Guatemalan Peace Accords, ending almost four decades of fighting between the nation's military and guerilla forces (Advancing, 2007).

What ended the longest armed confrontation in the history of Central America also brought forth greater recognition and acceptance of indigenous populations through the translation of voting materials and other various important official documents into different languages (International Republican Institute, 2006). This increase in diverse translation allowed indigenous and other minority groups that had previously been neglected by the system the opportunity to play a part in the political process (International Republican Institute, 2006).

Guatemala’s government is characterized as a presidential democratic republic, similar to the United States, with executive, legislative, and judicial branches. The executive branch is limited to one four-year term which contributes to the climate of political instability. The legislative branch makes an effort to be representative of the general population, yet constituents still have doubts about the fairness of elections. While the efforts of the Peace Accord were ideal in theory, in reality there were still definitive challenges facing the Guatemalan people. Despite an official end to decades of civil war, Guatemalans have continued to face challenges in consolidating their democracy.

Women and indigenous peoples in particular remain marginalized from political life, and high rates of voter abstention continue to result in limited representation in democratic institutions (National Democratic Institute for International Affairs, n.d.). Citizens have also expressed concerns about the legitimacy of the political process itself. In 2005,

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III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I DEMOGRAPHIC & ECONOMIC INDICATORS

a study using a Latino barómetro survey showed that only 23% of Guatemalans consider elections in their country to be generally fair (National Democratic Institute for International Affairs, n.d.). In addition to the notion of fairness, citizens in the study were also concerned with the impact of a legally-mandated increase in the number of voting stations, accuracy of the voter registry, resurgence in partisan violence and intimidation, and influence of illicit funds in campaigns (National Democratic Institute for International Affairs, n.d.). These fears threaten to weaken the people’s confidence in the electoral process and discourage citizens from voting, especially in indigenous communities (National Democratic Institute for International Affairs, n.d.).

Today, Guatemalans are anticipating the upcoming 2007 election. This election will serve as an important test of the country’s democratic system. In a recent poll in May 2007, 1,000 citizens were asked which party they would vote for. The results of the poll showed candidate Alvaro Colóm (UNE) to be favored by the people with a vote of 26% (Leftist, 2007), a result that, if true, would result in the country being led by yet another new political force.

C. DEMOGRAPHIC INDICATORS A country’s demographic makeup has a profound impact on observed health outcomes. Of the 12.4 million people who currently reside within Guatemala, 47% live in urban settings, meaning these people are concentrated in just a handful of cities (U.S. Agency for International Development, 2007). Within these cities, they face the burden of high population density paired with

an infrastructure that is unable to support their numbers. Meanwhile, the other half of the population is comprised of a disaggregate group spread across diverse, unforgiving terrain which impedes development and lowers health outcomes.

Among these disaggregate groups, there is a variety of religious affiliations and languages. One example of this diversity is the syncretism of the practice of Roman Catholicism with traditional Mayan beliefs and customs (Wikipedia, 2007). Similarly, while the county’s official and primary language is Spanish, 23 additional languages are spoken by 40% of the population of whom many do not speak any Spanish (Wikipedia, 2007). This diversity presents a particularly important barrier to health education and promotion activities.

Guatemala is a very young country, with 40% of the population below the age of fifteen (U.S. Agency for International Development, 2007).

This percentage is expected to grow as a result of extremely high fertility rates; the average Guatemalan woman gives birth to four children during her lifetime. However, it is important to note that for every 1,000 live births 30.8 deaths occur, leaving infant mortality as one of the highest for the region (U.S. Agency for International Development, 2007).

Further impacting women’s health, health education and promotion activities are hindered by disparities in literacy rates. Only 65% of females are able to read and write; in contrast, the male literacy rate is much higher at 80%. Although efforts have been made to improve the education system, secondary school completion remains low

7 Assessing the Performance ofChinese the Health System Evaluation of the CDCUSC- In Guatemala

at only 10% of the population (U.S. Agency for International Development, 2005)

D. ECONOMIC INDICATORS Guatemala can be described as a lower to middle-income developing nation. This becomes apparent when viewing poverty levels, which remain steady at 56% (United States Central Intelligence Agency, 2007).

Sixteen percent of the population lives in extreme poverty with scarcely enough money to feed the family.

They have to make difficult decisions in terms of weighing the need to purchase auxiliary goods and services against the minimum food required to simply subsist. Another key economic indicator is the country’s GINI score, a measure of inequality distribution (The GINI Score is a measure of inequality in terms of per capita income and was created by the World Health Organization [WHO]).

Guatemala’s score of 0.55 indicates a high degree of inequality of wealth distribution and sets the country in one of the lowest brackets when compared to neighboring countries (United Nations, 2004). The Human Development Index (HDI) further describes Guatemala’s economic status; ranked 117 of 177 countries, Guatemala has the lowest HDI of any country in Central or South America (United Nations, 2004). The WHO has ranked their healthcare system 78th amongst all nations, which is reflected by the fact that only 5% of its Gross Domestic Product (GDP) is spent on healthcare according to 2000 data from WHO (World Health

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Organization, 2000).

E. HEALTH NEEDS

Table 1: Adjusted Mortality Rates

When contextualizing Guatemala’s health status through its morbidity and mortality rates, it is important to note that the causes of death still include treatable and preventable diseases, such as diarrhea, pneumonia, cholera, malnutrition, and tuberculosis.

While general mortality rates are higher in Guatemala than other areas of both Central America and the United States, this discrepancy is most profound when one considers communicable diseases (see Table1).

Specifically, tuberculosis, AIDS, malaria, and dengue comprise key contributors to the overall burden of disease in the population (see Table 2).

Malaria infections comprise nearly 56% of all reported cases in Central America. These infectious diseases, in combination with malnutrition, contribute to the high rates of infant mortality which are the third highest in all of the Americas (PAHO, 2006).

Table 2: Morbidity Indicators

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Nutritional Deficiencies The burden of malnutrition is a significantly growing problem as food insecurity worsens throughout the nation. Approximately 50% of all Guatemalan children under the age of 5 suffer from some form of chronic malnutrition, as do 30% of pregnant women. In particular, vitamin A deficiency afflicts 50% of all preschool children and 35% of non-pregnant women (Pan American Health Organization, 2001). It has also been found that iron deficiencies are prevalent in 40% of this population.

Contributing to malnutrition is the prevalence of recurring diarrhea.

The distribution of acute diarrheal infections varies by both geographic location and socioeconomic status.

About 35% of the rural population suffers from these infections compared to only 25% of their urban counterparts. In addition to these demographic factors, statisticians have observed that diarrheal infections most frequently begin when infants are weaned from breast milk to solid food sources. This indicates that the most common form of diarrheal infection occurs through oral-fecal routes (World Health Organization, 2007).

Another factor contributing to the rise in food insecurity is cyclical, torrential rainfall. Flooding caused by torrential rain inundates areas where soil is disturbed by agricultural farming. Since the majority of poor households rely on subsistence farming to meet their caloric needs, damages caused by these severe storms pose a serious threat in production of adequate

food supplies. In 2005, the arrival of Hurricane Stan resulted in an agricultural loss of approximately US $207 million (Guatemala Food Security Warning, 2005).

HIV/AIDS As with many other countries around the world, HIV/AIDS is a growing epidemic in Guatemala that requires national attention.

Current estimates state that HIV prevalence is approximately 825 per 100,000 individuals, yet these numbers are grossly underestimated.

This underreporting is due to stigmatization largely arising from conservative Roman Catholic beliefs and prejudice toward people living with HIV/AIDS (Mendoza, 2007).

Sexual transmission by heterosexual males is responsible for the majority of cases, an uncommon trend creating a unique situation unparalleled in most other countries.

Currently, both the Guatemalan government and individual nongovernmental organizations (NGOs) are working to provide HIV testing and antiretroviral (ARV) medication to the population (Mendoza, 2007).

However, testing is extremely expensive, and many people fear learning of a sero-positive status, resulting in low testing rates.

Furthermore, medications provided by these organizations do not necessarily reach their intended populations, come to the government at extremely high cost, and place high financial limitations on both the individuals receiving and institutions providing them (Mendoza, 2007).

Disproportionately affected by these factors are migrant workers, sex workers, rural inhabitants, and pregnant women. The failure to provide ARVs to pregnant women results in vertical transmission of HIV which further contributes to infant

mortality. Beginning in 1999 through 2008, Guatemala has developed a series of strategic plans to combat these issues. This five-point plan focuses on prevention, improving coordination, improving surveillance systems, promoting training and education, and improving treatment, care and support (Mendoza, 2007).

Maternal and Child Health As previously stated, maternal fertility rates show the average Guatemalan woman delivering four children during her lifetime (USAID, 2007). These high rates can be attributed to the low prevalence of modern contraceptive use. This is compounded by a traditional government strategy that focuses on abstinence and fidelity. The average Guatemalan woman typically receives only one antenatal physician visit, since subsequent visits are only feasible for the wealthiest members of the population (USAID, 2007).

These low follow-up rates can also be attributed to poor bed-side manners on the part of the country’s doctors and medical staff, long distances to rural offices, and women’s inability to take extra time away from the home.

The disconnect between mother and physician results in and is illustrated by the low percentages of assisted deliveries overseen by healthcare professionals.

Human Trafficking Guatemala serves as a source, transit, and destination country for human trafficking (gvnet, 2007). Typically, boys, girls, and young women from lower income families are targeted and forced into prostitution. The victims are lured by promises of employment, which are advertised through media, newsprint, and 15

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personal solicitation. Exacerbating this problem are unregulated adoption practices that provide an additional source for trafficked infants (PAHO, 2003). Trafficking poses a serious health threat to these victims through a variety of channels. Violence, which is not uncommon in these situations, can lead to depression, injuries, and sometimes suicide or death (PAHO, 2003). In addition, female reproductive health is affected through the contraction of sexually transmitted infections, unwanted pregnancies, and unsafe abortions.

Trafficking victims also serve as vectors for contracting HIV/AIDS, due to lack of condom use, rough sex, and repeated rapes (PAHO, 2003).

These situations also breed high levels of substance abuse through both involuntary sedation and as a coping mechanism. Finally, access to healthcare is limited in these situations, causing previous injury and undiagnosed illnesses to progress to their most severe phases (PAHO, 2003).

Drug Trafficking Parallel to human trafficking is the issue of drug trafficking. Postconflict environments combined with depressed economic states, mass urbanization and poverty, high proportions of youth and easy access to guns create an ideal environment for the operation of drug cartels (UNODC, 2007). These factors are further amplified by Guatemala’s geographic location between Colombia and the United States, making it a pivotal player between these sending and receiving nations.

Immunizations Although routine vaccinations are entirely covered by the government, vaccination rates speak to barriers of access. For instance, in 20052006, vaccine rates ranged from 84% coverage of DPT3 to only 49% for tetanus in children aged 3-59 months. The government has attempted to expand upon these services by adding a pentavalent vaccine to childhood immunization schedules. A new law is also pending in the congress that will emphasize government responsibility in ensuring availability and access to vaccinations for the entire country. These efforts are further supported by surveillance systems that monitor various infectious diseases, such as measles, rubella, and chagas disease.

Environmental Health In an era of growing concern for the impact of environmental change, it is important to note the various environmental pressures in Guatemala that affect health. The effects of environmental degradation are apparent in increasing deforestation, soil erosion, pollution, and loss of biodiversity, all of which are occurring at stunning rates (EMDAT, 2007). The resulting climate change has been marked by increases over the past decade in natural disasters such as earthquakes, floods, and droughts. The effect of indoor air pollution caused by the persistent use of wood for fuel is contributing to acute respiratory infections in rural populations where electrical connections are virtually nonexistent.

Since they spend the most time at home, women and children are disproportionately affected by these

respiratory infections that are a leading cause of death in the country (Ahmed, n.d.). The reduction of indoor air pollution would address two of the eight Millennium Development Goals (Goals 4 and 5).

Sanitation One of the most important and immediate problems facing Guatemalan communities is limited access to proper sanitation and potable water. While access to improved water sources is stated at 75% of the population, data indicates that in rural areas, 88% of the population does not have access to such potable water, and are thus vulnerable to waterborne illnesses (PAHO, 2006). Furthermore, there is limited access to sanitation facilities, and those that do exist are in a state of disrepair. Additional sanitation concerns include the need for improved latrines and sanitation educational outreach activities.

Previous efforts to address this issue have failed due in part to lack of cultural and environmental sensitivity when interacting with these populations.

Transportation Infrastructure Many of Guatemala’s health problems are associated with the inability of various communities to interact with each other. Although the country possesses nearly 13,000 kilometers (km) of highway, roadway conditions are poor and there is a low density of telephone and electrical infrastructure (GIPC, 2004). The railways have reached such an immense state of disrepair that they are no longer open to commercial use. Therefore, the capacity to handle freight is limited to three major ports and a single airport (GIPC, 2004). These infrastructures are left vulnerable to natural disasters

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such as hurricanes that easily decimate the existing networks.

These dilapidated routes make travel a perilous endeavor, yet communities have no choice to but to embark on these journeys to seek potable water and medical attention (tmcnet, 2007).

Indigenous Groups While the diversity of the Guatemalan population poses a significant barrier to health outreach programs, this is partially offset by strong local communities. For instance, the K’iche people, who are spread throughout the central highlands and other parts of Guatemala, have partnered with NGOs such as Health Unlimited to create culturally tailored educational youth radio programs. These efforts have helped their communities to address their own local needs by promoting environmental conservation to combat water and soil contamination (PCI-Media Impact, 2007). Similarly, the Kaqchikel, another Mayan group, have organized the Wuqu’kawog Organization, which promotes the provision of health services in the people’s native language, works to obtain translated medical resources, and provides medical training to traditional healers (Wuqu’kawq, 2007). Another example of community empowerment includes the Q’eqchi people, whose projects have included road-building efforts to improve access to schools and facilitate education for both youths and adults. Of particular importance to the health of indigenous populations is the practice of Mayan midwifery, which occurs with 70% of all births. The role of midwives is especially important since only 60% of women receive prenatal care from a qualified individual, and over 13% receive no prenatal care at all. These

midwives, known as comadronas, do receive some medical support in the form of monthly meetings with healthcare providers that allow them to trade experiences regarding their practices and values. However, comadronas remain hesitant to trust Western healthcare providers due to mutual stigmatization and lack of belief in the other’s medical practices (Seva, 2007).

F. ORGANIZATION AND MANAGEMENT OF THE HEALTHCARE SYSTEM The health care system in Guatemala is comprised of three individual sectors. These are the public sector, the private for profit sector, and the non-profit sector (GH, 2001).

The public sector comprises two autonomous groups, the Ministry of Public Health and Social Welfare (MSPAS), and the Guatemalan Social Security Institute (IGSS).

Public funding is distributed almost equally between these organizations (Profile, 2001). The non-profit sector consists of over 1,000 nongovernmental organizations, of which only 18% actually engage in healthcare activities. Their primary role is to expand the coverage of basic services, and many draw their financing from the MSPAS (Profile, 2001). The for-profit sector consists of private hospitals, physicians, clinics, laboratories, and pharmacies that are primarily located in the capital and major cities. This sector provides limited coverage and is only accessible to the wealthiest population.

Ultimately, the management, regulation, and surveillance of these facilities fall under the jurisdiction of

the MSPAS (Profile, 2001).

The Ministry of Public Health and Social Welfare (MSPAS) The MSPAS is the executive branch of the healthcare system and provides steering and oversight of the system. It is also one of the principal providers of healthcare to the uninsured and carries out programs for health promotion and risk protection. One important aspect of these efforts includes education programs using radio and television advertisements for the prevention of HIV/AIDS, dengue, and vaccinepreventable disease. According to the Guatemalan constitution, health is viewed as a public right, and the health code stipulates that the MSPAS is formally responsible for leadership in the healthcare sector.

This oversight is provided through five separate domains: management, regulation, surveillance, coordination, and evaluations of activities and institutions. However, its regulatory capacity is limited by its financing (Profile, 2001).

The Guatemalan Social Security Institute (IGSS) The IGSS provides both basic and expanded services. For instance, services rendered to pregnant women include prenatal checkups, tetanus prevention, micronutrient supplementation, and education to facilitate proper birthing procedures.

Services provided for infants and preschoolers include vaccination, diarrheal control, and nutritional assessments. They also serve in an emergency capacity and provide a variety of environmental interventions ranging from vector control to water quality evaluation (Profile, 2001).

The IGSS is financed by mandatory contributions from both workers and 17

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employers that mainly covers formal workers in the capital and along the southern coast. It provides health services and social security as its two primary deliverables. Recently, gaps in services have forced this entity to contract with private providers to expand coverage.

Issues With Service Delivery • Currently, there is duplication of services in which payment for a single visit is rendered multiple times to multiple service providers. In the treatment of any given disease, a patient may see providers from MSPAS, private laboratories and IGSS, making them accountable to every sector.

• Health services and healthcare spending remain centered almost exclusively in urban areas. By contrast, remote rural areas tend to receive just one physician visit per month, with basic care provided by volunteers and traditional healers. These traditional healthcare workers and pharmacists fill the gaps in the public system.

• The quality of healthcare varies with recipients’ ability to pay. The poor and indigent are often served by the MSPAS. Urban wage earners are primarily served by the IGSS, and wealthier members of the population seek care in the private sector.

• Despite the efforts of these organizations, a significant number of people lack access to any healthcare services. General lack of knowledge about the benefits of modern medicine results in individuals seeking care from nonqualified providers.

Strengths of the Healthcare System Despite the current state of Guatemala’s healthcare system, the

country does have several resources whose potential for positive impact will be substantial when fully realized.

For instance, the existing network of community comadronas provides a culturally competent source of primary care for outlying population.

While the comadronas’ quality of care may not yet be on par with that of certified nurses, with training they would be in a unique position to bypass many of the cultural and language barriers that have impeded efforts to bring modern medicine to outlying and indigenous communities. Another key resource available to Guatemala is the sheer number of stakeholders invested in the country’s health care system.

From close-knit community advocates like those serving the indigenous populations to investments from major health organizations like PAHO and USAID, a variety of healthcare advocates exists, each with unique perspectives and resources to bring to bear against each health concern.

Successful partnerships like those created by Rubella Watch and the Onchocerciasis Elimination Program of the Americas serve to demonstrate the potential for such collaborations.

While collaboration between the existing partnerships is inconsistent, their future potential remains great.

Challenges within Healthcare System One of the major challenges in the current healthcare system is the lack of accountability and communication within government, non-governmental organizations, and private organizations. Because detailed information is not collected on provider services, government health employees frequently shirk their duties in order to run private clinics for their own benefit, drawing paychecks from both their private

practices and government salaries.

Furthermore, there is poor planning with regards to the distribution of services, a lack of accreditation for healthcare professionals, and few existing standard protocols for services and care. While healthcare is viewed as a constitutional right, there is no actual commitment to universally guaranteed services.

Ultimately, one of the largest problems is the health system’s financial instability, which undermines the ability of any given program.

Financial breakdown of the healthcare system Healthcare system financing is provided through general taxation, taxation on wages, out of pocket payments, and international donations. Total expenditure on health as a percentage of GDP has been steadily rising from 1996 to 2005 from 3.6% to 5.7%. The majority of financing is provided through households who contribute roughly 43% of all healthcare funding. A decreasing portion of the general government expenditure on health has been funded by social security funds from 52.3% in 1996 to 47.7% in 2005. Consequently, private sector expenditure on health saw a decline from 65.8% to 59.6% during the same period. This indicator is an aggregate of private households’ out-of-pocket payment and prepaid and risk-pooling plans. Currently, the Ministry of Finance provides approximately 27% with companies and donor institutions providing 22% and 7.8%%, respectively. Public spending has steadily increased since the late 1990s, with the majority of funds concentrated in hospitals and not based on performance indicators

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(WHO, 2007).

G. HEALTH SYSTEM RESOURCES Human Resources The efficiency and quality of a health system can be limited if there are problems with the health care workforce. Human resource availability and composition are important indicators of the strength of a health system. A consensus on the optimal level of health workers within a population does not exist (WHO, 2007). However, there is evidence that the number and quality of workers are positively associated with immunization coverage, outreach of primary care, and infant, child, and maternal survival. In addition, when considering the ability to implement health system reform, the workforce strength and capacity can either be a great facilitator or a great barrier (Homedes N and Ugalde A, 2005).

When examining the current state of human resources for health, it is important to start with the historical impact of the World Bank which began leading health reforms in Latin America in the 1980’s. The economic downturn that the region was experiencing during this time period created an opportunity for the World Bank to provide loans to the various Ministries of Health and Social Security Funds in the region.

The World Bank became the largest health sector lender by the early 1990’s (Homedes N and Ugalde A, 2005). These loans were offered with guidelines for health sector reform according to the principles of the World Bank. Despite the fact that the need to improve the health

workforce in Latin America had previously been noted in a number of health sector assessments, strategies for addressing human resources needs were not included in the World Bank guidelines (USAID, 1977 and Colburn FD, 1981). It was the belief of the World Bank that market forces would resolve human resource needs in the health sector. Unfortunately, the strategies outlined by the World Bank for health sector reform backfired in the area of human resources, resulting in negative consequences on the workforce. The reforms also hid structural problems that needed to be considered when designing human resource problems (Homedes N and Ugalde A, 2005). As can be appreciated from the following text, generating human resources for health remains a challenge in Guatemala.

According to 2001 data from PAHO, there are 51,000 persons working in the health sector in Guatemala.

Fifty-seven percent work in the public sector, 26% are community volunteers, and 17% are employed in the private sector (PAHO, 2001).

The Ministry of Public Health and Social Assistance employs 19,385 people across varying functions as follows: 12.4% professionals, 8.8% service staff, 26.5% auxiliaries, and 52.3% administrative and general service staff. The ration of physicians to total population is 9 per 10,000, with a disproportionate percentage (80%) remaining in metropolitan areas where the ratio of physicians to people is already 28 per 10,000.

The number of physician specialists outweighs the number of primary care physicians, illustrating that training is not being directed to the country’s primary needs. In addition, the practice of medicine is not

specifically regulated by the health code; rather, physicians are bound by the Ethics Code of the Association of Physicians and Surgeons which delineates specific penalties, including trial by the Professional Association of Physicians and Surgeons Tribunal of Honor. The Health Code does state that only licensed association members may practice medicine. In addition, the Association is required by law to ensure and uphold ethical and responsible practice by its members, and to fuel improvement and excellence in all things related to the medical profession (Center for Reproductive Law and Policy, 2001).

In developing countries drug sellers and pharmacists may often be the first health contact for sick individuals. Therefore, it is important to distinguish between pharmacists and drug sellers as both can be found in developing countries such as Guatemala. Pharmacists are individuals who have had formal training in pharmaceutical sciences.

In contrast, drug sellers include individuals who are associated with pharmacies, but do not have formal training in pharmaceutical sciences. Drug sellers also include individuals who provide access to pharmaceuticals outside of a pharmacy, such as in food markets (World Bank, 2007). There are two universities in Guatemala that formally train pharmacists. According to PAHO data from 2001, there are 900 pharmacists and 1100 pharmacy technicians in the country (PAHO, 2001). Unfortunately, not all pharmacists are trained in health care provision. Thus, patients may be put at risk of receiving inappropriate care if they seek care from a pharmacist who is not suitably trained.

Information on regulation of the 19

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practice of pharmacy is not available.

There is also a great need for nursing professionals in Guatemala.

According to PAHO data from 2001, there are only 3 professional nurses, 11 nursing aides, and 20 midwives per 10,000 people. Similar to the distribution of physicians, there are more professional nurses in metropolitan areas than in rural areas, with 4.9 professional nurses per 10,000 people in metropolitan areas (PAHO, 2001).

Traditional medicine represents an important avenue for addressing the health care needs and human resource deficits in Guatemala. The role of traditional medicine and its practitioners in developing countries has been recognized by WHO and PAHO, both of whom have attempted to promote policies directed at testing out ways of incorporating traditional medicine into government health systems with an emphasis on supporting primary health care.

The Health Code in Guatemala acknowledges traditional medicine as one of its areas of competence with licenses for traditional medicine practitioners being issued by the Department of Public Health and Local Health Centers. In order to receive a license, candidates must receive training. The current estimate is that approximately 10% of traditional practitioners are licensed, although there is no accurate estimate of the actual total number of traditional medicine practitioners in the country. Unlicensed practitioners only experience difficulties when they practice outside of their communities, meaning that there is little incentive for many to take on outside training.

When attempting to practice outside of their communities, they may be at risk of being taken to court or

accused of giving poor medical care.

Despite recognition of traditional medicine in the Health code, there is a perception that traditional healers are ignored at the national level (Nigenda G, Mora-Flores G, AldamaLopez S, and Orozco-Nunez, 2001).

In an attempt to help fill in the gaps for human resources within the health sector, Guatemala receives volunteers from all areas of the world.

These foreign health workers provide a variety of health services and tend to focus on rural and indigenous populations who experience the greatest health disparities. In particular, Cuba has more than 500 doctors and other health workers in Guatemala concentrated primarily in the western and northern areas where two different indigenous populations live.

Health Facilities The breakdown of health facilities is as follows (see chart below): Goals for a Better Healthcare System Based Upon the 2000 Plan The following are goals for improving the entire national health system set out by the MSPAS during a period of reform in 2000: •

Reorganization of services, facilities, and finances

•

Integration

• •

Modernization Increase coverage and improve quality of basic health services

•

Emphasize prevention and control of priority problems

•

Improve facility management

•

Promote general health and healthy environment

•

Improve quality of water and sanitation

•

Increase social participation and oversight

•

Improve coordination of international technical cooperation

While these have remained constant objectives, no specific goal has been completed. Since the government transitions every four years, it has been difficult to maintain progress in these areas.

Public Health Currently, the public health sector in Guatemala is headed by the MSPAS, with support from local universities and private enterprise, NGO’s, and other international agencies. The MSPAS has seen some success in stewardship; however, implementation and sustainability

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of programs and mandates has been difficult due to the constantly revolving governmental power.

This has led to a fragmentation of strategies and campaigns as well as created a lack of communication and collaboration between the social service sectors. Despite these issues, however, there have been several achievements in recent years. In order to disperse the budget and engage communities in addressing their own problems, the MSPAS issued a policy which gave each municipality its own budget specifically for social services aimed at improving the health and well-being of the community. This program was called the Healthy Municipality Movement. Currently, the healthiest municipalities are Escuintla and Huehuetenango. The city of Antigua also conducts its own version of the project as part of an overall city and community development plan (PAHO, 2007). In addition, there have been some country-wide projects that have demonstrated the potential strength of the system.

Rubella Watch As a part of National Vaccination Week conducted by the WHO in April of 2007, the entire country set out to finally become certified as a measles and rubella free zone. Beginning with students and families of the University of San Carlos in Guatemala City, a six week campaign was undertaken to vaccinate 7.3 million women and men aged 9-39 years with the measles-rubella vaccine. By the end of May 2007, an astonishing 98% of the targeted population was vaccinated, which meant that the country could be certified. To ensure compliance with the program the municipalities extended the

project for a couple of extra weeks with the help of the Pan-American Health Organization (PAHO). This project was by far one of the greatest successes of public/private and governmental partnerships demonstrated within the Guatemala (PAHO, 2007).

Central American Diabetes Initiative (CAMDI) Beginning in March of 2000 PAHO initiated a collaborative project with Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua. This diabetes program was divided into two distinct phases. The first phase focused on identifying the target population, assessing the quality of care in the region, and delineating improvement methodologies regarding the quality of care.

The second phase focused upon implementing an integrative one year intervention to improve the quality of care as well as educate professionals, patients, and the general population about risks, prevention, and control of diabetes. The overall goal of this project was to develop sustainable national campaigns that would be ubiquitously applied across all nations. The latter part of phase two is still under way (PAHO, 2007).

Rotavirus Surveillance System Diarrheal infections stemming from the rotavirus are estimated to cause over 15,000 deaths and 75,000 hospitalizations each year in the Americas. Based upon this information Guatemala developed a hospital-based surveillance system in 2002. This program began as a joint effort between the MSPAS and PAHO in preparation for the implementation of a new rotavirus vaccine, whose

release is anticipated in the next couple of years. The program has already led to the expansion of the country’s surveillance systems, a better understanding of the disease burden, and a reduction of overall disease prevalence (PAHO, 2007).

Onchocerciasis Elimination Program of the Americas In the 1990s, a project was started by the Carter Center and PAHO to eliminate onchocerciasis (river blindness). When this project was first conceived, over 500,000 people in the Americas were affected by river blindness. To meet this problem the Centers of Disease Control, the MSPAS, local academic institutions, and local non-governmental agencies came together in cooperation.

Headquartered in Guatemala, the coalition set out overall goals to treat existing cases and prevent future infections. They began by targeting the most affected populations in each of the Pan American countries, which in Guatemala were the coffee plantation workers. By 2003, the project reached a landmark achievement by treating 85% of cases in all endemic countries, the level necessary to halt transmission of the disease. Since then six of the 13 countries have maintained the twice annual dosage of Mectizan in order to stave off new infections. Efforts led by the Carter Center and the Bill and Melinda Gates Foundation to raise the estimated $15 million to end river blindness in Latin America have thus far been successful (The Carter Center, 2007).

Chagas Disease Due to the high number of children affected by chagas disease, elimination has remained a high 21

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priority among the 2010 Goals as well as one of six international commitments announced at the 2002 WSSD Summit in Johannesburg (World Summit on Sustainable Development). Subsequently, a project began to address this growing health issue in Guatemala as a collaborative effort between the MSPAS, PAHO, and JICA (Japan International Cooperation Agency).

It was conducted initially in four country departments, Copรกn, Lempira, Ocotepeque and Intibucรก, and was aimed at eliminating the disease. Preliminary efforts began with training staff, data collection, and initiatives to improve housing situations for affect populations.

Currently the project is focusing on prevention activities and working on updating published information regarding its progress (PAHO, 2007).

Table 3: Primary Stakeholders of the Guatemalan Health System

H. THE KEY STAKEHOLDERS Stakeholder Analysis In order to properly assess the healthcare system and make future recommendations, one must first take into consideration the key stakeholders that would be involved in implementing and evaluating changes, as well as those who would be directly affected. Tables 3 and 4 give a brief and general outline of both primary and secondary stakeholders and their functions within the system. Their expected roles in the proposed processes are defined, outlined, and contrasted against the actual roles that they play in the current health care system at the present time. Important actions and the impacts of these proposed changes are presented as a cursory outline in order to illustrate how stakeholders would need to interact with one another in order to build and facilitate a solid, sustainable 22 Assessing the Performance of the Health System In Guatemala

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III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I THE KEY STAKEHOLDERS

Table 4: Secondary Stakeholders of the Guatemalan Health System

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III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I FUTURE IMPLICATIONS & REFERENCES

I. FUTURE IMPLICATIONS A unique opportunity exists to make sustainable improvements in the Guatemalan health sector.

The preliminary recommendations contained here are based solely on pre-trip research. The following opportunities for improvement will be explored during an intense three week in-country public health practicum experience.

Recommendations to Improve Sanitation Poor sanitation undermines efforts to combat communicable diseases transmitted through the fecal-oral route. The success of any sanitation program will hinge on several key elements including, but not limited to: allowing communities to control their own resources, organizing community participation to meet their desired goals, allowing rural populations to connect with the land both physically and spiritually, and empowering populations to devise their own solutions.

Recommendations to Strengthen Human Capital There are several opportunities to strengthen human capital in the Guatemalan health sector. The first opportunity is to engage human resources in the health sector in health system planning. The number of primary health care providers needs to be increased so that primary care providers exceed specialists. This can be accomplished by looking outside of the physician and nursing community for primary health care. Pharmacists can be trained as advanced practitioners that provide basic primary care and

long-term disease state management.

In addition to placing more nurses and physicians in rural areas, the number of primary care providers in rural areas can be increased by training local residents as community health workers. Finally, the number of available primary care providers can be increased by fully recognizing the important role of traditional healers and allowing them to practice autonomously in the primary care setting. To overcome the distrust between the comadronas and the Western healthcare system, particular attention should be placed upon providing culturally adapted content in training programs, providing opportunities to interact with physicians and nurses, increasing financial resources, and boosting coordination between government and NGOs for training and support.

These preliminary recommendations will be modified and expanded based on interactions with stakeholders in Guatemala. Specifically, input will be gathered from local offices of PAHO, WHO, USAID, INCAP, World Bank, rural and urban medical centers, local NGOs, and the University of San Carlos faculty and students. Information gathered from these sources in Guatemala will be incorporated into information discussed herein. A final set of feasible and sustainable recommendations will be presented to stakeholders and documented in a post-trip report.

J. REFERENCES 1. Ahmed, K., Yewande, A., Barnes, D.F., Cropper, M.L., Kojima, M. (n.d.)

Environmental Health and Traditional Fuel in Guatemala. Direction in

Development pp 1-144 2. The Carter Center (2007).

Onchocerciasis Elimination Program of the Americas. Retrieved July 22, 2007 from http://www.cartercenter. org/health/river_blindness/oepa.html 3. The CIA World Fact Book: Guatemala (2006). Retrieved July 21, 2007 from www.cia.gov 4. Derek, M. A. (2004, April). USGuatemala (1901-2002). Retrieved July 22, 2007, from http://www. cooperativeresearch.org/timeline. jsp?timeline=guatemala 5. EM-DAT Emergency Database. (n.d.) Retrieved July 3, 2007, from http://www.em-dat.net/disasters 6. Environment at a glance (2004).

Retrieved July 3, 2007, from http:// siteresources.worldbank.org 7. Federal Ministry for Economic Cooperation and Development (FMECD). (2006). Guatemala Case Study in Education and Information Division Observations on Service Delivery in Fragile States and Situations - the German Perspective (pp. 20-24). Berlin: FMEC. 8. GH: Guatemala Health (2007).

Guatemala Health By Google.

Retrieved July 1st, 2007 from: http:// www.nationsencyclopedia.com/ Americas/Guatemala-HEALTH.html 9. Guatemala Infrastructure, Power and Communications (GIPC). (2004) National Economies Encyclopedia retrieved July, 2007 from http:// worldbank.org 10. Guatemala - National Expenditure

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III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I REFERENCES

on Health (Quetzales). Retrieved July 5, 2007, from World Health Organization http://www.who.int/ nha/country/GTM-E.pdf.

11. Guatemala Risk, Infrastructure Risk. (2007). Retrieved July 3, 2007, from http://www.tmcnet.com/ usubmit/2007.htm 12. Guatemala food Security Warning. (October 2005). Flooding, Mudslides and Crop Losses in Guatemala. Retrieved July 6, 2007 from http://www.fews.net/resources/ gcontent/pdf/1000818.pdf 13. Human Trafficking and Modern Day Slavery (n.d.). Retrieved July 22, 2007 from http://gvnet.com/ humantrafficking/Guatemala.htm.

14. International Republican Institute.

(2006). Advancing Democracy in Guatemala. Retrieved July 22nd, 2007 from http://www.iri.org/lac/ guatemala.asp 15. Mendoza, A. (May, 2007).

Health-Guatemala: AIDS Patients Suffer Epidemic of Discrimination.

Retrieved July 15, 2007 from ISP news http://ipsnews.net/news. asp?idnews=33740 16. National Democratic Institute for International Affairs. (n.d.).

Latin America and the Caribbean: Guatemala. Retrieved July 22nd, 2007, from http://www.ndi.org/ worldwide/lac/guatemala/guatemala. asp 17. Observations on Service Delivery in Fragile States and Situations - the German Perspective (November 2006) Federal Ministry for Economic Cooperation and Development: Development Education and Information Division.

18. O’Neil, J., Bartlett, J., Mignone,

J. (June 2005). Best Practices in Intercultural Health. Prepared for the Inter-American Development Bank and the Pan American Health Organization. Retrieved July 1st, 2007 from http://idbdocs.iadb.org/wsdocs/ getdocument.aspx?docnum=564741 19. PAHO (2007). Chagas Disease Control Project: 2003 Annual Report.

Retrieved July 22, 2007 from http:// www.paho.org/English/AD/DPC/CD/ dch-hon-informe-2003.htm 20. PAHO (2007). The Central America Diabetes Initiative (CAMDI).

Retrieved July 22, 2007 from http:// www.paho.org/English/ad/dpc/nc/ camdi.htm 21. PAHO (2001). Country Health Profile: Guatemala. Retrieved July1st, 2007 from: http://www.paho.org/ english/sha/prflgut.htm 22. PAHO (2007). Healthy Municipalities, Cities, and Communities: Evaluation Recommendations for Policy Makers in the Americas. Retrieved July 22, 2007 from http://www. paho.org/English/AD/SDE/HS/MC_ Recommendations.pdf 23. PAHO (2007). Healthy Municipalities and Communities – Country Profile. Retrieved July 2007 from http://www.paho.org/English/ AD/SDE/HS/hmc_Guatemala.htm 24. PAHO (2006). Health Situation in the Americas: Basic Indicators. Health Analysis and Statistics Unit retrieved July 21, 2007 from http://www.paho. org 25. PAHO (2007). Human Trafficking Fact Sheet (2003). Retrieved July 22, 2007 from http://paho.org 26. PAHO (2007). Immunization Newsletter. Retrieved July 22, 2007

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from http://www.paho.org/English/ AD/FCH/IM/sne2703.pdf 27. PAHO (2006). Increasing education access, quality, and equity in Guatemala. Latin American and Caribbean Education Profiles 1999– 2004. Retrieved July 21, 2007 from www.usaid.org 28. PAHO (2006). Profile of the Health Services System Guatemala.

Retrieved July 22, 2007, from http:/ www.paho.org/English/DD/AIS/BIbrochure-2006.pdf.

29. PAHO (2007). Rubella Watch (2007). Retrieved July 22, 2007 from http://www.paho.org/English/AD/ FCH/IM/NL_RubellaWatch2007_03. pdf 30. Timeline: Guatemala. A chronology of key events. (2007, July 19). Retrieved July 21, 2007, from http://news.bbc.co.uk/go/pr/ fr/-/1/hi/world/americas/country_ profiles/1215811.stm 31. UN Human Development Report (2004). Cultural liberty in today’s diverse world. New York, New York: United Nations Development Programme.

32. USAID (May 2007). Country Health Statistical Report: Guatemala.

Retrieved July 21, 2007 from www. usaid.gov 33. USAID (2006). Guatemala: Country Health Statistical Report (2006). Retrieved July 15, 2007 from http://www.usaid.gov 34. Violent Crime and Drug Trafficking pose serious threats to development in Central America, UNODC reports (May, 2007).

Retrieved from UN Office of Drugs and Crime July 22, 2007 from http:// 25

III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I REFERENCES

www.unodc.org/unodc/press_ release_2007_05_23.html 35. Wikipedia Encyclopedia (2007).

Guatemala. Retrieved July 21, 2007, from http://en.wikipedia.org/w/ index.php?title=Guatemala&old id=147273956 36. World Bank (April 2007).

International Monetary Fund: World Economic Outlook Database.

Retrieved July 21, 2007 from http:// wwww.worldbank.org 37. World Health Statistics (2007).

Retrieved July 8, 2007, from http:// www.who.int/whosis/en/ 38. The World Health Report 2000 – Health systems: Improving performance (2000). Retrieved July 21, 2007 from http://www.who/int

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 INTRODUCTION & STAKEHOLDERS

IV. POST-TRIP REPORT GUATEMALA: A HEALTH SYSTEM AND COUNTRY IN TRANSITION PART 2 A. INTRODUCTION Guatemala is a Central American country with immeasurable potential, yet continues to struggle with basic health issues that hinder its development. In order for the country to transition from a developing to a developed nation, issues facing the health system must be addressed. This paper is part two in a two-part series that documents the analysis of the Guatemalan health system. Part One provided a detailed history of Guatemala as it relates to health, based on a comprehensive review of the literature. In that document, major issues confronting the Guatemalan health sector were identified and preliminary suggestions for strengthening the health sector were made. The reader may refer to this document for a full understanding of the context upon which this current paper is based. Part Two is based upon data gathered during an intensive, in-country investigation of the health system. This investigation involved meeting with key stakeholders such as: faculty and students at the University of San Carlos School of Public Health, the Pan-American Health Organization, USAID, the Nutrition Institute of Central America and Panama (INCAP), Inter-Development Bank (IDB), World Bank (WB), the Ministry of Public Health and Social Assistance (MSPAS), faculty of the National School for Nursing,

community health department officials, representatives at local nongovernmental organizations (NGO’s), members of the national tourist bureau, and many more. Based on the foundation built in phase one and the information collected in phase two, comprehensive stakeholder and SWOT analyses were performed. These culminated in recommendations for strengthening the Guatemalan health system.

Through this process many opportunities for improving upon the health system were identified, however the analyses and recommendations in this paper have been limited to the most immediately tangible options. The future for this health system is bright, but will depend on the ability of emerging leaders to support sustainable and equitable changes. Above all, good stewardship is essential for the country to successfully address the issues facing the health system.

B. THE STAKEHOLDERS In this section, we begin with a basic overview of each stakeholder interviewed during the course of our investigation and provide a description of how this information was utilized in a stakeholder analysis.

The stakeholder analysis will provide not only a visual representation of the data collected through extensive interviews but will also provide common themes of consensus and conflict observed during our analysis.

From this analysis, a conclusion description of various stakeholder relationships will be described as well as an analysis of potential benefits that would arise from forging new cooperative relationships.

During a three-week period, more than 13 different organizations linked to health care in Guatemala were interviewed. These groups included international representatives, national representatives, community leaders, and regional representatives providing distinct services to the population.

These groups were experts in their respective areas of interest and heavily involved in the health sector.

Since stakeholders provided various levels of health care service it is important to note the breakdown of these levels and the scopes of services provided. This layered approach, provides a foundation that allows the team to logistically approach common themes and goals when performing a complex assessment.

International Organizations Representatives from this group includes: The Pan American Health Organization, the International Center for Food and Nutrition, The World Bank, The International Development bank, USAID, and the United Nations Family Planning Association.

International Organizations normally operate with larger budgets but funds are usually allocated to sub divisional programs that are strictly regulated by the larger operating organization.

As such, these smaller branches normally provide services focusing on specific health issues and are unable to expand their influential sphere without partnering with additional subdivisions with financial resources.

However, international organizations are able to create solid partnerships with organizations at other levels and may expand the breadth of their projects in this manner.

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 STAKEHOLDER ANALYSIS

National Organizations

Regional/Local Organizations

Stakeholders representing the national level include: The Department of Epidemiology, the Ministry of Health, and INGUAT. At this level, national organizations are under direct government control and are limited by the percent of health care funds directed to specific services. Furthermore, the national level directly controls most organizations at the regional level and as such policy at the national level is reflected through health services provided at the regional level. Since financial and human resources tend to be large barriers to increased service delivery, the National level could benefit from solid partnerships with international organizations.

Amongst this group are government supported organizations as well as a aeries of independent non governmental organizations. These stakeholders include: Universidad de San Carlos, Health Posts, ASECSA, The School of Nursing, and various religious organizations. At the regional levels these organizations are either controlled by government organizations at the national level and are limited by national policy or are completely independent operating organizations with extremely limited funding and resources. Data indicates that regional programming usually the most effacious form of initiating change and as such attention needs to be directed to creating sustainable programs amongst these organizations.

C. THE STAKEHOLDER ANALYSIS The four tables below were created to illustrate the stakeholder analysis process that occurred. After each stakeholder was interviewed, they were assessed based upon their expectations for improving the health care system, their perceived barriers for accomplishing this goal, the resources that they would need to commit to assist in creating change and the conflicting interests that they would experience during this process.

In order to simply this process, overlapping areas of consensus and discord with regard to the expectations are highlighted to better illustrate this point.

Table 1: Expectations of the various Stakeholders

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 STAKEHOLDER ANALYSIS Table 2: Expectations of the various Stakeholders (highlighting areas of consensus)

Table 3: Expectations of the various Stakeholders (highlighting areas of discord)

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 STAKEHOLDER ANALYSIS Table 4: Resource commitments from the various Stakeholders

Table 5: Conflicting interests between the various Stakeholders

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 AREAS OF CONSENSUS & DISCORD

D. AREAS OF CONSENSUS Almost every stakeholder agreed that a multi-sectorial approach and efficient management of resources are two keys areas that must be improved in order to advance health care in Guatemala. With respect to a multi-sectorial approach, all stakeholders recognize the need to communicate and cooperate with one another in an attempt to reduce redundancy and maximize efficiency.

If all sectors of health care and prevention worked in concert then a direct and natural result would be the increased efficiency of resource allocation. While an important step toward recognizing a solution to the problem has been made, these two concepts are umbrella terms that include many other aspects such as communication, allocation, trust and information sharing that are not necessarily accomplished easily.

As such stakeholders must now ask themselves how they will undertake a multi-sectorial approach in light of these preexisting barriers.

All stakeholders did not agree upon other areas of general consensus but a majority mentioned these areas as important steps for the future of health in Guatemala.

Training professionals and investing in health advocates, a subset of resource management would allow more individuals with health education and knowledge to enter communities at the local levels and would maximize health education throughout the country. In relation to this, education was indicated as an important aspect to training health professionals and advocates and would reduce erroneous information from entering the population.

In the areas of policy and management, stakeholders pointed to evidence based policy, promoting sustainability and tackling potable water sources and malnutrition as important sectors for reform.

Evidence based policy refers to the initiation of public policy based upon rigorous scientific evidence. An example in relation to Guatemala would be the efficacy of using commadronas to reduce maternal mortality since the literature demonstrates that women are more likely to seek health care if it is under direct supervision of the commadronas. This form of policy would provide the impetus for health care organizations to produce more results and would lead to the replacement of defunct outdated policies. In addition, the incorporation of policies into the international and national agendas would also provide the foundation for sustainability, an essential component of all health programs.

Potable water and malnutrition were also mentioned by many stakeholders and logically reflects the data which indicated that many causes of morbidity and mortality in Guatemala stems from deficiencies in nutrition and access to clean water sources.

E. AREAS OF DISCORD Because many of these organizations operate at different levels within the health care system, there were also many areas of discord with respect to expectations. This discord may be a mere reflection of these stratums but they also reflect some of the problems inherent in the current system.

Two categories demonstrated the most discord among stakeholders: (a) increasing the capacity of the ministry of health and (b) transparency among stakeholders. With respect to the MOH capacity, the interview sessions yielded large debates about this matter. Some stakeholders voted for increasing the capacity of the MOH so that Guatemala would not need to rely heavily on international organizations and outside financing.

They believe that placing the control within this governing body would increase the responsibility of the MOH and would force them to carefully reorganizing their funding and programming. However, some stakeholders were adamantly against giving more responsibility to the MOH. These stakeholder cited mistrust, corruption, and previous failures as reasons against providing the MOH with more responsibilities.

This debate highlights the problems associated with creating a muti-sectorial approach because communication and mistrust still stand as barriers to cooperation and communication.

Additional areas that were mentioned in this section but were not necessarily expected by all stakeholders included producing more publications, becoming environmentally conscious, focusing on primary prevention rather than tertiary care, increasing contraception and family planning and participating in defining health priorities. While some of these expectations directly address severe health indicators (i.e., maternal mortality, infant mortality, STI control, etc) others reflect the differences between organizations in how they perceive their responsibilities (i.e., defining health priorities).

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 RESOURCE COMMITMENT

F. RESOURCE COMMITMENT

G. CONFLICTING INTERESTS

H. STAKEHOLDERS SUMMARY

Looking at the chart that lists resource commitment, it is clear that each organization has resources that they are already committing into the system and demonstrates that there are additional resources that can be provided to maximize efficiency. The diverse backgrounds of the stakeholders allow unique contributions to be added that can ultimately enhance the health system.

Among some of these unique contributions are community contacts and cultural sensitivity experts.

Naturally many stakeholders have conflicting interests when it comes to initiating change and committing resources. The most important conflict, in terms of Guatemala, is the lack of trust that exists among many of the organizations. Not only cant they distrusting between strata of influence but also they are also distrustful within their own strata.

Many organizations are hesitant to share information, publish data or listen to their peers because their missions and goals are not necessarily aligned. Add this to the perceived corruption occurring throughout the country and distrust becomes a widespread problem and one of the greatest barriers to cooperation.

Currently, though they are broadly united in ideology, many of Guatemala’s health care stakeholders maintain only cursory lines of communication with one another.

This is especially true between sectors. While international aide agencies may communicate with one another, for instance, peripheral stakeholders like INGUAT, the government tourism agency, or grassroots health organizations like ASECSA may not have established relationships or collaborations with other sectors and agencies (see figure 1 on the next page). Though the Ministry of Health serves as a hub of communication with many disparate health stakeholders reporting to them in one form or another, the current political structure which sees new administrations in power every four years limits the government’s ability to coordinate and facilitate enduring collaborations between stakeholders. The result of this lack of coordination can be seen in the provision of redundant services and missed opportunities for collaboration. For instance, the IDB is frequently employs international consultants to handle their statistical analyses despite the availability of local statisticians at USAC.

Community contacts are an integral part of organizational operations.

These contacts can allow for liaisons between organizations, can access unique funding sources and have tight relationships with particular communities. The latter contact can also be described as a “change agent” or an individual within a community with the unique ability to influence change in health behaviors.

Each organization has differing forms of these contacts and as such should utilize these individuals by maximizing their skills while allowing other organization to capitalize on these contacts.

Cultural sensitivity experts also provide essential functions since that are usually in the best position to act as change agents. Since Guatemala is such a diversified nation, it is extremely important to recognize cultural practices and beliefs when tailoring health interventions. Some of these organizations operate within specific cultural communities, which places these health advocates in a unique position to train other health advocates about important cultural practices.

As previously mentioned, supervising agencies often also operate with different agendas and as such sub divisional programs are limited on their scope of practice. The best way to elucidate this concept is to describe it in the terms of USAID an international organization tat has been assisting many nations throughout the world. With respect to Guatemala, there are large-scale programs that directly address family planning and aim to reduce maternal and infant mortality. However, since the US government controls USAID, they are limited by the government’s policy that abstinence should occur before the use of condoms. With different organizations under the direct control of different policies, creating uniform care can be challenging.

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 CONFLICTING INTERESTS Figure 1: Current communications channels existing among the Stakeholders Figure 1 illustrates a proposed shift in communication lines between the Guatemala’s health stakeholders. While the government would still plays a central role as a coordinating entity between the various stakeholders, this model suggests stronger ties be made between all stakeholders. The benefits of such collaboration are manifold. For instance, a coalition of academic, NGO, and local agencies could serve to address the lack of continuity posed by the government’s four year cycles. As many of these stakeholders, like universities, are free from funding cycles and other time constraints, they could work with the changing government administrations to ensure continuity and sustainability of existing interagency relationships.

While not meant to be an exhaustive list, the potential benefits of such a collaboration would also include improved health indicators in the country, better stewardship, reduced redundancy/inefficiency, health issues prioritization, sustained ecotourism, increased cooperation/ partnerships, increased inequity, empowered communities, checks and balances, increased government capacity, increased sustainability of health programs, greater community involvement, decreased global warming, improved education indicators, increased qualitative and quantitative health data, economic growth, and expanded health service capacity.

Figure 2: Proposed communication channels among the various Stakeholders

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 THE SWOT ANALYSIS

I. THE SWOT ANALYSIS The fundamental analysis of this paper is based on the review of the strengths, weaknesses, opportunities, and threats (SWOT) of the Guatemalan health care system. This assessment includes all aspects that contribute to the system: stakeholders, financial and human resources, stewardship and management, coordination and communication on many levels, accountability and transparency inherent to the system, and cultural distinctions. This SWOT analysis has allowed for an in-depth investigation into how the system functions, where the faults lie, how these faults might be overcome, and what threatens improvement of the system as a whole.

The SWOT Analysis is summarized in Table 6: SWOT Analysis of the Guatemalan Health System, and described thereafter.

Table 6: SWOT Analysis of the Guatemalan Health System

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 THE SWOT ANALYSIS: STRENGTHS & WEAKNESSES

1. STRENGTHS

Working to improve health

Identification of problems and solutions

Another great strength of the system is the multiplicity of organizations working in the health sector to improve health and support reform.

Each of these organizations has its own connections within the community and has established important partnerships. Successful programs such as Creciendo Bien have been initiated and contributed to vast improvements within communities. Through these partnerships and programs, community leaders have been identified which has created a strong foundation for future community empowerment projects.

Since the Peace Accords of 1996, Guatemala has come a long way in the overall development of the country, especially in terms of health. Eleven years ago the country was emerging from a thirty-year civil war, and today stakeholders have made important steps towards achieving health sector reform.

For example, they have designed culturally sensitive projects and programs, worked on women’s education and empowerment to reduce maternal mortality and improve living conditions, recognized the importance of good nutrition, and worked to prioritize pressing issues as well as underserved populations in rural areas. Guatemalan society is beginning to recognize the importance of social investment by creating new policies to support human rights. Progress has been made in decentralization of budgets for health and social services, identification of community needs, and collection of information and subsequent analysis. The latter has manifested in a centralized data management system (SIGSA), which is currently in the construction process, but has substantial support from government and academia alike. Recognition of the importance for technology like this system will improve capabilities and capacity for change and maintenance. In fact the Inter-Development Bank (IDB) has started providing grants for technical support of government run programs.

Awareness of the need for education Perhaps one of the most important strengths is the ever-increasing recognition of the importance of education. Through the recent efforts to reform social services and health care, all stakeholders have come to realize that these projects can only go as far as the understanding of the population involved. Thus, educational components have been incorporated into programs to support intervention efforts. These have manifested in family planning programs, translation of educational materials into the many languages spoken throughout the country, comprehensive teacher training, and improved training for health workers.

Traditional Healers In addition to the various strengths mentioned previously, traditional healers have also been acknowledged as important and indispensable resources within the system.

For instance, the large network of comadronas is now being

incorporated into health care by several organizations, as well as being integrated into hospital staff and nursing efforts.

2. WEAKNESSES Systemic Ideologies The Guatemalan health care system is based on the traditional leadership practices of a top down approach to address health issues. Since the war, health campaigns have been mainly curative in nature, focusing more on survival than sustainability. With many agencies working to achieve individual agendas, a universal lack of communication, coordination, and organization of stakeholders and organizational objectives has become the norm. This has led to fragmentation on all levels of the system.

Lack of Resources Though resources are available, distribution and maximization of resources remain problematic.

There is a lack of continuity in political leaders who decide on resource allocation, and institutional inflexibility does not allow resources to be redirected or important changes to be made. This results in misaligned fiscal budgets where the tax burden hasn’t been achieved to support system, as well as inefficient allocation of monetary resources for health and lack of accountability for use of health finances. In turn, the health sector budget is primarily dedicated towards curative services, leaving very little for public health and prevention endeavors. Human resources for health at the provider level, technical expertise level, and leadership level are also lacking.

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 THE SWOT ANALYSIS: STRENGTHS & WEAKNESSES

Data Management With respect to much of the rest of the world, Guatemala is years behind in technology and data management. Currently, only 1% of the national population uses computers (Cheesman, personal communication, 2007). This lack of a technical and research culture has resulted in weak data organization, analysis, monitoring, and evaluation.

Data is not being shared between organizations as much as it should, and the information that is collected within each system moves slowly and often becomes obsolete before it reaches final analysis. This issue is caused by the low technical capacity of the MSPAS, health professionals and health educators. Without trained researchers, exchanges of information and ideas are essentially non-existent.

Stewardship and Political Insecurity While professionals in the health care industry appear to have the knowledge to improve the system, they have not taken leadership roles to empower communities and maximize resources. They are perfectly poised to affirm their authority, yet there is a general sense that someone else will or should take care of the issues at large. The government exhibits similar behavior by making decisions about health issues based on political interests rather than population needs. The MSPAS does not effectively regulate or control service providers, in any of the public, private and nonprofit sectors, and there is weak implementation of projects with relatively no sustainability. Though decentralization is a provision of the annual budget allocation and

measurements of health indicators to address current issues, there is no governmental mechanism to monitor and evaluate these processes and thus financial resources are often squandered. In addition, another major limitation of the system that challenges sound stewardship is the ever revolving government which changes every four years when a new political party and government officials come into power. Since most local agencies and organizations are not immune to the repercussions of these changes, they lack a longterm view for planning and project implementation. Often, projects are thrown out with the new political regimes, thus organizations are unable to plan for long term projects.

Furthermore, there is no customer service training for representatives and medical professionals working for the MSPAS and IGSS. When considering this general breakdown in stewardship, it is no surprise that there is little or no trust in governmental systems.

Education Implementation Although there has been progress in terms of education there is still enormous room for improving upon its weaknesses. Curriculums in schools are not reflective of community realities and matriculation rates suffer when children and parents cannot relate to the programs. Often times, health education in schools is saved only for high levels of education, and there is still poor training in health administration. For example, epidemiologists are placed in administrative positions for which they receive no official training. Low levels of literacy also impact available human resources for health and

their ability to communicate with the underserved populations.

Human Resources Human resources are scarce and the ones that do exist are underutilized, under-appreciated, and insufficiently supported. Comadronas are not fully recognized and accepted by the modern healthcare system, and although they are becoming more and more integrated into medical practices, large gaps in collaboration still exist. Physicians and other medical professionals are hesitant to practice in rural areas due to poor living conditions, and lack of monetary incentives. Moreover, there is little support or planning for regional growth and decentralization of resource management.

Population Disparities One of the obvious weaknesses residing within communities is rampant poverty. Poverty breeds chronic malnutrition, both undernutrition as well as, over-nutrition, which in turn leads to complex diseases of duality caused by diet deficiencies and excesses. This malnutrition is caused by the inequitable distribution of nutritional resources and education, for which there are implications for national development. One-half of the national population is greatly dispersed in rural areas, while the other half is condensed to a handful of cities. This dichotomy has created vast differences in morbidities in both non-communicable and communicable diseases, demanding different prevention and treatment approaches. Finally, there is a lack of stable sanitation infrastructures and regulations on community and

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 THE SWOT ANALYSIS: OPPORTUNITIES AND THREATS

national levels. Most of the used water ends up in rivers, and 40% of the population has no potable water.

Only 1% of sewage water is treated, which is no surprise when one sees that a small percentage of treatment plants are functioning at only 60% capacity. Since treated water is a luxury that only the rich, urban communities can afford, the poorest people end up paying the most for water – in time spent retrieving it from wells, boiling it for use, and preventing illnesses and mortalities (Lujan, personal communication, 2007). In fact, women spend an average of four hours per day fetching water which means that they cannot devote ample time to family, health, nor education, and are more likely to contract diseases (Fischer, personal communication, 2007).

3. OPPORTUNITIES Form Stakeholder Coalitions The recent reformation of the National Public Health Association (NPHA) has innumerable possibilities.

This organization can: promote better stakeholder coordination and communication, provide health messages and information to the public, work on policy development by involving community leaders, and offer additional training outlets for professionals and health workers.

Integrate Traditional Healers While there has been increased recognition of traditional healers such as comadronas, there is still immense potential in the experience, wisdom, and ability to reach the public that is far from being exhausted. This group of

human resources could be utilized to cover lots of ground in primary care, where the existing workforce cannot. The cultural and linguistic expertise of these healers can help overcome communication barriers and strengthen relationships between medical professionals and otherwise fearful, indigenous populations.

Change Provider Paradigms With a foundation and belief in the traditional health system mechanism, the principle providers of primary care are doctors. While there are an infinite number of these medical professionals, there exists a whole realm of human resources upon which the system has yet to capitalize. Advanced practice nurses, clinical pharmacist specialists, and community based health workers can certainly step in to fill gaps in primary service provision which is less expensive and removes pressure from the system since less schooling is required and more people can participate in these fields.

Invest in Human Potential Investment in social capital by strengthening and maximizing human potential is perhaps one of the greatest untapped resources in the Guatemalan health system. This can be accomplished by improving upon and investing in education, rural development programs such as those proposed by the IDB, and community empowerment efforts that will enable the people to make informed demands of the system.

Develop Health Policy In recent history, certain policies have been passed through Congress in support of health, specifically the Health and Development Laws which support nutrition programs, women’s health and education, and health rights. These laws have made ground-breaking progress in health policy development, but there is still more ground to cover in regards to enforcement of these laws.

4. THREATS Bridge Alliances Organizational Issues Partnerships are an essential element in promoting progress and change.

Strategic alliances with non-health sector entities or the private sector will allow health organizations to leverage support and resources in order to raise community awareness and reform health sector. There is also the potential to coordinate NGOs, the government, and other local agencies and key players to align for more concentrated efforts to combat health issues.

The National Public Health Association (NPHA) has infinite potential; however, there are certain barriers that threaten its success.

The Association has dissolved once in the past, therefore its successful continuation rests on the following issues: coordination, recruitment, literacy rates and lack of training. There is always difficulty in coordinating stakeholders for effective and efficient meetings. With so many individual objectives, it is often complicated to align visions.

Recruiting members and participants

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 RESTRUCTURING & REVITALIZATION GOALS

appears to have been a weakness in past endeavors, and since many of the organizers lack this type of training, this continues to pose problems. Thus far, they have also limited the type of persons recruited to participate in the Association to those in the medical and public health professions. Literacy rates and linguistic variability also cause barriers to information dissemination and utility among the public and those outside of the Association. Finally, past members of the Association have lacked training in policy development and coordination which could also serve as a major societal contribution.

Integration Issues While tradition poses much transferable strength, it can also present barriers to the integration of modern and conventional practices.

Comadronas and other traditional healers have strong roots in tradition which make their transition into more westernized ideas difficult.

Conversely, there are still many practitioners of western medicine that do not fully acknowledge the role of the comadronas. This attitude leads to stigmatization of them by professional medical practitioners. To take full advantage of this workforce, these roadblocks must be overcome by both sides of the medical world.

Capitalizing on Human Resources There are very basic issues facing the expansion of the primary health service provider workforce. Currently, many nurses, pharmacists, and community based health workers lack culturally appropriate training in public health and primary prevention skills. This is due to lack of accredited

education programs and resources to conduct them. Also, strong roots in the traditional system prevent many from seeing the potential in incorporating these human resources as assets for care provision and disease prevention.

Communication Challenges Communication with non-health sector entities or the private sector has been a challenge for public health officials. Representatives of the health sector must learn to market their efforts to the private sector in order to raise community awareness, leverage resources, and garner support to reform the health sector. Without this type of strategic communication, the private sector will not see the value in investing in health.

Investment Issues Investing in social capital can present rather complex obstacles to success.

With regards to education, there is a lack of teacher training, accreditation, and evaluation. As demonstrated by the delay in congress to approve the rural development programs, there is difficulty in proving the potential and capacity of rural populations to contribute to the economy and society. In addition, tailoring culturally sensitive materials for community empowerment takes time and training, both of which participants in the system already lack for basic services.

approved Health and Development Laws has been quite a task to enforce. While the Laws provide a good foundation for human rights in regards to health, corruption within the system unfortunately presents roadblocks to adherence.

All levels of the government need to be in sync; however coordination is difficult when political agendas take precedence.

J. PROPOSED GOALS TO RESTRUCTURE AND REVITALIZE THE GUATEMALAN HEALTH SYSTEM Based on Parts 1 and 2 of this report, Table 7, page 38 describes three thematic areas to enhance the performance of the Guatemalan Health System expressed as goals along with topical issues expressed as objectives. This is followed in page 39, by a narrative for each goal and objective elaborates on the rationale for the each thematic area.

Lack of Enforcement of Health Related Laws Law enforcement in Guatemala is a difficult task. Even the current,

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 RESTRUCTURING & REVITALIZATION GOALS

Table 7: Proposed goals to restructure and revitalize the Guatemalan Health System

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 RESTRUCTURING & REVITALIZATION GOALS

1. GOAL #1: RAISING AWARENESS AND COMMUNITY EMPOWERMENT In order to improve the health system in Guatemala awareness needs to be raised in the society by empowering the community. There are various recommendations that can assist in the achievement of this goal such as: utilizing media as a tool for dissemination of health information; improving educational institutions; and improving and expanding upon existing community development councils (CDCs) as means to hold and community leaders accountable.

Utilize media as a tool for dissemination of health information First, development of educational lessons that are culture and language appropriate via media can be suitable steps toward this progress. Folk media for example, can introduce and reinforce culturally sensitive health messages to each community. Another way to raise awareness is to create a network of various organizations.

This network of organizations can create pamphlets and educational materials on nutrition, family planning, maternal and child health, and sanitation. It can also facilitate the exchange of information on various regional health issues between rural and urban populations for raising this crucial awareness.

Improve educational institutions Improvement in educational institutions can also assist in the achievement of community empowerment and raising awareness. Investment in

teacher training to improve youth matriculation rates and stress on health education curricula in primary schools are great foundations to better the community is vital.

Educating men to make better family and community decisions as well as creating more adult education classes with marketable skill training can also play a big part for the next generation cycle.

Improve and expand upon existing community development councils (CDCs) as means to hold and community leaders accountable In addition to the development of culturally appropriate lessons and improving education institutions, improving and expanding upon existing community development councils (CDCs) as a means to hold community leaders accountable for their actions can also assist in community awareness and empowerment. This can be done through a variety of steps. For example, the raising of awareness about community development councils and educating communities on the Urban and Rural Development Council Law, as well as, amending the current Urban and Rural Development Council Law can all be beneficial in expanding upon existing CDCs. 2. GOAL #2: INCREASING AND IMPROVING COOPERATION, COMMUNICATION AND ACCOUNTABILITY A series of recommendations that would increase and improve cooperation, communication and accountability in the health care system of Guatemala include: development of annual, bi-annual and quarterly conferences with

USAC and NPHA as coordinators; improvement of data management, analysis, and evaluation through a centralized system with decentralized collection; and implementation and enforcement of evaluation and monitoring processes for all organizations.

Develop Annual, Biannual and Quarterly conferences with USAC and NPHA as coordinators One of the ways to increase and improve cooperation, communication, and accountability in the healthcare system of Guatemala is the development of annual, bi-annual and quarterly conferences with USAC and NPHA as coordinators. This can be accomplished through inviting international and private stakeholders as guest speakers to address health issues; creating conference modules specific to the exchange of data sets; intervention programming progress and emerging health issues; and varying the location of meeting to expose stakeholders to diverse regions.

Improve data management, analysis, and evaluation through a centralized system with decentralized collection Data management is also important in the improvement of accountability and communication. For example, an improvement in data management, analysis, and evaluation through a centralized system with decentralized data collection can strengthen active collection capabilities and fortifying passive collection capabilities. In addition, gathering all stakeholders to agree on a single system for timely information dissemination, and educating and encouraging health providers in all decentralized

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 RESTRUCTURING & REVITALIZATION GOALS

areas about uniform collection and measurement can be highly beneficial in the improvement of cooperation, communication and accountability.

Implement and enforce evaluation and monitoring processes for all organizations Another recommendation to increase and improve cooperation, communication, and accountability in the healthcare system of Guatemala is to implement and enforce evaluation and monitoring processes for all organizations. This can be obtained through the creation of performance-based evaluations and rewards as an incentive for quality care. Additionally, creating checks and balances by compelling institutions to demonstrate positive efforts and budgeting based upon merit and promoting decentralize health prioritization while maintaining central oversight are all important factors to consider in improvements of healthcare system of Guatemala.

3. GOAL #3: INCREASING AND IMPROVING CAPACITY AND RESOURCES A series of recommendations that would increase and improve the health system’s capacities and resources include: increasing and sustaining the training of traditional, unconventional and community health workers/promoters; improving professional capacity; improving financial resources at all levels; and improving sanitation and potable water sources.

Increase and sustain training of traditional, unconventional, and community health workers/ promoters

Traditional, unconventional and community health workers are a much underutilized, abundant resource that pre-exists within many of the communities and thus have potential for future health promotional activities. Streamlining the training of these health workers will ensure that uniform promotional messages are disseminated across the country and throughout all communities. However, when training community health workers cultural differences must be acknowledged and as such cultural sensitivity training must be included in all training programs. Furthermore, Comadronas should be approached as leaders in providing primary care in rural and indigenous communities.

Since these Comadronas are already utilized by the majority of these populations, the integration of their services into the health system would allow adequate medical care to reach into areas where care has previously been sporadic. Finally, pharmacists and pharmacology technicians represent an untapped resource for the promotion of health information. Since pharmacies represent the primary health contact for many communities, the training of these personnel would allow the dissemination of information at a critical point in medical care and would provide an additional avenue of health promotion that has not yet been explored.

Improve professional capacity There are many ways to expand upon the professional capacity within Guatemala’s health care system. One route to accomplish this involves the restructuring and expansion of university level health professional education. For example, the public health program should include focus

areas in health promotion, health policy, health communication and health economics. Furthermore, all medical schools should require at least one year of public health training to attenuate future physicians to the multidimensional approach of health care. By adjusting the paradigm of the public health worker, all professionals within the health care sector will evaluate specific health issues and needs not only in the context of tertiary care but in the context of primary prevention.

However, adjusting paradigms is not the only method to accomplish change. Many rural areas are in dire need of permanent health care personnel to address their needs yet very few professionals work within these areas. Since educational institutions, sanitary conditions and potable water sources are scarce, many physicians are reluctant to work in these areas. To entice health professionals to live and work within these communities, much of this infrastructure must be built and incentives must be provided that would allow professionals to establish roots among communities.

Improve financial resources at all levels It is well established that adequate distribution and management of financial resources would allow programs to succeed and communities to flourish. One way to bolster the amount of available financial resources in Guatemala lays in taxation. By taxing the highest quintile and adjusting the tax brackets, many additional funds would be created. This can be accomplished through wealth taxation, property taxation or sin taxation, but should be considered when trying to raise future funds.

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IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2 REFERENCES (IN-DEPTH INTERVIEWS IN GUATEMALA)

Furthermore it is necessary that the central government allocate more finances toward health care spending. Currently one percent of the GDP is funneled toward health care. This percentage must rise toward seven to ten percent of the GDP in order for sufficient funds to become available. At the community level, micro-financing can raise many impoverished businesses and can improve economic levels. Microfinancing also has the added benefit of promoting female empowerment since most small loans are doled out to women and are managed wisely.

Improve water sanitation and potable water sources One of the most severely overlooked and underdeveloped infrastructures in the Guatemalan public health system is water sanitation. Clean, potable water is deficient in approximately 30% of the population. Currently only 2 of the 5 established water treatment plants are operating, and of those running plants, operation is only at approximately 60% capacity. Water sanitation is often the source of various infectious and communicable diseases. Stale water provides a breeding ground for mosquitoes carrying malaria and dengue. Water sources become contaminated due to poor waste management, increasing the incidence of diarrhea. As a result, diarrhea is the second leading cause of child mortality. More of a priority must be placed on water sanitation and health promotion and education in order to alleviate the Guatemalan population from these endemic diseases. Communities must be educated in a culturally sensitive and appropriate manner on hygiene and facility maintenance. Communities

must also be empowered and mobilized in order to recognize the need for sanitation infrastructure and demand provisioning of such resources from the government.

Furthermore, political and community leaders must recognize the need in prioritizing the subtle and essential services needed by the community over popular amenities such as soccer fields and public plazas.

K. REFERENCES (IN-DEPTH INTERVIEWS IN GUATEMALA) Chimaltenango Site Visit to ASECA, Community Services Association Site Visit to Kaslen in Comalapa Town (Rural Services & Hospital) Site Visit to Chimaltenango Area Health Office & Services El Shaddai Ministries’ Health & Social Programs: Ms. Carmen de Arimany, President, Manos de Amor Fraternidad Cristiana de Guatemala: Pastor & Dr. Jorge H. López Interamerican Development Bank (IDB): Mrs. Nora Alvarado, Chief, IDB Health Projects Instituto de Nutrición de Centro América y Panamá (INCAP): Dr. Hernan Delgado, Director Lic. Mireya, Surveillance Monitoring and Evaluation Lic. Jesus Bulux, Scientist, Micronutrients Dr. Ricardo Lujan, Scientist, Implementation of Healthy Environments Licda. Maggie Fisher, Social Communicator

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Instituto Guatemalteco de Turismo: INGUAT Representatives Master of Public Health Program, University of San Carlos of Guatemala (USAC): Dr. Jorge Bolivar Diaz, Professor, Environmental Health Dr. Joel Sical Flores, Professor, Health Administration Dr. Giovanni Salazar, Professor, Health Promotion & Health Education Dr. Mario R. Salazar, Profesor, Epidemiology, and Director, MPH Program Dr. Otto Hugo Velásquez, Profesor, Research Ministry of Public Health and Social Welfare: Dr. Betty Gordillo, Director, Infectious Diseases Dr. Enrique Eugenio Duarte, Director, Emergency Preparedness/Disasters Dr. Mario Gudiel, Director, Epidemiology Division Dr. Xiomara Castaneda, Director, Supervision of Areas Dr. Mirna Tellez, Health Center Director, Colonia Centro America National Nursing School: Licda. Rutilia Herrera, Director Pan American Health Organization/ World Health Organization; Guatemala: Dr. Hilda Real, Acting Director Dr. Isabel Enriquez, International Cooperation and Health Situation Analysis Lic. Maggie Fisher, Food and Nutritional Security Consultant, Food and Nutritional Security Situation School of Medicine, University of San Carlos of Guatemala (USAC): Dr. Alfredo Moreno, Director of Research, School of Medicine, USAC Dr. Jesus Oliva, Dean, School of Medicine, USAC June 2008

V. OVERALL CONCLUSIONS AND RECOMMENDATIONS INTRODUCTION

Dr. Pedro Miranda, Director, Rural Professional Supervised Exercise, USAC Dr. Oliver Valiente, Director, Hospital Professional Supervised Exercise, USAC United States Agency for International Development (USAID/Guatemala): Isabel Stout, Office Director, a.i.

USAID/Guatemala Luigi Jaramillo, Quality in Health Project Fidel Arevalo, Maternal & Child Health World Bank/Guatemala: Mr. Mario Marroquin, Chief, WB Health Projects Other: Dr. Sindy Cheesman Dr. M. Roberto Calderón, International Health Consultant

V. OVERALL CONCLUSIONS AND RECOMMENDATIONS A. INTRODUCTION The University of Southern California’s (USC) Master of Public Health Practicum/Internship in Guatemala proved to be a rewarding experience for both students and Guatemalan counterparts. USC students rated this field experience as the best course they had ever had. Guatemalan counterparts appreciated the input and insight of the highly qualified students that, in addition to their role as “interns and researchers”, acted in reality as “evaluators and consultants”. The goal to provide students with an applied learning experience through an assignment/ consultancy that would simulate and reflect what they will be doing in their future careers as public

health practitioners and leaders was totally fulfilled. Students learned and practiced being collaborative leaders of change networking and working in concert with Guatemalan MPH students and faculty, as well as a variety of public health stakeholders from the private, public, non-profit sectors and international organizations and donors. The goal to link the USC Public Health Practicum/ Internship in Guatemala with the MPH program at the Universidad de San Carlos de Guatemala (USAC) ensuring coordination, involvement and ownership of USAC in this activity was completely fulfilled also.

USAC MPH faculty and students contributed with time and effort to the research and assessment conducted, particularly the MPH Program Director.

The field internship experience culminated in a Technical and Scientific Session held at the Metropolitan University Center on August 10, 2006 (see program invitation, on page 43). At this event, attended by close to 100 Guatemalan medical and public health professionals from different disciplines and sectors, a powerpoint presentation was given by the USC students and the practicum designer and coordinator on the “Guatemalan Health System” and the “Critical Importance of Global Health Training” including types of public health challenges, public health intelligence and leadership, protecting health in a changing world, global health systems of wealthy, transition and poor countries, and some of the methodological tools used to conduct the assessment of the Guatemalan Health System i.e., Delphi Technique, Action Learning, Stakeholders Analysis, and SWOT Analyses.

In summary, the USC MPH Practicum in Guatemala comprised three phases: Phase I: Literature Review, five weeks during June and July 2007 Phase II: Field Experience in Guatemala, three weeks during June 23 through August 11, 2007 Phase III: Final Report Writing, two weeks in August 2007.

In total, the final product of this undertaking reflects a level of effort equivalent to ten weeks of work by a team of fifteen people (twelve USC MPH students, two Westmont College pre-medical school students and English/Spanish translators, a USC practicum designer, director and professor) excluding time for initial planning and guidance and final editing and publishing.

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V. OVERALL CONCLUSIONS AND RECOMMENDATIONS THE CHALLENGES THAT HEALTH SYSTEMS FACE TODAY

The USAC/USC Technical and Scientific Session provided to all stakeholders in attendance a forum to discuss the strengths, weaknesses, threats and opportunities of the health system in Guatemala, it also provided the opportunity to reflect on lessons learned and best practices to enhance the performance of the health system, develop social, built, economic and service environments conducive to good health, reduce health disparities among vulnerable populations, increase life expectancy and quality of life, and improve the health status and wellbeing of individuals, families, communities and the Guatemalan population as a whole.

This publication would not be complete without a discussion and guidance to improve the performance of health systems and population health outcomes. The following statements, contributions and recommendations are presented to the reader to stimulate discussion and reflection, propel continued dialogue, further develop strategies and policies, and encourage the pioneering of new combinations of innovative approaches to reform health systems improving their performance and health outcomes (taken, adapted and/or quoted directly from the World Health Organization Report 2000: Health Systems: Improving Performance).

B. THE CHALLENGES THAT HEALTH SYSTEMS FACE TODAY 1. Many countries are falling far short of their potential, and most are making inadequate efforts to achieve responsiveness and fairness

in financing. There are serious shortcomings in the performance of one or more functions in virtually all countries.

2. Health systems failures result in very large numbers of preventable deaths and disabilities in each country, unnecessary suffering, injustice, inequality and denial of the basic rights of individuals. The impact is most severe on the poor, who are driven deeper into poverty by lack of financial protection against ill-health.

3. There are countless highly skilled, dedicate people in all systems working at all levels to improve the health of their communities.

4. Health systems have already contributed enormously to better health for most of the global population during the 20th century.

In the 21st century, they have the power and the potential to achieve further extraordinary improvements.

5. Health systems can misuse their power and squander their potential. Poorly structured, badly led, inefficiently organized and inadequately funded health systems may do more harm than good.

6. The ultimate responsibility for the overall performance of a country’s health system lies with government, which in turn should involve all sectors of society in its stewardship.

The careful and responsible management of the well-being of the population –stewardship—is the very essence of good government.

7. The health of the people is always a national priority. The government responsibility for it is continuous and permanent.

8. Stricter oversight and regulation of private sector provider and

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insurers must be placed high on national policy agendas. Good policy needs to differentiate between providers (public or private) who are contributing to health goals, and those who are doing damage or having no effect, and encourage sanction appropriately.

9. Policies to change the balance between provider’s autonomy and accountability need to be monitored closely in terms of their effect on health, responsiveness and the distribution of the financial burden.

10. Consumers need to be better informed about what is good and bad for their health, why not all of their expectations can be met, but that they still have rights that all providers should respect.

11. Consumer interests in health are weakly protected in countries at all levels of development. The notion of “patient rights” should be promoted and machinery established to investigate violations quickly and fairly.

12. The most obvious route to increased prepayment is by raising the level of public finance for health. This is difficult if not impossible for poor nations.

Governments could encourage different forms of prepayment –jobbased, community-based, providerbased—as part of a preparatory process of consolidating small pools into larger ones.

13. Governments need to promote community rating, a common benefit package and portability of benefits among schemes, and to use public funds to pay for the inclusion of poor people into such schemes.

14. Insurance schemes designed 44

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V. OVERALL CONCLUSIONS AND RECOMMENDATIONS HOW TO IMPROVE HEALTH SYSTEM PERFORMANCE

to expand membership among the poor are an attractive way to channel external assistance in health, alongside government revenue. Alert stewardship is needed to prevent the capture of such schemes by lowerrisk, better-off groups.

15. Mechanisms are needed in most low and middle-income countries to separate revenue collection from payment at the time of service utilization, thus allowing the great majority of financing for health to come through prepayment.

16. More pooling of finance allows cross-subsidies from rich to poor and from healthy to sick. Risk pooling in each country needs to be designed to increase such cross-subsidies.

17. Payment to service providers of all types needs to be redesigned to encourage providers to focus on achieving health system goals through the provision of cost-effective interventions to people with common conditions amenable to prevention or care.

18. On an international level, the largely private pharmaceutical and vaccine research and development industry must be encouraged to address global health priorities, rather than concentrating on “lifestyle” products for more affluent populations.

19. Serious simultaneous imbalances exist in many countries in terms of human and physical resources, technology and pharmaceuticals.

Many countries have too few qualified health personnel, others have too many.

20. Health system staff in many

low income nations is inadequately trained, poorly paid, and work in crumbling, obsolete facilities with chronic shortages of equipment. One result is a “brain drain” of talented but demoralized professionals who either go abroad or move into private practice.

identify the principal policy challenges at any time, and to assess the options for dealing with them.

21. Overall, governments have too little of the necessary information to draw up effective strategies.

National Health Accounts (NHA) offer an unbiased and comprehensive framework from which overall situation analyses can be made, and trends monitored. They should be more widely created and used.

C2. Service Provision: delivering public, personal and private health services.

C. HOW TO IMPROVE HEALTH SYSTEM PERFORMANCE

28. In order to move towards higher quality care, a better information base on existing provision is required.

Local and national risk factors need to be understood. Information on numbers and types of providers is a basic –an often incompletely fulfilled-requirement.

C1. Stewardship: oversight; acting as the overall stewards of entrusted resources, powers and expectations, setting and enforcing the rules of the game and providing strategic direction for all the different actors involved.

22. Sound stewardship is needed to achieve better health system performance 23. Stewardship of the health system is a government responsibility. To discharge it requires an inclusive, thought out policy vision that recognizes all principal players and assigns them roles.

24. Stewardship uses realistic resource scenario and focuses on key functions and goal achievement, broken down into important population categories, such as income level, age, sex and ethnicity.

26. Influence requires regulatory and advocacy strategies consistent with health system goals, and the capacity to implement them cost-effectively.

27. Private provision of health services tends to be larger where country income levels are lower. Poor countries need to develop clear lines of policy towards the private sector.

29. An understanding of provider market structure and utilization patterns is needed so that policymakers know why this array of provision exists, as well as where it is growing. Information on the interventions offered and on major constraints on service implementation is also relevant to overall quality improvement.

30. An explicit, public process of priority setting should be undertaken to identify the contents of a benefits package which should be available to all, including those in private schemes, and which should reflect the local disease priorities and costeffectiveness, among other criteria.

31. Rationing should take the form

25. Stewardship calls for the ability to 45

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V. OVERALL CONCLUSIONS AND RECOMMENDATIONS HOW TO IMPROVE HEALTH SYSTEM PERFORMANCE

of excluding certain interventions from the benefit package, not leaving out any people.

but they are still often rudimentary and are not yet widely used as tools of stewardship.

32. A regulatory strategy that distinguishes between the components of the private sector, and includes the promotion of selfregulation, needs to be developed.

Aligning organizational structures and incentives with the overall objectives of policy is a task for stewardship, rather than one left only to service providers.

37. NHA data allow the ministry of health to think critically about input purchasers by all fund-holders in the health system. The concept of strategic purchasing does not apply to the purchase of health care services.

It applies equally to the purchase of health system inputs –trained personnel, diagnostic equipment, vehicles, etc.

33. Monitoring is needed to assess behavioral change associated with decentralizing authority over resources and services.

38. Where health system inputs are purchased by other agencies (private insurers, providers, households or other public agencies) the ministry’s stewardship role consists of using its regulatory and persuasive influence to ensure that these purchases improve, rather than worsen, the efficiency of the input mix.

C3. Resource Generation: creating resources through investment and training including investing in people, buildings and equipment, and generating the human and physical resources that make service delivery possible.

34. Stewardship has to monitor several strategic balances and steer them in the right direction when they are out of equilibrium.

35. A system of national health accounts (NHAs) provides the essential information base for monitoring the ratio of capital to recurrent expenditure, or of any one input to the total, and for observing trends.

36. NHAs capture foreign as well as domestic, public as well as private inputs and usefully assemble data on physical quantities (numbers of nurses, CT scanners, district hospitals) as well as their costs. NHAs in some form now exist for most countries,

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39. Ensuring a healthy balance between capital and recurrent spending in the health system requires analysis of both public and private spending trends and a consideration of both domestic and foreign funds.

40. A clear policy framework, incentives, regulation and public information need to be brought to bear on important capital decisions in the entire system to counter ad hoc decisions and political influence.

41. At an international level, stewardship of pharmaceuticals and vaccine inputs consists of influencing the largely private research and development industry to address global health priorities. At national level, the key tasks are to ensure cost-effective purchasing and quality control, rational prescribing, and consumers being well informed.

42. Health financing strategies Assessing the Performance of the Health System In Guatemala

need to ensure that poor people, in particular, get the drugs they need without financial barriers at the time they are sick.

43. Major equipment purchases are an easy way for the health system to waste resources, when they are underused, yield little health gain, and use up staff time and recurrent budget.

C4. Health System Financing: revenue collection, pooling of resources and strategic purchasing of interventions and services.

44. In all settings, very high levels of fairly distributed prepayment, and strategic purchasing of health interventions, are desirable.

Implementation strategies, however, are much more specific to each country’s situation.

45. Poor countries face the greatest challenge. Most payment for health care is made at the time people are sick and using the health system.

Out-of-pocket payment for care, particularly by the poor, should not be relied on as a long-term source of health system finance.

46. The most obvious route to increased prepayment is by raising the level of public finance for health, but two immediate obstacles appear.

• The poorest countries as a group manage to raise less, in public revenue, as a percentage of national income than middle and upper income countries.

• Ministries of finance in poor countries, often aware that the existing health system is performing poorly, are skeptical of its claims on public revenues.

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V. OVERALL CONCLUSIONS AND RECOMMENDATIONS BIBLIOGRAPHY

47. Although most industrialized countries already have very high levels of prepayment, some of these strategies are also relevant to them.

For its income level, the United States has an unusually high proportion of its population without health insurance protection.

48. To ensure that prepaid finance obtains the best possible value for money, strategic purchasing needs to replace much of the traditional machinery linking budget holders to service providers.

49. Strategic purchasing means ensuring a coherent set of incentives for providers, whether public or private, to encourage them to offer priority interventions efficiently.

50. Selective contracting and the use of several payment mechanisms are needed to set incentives for better responsiveness and improved health outcomes.

51. The fundamental goals of a health system are good health, responsiveness to people’s expectations (where both level and distribution matter for each of these goals) and fairness of contribution to financing the health system.

52. Achieving these goals depends on the effectiveness of four main functions of a health system: service provision, resource generation, financing and stewardship.

VI. BIBLIOGRAPHY 1. World Health Organization.

World Health Organization Report 2000: Health Systems: Improving Performance. Geneva, Switzerland.

2. Matcha, Duane A. Health Care Systems of the Developed World.

Praeger Publishers. USA 2003.

3. Roemer, Milton I. National Health Systems of the World. Volume I: The Countries. Oxford University Press.

New York, USA 1991.

4. Graig, Laurene A. Health of the Nations. Third Edition. Congressional Quarterly, Inc., Washington, D.C., 1999.

5. Fried, Bruce J. and Laura M Gaydos. World Health Systems: Challenges and Perspectives. Health Administration Press. Chicago, Illinois, USA 2002.

6. Hurrelmann, Klaus and Ulrich, Laaser. International Handbood of Public Health. Greenwood Press. West Port, Connecticut, 1996.

7. World Health Organization.

Vaccines and Biologicals. Health Sector Reform (HSR): The Impact of Health Sector Development on Immunization Services. Fact Sheet 1, Expanded Programme on Immunizacion, WHO, Geneva, Switzerland, December 2003.

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