Health Care Reform in Guatemala - Stories - People's Health Assembly - December 2000
Health Care Reform in Guatemala
Hugo Icu
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Good morning everyone. I have the honor of sharing with you the process of the health care reform in my country, Guatemala that has been documented by the Association of Community Health Services (ASECSA), the National Health Network, a civil society organization that I represent.
My name is Hugo Icu, and am a medical doctor of Mayan Kakchiquel origin. I come from Guatemala in Central America. Guatemala is a country of 11 million inhabitants where 70% of the population is indigenous and 30% are of mixed blood, descendants of the Spanish who colonized and dominated us for over 500 years. Guatemala is a multicultural and multilingual country, where there are 23 ethnic groups and 22 indigenous languages. However, our official language is Spanish. The indigenous peoples maintain our own visions about life, the land, the universe, and of course about health and illness. We have a rich traditional medicine with knowledge, practices and therapeutic resources maintained and passed on from generation to generation.
In Guatemala more than 60% of the population lives in rural areas in conditions of extreme poverty. More than half of our people are unable to read or write. Our principal means of subsistence is agriculture, but the arable land is in the hands of a few wealthy landowning families.
45% of the population has no access to health services. The infant mortality rate is 190 per 1000 live births. The principal causes of infant mortality are diarrheal diseases, respiratory infections and malnutrition. Tying to revert these structural problems we lived at war for over 36 years. This left 150,000 dead, 200,000 orphans and 60,000 widows.
Health care reform in Guatemala has been promoted since 1991 by advisors of the Interamerican Development Bank – IDB – and successive governments. However the real implementation began in 1997 after the signing of the Peace Accords. This reform is part of the tendencies toward modernization of the state, taking place over several years. It proposes a reordering of the health sector in which the roles and functions of the state, the market, and civil society are redefined. The objective is to privatize health care at the expense of the public health services. The IDB has been the most important financial institution in the strategic support of the reform with the Program for the Improvement of the Health Services, and it has determined the fundamental characteristics of the reform. These are based on the principles of the World Bank put forth in such reports as: Financing of the Health Services in the Developing Countries, the Agenda for Reform (1997) and the World Development Report, Investing in Health (1993). The guidelines for the reform were outlined in the Health Policy 1996-2000 of the government of President Arzu. The most relevant facts of this process are:
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A redefinition of roles and functions between the Ministry of Health, Social Security and both the private for profit and not for profit sectors.
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The approval of a new Health Code.
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The implementation of primary health care through the Integral System of Health Care
(SIAS)
The SIAS is based on contracting private providers and administrators for health services. To function they only need to demonstrate management capacities. For example, the SIAS have involved savings and loan cooperatives, an American petroleum company (BASIC) and cable TV enterprises. The population is divided into jurisdictions of 10,000 inhabitants, which are offered to private institutions. The services provided by the private entities are supposed to meet requirements determined in a vertical manner. This included the organizational model at the local level, the basic package of services and the budget per capita on the average of $5 per person per year. The local organizational model requires the collaboration of a malaria worker and so called health ´´guardian´´ for every 20 families. At the government level it requires an institutional facilitator, an auxiliary nurse and an ambulatory doctor for each jurisdiction. That is, the SIAS has generated a system that basically consists of voluntary personnel. .
The problems that have been identified in the implementation of the SIAS and the health care reform are:
The provision of a limited, selective, low quality package of health services.
The sustainability of the services depends on volunteers with heavy responsibilities. The health care of the poorest populations depends on volunteer workers. If the volunteer fails, the system fails. In this way the government is able to maintain a low budget for the Ministry of Health, which historically has been about 1% of the GNP.
The rich experience of traditional resources and practices is not taken into account.
The inspiration for the reform comes from other models such as those of Chile and Colombia.
The implementation is in a vertical manner without consultation with the community and others health organizations.
With the increase in the commercialization of health, the economic sectors tend to dominate health policy decision-making.
The privatization results in the community making demands on private institutions and not on the state, which has the constitutional responsibility for health.
Various sectors of the population are marginalized and the services are inequitable.
There is the incentive to introduce invasive and dangerous diagnostic practices.
The doctor patient relationship is destroyed.
We are faced with the dehumanization of health, with the loss of the right to health, where what is valued is what you pay, where the solidarity and complimentarity of our Mayan ancestors is substituted by individualism and competition. As the marketing of health services increases it will be the external, negative, individualistic and egoistic values that will rule our health system.
After the signing of the Peace Accords in 1996, the military war ended. Now we are facing a worse war, that of a globalized world with marketing norms which only sharpens the poverty and inequality of our peoples. The thrust for these changes, as I said, comes from the influence the Bank has exerted on our decision makers- And the people have been left to pick up the pieces of a system that is flawed to our local realities. You in the audience be the judges.
Thank you.
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