1.GHLR.GuatemalaAssessment.Narrative

San Gabriel Valley and Metropolitan Service Planning Area Health Office (SPA 3 & 4)
June 2008
Institute for Health Promotion and Disease Prevention
CASE STUDY
Institute for Health Promotion and Disease Prevention Research
ASSESSING THE PERFORMANCE
OF THE HEALTH SYSTEM IN GUATEMALA
Volume I: Narrative Edition
GLOBAL HEALTH LEADERSHIP REPORTSBEST PRACTICE SOLUTIONS TO ENHANCE THE PERFORMANCE OF HEALTH SYSTEMS
M. RICARDO CALDERÓN, SERIES EDITOR

Assessing the Performance of the Health System In Guatemala June 2008
2
At a GlanceINSTITUTE 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 neces-
sarily 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
2
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.

Evaluation of the Chinese CDC- USC-Assessing the Performance of the Health System In Guatemala June 2008
3
I. EXECUTIVE SUMMARY 4
A. Acknowledgements
II. THE GUATEMALA SUMMER PRACTICUM 8

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 11
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 43

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 47
ASSESSING THE PERFORMANCE OF THE HEALTH SYSTEM IN GUATEMALA
TABLE OF CONTENTS

4
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,
EXECUTIVE SUMMARY

5
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, Pre-
Trip 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
EXECUTIVE SUMMARY

6
ACKNOWLEDGEMENTS
Andrea Cooper, PharmD,
University of Southern
California, Los Angeles, CA
& BCPS.
Nik Gorman, B.A. Psychology,
Lewis and Clark College,
Portland, OR. MPH, Biostatistics
and Epidemiology, 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.
Katrina Kane, B.A. Kinesiology
and Applied Physiology,
University of Colorado, Boulder,
CO. MPH, Global Health
Leadership, 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.
Liyan Moghadam, B.S.
Physiological Sciences, B.S.
Biochemistry, University of
Arizona, Tucson, AZ. MPH
Global Health Leadership,
California, Los Angeles, CA.

7
ACKNOWLEDGEMENTS
Robyn Eakle, B.A. French
Literature and Comparative
Literature, University of
Washington, Seattle, WA.
MPH, Global Health
Southern California, Los
Angeles, CA
Wilson Ong, B.S. Biological
Southern California,
Los Angeles, CA. MPH,
Global Health Leadership,
California, Los Angeles, CA.
Lawrence Ham, B.S. Biology,
University of California,
Riverside, Riverside,
CA. MPH, Global Health
Angeles, CA.
Mana Pirnia, B.A. Psychology
University of California, Los
Angeles. MPH, Global Health
Angeles, CA.
Roberto Daniel Valladares
Calderón, B.S.Chemistry
& B.S. Biology, Westmont
College, Santa Barbara, CA.
Cándida Elisabeth Valladares
Calderón, B.S. Chemistry & B.A.
Biology, Westmont College,
Santa Barbara, CA.
Brian Sandoval, B.S.
Physiology, California State
University, Long Beach
& MPH, Global Health
Southern California in Los
Angeles, CA
Amy Yeh, B.S., Biological
Sciences & B.A. Political
California, Irvine & M.A.,
Medical Sciences, Boston
University & MPH, Global
Health Leadership, University
of Southern California, Los
Angeles, CA

8
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 world-
class 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
II. THE GUATEMALA SUMMER PRACTICUM

93
Guatemalan Health System and its
capacity and effectiveness to provide
health promotion and disease
prevention and control services to
the entire population
• Assess the strengths, weaknesses,
opportunities and threats (SWOT
Analysis) of the health system
• 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
to an Assessment of the Guatemalan
Health Sector as follows:
PHASE I
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:
• 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
of morbidity and mortality,
demographic patterns and trends of
disease.
3. ORGANIZATION AND
MANAGEMENTN OF THE HEALTH
SYSTEM: public, private and non-
profit health programs and services.
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
GUATEMALA PRACTICUM DESCRIPTION
II. THE GUATEMALA SUMMER PRACTICUM

10
II. GUATEMALA SUMMER PRACTICUM
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 non-
profit 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 key-
informant 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
GUATEMALA PRACTICUM DESCRIPTION

115
III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I
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 in-
country 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. USAC-
MPH 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,
MPH, Professor, Health Promotion
• 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
INTRODUCTION

12
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,

13
DEMOGRAPHIC & ECONOMIC INDICATORS
7
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
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
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
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

14
Organization, 2000).
E. HEALTH NEEDS
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).
HEALTH NEEDS
Table 1: Adjusted Mortality Rates
Table 2: Morbidity Indicators
III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART IIII. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART IIII. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART IIII. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART IIII. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART IIII. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I

15
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 non-
governmental 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
HEALTH NEEDS

16
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. Post-
conflict 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 2005-
2006, 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 (EM-
DAT, 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
HEALTH NEEDS
III. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART IIII. PRE-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART I

17
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 non-
governmental 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 vaccine-
preventable 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
ORGANIZATION AND MANAGEMENTOF THE HEALTHCARE SYSTEM

18
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
ORGANIZATION AND MANAGEMENTOF THE HEALTHCARE SYSTEM

19
(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 back-
fired 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
HEALTH SYSTEM RESOURCES

20
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, Aldama-
Lopez 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

21
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).
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

22
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, Copán,
Lempira, Ocotepeque and Intibucá,
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).
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
THE KEY STAKEHOLDERS
Table 3: Primary Stakeholders of the Guatemalan Health System

23
THE KEY STAKEHOLDERS
Table 4: Secondary Stakeholders of the Guatemalan Health System

24
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).
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). US-
Guatemala (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
FUTURE IMPLICATIONS & REFERENCES

25
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).
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
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/BI-
brochure-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://
REFERENCES

26
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.
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
REFERENCES

27
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 non-
governmental 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.
IV. POST-TRIP REPORT: GUATEMALA: A HEALTH SYSTEM & COUNTRY IN TRANSITION: PART 2
INTRODUCTION & STAKEHOLDERS

28
National 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.
Regional/Local 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.
STAKEHOLDER ANALYSIS
Table 1: Expectations of the various Stakeholders

29
Table 3: Expectations of the various Stakeholders (highlighting areas of discord)
Table 2: Expectations of the various Stakeholders (highlighting areas of consensus)

30
Table 4: Resource commitments from the various Stakeholders
Table 5: Conflicting interests between the various Stakeholders

1.GHLR.GuatemalaAssessment.Narrative

1.GHLR.GuatemalaAssessment.Narrative

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