"Guatemala’s Healthcare System at a Crossroads" by Isabella Centeno Solis

Guatemala’s Healthcare System at a Crossroads

Isabella Centeno Solis, Frederick Community College

Abstract: As of 2025, many Guatemalans do not have access to basic health care. The Ministry for Health and Social Assistance (MSPAS) and the Guatemalan Social Security (IGSS) provide public healthcare, but funding is insufficient: rural areas have limited access to services and skilled personnel, who are predominantly located in urban hospitals. Community health care workers can only provide preventive care, not curative services. The existing infrastructure makes it difficult to extend aid to rural areas that already lack skilled personnel.. The IGSS coverage (employer-provided benefits) is only 18% and is located primarily in Guatemala City, the capital (Avila et al., 2015). Private healthcare is extremely expensive for the average Guatemalan but has higher patient treatment rates. Non-governmental organizations running private healthcare operate with varying schedules and quality of care. Decentralization of healthcare creates a fragmentation with unequal access to services and less than full capacity. The current public health care system needs to be reformed to reach all Guatemalans. Municipalities should create municipal health boards to plan and monitor the services of public health care alongside funding. The services of health posts need expansion: providing preventive services, alongside a branch office hospital providing curative measures. To encourage local doctors to stay in underserved areas, municipalities should be empowered to pay off their debts through raising taxes, prompting citizens to pay for better services. This would lead to the production of more jobs, qualified workers, higher salaries, and economic growth. Social empowerment fosters a sense of community and enables people to advocate for their interests.

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Introduction

Guatemala’s Constitution states that “the State will see to the health and social assistance of all the inhabitants” (Constitution, art. 94, § 7). The government assures this fundamental right, yet many Guatemalans lack proper medical care and do not have access to the basic health services that are already provided. Moreover, decentralization, or the distribution of power to local governments and people, has had a large impact on the services that both public and private health spheres provide. These services provided do not reach the entire population’s needs. As a result, Guatemala heavily lacks the proper care for a large majority of its population. Decentralization of healthcare creates a fragmentation of both public and private healthcare due to insufficient funding and the capacities of both personnel and facilities. Reforming the public health care system is necessary to mitigate current inequalities and create better care for all. 

At the end of the Guatemalan Civil War in 1996, a time of great instability, the Guatemalan government oversaw the function of the health system as its provider. More specifically, the institution of the Health Council, or Cápsula Distrital, oversaw the implementation of all workers into the system, limiting the power of the people to make decisions (Driese, 2022, p. 31). The government made all the decisions, leaving Guatemalans without the ability to give valuable input on what services they truly needed. However, as of 1997, “the government transferred its administration and delivery of primary health care services to private entities through signed agreements (convenios)” (Verdugo, as cited in Driese, 2022, p. 32). This change signaled a major transformation in the role of the government. No longer was it in charge of overseeing, but the power was transferred to private organizations, such as non-governmental organizations, or NGOs. As a result, the government took a step back in its power to oversee and left the decision-making to organizations not affiliated with it, and that had the ability to create their own set of rules. However, this would eventually lead to a significant problem in the area of health care access: the growing gap between private and public healthcare and the people who could afford to pay for better quality services through higher fees that the general population could not afford.

Decentralization, which is defined as the distribution of power to local governments and the people, has had a large impact on the services provided by both public and private health systems. The World Health Organization (WHO) describes how decentralization reforms in the 1980s were enacted in countries “to address the limitations of centrally governed health systems to reach underserved communities in low- and middle-income countries” (WHO, 1987, as cited in Abimbola, 2019, p. 606). These communities had little to no access to healthcare due to varying factors, such as poverty, rural settings, and lack of transportation. It is also important to note that decentralization strives to increase social participation as the main result of its allocation of power. Ruano (2011) explains how social participation “is an empowering process that improves the quality of life of community members…and builds a better relationship between the state and its inhabitants” (p. 99). In doing so, it allows the community to decide what needs are the most necessary through the introspection of its current population. This is the central tenet of decentralization: community activism and engagement. 

Understanding Public Healthcare in Guatemala

The public health system in Guatemala is meant to cover the majority of the population through its services that the Ministry of Health (MOH) oversees. All Guatemalans ideally qualify for the programs of the Ministry for Health and Social Assistance, or MSPAS (Driese, 2022). However, the MSPAS funding is often insufficient, leaving the rural poor (and majority indigenous) with no access, as well as creating inequalities within the services provided, and the quality of personnel, which is further exacerbated due to institutional corruption (Calderón Pinzón, as cited in Driese, 2022, p. 50). This is due to the decentralization within the MSPAS: its main services run separately from each other, leaving patients to have to choose from what would fit them best. On the other hand, the Guatemalan Social Security (IGSS), is a public service that provides private insurance. Its services are supplied for Guatemalans employed in the formal sector, such as those in government jobs, and for their relatives, as well as for those with disabilities (Driese, 2022). The population that the IGSS successfully covers is slight – only 18% (Peña, 2013, p. 20). Moreover, the IGSS specifically focuses on hospital care and specialized facilities, which are heavily concentrated in the capital, Guatemala City (Peña, 2013). As a result, this reinforces the inability of rural populations to access basic public healthcare.

Limitations of Health Care Workers

In public care, health centers deliver the majority of primary care to Guatemalans in suburban areas, yet rural populations do not have easy access. As a result, community health care workers (CHWs) were first introduced in the early 1970s and focused on bringing health services to rural, indigenous populations in the highlands of Guatemala (Colburn, as cited in Driese, 2022, p. 19). Later, the Integrated Health Care System (SIAS) came in with their guardianes de salud (health guardians). These guardianes work directly for the SIAS, unlike CHWs, who encompass a broader network of positions throughout the country. It is the SIAS's job to hire NGOs to act as both spokesmen and caretakers under health centers in order to reach populations without access to basic services (Maupin, 2011). The people acting as guardians link primary health care, MSPAS services, and private care together. In short, this is a decentralized version of healthcare that not only reaches underserved communities but also allows workers to increase participation of citizens within the healthcare they can access. 

While community activism is highly regarded and needed, the guardianes’ inability to serve as a provider of curative services is a major concern. The role of the guardianes is not curative, only preventive: their role is to “guard” the health of their community. Maupin (2011) explains that they serve as a point of reference for their communities, but their patients are in charge of accessing higher levels of care (p. 46). A large issue with their role is the lack of “curing” that the guardianes do. Their job is based on monitoring the health of their community and educating them about their bodies and health. Decentralization in the SIAS system “denies guardians the power and authority of the position” (Maupin, 2011, p. 50). Guardians do not have the authority to recommend or give pharmaceuticals, nor do they have adequate training to diagnose illnesses (Maupin, 2011). As a result, many of these workers are frustrated with the limited capacities and knowledge they are provided with, as their role is a volunteer position. As a result, they continue to advocate for better training and the ability to use curative training in order to successfully address health concerns of the populations.

Health Posts in Rural Guatemala

Health posts are facilities that are run under the direction of each municipality in Guatemala, yet many lack the capacity to serve the community. As of March 2020, there existed 1,200 health posts for all of Guatemala’s 17 million citizens (International Trade Administration, 2020). Many of these posts are located in rural areas, where access to clinics and hospitals is difficult. This is highly alarming, as in no way do these health posts have the funds, capacity, or personnel to effectively care for such an extensive number of people. Due to this, a few CHWs run the health posts with the aid of community volunteers. Hernández and Sebastián (2013) explain how reforms during the 1990s “established the decentralization of administrative authority to the regional level in order to facilitate responsiveness to the needs and situations of the regions” (p. 2). In doing so, this allowed municipalities to focus directly on the needs of their people without worrying about what neighboring municipalities needed. The goal of these reforms was to focus on efficiency. However, while the need for efficiency was important, so was the increase in spending that corresponded. The authors point out that the institutional mechanisms to evaluate this efficiency were never established, which further led to inequities in the distribution of the programs and access to Guatemalans (Hernández & Sebastián, 2013). Specifically, the sector of the MSPAS dedicated to the “direction of delivery of service and technical execution” is falling behind (Driese, 2022, p. 22). This is reflected in the fact that as of 2011, only 18% (1,492) of total healthcare facilities, including health posts, were public, and a minuscule 1% (125) were IGSS-run (a total of 1,617) (Peña, 2013, p. 20). Under this decentralization, the organizations that it covered were never fully impacted, often leaving them without the necessary funding to carry out actions. 

Health posts, while linking the community to healthcare, are often underutilized and inefficient. This is due to “their perceived low quality of care, lack of resources, and being chronically understaffed” (Maupin, 2011, p. 51). Underfunding of health posts is primarily due to decentralization reforms at the municipal level. While these reforms theoretically establish the importance of community engagement, it is often not carried out. Brink-Halloran (2009) explains that personnel at the municipal level are extremely lacking: there is an insufficient quantity of workers with the skills required, as well as the funding to maintain and attract those who are qualified (p. 32). Many of the people who use these facilities are those living in rural, poor areas, who are often indigenous peoples (Gragnolati and Marini, 2003). They do not have the means to travel far in search of better facilities and care and must suffice with what is closest to them. Hernández and Sebastián’s (2013) study on the efficiency of health posts in the Guatemalan Department of Alta Verapaz concluded that as of 2009, 29% of health posts “were operating with high efficiency, 29% with moderate efficiency, 21% with poor, and 21% with very poor efficiency” (p. 4). These numbers were significantly lower than those of 2008, which signaled a difference in the amount of funding received and how each health post utilized it. Funding in rural areas is much lower than in urban areas, even though patients exceeds the total healthcare providers. Hernández and Sebastián (2013) also explain how in Alta Verapaz, one health post will cover a population of 2,000 people and have one or two nurses running the post with a few community volunteers (p. 2). Due to the local government’s low investment in healthcare, the funding per patient that a post needs to successfully take care of a population is insufficient, as well as the ratio of healthcare workers to patients.

Health posts are often in competition with community health care workers. Some health posts provide free services and consultations for the community they are located in, while others are privately managed by the workers. Again, health posts are designed to serve small villages that do not have close access to primary health services. Yet because of the competition between the two services, the MSPAS posts are continuously underutilized. Maupin (2011) details that in the municipality of San Martín, three out of the four available health posts were always closed (p. 51). The community engagement that decentralization advocates for is clearly in conflict. The two services are in a continual fight with each other to see who can provide the best service to the community and for a fair (or free) price. As a result, there exists an ongoing conflict of deciding to pay for better services or not pay for services that are of lesser quality. The imbalance between curative and preventive care further creates a burden on the patient to find the best service fit for them instead of leaving the task to the service itself.

The Private Healthcare Sector

Private healthcare, while far more expensive than public healthcare, is greatly preferred when people can afford it. Private services are broken down into for-profit (specialized private organizations such as hospitals and laboratories) and nonprofit (NGOs and international and religious organizations that provide community-based services) (Peña, 2013). Liebig (2001) explains how private insurance is often utilized as a backup for public services when they do not reach the intended population (p. 23). Yet the percentage of people who use this is minimal as few have the funds to pay higher copayments and afford travel to better facilities. Generally, the private sector has always had better funding and can invest in newer facilities and equipment (International Trade Administration, 2022). Therefore, these programs have greater success rates in treating patients. Yet the percentage of the population that private care covers is only 3% (Bowser, 2009, p. 34). This percentage of the population is primarily urban and wealthy. As a result, this leaves the rest of the country without the ability to access better services.

The Guatemalan population maintains private, for-profit organizations through their own funding. Under this category are some hospitals, laboratories, and clinics. Often, the people utilizing these services are wealthy and live in urban centers; most of them live in the capital, Guatemala City, and its outskirts. More often than not, clients have better-paying jobs that allow them to have private insurance and pay for out-of-pocket services (Avila, as cited in Fagan, 2017, p. 2). The MSPAS runs many of these private services, their management and regulation, financing, and training (Pan American Health Organization, 2007). Yet again, decentralization creates a fragmentation of the services and to whom it is provided. While the reforms allow municipalities and local towns to take charge of what issues to focus on, the funding and training is never entirely available. Additionally, contributions to the private services are out-of-pocket from households (Pan American Health Association, 2007). These payments make up the main financing of private services. Driese explains how decentralization reforms aimed to utilize user fees to pay for the facilities that patients visited, instead of the government itself for providing them (Keshavjee, as cited in Driese, 2022, p. 31). Yet this method is not practical in a country where a significant portion of the population lives below the poverty line. Only those with sufficient spending ability are able to pay for private services. Therefore, they are placed with the burden of looking elsewhere for healthcare, whether it is satisfactory or not. Civic engagement is what keeps these organizations up and running, but also keeps the marginalized away from utilizing better services.

Non-Governmental Organizations (NGOs) and Their Role

As for private, nonprofit organizations, NGOs were once centralized, which ideally allowed them to cover the needs of the entire population. However, in tandem with decentralization reforms, a program that transferred the power from the government to NGOs through the Coverage Extension Program (PEC) was created in the 1990s (Driese, 2022). The PEC allowed NGOs to run their services without government interference, which in turn let them focus specifically on the populations and areas that need the most assistance. Under the PEC, NGOs were contracted to provide basic services to rural populations in Guatemala (Avila et al., 2015). The program ran from 1996 to 2014, and while it was successful under certain presidential administrations, it was also lackluster in others. Peña (2013) dictates its strengths: administration efficiency, use of alternate, additional personnel, and the use of planning tools (p. v). Its efficiency is highlighted in the stark increase in population that obtained healthcare coverage: from 0.46 million in 1997 to 4.3 million in 2012 (Peña, 2013, p. 4). While the numbers seem convincing, it only served just over 50% of the rural population. The program would have greatly benefited from an increased budget, but due to the nature of the program, NGOs were unable to obtain funds from the government, as they were managed without the government’s help. In the end, the PEC program was canceled in 2014 as a result of extremely high costs and potential debt issues (Avila et al., 2015). This, once again, created a great loss in access to healthcare in rural areas.

Grassroots organizations, such as NGOs, provide inefficient and chaotic services when under the impact of decentralization. As they are no longer under the care of the PEC program, they are free to run how they see best. Hérnandez and Sebastián (2013) explain that “health sector reform policy to expand coverage by contracting non-governmental organizations (NGOs) to provide a basic package of services in the most remote rural areas has been reported to contribute to inequity through segmentation of the health system for different population groups” (p. 2). Many NGOs operate separately from each other, with differing schedules, personnel, and quality of care, among many other factors. Many are faced with choosing between several options when seeking care, especially for indigenous people living in rural locations (Rohloff et al., 2011). These factors, in turn, create a barrier to access; without guidance in the healthcare landscape, indigenous patients must navigate a system without much knowledge of it, trying out different resources and obtaining varying results before landing on one that fits their needs. Rohloff et al. (2011) demonstrate how the community of Chiqul Juyu’, a small village in Sololá, has four operating NGOs attempting to serve the community with their programs, but they do not communicate with each other at all (p. 431). The community workers who are employed under these NGOs complain of in-fighting between personnel and undermining the authority of the community workers themselves, among other issues (Rohloff et al., 2011). As a result, community workers no longer want to work for these organizations as they are undervalued, which further leaves communities without even basic care. The myriad of issues that arise from decentralizing health care impact the most vulnerable. 

While NGOs promote community activism and engagement, their community workers are often taken for granted, which creates burnout. Usually, community workers are put on the sidelines when working with physicians from NGOs. Instead of teaching them valuable lessons that they could utilize in their communities, they work as aides to physicians, accompanying them on medical missions to different towns (Rohloff et al., 2011). This leaves communities without the necessary help they need, especially since NGO physicians often do not speak indigenous languages or understand their cultural norms and traditions. Community workers play an important mediation role between the caregiver and the patient – without them, a misunderstanding may occur. However, this hinders health workers from self-organizing to take care of patients and leads to burnout. The concept of “development burnout,” where “NGO workers express apathy and cynicism about the potential for their projects to generate lasting change,” is a major problem (Clifford, as cited in Rohloff et al., 2011, p. 432). Community workers convey their frustrations about their inability to treat their community successfully, but without the proper training and tools necessary to do so is extremely difficult.

A Three-Step Method for Reforming Public Healthcare

The current public health care system is in need of reform at several levels for it to function. To begin, municipalities should create municipal health boards to plan and monitor the services of public health care, along with funding. These health boards are created to oversee and tie in the services of public health. Ruano (2013) explains that these boards “tailor national policies to local needs” (p. 3). Therefore, they have the ability to put into practice exactly what the community needs, focusing on what is most important. A successful health board was put into place in Palencia, Guatemala, where members “coordinate the work of the municipality, the health center, and the NGO that works under the extension of the care program” (Ruano, 2013, p. 3). The board works together with parties from both the municipal government and health services, along with community members, to create policies. As a result, they use citizens’ voices to better their municipalities and focus on programs to reach all people, not just those who are underserved. De Vos et al. (2009) describe how “empowerment frameworks often focus on enhancing people’s and communities’ capabilities” (p. 26). This level of care focuses on strengthening community empowerment and the collaboration between different sectors of the healthcare system in order to successfully implement policies and programs.

Services of health posts require expansion, providing preventive services, alongside a main branch office hospital providing curative measures. The current state of health posts in various municipalities depends on the quality of care that healthcare workers provide, as well as the funding available. Often, health posts are not operating with complete efficiency. The expansion of health posts would allow workers to provide in-depth preventive and curative services, the latter of which is often relegated to the capital, where the necessary funding, equipment, and specialized doctors are located. Successfully transferring some of the curative services that hospitals provide to these branch hospitals would provide more well-rounded care and increase the resources available to underserved areas (Gragnolati & Marini, 2003). Moreover, if community health workers and guardianes were given the ability to diagnose and cure, it would successfully empower them to help their communities. Additionally, existing hospitals outside the capital do not have the necessary labor force or equipment. The establishment of curative practices in these hospitals would allow Guatemalans to find those services within an accessible distance from their homes, instead of traveling hours to the capital, which is difficult for those without easy access to transportation. Therefore, if a patient required specialized care, doctors who have done the best of their work within the curative realm of care would then refer their patients to the main hospitals in Guatemala City. The establishment of curative practices in municipalities is essential to creating a comprehensive primary health plan that addresses the needs of the population and simultaneously empowers health care personnel to make the proper referrals and provide indispensable services that, for now, are lacking. 

To encourage local doctors to stay in underserved areas, municipalities should empower themselves to pay off their debts and fees. High-skilled workers are harder to find outside of the capital: 80% of doctors work in Guatemala, Sacatepéquez, and Quetzaltenango, and the remaining 20% are scattered in departments farther away from the capital (Peña, 2013, p. 22). This is a result of private services hiring more qualified doctors, which leaves public health services with less capable doctors. If local doctors were incentivized to stay in their municipalities without the burden of having to pay off their debts from medical school, this would diminish the large number who go to the capital city to work due to higher salaries motivating them. While the salaries would still differ in amount due to available funding, doctors would have the ability to utilize their earnings without needing to worry about repaying their medical school fees.  Additionally, Abimbola et al. (2019) explain how local hiring leads “to improved retention and reduced absenteeism” (p. 612). With the assurance of doctors staying in certain municipalities, local health boards would not have to worry about continuous spending on hiring and finding new, capable personnel, and instead focus on supporting their doctors financially. Currently, universities such as Rafael Landívar and San Carlos require their medical students to practice community service in rural areas as a prerequisite for their graduation (Peña, 2013). The current students who serve these municipalities could become their doctors, if an acknowledgement were created with the municipalities to fund their stay and services. This in turn, would empower doctors to use their skills to serve their communities to the best of their ability.  

To pay off these medical school debts, municipalities could raise taxes, prompting citizens to pay for better services. Currently, various municipalities’ tax collection is already low: in 2016, just 1.6% of municipalities’ budgets were used towards health services (Fagan, 2017). Yet while this number is low, municipalities “are legally mandated to participate in health provision and may allocate both own-source and transfer revenue to health” (HEP+, as cited in Fagan, 2017, p. 17). Own-source taxes are those that the local government collects at its disposal. Fagan (2017) suggests the potential taxation of municipal services like electricity, which are currently not taxed. The revenue gathered here would go towards paying off doctors’ debts, as well as expanding public health services. People would pay higher taxes to achieve better health care and receive higher-quality services. Additionally, the government already has a limited fiscal spending – their Gross Domestic Product (GDP) spending on healthcare is just 2.6%, while the World Health Organization (WHO) recommends that countries spend at least 5% of their GDP on healthcare (Peña, 2013, p. 3). As a result, this three-part plan would lead to the production of more jobs, qualified workers, higher salaries, and economic growth, a continuous cycle to benefit municipalities and the country.

The current health system of Guatemala is fragmented under decentralization policies. This has led to insufficient funding of public health as well as limited services in rural, underserved areas. Moreover, the current focus on preventive care does not acknowledge the need for curative care, which is necessary not just in the capital city. Private care is also impacted: NGOs run on differing schedules and quality of care, as well as their workers face burnout due to infighting. As a result, it is necessary to reform the public health care system to create better health care for all, not just for those who are able to afford it. An expansion of health posts alongside a branch department of hospitals would allow citizens to easily access both preventive and curative services within their municipalities, without needing to travel to the capital city, which is many hours away. Additionally, the empowerment of local doctors to stay in underserved areas through municipalities paying off their debts through the raising of local taxes would diminish the lack of doctors found in these municipalities and would also lead to economic growth and quality care. Here, social empowerment in local municipalities is a necessary factor. It fosters a sense of community and enables people to advocate for their interests as they recognize the power they have to make positive changes and handle previous challenges. Guatemala has the opportunity to create a far-reaching change for its people; whether or not it institutes it determines their perspective on the necessity of healthcare for all, as promised in its Constitution. 

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