Overview
According to the 2014 mortality data, the three leading causes of death in all age groups are: pneumonia, acute infarction and diabetes. Diabetes begins to appear within the first 10 causes of death from 30 years of age, and it becomes the leading cause of death after the age of 45.
The Health System Guatemala is organized into various entities including the Ministry of Public Health and Social Assistance (MSPAS), the Guatemalan Social Security Institute (IGSS), Military health, the Universities and Training institutions of human resources, private entities (clinics, private clinics, etc.), NGOs, community organizations and professional associations.
The MSPAS is the primary public health care provider since it takes care of the 27% of the population. Its services are divided into three levels of care.
Care level I is the first contact for the population with the health services, through local and community actions covered by the basic health services. At this level are the Community Health Center and the Health Post, which offers preventive care services. The health posts are located in main towns and villages to cover from 2,000 to 10,000 people. Basic service can also be provided by NGOs and community organizations.
Care level II is where expanded health services are provided, aimed at solving problems of patients that need medical care in the first level. The services include things like X-rays, emergencies, general surgery, specialist appointments, etc.
Care level III has health services aimed at highly complex patients referred from previous levels of care or aimed at those patients who come spontaneously for emergency services. Typical institutions of this level are the Regional Hospitals, National Hospitals and National Referenced Specialized Hospitals.
The Guatemalan Social Security Institute (IGSS) provides medical program services related to sickness, maternity and accidents through mandatory insurance contributions by employers and employees. It provides medical care to members, pensioners, retirees and beneficiaries of state government. Service benefits are provided in clinics, hospitals and other medical units. It is estimated that the IGSS covers about 17% of the population. They are located mainly in urban areas.
The private sector can be divided into two categories. There is the profit sector, which consists of hospitals, nursing homes, clinics, pharmacies and laboratories. There is also the non-profit sector, formed by NGOs.
What happens if you need to see a doctor?
A patient in the urban area has a different experience than the patient in a rural area. When you need to see a doctor in urban areas, there are health centers, private clinics, nursing homes, NGOs, and municipal clinics that provide health care services. Where you will go depends on variables such as: level of education, income, ethnicity, race and gender. Most of the population uses public health services. In Guatemala 52.8% of people are in poverty and extreme poverty, 39.8% of them are indigenous and 13% non-indigenous. Of this population, 35.3% live in rural areas an 11.2% in urban areas. Because of these determinants, people with the highest income are more likely to access health services of higher quality than those with lower income.
For patients in rural areas, the health access is difficult. In some areas (villages, hamlets, etc.) there are no health posts or health centers at all. If there are health posts they might have no healthcare staff, but only health promoters and midwives. Often the health post is under supplied, so you have to go to city center anyway to get medical care.
Patients in rural areas who need specialized care that can only be found in regional hospitals have to travel anywhere from 50 to 500 kilometers. Many patients have to start their journey one day before their appointment to be on time at the hospital. In big hospitals, people come in the very early hours of the morning to queue and wait to be seen. Because of the difficulties they have to face, people in rural areas often prefer to see traditional healers and spiritualists to try to solve their problems.
Who decides what medicine a doctor can prescribe
The Ministry of Public Health and Social Assistance (MPAS) has a comprehensive health care standard for the first and second level of care. The MPAS has a basic list of drugs that each health post and health center should provide. Within that list, for diabetic people, there are: NPH insulin, metformin, sulfonylureas. However, most public services do not have all drugs. In particular, there is a lack of insulin and basic supplies such as syringes, alcohol, cotton. In this situation the doctor examines the patient´s social environment, taking into account factors such as income, compliance with treatment, cost and access to the drug, to decide whether he should prescribe it to the patient. For example, the doctor usually prescribes only NPH insulin for economic cost. Lantus has a much higher cost.
In the private sector and in the third level of MPAS, standards of care are not always upheld, since many drugs are prescribed under pressure from pharmaceutical companies that constantly visit doctors. This obviously affects the patient’s treatment.
Practically, what is it like to live with diabetes in Guatemala?
Newly diagnosed patients are admitted for a week in some hospitals, and in some cases not due to overcrowding of beds in the hospital. Most patients with type 1 diabetes are pediatric patients and often they have complications, arriving with metabolic imbalance and emergencies several times a year. Many patients cannot afford treatment since most of the population, as mentioned above, lives in poverty or extreme poverty. Because of shortages of public assistance centers, patients have to pay for insulin, syringes, test strips and glucometers, to manage their diabetes.
There is a big lack of diabetes education, which includes food knowledge, foot care, physical activity, identification of hypoglycemia and insulin dose adjustment. Most patients do not reach their treatment goals, which means there is a high risk of complications and death.
What about getting admitted to hospital?
Getting admitted to hospital is similar to the process for going to the doctor as outlined above. Patients with diabetes (type 1 and type 2) represent 30-40% of patients treated in hospital emergency rooms and 25% of total hospitalized. 50% of them do not know they are diabetic. Only 10-20% of those who know about their disease are regularly monitoring it.
How does diabetes care vary throughout the country?
As mentioned above, there is a big gap in access to care between rural areas and urban areas. People who live in urban areas have more easy access to public care or specialist care in hospitals. People with diabetes who need insulin and live in rural areas do not have access without paying for it. A vial of insulin is very expensive for anyone who lives in extreme poverty. Sometimes they have to decide between insulin or food because they cannot afford both.
A big thank you to Luisa Fernanda Pérez Barcárcel, Eder Roderico Chen Xol, and Anna Maria Sanna for helping provide and translate this information.