Visit of UN Special Rapporteur on the right to the highest attainable standard of health to Guatemala from 12–18 May 2010

Mr. Anand Grover, UN Special Rapporteur on the right to the highest attainable standard of health, visited Guatemala between 12–18 May 2010.

On 18 May, he conveyed to the Government his preliminary reflections on his visit. Later on 18 May, he held a press conference in Guatemala City. He opened the press conference with some preliminary remarks about his visit. These remarks are set out below.
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Good morning ladies and gentlemen.

I would like to warmly thank the Government for inviting me to Guatemala and for facilitating a rich and interesting programme of meetings in Guatemala City, Malacatancito, San Ildefonso Ixtahuacán and Huehuetenango. I also would like to acknowledge the traditional inhabitants of this land, the indigenous peoples of Guatemala: the Mayan, Xinca and Garifuna, and I pay my respects to them.

During my visit I met with the Vice-President, Ministers of Finance and Health, members of the Constitutional Court, the Ombudsman, the First Vice-President and elected representatives of the Congress, the Presidential Commission on Human Rights, public officials from the national and local levels, numerous health professionals, civil society organisations – and many other experts, too numerous to mention.

I take this opportunity to thank all for the open and candid exchanges, and those who have generously given me the benefit of their time and experience. We have worked in a spirit of dialogue and cooperation in order to best address the needs of the peoples of Guatemala.

Following this mission, I will be submitting a report to the United Nations Human Rights Council that will primarily consider three issues of concern to me in this mission. These include indigenous health, women’s health (including sexual and reproductive rights) and access to medicines. These issues will be considered in the context of Guatemala’s international and national legal obligations regarding the human right to the highest attainable standard of health, and will include recommendations to the Government and others.

The following preliminary remarks are – and should be reported as – work in progress. Also, these remarks only touch upon some of the issues that my report will consider.

1. Historical, political and economic context.

Guatemalan society is marked by deeply embedded inequalities, discrimination and racism, which are in large part the result of dispossession and social exclusion that can be traced back to the Spanish conquest and colonisation. Moreover, the legacy of Guatemala’s 36-year civil war continues to weigh heavily upon society.

Guatemala is a middle-income country, with a strong agricultural exports sector, and yet is ranked 122 of 182 countries in the human development index. The per capita gross national income of Guatemala is USD$4690, and yet the wealthiest 20 per cent of the population consumes 51 per cent of Guatemala’s gross domestic product (GDP). As such, around 51 per cent of the population lives on less than USD$2 per day.

Public, private and social security expenditures make up 6.5 per cent of the country’s GDP, putting it on par with other parts of Latin America.  However, Guatemala’s health indicators are amongst the lowest in the region. I have observed that the primary difference between Guatemala and other countries in the region is that public expenditure comprises a much larger proportion of this aggregate percentage in other countries, and their health sectors are better organised. This demonstrates that even the scarce resources available for health in Guatemala can be allocated more efficiently.

To their credit, some senior Government leaders attach a priority to human rights, including the right to health, and recognise the issues faced by the nation. However, neither the Government’s domestic nor international policies leave any room for complacency. There is a constitutional right to health guaranteed to the citizens of Guatemala, but it is not being fulfilled.

2. Health system and underlying determinants of health.

The right to health is an inclusive right extending not only to timely and appropriate health facilities, goods and services, but also to a wide range of underlying determinants of health, such as access to safe food and adequate nutrition, safe and potable water and adequate sanitation, adequate housing, and access to health-related education and information. Deficiencies in these areas in Guatemala have manifested themselves in otherwise preventable health conditions, such as chronic malnutrition, that affects 50 per cent of the population. Consequently, the health sector in Guatemala has shouldered an undue burden, of which the Government is aware. For example, I am informed that the Ministry of Health has started working with mayors to ensure the potable of the water supply.

During my visit to Guatemala, numerous stakeholders have expressed concerns that the various authorities are not doing enough in meeting their obligations related to the right to health, including the underlying determinants. Public investment in health has declined in the last two decades, and the little investment that is being made is largely at the tertiary level. Moreover, the trauma of the civil war has lead to a significant burden of mental illness and disability, which currently is not being addressed adequately by the Government. Only 1 per cent of the current health budget is allocated to mental health care and community mental health services do not exist. The country’s only mental health institution is significantly over capacity, and much of their resources are exhausted through detention of unsentenced prisoners and persons with mentally disabilities – both groups that ought to be more appropriately housed separately.

The health sector is under-resourced severely and overly concentrated in urban areas. Despite the availability of free health services from the Ministry of Health and the premium-based services from the Institute for Social Security, increasing privatisation of health services, along with a lack of public expenditure, results in a fragmented healthcare system in which primary and secondary level care is frequently unavailable in rural areas. It is these rural communities that most need access to comprehensive primary health services, as they often cannot access the well-developed tertiary-care facilities located in the large metropolitan areas, nor can they afford to pay the high prices of private healthcare.

As well as increased resource allocation to rural services, there needs to be concerted efforts made to comprehensively incorporate rural health training into the curricula of medical professionals. Many stakeholders confirmed that doctors and other health workers are not currently trained to address the particular problems faced in rural communities and, for that reason, amongst others, there is reluctance on the part of these professionals to work in more remote areas of the country. Those that receive such training must be supported adequately in meeting the challenges of serving such communities.

3. Indigenous peoples’ health.

The indigenous people of Guatemala have faced consistent racism, exclusion, discrimination and marginalisation, as well as a lack of respect for their cultural practises, in health service delivery. For example, I was told of indigenous women being chastised for having too many children. Moreover, there is no concerted effort to provide health services to indigenous peoples in their own languages. To its credit, the Government of Guatemala has recognised its shortcomings regarding indigenous peoples’ health and has taken some steps to address this gap, such as by establishing the Indigenous Peoples Unit in the Ministry of Health.

Nonetheless, there is an alarming shortage of health resources devoted to the indigenous peoples of Guatemala. For example, maternal mortality rates among indigenous women are three times greater than that of non-indigenous women. Child mortality rates between the two communities show a similar disparity. I feel that many of these maternal and infant deaths would have been preventable, but for the near absence of primary and secondary healthcare services in rural and indigenous communities. Moreover, other preventable conditions prevail within indigenous communities due to lack of food, and safe and potable water. For instance, the prevalence of chronic malnutrition is 70 per cent. Other underlying determinants of health, such as limited education opportunities and poverty, although they exist throughout the country, have a disproportionate impact in indigenous communities.

I am told that the cash transfer programme, Mi Familia Progresa, has been expanded to now cover 500,000 families in more than 140 municipalities identified as the most vulnerable, which largely consists of indigenous community members. I would like to commend the Government for establishing this initiative. This cash transfer programme, however, needs to be strengthened and improved through increased transparency and monitoring to ensure its sustainability and continuing effectiveness. In parallel, health infrastructure and outreach capabilities need to be developed so that members of these communities have immediate access to health services. Providing cash transfers to individuals in these communities becomes futile if quality and comprehensive services are not freely available, and out-of-pocket expenses such as transport and medications absorb these transfers.

In my view, it is crucial that more attention is devoted to the health situation of the indigenous people, including from a gender perspective.  The Government lacks a comprehensive, national indigenous health policy. Health services, catering for the distinctive cultural, linguistic and other needs of indigenous peoples, are urgently needed. Language services must available at the point of delivery.  If translators are unavailable at healthcare facilities, telephone and other inexpensive modern translation services can be utilised, as has been trialled successfully in other nations with diverse linguistic populations.  This would provide effective health services, but also represent a sign of respect for the indigenous community.  

Fortunately, the Government has recognised that more must be done in order to fulfil its obligations regarding the right to health of indigenous peoples. Because of fundamental discrimination that has historically occurred, the Government must implement both short-term measures to allow for better communication and representation, but also long-term strategies, such as education, food security and nutrition, land reform and outreach services, in order to ensure access to health services for indigenous peoples.

4. Women’s health, with a focus on sexual and reproductive health.  

The health indicators of women in Guatemala are deeply troubling. The percentage of women who have suffered some kind of violence in their lifetimes is nearly 45 per cent, and is particularly high in urban and indigenous populations. The incidence of violent crime directed against women is increasing annually, unlike maternal mortality; I feel that these numbers suggest the existence of deep-seated gender inequities and hatred that clearly affect the rights to health and life of women in Guatemala.

I commend the Government for taking affirmative steps to address the issue of violence against women, such as in the Hospital General San Juan de Dios, which now has a specialised sexual abuse unit.  There has also been a law introduced on the topic of sexual violence and trafficking of persons. However, much still needs to be done to train healthcare workers more generally concerning violence against women, particularly in the case of domestic violence, in order to better identify and work with these victims.  Such training and services must be available across the country and targeted specifically at vulnerable communities.

Violence against women does not just include physical violence, but also structural violence, resulting in preventable deaths during pregnancy. Guatemala has the highest maternal mortality rates in Central America, and amongst the five highest in Latin America. While I note that maternal deaths have declined in recent years, much more needs to be done to address the situation. Again, this problem disproportionately impacts indigenous communities.

It is necessary that the Government first increase investment in primary healthcare, which is the most direct way of reaching rural and indigenous women. There are very simple, cost-effective measures that have been trialled in other countries, including in sub-Saharan Africa. For instance, a voucher system for transport to health services, which could be considered in the short-term to improve the health situation of all Guatemalan women. Additionally, the Government should make use of existing traditional healthcare institutions, such as midwives, and new approaches such as Casa Materna, which is a facility established to provide accommodation for residents of remote areas prior to delivery. Such institutions, however, must also respect indigenous traditions, such as in southern Mexico where family members are allowed to stay with or frequently visit the in-patient.

In addition to obstetric services, it would be desirable for a law to be enacted ensuring universal access to contraceptives for women, as well as family planning services. I commend the Government’s initiative in passing the Universal and Equitable Access to Family Planning Services Law.I am informed that Government is undertaking to steps to provide for free universal family planning services through other agencies as well. Family planning and sexual education services need to be designed, which are acceptable to communities. For instance, the promotion of pregnancy spacing is generally considered one of the more culturally acceptable measures of family planning in Guatemala.

Additionally, abortion is currently illegal in Guatemala, except in very limited medical circumstances. I am deeply concerned that abortion is even illegal in the case of rape or sexual violence, unless there is a coexisting medical necessity to perform the abortion. This law makes it all the more necessary to provide universal access to family planning, contraception and sexual education.

A crucial element in both women’s health rights and the health rights of indigenous peoples is the treatment of midwives. Midwives play a central health role in the culture of many of the indigenous peoples of Guatemala. As such, I feel that they are in an excellent position to facilitate interaction between indigenous communities and mainstream health services. There is scientific evidence from other developing countries that midwives are an essential component in comprehensive plans to address maternal health. Unfortunately, midwives have reported that healthcare facilities treat them very poorly, asking them to work on tasks that do not take advantage of their many skills.  My feeling is that there is a tremendous opportunity for the Government to promote information exchange and training between midwives and mainstream services, which will enhance service delivery to indigenous communities and result in dissemination of health education to these communities.

5. Access to medicines.

The Government has made numerous efforts to ensure a continuous and adequate supply of medicines at low cost to the Guatemalan people through its national procurement procedure and the provision of free medications at government hospitals.

In meetings with government officials and civil society groups, I have come to know more about the Government’s current drug procurement policy, which consists of an open-bidding system and a direct purchase system. The procurement prices in the open-bidding system are subject to legal challenge and various actors have informed me that these challenges have been used to delay procurement, thereby limiting supply of essential medicines.  As a result, the Government has begun to use a direct purchase system through which there is little competition, resulting in the procurement of drugs at much higher prices than would otherwise be the case. Furthermore, it allows Government officials far too much discretion in determining which companies to contract with, leaving open the possibility of abuse. I hope that the Government will make use of regional purchasing programs, such as those established by PAHO and the WHO, to secure low-cost medicines for the population.

Moreover, the Government’s ascension to the Central American Free Trade Agreement has required it to put in place intellectual property polices that curtail access to medicines. Increased intellectual property protections, such as data exclusivity, that prevent generic drugs from reaching the public market as quickly as possible, allow branded drug companies to retain monopolies on drugs. This results in much higher prices for medicines.  In a country where 80 per cent of all medical expenditures are out-of-pocket and the majority of people live in poverty, I believe this is a disastrous outcome. I feel that the Guatemalan Government should make use of all necessary TRIPS flexibilities in order to expedite access to generic drugs.  

6. Conclusion.

As I have already observed, these remarks are preliminary. And they are certainly not comprehensive. The recommendations made in this statement are also preliminary.

I have the impression that, while some progress is being made in realising the right to health for all in Guatemala, there remains a long way to go. The grave structural problems require greater political commitment and will. A comprehensive national health plan is required as a matter of urgency to fulfil the international obligations of the Government. Given the indicators are so dire, this situation also requires long-term structural changes to be implemented in a targeted and coherent manner, concerning food security, education, social security, employment, and land reform – all of which are relevant to health.

Given that some progress has already been made, all of these changes are feasible.

Anand Grover
UN Special Rapporteur on the right to the highest attainable standard of health
18 May 2010