18 oct. 2018

Once upon a time there was health in Honduras!

In the middle of the last century several international declarations arose that defended the fundamental rights of the human being, among these basic and fundamental rights, health was indisputable, since this allows us to access more complex rights such as social and political. Health is a social benefit, it behaves as an index of the welfare and balance of the community and the individual. Society must aspire to continuously improve this level of health through energetic actions without distinctions between its individuals and the relationship with the environment; Therefore, this transformation should not be limited only to health or government institutions, since it excludes a large part of the social context. A health reform would require an absolute intromission that seeks to implement health protocols and doctrines according to our social needs, renovation of any obsolete or precarious physical-virtual structure and finally the establishment of new managerial models with funding that guarantees its optimal performance. [Rev Med Hond2004; 72: 110-113]  

In Honduras, a physical, financial and organizational deterioration of the entire national network of health has been observed since the last several decades. In addition, some sectors demand a rapid privatization of the health care service, without evaluating first all the possible edges and scenarios of a national chaotic reality. The rudimentary health network in Honduras does have some competent programs, among these and perhaps my favorite, the Expanded Immunization Program or EPI, which has enormous results, greater national scope and sustainability sponsored by governmental and non-governmental organizations. With a deficient infrastructure in hospitals and health centers, medical-health care that does not offer the quality and coverage required, the imperative need for equitable investment in structure-equipment and the almost null maintenance of these infrastructures since decades are some of the variants that characterize our health network.

The Honduran Ministry of Health has 1,635 public health facilities: 7 national hospitals, 6 regional hospitals, 16 area hospitals, 436 CESAMO (health center with general practitioner and dentist), 1,078 CESAR (rural health center, served by a doctor or a nurse), 74 maternal and child clinics, 3 peripheral emergency clinics (CLIPER) and 15 CEO (dental schools). The IHSS (Honduran Institute of Social Security) has 2 hospitals, 7 peripheral clinics, 1 dental center, 2 medicine and rehabilitation centers and 1 center for elderly care. This represents 10.1 doctors / 10,000 inhabitants, 9.5 hospital beds / 10,000 inhabitants, 0.4 hospital / 100,000 inhabitants, 2.1 units of computerized tomography / 1 million inhabitants and 0.7 radiotherapy units / 1 million inhabitants. Total health expenditure as a percentage of the Gross Domestic Product-GDP is only 8.5% and represents only 11.5% of the Honduran annual budget. The private sector has 1,131 health facilities. [taken from article]  
The Honduran government recently published a legislative decree with the purpose of intervening the national system of health, through the creation of an intervening board subject to submit a quarterly report and focused primarily on correcting the entire health network. 
Every day in the health care centers, a large part of the population is obliged to buy all the supplies and medicines that have been repeatedly depleted [ for example: acetaminophen, antihypertensives, oral hypoglycemic agents, anti-inflammatories, insulin, antibiotics, iodine, cotton, syringes, sheets, set for minor or major surgeries, etc. ], in addition to relying on interns and doctors who are doing their professional practice with goverment, both of them subjected to an enormous work and administrative load [ Where is the professional staff hired for doing this and who actually earn a salary? ] To face constant strikes by doctors, nurses, administrative-care personnel, suffer in the flesh the fruitless protocolization of procedures and standards in hospitals and healthcare centers [ at the emergency room infants killed by diarrhea because they did not get rehydrated inmediately by the student or intern without supervision by the doctor on duty, a complex case in under 5 years old child with complicated pneumonia not full recovered after brief stay at public hospital, too soon discharge and who died in her home 3 days after discharge due to complications, overcrowding in waiting rooms without triage, referrals to another hospital level without meeting the requirements or minimum considerations for transfer, etc. ] and to continue prostrate and hesitant, longing for a better Honduras. 

I applaud all those doctors, nurses and care personnel who with temper and conscience have assimilated this reality without decaying, surpassing themselves by serving with candor, efficiency and humanism to our Honduran population. Together, a better world is possible!

17 oct. 2018

Once upon a time there was a paradise called Honduras!

Once upon a time there was an impoverished and sunken Honduras faced with an undeniable atmosphere of violence and social insecurity, and the problems were worsened by a low standard of living. This reality is rejected by many and ignored by others; perhaps those who do recognize the problem lack incisive judgment, social objectivity and impartiality. There are also many who lack a social conscience; insipid citizens who are absorbed in a distorted image of social communication in a society increasingly corroded and degenerated.

As a recent World Bank report notes, Honduras is among the 3 most economically unequal countries in the world next to South Africa and Haiti. It is evident the lack of investment, unemployment / underemployment and the reduced economic activity. These variants does not match with the data provided by government authorities, which cynically shows exorbitant figures and a robust, growing and sustainable country.

At the national level, the unemployment rate is around 6.7% and an alarming underemployment rate of 44% of the working population, who, despite generating income, do not reach the minimum established by law. After a millionaire government investment ($181 million US dollars in social protection programs in the last 3 years), the national poverty rate increased by 1.5%. In only the first half of 2018, Honduras counted nearly 2,000 violent deaths. According to the FOSDEH, about 69% of the population lives in poverty and around 40% in extreme poverty [households with a single parent, child labor and sexual exploitation in the streets, organized crime and criminal gangs that operate with vast territories, enormous difficulties in obtaining drinking water, electric power, food, decent housing, health and basic education]. 

A report from the Immigration and Customs Enforcement Service of the United States of America, the National Institute of Migration of the United Mexican States, the Consular and Migratory Observatory of Honduras [Conmigho] and the Consular Network of Honduras accredited abroad, indicated a decrease of 30.8% of the Honduran migratory index in 2017 and they attributed these results to the wholistic approach of the Honduran government together with international diplomatic strategies. 
Contrary to these figures, two days ago a caravan of almost 2,000 Hondurans left for the United States of America from the north-western part of the country. This huge group of Hondurans seeking asylum includes children, the elderly and many people with physical disabilities. These Hondurans justify this exodus by referring to the lack of security and the poor quality of life for the majority of Hondurans. The caravan continues despite the recent declarations of the governments of Guatemala, Mexico and the United States of America who demand compliance with their immigration laws.

To be continued...

¡Érase una vez la salud en Honduras!

A mediados del siglo pasado surgieron varias declaraciones internacionales que defendían los derechos fundamentales del ser humano, entre estos derechos básicos y fundamentales, la salud fue indiscutible, ya que esta nos permite acceder a derechos mas complejos como el social y el político. La salud es un bien social, se comporta como un índice del bienestar y equilibrio de la comunidad y el individuo. La sociedad debe aspirar a mejorar continuamente este nivel de salud mediante acciones enérgicas sin distinciones entre sus individuos y la relación con el ambiente; por lo cual esta transformación no debe limitarse sólo a instituciones sanitarias o gubernamentales, ya que excluye gran parte del contexto social. Una reforma sanitaria requeriría una intromisión absoluta que busque implementar protocolos y doctrinas de salud acordes a nuestras necesidades sociales, renovación de toda estructura físico-virtual obsoleta o precaria y finalmente el establecimiento de  nuevos modelos gerenciales con financiamiento que garantice su desempeño óptimo.  [ Rev Med Hond 2004; 72:110-113 ]

En Honduras se observa desde hace varias décadas un deterioro físico, financiero y organizacional de toda la red sanitaria nacional, además que algunos sectores demandan por una rápida privatización del servicio asistencial de salud, sin que antes se evalúen todas las aristas y escenarios posibles de una realidad nacional caótica. La rudimentaria red de salud en Honduras si cuenta con algunos programas competentes, entre estos y quizás mi favorito el Programa Ampliado de Inmunizaciones o PAI, el cual ostenta enormes resultados, mayor alcance nacional y sostenibilidad auspiciada por organizaciones gubernamentales y no gubernamentales. Con una infraestructura deficiente en hospitales y centros de salud, una atención médico-sanitaria que no cumple la calidad y la cobertura requerida, la imperiosa necesidad de inversión equitativa en estructura-equipamiento y el casi nulo mantenimiento de dichas infraestructuras durante décadas son algunas de las variantes que caracterizan nuestra red de salud.

La Secretaría de Salud Hondureña cuenta con 1,635 establecimientos públicos de salud: 7 hospitales nacionales, 6 hospitales regionales, 16 hospitales de área, 436 CESAMO (centro de salud con médico general y odontólogo), 1,078 CESAR (centro de salud rural, atendidos por un médico o por una enfermera), 74 clínicas materno-infantil, 3 clínicas de emergencia periférica (CLIPER) y 15 CEO (centros escolares odontológicos). El IHSS (Instituto Hondureño de Seguridad Social) cuenta con 2 hospitales, 7 clínicas periféricas, 1 centro odontológico, 2 centros de medicina y rehabilitación y 1 centro de para atención del adulto mayor. Esto representa 10.1 médicos/ 10,000 habitantes, 9.5 camas hospitalarias/ 10,000 habitantes, 0.4 hospital/ 100,000 habitantes, 2.1 unidades de tomografía computarizada/ 1 millón de habitantes y 0.7 unidades de radioterapia/ 1 millón de habitantes. El gasto total en salud como porcentaje del Producto Interno Bruto-PIB es solamente un 8.5% y representa sólo el 11.5% del presupuesto anual hondureño. El sector privado cuenta con 1,131 establecimientos de salud. [tomado de artículo] 

El gobierno Hondureño publicó recientemente un decreto legislativo con el propósito de intervenir el sistema nacional de salud, mediante la creación de una junta interventora sujeta a presentar un informe trimestral y enfocado fundamentalmente en corregir toda la red sanitaria. 
Diariamente en los centros asistenciales se margina a gran parte de la población a comprar todos los insumos y medicamentos desabastecidos en reiteradas ocasiones -ejemplo: acetaminofén, antihipertensivos, hipoglucemiantes orales, antiinflamatorios, insulina, antibióticos, yodo, algodón, jeringas, sábanas, set de cirugía menor/mayor, etc.-, además de confiar en los internos y médicos en servicio social sometidos a una enorme carga laboral y administrativa -¿Dónde está el personal profesional contratado que devenga un salario?-, afrontar las huelgas constantes por médicos, enfermeras, personal administrativo-asistencial, sufrir en carne viva la protocolización infructuosa de los procedimientos y normas en hospitales y centros asistenciales -infantes muertos por diarrea no rehidratada a priori por un estudiante o interno carente de supervisión por el médico de turno, caso complejo en menor de 5 años con neumonía complicada aún no recuperada después de breve estancia hospitalaria, egreso hospitalario forzado y muerte domiciliaria a los 3 días del egreso por complicaciones, abarrotamiento en salas de espera sin triage, remisiones a otro nivel hospitalario sin que se cumplan los requerimientos ni consideraciones mínimos para dicha movilización, etc.- y a continuar postrados y vacilantes, anhelando un mejor Honduras. 

Aplaudo a todos esos médicos, enfermeras y personal asistencial quienes con temple y consciencia han asimilado esta realidad sin decaer, superándose a sí mismos al servir con candidez, eficiencia y humanismo a nuestra población hondureña. ¡Juntos, un mundo mejor es posible!