Background and Setting
According to Tuna et al. (2015), the good functioning of health systems improves the health of the population, provides social protection, responds to the legitimate health expectations of citizens and contributes to economic growth in a country. For many years however, the health system in Honduras has been facing difficulties because of its limited capacity to help reduce the gap in the unacceptable health exclusion situation. In the National Health Plan (2014-2018), it is stated that weak governance, poor system management capacities, and a rigid human resource administration has made it difficult to streamline management to increase access of health services to the general population; all this is summed up by the current crisis in the health sector. According to the Pan American Health Organization (2012), the Honduran health system is also characterized by fragmentation and problems of coordination and articulation between institutions and service units. One of the results of this is the duplication of activities, efforts and resources. The World Health Organization (WHO, 2009) classifies Honduras in position 131 out of 191 countries in its performance of national health systems.
The health sector in Honduras consists of two subsectors: a public subsector, which is the Ministry of Health and the Honduran Institute of Social Security (IHSS), and a private subsector made up of for-profit and non-profit institutions. The Ministry of Health provides services to 60% of the population, IHSS for 12%, and the private sector for 10%. According to the Institute of Access to Public Information (2015), in Honduras almost 9 out of 10 people are not covered by any kind of health insurance, and it is estimated that 18% of the population (more than 1.5 million Hondurans) do not have access to health services.
The hospital infrastructure and health centers are deficient, and the services are not of the required quality and coverage. Some public centers date from the beginning of the last century and would require heavy investment in infrastructure and equipment if they were to provide the services in optimal conditions which were free of risk. Maintenance has been scarce and has led to the constant deterioration of both infrastructure and equipment.
World Health Statistics run by the World Health Organization indicate that in Honduras, the total health expenditure as a percentage of GDP is 8.5%, which is lower than the average for the Americas (14.1%). In addition to this, the Secretary of Finance in Honduras has calculated that the health sector accounts for 11.5% of total expenditure of the national budget. This has declined by 3.7% in the last 5 years. In the National Health Plan (2014-2018) it was found that for 2017, the main sources of health financing in Honduras were the government (54.7%), households, as out of pocket expenses (34.4%), and external cooperation (8.2%).
In Honduras there is a very outdated human resources policy at governmental level, and there is no planning in the field, or coordination between the different institutions involved. The Ministry of Health had 23,954 employees in 2013 of which only 13% were medical professionals (PAHO, 2012). This has been gradually reduced since 2008 when medical professionals represented 22.9% of the staff (UNAH, 2009). Of the employed staff 68.34% are women and 31.66% are men, which represents a trend towards feminization of the health workforce. The country has a high deficit of coverage of professional physicians, even though 46% of physicians are unemployed (PAHO, 2016). This workforce of unemployed physicians could reduce the deficit in coverage. The brain drain in Honduras, with the emigration of health professionals, has resulted in an annual cost of between $4,089 and $3,592 million (Secretary of Finance in Honduras, 2015). It is expected that this will continue to increase in the health sector, especially among professional doctors and nurses. There was a significant adjustment and wage control in 2014 due to the agreements signed with the International Monetary Fund (IMF) and the World Bank (WB) to reduce the wage bill. The decrease in the payment of salaries in the health sector was the result of the beginning of the process of revision and purification of the payrolls. In the last 15 years the salaries paid by the Central Administration have decreased by 6%; in the period of 2013 and 2014 they reduced by 2.3%.
During the last 25 years the health sector has gone through several restructuring and modernization processes. These were linked to the National Poverty Reduction Strategy, from 1998 onwards, after the devastation caused by Hurricane Mitch. Recent structural reforms in the health sector place private providers, for-profit companies, and the family/individual care at the center, and aim for the role of the state becoming more subsidiary, with the state being there to serve the most vulnerable sectors. These reforms are aimed at providing a more universal healthcare model and providing increased coverage of healthcare. They also involve the separation of roles between buyer and supplier. This separation has generated controversy between sectors, and members and professionals of the health services who associate it with the privatization of the health systems (Carmenate-Milián et al., 2017).