Addressing the Health Care Needs of Honduras with International Non-Governmental Organizations: Nuisance or Necessity
By: Paul B. Jones
The Honduran government utilizes international non-governmental organizations (NGOs) as a means of addressing the primary health care needs of its rural citizens. Backed by committed medical professionals, generous donors and local partners; international NGOs and their brigades have provided medical attention and medicine to hundreds of thousands of men, women and children. Involvement of international non-governmental organizations in providing assistance and augmentation to domestic efforts in Honduras is not a new phenomenon, but rather a continuation of years of involvement by a variety international actors including; United States, United Nations, World Bank and World Vision, to name a few. In order to successfully address the health care crisis in Honduras and Latin America it is essential that national governments, ministries of health, international non-governmental organizations and domestic groups coordinate efforts, creating a sustainable system which meets the health care needs of all. Indeed, the future of health care in Honduras and more broadly throughout Latin America is bright. The existing health and educational infrastructure in Honduras has tremendous potential for growth and improvement, which could be realized if political actors harness the overwhelming desire for accessible health care into a political mandate, in a country with considerable need. Thus, I remain optimistic for the future, advances have been made by employing multi-disciplinary approaches in development, education and job creation which allows men and women to become productive citizens who are actively engaged and empowered to make decisions about their future and the future of Honduras.
Honduras has a long and complex history as a nation, gaining independence from Spain in 1821. The country is richly endowed with resources and agricultural potential despite its mountainous geography:
“Honduras should have been a modest, Central American success…. Instead it became a beggar nation, a sieve for international aid, a country for rent. It sits at the bottom of the Central American list in terms of literacy, health care, nutrition, per capita income, life expectancy, and unemployment.”
Today Honduras is the second poorest nation in the Western Hemisphere after Haiti, with 80% literacy for people 15 years and older, it has a GDP of 7 billion dollars (US$) and spends 5.9% to service its debt and 3.2% of the GDP on health. Honduras has a GDP per capita of 2665 (PPP US$) and life expectancy is 67.8 years. Poverty and inequality is wide spread with 20.7 % of the population living on $1(US$) a day and 44.0% living on $2 (US$) a day having a Gini index of 55.0 according to the Human Development Report (2005). To the credit of the of the Honduran people, there have been improvements in the last 10 years in terms of literacy rates, GDP and overall Human Development Index scores. Additionally, 40.3 % of the population is under 15 years of age which must be seen as a tremendous potential, especially for economic growth. Thus more needs to be done to educate and train young men and women to become productive members of Honduran society, which in turn will break the cycles of poverty and despair.
The history of foreign involvement in Honduras is long standing, beginning with professional military training from the United States in the 1940s and 1950s and involvement of foreign fruit and mining companies. As a nation it experienced relative stability compared to its neighbours despite numerous military dictatorships from 1963-1980. During the 1980s Honduras was heavily militarized by U.S. involvement in the region. Honduras was used as a staging ground for anti-Sandinista Contras who fought in neighbouring Nicaragua as well as for Salvadoran forces which engaged in a civil conflict with leftist groups in El Salvador (Kruckewitt 170-177). It garnered increasing aid in the 1980s from the Reagan administration as part of its policy supporting right wing groups which opposed socialist and leftist groups throughout Central America, and consolidated the power of the military within Honduran society (Kruckewitt 193). From into the 1990s Honduras began a process of demilitarization and increased influence of civilian politicians. Military elites retain important influence as the new economic elites within the country, while still many land owners and economic elites are foreign nationals. In the 1990s Honduras set about on a program of development in accordance with the Washington Consensus and support of international institutions like the United Nations and World Bank. One of the central problems of the Washington Consensus policy according to Stiglitz was the narrow focus on economics which hoped that “…somehow, other societal concerns [health care, education and social services] would be addressed in some other context” (23). Additionally, McMichael claims there was a downgrading of social development goals and an upgrading of participation in global markets” throughout Latin America (158). Some Community Drug Funds (CDFs) were initiated in the 1990s to meet the demands of citizens for affordable medicine near where they lived. Infrastructure was improved with numerous schools and roads being built, which helped increase literacy rates and improve transportation. These positive developments were set back considerably by the destruction caused by Hurricane Mitch in 1998 which caused an estimated 5.6 billion dollars in damage and killed 5,600 (CIA World Factbook: Honduras). The hurricane destroyed much of the newly built infrastructure and displaced thousands of families. Some good came from the disaster though, raising awareness about the plight of the Honduran people, which led to greater involvement of international non-governmental organizations and an influx of foreign aid to help Hondurans recover and rebuild. Since 1998, the Cuban government has sent 350 doctors to provide service to poor Hondurans in rural clinics, arguably “tilling the soil in the poor countryside so that it is ready when political opportunity presents itself as it has in Venezuela” according to O’Grady. According the Honduras: CIA World Factbook estimates; Honduras is home to 70% of the HIV/AIDS cases in Central America (some 63,000 cases as of 2003) which adds uncertainty to Honduras’s future.
While international efforts to address the health care crisis in Honduras and Latin America are noble, they are often fragmented. Increased effort is needed to coordinate the work of the Ministry of Health with non-governmental organization to ensure that health care is equitably provided to the greatest number of Hondurans. Currently there are seven national hospitals, six regional hospitals, 254 clinics staffed by doctors and 848 health post staffed by nurses throughout Honduras. Greater coordination amongst the various actors will help ensure that improvements are made to the health care system and that it will be sustainable, able to adequately address domestic need. This in combination with regional initiatives coordinated by the Pan American Health Organization (a regional branch of the World Health Organization) to address basic health care needs in Honduras and other highly indebted poor countries (HIPC), which are considered a priority by the PAHO. They are considered priority countries because a significant portion of their GDP goes towards servicing their debt, leaving little to spend on health care and education (PAHO website). Despite these concerns, there are encouraging developments including the establishment of community drug funds and building of medical clinics through partnerships between Honduran organizations like Help in Action and international non-governmental organizations like World Vision and Friends of Honduran Children.
Greater effort is needed to ensure that there is not redundancy within the system so that overlap and budgetary waste is removed. Currently the Ministry of Health (MOH) provides “immunization, prenatal care, growth and development, family planning, and treatment of tuberculosis and of sexually transmitted diseases” free of charge (Fielder Suazo 364). At present the MOH has a user fees system which attempts to generate some additional revenue to defray the cost of health care delivery in Honduras. Research by Fiedler and Suazo noted that user fees “…equalled just 2% of MOH expenditures. The systems’ administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care” (Fielder and Suazo abstract). Furthermore, the Honduran government created a minimum wage for public-sector general practitioners of $1,500 per month and almost $2,500 per month for specialists in the 1990s, further increasing the budgetary burden for the MOH (O’Grady). This has lead to a fragmentation within the Honduran health care system and unequal service. Fielder and Suazo noted “locales with more resources are likely to spend more on health, resulting in more health care services for persons living in wealthier areas (363). In addition to inequality in service, Mills stated that decentralization of health care runs the risk on becoming dominated by local elites (qtd. in Fielder and Suazo 362). I saw evidence of this while on Medical Brigade in the department of Yoro (18 departments in Honduras similar to provinces). A Mayor tried to walk to the front of the line for medical attention but was quickly turned back by an interpreter who succinctly said, “We don’t do politics…end of the line”. More must be done to ensure there is equal access to care for all Hondurans.
Fragmentation has also hurt Community Drug Funds (CDFs) which were inspired by the Bamako Initiative (1987) in Africa which sought to reorganize and revitalize health care systems through greater community participation. CDFs were partnership created by NGOs to increase access to medications in rural or under serviced regions of Honduras. Initial stocks of drugs are given free of charge to the local community to create loyalty and then additional drugs are sold similar to a pharmacy. According to Fiedler and Wight by 1998, CDFs were operated by a relatively small number of NGOs (69% of the CDFs were run by Programs for the Development of Infants and Children (PRODIM), World Vision and Save the Children) (321). CDFs are also plagued by inefficiencies in the allocation of resources and funds to purchase drugs, each CDF purchase drugs from partnering NGOs or wholesalers. The current arrangement means that CDFs often do not have adequate supplies of drugs on hand to meet local needs and have problems with expiration of their stocks. Through greater coordination CDFs could take advantage of economies of scale improving their stock of medicines and realizing an annual savings of 217 888 lempiras ($15 000 US$) according to Fielder and Wight (334).Disparity in support for CDFs from NGOs has meant that they have had mixed results, though, “based on morbidity data, these institutions appear to be filling an important gap in the health care delivery system in Honduras” (Fiedler and Wight 335). Many NGOs which provide support for CDFs also operate traveling Medical Brigades, which provide primary health and dental care to remote villages. Peterborough Medical Brigades run by Friends of Honduran Children provides medical/dental services and drugs for gratis (meaning free). Thus community drug funds and brigades provide accessibility to medicines and medical attention to poor rural communities in remote areas.
In addition to direct medical care many international NGOs provide assistance to educational programs which seek to empower Hondurans to become productive members of society. Joseph Stiglitz said, “Knowledge about health and the environment can have an immense effect on the quality of everyday life, and affect the sustainability of the environment and even long-run living standards” (23). Thus, numerous projects are underway involving child sponsorship to ensure children have access to education and nutrition. There are orphanages run throughout the country to provide a safe and nurturing environment for orphaned children and a project called Nuevo Paraiso (New Paradise) for single mothers and their families. There are many programs like Flor Azul, a farm school run by Sociedad Amigos de los Niños which trains rural boys in agricultural techniques and is supported by Friends of Honduran Children. As well as numerous other examples of NGOs which are helping educate and train Honduran men and women so that they can be empowered to take charge of their lives and improve their situation. Many organizations are also active in starting micro-enterprises including growing specialty coffee, raising livestock, making bricks and wood furniture all of which are sustainable ways of generating income by providing goods to meet the demands of local communities.
The future looks bright for Honduras and Latin America, in recent years there has been modest growth in their economies especially in manufacturing sectors and maquiladoras. Maquiladoras provide jobs in the manufacturing of textiles which pay better and offer shorter hours than working as migrant labourers in sugar cane fields or banana plantations. According to the Asociación Hondureña de Maquiladoras between 1989 and 1998 the sector grew from 8000 to 100 000 workers and has become a cornerstone of the Honduran economy (qtd. Ver Beek 1555). In 2004 a Central American Free Trade Agreement (CAFTA) was signed between Honduras, Guatemala, Nicaragua, El Salvador and the United States (Buckman 74). This has helped boost the gross domestic product of Honduras and provided cash to reinvigorate the economy. Interestingly enough, Maquiladoras pay a mean income of $141 a month which surpasses the legislated minimum wage of $85 dollars a month and mean of $91 dollars a month by applicants to Maquiladoras, which counters claims that they pay less than other comparable jobs (Ver Beek 1158). Ver Beek found that income was positively correlated to experience and that years of experience in the maquiladora positively correlated with voting as well as an increased sense of influence in politics (Ver Beek 1558-1559). Ver Beek did however find 47% of employees of maquiladoras and only 11% of applicants reported health problems affecting their ability to work in the last month (1560). This raises some serious questions about health and safety in maquiladoras which should be further investigated. I wonder to what extent there was a bias in results with employees over reporting incidence of health problems with the hope of receiving compensation or sick days, while applicants minimize their health concerns to increase the strength of their application. At any rate, further research must be done to clarify the health implications of working in Maquiladoras.
Honduras utilizes international non-governmental organizations as a means of addressing the health care needs of its citizens in rural areas. Thus it is able to balance its responsibilities to provide care for its citizens, with its fiscal responsibilities to creditors in the developed world. The Honduran government navigates along a precarious middle path, which is not wholly independent of international commitments or market forces, nor totally dependant upon external forces. International non-governmental organizations improve accessibility and service to remote and under serviced regions through the use of foreign trained doctors from Cuba and committed medical professionals from the United States, Canada and Italy. These NGOs provide medical brigades and support for community drug funds as well as other services to address the health and educational needs of Hondurans. Involvement of international NGOs is crucial to maintaining stability, augmenting the domestic efforts of the Ministry of Health in Honduras. Their involvement is not a new phenomenon in Honduras and I see no signs of international NGOs diminishing their levels of support in the near future, but rather continued engagement and partnerships is necessary for sustainable development of the Honduran health care system. Thus, the Honduran Ministry of Health is in a strong position to benefit from the involvement of international organizations, learning from their experience and expertise, while adapting it to meet domestic needs. HIV/ AIDS and other illness make the involvement of international non-governmental organizations essential to help combat their spread. Indeed, the future for Honduras and Latin America is bright, each posses vast natural resources and a young population base which can provide the foundation for growth and development if properly partnered with education and investment.
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