December 2015

This document/publication was produced for review by the United States 

Agency for International Development. It was prepared by Cindi Cisek, 

Chloé Revuz, and Christina Kramer for the Strengthening Health 

Outcomes through the Private Sector (SHOPS) project.

GUATEMALA HEALTH SYSTEM 

ASSESSMENT 2015:

PRIVATE SECTOR ASSESSMENT OF

FAMILY PLANNING, ANTENATAL CARE, 

AND DELIVERY
Recommended Citation: 

Cisek, Cindi, Chloé Revuz, and Christina Kramer. December 2015. Guatemala Health System Assessment 2015: 

Private Sector Assessment of Family Planning, Antenatal Care, and Delivery. Bethesda, MD: Strengthening Health 

Outcomes through the Private Sector Project, Abt Associates Inc.

Download copies of SHOPS publications at: www.shopsproject.org

Cooperative Agreement: GPO-A-00-09-00007-00

Submitted to: Marguerite Farrell, AOR

Bureau of Global Health

Global Health/Population and Reproductive Health/Service Delivery Improvement

United States Agency for International Development 

Yma Alfaro

Health Project Management Specialist

United States Agency for International Development, Guatemala

Abt Associates Inc. 

4550 Montgomery Avenue, Suite 800 North

Bethesda, MD 20814 

Tel: 301.347.5000 Fax: 301.913.9061

www.abtassociates.com

In collaboration with:

Banyan Global • Jhpiego • Marie Stopes International 

Monitor Group • O’Hanlon Health Consulting 
GUATEMALA HEALTH SYSTEM 

ASSESSMENT 2015:

PRIVATE SECTOR ASSESSMENT 

OF FAMILY PLANNING, 

ANTENATAL CARE, AND 

DELIVERY

DISCLAIMER

The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for 

International Development or the United States government.
TABLE OF CONTENTS

Acronyms ..........................................................................................................................vii

Acknowledgments .............................................................................................................ix

Executive Summary..........................................................................................................11

1 Introduction................................................................................................................17

1.1 Antecedents ............................................................................................................17

1.2 Scope of Work.........................................................................................................17

1.3 Key Concepts - Definitions ......................................................................................18

2 Methodology...............................................................................................................20

2.1 Approach ...............................................................................................................20

2.2 Sources of Information ............................................................................................21

2.2.1 Literature Review and Background .................................................................21

2.2.2 Market Segmentation Analysis........................................................................21

2.2.3 Field Work ......................................................................................................21

2.3 Timeline ...............................................................................................................22

2.4 Limitations ...............................................................................................................22

3 Current Health Context in Guatemala.......................................................................24

3.1 Background .............................................................................................................24

3.2 Health Seeking Behaviors .......................................................................................25

3.2.1 Overview ......................................................................................................25

3.2.2 Family Planning ..............................................................................................27

3.2.3 Current Use of Contraception .........................................................................29

3.3 Maternal Health .......................................................................................................31

3.3.1 Antenatal Care................................................................................................32

3.3.2 Delivery ......................................................................................................33

3.4 Health Financing and Out-of-Pocket Expenditures ..................................................34

4 The Guatemalan Health Sector and the Role of the Private Sector........................37

4.1 Health Sector Overview...........................................................................................37

4.1.1 Ministry of Health and Social Welfare .............................................................39

4.1.2 Guatemalan Institute for Social Security .........................................................41

4.1.3 Private Sector.................................................................................................42

4.2 Market Segmentation ..............................................................................................43

4.2.1 Family Planning ..............................................................................................43

4.2.2 Antenatal Care................................................................................................48

4.2.3 Delivery ......................................................................................................49

4.2.4 Summary of Market Segmentation Findings ...................................................52

5 Findings......................................................................................................................55

ii
5.1 Overview ...............................................................................................................55

5.2 Enabling Environment .............................................................................................55

5.2.1 General Policy and Regulatory Review...........................................................55

5.2.2 National Health Council ..................................................................................57

5.2.3 National Commission for Contraceptive Security ............................................57

5.2.4 Other Key Advocacy Organizations ................................................................58

5.3 Public Sector Organizations ....................................................................................58

5.3.1 MSPAS ......................................................................................................58

5.3.2 Guatemalan Institute for Social Security .........................................................62

5.4 Nongovernmental Organizations .............................................................................63

5.4.1 APROFAM......................................................................................................63

5.4.2 PASMO/Red Segura.......................................................................................66

5.4.3 WINGS ......................................................................................................67

5.5 For-Profit Private Sector..........................................................................................68

5.5.1 For-ProfIt Private Providers.............................................................................68

5.5.2 Social Health Enterprises................................................................................69

5.5.3 Health Insurance and Microinsurance.............................................................70

5.5.4 Corporate Social Responsibility ......................................................................71

5.5.5 Worker Health and Well-Being........................................................................73

6 Recommendations.....................................................................................................74

6.1 Health System stewardship .....................................................................................74

6.2 Service Delivery ......................................................................................................74

6.3 Demand Side...........................................................................................................76

6.4 Supply Side .............................................................................................................76

6.5 Human Resources for Health ..................................................................................77

Annex A: Stakeholders Interviewed for PSA...................................................................78

Bibliography......................................................................................................................81

iii
LIST OF TABLES

Table 1: Guatemala Global Health Indicators.................................................................................................... 25

Table 2: Guatemalan Population's Accessibility to MSPAS Service Delivery Points............................ 25

Table 3: Guatemala Family Planning Indicators, 2008.................................................................................... 27

Table 4: Primary Source of Family Planning for WRA Knowing Where to Source a Family Planning

Method (%)........................................................................................................................................................... 31

Table 5: Guatemala Maternal Health Indicators............................................................................................... 31

Table 6: Number of ANC Visits ............................................................................................................................... 33

Table 7: Personnel Attending Deliveries, 2013 (%).......................................................................................... 33

Table 8: Health Financing by the Numbers........................................................................................................ 35

Table 9: Overview of Health Sector Stakeholders............................................................................................ 37

Table 10: MSPAS Health Infrastructure by Facility Type................................................................................ 40

Table 11: IGSS Programs 2015 Operations Plan............................................................................................... 42

Table 12: Number of Private Health Facilities by Type, January 2015 ..................................................... 43

Table 13: Source Providing Each Type of Family Planning Methods - Countrywide.......................... 45

Table 14: Sources of Injectables According to User Profile (N=1,905).................................................... 47

Table 15: Sources of Sterilization According to User Profile (N=2,433).................................................. 47

Table 16: Place of Delivery and Place Where ANC Was Received (%)..................................................... 49

Table 17: Place of Delivery According to User Profile (N=2,433) .............................................................. 50

Table 18: Legislation Related to Sexual and Reproductive Health in Guatemala 2001-2012......... 56

Table 19: APROFAM's Leading Social Programs .............................................................................................. 65

iv
LIST OF FIGURES

Figure 1: Steps in a Private Health Sector Assessment.................................................................................. 20

Figure 2: Mortality Rate in Central American Countries (Children Under 5) - 2013 ........................... 24

Figure 3: Health Seeking Behavior at Time of Illness- Western Highlands - 2011.............................. 26

Figure 4: Place of Treatment - Western Highlands - 2011........................................................................... 26

Figure 5: Total Fertility Rate in Guatemala, 1987-2008.................................................................................. 27

Figure 6: Family Planning Method Use by Type in Guatemala (%)........................................................... 28

Figure 7: Evolution of Modern CPR in Guatemala (%) WRA in Union...................................................... 28

Figure 8: Evolution of Modern Contraceptive Method Mix for WRA in Union (%)............................. 29

Figure 9: Type of Modern Method Used among WRA in Union, Countrywide vs. Western Highlan

ds (%)........................................................................................................................................................................ 29

Figure 10: Maternal Mortality Rates in Latin America and the Caribbean, 1990-2013...................... 32

Figure 11: Health Expenditure Per Capita (Constant 2005 International $)........................................... 35

Figure 12: Human Resources for Health Indicators in Selected Latin American Countries ............. 38

Figure 13: Changing Market Share for Family Planning Products - All Methods................................ 44

Figure 14: Source of Family Planning Methods by Region (All WRA) (%).............................................. 44

Figure 15: Socio-Economic Characteristics of Modern Method Users (All WRA) (%)........................ 45

Figure 16: Source of Modern Contraceptives by Wealth Quintiles (%)................................................... 46

Figure 17: Place Where ANC Is Received (%) .................................................................................................... 48

Figure 18: Source of ANC by Wealth Quintile (%)........................................................................................... 49

Figure 19: Place of Delivery According to Wealth Quintiles - Countrywide.......................................... 51

Figure 20: Place of Delivery According to Wealth Quintiles - Western Highlands ............................. 51

Figure 21: Place of Delivery According to Wealth Quintiles - Guatemala City..................................... 52

v

ACRONYMS

ANC Antenatal care

APROFAM Asociación Pro Familia, IPPF Affiliate of Guatemala 

BEOC Basic Essential Obstetric Care 

CABEI Central American Bank for Economic Integration

CAIMI Centros de Atención Integral Materno Infantiles, Centers for Integrated 

Maternal-Infant Care 

CAP Centro de Atención Permanente, Permanent Care Center

CAT Comadrona Adiestrada Tradicional, trained traditional birth attendant

CentraRSE Centro para la Acción de la Responsabilidad Social Empresarial en 

Guatemala, Center for Corporate Social Responsibility

CEOC Comprehensive Essential Obstetric Care

CDCS USAID Country Development Cooperation Strategy

CNAA Comisión Nacional de Aseguramiento de Anticonceptivos, Contraceptive 

Security Committee

CPR Contraceptive Prevalence Rate

CSR Corporate Social Responsibility 

DRACES Departamento de Regulación, Acreditación y Control de Establecimientos 

de Salud, General Directorate for Health Regulation, Vigilance, and 

Control

ENCOVI Encuesta Nacional de Condiciones de Vida, National Survey on Living 

Conditions

ENSMI Encuesta Nacional de Salud Materno Infantil, National Survey on 

Maternal and Child Health

EPSS Empresa de Promoción de Servicios de Salud, Enterprise for Promotion 

of Health Services

GDP Gross domestic product 

IDB Inter-American Development Bank

IGSS Instituto Guatemalteco de Seguridad Social, Social Security Institute of 

Guatemala

IPPF International Planned Parenthood Federation 

MSPAS Ministerio de Salud Pública y Asistencia Social, Ministry of Health and 

Social Welfare 

NGO Nongovernmental organization

OSAR Observatorio de la Salud Reproductiva, Reproductive Health Observatory

PASMO Pan American Social Marketing Organization, created by PSI

PEC Programa de Extensión de Cobertura, Program for Extended Coverage, 

MSPAS policy (1996-2014)

PPP Public-private partnership

vii
PSA Private Sector Assessment 

PSI Population Services International

REDMISAR Red de Mujeres Indígenas por la Salud Reproductiva, Network of 

Indigenous Women for Reproductive Health

RH/FP Reproductive Health/Family Planning

SBA Skilled birth attendant

SHOPS Strengthening Health Outcomes through the Private Sector Project 

(USAID-funded; 2009-2015)

TBA Traditional birth attendant, also called comadrona

TFR Total Fertility Rate

UNAIDS United Nations Program on HIV and AIDS

UNDP United Nations Development Program

UNESCO United Nations Educational, Scientific and Cultural Organization

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

USAID United States Agency for International Development 

WHIP Western Highlands Integrated Program

WHO World Health Organization

WRA Women of Reproductive Age

viii
ACKNOWLEDGMENTS

The authors thank Baudilio López, Yma Alfaro, and Romeo Menéndez from USAID/Guatemala 

for their generous support and clear guidance throughout this assessment. They also thank 

Martha Mérida and Eugenia Monterroso for their valuable participation in the planning and data 

gathering phases of this report, as well as being available for clarifications. Leslie Miles and 

Linda Moll also provided detailed, thoughtful input to finalize this report. And finally, the authors

thank colleagues on the SHOPS project who gave technical input at critical moments, especially 

SHOPS Deputy Director Caroline Quijada.

ix

EXECUTIVE SUMMARY

PURPOSE OF THE ASSESSMENT

The Strengthening Health Outcomes through the Private Sector (SHOPS) project conducted a 

private sector assessment (PSA) in Guatemala at the request of USAID/Guatemala in order to

identify the strengths and weaknesses of the private health sector and solicit recommendations 

from private sector stakeholders to strengthen health system efforts in the country. The findings 

and recommendations of the PSA will serve as a resource for public sector, private sector, and 

international stakeholders as they work to improve health outcomes in Guatemala. The PSA 

focused on the private sector’s current role in family planning and maternal health services and 

identified ways to mobilize untapped private sector resources to increase supply and demand of 

services. 

METHODOLOGY AND LIMITATIONS

Following the model that SHOPS has used in over 20 PSAs, the assessment team began by 

clarifying the scope of work with USAID and reading the literature that was pertinent to the 

assessment topics. Next, they conducted a market segmentation analysis, conducted in-depth 

interviews with key informants within the country, and submitted a draft report for feedback from 

USAID. After addressing USAID’s comments, SHOPS finalized the report. 

The scope for this assessment was limited to family planning, antenatal care, and safe 

deliveries. The PSA team limited its scope to assess source and use of the private sector, 

without addressing quality of services. Commodity supply was purposely excluded from the 

scope because it has been covered through other assessments. 

A challenge in data analysis stemmed from the data sources, which were dated and from 

different time periods and different regions. The team used the latest available data to conduct 

secondary analyses. These data existed in several national databases (Encuesta Nacional de 

Salud Materno Infantil (ENSMI) conducted in 2008-2009;

1 National Health Accounts, conducted 

in 2014; Encuesta Nacional de Condiciones de Vida (ENCOVI), conducted in 2012) as well as a 

database from USAID’s Western Highland Integrated Program (WHIP) baseline from 2013 used 

by the agency to measure the impact of its integrated programs. Additionally, the differences in 

sampling for ENSMI 2008-2009 (presenting data at the national level, with a possibility to 

disaggregate at the departmental level) and for the WHIP baseline database from 2013 

(focusing on USAID priority municipalities in the Western Highlands) make it impossible to 

directly compare the two surveys. The team did not conduct quintile analysis at the 

departmental level due to inadequate sample sizes and thus it was not possible to identify 

variations across departments in the country. 

And finally, the assessment occurred at a time when the Guatemalan government, including the 

Ministry of Health and Social Welfare (MSPAS), was experiencing a severe political crisis, which 

introduced a level of uncertainty among the informants. It also made some of them reluctant to 

go into much depth with the interviewers.

1 ENSMI 2008-2009 is synonymous with the Demographic and Health Survey. Although the resulting report was 

authored by MSPAS in 2010, throughout this report, “ENSMI 2008-2009” is used to refer to the study.

11

 
KEY FINDINGS

Guatemala has a strong regulatory framework that guarantees access to maternal health, 

reproductive health, and family planning services, providing a legal basis to guarantee and 

defend the right to these services. Nonetheless, there is still strong ideological opposition from 

both religious and political entities that challenge the family planning program. For more than a 

decade, advocacy organizations have been working to increase awareness of the importance of 

contraceptive security, to advocate for a multisector approach, and to address key policy and 

programmatic gaps. In 2009, the National Commission for Contraceptive Security (CNAA) was 

officially created to be led by the MSPAS’ National Reproductive Health Coordinator. Despite 

important legal and regulatory advances, stakeholders report that there are still budget shortfalls 

for contraceptives and limited competitive procurement options 

to ensure efficient use of resources. In addition, a high 

percentage of funds that are dedicated to reproductive 

health/family planning services are not effectively executed; 

budget allocations are received late; funds are poorly spent or 

not spent at all. Many of these issues still require constant 

advocacy to ensure that they are appropriately addressed with 

each annual budget law. In late 2013, CNAA published its 

Market Segmentation Strategy for contraceptives, which 

recognizes the importance of a sustainable, total market 

approach. The strategy outlines different scenarios for reducing 

unmet need and shifting method mix, but does not define 

specific actions to achieve the scenarios. In March 2015, the 

CNAA was planning to hold a workshop to discuss how to take 

the market segmentation strategy to the next level. 

MSPAS is currently facing a severe financial crisis that is not likely to be resolved in the short

term. As seen in the secondary analysis, MSPAS’ share of the provision of family planning, 

antenatal, and maternal health services has increased over time, in some cases significantly, 

contributing to an increasing financial deficit for MSPAS and underlining the need for a more 

balanced, sustainable total market. As reported by stakeholders, there are widespread stock 

outs of essential medicines including vaccines. In the Western Highlands, second-level facilities 

that serve as maternity centers report stock outs of anesthesia and other supplies that inhibit 

their ability to provide caesarian deliveries so all non-vaginal deliveries are being referred to 

second- and third-tier hospitals, overburdening these facilities as well. Stakeholders report that 

budgets for contraceptive supplies fall short of the demand for services. There are stock outs of 

family planning commodities at all levels. 

The Guatemalan Social Security Institute (IGSS) is the second largest health service delivery 

institution in the country. There is evidence that a large percentage of IGSS beneficiaries and 

their dependents are seeking family planning services at non-IGSS facilities. Many of these 

users are going to MSPAS, creating additional burden for that financially struggling institution. 

IGSS’ family planning program is institutionalized under Resolution No. 1165; stakeholder 

interviews suggest that there is not widespread knowledge of IGSS policy to provide family 

planning services, and contraceptives are not widely available. In addition, Resolution 1165 

includes some key policy barriers to family planning access, including stating that beneficiaries 

and affiliates are only eligible for family planning services up to 26 weeks postpartum, requiring 

a written request for sterilization services by the beneficiary, and requiring that women have at 

least two living children. Despite these shortcomings, almost all stakeholders recognize that 

IGSS has a critical role to play and must be a key player in ensuring a more balanced, 

sustainable market.

Guatemala has a strong legal 

framework that facilitates access 

to sexual and reproductive health 

services and family planning. 

MSPAS, IGSS, and APROFAM 

are the largest service providers.

The private sector represents a 

large and growing segment of the 

health system. Many 

Guatemalans, regardless of their 

income levels, seek health 

services in the private sector even 

though this requires out-of-pocket 

spending.

12
Guatemala has several NGOs that have and can play important roles in service delivery, 

including the International Planned Parenthood Federation affiliate, APROFAM, which is the 

second largest provider of family planning methods after MSPAS. APROFAM’s mobile units are 

the only ones in the country that are equipped to provide laparoscopic voluntary surgical 

contraception. These social programs will continue to require significant subsidy given the costs 

associated with reaching remote areas. APROFAM also has an underutilized capacity for 

delivery services, which could be used to ease the volume of clients at MSPAS. 

Guatemala’s private sector represents a large and growing segment of the health care market, 

including high-end tertiary hospitals, small specialty and general clinics and hospitals, individual 

practices, pharmacies, and traditional providers. Regardless of income level, many 

Guatemalans seek care in the private sector, and although the use of private sector providers 

involves out-of-pocket payments, many households use the private sector as their first point of 

care. For example, Guatemala’s second largest city, Quetzaltenango, has a very strong network 

of private hospitals and lower-level facilities, both for general medicine as well as a wide variety 

of specialties. After Guatemala City, Quetzaltenango has second largest conglomeration of 

private facilities, and the private health care market in Quetzaltenango municipality is becoming 

saturated. There is an opportunity to explore what types of incentives would encourage new 

private sector providers to expand in other medium-size cities in the Western Highlands. Private 

health insurance represents a small segment of the Guatemala health care market, with less 

than 5 percent of the Guatemalan population covered by a private health insurance scheme 

(MSPAS 2010). Interviews with representatives from the insurance industry suggest that the 

segment is growing and that over 90 percent of the population covered resides in Guatemala 

City. Nonetheless, there are interesting trends in health insurance targeted toward lower-middle 

and middle-income groups. 

RECOMMENDATIONS

Health System Stewardship

Stewardship that engages multiple private 

sector players

Guatemala’s MSPAS is charged with stewardship or 

governance (rectoría) of the overall health sector. 

However, in practice, coordination and 

communication among sectors is limited, particularly 

concerning IGSS and the private sector. At the 

same, various commissions for multi-sectoral 

dialogue exist in Guatemala, yet there is little 

engagement of the for-profit private sector in these 

fora. The PSA team recommends that MSPAS continue to look for opportunities to engage new 

private sector players, including the for-profit sector. This would include participation of the forprofit sector, including the pharmaceutical industry as well as professional medical associations, 

such as the College of Physicians and Surgeons, Association of Obstetricians and 

Gynecologists, Association of Pediatricians, and others.

Advocacy to improve market inequities

Despite important legal and regulatory advances, Guatemalan advocacy organizations report 

that there are still budget shortfalls for contraceptives and limited competitive procurement 

options to ensure efficient use of resources. In late 2013, CNAA published its Market 

Segmentation Strategy for contraceptives, which recognizes the importance of a sustainable, 

total market approach. The strategy outlines different scenarios for reducing unmet need and 

The Guatemalan health system can be 

strengthened by:

• Increasing cross-sectoral coordination, 

including the private for-profit sector

• Advocating to improve market inequalities

• Expanding options of services 

• Expanding health insurance and micro 

insurance to cover the middle-income segment

• Promoting synergies between the commercial 

sector and private for-profit companies

• Creating a professional midwife cadre to assist 

births outside medical facilities

13
shifting method mix, but it does not define specific actions to achieve the scenarios. The market 

segmentation analysis conducted by PSA team suggests that there are still important inequities 

in the delivery of FP, ANC, and delivery services, and the potential to move upper health 

quintiles toward private sector channels. 

The team recommends that the CNAA strengthen the engagement of the for-profit private sector 

as part of a sustainable health market, as well as identify specific next steps for all sectors. 

CNAA should also consider the comparative advantages of NGOs and the for profit sector to 

expand access to ANC and delivery services.

Service Delivery

IGSS to increase its provision of FP, ANC, and delivery services

The Guatemalan Social Security Institute is the second largest health service delivery institution 

in the country. There is evidence that a large percentage of IGSS beneficiaries and their 

dependents are seeking family planning services at non-IGSS facilities. Many of these users are 

going to MSPAS, creating an additional burden for that institution. Stakeholder interviews 

suggest that there is not widespread knowledge of IGSS policy to provide family planning

services, and contraceptives are not widely available.

We recommend that IGSS’ stakeholders conduct a review of Articles 4 and 5 of Resolution 

#1165 to ensure that it is consistent with Guatemala’s law on universal access to FP services. 

IGSS plays a very small role in ANC services, even among the highest wealth quintiles. The 

PSA team recommends that IGSS strengthen provision of ANC services as well as delivery 

services outside of Guatemala City. Given its infrastructure and resources, IGSS is the 

organization that will have the most immediate and significant impact on strengthening RH/FP 

and MH services. 

The PSA team recommends continued high-level advocacy with IGSS to ensure that IGSS 

realizes its role as a strategic player in ensuring a more balanced, sustainable market for FP, 

ANC, and delivery services, sharing facilities and resources, and avoiding an unnecessary 

duplication of facilities and services.

APROFAM to identify its comparative advantages and commit to strengthen and 

subsidize high priority areas

APROFAM is in a critical time striving to maintain its leadership position as the 2nd largest 

provider of FP services in the country, while streamlining operations and increasing its overall 

sustainability. APROFAM’s mobile units represent an important comparative advantage for the 

organization since they are the only ones in the country that provide laparoscopic surgical 

sterilization. However, APROFAM should seek to strengthen coordination, promotion and 

dissemination of these medical outreach activities with other key stakeholders to ensure that 

they are optimizing number of people who can benefit from services. Additionally, APROFAM’s 

hospitals, particularly in the Western Highlands, report underutilized capacity for delivery 

services, which through appropriate targeting and demand-side financing (e.g., vouchers) could 

be used to improve MH indicators in that region.

The PSA team recommends that APROFAM determine what social programs are essential to its 

mission and then continue its full commitment to their success, using the STF to cross-subsidize 

high priority activities. 

Red Segura to consider targeted expansion of geographic coverage and MH services

Red Segura has proven to be a successful model for increasing IUD and implant use through 

private providers. Given the network’s success in rapidly expanding provision of long-acting 

14
methods in the private sector, there are opportunities to consider for targeted expansion to 

priority geographic areas and to incorporate additional MH services among participating 

providers, particularly among middle-income users that are largely using the public sector for 

ANC and delivery services. 

The team recommends that PASMO/Red Segura develop its sustainability strategy, identifying 

which elements of the provider network are essential to long-term access to key FP, ANC, and 

delivery services in the for-profit private sector. It should also identify opportunities for 

expanding geographic access and providing broader MH services. 

Enterprise for Promotion of Health Services (EPSS) as a sustainable and scalable private 

sector health care model

The EPSS represents an innovative, sustainable private sector health care model. EPSS 

management is open to exploring options for increasing access to reproductive health, family 

planning, and maternal health services among its network of private providers. EPSS’ proven 

business model and large network of enrolled members represents a very interesting 

opportunity for large-scale expansion of family planning and reproductive and maternal health 

services, such as including family planning services in the health insurance policies that are 

focused specifically on women, e.g., Banrural’s Vivo Segura. The PSA team recommends 

exploring opportunities to expand access to RH/FP and MH services, building on EPSS’ 

sustainable and scalable service delivery health model.

The PSA team recommends exploring opportunities to expand access to RH/FP and MH 

services, building on EPSS’ sustainable and scalable service delivery health model.

Demand Side

Targeted demand generation among underserved groups

The team recommends that the country engage in demand generation activities that recognize 

important differences within the population, for example, urban/rural, ethnic groups, age, and 

levels of wealth. Donors and other stakeholders could contribute to this effort by supporting 

behavior change communication activities on family planning and safe motherhood through its 

partners in the WHIP. The behavior change communication campaigns should include 

information on how to access private providers and NGOs, including locations and services 

available.

Supply Side

Health insurance and micro insurance to expand access among middle income

Private health insurance represents a small but growing segment of the Guatemalan health care 

market. The PSA team recommends exploring strategic partnerships with insurance agents to 

expand access to RH/FP and MH services for middle-income populations. The strongest 

potential for growth in insurance products is within middle income populations in large urban 

centers.

Corporate social responsibility and private partnerships to create strategic synergies

Guatemala’s for-profit commercial sector has a strong, sophisticated base of corporate 

engagement and social responsibility in health. Many of these organizations are already 

supporting RH/FP and MH services through their existing programs.

The PSA team recommends exploring strategic partnerships that focus less on financial 

leveraging and more on identifying added-value and comparative advantage among 

organizations.

15
Human Resources for Health

Cadre of skilled birth attendants to address non-facility based births

The majority of women countrywide and in the Western Highlands deliver either in their own 

home or in the home of a TBA, and many TBAs are illiterate and not qualified to manage 

emergency cases. The team recommends creating a professional midwife cadre either as a 

specialization within the nurse cadre or as a separate category. Similarly, the team recommends 

that Guatemala recognize SBAs in the formal sector and standardize their qualifications and 

scope of practice. And finally, the team recommends increasing the number of SBAs through 

training. 

16
1 INTRODUCTION

1.1 ANTECEDENTS

Guatemala suffers high levels of inequality and widespread 

poverty, with more than half of its 15 million inhabitants living 

below the national poverty line and 14 percent living on less 

than US$1.25/day (UNICEF, 2013a). Life expectancy is 

short, at 72 years for both sexes (WHO, 2014a), and 

maternal mortality is high at 113 per 100,000 live births in 

2013 (MSPAS, 2015), among the highest in Latin America 

and the Caribbean along with Bolivia, Guyana, Haiti and 

Honduras (UNICEF, 2013b). Overall, the country is ranked 

125 of 187 in the 2013 Human Development Index, only above Honduras, Nicaragua, and Haiti 

in the Latin America and Caribbean region.

2

Despite significant improvements in the last decade, the country is still facing major challenges 

in health. The conditions are acutely worse in regions with predominantly indigenous, rural, and 

poor populations. In collaboration with the Ministry of Health and Social Welfare (Ministerio de 

Salud Pública y Asistencia Social, MSPAS), USAID identified the Western Highlands as its 

focus region for its 2012-2016 Country Development Cooperation Strategy (CDCS). In this 

region, which faces particularly severe challenges in health, more than 60 percent of the 

population is indigenous, compared to 29 percent at the national level, and 49.6 percent of 

children under five suffer malnutrition (USAID, 2012). USAID’s CDCS concentrates its activities 

on 30 municipalities in five departments (Huehuetenango, Quetzaltenango, Quiché, San 

Marcos, and Totonicapán) through an integrated effort to reduce poverty and chronic 

malnutrition, improve health and nutrition, and increase health service utilization.

1.2 SCOPE OF WORK

USAID/Guatemala requested that the Strengthening Health Outcomes through the Private 

Sector (SHOPS) project conduct a private sector assessment (PSA) of the Guatemalan health 

sector to identify strengths and weaknesses and provide recommendations to strengthen the 

health system and inform the development of its next CDCS. The assessment was designed to 

determine the private sector’s role in family planning, antenatal care (ANC), delivery, and 

maternal and child health and to identify ways to mobilize untapped private sector resources. 

The PSA focused on private sector service delivery trends both at the national level and within 

USAID’s focus areas of the Western Highlands. Simultaneously, USAID asked the Health 

Finance and Governance project to conduct a Health Sector Assessment in the country. 

Together, the reports provide USAID and other stakeholders with an overview of the 

Guatemalan health sector and summarize challenges and opportunities for stakeholders to 

strengthen the health system.

The PSA was designed to determine the current role, coverage, and use of the private health 

sector in Guatemala for family planning and selected maternal health services (specifically, 

ANC, delivery, and newborn care), to address gaps in public services and provide opportunities 

2 Human Development Index, http://hdr.undp.org/en/countries/profiles/GTM

More than half of Guatemala’s 15 

million inhabitants live in extreme 

poverty. Despite recent 

improvements in health 

outcomes, many challenges 

remain, especially in the Western 

Highlands where many rural and 

impoverished indigenous people 

live.

17

 
to increase the private sector’s role. The assessment was designed to answer the following 

questions: 

 What is the general role of the private sector in delivering family planning and maternal 

health services, especially in the Western Highlands?

 Where is the population currently sourcing its family planning and maternal health services?

 How could the private sector be more engaged or play an increased role in the delivery of 

family planning and maternal health services? To what extent and under what 

circumstances would independent private providers be interested in providing family 

planning or maternal health services?

1.3 KEY CONCEPTS - DEFINITIONS

For the purposes of this assessment, the following definitions are applied consistently 

throughout the report:

BEOC/CEOC: Basic Essential Obstetric Care (BEOC) and Comprehensive Essential Obstetric 

Care (CEOC) are the globally recognized levels of care that must be available to meet obstetric 

needs and are vital in reducing maternal mortality and morbidity.

Comadrona: Comadrona is the Guatemalan traditional birth attendant (TBA). While the 

attendant is an important player in the Guatemalan health sector, attendant profiles and skill 

levels vary. A comadrona can be either non-specified, trained (Comadrona Adiestrada 

Tradicional), or empirical. See “skilled birth attendant” in this list for more discussion. 

Throughout the report, TBA will be used to refer to the comadrona.

Health care provider: SHOPS considered health cadres that were present in the latest 

Demographic and Health Survey (Encuesta Nacional de Salud Materno Infantil (ENSMI), 2008-

2009). The health cadres involved in family planning and maternal health services are doctors, 

ambulatory doctors, nurses, TBAs, health promoters, health guardians, and traditional healers. 

IGSS: The Guatemalan Social Security Institute (Instituto Guatemalteco de Seguridad Social, 

IGSS) is a hybrid institution funded through public and private (employers) channels to cover 

workers in the formal sector. As of the 2011 IGSS Annual Report, the most recent year for 

which data are available, IGSS covers 17 percent of the Guatemalan population. 

Key health stakeholder: A key health stakeholder is an individual or group which can affect or 

is affected by an organization, strategy, or policy in health. Annex A lists the key health 

stakeholders interviewed for this PSA.

Maternal health: For this assessment, SHOPS limited its definition of maternal health issues to 

ANC, delivery, and trends related to access and availability in the public and private sectors. 

Private health sector: The private health sector in Guatemala comprises for-profit commercial 

entities as well as nonprofit organizations, such as NGOs and corporate entities dedicated to 

health. The private sector is engaged in provision of health services, products, or information as 

well as advocacy and behavior change.

Public-private partnership (PPP): A PPP in health is any formal collaboration between the 

public sector (national and local governments, international donor agencies, bilateral 

government donors) and the nonpublic sector (commercial and nonprofit, traditional healers, 

midwives, or herbalists) in order to jointly regulate, finance, or implement the delivery of health 

services, products, equipment, research, communications, or education (Barnes, 2011).

18
Public sector: The public health sector in Guatemala comprises MSPAS and IGSS. MSPAS is 

the sector’s overall governing body and the largest provider of health services in Guatemala, 

with a network of local, regional, and national health facilities.

Skilled birth attendant (SBA): While discrepancies exist among countries regarding the profile 

of SBAs, the World Health Organization (WHO) advocates for deliveries to be assisted by 

accredited health providers who have been “educated and trained to proficiency in the skills 

needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal 

period, and in the identification, management and referral of complications in women and 

newborns” (WHO, 2004). Guatemala has not yet completed training or accreditation of

professional midwives, so most skilled birth attendance is provided by nurses and 

obstetrician/gynecologists (OB/GYNs) and general practitioners. Additionally, the comadronas, 

(TBAs), often lack any training and education and are not accredited as providers.

Skilled health professional: This professional is a provider accredited by MSPAS for the 

provision of care. Health professionals in Guatemala have the legal obligation to be affiliated 

with a corresponding college (such as the College of Physicians and Surgeons, or the College 

of Pharmacists and Chemists). 

Total market approach: A total market approach is a coordinated effort incorporating the public 

and private sectors to increase access to family planning (or other health products/services) in a 

given country. The objective of a total market approach is to better use the comparative 

advantages of public and private sources of health goods and services to increase access to 

and sustainability of priority health products (Crosby et al., 2010). 

Traditional birth attendant (TBA): The WHO defines a traditional birth attendant as a person 

who assists the mother during childbirth and who initially acquired her skills by delivering babies 

herself or serving as an apprentice to other TBAs. Guatemalan TBAs are usually called 

comadronas.

19
2 METHODOLOGY

2.1 APPROACH

The SHOPS project has conducted over 20 PSAs around the world, providing useful 

recommendations to major stakeholders on how to better integrate the private health sector and 

reach sustainability. Throughout the years, the project developed the five-step PSA

methodology summarized in Figure 1 that emphasizes collaboration and engagement with local 

stakeholders in order to ensure accuracy and buy-in for the key findings and recommendations. 

FIGURE 1: STEPS IN A PRIVATE HEALTH SECTOR ASSESSMENT

Source: Assessment to Action, SHOPS Project, 2014

The SHOPS LAC Regional Director managed the whole PSA process and contributed to the 

report. The PSA assessment team consisted of five key people: a team leader, 

researcher/analyst, and two public health experts who assisted in interviewing and data 

collection. This core team was supported by SHOPS’ expert technical staff at headquarters for 

specific questions.

In Guatemala, the PSA team used a mix of quantitative and qualitative methods to assess the 

role of the private sector in the areas of family planning, determine the legal and regulatory 

framework governing the private sector, and identify PPP opportunities. Among other sources, 

the team used data from ENSMI 2008-2009, the Western Highland Integrated Program (WHIP) 

baseline survey, and the National Survey on Living Conditions (Encuesta de Condiciones de 

Vida, ENCOVI) 2011, to understand contraceptive prevalence, unmet need for contraception, 

contraceptive method mix, and source of family planning, and to quantify the size and role of the 

private health sector in the country and in USAID’s focus region of the Western Highlands.

The PSA team then conducted about 50 in-country interviews both in the capital city and in the 

Western Highlands. Combining quantitative and qualitative approaches allowed for validation, 

verification, and triangulation of private health sector data. 

Key steps included:

1. Clarification of the scope of work with USAID to understand the priority points

2. Receipt of recommendations from USAID on whom to interview

3. Literature review

4. In-depth interviews in Guatemala

5. Market segmentation analysis

6. Submission of draft report submitted to USAID for feedback

7. Revision and finalization of report and recommendations (September 2015)

20
After finalizing the scope of work with USAID, the assessment team used the PSA approach 

outlined in Figure 1. Throughout the five steps of the approach, the team emphasized 

collaboration and engagement with local stakeholders to ensure accuracy and buy-in for the key 

findings and recommendations. 

2.2 SOURCES OF INFORMATION

2.2.1 LITERATURE REVIEW AND BACKGROUND

A complete bibliography of documents reviewed for this PSA is found in Annex B. The SHOPS 

team analyzed data from the ENCOVI 2011, and service delivery statistics from the National 

Statistics Institute to inform development of assessment questionnaires. The SHOPS team also 

used data from the National Health Accounts (NHA) exercise conducted in Guatemala to 

analyze health trends and behaviors. 

2.2.2 MARKET SEGMENTATION ANALYSIS

To inform this PSA, the team conducted a market segmentation analysis. Data analyzed for this 

exercise came from the sources below: 

 The series of ENSMIs, also known as Demographic and Health Surveys, conducted 

periodically by MSPAS, the latest dating from 2008-2009, and

 USAID’s WHIP baseline study, conducted in 2013 in USAID’s focus area of the Western 

Highlands. 

The segmentation analyzed sourcing patterns for family planning, ANC, and delivery according 

to users’ profiles, particularly their residence or wealth quintile.

2.2.3 FIELD WORK

See Annex A for a complete list of the individuals and institutions that provided information and 

their perspectives to this assessment. SHOPS interviewed representatives from the following 

organizations:

For-profit private sector

 Network of private providers

 Private facilities (hospitals and clinics)

 Private insurance companies

 Banking institutions

Nonprofit private sector

 Corporate foundations and groups engaged in social responsibility 

 Social enterprises (e.g., microcredit institutions, social insurance schemes, pharmacies)

IGSS

 Representatives from the management team

 Representatives from the board of directors

 IGSS health facilities director at the local level

21
Public sector

 MSPAS

 Professional councils 

 Public facilities

Development partners

 International donors

 Multilateral organizations (e.g., Pan American Health Organization, Inter-American 

Development Bank)

 International project implementers

The stakeholders were identified and purposively sampled in coordination with USAID and its 

partners in Guatemala. The team compiled an initial list before arriving in Guatemala and 

finalized it with USAID upon arrival. The initial list was supplemented using snowball sampling 

during the course of the assessment, with teams asking interviewees for the names and contact 

information of additional stakeholders to interview. Throughout the report findings are stated as 

the composite opinion from the many stakeholders interviewed during the assessment.

2.3 TIMELINE

 December 2014: Finalized SHOPS scope of work

 January−February 2015: Conducted data analysis on ENCOVI and NHA data, literature 

review and prepared for field visits

 February 23−March 7, 2015: Conducted interviews with key stakeholders in Guatemala City, 

Quetzaltenango, Huehuetenango, and Totonicapán 

 March 2015: Conducted market segmentation analysis

 March−June 2015: Developed PSA draft report

 July 2015: Submitted PSA draft report to USAID for review 

 September 2015: Finalized PSA report 

2.4 LIMITATIONS

While the PSA provides an overview of the private health sector in Guatemala, several factors 

might limit its generalizability. Due to the limited timeframe to conduct the assessment and 

interview stakeholders in country, the team sampled key organizations and providers, thus 

potentially missing some important stakeholders in the private sector. Some institutional 

stakeholders (particularly at IGSS and MSPAS) were reluctant to respond to an interview and/or 

had limited time to speak with interviewers. In addition, the assessment occurred in the midst of 

an institutional crisis at MSPAS as well as during an election year. At the time of the interviews, 

there were many changes being implemented within the health system. 

The team used the latest available data (ENSMI, 2008-2009; NHA, 2014; ENCOVI, 2011; and 

the WHIP baseline database, 2013) to conduct secondary analyses. Guatemala’s major source 

of family planning and reproductive health data, ENSMI 2008-2009, is dated, and the results of 

22
the next survey might present a different picture of private sector health trends. Additionally, the 

differences in sampling for ENSMI 2008-2009 (presenting data at the national level, with a 

possibility to disaggregate at the departmental level) and for the WHIP baseline database from 

2013 (focusing on USAID priority municipalities in the Western Highlands) make it impossible to 

directly compare the two surveys. While the data in the WHIP baseline seem to present 

improvements in family planning and maternal health indicators from the 2008-2009 ENSMI, the 

2015 version of the ENSMI would need to be analyzed to confirm any trends. It should also be 

noted that for the market segmentation analysis, the team did not conduct quintile analysis at 

the departmental level due to inadequate sample sizes and thus it was not possible to identify or 

explore possible variations across departments in the country. 

The PSA team limited its scope to assess source and use of the private sector in family 

planning and selected maternal health services and did not address any other health area that 

might be included in the USAID/Guatemala portfolio, such as nutrition. Additionally, in the areas 

considered, the team did not address quality of services. For example, the team did not 

evaluate the quality of ANC and cannot make any judgement on its impact on reducing maternal 

mortality. Finally, it should be noted that USAID directed the PSA team to exclude analysis of 

commodity supplies for family planning and maternal health as other assessments have already 

documented these issues.

23
3 CURRENT HEALTH CONTEXT 

IN GUATEMALA

3.1 BACKGROUND

Guatemala faces numerous health and health system 

challenges: For example, prevalence of communicable 

diseases has dropped in the past 25 years, and mortality from 

these diseases has decreased, from 31.5 percent in 2001 to 19 

percent in 2012. Nevertheless, mortality due to noncommunicable diseases such as diabetes and cardiovascular 

diseases has increased from 9 percent to 23 percent in the 

same timeframe (MSPAS, 2014). In 2015, maternal mortality 

remains high and the double burden of malnutrition (chronic 

malnutrition especially for children under five as well as overweight and obesity) represents an 

additional challenge to the delivery of health services. As previously mentioned, population 

groups who are poor, living in rural areas, and/or are indigenous suffer the highest burden. In 

addition, Guatemala’s health indicators tend to be worse than other countries in the region; for 

example, the children under five mortality rate is the highest in the Central American region as 

seen in Figure 2. Table 1 presents several other indicators related to the country’s the health 

status. 

FIGURE 2: MORTALITY RATE IN CENTRAL AMERICAN COUNTRIES (CHILDREN UNDER 5) - 2013

Source: World Bank, 2015.

Latin America (developing 

countries only) average

0

5

10

15

20

25

30

35

Mortality rate - under

5 (2013) per 1,000 live

births

Latin America

(developing countries

only) average

The sudden cancellation of the 

Extended Coverage Program 

(PEC) has left many inhabitants 

of the Western Highlands with 

limited or no access to health 

services. PEC’s termination has 

had the greatest negative effect 

on poor indigenous populations 

and rural communities.

24
TABLE 1: GUATEMALA GLOBAL HEALTH INDICATORS

Indicator Value Date

Total population 15,083,000 2012

Population living in urban areas 51% 2013

Life expectancy at birth (both sexes) 72 2012

Population under 15 40.4% 2013

HIV prevalence rate (among adults 15-49) 0.6% 2013

Source: WHO Global Health Observatory Data Repository: http://apps.who.int/gho/data/node.country.country-GTM?lang=en

At the time of the PSA, approximately 4 million residents of rural, indigenous areas had 

insufficient or no access to health services, due largely to an institutional crisis at MSPAS that 

resulted in the cancellation of the Program of Extended Coverage (Programa de Extension de 

Cobertura, PEC); PEC allowed MSPAS to contract-out the delivery of primary health care 

services to NGOs in areas that lacked access to public facilities (Avila et al., 2015). Remote 

location, poor public transportation infrastructure, cost of travel, and frequent impassability of 

roads in inclement weather make distances to the closest public health center or public hospital 

major obstacles to the indigenous populations who live in remote areas (Chomat et al. 2014). In 

2015, the USAID Health Financing and Governance project conducted an analysis with the 

USAID GeoCenter and presented the population’s accessibility to MSPAS health centers before 

and after the cancellation of PEC. Table 2 presents findings of the analysis. The reduction in 

accessibility, with 1.7 million more Guatemalans now being more than five kilometers from a 

health facility, is most acutely felt in Alta Verapaz, Quiche, Petén, and Huehuetenango. 

Regardless of the issues that existed with the PEC network, the loss of over half of the service 

delivery points in the country will have an impact on access to health services.

TABLE 2: GUATEMALAN POPULATION'S ACCESSIBILITY TO MSPAS SERVICE DELIVERY 

POINTS

With PEC in Place Without PEC in Place

Accessibility

(kilometers)

Population 

with Access % Accessibility(kilometers)

Population 

with Access %

0-5 km 12,924,050 85.5 0-5 km 11,214,075 78.1

5-10 km 1,227,045 8.5 5-10 km 2,407,356 16.8

10-20 km 184,560 1.3 10-20 km 634,408 4.4

> 20 km 38,873 0.3 > 20 km 111,127 0.8

Source: USAID GeoCenter, 2015, Avila et al., 2015

Closing the access gap between population groups is the main priority of the MSPAS team in 

charge of monitoring completion of the Millennium Development Goals (Secretaría de 

Planificación y Programación de la Presidencia República de Guatemala, 2010). However, lack 

of funding is preventing improving the availability of quality services.

3.2 HEALTH SEEKING BEHAVIORS

3.2.1 OVERVIEW

According to ENCOVI 2011, only half (49 percent) of 

Guatemalans visit health providers for any kind of service 

when experiencing a health problem. Twenty-nine percent 

self-medicate or ask a family member for help, and 22 

percent do nothing. This behavior is consistent 

1. Health-seeking behavior varies 

greatly by wealth quintile. The lowest 

quintiles are less likely to seek skilled 

care, suggesting differences in 

behavior and potentially unequal 

access to health care. Culture is an 

important factor that influences healthseeking behavior, especially among 

Guatemala’s diverse ethnic groups.

25
countrywide, including in the Western Highlands, where 51 percent self-medicate or do not seek 

care, as shown in Figure 3. 

FIGURE 3: HEALTH SEEKING BEHAVIOR AT TIME OF ILLNESS- WESTERN HIGHLANDS - 2011

Source: ENCOVI 2011

ENCOVI 2011 also found that at the national level, people who do seek treatment go to private 

for-profit facilities (34 percent), pharmacies (9 percent), and IGSS facilities (7 percent). Public 

(MSPAS) facilities represent a quarter (28 percent) of all the places where people seek care. 

Again, behavior in the Western Highlands reflects the countrywide breakdown, as seen in 

Figure 4. 

FIGURE 4: PLACE OF TREATMENT - WESTERN HIGHLANDS - 2011

Source: ENCOVI 2011

Health seeking varies greatly by wealth quintile; lower quintiles are less likely to seek qualified 

care, which suggests behavioral difference and potentially unequitable access to health. 

40%

9%

32%

19%

Visited a doctor,

dentist,OBGYN,

psychologist

Consulted an auxiliary

nurse

Auto-medicated or asked

a family member

Did nothing or other

36%

9%

5%

28%

22%

Private For-Profit facility

Pharmacy

IGSS

MSPAS Facility

Other

26
Additionally, culture is an important factor influencing care seeking in Guatemala, with its large 

indigenous population and various ethnic groups.

3.2.2 FAMILY PLANNING

Guatemala faces significant challenges in improving the sexual and reproductive health of its 

citizens. Table 3 provides an overview of indicators on family planning.3

TABLE 3: GUATEMALA FAMILY PLANNING INDICATORS, 2008

Indicator Value

Total fertility rate (TFR) 3.6

Contraceptive prevalence rate (CPR) for women of reproductive 

age (WRA) married or living in union, all methods 54.1%

CPR for WRA in union, modern methods 44.0%

Contraceptive prevalence rate (among girls 15-19%) 14.6%

Source: ENSMI 2008-2009

Guatemala has a high TFR of 3.6 births per woman. 

Although Guatemala’s TFR decreased 35 percent 

between 1987 and 2009, it remains higher than in 

all other Central American countries, and for the 

region as a whole, whose average TFR is 2.1 

(WHO, 2012). As Figure 5 shows, the decrease in 

TFR in Guatemala is mostly due to TFR reduction in 

rural areas, which accelerated between 2002 and 

2009. However, a gap between rural areas and 

urban areas remains. On average, women in rural 

Guatemala still have 1.3 more children than women in urban areas: the rural TFR is 4.2, 

whereas the urban TFR is 2.9.

FIGURE 5: TOTAL FERTILITY RATE IN GUATEMALA, 1987-2008

Source: ENSMI 1987 through 2009-2009

As illustrated in Figure 6, permanent methods are the most common methods in Guatemala, 

followed by long-acting and reversible methods. Short-acting methods needing resupply (such 

3 It is important to note that Guatemala is implementing a Demographic and Health Survey in 2015, and data from this 

survey could differ from the indicators in this report.

4 3.8 4.1

3.3

2.9

6.4 6.1 5.8

5.2

4.2

0

1

2

3

4

5

6

7

1987 1995 1998-99 2002 2008-09

Children

Urban

Rural

Total TFR

Guatemala’s total fertility rate (TFR) of 3.6 births 

per woman is higher than the regional average. In 

rural areas, the TFR is higher (4.2) than in urban 

areas (2.9). Approximately half of women of 

reproductive age use contraceptives. Injectables 

and female sterilization are the most commonly 

used methods.

Most women in the Western Highlands seek 

contraceptives in the public sector, and most 

urban women obtain their methods in pharmacies.

27

 
as pills and condoms) are not preferred. Traditional methods are still used by 17 percent of 

users at the national level. 

FIGURE 6: FAMILY PLANNING METHOD USE BY TYPE IN GUATEMALA (%)

Source: ENSMI 2008-2009

As Figure 7 illustrates, there was steady growth in the use of modern methods between 1987 

and 2009, with the greatest gain seen in rural areas. However, the modern methods CPR in 

Guatemala remains lower than that of its regional counterparts, with modern contraceptives 

used by only 44 percent of married WRA in 2008. The urban-rural gap shrank by a third 

between 1987 and 2008, but it persists, with modern methods CPR 20 percentage points higher 

in urban areas than in rural areas. The gap between total CPR and modern methods CPR also 

increased slightly, from eight percentage points in 2002 to 10 percentage points in 2008-2009 

ENSMI. This suggests that more women are adopting family planning practices, but not 

necessarily a modern contraceptive method. 

FIGURE 7: EVOLUTION OF MODERN CPR IN GUATEMALA (%) WRA IN UNION

Source: DHS, http://www.statcompiler.com/

Changes in the contraceptive method mix for WRA in union in Guatemala since the late 1980s 

have been primarily driven by increased use of injectable contraceptives and female sterilization 

(Figure 8). Female sterilization has had a historically large share of the market, growing from 10 

percent in 1987 to 19 percent in 2008. The market share of injectable contraceptives also grew 

during the period, from 0.5 percent to almost to 15 percent. Use of other methods remained 

relatively constant (e.g., CPR for male sterilization went from 0.9 percent in 1987 to 0.8 percent 

in 2008, and for oral contraceptives went from 3.9 percent to 3.6 percent). Though the utilization 

rate is still low, CPR for condoms doubled, from 1.2 percent in 1987 to 3.2 percent in 2008. 

14

30

38

17

0 Short acting

Long acting and

reversible

Permanent

Traditionnal

43% 49% 52% 57% 66%

14% 20% 28% 35% 46%

1987 1995 1998-99 2002 2008-09

Urban Rural

28
FIGURE 8: EVOLUTION OF MODERN CONTRACEPTIVE METHOD MIX FOR WRA IN UNION (%)

Source: DHS, http://www.statcompiler.com/

3.2.3 CURRENT USE OF CONTRACEPTION

According to ENSMI 2008-2009, total contraceptive use by women in union is 54.1 percent and 

a high proportion of family planning users in Guatemala City and the Western Highlands report 

using traditional methods (17 percent and 20 of total CPR, respectively). Figure 9 compares 

overall modern method prevalence nationally and in the Western Highlands using 2008-2009

ENSMI data. In 2008-2009, injectables and female sterilization were the most commonly used 

modern methods, both countrywide and in the Western Highlands region. A historical trend also 

indicates a decrease in sterilization and an increase in injectables. In 2008-2009, Condom and 

oral contraceptive use was slightly higher in the Western Highlands region compared to 

countrywide, while injectable use was lower in the Western Highlands than countrywide. Fewer 

than five percent of women countrywide and in the Western Highlands reported using IUDs.

FIGURE 9: TYPE OF MODERN METHOD USED AMONG WRA IN UNION, COUNTRYWIDE VS. 

WESTERN HIGHLANDS (%)

Source: ENSMI 2008-2009, WHIP 2012

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

 1987 DHS 1995 DHS 1998-99

DHS

 2002 RHS 2008-09

RHS

Other modern methods

Male sterilization

IUD

Oral contraceptive

Condom

Injectable

Female sterilization

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Countrywide

2008

Guatemala City,

2008

Living in the

Western

Highlands,

ENSMI 2008

Living in the

Western

Highlands, WHIP

2012

Oral contraceptive

Condom

Injectable

IUD

Sterilization (male and female)

Other modern

29
Total contraceptive use reported by men in union age 15-59 at 59.2 percent is close to the 

percentage reported by women, and 13.7 percent report using a traditional method. As with 

women, men in urban areas, especially in the capital city, are more likely to use modern 

methods of contraception, at 58.1 and 63.2 percent, respectively. Female sterilization is an 

essential method of family planning in Guatemala, but the share of vasectomies is limited, 

reaching only 0.7 percent of men married or in union in 2008 (MSPAS, 2011). In the youngest 

age groups, male condoms are the second most used modern method, after injections: 

condoms are used by 4 percent of 15-19 year olds; 6.4 percent of 20-24; and 8.2 percent of 25-

29 year olds. 

For the Western Highlands, data are also presented from the 2012 WHIP survey. While 

methodological differences make it difficult to directly compare the 2008-2009 ENSMI data for 

Western Highlands to the 2012 WHIP data, it is notable that the more recent WHIP survey 

revealed higher levels of injectable contraceptive use among modern method users in this 

region, with an estimated 56 percent of all modern method users choosing this method. That is 

a substantial increase from the 29 percent share found in the 2008 RHS. The second most 

common modern method reported in the Western Highlands in 2012 was sterilization (male or 

female) at 28 percent. 

While some women use resupply methods (oral contraceptives, condoms, or injectables), not all 

WRA know where to procure family planning methods, and regional disparities remained for 

women to know where to source their method. In 2008, 89 percent of WRA in Guatemala City 

knew of a family planning source, compared to just 66 percent of women living in the Western 

Highlands (MSPAS, 2010). WRA living in the Western Highlands most commonly cited the 

public sector as a family planning source (74 percent), whereas WRA living in Guatemala City 

mentioned pharmacies the most (35 percent), as illustrated in Table 4. Both at the national and 

regional level, as the respondent got older, APROFAM, the International Planned Parenthood 

Federation (IPPF) affiliate of Guatemala, was increasingly cited as a source and pharmacies 

were less cited. The youngest group vastly cited private pharmacies as a source, perhaps 

because of the lack of access to public health services. Additionally, they are also the biggest 

users of condoms, the method that is most commonly purchased in private pharmacies, as 

reported by 88.2 percent of male respondent in the 2008 DHS (MSPAS, 2011).

Interestingly, only 1 percent of respondents, including in Guatemala City, cited IGSS as the 

primary source where they knew they could procure family planning methods. Actual sourcing 

patterns for family planning methods will be discussed later, in the market segmentation 

analysis (Chapter 4). 

30
TABLE 4: PRIMARY SOURCE OF FAMILY PLANNING FOR WRA KNOWING WHERE TO SOURCE A

FAMILY PLANNING METHOD (%)

Public Sector / 

MSPAS IGSS Private For-Profit APROFAM Private Pharmacies Other

Residence

Countrywide 62 1 1 12 22 1

Guatemala City 33 1 2 27 35 0

Western 

Highlands 74 0 1 7 16 2

By age

15-19 52 0 1 6 40 1

20-24 62 0 1 11 23 2

25-29 70 1 2 13 13 1

30-34 67 1 1 16 13 2

35-39 70 0 2 17 10 1

40-44 67 0 1 19 11 2

45-49 66 2 0 23 8 1

Source: ENSMI 2008-2009

3.3 MATERNAL HEALTH

Maternal health remains a challenge in Guatemala, especially in the Western Highlands and 

among the most vulnerable populations. Table 5 summarizes maternal health indicators. 

TABLE 5: GUATEMALA MATERNAL HEALTH INDICATORS

Indicator Percent

Births attended by skilled health personnel 51.0*

Births attended by skilled health personnel, among girls aged 15-19 92.6*

Antenatal care coverage

(at least one visit)

93.0

Rate of exclusive breastfeeding of infants under 6 months 49.6**

% of WRA with anemia 30.4**

% of infants born with low birth weight 11.4**

% of C/sections 16.3

% of women with a height <145 cm with children <5 years 31.2

% of women with children <5 years of age with an body mass index of 30.0 or more 15.4

% of women with children <5 years of age with an body mass index of between 25.0 and 

25.9 (overweight)

35.0

Sources: All data points come from ENSMI 2008-2009 except for those indicated with (*) that come from WHO 2012 and (**) that come from the World 

Bank Group World Development Indicators databank. 

Maternal mortality is high in Guatemala and has slowly declined

since 2007 reaching 113 maternal deaths for 100,000 live births 

in 2013 (MSPAS, 2015). Although there are discrepancies in the 

reporting of maternal mortality rates, Guatemala’s trend is far 

above the regional average for developing countries in Latin 

America and the Caribbean of 87 per 100,000 live births (World 

Bank, 2015) (Figure 10). Among women of all ages, the top causes of death were hemorrhage 

(41 percent) and eclampsia and pre-eclampsia (25 percent. That these are preventable 

Forty-eight percent of deliveries 

occur at home or with a 

traditional midwife rather than in 

a health center with skilled birth 

attendants.

31
conditions highlights the need for improved access to timely and high-quality obstetrical care, 

which is likely exacerbated by the frequency of home delivery (48 percent) and/or birthing with a 

traditional birth attendant (TBA), rather than in a health facility with skilled birth attendants.

FIGURE 10: MATERNAL MORTALITY RATES IN LATIN AMERICA AND THE CARIBBEAN, 1990-

2013

Source: World Bank Development Indicators, 1990-2013

3.3.1 ANTENATAL CARE

ANC coverage is high in Guatemala. According to ENSMI 2008-

2009, 80 percent of pregnant women overall had received at 

least four ANC visits, the WHO standard for ANC care, and 93 

percent had received at least one visit. However, it is important 

to remember that number of visits and quality of care are not 

necessarily related. ENSMI 2008-2009, for instance, reports a 

decline in tetanus toxoid immunization coverage from ENSMI 

2002, from 49.7 percent of pregnant women receiving at least 

two tetanus toxoid shots in 2002 to 42.7 percent in 2008, 

although they made the same number of visits. Most women received their first ANC visit during 

the second trimester of their pregnancy, with little variation by region. About 77 percent of 

women in the Western Highlands received their first ANC visit between 20 and 25 weeks, 

compared to 81 percent of women nationwide.

More recent data from the Western Highlands shows that 98 percent of women saw a skilled 

health professional for at least one of the ANC visits. Additionally, the data suggest that women 

consult providers several times during their pregnancies (Table 6). According to the WHIP, 63 

percent of women indicated having received ANC in the course of their first trimester and 17 

percent within the fourth month of pregnancy.

0

50

100

150

200

250

300

1990 2000 2005 2010 2013

Guatemala

Latin America

(developing only)

The community plays an 

important role to ensure that 

pregnant women receive 

antenatal care. Traditional 

midwives or other communitybased workers visited about 

one fourth of pregnant women in 

the Western Highlands.

32
TABLE 6: NUMBER OF ANC VISITS

Number ANC visits (N=3740) % WRA (n=3740)

Fewer than 4 18

4 or more 80

Did not know / did not respond 2

Total 98

Source: WHIP baseline survey 2012

The role of the community to reach out to women to provide ANC is important. Twenty-two 

percent of women from the Western Highlands interviewed during ENSMI 2008-2009 reported 

that somebody came to their homes to provide care during the pregnancy. However, 91 percent 

of those visitors were TBAs, suggesting that the quality and services provided were not likely to 

meet recommended standards of care, due to uneven training levels among TBAs.

3.3.2 DELIVERY

In 1999, at the International Conference on Population and 

Development + 5, Guatemalan representatives concurred with 

the international target of 90 percent of deliveries to be attended 

by skilled health professionals. Currently, the country reaches 

this goal only for births among girls age 15-19, and the WHO 

World Health Statistics report (2014b) indicates that Guatemala 

ranks second to last in the Latin America and Caribbean region with only 51 percent coverage 

of deliveries by skilled health professionals. 

An estimated 43 percent of deliveries countrywide take place at home, with no skilled providers 

present (MSPAS, 2010). Teen mothers (age 15-19) is the group that is most apt to deliver in a

health facility (MSPAS, IGSS, APROFAM) and, at the national level, institutional delivery 

reaches 97 percent of the age group. The proportion is smaller in the Western Highlands, where

only 36 percent of teen mothers had an institutional delivery. 

However, the WHIP baseline survey indicated a change in trends; its data show that the 

majority of deliveries (70 percent) in 2012 were attended by skilled personnel (Table 7 below). 

Unlike in the 2008-2009 ENSMI, where the youngest group exhibited a different behavior from

the older groups, age of women is not a major differentiator: 67 percent of deliveries for women 

15-19 were attended by medical personnel, but not necessarily within institutional facilities, as 

53 percent delivered at home (Angeles et al., 2014). 

TABLE 7: PERSONNEL ATTENDING DELIVERIES, 2013 (%)

Age of pregnant women (%)

Type of Personnel 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Average

Medical personnel 67 71 67 66 83 72 60 70

Other personnel 33 29 33 32 17 26 40 29

No one 0 0 0 2 0 3 0 1

Total 100 100 100 100 100 100 100 100

Source: WHIP Survey 2013

The State of the World’s Midwifery (WHO, 2014c) projects that Guatemala will need enough 

midwifery services to cover 63.1 million ANC visits, 9.9 million births, and 39.8 million postnatal 

care visits between 2014 and 2030. 

The holistic approach that guides 

the Mayan medical system is not 

integrated into the formal health 

care system, which is based on 

Western medicine.

33
Strong regional differences exist in women’s behaviors at the time of delivery, and interviewees 

cited cultural context, geographic isolation of the communities, and lack of availability of 

services as potential reasons for women to deliver their children at home. This sentiment was 

repeated in the PSA interviews. The holistic approach that guides the Mayan medical system is 

not integrated into the official health care system based on Western medicine. 

This barrier is particularly significant for delivery, and in 2008, the rate of indigenous women 

delivering at home was 2.5 times higher than that of non-indigenous women (67 percent of 

women delivering at home are indigenous, as opposed to 26 percent who are not). Through the 

PSA interviews, informants highlighted various barriers for safe deliveries in rural Guatemala. 

Among these were difficult access to health facilities from remote communities, lack of funds to 

transport the women to the nearest health facilities, cultural barriers in health facilities that are 

not designed for the integration of the community, and lack of training that leaves TBAs unable 

to recognize danger signs quickly and seek referral. Data from the 2013 WHIP baseline survey 

indicate that in order to prepare for delivery, 75 percent of patients had saved money, 55 

percent of them had secured transportation, but only a small proportion of them (7 percent) had 

identified blood donors. Additionally, WHIP baseline survey data indicate that a third of 

deliveries were C-sections, which is extremely high and suggests the reasons for this rate 

should be examined.

Currently, no professional midwifery training is carried out in Guatemala. MSPAS, in partnership 

with the Guatemalan Universidad da Vinci and the Peruvian Universidad de San Martin de 

Porres, is implementing a new midwifery training program based on a Peruvian model. This 

training is to be implemented in Huehuetenango in the Western Highlands and is designed to 

strengthen the supply of skilled attendants by recruiting students from the local communities, 

anticipating increased retention. It is not clear if this training will be the gateway for more 

courses and if it will substantially increase the number of SBAs. There needs to be a doubling of 

skilled attendance by 2020 in order to increase met need to 90 percent by 2020 (WHO, 2014c). 

If professional midwives are not trained, then accredited post-graduate courses for nurses in 

midwifery skills, will be essential.

3.4 HEALTH FINANCING AND OUT-OF-POCKET 

EXPENDITURES

Guatemala suffers from inadequate funding in health. 

Unlike other countries in the Latin American region that 

have seen their health expenditures grow in the last 

decade, health expenditures have stagnated in 

Guatemala, far below the amount spent per capita in the 

region, as illustrated in Figure 11. 

Out-of-pocket payments account for 

fifty-seven percent of the total health 

expenditure in Guatemala. These 

payments go toward basic health 

commodities, medical consultations, 

and access to private hospitals.

34
FIGURE 11: HEALTH EXPENDITURE PER CAPITA (CONSTANT 2005 INTERNATIONAL $)

Source: World Bank Databank 2015

The Guatemalan health system is mostly financed by private funds, as presented in Table 8. 

Notably, the share of government expenditures on health has decreased in the last five years 

while the share of private expenditures on health has steadily increased. Out-of-pocket 

expenditures are high and have remained roughly at the same share of total private 

expenditures on health since 2010 (81.3 percent in 2010, 81.2 percent in 2013). 

TABLE 8: HEALTH FINANCING BY THE NUMBERS

2010 2011 2012 2013

General government 

expenditure on health as % of 

total health expenditure 

40.8 37.8 38.0 37.4

Private expenditure on 

healthas % of total health 

expenditure

59.2 62.2 62.0 62.6

GGHE as % of General 

government expenditure 20.3 17.6 18.3 17.0

Social security funds as % of 

GGHE 45.6 48.3 52.5 43.7

Private insurance as % of 

PvtHE 4.4 4.7 4.8 5.2

Out of pocket expenditure as 

% of PvtHE 81.3 80.6 80.7 81.2

Source: WHO http://apps.who.int/nha/database/DataExplorerRegime.aspx 

0

200

400

600

800

1000

1200

2005 2006 2007 2008 2009 2010 2011 2012 2013

Constant 2011 international dollars

Latin America & Caribbean

(all income levels)

Latin America & Caribbean

(developing only)

Guatemala

35
Total health expenditure as a percentage of gross domestic product (GDP) is low in Guatemala, 

reaching 6.5 percent of GDP in 2013, below the average for Latin America and the Caribbean of 

7.6 percent (World Bank, 2015).

Public expenditures on health represent contributions from central government and 

municipalities. Combined, these entities spent Quetzals (Q) 5,105 million (US$650 million) in 

2013, which represents only 19 percent of total health expenditure and was equivalent to 1.2 

percent of GDP, similar to the percentage they spent in 2005. In recent years, public 

expenditures have fluctuated: government expenditure was Q4,287 million (US$546 million) in 

2012, increased in 2013, declined in 2014, and increased again, to Q5,400 million (US$687 

million), in 2015. These increasing expenditures are attributable to MSPAS despite reductions to 

health spending by municipalities. The annual per capita expenditures from MSPAS was 

approximately one-fifth (Q184 or US$23) of what IGSS beneficiaries received (Q841 or 

US$107) in 2013 (Avila et al., 2015). 

Private expenditures by employers are their contributions to the IGSS and private insurance, 

and their direct financing of the provision of medical services and workplace care. Private health 

insurance in Guatemala accounted for 11.4 percent of total health expenditures in 2013 (Q2,804 

million, US$357 million), equivalent to 0.6 percent of the GDP (Avila et al., 2015). 

The inadequacy in government funding for health has resulted in an increasing share of total 

health spending in the form of out-of-pocket payments, an unwieldy burden for households. 

Currently, households are the main source of health financing in Guatemala. Fifty-seven percent 

of the total health expenditure in Guatemala comes from out-of-pocket spending. These private 

payments go toward commodities, medical consultations, and access to private hospitals. 

Guatemala mobilizes resources for health sector from a dedicated tax. Since 2004, the Tax Law 

on Distribution of Alcoholic Beverages (Decree21-04) has guaranteed that 15 percent of tax 

income would be dedicated to financing reproductive health and family planning, as well as the 

prevention of alcohol consumption and smoking. However, the disbursement and amounts have 

varied over the years, affecting the execution of the reproductive health program. Tax collection 

from alcoholic beverages and tobacco amounted to Q431 million (US$55 million) in 2013, out of 

which Q46.2 million (US$5.9 million), or 11 percent, was collected specifically from alcoholic

beverages. The percentage spent of this specific tax (the execution rate) was 86 percent in 

2013 and 72 percent in 2014. The 15 percent of the tax allocated to health programs was Q6.1 

million (US$781,000) in 2013; the amount declined to Q5.3 million (US$679,000) in 2014.

36
4 THE GUATEMALAN HEALTH 

SECTOR AND THE ROLE OF 

THE PRIVATE SECTOR

4.1 HEALTH SECTOR OVERVIEW

Many key health stakeholder groups operate in the 

Guatemalan health sector (Table 9). During the PSA 

field work, the team interviewed a number of these 

stakeholders; Annex A lists the informants by name 

and organization. 

TABLE 9: OVERVIEW OF HEALTH SECTOR STAKEHOLDERS 

Public Sector For-profit 

Private Sector 

Nonprofit and 

Faith-based 

Private Sector 

Donor 

Countries, and 

Implementing 

Partners

Multinational Donors 

and Cooperation/ 

Reimbursable 

Cooperation

● Ministry of 

Public Health and 

Social Welfare 

(national and local 

levels) 

● Guatemalan 

Social Security 

Institute 

● Military Health 

Service (limited 

involvement in 

health) 

● Private 

pharmaceutical 

laboratories:

-Bayer HealthCare

-Pfizer

-ABL Pharma

● Private 

pharmacies 

● Private forprofit providers 

● Private health 

facilities 

● APROFAM

● Pan 

American Social 

Marketing 

Organization 

(PASMO)

● Medical 

college 

● Pharmaceutical college 

● Universities

● Donor 

countries: 

-USA

-Spain

-Japan

-Sweden 

-Canada

● Population 

Services 

International 

● University 

Research Co., 

LLC

● Futures 

Group

● John Snow, 

Inc.

● Medicus 

Mundi

● Inter-American 

Development Bank

● World Bank Group 

(including International 

Bank for Reconstruction 

and development)

● Central American 

Bank for Economic 

Integration (CABEI) 

● United Nations 

Development Assistance 

Framework (UNDAF): 

-UNDP

-UNICEF

-UNFPA

-UNESCO

-UNAIDS

● Global Fund to Fight 

AIDS, Tuberculosis and 

Malaria

Guatemala’s public health sector includes multiple government entities that provide care to 

different segments of the population. MSPAS is the overall steward of the Guatemalan health 

system; as such, it is responsible for policy formulation and resource mobilization. In addition, 

MSPAS provides health care services to the general population—it is Guatemala’s largest 

MSPAS is the main health care provider in 

the country, and IGSS is the second largest.

A large percentage of Guatemalans also 

seek care in the private sector through 

private health insurance or out-of-pocket 

payments. They go to private hospitals, 

clinics, or pharmacies.

37
health care provider, providing approximately 71 percent of all health care services. The Ministry 

of Defense has its own health care network and covers service members and their dependents, 

approximately 0.5 percent of the population. Both of these entities have their own network of 

hospitals, health centers, and health posts, with little coordination between them.

The IGSS is a public-private entity that covers formally employed workers and their dependents. 

Although the Guatemalan Constitution states that all citizens have a right to social security 

services, only 18 percent of the population is covered through IGSS. Those who are employed 

in small companies or self-employed have limited enrollment in the IGSS system. 

Additionally, a large percentage of the Guatemalan population seeks care through the private 

sector, both for-profit and nonprofit. The private sector, comprising private hospitals, clinics, 

pharmacies, and other facilities, provides services for people who either have private insurance 

or pay out-of-pocket (MSPS, 2012). MSPAS oversees private sector facilities through the 

General Directorate for Health Regulation, Vigilance, and Control (Departamento de 

Regulación, Acreditación y Control de Establecimientos de Salud, DRACES), which is 

responsible for overall regulation and licensing of for-profit private sector facilities. Finally, 

traditional medicine practices and various community-based health services (such as those 

provided by TBAs, or comadronas) complement the more formal elements of Guatemala’s 

health system.

Human resources for health in Guatemala are insufficent, as measured by health worker 

density, the most commonly use indicator. Figure 12 illustrates health worker density in five 

Central American countries. With a ratio of 12.5 health workers (physicians, nurses, others) per 

10,000 inhabitants (MSPAS/PAHO, 2013), Guatemala has the lowest health worker density in 

the region. The ratio is also well below WHO recommendation of 22.8 health workers per 

10,000 inhabitants as the bare minimum for a functional health system (Avila et al., 2015). 

FIGURE 12: HUMAN RESOURCES FOR HEALTH INDICATORS IN SELECTED LATIN AMERICAN 

COUNTRIES

Sources: PAHO, 2013 (health workers density); WHO Global Health Repository: http://apps.who.int/gho/data/node.country.country-GTM?lang=en

(nursing and midwifery personnel – latest available data). 

Health professionals in Guatemala are well organized according to their health profession. To 

practice, they are legally obliged to be affiliated with their corresponding college (College of 

Physicians and Surgeons, College of Pharmacists and Chemists, etc.). Other, non-mandatory 

0

5

10

15

20

25

30

35

40

45

Guatemala Costa Rica El Salvador Honduras Nicaragua

per 10,000 population

Health workers density per 10,000

population

Nursing and Midwifery personnel

density per 10,000 population

38
associations exist, such as the Guatemalan Association of Female Physicians and the 

Guatemalan Association of Obstetrician and Gynecologists, with local sections throughout the 

country.

Findings from the PSA regarding each of the groups of actors are discussed in Chapter 5. The 

following sections discuss the three major health care actors—MSPAS, IGSS, and the private 

health sector—in more detail below.

4.1.1 MINISTRY OF HEALTH AND SOCIAL WELFARE

Guatemala’s Health Code establishes that MSPAS 

shall “formulate, organize, and direct the execution of 

policies, plans, programs and projects for the delivery 

of health services to the general population” and that 

MSPAS is charged with stewardship or governance 

(rectoría) of the health sector. As stated in the 

introduction to this section, MSPAS is Guatemala’s 

largest health care provider, providing 71 percent of all 

health care services. It also is the major provider of modern family planning methods: its role

increased from 32.2 percent in 2002 to 50.9 percent in 2008 (ENSMI 2002/2008). It is the major 

provider of Guatemala’s two most widely used family planning methods: 77 percent of all 

injectable users and 42 percent of sterilization users receive services from MSPAS. Given that a 

high percentage of women still receive ANC and delivery services in their homes, MSPAS is the 

second largest provider of these services as well as the largest provider of facility-based care. 

MSPAS facilities are located in urban and rural areas. They range from basic primary care posts 

to high-end tertiary hospitals—although hospitals are located mostly in urban areas. These 

facilities provide services free of charge, with the exception of some hospitals that take 

donations. 

MSPAS categorizes its service delivery infrastructure into three different levels, with various 

types of service delivery facilities at each level. Family planning, however, is provided at all 

levels. The first level of care has 1,492 facilities, representing 74 percent of all facilities; they are

1) convergence centers (covering fewer than 1,500 inhabitants), which are storage points for 

medicines and meeting points for outreach personnel, 2) health posts (covering 2,000 

inhabitants), which serve as a link to the health network and are normally staffed by a nurse 

assistant (auxiliar de enfermeria) to provide basic health services, and 3) strengthened health 

posts (approximately 5,000 inhabitants), which provide basic health services and refer more 

complex health issues to MSPAS health centers.

4 In 2002, the General Decentralization and 

Municipal Code Law delegated the responsibility for establishing and administering public health 

services to municipalities.

The second level of care (representing 23 percent of all facilities) comprises: 1) health centers, 

2) Type A health centers (with inpatient care and housing 30-50 beds), providing pediatric and 

emergency care, 3) Type B health centers, which focus on promotion, prevention, recuperation, 

and rehabilitation services, 4) Permanent Care Center (CAP) dedicated to provision of normal 

deliveries, 5) Ambulatory Care Centers (CENAPA) which provide outpatient care only, and 6) 

Centers for Integrated Maternal-Infant Care (CAIMI), which attend both normal and high-risk 

deliveries and have operating theaters. The government has expanded CAPs and CAIMIs to 

more rural areas, but there are still significant gaps in infrastructure, personnel, and resources. 

Health Area Directorates (DAS) and Municipal Health Districts (DMS) are responsible for local 

4 http://www.mspas.gob.gt/index.php/en/mspas/red-de-servicios.html

MSPAS is the primary supplier of the two 

most widely used family planning methods in 

Guatemala, providing 77 percent of 

injectables and 42 percent of sterilizations. 

In the Western Highlands, the availability of 

services is limited. More than 89 percent of 

facilities are first-level facilities, and 11 

percent are secondary facilities.

39

 
implementation. The assessment team was not able to collect data on the availability of MSPAS 

facilities at the departmental or district level through stakeholder interviews or MSPAS’ website.

The third level of care with 51 facilities (3 percent of all facilities) is focused on specialized 

hospital services, which are referral points for first- and second-level facilities. It includes 1) 

departmental hospitals, 2) regional hospitals, and 3) referral hospitals. In terms of MSPAS’ 

budget, the majority of resources are allocated to the hospital network. Not surprisingly, these 

specialized services are concentrated in urban areas with higher income levels, leaving rural 

populations vulnerable and without access to specialize services.

TABLE 10: MSPAS HEALTH INFRASTRUCTURE BY FACILITY TYPE

Level of Care Type of Establishment Number of Establishments

First

Convergence center 2,220*

Health post 1,302

Second

Health center 902

Health center with 

specialties 21

Mobile clinic 379

Third

Hospital level 1 13

Hospital level 2 32

Hospital level 3 6

Source : MSPAS Strategic Plan, 2014-2019

* Convergence centers, rudimentary health posts operated by NGOs under contract with MSPAS (MSPAS, 2014) will likely be 

closed from the cancellation of PEC and the organizational crisis at MSPAS, leaving many in the rural population without access 

to public health care, a situation which is only beginning to be addressed in mid-2015 (Avila et al., 2015).

In the Western Highlands, the availability of MSPAS health facilities is limited. More than 89

percent of all facilities represent first-level facilities and 11 percent are secondary facilities

(Angeles et al., 2014). Health care professionals are concentrated in second-level facilities 

(CAIMIs) and permanent care centers.

Only 19 percent of health facilities report having adequate roofing, walls, windows, and floors. 

Twenty-six percent possess all essential utilities and equipment: electricity, drinking water, a 

refrigerator, and an instrument sterilizer. Thirty-seven (37 percent) percent of facilities have an 

in situ pharmacy (Guatemala National Statistics Institute, Municipal censuses 2008-2011).

MSPAS monitors the health sector via a Health Management Information System (Sistema de 

Información Gerencial en Salud, SIGSA), which tracks health information by demographics, 

socioeconomic, deaths, illnesses and risks, resources, access and coverage.5

5 http://sigsa.mspas.gob.gt

40

 
4.1.2 GUATEMALAN INSTITUTE FOR SOCIAL SECURITY

The IGSS, created by law6 in 1946 as an 

autonomous entity, is the second largest health 

service delivery institution in Guatemala. Its 

beneficiaries are public and private sector workers

and retirees. In 2013, IGSS reported a total beneficiary population of 2.643 million people (or 

about 17 percent of the population) including direct beneficiaries, spouses, and children under 

seven years of age. IGSS has a service delivery network of 123 medical units, of which 23 are 

hospitals, located in all departments. Forty of the medical units are in Huehuetenango, 

Quetzaltenango, Quiché, San Marcos, and Totonicapán, which MSPAS and USAID have 

declared as priority areas for integrated development activities in 2012-2016. According to IGSS 

representatives, the current infrastructure is insufficient to meet the needs of the insured 

population and its beneficiaries. IGSS is finalizing construction of the Regional Hospital of 

Quetzaltenango, which will serve as a referral center for multiple Western departments. Within 

the next five years, IGSS plans to build a new complex of four specialty hospitals. 

The governance of IGSS is delegated to the Board of Directors, which oversees administration 

and management. IGSS provides coverage for its members based on a public group insurance 

system. Membership in the IGSS health insurance plan is compulsory for employees in the 

formal sector and is financed through contributions from workers and employers. The rate of 

contribution is specified by law and based on the worker’s salary level. 

Decree 295 establishing IGSS stated that the system must be financed by three parties: 

employees (25 percent), employers (50 percent), and the State (25 percent). The portion from 

the State must be financed by taxes created for that purpose and, while collected by the 

government, must be available as exclusive property of the Institute. Nevertheless, the 

government of Guatemala stopped giving resources to IGSS in the mid-1950s when a contrarevolution regime was established. By December 2014, the total State debt to IGSS amounted 

to Q27.8 billion (US$3.6 billion). In February 2015, President Otto Perez Molina signed an 

agreement with IGSS authorities to pay the debt as an employer to IGSS, which accounts for 

Q5 billion (US$649.7 million). The amount was to be paid in installments. The agreement did not 

cover the remaining Q22.8 billion (US$2.9 billion) of the debt.

In 2013, IGSS health expenditures totaled Q4.7 billion (US$600 million), close to the Q5.1 billion 

(US$650 million) spent by MSPAS, which covers far more people (Avila et al. 2015). Table 11

lists the main programs provided to IGSS beneficiaries.

6 Decreto N° 295 -Ley Orgánica del Instituto Guatemalteco de Seguridad Social

According to IGSS representatives, the 

current infrastructure is insufficient to meet 

the needs of its beneficiaries.

41

 
TABLE 11: IGSS PROGRAMS 2015 OPERATIONS PLAN

Program Population and Type of Coverage

IVS (Disability, 

Retirement, and 

Survival)

Protects the insured for permanent disability (disability) or when the condition ends 

or acquires retirement upon reaching a certain age. 

Provides protection for surviving beneficiaries, providing medical care and pecuniary 

benefits.

PROCAPI (Program of

Special Protection for 

Domestic Workers)

Provides protection for maternity and accidents for domestic workers and their 

children under five since September 2009 and currently covers women who work in 

Guatemala Department. Services are provided only in IGSS-owned medical units.

EMA (Programa de 

Enfermedad, Maternidad 

y Accidentes)

Provides medical assistance to the insured member and family, and economic 

assistance to the member who is temporarily incapacitated and unable to work.

Provides maternity medical-surgical, preventive, and curative care in prenatal, 

delivery, and postnatal period for beneficiaries; full (100 percent) salary paid to 

insured during maternity leave.

Provides specialized care for adolescents under 19 in the capital who are cared for by 

traditional midwives; deliveries may be conducted in the home or in an IGSS facility.

Includes accident medical care for any event that caused an injury or functional 

disorder and provides temporary financial benefits in the event of temporary 

incapacity of the member.

Source: PSA team interviews with IGSS officials 

4.1.3 PRIVATE SECTOR

Nongovernmental organizations 

Guatemala has a multitude of NGOs working in the health 

sector, many of them working at the regional and 

departmental levels. The majority of NGOs focus on 

preventive health programs, education, and some also 

provide clinical services. This report highlights the two largest 

NGOs for family planning and maternal health with nationwide 

coverage. Please see Section 5.5 for more information on 

NGOs.

For-profit private sector 

Guatemala’s private sector represents a large and growing segment of the health care market, 

including high-end tertiary hospitals, small specialty and general hospitals (95), clinics for 

specialized medicine (2,927), clinics for general medicine (1,103), and laboratories (1,373), 

representing approximately 60% of all registered facilities. According to DRACES, there are well 

over 9,000 private facilities related to health in Guatemala (Table 12).

According to DRACES, there are 

more than 9,000 private health 

facilities in Guatemala. APROFAM 

and PASMO are the two largest 

NGOs in family planning and 

maternal health with national 

coverage.

42
TABLE 12: NUMBER OF PRIVATE HEALTH FACILITIES BY TYPE, JANUARY 2015

Facility Type Number

Health clinic 1,103

Specialized clinic 2,927

Dental clinic and laboratories 1,651

Alternative medicine center 241

Hospital (including outpatient only facilities) 135

Laboratories (various) 1,688

Other (including sports facilities and nursery homes) 1,808

Total 9,553

Source: General Directorate for Health Regulation, Vigilance, and Control (DRACES) interview, 2015

As stated above, the private for-profit sector is a key player in health services in Guatemala, 

even though, as the following market segmentation analysis shows, its market share in terms of 

provision of family planning, ANC, and delivery services is limited. 

4.2 MARKET SEGMENTATION

SHOPS conducted a market segmentation analysis of family planning, ANC, and delivery 

service provision to understand sourcing and behavior by wealth quintiles of clients accessing 

these services. While the market segmentation analysis of sourcing by quintile group has been 

used extensively for family planning services, it is increasingly being used to understand and 

improve equity of services in other health areas. To our knowledge, this is the first such analysis 

of ANC and delivery services in Guatemala.

4.2.1 FAMILY PLANNING

Sources of Services and Products

In Guatemala, the public sector has long history been the most important provider of family 

planning products/services. Figure 13 presents a breakdown of market share for all family 

planning products between 2002 and 2008, during which time MSPAS’ role increased from 32 

percent to 50 percent. In the same period, IGSS’ share increased slightly from 6 to 9 percent, 

and APROFAM’s share dropped from 32 percent in 2002 to 16 percent in 2008. Pharmacies 

remained a stable source of services and products at about 10 percent of the market in both 

2002 and 2008. 

43
FIGURE 13: CHANGING MARKET SHARE FOR FAMILY PLANNING PRODUCTS - ALL METHODS

Source: ENSMI 2002, 2008-2009

Figure 14 shows the source of family planning methods in different geographic areas. The 

public sector (MSPAS) is the primary source of family planning methods countrywide and in 

both Guatemala City and the Western Highlands region. In Guatemala City, IGSS is the second 

most common source of family planning methods due to a larger share of the formal 

employment sector in that area. In contrast, both countrywide and in the Western Highlands, the 

second most common source of family planning methods is APROFAM. The use of pharmacies 

is slightly higher in Guatemala City than the national average or Western Highlands. 

FIGURE 14: SOURCE OF FAMILY PLANNING METHODS BY REGION (ALL WRA) (%)

Source: ENSMI 2008-2009

Sources of family planning commodities change according to the type of method (short-acting, 

long-acting, and permanent). As illustrated in Table 13, MSPAS is the largest provider of 

3% 3%

14% 9%

13%

12%

32%

16%

6%

9%

32%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002 2008

MSPAS

IGSS

Aprofam

Pharmacy

Private for profit

Other

0%

10%

20%

30%

40%

50%

60%

70%

MSPAS IGSS Private for

profit

APROFAM Pharmacy Other

Countrywide

Western Highlands

Guatemala City

44
short-acting and permanent methods, at 58 percent and 42 percent of the market, respectively. 

APROFAM dominates the market for long-acting methods (mostly implants), providing 58 

percent of the services. Interestingly, the pharmacy sector provides only 24 percent of the shortacting contraception overall, far less than MSPAS. IGSS participation in short- and long-acting 

methods is limited, and is not significant in permanent methods.

TABLE 13: SOURCE PROVIDING EACH TYPE OF FAMILY PLANNING METHODS - COUNTRYWIDE

Source Short-acting Long-acting Permanent

Public sector 58 26 42

IGSS 3 2 17

Private for-profit 3 12 15

APROFAM 7 58 25

Pharmacy 24 0 0

Other 5 2 2

Total 100 100 100

Source: ENSMI 2008-2009

Socio-Economic Analysis of Family Planning Users

The quintile analysis for use of modern methods across geographic regions is shown in Figure 

15. In the Western Highlands, modern method users from the different wealth quintiles are 

represented relatively equally, whereas users from the two wealthiest (4th and 5th) quintiles 

largely dominate the group of modern method users in Guatemala City. 

FIGURE 15: SOCIO-ECONOMIC CHARACTERISTICS OF MODERN METHOD USERS (ALL WRA) (%)

Source: ENSMI 2008-2009

As seen below, there are wide variations in sourcing across wealth quintiles. The public sector i

s the predominant source (81 percent) of modern contraceptive methods for wealth quintiles 1-

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Countrywide Western Highlands Guatemala City

Q5 (Richest)

Q4

Q3

Q2

Q1 (Poorest)

45
3, but provides just 43 and 18 percent of modern contraceptives to quintiles 4 and 5, respectivel

y (Figure 16). APROFAM, forprofit providers, and pharmacies are the predominant sources for the two wealthiest quintiles. M

ore than 82 percent of users sourcing from the private forprofit sector are from those quintiles, as are 66 percent of APROFAM users and 71 percent of p

harmacy users (data not shown).

FIGURE 16: SOURCE OF MODERN CONTRACEPTIVES BY WEALTH QUINTILES (%)

Source: ENSMI 2008-2009

SOURCING AND QUINTILE ANALYSIS OF MOST WIDELY USED MODERN METHODS

Injectables

The public sector is by far the largest provider of injectable contraception (Table 14). Our market 

segmentation analysis indicates that the majority of income quintiles (1-4) source their injectable 

products from MSPAS. Only 18 percent of IGSS beneficiaries obtain injectable contraception at 

IGSS facilities; 52 percent of them source their injectable contraception from MSPAS. 

Interestingly, another 18 percent of IGSS beneficiaries purchase their injectables from private 

pharmacies. Only the 5th quintile is diversified in its sourcing patterns for injectable 

contraception, with 64 percent sourcing from pharmacies, private for-profit providers, and 

APROFAM.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1

(Poorest)

Q2 Q3 Q4 Q5

(Richest)

MSPAS

IGSS

APROFAM

Private for profit

Pharmacy

Other

46
TABLE 14: SOURCES OF INJECTABLES ACCORDING TO USER PROFILE (N=1,905)

Public Private

MSPAS IGSS Private forprofit APROFAM Pharmacy Other Total

According to residence (% of users)

Countrywide 77 3 3 4 8 4 100

Western 

Highlands 83 0 2 2 7 6 100

Guatemala City 56 10 8 9 13 5 100

According to IGSS coverage (% of users)

IGSS 

beneficiaries 52 18 4 5 18 3 100

Others 82 0 3 4 7 5 100

According to wealth quintile (% of users)

Q1 (poorest) 92 0 0 0 2 5 100

Q2 89 1 0 1 4 5 100

Q3 80 2 1 5 6 5 100

Q4 69 7 3 8 11 3 100

Q5 (highest) 27 5 20 11 33 4 100

Source: ENSMI 2008-2009

Sterilization

The public sector is a major provider of female sterilization throughout the country (Table 15). 

MPAS is the primary source for sterilization for quintiles 1-4. Only a small percentage of IGSS 

beneficiaries (34 percent) seek sterilization services from IGSS’ facilities; approximately a 

quarter of the IGSS-eligible population is sourcing either from MSPAS and APROFAM. Only the 

5th quintile is diversified in its sourcing patterns for sterilization services with 30 percent

sourcing from private for-profit providers and 27 percent from APROFAM.

TABLE 15: SOURCES OF STERILIZATION ACCORDING TO USER PROFILE (N=2,433)

MSPAS IGSS Private for-profit APROFAM Pharmacy Other Total 

According to residence (% of users)

Countrywide 42 17 15 25 2 100

Western 

Highlands 55 2 20 23 2 100

Guatemala 

City 26 36 17 21 1 100

According to IGSS coverage (% of users)

IGSS 

beneficiaries 26 34 15 24 1 100

Others 47 11 15 25 2 100

According to wealth quintile (% of users)

Q1 (poorest) 71 4 3 19 3 100

Q2 63 9 7 19 3 100

Q3 49 16 7 27 1 100

Q4 41 20 12 25 3 100

Q5 (highest) 21 21 30 27 0 100

47
Source: ENSMI 2008-2009

4.2.2 ANTENATAL CARE

Sources of Services

The major source of ANC across all geographic regions is 

home-based care at 41 percent countrywide (Figure 17). 

Even in Guatemala City, where the availability of health 

services and IGSS coverage is high, there is a high 

percentage of women who report home-based care. In fact, 

although IGSS has a constitutional mandate to provide 

health care at a nationwide level, its participation in 

providing ANC is very low in Guatemala City (<10 percent), 

lowest countrywide (<5 percent), and practically non-existent in the Western Highlands where 

the most vulnerable population lives. TBAs are the major provider (81 percent) of home-based 

care (MSPAS 2010), and TBAs are also key players when women seek ANC outside of their 

homes: 46 percent reach out to them, while 52 percent visit skilled providers and 2 percent visit 

other community-based personnel. In Guatemala City, the for-profit private sector in an 

important provider of ANC services. 

FIGURE 17: PLACE WHERE ANC IS RECEIVED (%)

Source: ENSMI 2008-2009

The sourcing pattern for ANC changes slightly when considering the number of visits to each 

provider. The three main sources remain the public sector (41 percent), home ANC (36

percent), and private for-profit (16 percent). Interestingly, the WHIP data present a different 

reality for the Western Highlands in 2012, where the public sector appears to be almost the only 

source of ANC (84 percent of visits). Additionally, WHIP data indicate that 86.2 percent of ANC 

care was performed by a physician or nurse (Angeles et al., 2014).

While the place of ANC could potentially have an impact on the place of delivery, the place of 

ANC does not necessarily lead to delivery in the same sector. Health sector institutions that 

provide ANC retain women for delivery in approximately one out of three cases. MSPAS retains 

36 percent of its ANC patients for delivery, IGSS retains 35 percent, and the private for-profit 

sector retains 33 percent. Many women change sectors and receive ANC services at IGSS or 

private for-profit clinics but deliver at public facilities (44 percent and 46 percent respectively).

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

MSPAS IGSS Private ForProfitAPROFAM Home Other

Countrywide

Western Highlands

Guatemala City

Sources of ANC differ by wealth 

quintile. All wealth quintiles use homebased care for ANC services, 

although use of home-based care 

gradually decreases as wealth 

increases. The role of the private forprofit sector is highest in top two 

wealth quintiles.

48
TABLE 16: PLACE OF DELIVERY AND PLACE WHERE ANC WAS RECEIVED (%)

Place where 

ANC was 

received

Place of delivery

MSPAS IGSS Private 

For-Profit

Private 

House 

(own / 

TBA)

Other Total

MSPAS 36 3 2 57 1 100

IGSS 44 35 14 7 0 100

Private forprofit 46 6 33 12 3 100

Private house 

(own / TBA) 25 7 2 66 1 100

Source: ENSMI 2008-2009

Socio-Economic Analysis of ANC Users

As illustrated in Figure 18, sources of ANC differ according to wealth quintiles. Interestingly, all 

wealth quintiles use home-based care for ANC services, although it gradually decreases as 

wealth increases. The role of the private for-profit sector increases significantly in the fourth (33 

percent) and fifth (54 percent) quintiles. IGSS and APROFAM play a small role in ANC services, 

with IGSS playing no role in the two poorest quarters. 

FIGURE 18: SOURCE OF ANC BY WEALTH QUINTILE (%)

Source: ENSMI 2008-2009

4.2.3 DELIVERY

Sources of Services

The majority of women countrywide (48

percent) and in the Western Highlands 

(64 percent) deliver either in their own 

0%

20%

40%

60%

80%

100%

Q1 (Poorest) Q2 Q3 Q4 Q5 (Richest)

MSPAS

IGSS

APROFAM

Private For-Profit

Home

Other

In the lowest wealth quintile, home births are most common in 

the lowest wealth quintile. In the highest wealth quintile, the 

largest proportion of births (37 percent) occurs in the private forprofit health sector. The National Health Council, CNAA, OSAR, 

and REDMISAR under the leadership of MSPAS constitute and 

effective framework to advocate for and achieve multisectoral 

coordination and optimization of major service providers.

49
home or in the home of a TBA, followed by facility-based delivery at MSPAS at 38 percent 

countrywide and 28 percent in Western Highlands (Table 17). Only in Guatemala City are 

facility-based deliveries the primary source for delivery—with MSPAS at 43 percent. Also in 

Guatemala City, IGSS is the second source of delivery services (30 percent). The for-profit 

private sector is the third most important source of facility-based deliveries in Guatemala City 

and countrywide. APROFAM plays a very small role in delivery services.

TABLE 17: PLACE OF DELIVERY ACCORDING TO USER PROFILE (N=2,433)

Place of delivery according to residence (%)

Public 

Sector IGSS Private For-Profit APROFAM

Private 

House 

(own / 

TBA’s)

Other

By residence

Countrywide 36 8 7 1 48 0

Western 

Highlands 28 1 5 1 64 0

Guatemala 

City 43 30 16 2 10 0

According to IGSS coverage (% of users)

IGSS affiliates 27 42 20 3 7 0

IGSS 

beneficiaries 28 42 14 2 13 0

Not covered 

by IGSS 40 4 7 1 48 0

According to wealth quintile (% of users)

Q1 (poorest) 23 1 0 0 76 0

Q2 37 4 1 0 56 1

Q3 50 8 4 1 36 0

Q4 51 23 12 2 13 0

Q5 (highest) 33 21 37 3 5 0

Source: ENSMI 2008-2009

Socio-Economic Analysis of Women Delivering

As illustrated in Figure 19, a significant proportion of all wealth quintile groups countrywide seek 

delivery services from the MSPAS, with the share highest in the middle-income groups (Q3 and 

Q4). Public sector delivery is proportionately the lowest in the first quintile, which is dominated 

by home delivery. The private for-profit represents the largest share of the market for the fifth 

quintile with 37 percent of deliveries.

As illustrated in Figure 20, in the Western Highlands, a significant proportion of all wealth 

quintiles have home-based deliveries. MSPAS is the second most important provider of delivery 

services, gradually increasing in quintiles 1-4. Interestingly, in the fifth wealth quintile there is a 

dramatic increase in the percentage of women who seek delivery services in the for-profit 

private sectors. 

50
As illustrated in Figure 21, in Guatemala City, the share of home delivery is lower than 

anywhere in the country. IGSS share reaches a higher amount than anywhere in the country at 

20 percent, 40 percent and 30 percent for Q3, Q4 and Q5 respectively. 

FIGURE 19: PLACE OF DELIVERY ACCORDING TO WEALTH QUINTILES - COUNTRYWIDE

Source: ENSMI 2008-2009

FIGURE 20: PLACE OF DELIVERY ACCORDING TO WEALTH QUINTILES - WESTERN HIGHLANDS

Source: ENSMI 2008-2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1

(Poorest)

Q2 Q3 Q4 Q5

(Richest)

MSPAS

IGSS

APROFAM

Private For-Profit

Private House (own /

comadrona)

Other

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1

(Poorest)

Q2 Q3 Q4 Q5

(Richest)

MSPAS

IGSS

APROFAM

Private For-Profit

Private House (own /

comadrona)

Other

51
FIGURE 21: PLACE OF DELIVERY ACCORDING TO WEALTH QUINTILES - GUATEMALA CITY

Source: ENSMI 2008-2009

4.2.4 SUMMARY OF MARKET SEGMENTATION FINDINGS

Family Planning

 In USAID’s 30 focus municipalities within the Western Highlands, 39 percent of WRA 

interviewed reported using a modern method of family planning (Angeles et al., 2014). 

Short-acting methods requiring resupply were the most popular, followed by permanent 

methods. As in the 2008-2009 ENSMI, long-acting methods other than permanent methods 

were low, at 5 percent of users.

 MSPAS is by far the major provider of family planning products and services for both shortacting and permanent methods. MSPAS’ provision of modern family planning methods 

increased significantly, from 32.2 percent in 2002 to 50.9 percent in 2008 (MSPAS, 2010). 

MSPAS is the major provider of family planning for all wealth quintiles except the fifth 

quintile. MSPAS is also the largest provider for Guatemala’s two most widely used methods: 

injectables (79 percent) and female sterilization (43 percent) services.

 APROFAM’s role in the provision of family planning services has decreased significantly 

from 32 to 16 percent from 2002 to 2008, although APROFAM continues to be the second

most important source of family planning. It is the most important provider in the private 

sector. In 2008, APROFAM was also the largest provider of implant services. APROFAM’s 

role in family planning and maternal health services will be further discussed below in the 

NGO section, including its network of clinics and its community-based distribution program.

 While IGSS is the second largest health care provider in the country and serves a large 

beneficiary population, it provides only 9 percent of family planning services (an increase 

from 6 percent in 2002). Only in Guatemala City is IGSS the second most common source 

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1

(Poorest)

Q2 Q3 Q4 Q5

(Richest)

MSPAS

IGSS

Private House (own /

comadrona)

Private For-Profit

APROFAM

Other

52
of family planning. Interestingly, only a small percentage of IGSS beneficiaries seek their 

services from IGSS facilities. They use the public sector (28 percent), the private for-profit 

sector (10 percent), APROFAM (17 percent), or pharmacies (17 percent). For injectable 

services, 52 percent of IGSS beneficiaries source their method from MSPAS. For 

sterilization services, 26 percent of IGSS beneficiaries go to MSPAS, 24 percent go to 

APROFAM, and 15 percent go to the for-profit private sector. 

 Pharmacies are the primary source of oral contraceptives (34 percent) and condoms (72 

percent), which is common for resupply methods, and representing overall 12 percent of 

family planning supply. Private for-profit providers supply 9 percent overall, primarily for 

IUDs, implants, and sterilization services. Interestingly, pharmacies are a source of supply 

for all wealth quintiles, including a small percentage of the lowest quintiles. Pharmacies and 

for-profit providers account for a larger percentage of the highest wealth quintile, reaching 

20 percent (pharmacies) and 23 percent (private for-profit providers). 

Antenatal Care

 The major source of ANC across all geographic regions is home-based care. Even in 

Guatemala City, where the availability of health services and IGSS coverage is high, a high 

percentage of women report receiving home-based care. TBAs are the major provider (81 

percent) of home-based care, and they are also key players when women seek ANC outside 

of their homes. ENSMI 2008-2009 reports that TBAs cover 33.2 percent of ANC services 

nationwide. However, the most recent data from the WHIP indicate that 86 percent of ANC 

care was performed by physicians or nurses. 

 Women who seek ANC at MSPAS or in their homes are most likely to delivery at home (57

percent) or in MSPAS (36 percent). Women receiving ANC from a private for-profit provider 

are most likely to deliver at MSPAS (46 percent) or in a private for-profit facility (33 percent), 

and are less likely to have a home delivery (12 percent). Women receiving ANC services 

from IGSS are most likely to delivery at MSPAS (44 percent) or an IGSS facility (35

percent), and least likely to delivery at home (7 percent).

 There is a potential to increase the role of IGSS for ANC and encourage WRA to remain 

with IGSS for delivery, as 44 percent of women receive ANC at IGSS.

Delivery

 The majority of women countrywide (48 percent) and in the Western Highlands (64 percent) 

deliver either in their own home or in the home of a TBA. MSPAS is the second most 

important provider of delivery services, gradually increasing in quintiles 1-4. at 38 percent 

countrywide and 28 percent in Western Highlands, is the second highest source of delivery 

services. 

 Only in Guatemala City are facility-based deliveries the primary source for delivery—with 

MSPAS at 43 percent. Also in Guatemala City, IGSS is the second source of delivery 

services (30 percent). The for-profit private sector is the third most important source of 

facility-based deliveries in Guatemala City and countrywide. APROFAM plays a very small 

role (2 percent) in delivery services.

 Countrywide, a large proportion of all wealth quintiles seek delivery services from the 

MSPAS, with the share highest in the middle-income groups (Q3 and Q4). Public sector 

delivery is proportionately the lowest in the first quintile, which is dominated by home 

delivery (86 percent). The private for-profit represents the largest share of the market for the 

fifth quintile with 37 percent of deliveries.

 In the Western Highlands, a significant proportion of all wealth quintiles have home-based 

53
deliveries. MSPAS is the second most important provider of delivery services, gradually 

increasing in quintiles 1-4. In the wealthiest quintile there is a dramatic increase in the 

percentage of women who seek delivery services in the for-profit private sectors. 

54
5 FINDINGS 

5.1 OVERVIEW

This chapter reports findings about key public sector organizations’ engagement with the private 

sector, key activities of leading NGOs, the for-profit sector, corporate foundations, and social 

responsibility organizations. In this chapter, we also identify opportunities for strengthening 

overall private sector engagement, building on the comparative advantage of existing 

organizations, and identifying new opportunities for scalable and sustainable private sector 

initiatives.

5.2 ENABLING ENVIRONMENT

5.2.1 GENERAL POLICY AND REGULATORY REVIEW

Guatemala has a strong legal framework that guarantees access to maternal health, 

reproductive health, and family planning services, providing a legal basis to guarantee and 

defend the right to these services and products (Table 18). In 2001, the Law on Social 

Development was approved, defining reproductive health (Article 10) as a right of the 

Guatemalan population, which includes “effective access for persons and families to 

information, orientation, education, provision, and promotion of reproductive health services, 

including family planning services, prenatal care, delivery and post-partum, prevention of 

cervical and breast cancer, treatment during pre-menopause and menopause, diagnosis and 

treatment of prostate illnesses, diagnosis and treatment in infertility, sexually transmitted 

disease, HIV/AIDS, and attention for adolescents.”7 In 2004, the Tax Law on Sale of Alcoholic 

Beverages guaranteed 15 percent of tax income would be dedicated to financing reproductive 

health and family planning and prevention of alcohol consumption and smoking. In 2005, the 

Law on Universal and Equal Access to Family Planning was approved; however, Catholic 

Church opposition to regulation tied to the law delayed its implementation until 2009. In 2010, 

the Law for Health Maternity was approved, establishing budgeting minimums for reproductive 

health programs and commodity procurement.

7 Compendio de Leyes para la Accion en Salud Reproductiva en Guatemala, August 2014.

55

 
TABLE 18: LEGISLATION RELATED TO SEXUAL AND REPRODUCTIVE HEALTH IN GUATEMALA 

2001-2012

Year Law Implication

2001-2002

Law on Social Development and 

Policy on Population and Social 

Development

Article 10 defines people’s right of access and 

responsibility of government to provide 

reproductive health, maternal health, and family 

planning services.

2004 Tax Law on Sale of Alcoholic 

Beverages

Guarantees that 15% of all tax income is 

dedicated to financing RH/FP and other health 

services.

2005 Law on Universal and Equal Access 

to Family Planning

Law is approved, but not put into effect until 

2009 when regulation is approved.

2009

Regulation on the Law on Universal 

and Equal Access to Family 

Planning 

Required MSPAS, IGSS, and other public and 

private institutions to make modern 

contraceptives available.* The National 

Commission for Contraceptive Security (CNAA) 

is officially installed.

2010

Law for Healthy Maternity Decree 

32-2010

Decree 19-2010 approves a budget 

expansion that excludes an 

exception to the requirements in 

Decree 72-2008.

Article 27 establishes a minimal allocation of 

15% for reproductive health programs and of 

30% for the purchase of contraceptives.

Approval allows MSPAS to transfer funds to 

UNFPA for the purchase of contraceptives.

2010

MSPAS and UNFPA sign a new 

agreement to continue procurement 

of contraceptives.

MSPAS uses funds from the 15% tax to 

purchase contraceptives, creating the 

framework for the procurement of 

contraceptives in future years.

2012

Regulation for the Law for Healthy 

Maternity 

Governmental Accord 65-2012

The approval of the regulation allows for 

implementation of the law and the requirement

to spend at least 30% of the tax on the 

purchase of contraceptives.

2013

Law for the General Budget of 

Income and Expenses of the State 

for the 2013 Fiscal Exercise

Includes an article that allows the transfer of 

funds and upfront payment of contraceptives 

through UNFPA.

* http://www.ipsnews.net/2009/11/Guatemala-sex-education-family-planning-finally-available/

Political Commitment for Family Planning and Maternal Health

Despite a strong legal framework in Guatemala, there is still significant opposition to the family 

planning program from religious and political entities. For example, as noted above, 

implementation of the Law on Universal and Equal Access to Family Planning was delayed for 

four years by legal challenges from the Catholic Church. In addition, Guatemala has had several 

presidential administrations with strong religious affiliations and opposition to family planning. 

For example, when the PEC began in 1996, it did not cover family planning services. 

Legislation Mentioning the Private Sector

The Law on Universal and Equal Access to Family Planning Services and the Healthy Maternity 

law both recognize the important role of the private sector in providing these services. While 

various multisectoral commissions exist in Guatemala, coordination across sectors is still limited 

and there is no mechanism in place to ensure appropriate reporting of health statistics. IGSS, 

for example, is particularly averse to sharing its reproductive health/family planning (RH/FP)

data, and reporting of private sector activities is limited. As discussed below in Section 5.3.3, the 

56
recently passed Decree 13-2013 prohibits NGOs from receiving and directly managing 

government resources, though it does not strictly prohibit contracting with other private players. 

Given the recent cancellation of the major contracting-out mechanism for non-facility-based 

services through the PEC, the government appears to be wary of mechanisms that directly 

finance NGOs. As a result, some of the positive experiences and lessons learned from the PEC 

experience will be lost—primarily the opportunity to increase and strengthen community 

participation and integrate contracting out and performance-based financing. Prohibiting

contracting out to NGOs and other private entities is viewed by some experts as a major 

setback in advancing public-private partnerships and improving performance-based results.

5.2.2 NATIONAL HEALTH COUNCIL

MSPAS is the main regulatory agency, responsible for governance of the health sector and the 

country’s Political Constitution asks that IGSS and the ministry be coordinated (Art. 100). The 

National Health Council was established in 2001 as an Advisory Body with the broad goal of 

strengthening development of an integrated health system in Guatemala and more specifically

to promote coordination among health sector entities.8 According to the initial government 

decree, the members include the MSPAS; IGSS; National Association of Municipalities (ANAM); 

Coordinator for Commercial, Industrial, and Financial Associations (CACIF); Assembly of 

Professional Medical Associations; University of San Carlos of Guatemala; Ministry of 

Education; and private universities, as well as any other institution deemed necessary to serve 

temporarily. While the National Health Council provides a forum for dialogue among 

representatives of the public health sector, professional and academic associations, and the 

organized private sector, it lacks the regulatory power to issue agreements or resolutions with 

binding authority over any segment of the public health system, including MSPAS and IGSS, 

making it in essence a discussion forum with no power of enforcement. 

Within the last year, with renewed leadership by MSPAS, the council has started meeting more 

regularly. Its existence does provide an opportunity for the interchange of information regarding 

institutional priorities and programs, which may be taken into account as each institutional actor 

individually develops and implements its own health-related programs. Several PSA 

interviewees suggested that if it continues with strong MSPAS leadership and political 

commitment it could represent an opportunity to strengthen multisector participation, suggesting 

that the National Health Council and MSPAS be empowered to effectively coordinate the 

delivery of public health care services across sectors.

5.2.3 NATIONAL COMMISSION FOR CONTRACEPTIVE SECURITY

In Guatemala, a number of USAID’s cooperating agencies and other organizations advocate 

strongly for measures to achieve contraceptive commodity security. In 2009, the National 

Commission for Contraceptive Security (Comisión Nacional de Aseguramiento de 

Anticonceptivos, CNAA) was officially established and coordinated by MSPAS’ Coordinator of 

the National Reproductive Health Program. Other government and nongovernmental agencies, 

such as the Presidential Secretariat for Women, Office for the Defense of Indigenous Women, 

IGSS, APROFAM, and the Association of Guatemalan Female Physicians, participate in the 

CNAA. In late 2013, CNAA published its Market Segmentation Strategy for contraceptives, 

which recognizes the importance of a sustainable, total market approach, and the need for an 

increased role for the private sector. The strategy outlines different scenarios for reducing 

unmet need and shifting method mix, projections and scenarios for Guatemala’s three primary 

family planning providers, MPSPAS, IGSS, and APROFAM, through 2015, but does not define 

8 Acuerdo Gubernativo No. 68-2001.

57

 
specific actions to achieve these scenarios. Nonetheless, there are still some important barriers 

to sustainable access to contraceptive commodities, including insufficient budget, legislation 

that requires special exemptions to allow for international procurement, limited engagement of 

the private sector. IGSS also has official representation within CNAA, but it provides limited 

information on its family planning program; stakeholders commented that IGSS’ participation in 

CNAA is noncommittal, which precludes important synergies for health care services. In 2015, 

CNAA is planning to develop more concrete actions based on the market segmentation 

strategy. Commercial commodities providers are not included in the discussion.

5.2.4 OTHER KEY ADVOCACY ORGANIZATIONS

To counter a generally conservative environment, there are a number of Guatemalan advocacy 

organizations that monitor public policy related to reproductive health. The Reproductive Health 

Observatory (Observatorio de la Salud Reproductiva, OSAR) is a consortium designed to 

monitor implementation and fiscal management of public policy related to reproductive health. 

Member organizations of OSAR include the Congress of Guatemala, Faculty of Medicine from 

San Carlos University, Faculty of Medical Sciences and Health from Mariano Galvez University, 

University Institute of Women (Instituto Universitario de la Mujer de la USAC), the Women’s 

Health and Development Entity, the College of Physicians and Surgeons, the Guatemalan 

Association of Female Physicians, and the Guatemalan Association of Obstetrician and 

Gynecologists. OSAR is dedicated to the systematic follow-up and collection of data and 

indicators regarding the advancement and performance of health policy implementation. The 

Network of Indigenous Women for Reproductive Health (Red de Mujeres Indigenas por la Salud 

Reproductiva, REDMISAR) is a network of indigenous women’s organizations that started in 

2009 and has been involved in monitoring at the service delivery level. REDMISAR conducts 

monitoring visits every six months using a checklist to assess infrastructure, cleanliness, 

availability of health personnel, health and family planning commodities, and other aspects of 

service delivery. In Quetzaltenango there are 25 member organizations, 20 in Totonicapán.

Several PSA interviewees stated that MSPAS does not currently have a formal position on the 

role of TBAs in the health sector. Traditional community-based organizations among indigenous 

peoples, as well as the various community-based organizations and networks of community 

health facilitators and TBAs, constitute important elements of the country’s health system that

have not been successfully integrated into the national health system.

5.3 PUBLIC SECTOR ORGANIZATIONS 

5.3.1 MSPAS

MSPAS, which plays the dual role of “rector” (overall senior 

authority, or rectoría) of the country’s health system, and 

provider of publicly financed health services including the 

largest network of local, regional, and national health 

service providers. In practice, coordination and 

communication among sectors is limited, particularly 

concerning IGSS and the private sector. The PSA 

assessment took place at a time when Guatemala was facing notable challenges to its 

leadership in the political and social spheres, as well as facing potential transitions with the 

upcoming elections in the fall of 2015.

Based on interviews with ministry staff at central, regional, and departmental levels, it appears 

that MSPAS needs to strengthen its oversight of the health sector and engagement with other 

sectors. While various commissions for multi-sectoral dialogue exist in Guatemala, there is little 

According to some interviewees, is too 

early to know whether MPSAS’s new 

strategy can adequately replace the 

services previously provided under 

PEC or achieve the objectives of 

comprehensive primary health care.

58
engagement of the for-profit private sector in these fora and no mechanism by which the 

ministry can ensure all health system entities report health statistics so that the ministry can 

coordinate governance efforts in an informed way. This would include participation by the forprofit sector, including the pharmaceutical industry as well as professional medical associations, 

such as the College of Physicians and Surgeons, Association of Obstetricians and 

Gynecologists, Association of Pediatricians, and others.

Nearly all informants mentioned the institutional crisis that MSPAS is currently facing, which is 

linked to recurring insufficient budgets and weakened infrastructure for providing basic care. 

Stakeholders reported widespread shortages of essential medicines, including vaccines and 

family planning commodities as well as vital supplies for delivery services.

Program for Extended Coverage

Over the past 20 years, NGOs have been contracted by MSPAS to provide health services in 

rural areas, and they have played a major role in the expansion and improvement of health 

services throughout the country. This began with the signing of the Peace Accords of 1996, 

which provided a new impulse for the health system, mandating increased public expenditure 

for health and specifying that the funds should be used to extend health services to 

marginalized rural areas. Faced by many challenges to expanding its services directly, MSPAS 

elected to contract NGOs to expand coverage more rapidly through the Extension of Coverage 

Program (Programa de Extensión de Cobertura, PEC). The PEC system contracted private 

providers and administrators to provide health services to populations without access to a health 

post. PEC implementers included many types of organizations, from NGOs that provided health 

services, to savings and loan cooperatives, and other enterprises. 

PEC did not initially cover family planning services and products. Its incorporation of these 

services and products (condoms, oral contraceptives, and injectables) into its basic health 

services package in 2003 increased family planning coverage significantly. Through PEC, 

MSPAS expanded services from 4,400 community health centers, 380 basic health teams, and 

23,000 community facilitators9 to hard-to-reach communities throughout the country. The basic 

health teams visited convergence centers at least once per month to provide medical 

consultations, including family planning, growth monitoring and screening, vaccinations, and 

provision of vitamins and minerals. However, the PEC program suffered from poor 

implementation, including weak performance objectives and services, limited oversight and 

monitoring, and limited financing (including late payments) for implementing NGOs. In 2013, 

amidst criticisms and accusations of inefficiencies and lack of accountability of PEC contracts, 

Guatemala’s Congress passed Decree 13-2013, which sought to improve efficiency and 

transparency of the resources in the health sector and prohibited NGOs from managing 

government resources. The law provided a three-year period for MSPAS to phase out the PEC 

program, but at the end of 2014 MSPAS cancelled the program without having an alternative 

strategy in place. The abrupt cancellation was due to irregularities in implementation and 

resource management by some NGOs as well as lack of MSPAS resources to continue funding 

PEC. Some PSA interviewees suggested that, in addition to the above reasons, the PEC was 

dismantled due to the severe financial debt accrued by MSPAS in paying for these contracts, 

compounded by even more limited financial resources than in prior years. Regardless of the 

issues that existed with the PEC network, the loss of over half of the service delivery points in 

the country will have a negative impact on access to health services.

9 http://mspas.gob.gt/salud/web/index.php?limitstart=260

59

 
Strategy for the Institutional Development and Strengthening of the Primary Level of 

Care

For many stakeholders the failure and cancellation of the PEC program highlighted the 

magnitude of unmet need. MSPAS faces intense pressure to develop and implement an 

alternative strategy to provide health access to those populations covered through PEC, many 

of whom now are without access to basic care. In March 2015, MSPAS outlined an alternative 

strategy, which is focused on strengthening the first level of care, primarily health posts, to 

continue to support existing community convergence centers. Its components include:

 Strengthening of the health human resources, equipment, facilities, and medicines

 Promotion of family health and health education

 Monitoring, physical growth and promotion of good nutrition, and monitoring during the 

window of 1,000 days from conception to two years of age

 Zero Hunger Plan (Plan de Pacto Hambre Cero) health care with emphasis on neonatal and 

reproductive health

 Traditional alternative medicine

 Drinking water, and household and environmental sanitation

 Prevention and control of endemic diseases 

 Diagnosis, treatment, and referral services

The new strategy, which was planned to start in early 2015, will use existing personnel currently 

based at health posts as well as recruit mobile health teams of community outreach specialists, 

including one nursing assistant, six community facilitators, 10 midwives, and one data specialist. 

These additional personnel are expected to be recruited from former PEC staff. As provided by 

MSPAS, the estimated cost of each mobile health team is Q104,500 annually (US$13,600) 

however the assessment team was not provided with a detailed analysis of how these costs 

were estimated (MSPAS, 2015). The total strategy is projected to cost about Q123 million 

(US$16 million) versus the estimated Q430 million (US$56 million) the PEC would have cost. 

The population to be covered will include one health post, 2,000 to 2,500 inhabitants per sector, 

a maximum of 5,000 inhabitants per territory. Stakeholders interviewed for the PSA were 

unclear as to whether the new strategy will be able to reach the same number of people and 

whether MSPAS will be able to provide the significant funding it will need. It is still too early to 

tell whether this new strategy will adequately replace the services formerly provided by the PEC 

in a timely fashion, or achieve the lofty goals of comprehensive PHC.

Municipal-Level Partnerships

According to the Municipal Code (Decree No. 12-2002 as 

amended by Decree 22-2010), the Municipal Council is 

required to appoint several commissions including one on 

Health and Social Assistance; these commissions can 

make proposals to improve efficiency in municipal public 

services and management (Arts. 36 y 37). Furthermore, consistent with the objectives of 

decentralization, a municipality may be delegated the authority, based on its administrative 

capabilities, to deliver selected public services including compliance with sanitary control 

regulations governing the production, distribution, and consumption of food and beverages in 

order to guarantee the health of the municipal population (Art. 70) (Avila, 2015).

Because of limited access to health services and the failure of existing systems, several 

municipalities in the Western Highlands have entered into innovative partnerships to address 

Several municipalities of the Western 

Highlands developed innovative 

partnerships with MSPAS to confront 

the health needs of their citizens.

60
the health care needs of their populations, including agreements between municipalities and 

MSPAS at the departmental level. In these partnerships, MSPAS and municipalities share the 

responsibility for funding personnel, medical supplies and commodities, and training. One 

example is the municipality of La Esperanza (Quetzaltenango Department), which has 33,000 

inhabitants and 22 Development Councils (COCODEs) that are designed to guarantee the 

participation of indigenous groups in community development. Proposals and development 

projects are presented by the councils, reviewed and approved, and then financed by the 

municipality, but the process can take several years to complete given the need for local-level 

advocacy and planning and government funding cycles. Through this type of partnership, La 

Esperanza built a health center on municipal property that will be managed by MSPAS 

personnel. The municipality pays the salary of one medical coordinator, one professional nurse, 

one nurse assistant, one secretary, and one part-time environmental inspector. The health 

center has a family planning department that offers reversible contraception, and an agreement 

with APROFAM to provide permanent methods at the health center. While these partnerships 

demonstrate the resourcefulness of local communities to address their healthcare needs, they 

generally take several years to develop, are often under-funded, and not systematically 

developed or monitored.

Summary of Findings for MSPAS:

 MSPAS is charged with stewardship or governance (rectoría) of the health sector, however, 

in practice, coordination and communication among sectors is limited, particularly

concerning IGSS and the private sector, and while various commissions for multi-sectoral 

dialogue exist in Guatemala, there is little engagement of the for-profit private sector in 

these fora.

 In addition to leaving a large percentage of the population without access to health services, 

the recent legislation prohibiting contracting out to NGOs and cancellation of the PEC will 

also inhibit the health sector’s ability to explore new opportunities for public-private 

partnerships and integrate alternative models for achieving performance-based results.

 For more than a decade, MSPAS, donor-funded projects, and advocacy organizations have 

been working to increase awareness of contraceptive security and have made important 

advancements, including establishment of the CNAA. Nonetheless, there are still some 

important barriers to sustainable access to contraceptive commodities, including insufficient 

budget, legislation that requires special exemptions to allow for international procurement, 

as well as limited engagement of the private sector in the CNAA committee.

 The market segmentation analysis demonstrates that MSPAS is by far the major provider of 

family planning products and services for both short-acting and permanent methods. 

MSPAS’ provision of modern family planning methods increased significantly, from 32.2 

percent in 2002 to 50.9 percent in 2008 (MSPAS, 2010). MSPAS is the major provider of 

family planning for all wealth quintiles except the fifth quintile. MSPAS is also the largest 

provider for Guatemala’s two most widely used methods: injectables (77 percent) and 

female sterilization (42 percent) services.

 Countrywide, a large proportion of all wealth quintiles seek delivery services from the 

MSPAS, with the share highest in the middle-income groups (Q3 and Q4). Public sector 

delivery is proportionately the lowest in the first quintile, which is dominated by home 

delivery (86 percent). In the Western Highlands, a significant proportion of all wealth 

quintiles have home-based deliveries. MSPAS is the second most important provider of 

delivery services, gradually increasing in quintiles 1-4.



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5.3.2 GUATEMALAN INSTITUTE FOR SOCIAL SECURITY

IGSS has a service delivery network of 123 medical units 

distributed in all departments, of which 23 are hospitals. 

Forty units are located in the USAID focus areas of 

Huehuetenango, Quetzaltenango, Quiché, San Marcos,

and Totonicapán. According to IGSS representatives, the 

current infrastructure is insufficient to meet the needs of the insured population and their 

beneficiaries. IGSS is finalizing construction of the Regional Hospital of Quetzaltenango, which 

will serve as a referral center for multiple Western departments. Within the next five years, IGSS 

plans to build a new complex of four specialty hospitals in Guatemala City.

IGSS has been contracting private providers to expand the coverage of services. Since 2002, 

IGSS’s insured population was assigned to a membership medical unit; these units were in 

charge of a referral system to private providers. These contracted services allowed IGSS to 

expand coverage of ambulatory services while reducing the number of health posts it operated 

and gain in efficiency.

Regarding sexual and reproductive health services, IGSS provides services for the early 

detection of cervical cancer, breast cancer, prostatic cancer, menopause, health education, and 

promotion of family planning. IGSS’ family planning program is institutionalized under 

Resolution No. 1165 (August 2005). According to ENSMI 2008–2009, IGSS covers 10 percent 

of the market for family planning, making it a key player for the health system in Guatemala and 

a source of supply of products and services to its policyholders and beneficiaries. However, this 

percentage may have declined in recent years. The market segmentation analysis using 2008-

2009 ENSMI data suggests many IGSS users seek family planning services at MSPAS. More 

recent data (for 2012), from the CNAA Market Segmentation Strategy, suggest that IGSS 

provided only 7 percent of all family planning services. 

Resolution 1165 requires IGSS to budget sufficient resources for reproductive health and family 

planning services. However, during interviews with IGSS stakeholders, it was stated that 

contraceptive procurement is not being done at the central level; this function has been 

delegated to the region based on demand. However, in some departments, service sites had no 

commodities and were not familiar with Resolution 1165.

Stakeholder interviews suggest that there is not widespread knowledge of IGSS policy to 

provide family planning services, and contraceptives are not widely available. Informants 

pointed out that Resolution 1165 includes barriers to family planning access, including requiring 

that women have at least two living children to receive sterilization. According to interviews with 

advocacy groups, IGSS needs to address several institutional policies to harmonize norms and 

regulations regarding family planning with the Law of Social Development, Law on Universal 

and Equitable Access to Family Planning, Law for Healthy Maternity for Maternal and Neonatal 

Health issues, and other gender rights policies.

Interviews made it clear that providers, beneficiaries, and affiliates are not aware of the 

availability of family planning services through IGSS facilities. Employers do little to demand 

better quality and access to health services for their employees. 

Despite these shortcomings, almost all stakeholders recognize that IGSS has a critical role to 

play and must be a key player in ensuring a more balanced, sustainable market.

Summary of Findings for IGSS

 IGSS’ family planning resolution #1165 requires that IGSS budget for sufficient resources for 

reproductive health and family planning services; however, PSA interviewees suggested 

Nearly all stakeholders recognize that 

IGSS plays a critical role and must be a 

key actor to ensure a more balance 

and sustainable market.

62
that contraceptive procurement is not being conducted at central levels, and this function 

has been delegated based on demand.

 Resolution #1165 includes some key medical barriers to FP access, including stating that 

beneficiaries and affiliates are only eligible for FP services up to 26 weeks post-partum, 

requiring a written request for sterilization services by the beneficiary, and requiring that 

women have at least two living children.

 The institutional and budgetary autonomy of IGSS effectively isolates it from anything other 

than a voluntary coordination or sharing of resources with MSPAS. Protocols for reimbursing 

MSPAS for services provided to IGSS beneficiaries, sharing facilities and resources, and 

avoiding an unnecessary duplication of facilities and services should be an immediate 

objective.

 The market segmentation analysis suggests that only a small percentage of IGSS 

beneficiaries seek their FP services from IGSS facilities. Instead, they seek their services 

from MSPAS (28 percent), APROFAM (17 percent), pharmacies (17%), and for-profit private 

providers (10 percent). In terms of ANC services, IGSS plays a very small role in ANC 

services, even among the highest wealth quintiles. In Guatemala City, IGSS is the second 

highest source of delivery services (30 percent) and reaches a higher portion of wealth 

quintiles than anywhere else in the country at 20 percent, 40 percent and 30 percent for Q3, 

Q4 and Q5 respectively.

5.4 NONGOVERNMENTAL ORGANIZATIONS

Guatemala benefits from a wide range of international, regional, and local non-governmental 

organizations that have been instrumental in increasing access of RH/FP and MCH services to 

underserved populations, including indigenous populations. While the team met with multiple 

organizations, the PSA report focuses primarily on two of the largest NGO providers and 

opportunities for building on their comparative advantages to strengthen the overall RH/FP and 

MH market. The report also provides a brief overview of another smaller regional NGO called 

WINGS (Alas in Spanish) that focuses on providing family planning and reproductive health

services to underserved clients and most remote areas.

5.4.1 APROFAM

The Family Welfare Association in Guatemala (Asociación 

Pro-bienestar de la Familia, APROFAM) is a private, 

nonprofit organization affiliated with the International Planned 

Parenthood Federation with more than 50 years providing 

health services. During these five decades, APROFAM has 

been a key stakeholder in the delivery of women’s and children’s health services for lower- and 

middle-income clients with an emphasis on sexual and reproductive health. USAID provided 

significant support and investment over the years to help APROFAM achieve its leadership 

position although APROFAM no longer receives direct USAID-support. APROFAM is the 

second largest provider of family planning methods (16 percent) after MSPAS (50.9 percent).

Between 2002 and 2008, APROFAM’s role in the provision of family planning services fell from 

32 percent to 16 percent, which likely reflects APROFAM’s increasing emphasis on diversifying 

its services and client base to strengthen financial sustainability in preparation for USAID phaseout.

APROFAM provides comprehensive health services to Guatemalans who lack economic 

resources and have limited access to other private health services. APROFAM has a presence 

APROFAM’s mobile units are the 

only ones in the country equipped 

to provide laparoscopic voluntary 

surgical contraception.

63
in most departmental capitals through its network of 27 clinics spread across the country and 

through its social programs. Through its clinic network, APROFAM offers general medicine and 

specialty consultations, laboratory services, diagnostic services, sale of medicines, normal and 

caesarean deliveries, and short-acting, long-acting, and permanent contraception. Clinic 

services are financed through user fees, which are tailored to the geographic region and ability 

and willingness to pay. Services are cross-subsidized with different types of services across 

clinics because some clinics have higher profit margins. 

APROFAM is also playing an important role in maternal health services. Between 2012-2014, 

APROFAM attended 8,725 deliveries, averaging 2,908 deliveries per year, 65% by cesarean 

section. In the West there were 1672 births in the last three years, which means 19% of total 

deliveries by the institution attended. The demand for delivery services in APROFAM both 

nationally and in the Western Highlands is low, compared to the high demand for ANC.

APROFAM currently utilizes approximately 50% of installed capacity for deliveries, suggesting 

that there is potential for APROFAM to increase its support for skilled childbirth. APROFAM has 

also diversified its services SSR and has become an alternative in cities where it has 

established its clinics offering other services to women of reproductive age and affordable more 

beyond family planning and deliveries. For example, APROFAM averages 75,246 pap smears 

and 41,265 ultrasounds for pregnant women per year.

APROFAM also supports three main social programs that are subsidized through donor funding 

and designed to reach the underserved: the adolescent program, the community-based 

distribution program, and the mobile outreach program (Table 19). APROFAM’s mobile units are 

the only ones in the country that are equipped to provide laparoscopic voluntary surgical 

contraception and therefore represent a strong comparative advantage. Interviews with 

stakeholders indicated that MSPAS recognizes APROFAM’s major contribution to family 

planning coverage. These mobile outreach units will continue to require subsidy given the high 

(and unsustainable) costs associated with reaching remote areas. APROFAM reported that 

costing of mobile services needs to be adjusted in current agreements with external funders; the 

current reimbursement scheme is not covering full operating costs given that APROFAM is 

reimbursed on a per client basis and operating costs for reaching outlying areas may be higher 

than the total number of clients served. Other stakeholders reported that coordination and 

promotion could also be improved to ensure that mobile units serve a higher number of clients 

during their outreach services.

APROFAM has also built a strong network of community volunteers, designed to provide FP 

services in Guatemala’s remote areas. In 2014, APROFAM had 1,861 community promoters, a 

13 percent decrease from 2012 levels. In the Western Highlands, in 2014 APROFAM had a total 

of 376 promoters, a 33 percent decrease over 2012 levels. The gradual reduction in community 

promoters is related to APROFAM’s increasing emphasis on financial sustainability, lack of

supervision and follow-up, as well as competition by other NGO programs offering the same 

products in the same geographic areas, but with higher subsidies.

In 2009, USAID and APROFAM established a memorandum of understanding to develop a 

Sustainability Trust Fund (STF) to guarantee the continuity and sustainability of APROFAM’s 

social programs. In 2014, the fund had US$14.3 million, generating approximately US$1.5 

million in interest per year. The agreement stipulated that use of the STF will be overseen by 

committee, that USAID would participate as a passive observer, and that APROFAM would fund 

at least one project per year using the STF. In September 2014, SHOPS conducted an 

assessment of APROFAM’s ability to receive direct funds, which included several 

recommendations on how to best utilize the STF, including reviewing and strengthening 

APROFAM’s community promoter network given that lack of supervision and follow-up has 

resulted in loss of community promoters and supporting mobile units to continue strategically 

64
targeted provision of long-acting and permanent services in underserved areas in the Western 

Highlands, and using APROFAM’s installed capacity in the Western Highlands to partially 

subsidize referrals for deliveries.

TABLE 19: APROFAM'S LEADING SOCIAL PROGRAMS

Program Description Geographic Coverage Financial Support

Adolescent 

program

Peer educators sensitize, train, and 

promote responsible and informed 

of sexual and reproductive health 

and HIV management.

Urban and suburban 

areas, with some 

attempts to expand to 

rural areas

External donor support

Communitybased 

distribution

Volunteers who are recognized in 

the community as a source of 

supply of modern contraceptive 

methods for poor and indigenous 

women.

Distribution points are 

located in peri-urban and 

rural areas to strengthen 

the distribution coverage 

of contraceptives to 

ensure afforable access.

Self-financed by APROFAM, 

which purchases some 

commodities and gets others 

donated by IPPF. In 2013, 

cost recovery of this program 

was estimated at 83%.

Mobile 

health units

These five units are the only 

mobile units in the country that 

provide voluntary surgical 

contraception for men and 

women. Long-acting methods 

(insertion and removal of IUDs 

and implants) are also offered. 

MSPAS recognizes the importance 

of these efforts to expand family 

planning services in remote areas 

of the Western Highlands and 

supports coordination and 

community mobilization.

Coverage includes 

suburban and rural areas 

where public health 

services and private 

(almost nonexistent) are 

unable to offer them.

The beneficiaries are 

poor, rural, and 

indigenous women.

The program is highly 

subsidized and users provide 

only a symbolic fee or receive 

free services. In 2012, cost

recovery was estimated at 

41%. For services from the 

two mobile units funded by 

USAID for the Western 

Highlands, users do not pay;

APROFAM receives financial 

support through PASMO. For 

services from the two mobile 

units financed by Bergstrom, 

APROFAM charges Q25 per

service. For services at the 

unit financed by APROFAM 

with its own funds,

APROFAM charges Q60 per 

procedure. 

Summary of Findings for APROFAM:

• APROFAM is in a critical time where it is striving to maintain its leadership position as 

the second largest provider of FP services in the country, while streamlining operations 

and increasing its overall sustainability through diversification. APROFAM no longer 

receives direct support from USAID, and it receives minimal external donor funding for 

specific components of its portfolio.

• APROFAM’s mobile units represent an important comparative advantage for the 

organization since they are the only ones in the country that provide laparoscopic 

surgical sterilization. MSPAS also recognizes these units to be complementary to its 

actions and allows APROFAM to collaborate in targeted public sector outreach

initiatives. However, APROFAM should seek to strengthen coordination, promotion and 

dissemination of these medical outreach activities with other key stakeholders to ensure 

that they are optimizing number of people who can benefit from services. 

65
• APROFAM’s social programs providing services to poor and remote areas will always 

require significant subsidy, and external funding may not cover all costs. APROFAM 

must decide what social programs are essential to its mission and continue its full 

commitment to their success. For example, APROFAM’s community-based distribution 

program has reduced its coverage due to the organization’s need to streamline activities 

and the presence of other donor-supported activities in these areas that support similar 

activities.

• APROFAM’s hospitals, particularly in the Western Highlands, report underutilized 

capacity for delivery services, which through appropriate targeting and demand-side 

financing (e.g., vouchers) given the urgency to improve MH indicators in that region. As 

mentioned above, these services could also be partially subsidized by APROFAM’s STF.

5.4.2 PASMO/RED SEGURA

Population Services International (PSI) established the Pan 

American Social Marketing Organization (PASMO) to 

strengthen social marketing and behavior change 

communication for HIV/AIDS prevention in the Central

America region. Since its founding in 1997, PASMO continues 

to expand its portfolio in Guatemala to include private- and 

public-sector interventions. PASMO has a presence in every 

country in the region and is headquartered in Guatemala. The 

social marketing organization has grown its portfolio to include 

a wide range of health initiatives; many of them have achieved 

self-sufficiency. For example, PASMO’s condom social marketing initiative no longer receives 

donor support as KfW stopped providing financial assistance more than three years ago. 

Through Red Segura, PASMO developed a strong network of private providers that has 

increased provision of IUD services among private providers over the last five years. Launched 

in 2009, Red Segura currently includes 243 private providers, primarily gynecologists (80

percent) and general physicians (20 percent). While the network is national, the majority of 

providers are located in Guatemala City. Out of 243 providers, only 26 are located in the 

Western Highlands. Providers must be certified and active members of the Medical College. 

The network succeeded in recruiting a substantial number of active providers, although 

recruitment and training of providers are time and cost intensive considering the large attrition 

rate. PASMO estimates that to date it has recruited more than 900 providers, but many of them 

later withdrew or were dropped by PASMO due to inactivity, poor performance, or resistance to 

reporting. 

The benefits to providers to participate in the network include: 1) increasing their knowledge and 

skills in IUD and implant insertion, family planning, and counseling and informed consent, 2) 

receiving basic equipment, 3) access to affordable methods and other consumable supplies 

(cotton, gloves, etc.), and 4) receiving support from Red Segura’s promoter agents. The network 

employs one promoter agent per physician (estimated area of five kilometers), and there are 

approximately 60 promoters for the entire network. There are no established maximum pricing 

levels since the Guatemalan Colegio Médico does not allow it, but clients are referred to doctors 

based on their socioeconomic profile. Red Segura estimates that it costs approximately 

US$1,000 per provider to recruit and train each physician in the network. There are no fees for 

doctors to be members of the provider network. 

Red Segura has proven to be a successful model for increasing IUD and implant use through 

private providers (monitoring and evaluation data from Red Segura indicates a 73 percent

Red Segura has been a 

successful model to increase the 

use of IUDs and implants through 

private providers. Many people 

from the medium or high income 

sectors go to MSPAS facilities for 

family planning and maternal 

health services. There is an 

opportunity for the private sector to 

increase its market share with 

these clients

66
increase in IUD distribution between 2010 and 2011 and a 18 percent increase between 2013 

and 2014), however PASMO has not yet developed a sustainability strategy that would address 

long-term operation and management of the network. Nonetheless, given the network’s success 

in rapidly expanding provision of long-acting methods in the private sector, there are 

opportunities to consider with Red Segura for targeted expansion to priority geographic areas 

and to incorporate additional MH services among participating providers, particularly among 

middle-income users that are largely using the public sector for ANC and delivery services. 

Based on SHOPS’ market segmentation analysis of delivery services, even in Guatemala City a 

large percentage of the highest wealth quintiles are delivering at MSPAS (33%). Since a large 

percentage of the Red Segura network providers are gynecologists, there may be an 

opportunity to link the network (or selected providers) to provision of antenatal and delivery 

services through targeted, demand-side financing. Given that there is limited coverage outside 

of Guatemala City, the network could explore the feasibility of geographic targeting of new 

providers in priority regions; Quetzaltenango, for example as the second largest city, has a 

strong private health market. 

Summary of Findings for Red Segura:

 Red Segura represents a strong private network with a comprehensive service delivery 

model that has successfully increased provision of IUD services among private providers 

over the last five years. However, PASMO has not yet developed a sustainability strategy for 

the network and relies heavily on external donor funding.

 Despite the low coverage outside of Guatemala City, there is opportunity to explore 

geographic expansion of Red Segura providers in priority regions to further increase access 

to FP services. 

 In addition, given that 4th and 5th quintiles (highest) still rely strongly on home-based births 

and MSPAS, there is an opportunity to expand the provision of ANC and delivery services 

through the Red Segura network in Guatemala City and Quetzaltenango using targeted, 

demand-side financing.

5.4.3 WINGS

WINGS, which was founded in 2001, is a small NGO that provides reproductive health and 

family planning services to Guatemala’s most underserved and remote populations. WINGS

provides education and access to reproductive health services for rural, indigenous, and lowincome populations. Their primary technical areas include family planning services, cervical 

cancer screening and treatment, and adolescent information and services. WINGS operates 

one newly established clinic in Antigua, two mobile clinics, approximately 103 community 

volunteers who provide RH/FP information and services, and agreements with other private 

hospitals and clinics to provide facility-based services. They are almost exclusively financed 

through individual and organizational contributions, and they currently receive no financial 

support from USAID. They maintain institutional alliances with PASMO, APROFAM, SHEVA, 

and various other public and private hospitals and clinics to strengthen their collaboration and 

coordination. Given their relatively small structure, their strategic advantage is that they are able 

to respond quickly to specific needs for information, education, and services throughout the 

country’s most remote and difficult-to-reach areas.

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5.5 FOR-PROFIT PRIVATE SECTOR

5.5.1 FOR-PROFIT PRIVATE PROVIDERS

Guatemala’s private sector represents a large and growing segment of the health care market. 

Regardless of income level, many Guatemalans seek care in the private sector, and although 

use of private providers involves out-of-pocket payments, many household use the private 

sector as their first point of care. The for-profit private sector includes high-end tertiary hospitals, 

small specialty and general hospitals (95), clinics for specialized medicine (2,927), clinics for 

general medicine (1,103), and laboratories (1,373), representing approximately 60 percent of all 

registered facilities.

MSPAS oversees private sector facilities through the General Directorate for Health Regulation, 

Vigilance, and Control (Departamento de Regulación, Acreditación y Control de 

Establecimientos de Salud, DRACES), which is responsible for overall regulation and licensing 

of for-profit private sector facilities. Interviews with DRACES revealed that a fair number of 

facilities are opening every year, and at the time of the interview, there were 9,553 facilities 

related to health care registered in the country, with the majority registered in Guatemala City 

and Quetzaltenango. Most stakeholders interviewed recognized that Guatemala City and the 

municipality of Quetzalentango were the two main “hubs” for private sector providers, although 

data disaggregated by region or department are not easily available. 

The requirements and forms for registration are straightforward and easily accessible on the 

DRACES website. DRACES maintains an Excel database of all private providers, but the 

database does not allow for analysis by geographic area. DRACES is also responsible for 

monitoring all private sector facilities, although its resources are limited, and monitoring teams 

make only periodic visits to outside of Guatemala City. PSA interviews suggested that there are 

no incentives or credit opportunities available to encourage providers to open private practice 

outside of major urban areas.

Registration in Guatemala’s College of Physicians and Surgeons (Colegio de Médicos y 

Cirujanos de Guatemala, CMCG) is required by law in order for all physicians to obtain their 

license. CMCG currently has more than 19,000 registered physicians. Although CMCG statues 

stipulate that health workers should undergo periodic re-certification and accreditation 

procedures, the only requirement in practice is for active members to pay their monthly fees

(Decreto 72-2001). Thus there is little regulation of health workers once they are graduated and 

licensed. Professional medical associations also exist at the regional levels. Most providers 

interviewed agreed that there were no barriers to the establishment of private sector health 

facilities. Many of these professional medical associations are involved in supporting continuing 

education, but with limited engagement and awareness of priority public health issues, such as 

reproductive health, family planning, and maternal health services.

Regarding the for-profit sector’s role in the provision of RH/FP and MH services, according to 

2008-2009 ENSMI , approximately 9 percent of women seek their family planning services 

through a private hospital, clinic, or provider, primarily for IUDs (13 percent of private for-profit

sector users for family planning) and implants (9 percent of private for-profit sector users for 

family planning). This percentage is fairly consistent both in Guatemala City and country-wide.

The largest percentage in use of the for-profit private sector for FP services in from the highest 

wealth quintile, however a large percentage of this quintile (approximately half) still use public 

sector for FP services. In terms of ANC, while all wealth quintiles use home-based care for ANC 

services, the role of the for-profit sector increases significantly in the higher wealth quintiles (4th

and 5th). In Guatemala City, the for-profit private sector in an important provider of ANC services 

in Guatemala City. In terms of facility-based deliveries, the for-profit private sector is the third 

68
most important source of facility-based deliveries in Guatemala City and countrywide. The 

market segmentation analysis suggests many women may seek ANC services in the for-profit 

private sector, but deliver at public facilities. PSA interviews with private providers offered 

anecdotal evidence to support this trend.

Summary of Findings for For-Profit Private Sector:

 The for-profit private sector infrastructure is strongest in urban areas, and most welldeveloped in Guatemala’s two largest cities, Guatemala City and Quetzaltenango. Given 

limitations of DRACES’ database, it is not possible to assess the availability of private 

providers in other urban areas.

 Guatemala’s medical associations serve as a licensing board for all physicians, public and 

private. However, the only requirement in practice is for active members to pay their monthly 

fees so there is little regulation of once they are licensed. Given that many of these 

associations support continuing education, there is an opportunity to increase their 

engagement on priority public health issues, such as reproductive health, family planning, 

and maternal health services.

 The market segmentation analysis demonstrates that Guatemala’s highest wealth quintiles 

are using the for-profit private sector (Q4 – 12 percent and Q5 – 30 percent) for family 

planning services (more than any other wealth quintiles), but a higher percentage still use 

MSPAS (Q4 – 41 percent and Q5 – 21 percent) as their main source of family planning. The 

same trend is true for delivery services, where 12 percent of Q4 and 37 percent of Q5 use 

for-profit providers, but a higher percentage still use MSPAS (Q4 - 51 percent Q5 – 33%).

Interestingly, higher wealth quintiles seem to seek ANC services in the for-profit private 

sector (Q 4 – 33% and Q5 – 54%) more than other FP or delivery services. These findings 

suggest that there is an important opportunity to move higher quintiles from MSPAS to other 

private sector sources for FP, ANC, and MH services.

5.5.2 SOCIAL HEALTH ENTERPRISES

There are several social health enterprises operating in 

Guatemala that have incorporated health services and 

insurance models into their structures to meet the needs of 

their beneficiaries. Several small social pharmacy franchises

operate throughout the country, providing discounted 

medical consultations as well as generic medicines. For 

example, in Quetzaltenango, the Association for the 

Potential of Human Development (Associacion para el 

Desarrollo del Potencial Humano) (ADEPH) manages 

several “social enterprise” pharmacies. The PSA team witnessed firsthand the strong demand 

that exists for these pharmacies. However, ADEPH representatives stated that their social 

enterprise faces strong pressure from Guatemala’s largest pharmacy chains, and their previous 

product sources are increasing product prices by 40-60%. Other pharmacy chains known for 

providing accessible pricing include Farmacias del Dr. Simi, which provides on-site 

consultations, as well as Farmacias de la Comunidad.

The Enterprise for Promotion of Health Services (EPSS) is a private company designed to 

increase access to affordable, quality health services for Guatemala’s population. The model is 

loosely based on Colombia’s Ley 100, which creates universal access to health services, 

administered through companies that manage health care consumer and provider networks. 

The premise is that 90 percent of all health issues can be resolved at the outpatient level. EPSS 

has operated in Guatemala since 2002 and provides health care services for more than 650,000 

The EPSS health model is an 

innovative and sustainable private 

sector initiative. EPSS has 

established unique partnerships 

with public institutions, and it has 

the potential for large-scale 

expansion of family planning, 

reproductive health, and maternal 

health services.

69
families. EPSS administers a large call center that is used to make referrals to a network of 

primary care providers like general practitioners as well as OB/GYNs and pediatricians, the two 

most requested specialties. EPSS currently works through an alliance with the Ministry of 

Education, where teachers have the option of entering the network and paying a premium that is 

deducted from their salary. EPSS also has an active alliance with Banrural, where its credit card 

holders may also participate in the primary care network. The EPSS represents an innovative, 

sustainable private sector health care model. EPSS management is open to exploring options 

for increasing access to reproductive health, family planning, and maternal health services 

among its network of private providers. EPSS’ proven business model and large network of 

enrolled members represents a very interesting opportunity for large-scale expansion of family 

planning and reproductive and maternal health services, such as including family planning

services in the health insurance policies that are focused specifically on women, e.g., Banrural’s 

Vivo Segura.

Summary of Findings for Social Health Enterprises:

 Several small social pharmacy franchises operate throughout the country, providing 

discounted medical consultations as well as generic medicines. Several PSA interviewees 

reported increasing difficulties in sourcing low-cost products and pressure from large 

pharmacy chains.

 EPSS’ health model represents a highly innovative, sustainable private sector health 

initiative that has established unique partnerships with both public (e.g. Ministry of 

Education) and private business (e.g. Banrural). EPSS’ model and large network of enrolled 

members represents an interesting opportunity for large-scale expansion of family planning 

and reproductive and maternal health services.

5.5.3 HEALTH INSURANCE AND MICROINSURANCE

Private health insurance represents a small, but growing 

segment of the Guatemalan health care market. Interviews with 

representatives from the insurance industry suggest that 

private health insurance is held by approximately 5 percent of 

the Guatemalan population, and more than 90 percent reside 

in Guatemala City. In Guatemala, the five private insurance companies with the largest 

revenues are 1) Seguros G&T, 2) Aseguradora Rural, 3) Seguros El Roble, 4) Seguros y 

Prevision CHN, and 5) Aseguradora General. Health and accident insurance represented 43 

percent of the overall market. Seguros G&T recently launched a maternity policy covering 

antenatal, delivery, and postnatal check-ups. Expenditures on private insurance plans reached

810 million quetzals (US$103 million) in 2013, representing only 3 percent of total health 

expenditure and 0.2 percent of GDP. Most people are enrolled in voluntary plans and most 

private health insurance plans are supported by employers on behalf of employees and 

provided by major corporations in the main cities (Avila, 2015).

In addition, there are interesting trends in health insurance targeting lower-middle- and middleincome groups. The Aseguradora Rural, S.A. has been operating in Guatemala for eight years, 

as a member of the financial group Banrural. Its clients include agricultural workers, 

housewives, teachers, and micro, small, and medium-sized enterprises. Products include: 

 Medical Insurance: Intended for individuals, groups, and families to provide coverage to the 

insured and family (spouse and children). The benefits cover outpatient visits, medications, 

laboratory tests and diagnosis, hospitalizations, and emergency. The premium is Q26 per 

month (US$3.40).

There are interesting trends in 

health insurance schemes aimed 

at the low and middle income 

sectors.

70
 Hospital Insurance: Offered to employees of a company or individuals and includes benefits 

for inpatient surgeries, doctor visits, and laboratory tests. The premium is Q36 per month 

(US$4.70).

 Vivo Seguro—Collective Cancer and Life Insurance for Women: Aimed at preventing and 

treating cancer in women. Coverage includes two visits to a gynecologist per year, 

preventive Pap tests, colposcopy, biopsy, and fine needle breast treatments such as 

cryotherapy. This insurance also includes: 1) discounts for drugs in the pharmacy network 

and procedures, examinations, consultations and general medical treatment in the EPSS 

provider network, 2) compensation for a covered cancer diagnosis in the amount of Q23000 

(US$3,000) when the cancer is diagnosed more than 90 days after the effective date of the 

policy, and 3) life insurance benefits of Q6,000 (US$780) for death from any cause. The 

premium is Q32 per month (US$4.20).

 Health insurance for microcredit clients: Covers borrower and spouse and children for 

medical appointments, medications, laboratory tests and diagnosis, hospitalization, and 

emergencies. This insurance is offered on a mandatory basis to all borrowers. Premiums are 

included in the loan administration fees. There are about 400,000 insured clients to date. 

Other microcredit organizations are also incorporating health services for their affiliated 

members. In Quetzaltenango, the private foundation, FUNDAP, has been operating for more 

than 30 years and manages more than 28 microcredit offices throughout the Western Highlands 

with more than 40,000 affiliates. In 2003, they developed a health component since many 

women were dropping out of community banks due to unanticipated health expenses. They 

operate a network of seven clinics at the departmental levels where members have access to 

free basic preventive and curative services, although FP services are not included. PSA 

interviewees suggested that this trend was common among microcredit institutions.

Summary of Findings for Health Insurance and Micro Insurance:

 Private health insurance represents a small, but growing segment of the healthcare market, 

and there are several interesting trends in health insurance attempting to target lowermiddle- and middle-income groups and incorporate maternal health and delivery services. 

 Microcredit organizations are also increasingly including basic health services for borrowers 

and dependents since unanticipated medical expenses are cited as one of the main reasons 

for faulting on microcredit loans.

5.5.4 CORPORATE SOCIAL RESPONSIBILITY

Guatemala’s for-profit commercial sector has a strong base of 

corporate engagement and social responsibility in health, and 

the team interviewed several groups such as the organization of 

cocoa producers or representatives from the banana industry. 

Among all corporate social responsibility (CSR) actors, the 

Center for Corporate Social Responsibility in Guatemala (Centro para la Acción de la 

Responsabilidad Social Empresarial en Guatemala, CentraRSE) stands out. Founded in 2003, 

CentraRSE has more than 100 member companies belonging to more than 20 sectors and 

subsectors of the country and employing 150,000 families. CentraRSE is a coalition of 

companies promoting the country's most influential CSR activities. CentraRSE’s provides 

education and training with local and international experts in the field of CSR, evaluation and 

measurement through established CSR indicators, support in setting priorities and developing 

action plans, and access to the latest information and trends in CSR. CentraRSE’s leadership 

considers that Guatemala’s corporate sector is ready to support the country’s underserved 

There are many opportunities for 

donors, implementing partners, 

and the private for-profit sector to 

collaborate on health initiatives.

71
communities as long as these initiatives are designed to improve the existing structures and not 

create parallel systems. 

Many of the country’s major corporate foundations are already sensitized to Guatemala’s priority 

health issues and have actively incorporated health, and even RH/FP, into their programs. 

Fundazucar’s program focuses primarily on education, health, and municipal strengthening. The 

program includes its “Mejores Familias,” which works with pregnant women in local communities 

to support them over a 24-month training period to develop proper care, preventive health, and 

nutrition for their children. Women from the community are trained as leaders, and with program 

staff they conduct monitoring visits to local homes. Fundazucar also has an existing partnership 

with the Escuintla Regional Hospital, which operates the hospital’s nearby outpatient clinic. The 

clinic charges patients a nominal fee for its services. In 2013, almost 50,000 consultations were 

provided in five medical specialties. 

Funcafe is a private, nonprofit organization established in 1994 to represent the social 

responsibility actions of the coffee sector. Its efforts are focused on the development of the rural 

populations in the regions where coffee is grown, working primarily in health, education, and 

food security. Funcafe maintains 16 health centers and health posts in coffee farms and nearby 

areas to serve more than 125,000 coffee workers and the general population of 13 departments. 

Service regions include the South Coast, San Marcos, Chimaltenango, Alta and Baja Verapaz, 

Quiché, and Huehuetenango. Funcafe supports preventive health; general health care; dental, 

pediatric and prenatal care; training in sexual and reproductive health; family planning; and 

prevention of cervical-uterine cancer. 

There are many foundations that understand the important role of family planning in a woman’s 

overall reproductive and maternal health and incorporate these vital services. Many of these 

organizations have collaborated recently with donor-supported initiatives, and some expressed 

donor burnout. Several PSA interviewees mentioned the need for better coordination among 

donors since so many are working in the private sector. Given the tremendous opportunity to 

collaborate with these partners on health initiatives, there is a need for better coordination 

among donors, and approaching and engaging these organizations in a coordinated fashion. 

Guatemala has the example of the Nutrition Alliance (Alianza para la Nutricion), which is an 

interesting model of corporate engagement where multiple organizations led by several of 

Guatemala’s prominent companies identify common themes and agendas for nutrition 

programming in order to better coordinate resources and interventions. This example could be a 

model for reproductive and maternal health engagement with the corporate sector.

Summary of Findings for CSR:

 Guatemala’s for-profit commercial sector has a strong, sophisticated base of corporate 

engagement and social responsibility in health. Many of these organizations are already 

supporting RH/FP and MH services through their existing programs. There is some 

sensitivity among these organizations regarding donor coordination, and a stated need for 

improved coordination and communication among the multiple donors that are interested in 

engaging with CSR initiatives.

 Guatemala’s Nutrition Alliance represents an interesting model of corporate engagement 

that leverages corporate resources and political support toward common objectives and 

agendas. While this type of coordinated effort requires strong leadership and time to 

establish consensus among multiple players, it represents an opportunity to limit duplication 

of effort and improve coordination of resources.

72
5.5.5 WORKER HEALTH AND WELL-BEING

A significant number of companies in Guatemala provide health services to their staff through 

company-owned facilities, on-site clinics, and workplace health programs, and contracted 

private health services. Many organizations (some with donor support) have established 

workplace wellness programs focusing on RH/FP, HIV, and general health services. APROFAM 

has worked for several years to establish partnerships with companies to support worker health, 

particularly for RH/FP services. APROFAM maintains partnerships with multiple companies to 

provide access to clinics as well as periodic, on-site services in RH/FP and information, 

education, and training services. For example, APROFAM has an ongoing agreement with 

Walmart at the national level to offer free care to its employees through APROFAM clinics.

Summary of Findings for Worker Health and Well-Being:

 Many companies provided supplemental coverage for health services to their employees 

through on-site clinics and workplace health programs for specialized services—and are 

willing to make additional investment in these services.

73
6 RECOMMENDATIONS

Based on key findings from the PSA, this report outlines several key recommendations 

regarding strengthening stewardship of a balanced, sustainable health market for RH/FP/MH 

services.

6.1 HEALTH SYSTEM STEWARDSHIP

Stewardship that engages multiple private sector players

Guatemala’s MSPAS is charged with stewardship or governance (rectoría) of the overall health 

sector. However, in practice, coordination and communication among sectors is limited, 

particularly between IGSS and the private sector. The institutional and budgetary autonomy of 

IGSS allows it to coordinate with MSPAS on a voluntary basis. There are various commissions 

for multi-sectoral dialogue exist in Guatemala, but there is little engagement of the for-profit 

private sector in these fora. For example, the CNAA involves the major NGO actors such as 

APROFAM and PSI, yet there is little engagement of other private sector organizations.

The PSA team recommends that MSPAS continue to look for opportunities to engage new 

private sector players. This would include participation of the for-profit sector, including the 

pharmaceutical industry as well as professional medical associations, such as the College of 

Physicians and Surgeons, Association of Obstetricians and Gynecologists, Association of 

Pediatricians, and others.

Advocacy to improve market inequities

Advocacy organizations have been working to increase awareness of the importance of 

contraceptive security, to promote a multisector approach, and to address key policy and 

programmatic gaps. In 2009, the National Commission for Contraceptive Security was officially 

created to be led by the MSPAS’ National Reproductive Health Coordinator. Despite important 

legal and regulatory advances, stakeholders report that there are still budget shortfalls for 

contraceptives and limited competitive procurement options to ensure efficient use of resources.

In late 2013, CNAA published its Market Segmentation Strategy for contraceptives, which 

recognizes the importance of a sustainable, total market approach. The strategy outlines 

different scenarios for reducing unmet need and shifting method mix, but does not define 

specific actions to achieve the scenarios. The market segmentation analysis conducted by PSA 

team suggests that there are still important inequities in the delivery of FP, ANC, and delivery 

services, and the potential to move upper health quintiles toward private sector channels.

The team recommends that the CNAA strengthen the engagement of the for-profit private sector 

as part of a sustainable health market, as well as identify specific next steps for all sectors. 

CNAA should also consider the comparative advantages of NGOs and the for profit sector to

expand access to ANC and delivery services.

6.2 SERVICE DELIVERY

IGSS to increase its provision of FP, ANC, and delivery services

The Guatemalan Social Security Institute is the second largest health service delivery institution 

in the country. There is evidence that a large percentage of IGSS beneficiaries and their 

74
dependents are seeking family planning services at non-IGSS facilities. Many of these users are 

going to MSPAS, creating an additional burden for that institution. IGSS’ family planning

program is institutionalized under Resolution No. 1165, but stakeholder interviews suggest that 

there is not widespread knowledge of IGSS policy to provide family planning services, and 

contraceptives are not widely available. In addition, Resolution 1165 includes some key policy 

barriers to family planning access.

We recommend that IGSS’ stakeholders conduct a review of Articles 4 and 5 to ensure that 

Resolution #1165 is consistent with Guatemala’s law on universal access to FP services.

IGSS plays a very small role in ANC services, even among the highest wealth quintiles. In 

Guatemala City, IGSS is the second highest source of delivery services (30 percent) and 

reaches a higher portion of wealth quintiles than anywhere else in the country at 20 percent for 

Q3, 40 percent for Q4, and 30 percent for Q5. Country-wide, however, IGSS performs only 8 

percent of all deliveries and only 1 percent in the Western Highlands. The PSA team 

recommends that IGSS also strengthen provision of ANC services as well as delivery services 

outside of Guatemala City.

Despite these shortcomings, almost all stakeholders recognize that IGSS has a critical role to 

play. Given IGSS’ infrastructure and resources, it is the organization that will have the most 

immediate and significant impact on strengthening RH/FP and MH services. 

The PSA team recommends continued high-level advocacy with IGSS to ensure that IGSS

realizes its role as a strategic player in ensuring a more balanced, sustainable market for FP, 

ANC, and delivery services, sharing facilities and resources, and avoiding an unnecessary 

duplication of facilities and services.

APROFAM to identify its comparative advantages and commit to strengthen and 

subsidize high priority areas

APROFAM is in a critical time striving to maintain its leadership position as the second largest 

provider of FP services in the country while streamlining operations and increasing its overall 

sustainability. APROFAM’s mobile units represent an important comparative advantage for the 

organization since they are the only ones in the country that provide laparoscopic surgical 

sterilization. However, APROFAM should seek to strengthen coordination, promotion and 

dissemination of these medical outreach activities with other key stakeholders to ensure that 

they are optimizing number of people who can benefit from services. APROFAM’s network of 

community volunteers, once a flagship program for the organization, has gradually reduced the 

number of its community promoters. APROFAM’s hospitals, particularly in the Western 

Highlands, report underutilized capacity for delivery services, which through appropriate 

targeting and demand-side financing (e.g., vouchers) could be used to improve MH indicators in 

that region. 

The PSA team recommends that APROFAM determine what social programs are essential to its 

mission and then continue its full commitment to their success, using the STF to cross-subsidize 

high priority activities.

Red Segura to consider targeted expansion of geographic coverage and MH services

Red Segura has proven to be a successful model for increasing IUD and implant use through 

private providers; however, PASMO has not yet developed a sustainability strategy that would 

address long-term operation and management of the network. Nonetheless, given the network’s 

success in rapidly expanding provision of long-acting methods in the private sector, there are 

opportunities to consider for targeted expansion to priority geographic areas and to incorporate 

75
additional MH services among participating providers, particularly among middle-income users 

that are largely using the public sector for ANC and delivery services. 

The team recommends that PASMO/Red Segura develop its sustainability strategy, identifying 

which elements of the provider network are essential to long-term access to key family planning, 

ANC, and delivery services in the for-profit private sector. At the same time it should identify 

sources for long-term funding. And finally, it should identify opportunities for expanding 

geographic access and providing broader maternal health services.

EPSS as a sustainable and scalable private sector health care model

The EPSS represents an innovative, sustainable private sector health care model. EPSS 

management is open to exploring options for increasing access to reproductive health, family 

planning, and maternal health services among its network of private providers. EPSS’ proven 

business model and large network of enrolled members represents a very interesting 

opportunity for large-scale expansion of family planning and reproductive and maternal health 

services, such as including family planning services in the health insurance policies that are 

focused specifically on women, e.g., Banrural’s Vivo Segura.

The PSA team recommends exploring opportunities to expand access to RH/FP and MH 

services, building on EPSS’ sustainable and scalable service delivery health model.

6.3 DEMAND SIDE

Targeted demand generation among underserved groups

In order for there to be a robust private sector, there has to be sufficient demand. The team 

believes that if there were more demand for family planning, especially for the full array of 

methods and for facility-based deliveries, the private sector could play a bigger role in providing 

services. 

The team recommends that the country engage in demand generation activities that recognize 

important differences within the population, for example, urban/rural, ethnic groups, age, and 

levels of wealth. Stakeholders could contribute to this effort by supporting behavior change 

communication activities on family planning and safe motherhood through its partners in the 

WHIP. The behavior change communication campaigns should include information on how to 

access private providers and NGOs, including locations and services available.

6.4 SUPPLY SIDE

Health Insurance and micro insurance to expand access among middle income people

Private health insurance represents a small but growing segment of the Guatemalan health care 

market. However, there are interesting trends in health insurance targeting lower-middle and 

middle-income groups. The Aseguradora Rural, S.A. has been operating in Guatemala for eight 

years, as a member of the financial group Banrural. Its clients include agricultural workers, 

housewives, teachers, and micro, small, and medium-sized enterprises. 

The PSA team recommends exploring strategic partnerships with insurance agents to expand 

access to RH/FP and MH services for middle-income populations. The strongest potential for 

growth in insurance products is within middle income populations in large urban centers.

CSR and private partnerships to create strategic synergies

Guatemala’s for-profit commercial sector has a strong, sophisticated base of corporate 

engagement and social responsibility in health. Many of these organizations are already 

76
supporting RH/FP and MH services through their existing programs. There is a stated need for 

improved coordination and communication among the multiple donors that are interested in 

engaging with CSR initiatives.

The PSA team recommends exploring strategic partnerships that focus more on identifying 

added-value and comparative advantage among organizations and less on financial leveraging.

The Alliance for Nutrition represents and interesting partnership model for engaging multiple 

private sector partners around a specific health issue, it but requires strong corporate and 

political leadership to bring key players to the table.

6.5 HUMAN RESOURCES FOR HEALTH

Cadre of skilled birth attendants to address non-facility based births

The majority of women countrywide (48 percent) and in the Western Highlands (64 percent) 

deliver either in their own home or in the home of a TBA. Many of these TBAs are illiterate and 

not qualified to manage emergency cases. Currently, there is no professional midwife cadre in 

Guatemala. 

The team recommends creating a professional midwife cadre either as a specialization within 

the nurse cadre or as a separate category. These professionals would be qualified to attend 

normal deliveries and refer complicated ones to OB/GYNs. Similarly, the team recommends that 

Guatemala recognize SBAs in the formal sector and standardize their qualifications and scope 

of practice. And finally, the team recommends increasing the number of SBAs through training. 

Donors could help develop curricula within private training institutions to train aspiring students 

or TBAs who want to upgrade their skills. There should be a scholarship program for students 

from indigenous and other underserved areas who commit to practicing in those areas after 

graduation. 

77
ANNEX A: STAKEHOLDERS 

INTERVIEWED FOR PSA

Organization Name Contact information

Public sector

Municipalidad La Esperanza, 

Quetzaltenango Cristian Ximin

Directora, Sistema Integrado de 

Atención a la Salud (SIAS), Ministerio de 

Salud Pública y Asistencia Social Nicté Ramírez 

Instituto Guatemalteco de Seguridad Social

Subgerente de Prestación de Servicios 

de Salud Byron Arana 

Jefe Dpto Medicina Preventiva Edwin Cambranes

Vocal de la Junta Directiva -

Representante de los patronos período 

2014 - 2016. 

Max Erwin Quirín 

Schoder

Director Departamental IGSS Occidente Octavio Cortes

IGSS - Huehuetenango Hugo Isaac Sum

Civil society

Asociación CDRO Totonicapán Benjamin Som salud.dac@asociacioncdro.com

Asociación CDRO Totonicapán Julia Rodríguez salud.dac@asociacioncdro.com

Asociación CDRO Totonicapán Walter Sac Escobar, salud.dac@asociacioncdro.com

ADEPH (Associacion para el Desarrollo 

del Potencial Humano)

Obed Velasquez gere@adeph.org.gt

ALAS Rodrigo Barillas director@wingsguate.org

rodrigobarillas@wingsguate.org

Alianza por la Nutrición Jorge Lavarreda jlavarre@cien.org.gt

APROFAM Ana Cecilia Fajardo 

Andrade

APROFAM Silvia Palma spalma@aprofam.org.gt

Asociacion de Farmacéuticos ASOFAGUA Martha Tanchez martha_tanchez@yahoo.com

Asociación de ginecología y Obstetricia 

de Guatemala (AGOG) - seccion 

NorOccidente

Roxanna Ramirez roxanademoir@msn.com

Asociación de Investigación, Desarrollo y 

Educación Integral (IDEI)

Janet Ikeda janet.m.ikeda@asociacionidei.org

BANASA Bernardo Roehrs broehrs@agromerica.com

Colegio de Farmacéuticos y Químicos de 

Guatemala

Sofia Posadas gerenciaadministrativa@colegiodefarmaceutico

syquimicos.gt

Colegio de Médicos y Cirujanos Porfirio Santizo info@colmedegua.org

FUNDAECO, Huehuetenango Julio López j.lopez@fundaeco.org.gt

FUNDAP Eunice Martínez jorge.gandara@fundap.com.gt

78
Instituto Universitario de la Mujer de la 

USAC

Patricia Borrayo miriamusac79@gmail.com

El Instituto de Salud Incluyente Juan Carlos Verdugo juancarlos.verdugo@isis.org.gt

Observatorio en salud reproductiva Mirna Montenegro mirnam.rangel@gmail.com

PSI/Pan American Social Marketing 

Organization (PASMO)

Pilar Sebastian Psebastian@pasmo-ca.org

Red de organizaciones de Mujeres 

Indigenas para la Salud reproductiva 

(REDMISAR)

Silvia Xinico silviaxinico@gmail.com

Red Segura Karen Steele ksteele@pasmo-ca.org

Universidad San Carlos de Guatemala -

USAC

Adrian Chávez adrianchavezgarcia@gmail.com

Private for-profit

EPSS – Empresa Promotora de Servicios 

de Salud

Rodolfo Muralles 2382-2002

ASEGURADORA GENERAL, S.A Donald Tijerino (502) 2331 -1880

ASEGURADORA GENERAL, S.A Verónica Lainfiesta (502) 2331 -1880

ASEGURADORA RURAL Christian Leuthold 23398888- Ext.302690

ASEGURADORA RURAL José Guillermo López 23398888- Ext.302690

ASEGURADORA RURAL Oscar Chamalé 23398888- Ext.302690

Asociacion Medica del occidente José Hasted / Ruby 

Montes de Oca 

77671698

Fundación del Café (FUNCAFE) Mynor Maldonado mynor.DMM@funcafe.org

FUNDAZUCAR María Silvia Pineda mspineda@azucar.com.gt

Development partners

DELIVER project Anabella Sanchez annabella_sanchez@jsi.com

HEPP project Herminia Reyes Herminia Reyes - hreyes@hpp-gt.org

HEPP project Maricela de la Cruz Marisela De La Cruz - mdelacruz@hpp-gt.org

IDB Ian MacArthur IANM@iadb.org

Iniciativa de Salud Mesoamericana 2015 Jorge Solórzano jsgua05027@gmail.com

Nutrisalud Angélica Bixcul abixcul@nutri-salud.urc-chs.com

Nutrisalud Ivan Mendoza ivanmendozagt@gmail.com

Nutrisalud Jose Eduardo Silva jsilva@urc-chs.com

Nutrisalud Melida Chaguaceda mchaguaceda@nutri-salud.urc-chs.com

OPS/OMS Guatemala Luis Roberto Escoto escotoro@paho.org

USAID

Hector Romeo 

Menendez hmenendez@usaid.gov

79

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