Guatemala is Central America’s most populous country, with 14.3 million people, of which about 40% are indigenous descent. Although Guatemala is a lower middle-income country with an average per capita income of $2,700, this figure masks extreme inequalities that reflect the exclusion and disparity that affect indigenous and rural populations. For example, the average time in school among indigenous people is only 3.8 years while it is 6.5 years among the non-indigenous. Almost 75% of indigenous people live in poverty compared with only 36% of the non-indigenous. These large inequalities are also present between rural and urban residents. Guatemala has a national poverty rate exceeding 50% and a rate of extreme poverty of 15%. While 46% of the total population lives in rural areas, 72% of the extremely poor live in rural areas.
Despite its middle income status, Guatemala’s health outcomes compare unfavorably with those of other much poorer countries. The child mortality rate at 42 per 1,000 live births is the highest in Central America and the third highest in the region after Haiti and Bolivia. The maternal mortality ratio of 136 per 100,000 live births is also one of the highest in the region, and the contraceptive prevalence at 54% one of the lowest. The health situation in Guatemala is essentially a tale of two countries. Paralleling the income and education disparities, large differences in health outcomes exist between urban, non-indigenous populations and rural, indigenous groups. Child mortality and malnutrition are 50% higher among rural and indigenous children. Maternal mortality is up to five times higher in some rural areas compared with Guatemala City. Skilled birth attendance among rural and indigenous women is less than half of that for urban and non-indigenous women.
In Guatemala, the face of poverty and hunger is young, indigenous and rural. Guatemala, with the fourth highest rate of chronic malnutrition in the world and the highest in Latin America and the Caribbean, faces a serious challenge to reduce chronic undernutrition, currently at 49.8% among children under 5, 66% for indigenous children. These high malnutrition rates have long term health, education and economic consequences for those who suffer from it. Unfortunately, there has been very little progress in reducing chronic malnutrition. The rate was 55% in 1995 and 54% in 2002.
While most health outcomes remain worse than in other countries in the region, over the last decade Guatemala has made significant progress in narrowing these gaps and improving health disparities. The child mortality rate, currently at 42 per 100 live births, is on track to achieve the Millennium Development Goal (MDG) target of 37. Total fertility fell from 5.0 in 1999 to 3.6 in 2009 with a comparatively greater decrease for indigenous women from 6.2 in 1999 to 4.5 in 2009, contraceptive prevalence increased to 54%; and skilled birth attendance increased to 51%. Prenatal care coverage rates are the same among urban, non-indigenous and rural, indigenous women, and immunization rates are the same for these groups of children. An important contributor to these improvements is the MOH’s extension of coverage (EOC) program instituted in 1998 which contracts Non-Governmental Organizations to provide itinerant health services to communities that otherwise would not have adequate access to health services. In addition, the MOH, with loans from the World Bank and IDB, is rapidly expanding provision of emergency obstetric care in rural areas with 140 additional health centers providing basic extension of coverage in 2010 and 12 additional centers providing comprehensive EOC (C-sections) by 2011.