By Lisa Nalven, M.D.
To help the OCHO team to better understand the health care system in Honduras, Dr. Patrocinio Sarmiento, medical director of the Atima Health Center, gave a presentation about the provision of care in Atima and the surrounding communities. Control of the current health care system was centralized in 2012, but because the new system failed to show sufficient improvement in the population’s health, it was determined that a change in the health care system was needed. Thus, in 2013, 42 municipalities were “decentralized,” based on their demonstrated ability to provide care at the local level. Atima was included in the decentralization process.
There are three health clinics in Atima’s region, and four medical teams with a primary care focus. Each team is responsible for nine communities within the region, caring for a total of about 19,000 people, or about 5,000 people per team. Each team includes one doctor, one nurse, and two health promoters/educators.
The health care providers have a map with color-coded pins, identifying the location of their patients, who are grouped according to a risk hierarchy that ranks each patient one to four. For example, risk group 4 includes patients with the highest risk, such as pregnant women, children under two years, and patients with diabetes, hypertension, or developmental disability. Each patient/family is visited once a month. The goal is to involve the entire family in health care – not only the patient and health care provider. With this goal in mind, the entire family receives health education about disorders such as diabetes, rather than just prescriptions for the patient. The nature of the monthly contact depends on the risk category; the medical teams provide home visits for high-risk patients (risk group 4) and group meetings at central locations for low-risk patients and families (risk group 1). In addition to providing acute care, the teams promote prevention, recovery, and rehabilitation. As a result, health care support is located at the family home and in the community (school, work), and appointments are scheduled at the health center. This level of health care is free to the patients. In this way, the entire community becomes educated about health care.
As part of the change to the local administration of health care, the government requires that monthly metrics are met, or local funding for health care will be lost. During the presentation, Dr. Patrocinio Sarmiento provided data demonstrating significant improvements in several key health outcomes during the first three years after decentralization. Overall, the number of people coming to the health center has increased. Dr. Patrocinio charted notable improvements in reproductive health, including a significant increase in the provision of Pap smears and birth control, and an increase in the number of prenatal visits before the end of the first trimester. During this past year, the team has focused on having women deliver their babies at the Atima Health Clinic or Santa Bárbara Hospital, if needed. Because HPV is the number-one sexually transmitted disease in the Santa Bárbara region, in 2016 the team initiated an HPV vaccination program for females 11 years and older.
Dr. Patrocinio noted that many families do not have the financial resources to go see doctors and specialists in San Pedro Sula. Although the doctor’s visit is free to the family, the cost of travel and accommodations can be a burden. In addition, although basic medical supplies and medications are covered by the national insurance system, other supplies, such as anti-seizure medication and ostomy bags, are not. At times, the supply of some medications is not reliable, independent of ability to pay. Despite these limitations, based on Dr. Patrocinio’s presentation, it appears that decentralization has lead to a positive change in the Atima community.
Other health data that Dr. Patrocinio provided:
- In 2016, there were 400 births in the region: 99 in Atima, and 300 high-risk deliveries that were sent to Santa Bárbara Hospital. In 2013, most births were at home, but this has shifted increasingly to births at medical centers.
- From 2013 to 2016, diagnosed cases of diarrhea and pneumonia decreased, a drop attributed to the water filtration plant that has had a big impact in Atima. (The filtration plant was an OCHO project).
- Primary causes of death in:
o Children – birth asphyxia. (In 2017, OCHO did trainings in neonatal resuscitation).
o General population – fires (cooking with fire pit inside the home) and violence.
o Women – complications of pregnancy and labor/delivery.
- Life expectancy is approximately 60 years.
- There are no mental health indicators or benchmarks in the system.
Dr. Patrocinio’s presentation was enlightening, an object lesson in the benefits of shifting administration to the local level, and thereby empowering an entire community to make a difference in the health status of its population. For all of us on the OCHO team, it provided a much better understanding of the systemic issues facing our partners in Atima. The insights we’ve gained will help OCHO to direct its efforts, projects, and health care resources in a way that supports the local needs — the goals identified by the Atima community — in order to have a sustainable impact.