RETURN TO RESTRICTED

REPORTS DESK Report No. WH-170a

WITHINONE WEEK

This report was prepored for use within the Bank and its affiliated organizations.

They do not accept responsibility for its.accuracy or completeness. The report. may

not be published nor may it be quoted as representing their views.

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT

INTERNATIONAL DEVELOPMENT ASSOCIATION

ECONOMIC DEVELOPMENT

AND EPROSPECTS OF

CENTRAL AMERICA

(in eight volumes)

VOLUME VIII

WATER SUPPLY, SEWERAGE AND PUBLIC HEALTH

Jul.ne 5, 1967

Western Hemisphere Department

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EQJIVALENTS

Currencies = 1 Central American peso(a unit of account)

= 1 Guatemalan quetzal1 U. S. dollar ) = 2. 5 Salvadorean colones

= 2. 0 Honduran lempiras= 7. 0 Nicaraguan cordobas= 6. 62 Costa Rican colones

Weights and Measures

1 manzana = 1. 727 acres = 0. 69 ha.1 (60 kilo) coffee

bag = 132 pounds16. 6 coffee bags = 1 metric ton1 short ton = 2000 pounds1 quintal = approximately 101 poundsApproximately

20 quintals = 1 short ton (sugar)1 banana box = 42 pounds1 banana stem = approximately 1. 35 banana boxes1 banana stem = approximately 57 pounds1 (cotton) bale = 480 lbs. net

VOLUME VIII - WATER SUPPLY, SB4ERAGE AND PUBLIC HEALTH

TABLE OF CONTENITS

Page No.

SUMIMARY AND CONCLUSIONS i - iii

CHA PTER

I POPULATION CHARACTERISTICS AND HEkLTIH 1

UI VITAL STATISTICS 3

III TOTAL HEALTH SECTOR EXPENDITURES 4

IV WATER SUPPLY AND SEVIERAGE 5

A. Wvater Supplies - Urban and Rural 5B. Sevwerage and Excreta Disposal 5

V `HO3PITALS AN4D OTHER HEALTH FACILITIES 7

VI PERSONNEL NEEDS AND TRAINING 8

VII COUNTRY PROGRAIS 9

A. Guatemala 9B. El SaLvador 13C. Honduras 15D. Nicaragua 19E. Costa Rica 23

'STATISTICAL APPENDIX

SUINARY1 AND CONCLU.3SIONS

1. In Central America, sanitary conditions and problems arebasically similar in the f:ive zountries and the prevalence of in-acdequate water supply and sewerage systems and the high incidence ofparasitic, ccmmunicable and preventable diseases continues to be ahindra.nce in developing a, healthy popula.tion a.nd, in some areas, af-fects the quality a.nd performrance of the labor force. Inv7estmentprograms for water supply, sewerage and public health a.re by their verynature, to a large extent, national in character, but the control anderadication of parasitic and communicable diseases is a matter ofdirect concern to the region as a. whole. The eradication of mallaria,now near completed, has in fact been achieved by a. ve(ry close co-or-dina-tion among the five countries with the assistance of thePan American Health Organization.

2. In the last several years substantial progress has beenmade in the region in the health field. Between 1950 and 1964 lifeexpectancy at birth - the most summary measure of the overall healthsituation - increased by 8.3 yea.rs for the four countries for whichdata.are available; i.e., excltding Honduras. This average concealsthe fa.ct that the increase in Juatemala. - 5.8 years - was smaller; inthe other three countries the increa.se wa.s about or over nine years.Progress has been more marked since 1960.

3. Death rates have gone down in Guatemala, El Salva.dor andHica.ragua, remained the same in Honduras and rose slightly inCosta. Rica.. Reflecting the almost comaplete eradication of malaria.,death rates frcm infective and parasitic diseases have decreased inall countries but El Salvador. In contrast, death rates from water-borne diseases - gastritis, enteritis and the like - ha.ve decreasedin only one country, rema.ined sta.tiona.ry in two and rose sharply inthe other two. The incidence of bnth categories of diseases arestill very high, although in most aspects of lealth the Centra.lAmerican region compares rather well vwith most Latin American coun-tries, including some with a substantially higher per capita incoae.

4. Provision of potable into-the-house piped water for theurban population - living in communities of 2,000 people or more -covers, on the average, about one hal' of that population, a.nd aboutone third is served by sewerage systems. These figures include thecapita.l cities comprising a.bout two-thirds or more of the urban popu-lation, which means tha.t the great bulk df urb:an communities- not tomention the strictly rura.l. area.s - is lacking in both safe potablewater and sewerage systems.

5. The ratios of hospital beds and physicians per inhabitantare still low, and an even greater deficiency is found in the nuTiberof health centers and the provision of medical services for pre-venting disease. In 1964 the number of physicians who were graduatedcould in several of the countries suffice to cover the increase in

ii

population and raise the physician-population ratio, but much largernumbers of medical doctors wiLl be required to improve the situationsubstantially.

6. Public investment in sanitation and public health by thefive countries from 1962-65 averaged CA$13.2 million ar.nual3y, andrepresented 11.3 percent of total direct public invest.ment dcuringthe ,eriod. The regirtnal tctn,;l rose from CA$12 04 million in 1962 toCA$18.2 million in 1966, the s<hare in toual public investment risingalso, from 12.4 to 13.4 perce:nt.

7. Investrnent programs for the period 1965-1969 were preparedby the five countries as part of their overall development plans. Itappears, in assessing such factors as project preparation, ac.equacyof organizaticn and funds avlailable to the countries durin.g the nextfour years, that the goals se- forth in the plans for urban water sup-ply and sewerage systems are not likely to be achieved within theperiod. If a country's definition of water supply to serve the ruralpopulation would mean tha-t one safe source of water be made availableto people living in close proximity, such a goal seems likely to beattained in all countries. If, however, piped water into the houseis the objective, there is no evidence to suggest that this can bedone in the visible future co:asidering the limitations of funds andconstruction and administrative capabilities.

8. Major high priority investment projects for which studieshave been completed or are underway for construction of water suppliesor sewerage systems total CA$.32.0 million in cost. Considering the1actors likely to limit the planning and execution of projects, thermission estimates for 1967-1970 a probable average annual investmentin public health, water supply and sewerage of CA$23.2 million whichwould represent an increase of 27.5 percent above the level reachedin 1965. The share of sanitation and public health in rising totalpublic investment, according to this projection, would drop slightlyfrom an average of 11.8 percent in 1962-1965 to 11.0 percent.

9. Given the prevalence of parasitic, communicable and water-borne diseases and the high mortality and morbidity rates from them,the Central American public health programs should concentrate heavilyon preventive rather than curative medicine. This is not to say thathospital facilities are adequate - far from it. But a vigorouls ef-fort in expanding the supply of safe potable water in the medium-sizeand small urban centers, as vell as health centers well distributed-throughout the countries, will surely yield much greater return perdollar invested and reduce the pressure for hospital facilities. Thegreat dispersion of the large rural population will for a long timemake it extremely difficult and costly to provide hospital service tothe great masses of Central Pmericans living in the rural areas. Onthe other hand, the tremendous advances made by modern medicine in earlydiagnosis of disease and in developing newi and effective vaccines anddrugs for a large variety of illnesses prevalent in the area - fromintestinal diseases to tuberculosis - should make prevention, earlydetection, and ambulant cure possible to a much larger extent than now.

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A determined effort in the creation of health centers would reducesubstantially the incidence of the most prevalent diseases and reachat relatively low cost the great mass of the population living inthe countryside.

10. In countries where the rate of construction of new facili-ties is less than desired it will be necessary to obtain greatercontributions than now proposed from the people benefited in the lo-cal communities and cities to supplement funds becoming available fromthe central government or the autonomous agencies or those which mightbecome available from foreign sources. Water and sewerage servicesare particularly fields of public investment for the financing ofwhich it should be feasible tc enlist local community effort. Theirbenefits are not only direct, immediate, and of high priority to thebeneficiaries but also, as corntrasted with education - which is tradi-tionally free of charge - the local authorities can collect user chargeswhich provide them with funds for covering totally or at least par-tially the investment cost and operating expenses. Efforts should beincreased, therefore, to obtain the financial participation of thecommunities to be served. In some instances, according to localconditions, it may be desirable to obtain a direct contribution tothe cost of the capital investment. More adequate charges for servicerendered may be established in many cases later on as the benefitsare felt and the coverage spreads. In the larger urban centers,particularly where some kind of system of charges or contributionsalready exist, the cost of expansions or improvements could probablybe covered by adequate adjustments of existing rates.

11. A determined effort is needed in all countries to increasethe output of adequately-trained nurses and health officials at alllevels, as on this finally depends the possibility of creating therequired health centers and pr-oviding adequate staff - both in numbersand quality - for the hospita:Ls. The training of sufficient numbersof sanitary engineers and in general of health officers capable ofplanning and administering well-balanced health programs is also anessential need for further progress. In the field of sanitation andpublic health - as in the case of education - the proper balance of theclifferent activities to be covered and emphasis on good quality of theservices can go a long way in increasing the benefits resulting fromthe investment and of the current expenditures related to it.

I. POPULATION CHARACTERISTICS AND HEALTH

1. Population censuses around 1950 and 1960 indicated an annualgrowth rate for the area as a whole of 3.4 percent and ranging by coun-try from 2.6 percent for Nicar-agua to 4.0 percent for Costa Rica (seeTable 11). The rate is higher' for urban than for rural areas. Migra-tion from rural to urban areas, particularly to the capital cities andto several port cities and indlustrial areas, helps produce a morerapid increase in the population of these communities than for thearea as a whole. The proportion of population in urban areas has beenincreasing in each of the couatries. It is now about 35 percent forthe area as a whole and increasing by about 0.3 percent per year. Asshown below, Honduras has the lowest proportion of urban population(30.0 percent) and Nicaragua the highest (41.0 percent).

Percentage of Population Living in Urban and Rural Areas,According to Censuses Around 1960, in CACM Countries

Cities100,000 Otheror more Urban Rural

Country inhabitants Areas Areas

Guatemala 1/ 13.4 20.2 66.hEl Salvador j 10.0 29.0 61.0Honduras 2/ 7.5 22.5 70.0Nicaragua 2/ 15.0 26.0 59.0Costa Rica 2/ 7.5 26.0 66.5

Total for CACM area 11.2 23.8 65.0

1/ Instituto de Fomento Municipal (INFOM): Una Entidad Estatal Aut6nomaLlamada a Promover el Progreso de los Municipios de Guatemala,Sumario, 46 p. (about 1965-66).

2/ PAHO/4HO: Health conditions in the Americas, 1961-65, ScientificPublication No. 138, August 1966.

3/ Computed using population data in Table 2.

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Percent of Population in CommunitiesWith

Between Total lessLes:s than 2,000 and than

Country Year 2 000 20,000 20,000

Guatemala 1963-64 67.4 21.4 88.8El Salvador 1963 61.5 20.8 82.3Hionduras 1963 .5-3 13.1 88.4NIicaragua 1965 58.0 19.0 77.0Costa Pica 1963 65.4 10.6 76.0

Tota,l CAOI.I Area 1963-1965 66.6 17.6 8L.2

2. *The distribution of the population geographically has cre-ated and helped perpetuate certain problems of health maintenance,iIuch of the rural population is in remote areas, which are almost inac-cessible by motor vehicle. Some localities are only reached, in fact,by water. Veery little in the .,ray of health service, medical or nursingcare, or improved sanitation facilities has been available to thesecomimunities until recently. Deaths ha.ve frequently gone unreported,leading to errors in populatior. estimates based on birth and death re-ports. Reports of disease ccc-rrence are inadequate, both quantitativelyand qualitatively, producing some gross inaccuracies in vital statistics.

3. The trend from rural to urba.n ha.s a direct effect on plannirigfor water supply and sewerage. Urban areas will experience higher thanannua.l increases in water (1br-,uimd tiv.n those for rural facilities.

II. VITAL STATISTICS

It. Life expectancy, which is approximately 56 years for thearea as a. whole, varies from 49.4 years in Guatemala, to 69.4 inNiicaragua (Table 3). A high birthrate is coupled with a high deathrate among children, particularly in the first year of life. Diarr-heal diseases and infectious diseases are a. principal cause of death -the principal cause in most of the countries of the area.

'.5. Typhoid fever, ithich is frequently a. water-borne disease,occurs with a, relatively high irequency (Table 4). The fatality rate,calculated on the basis of reported cases and deaths, appears to beexcessively high, indicating inadequate or, absence of, medica.l at--tention. For the area., the ra;e of 24.5 cases per 100-000 in 1965 com-pared with a. death rate of 1.4 is indicative that typhoid was a muchgreater factor in disability than it was as a. cause of death.

rD. Gastro-enteritis ra.nks as the major cause of illness anddeath in the countries of -the area. It is difficult to establishthe economic implications of this factor, particularly since givenfigures on the number of people affected undoubtedly do not include.3. vast number of cases which could result in absenteeism and temn-porary disability but are never reported. It seems reasonable toconclude, however, that gastro-enterit-s ha.s important implicationsfor econcmic activity and that efforts should be concentrated on re-ducing the rate through such preventive measures as better protectionof water and food supplies, greater provision for sewage and excreta.disposal, better nutrition, and more health education (Table 5).

7. Materna.l deaths were reduced about 25 percent from 1957 to1960 and, presumably, have decreased even further in more recent years.Ih-ie maternal death rate is sti:ll high, however, and can be expected toremain high until a. greater proportion of the rura.l population in re-mote a.rea.s are provided with cornprehensive health services (Table 6).

III. TOTA, hILALTH SECTOR EXPE1HDITUJES

o. Total annual expenditures for health and sanita.tion inrecent years ranged between CA$2.,L and CA$7.5 per capita. in thedif'ferent countries of Central America (Table 19). Per capita in-vestment expenditures for health and sanitation ha.ve been increas-ing and have averaged nearly CA"P7.00 for the area during the 1961-1965 period. Investments sho-v:in the government plans of each coun-t.ry in this sector would, if ca:rried out, nearly double on a per capitaba,sis during the years 1966-1970. In two countries (Guatemala andCosta Rica.) th1e proportion of investment expenditures for preventivemedicine (water supply, sewerage, and health centers) have been de-creasing while expenditures for curative medicine (hospitals) havebeen increasing proportionally.

9. The proportion of investment expenditures allocated towat6r supplies and sewerage was lower than that for hospitals andhealth centers in two count-.ies (Costa. Rica and Honduras) and higher inthe others in 1961-1965. During 1966-1970, water and sewer expendi-tures for Costa Rica and Honduras would be the higher of the two a.lloca-tions if government plans are carried out.

10. The highest planned per capita. investment is shown foricaragua. iit,n CA'A,118.4h0 per cap:ita from 1966 to 1970 for water supply,

sewerage and. exereta disposal on the basis of total expected populationin 1970 (Tabl.le 21). It is not prudent, however, to attach too muchirmportance t,o comparisons of per capita costs between co-ntries or evenfor systens within a country, because these figures will invariably bel%jer where additional populations can be served from an existing system.Costs will be higher where no facilities exist and wnere, to provide anyservice, a.n entire supply systemii must be built. Average per capitac(Dst estimates for the area of (,A$l.0O0 for rural water supply,CA$31.00 for urban water supply., and CA$j31.00 for urban sewerage arereasonably close to figures for the same facilities experienced inother countries of La.tin Arerica.

11. The per capita. investments planned for water, sewerage a.ndexcreta, disposa.l (Table 21). are lower in two (Guatemala and Honduras)of the three countries (Guatemala., Honduras, and Nicaragua) in which thepercentage of population served is now the lowest in the region and willst;ill be the lowest in 1970 (Tatles 9 and 10).

IV. WATER SUPPLY AM SEWERAGE

A. Water Supplies - Urban and Rural

12. Data concerning the percentage of the rural population servedby potable water supplies does not usually distinguish between the systemssupplying piped water to the interior of houses or to the individual yards,and the water supplies which make water available to the population atpublic taps or public wells to which the people must come from some distancearnd from which the water must be carried back to the houses.

:13. Progress in supp:Lyinlg water to the rural areas during the pastfive years has been greatest in El Salvador and secondly in Costa Rica(Table 8). For the years 1966-1970 the programs planned are of varioustypes, including large city wa-.er supplies such as those of Managua, Nica-ragua and several cities in Honduras, many smaller urban supply systems,rural town supplies, and rural well installations, as well as the improve-ment and extension of a number of existing systems of all types.

14. In some but not all countries autonomous agencies have been estab-lished with responsibility for planning, constructing, operating, andmEtnaging the water supply and sewerage systems. In other cases, eventhough no autonomous agency has been established, rate structures have beenstudied, changes have been proposed and in some cases have been made,which encourage municipalities to provide adequate systems for potablewater supply.

15. International agencies have assisted the countries in these pro-grams by providing consultant advisors in connection with various aspectsof the programs, fellowships for training, and loans for part or all ofthe cost of new works. Bilateral assistance has also been provided, prin-cipally by AID.

B. Sewerage and Excreta Disposal

16. The proportion of rural population with adequate excreta disposalvaries widely among the countries, ranging fror-a low 2.3 percent to ahiLgh of 47 percent as shown in the tabulation below for four of the coun-tries. The planned latrine building programs would not bring the regionto the goal of 50 percent of the rural population being served, althoughCosta Rica and Nicaragua would be close to this figure. Data are not avail-able concerning El Salvador.

Rural and Urban Population Served by Latrines in Four Countries

Guatemala Honduras Nicaragua Costa Rica

Rural population served 69,000 365,166 448,725 420,000Percent served 2.3 21.5 47 42§unber of latrines planned

1955-1959 30,000 31,300 40,000 15,500

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17. According to planned programs, sewerage would become aiailable to45 percent of the urban population in 1970. In two countries, however,(Costa Rica and El Salvador) 70 percent would have been reached and a third(Nicaragua) should be well on its way toward the same goal (Table 10), pro-vided that planned programs are carried out. The shortfall in meeting thePLnta del Este goal of 70 percent to be served by sewerage for the CACMcountries, although greater than originally hoped for, should not warrantundue attention. The pattern of development of sewerage services appearsto follow a course similar to that experienced in the highly developedcountries of the world where water supply more often than not precededprovision of sewerage facilities.

1B. WThile it is frequently necessary to assign a higher immediatepriority to water supply investrients, longer-range plans for developmentmust necessarily include both water supply and sewerage. Few communitiesand cities of the area have such plans. Such plans should be implementedby stages according to a schedu:Le that takes appropriate account of thetiming of need, costs of construction, and financial capabilities.

V. HOSPITALS A.ND OTHER HEALTH FACILITIES

19. The availability of hospital and clinic facilities varies morefrom urban to rural and from large city to remote rural community than itdoes from one country to another. Total numbers of facilities by countryare shown in Tables 11, 12, and 13. Average population served by eachhealth center or other health facility besides hospitals is also shown inTable 11. The ratio of hospital beds and physicians to population and theratio of physicians to nurses and nursing personnel is shown in Tables 14 and 15.The overall ratio of 2.6 beds per 1,000 is low, but does not indicate thereal extent of the deficiency. The hospitals are badly distributed, beinggenerally in the capital citiEs of the countries and their major politicalsubdivision, and in the larger, more important industrial or port cities.They are not readily accessib]e to the population of the remote, lesspopulated areas. M4oreover, mEny beds are in hospitals built to serve onlymembers of the various social security or workmen's compensation plans.Only recently have there been attempts to combine the available institutionsand facilities in a national hospital and health program coordinated by thenational health service. The statistics likewise fail to indicate the factthat many hospitals are irn antiquated structures, poorly laid out, and with-out adequate facilities, even sometimes lacking a proven safe water supply.

20. Many hosp-tals are poorly manned by too few doctors and nurseauxiliaries and very few nurses. These often w-rork ineffectively becauseof a highly compartmentalized organization and lack of uniform standardsof practice, salary, or hours of work. Too often they have been supportedby poorly equipped laboratories and by pharmacies that operate wastefullyunder little or no supervisory control. Where some hospitals are under-staffed, others can be found (sometimes in the same community) which areoverstaffed with doctors and other personnel.

21. Health centers are ;oo few in all the countries and especiallyin the remote rural areas. LLttle attempt has been made until recentlyto combine hospital, clinic, and health center facilities in one facilitywhere this would be a practical method of conserving available resources.Preventive and curative services generally have not been coordinated in thepast. Mobile health units (some water-borne) recently have been used toserve a small part of the remote rural population. An evaluation of theeffectiveness of these units should be made to determine whether this approachwarrants further expansion.

VT. PERSONNEL NEEDS AND TRAIWIDG

22. The supply of professionals and sub-professionals is inadequateto staff even the presently operating public health facilities. The desireof most doctors to practice only in the major centers of population leadsco a highly uneven distributior of available personnel. Consequently,some countries have instituted compulsory service by newly-trained orgraduated physicians in rural health units for one or more years in orderto assure rural health units of medical service. Even with such alloca-tions of trained medical personnel, many rural units lack adenuate staff.There is a universal shortage of public health nurses or even graduatenurses. Hence, there is widespread use of nurse auxiliaries, but manyof these are "practical" nurse auxiliaries with little, if any, specificformal training.

23. Enough physicians arE being produced or could be produced eitherin each country or in the CACM area to man all the curative and preventivefacilities now existing and to be established under present plans withinthe next five years. Since their preference is generally to practice inthe major population centers, rather than in the remote rural areas, thestaffing of rural units will remain a serious problem (Table 15). Publichealth training for graduate physicians is lacking in the Central Americanarea but is available elsewhere in the Americas. El Consejo Superior

IJniversitario Centroamericano (CSUCA) has been considering a proposalto establish a public health training center in El Salvador or elsewherein Central America or Panarna. Such a center appears to be a basic needof the area.

'4. Despite the crit:ical need for more graduate nurses, trainedpublic health nurses, and trained nurse auxiliaries, too few of theseare now being produced to promLse any material lessening of the shortage.iMioreover, there is a high attrition in service among those produced(Table 16)e

25;. Sanitary engineers are needed to man the public and privateagencies involved in planning, designing, constructing, operating, andsupervising the water supp:Ly, sewerage, and other engineering structuresoi health importance. The capability exists in the presently availableschools in Central America to produce the number needed to meet presentshortages. Although additionaL fellowship funds will undoubtedly berequired in connection with thz production of all types of health andengineering personnel where training must be done outside the country,the number of fellowships available has not apparently been the factorlimiting the number of professionals trained. It has apparently beendifficult in some countries to obtain candidates in some categories toaccept the fellowships available from PAHO/WHO (see Table 18).

VII. COUNTRY PROGRAMS

A. Guatemala

26. Gastro-enteritis infections and intestinal parasites in Guatema-la account for 38 percent of the reported deaths and a majority of thereported illnesses. Typhoid cases and deaths are excessively high (Table!Q). These data indicate a serious deficiency of safe water and sanitation.

Wllater Supply and Sewerage

27. Of the rural population (which is 67 percent of the total), notmore than 8 percent is served by piped water supplies and possibly anequal percentage by public hydrants or community wells. Of the urbanpopulation only 28 percent is served by house service and perhaps anequal additional percentage b;y public hydrants. In the capital city,65 percent are served by water piped to the house, the remaining 35percent depending on public taps.

28. Although installation of water supplies has been going on for anumber of years, only recently was there created an agency to be directlyresponsible for this activity in rural areas, Servicio Especial de SaludPublica (SESP), which is in the Ministerio de Salud Publica y AsistenciaSocial.

29. SESP has attempted to improve the water service to the ruralpopulation by providing service directly to each house, rather than bymeans of the traditional public tap, aiming to do so without any increasei:n total cost. Such service is in keeping with the findings of studieswhich show the importance of water availability in the house in reducinginfant diarrheal deaths. It is too soon, however, to evaluate this newapproach, which was initiated only in 1965.

30. Sanitation problems of urban areas have received and are receivingmore attention than those of rural areas, particularly in the capital -Guatemala City - but also in other urban communities.

131. The capital city is supplied with treated water of satisfactoryquality by two systems - one public and one private. Present constructionand improvement programs of the Direccion de Aguas y Drenajes of the Muni-cipality will largely eliminate the deficiencies as to quantity andpressure in certain sections of the city. The percent of the populationserved by house taps will be increased from 65 to 81 percent, leavingonly 19 percent dependent on public taps. The two systems presently havea capacity to supply 110 million liters per day, or about 204 liters perperson. Studies have been made and new sources of water will be tappedto increase the available supply.

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32. Other major urban communities are supplied with water that hasreceived partial or complete treatment. The Departamento de Acueductosy Alcantarillados of the Direccion General de Obras Publicas, the agencyresponsible for construction, up to the end of 1965 had provided water to135,000 persons in 43 cities. Construction and improvements planned forthe next five years will benefit an additional 192,000 residents of urbancomemunities outside of the capital city at a per capita investment cost ofabout CA$45.00. Even if fully carried out, such construction would stillleave 76 percent of the urban population outside Guatemala City withoutpiped water. The ten-year program adopted in 1964 was intended to assurepotable water to at least 70 percent of the urban population.

33. YMost municipal improvements in Guatemala, except for some inGuatemala City, are financed by the Instituto de Fomento Municipal (INFOM)which lends to the municipalities funds obtained from the government orfrom foreign sources, exercisirg supervision over their expenditure andover the technical adequacy of the works and their execution. INFOM ischarged with promoting the development of the municipalities; it followsa policy of not authorizing any loan to a municipality which has not esta-blished a potable water supiply. For guiding the water supplies program, thereis a Junta de Agua (Wiater Boarc.) within INFOM which, while including a re-presentative of the Association of Municipalities, does not include anyonewho specifically represents the City of Guatemala; the latter has autonomyfor its own program which is coordinated with that for the rest of the coun-try under voluntary relationships.

:34. Water supplies built by SESP or by Obras Publicas, with or withoutINFOM assistance, are turned over to the municipalities for operation andmaintenance with little, if any, guarantee or assurance that these will beadequate. The municipalities contribute from 20 to 30 percent of the initialcost of a new improvement. It has been customary to supplement this amountby funds raised through the sale of water rights to consumers. In the caseof the last expansion of the Guiatemala City system, this mechanism offinancing was employed and resulted in all capital requirements being metwithout need for borrowing. It is understood that this same approach will beattempted on the next stage of expansion. This scheme has much merit, butit is not known to what extent it has been employed in the smaller communi-ties of the country.

35. In the capital city, 60 percent of the population has availablea combined sewerage system which, at present, is financed by the municipalwater and sewer agency. Funds obtained through charges collected on thewater bill, fees for connections, and from allocation of taxes have apparentlybeen sufficient to cover the operating costs of both water and sewerage.The authorities have been contemplating a proposal to establish a systemof sewerage service charges to serve in the future to finance extensions,improvements, and maintenance.

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36. Many of the other departmental or municipal centers of thecountry are reported to be partially served by sewerage systems, most ofwhich are combined storm and sanitary systems and without treatment. Someof these serve less than 50 percent and none serve more than 75 percentof the population.

37. Of the rural population, 2.3 percent is served by latrines. Ofthe urban population, 13 percer.t is served by the sewerage systems and anadditional 15 percent by latrires. The latrine building program of theDivision of Environmental Sanitation in the Ministry, with an annual produc-tion of 6,ooo only provides for about 30,000 additional persons annuallycls compared to the annual incrEase in rural population of about 90,000.

38. The present water supply and sewerage program is jointly carriedout by INFOM, Obras Publicas, z.nd Guatemala City. It appears that the rateof progress in water and sewerage construction in the country is less thancould be desired. To what extent this can be attributed to the lack of astrong central organization such as recently created in adjoining countries isd1ifficult to know It would sEem that even though a decision is taken to'Leave operation and maintenance at the local level, there would be merit.in creating a unit at national level whose specific functionit would be toassist the local government in preparing projects, arranging for financing,supervising and assiting in operations, and, in general, coordinating thenational water and sewerage programs.

Engineering and Medical Manpower

3.9. Guatemala has a number of competent sanitary engineers, but thisnumber needs to be increased to enable the needed and planned constructionprograms to take place on schedlule. Some of the engineers participate in-the teaching of the sanitary engineering course offered by the Universityof San Carlos, which is sponso:red by the Consejo Superior Universitario deCentro America y Panama. This is attended by graduate engineers from severalCACM countries under fellowships available from WHO/PAHO and AID.

40. There was poor distribution in 1958 of the 730 physicians, 79.5percent of whom practiced in Guatemala City, serving 17 percent of the popu-lation (Table 15). While the number is reported to have increased mate-rially, it was not determined to what extent this may have improved thedistribution. The number of phaysicians graduated annually from the medicalschool is expected to more than double by 1969. Similar personnel shortagesand maldistributions exist in other categories of health personnel, especial-ly nurses, nurse auxiliaries, and public health nurses. Guatemala does notappear to have benefited from available fellowships in proportion to need(Table 18).

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Investment Program

41. Among the major projects, SESP has proposed a ten-year programfor providing water supplies to 50 percent of the rural population at anestimated total costcf about CA$15 million, but the proposed financialsupport for the program amounts to only 3.4 million out of a neededCA$4.8 million for the period 1965-1969. A sewerage construction projectfor Guatemala City extending over fifteen years, for which a $1,000,000external loan would be needed for the first stage, has been approved by theCity Council. The 15-year project is estimated to cost CA$38.5 millionand is to be financed largely by a total assessment of $0.55 per squaremeter of land to be served, to be paid off over a ten-year period. Thisproject, when completed, will provide two treatment plants and will extendthe service, gradually reducing the number of houses dependent on septictanks or latrines.

h2. The investment program in health and sanitation contained in theGuatemalan five-year development plan calls for a total of CA$53.0 millionfrom 1966-1970, a figure more than twice the investment actually achievedin 1961-1965. The plan contemplates for Guatemala City the same share oftotal investment as in the past five years with regard to water supplyand sewerage. For investment outside the capital city, the plan representsa very large shift from water Eupply and sewerage systems to hospitals,health centers and posts and other services. Greater emphasis on areasoutside of Guatemala City is a move in the right direction as far as hos-pital and health centers facilities are concerned. There is ample needfor the expansion of water supply and sewerage facilities, especiallyoutside Guatemala City, where the municipality has been using its ownresources to improve the water and sewerage systems. With the assistanceof IDB loans, various municipalities are expanding their waterworks,although the greater priority given in the plan to hospitals and healthcenters as compared to water supply and sewerage systems represents a shiftfrom environmental to curative medicine which, prima facie, does not appearin the right direction. Mukch wrill depend on the relative importance givento hospitals as compared to health centers and posts.

43. In view of financial and administrative limitations and the verylarge increase that the Governnment plan represents over recent years, theprogram appears too ambitious and is not likely to be realized. Takingaccount of such limitations and the status of preparation of projects, themission considers that the investment likely to be realized from 1967through 1970 may be some CA$17 million, rising through the period. Thegreater emphasis given in the program to areas outside Guatemala City mayresult in great benefits for a large proportion of the population havingat present none or very limitedl health services.

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B. El Salvador

44. The proportion of total. government expenditures for health hasaveraged slightly over 10 percent for the past ten years. The per capitaexpenditure for all health and sanitation services was slightly above theaverage for the CACM area at CA$3.96 in 1963. Capital investments in thissector have been increasing and are now near the average for the area. Thisis true also for per capita investments in water supply and sewerage.

1Wfater Supply and Sewerage

h.5. Nearly half the population lacks a continuous, dependable, safe,and adequate water supply (Table 9) only 33 percent of the rural populationis supplied (Table 8) and only 1.5 percent by water piped into the houses i/;35 percent of the urban population still lackcs this service (Table 7). Al-though the typhoid case rate has been reduced from 92.9 in 1959 and 89.4per 100,000 population in 1962 to 39.4 in 1965, it is still well above theaverage rate of 24.5 in the Central American area (Table 4).

46. ANDA (Administracion Nacional de Acueductos y Alcantarillados),a semi-autonomous public agency, was established in 1961 with responsibilityrfor the community potable water supply program, including the operation ofseveral hundred supplies installed originally by the special health agencyin the Ministry of Health and VKelfare. Official concern with water supplyadequacy appears to have ncw become minimal on the part of the Ministry.

47. The lai-, creating ANDA preserved, in the Direccion General deSanidad, the responsibility for setting standards of hygienic quality ofwater, but the health agency appears to interpret this narrowly in termsof laboratory examinations rather than in terms of sanitary engineeringcriteria as to location, construction, and operation, and is inadequatelystaffed to exercise appropriatE concern or supervision.

418. ANDA appears to be mcire adequately staffed, but still limited bothstaff-wise and financially in extending its operations to bring under itsmanagement at an early date all. public water supplies. Only 50 supplieshad been acquired up to 1966, with 100 others scheduled for 1966 and 1967,and the remainder during 1968 End 1969.

lJ PAHO/IHO: Health Conditions in the Americas, 1961-1965. ScientificPublication No. 138, August 1966, Table 1, P. 116.

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49. An adequate wJater rate structure for all systems is needed wThichwill serve as a basis for collecting revenues from the sale of water suf-ficient to cover all costs an,l to generate revenues which can be appliedagainst future major expansionas. ANDA has proposed a rate structure whichestablishes a uniform charge applicable throughout the country and incor-porates a classification system for various categories of consumer, basedon property value. The systemn is highly complex and assumes that thereis a good cadastral service of the government which regularly establishesproperty values. Although denDt service and amortization is covered inthe rate formula, no provisio:n is made for depreciation so far as canbe determined. It is believed that certain problems may develop inthe future if the proposed structure is adopted. One of these wouldoccur if a major city was to initiate a major construction program ata cost which might necessitate raising rates in outlying communitiesto pay for it, since a uniforn tariff would be involved and all consumerswould therefore share all costs.

'0. Total investrment expenditures in health and sanitation for 1966-1L970 were planned by the authorities in CA$36.5 million or, an annual averageof CA$7.3 million as compared with an annual actual average of CA$3.9million for 1963-1965. With regard to water supply and sewerage theimplementation of the program will be the responsibility of ANDA. ANDAhas gradually taken over municipal systems, embarked on modest investmentand is due to put into effect early in 1967 a tariff schedule designedto produce modest surpluses to help finance the investment program ofC,A$ll million for 1966-1969. It will probably expand the program toinclude a major water distribution project for metropolitan San Salvador,the first phase of which could be ready for construction in 1968.

51. ANDA has in mind. two projects to speed up its constructionprogram, for both of which it would need external financial assistance.rhe first would be developed on the basis of feasibility studies recentlybegun by international consultants. This project is intended to improveand extend the water supplies of the metropolitan area and 140 smallurban communities, and would introduce potable water supplies into 350rural communities with an average population of 500. This is intendedto satisfy by about 20 percent each year the demand for water createdby the increasing industrialization and new urban developments. Theother project, costing $6 million and already approved by IDB, envisagesimproving and extending water supplies in 80 urban communities and 51rural communities and providing sewerage in eight urban communities.

Hospitals and Health Centers

52. The proposed investnments in hospitals and health centers amoun-ting to less than 20 percent of the investments in health and sanitationappear to be moderate or even low. The number of hospital beds per1,000 population for the whole country (2.3) is almost the lowest inthe region; the number in the capitals and large cities (6.5) is thelowest in Central America, aid the number in the remainder of the country(1.4) is not higher than the average. On the other hand, El Salvadorappears to have more health centers, health units, and posts available

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to serve the population than other countries of the area as measured bypopulation served by each such installation (Table 11). In this field ofpublic health the public investment program is not likely to be fullyrealized. However, the authorities will probably be able to invest - withthe help of a loan of $2.5 million equivalent from the Federal GermanGovernment - about CA$8 million in 1966-1969, largely in hospitals andhealth centers outside the capital city, a correct reflection of thecountry needs.

Engineering and Medical Manpower

53. More sanitary engineers are needed to staff the national andregional health organizations as well as to provide ANDA with the numberneeded to carry out its programs.

54. The country is not wrell equipped with physicians and outside ofthe capital and larger cities is very poorly served. Even though theunilversity has recently increased its production per year, the needs willnot be met in the foreseeable future. The supply of nurses and nurseauxiliaries is about average for the area (Table 16) which means fewerthan needed, to staff even the present facilities.

C. Honduras

55. Honduras has the highest proportion of total population in ruralareas of all the CACM countries (See Table 1). The rate of growth islow (2.5) for the rural popuLation and high (8.1) for the urban population.

56. The death rate for Infants under one year is the highest in thearea - 91.6 as compared to 70) per 1,000 population for the CACM area.Maternal death rate is the highest in the area - 1.9 per 1,000 live births,compared to 1.3 for the area as a whole. The birth rate in 1964 was thehighest of any CACM country - 48.1 as compared with 41.9 per 1,000 popu-lation for the CACivi area (Table 3). The highest typhoid case rate in1965 and the highest death rate from typhoid in 196h are reported forHonduras - 45.5 and 4.9 respectively, compared to the corresponding CAGMrates of 24.5 and 1.4 per 100,000 population. (Table 4).

57. Total government expenditures for health have been a small anddecreasing proportion of all expenditures. Capital investments in thissector have not been budgeted to increase materially as planned and needed.

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Water Supply and Sewerage

58. Piped water supplies are generally lacking in rural areas anddeficient in urban areas as to dependability, pressure, sanitary quality,and volume available. This situation undoubtedly accounts in large partfor the prevalence of diseases generally associated with lack of adequatesanitation or safe water supplies.

59. Most of the few reasonably safe water supplies of rural centerswere furnished between 1952 and 1958 under the program of Servicio Coopera-tivo Interamericano de Salud PuDlica (SCISP), which was discontinued in1958. A few additional supplies have been constructed since then by otheragencies, more recently by Servicio Autonomo Nacional de Acueductos yAlcantarillados (SANAA), but in general these lack chlorination or othertreatment, even though some are from unprotected surface sources. WHO/PAHOhave assisted through their zone offices and by assignment of an engineer tothe country in re-instituting a program of rural water supply constructionunder a plan for the country as a whole. AID, CARE, UNICEF, and IDB havealso assisted by providing funds and/or materials. local communities havecontributed labor, materials, and funds amounting to date to over 20 percentof the total cost of the work initiated in 24 rural communities. This pro-gram, to be completed around 1968, is estimated to cost about CA$1.3 million.

60. The water supplies of the three principal cities - Tegucigalpa,the capital, San Pedro Sula, the principal industrial city, and PuertoCortes, the principal Atlantic port - ail are deficient as to service,pressure, sanitary quality, and. volume available from developed sources.'Studies have been made for improvements to these and to six other urbansupplies, but action has been d.elayed by a number of factors. These include:

a) need for external financing to supplement funds allocatedby the government;

b) need for reorgani.zation.rof SANAA, which has had a newmanager appointed as a first step;

c) failure to secure satisfactory bids on installation of apipeline from a new source; and

d) failure to purchase land on one recommended watershedbefore it was purchased for country home sites.

61. Sewerage systems generally are lacking in the urban areas, as arelatrines in the rural areas. A latrine construction program, being carriedon in rural areas by Direccion General de Sanidad of M.S.P.S.A., and sewerconstruction by SANAA in a few cities is proceeding at a pace which willnot achieve the Punta del Este goals in less than about 20 years.

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62. A badly needed intercepting sewer paralleling the river in Tegu-cigalpa is under construction by SANAA with government funds.

613. The improvement of the water supply and sewerage systems ofSan Pedro Sula has been delayed by an unwillingness of the municipalityto turn over to SANAA the present works, the responsibility for carryingout improvements and for managing the systems, including control of reve-nues. Up to now, revenues have gone into the general funds of the muni-cipality and have been used forcther expenses unrelated to the water andsewerage systems. A new municipal government came into office recently,andi the authorities feel that the obstacles to an agreement with SANAAshould be surmountable.

Hospitals and Health Centers

6)4. Hospital care in Honduras, as in some other CACM countries, isinadequate. The beds available are too few for the total population,badlly distributed, unavailable to many persons, and are in antiquatedstructures which are poorly laid out without adequate facilities even, some-times, without a safe water supply. These hospitals are poorly manned bytoo few doctors, nurses, and nurse auxiliaries. All staff work ineffective-ly in a highly compartmentalized organization without uniform standards ofpractice, salary or hours of work, and are supported by poorly-equippedlaboratories and by pharmacies that operate wastefully under little or nosupervisory control.

65. Health centers are too few and the preventive and curative ser-vices provided at the health centers and hospitals have not been coordinatedin the past.

Engineering, Medical, and Other Health Personnel

66. The country is currerntly credited with having only one sanitaryengineer, but many have been trained and after serving in the government,have left to go into more lucrative general engineering or contractingbusinesses. Civil engineers without specialized training are being used,and for major work within the foreseeable future outside consultants willbe required if proposed programs are to be implemented. The country is not-is well supplied with medical practitioners as the rest of the CACM areaand the rural area is very poorly supplied (Table 15). There are not enoughtrained public health nurses arid graduate nurses, whichhbs resulted in theuse of auxiliaries, many of wlhci. are "practical" nurse auxiliaries withlittle, if any, formal training.

67. The national developnment Five Year Plan calls for the construc-tion by 1970 of water supply systems serving a population of 97,000 in 116small rural communities, at a cost of CA$3 million. This is intended tobring the percent of rural popuLlation served to 13 percent from the present

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7 percent (Table 8), a figure considerably below the objective set atPunta del Este. A more rapid progress might result if more reliance wasplaced on obtaining funds from communities which will benefit from theimprovements. Consumers now pay a water tax intended to cover only thecosts of operation and maintenance.

68. The total investment planned for 1965 to 1970 for urban watersupplies is around CA$3 million, but the percent of urban population servedwould be brought only to 44 percent by 1970 from the present 39 percentais compared to the corresponding percentages for the CAGM area of 66 percentand 49 percent, respectively (Table 7). At this rate, the Punta del Estegoal of 70 percent cannot be attained in the foreseeable future.

69. The project for imprcvement of Puerto Cortes includes sewerage,drainage, and land reclamation, as well as city planning and water supplyimprovement. WHO, with funds from the United Nations Technical Assistance,made a feasibility study and UNDP is considering a request for further fundst;o pay for detailed engineering plans and specifications, earth-movingequipment, and consultant services, even though existing studies would like-ly permit an appraisal by most financial institutions. An estimated CA$Lmillion will be needed later tco finance the construction of the water supply,sewerage, and drainarp systems. The main agency SANAA (Servicio AutonomoNacional de Acueductos y Alcantarillados) is carrying out two small projectswith financial assistance from AID and IDB, one for improving water systems.in 11 towns and the other for rural aqueducts. SANAA has begun to planfor a larger project for water and sewerage in Tegucigalpa. lhe principalobstacle to the expansion of SINAA is its weak financial position; the agencyhas a current account deficit and no firm plan exists to institute sufficientwater and sewerage charges which are needed to help it finance its programs.

70. The current and projected per capita investment expenditures forhospitals and health centers in Honduras are less than the average for theCACI area (Table 21). Support has been given by or requested from AID,PAHO/WiHO, IADB, and UNDP, for -;he projects designed to help correct thesituation, but more is needed as well as a greater commitment on the partof the government. The governmentts original hospital construction pro-gram, to be financed out of the budget, would involve expenditures ofCA$l4 million over the period 1L965-1969, though there have been some lateracljustments. 1AThile the hospital program is likely to take considerablylonger than expected, its general goals appear reasonable: it aims atraising the number of beds per thousand inhabitants from 1.8 at present to2.3, including facilities in various provincial centers and also aims atimproving existing facilities rather than emphasizi-ng new construction.Staffing of both new and existing facilities is a problem which needs tobe resolved before new constru3tion is undertaken.

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D. Nicaragua

71. Premature deaths and disease from preventable intestinal ailmentsassociated with unsafe water supplies and lack of sanitation continue totake a heavy toll in the productive capacity of the population.

72. The percentage of deaths from infective and parasitic diseasesis the highest in the area, (14.3 percent), (Table 3). The percentage ofdeaths from gastritis, enteritis, etc. is slightly above the average forthe area (Table 5). Typhoid fever cases reported have been reduced toone of the lowest rates in the GACM area, but the death rate from thisdisease remained the highest in 1964 (Table 4), suggesting a deficiencyin medical care.

73. The percentage of total government expenditures devoted to healthgradually increased from 3.5 percent in 1955 to over 9 percent in 1965.The per capita investment in health and sanitation facilities has been thehighest in the area since 1961 and, on the basis of plans, will be exceededon:Ly in 1967 and 1968 during tha next five years.

Water Supply and Sewerage

74. Presently operating and planned programs for the provision ofsafe water supplies and sewerage are proceeding too slowly to attain thestated objectives, which are still short of the goals of Punta del Este.

75.. Only 36 percent of the urban population was served by piped wateri.n 1965 as compared to 6.5 percent for the area. This will be raised to60 percent by 1970 if all plans a.re carried out, but this will be less thanthe average of 66 percent for the area and less than the Punta del Estegoal of 70 percent (Table 7) which should be reached in about 1973 at thepresent rate of construction.

76. A step forwrard was taken with the extension and improvement ofthe water supply of Managua, the first major phase of which was completedjust recently, with the help of an IDA Credit. The public Mvanagua WaterCompany (Empresa de Aguadora de Managua) is in a good position to completethe extension of the system to the remaining areas of the city as they aredeveloped with little, if any, further outside assistance. The water qualitywill be improved by maintenance of adequate pressures throughout the system,together with continuous, properly controlled chlorination at the sourceand of newly installed portions of the system. Sources of potential conta-mination by back-flow through cross-connections and submerged inlets on thedistribution system and plumbing system will need to be located and removedand new installations of such arrangements will need to be prevented.

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77. Three other principal cities - Leon, Chinandega, and Granada -have water supplies that are believed to be in such poor condition as toneed complete remodeling. Forty-nine of the other fifty urban watersupplies require extensions, completion of works, and/or chlorination.Seventy urban communities are without any piped water supply.

78. Water revenues in most communities are not satisfactory. Ratesare too low and many consumers are exempt from the charges. The ManaguaWater Company established new rates in 1964 intended to provide adequate

funds for operation and expansion of the new system.

79. Only 2.1 percent of the rural population had piped water in1965 - the lowest percentage in the Central American area. Completionof presently planned projects will only raise this to 10.5 percent whichwill still be the lowest in the area and far short of the goal of50 percent set at Punta del Este (Table 8) which is not in sight at thepresent rate of investment.

80. Only 14.7 percent of the urban population was served by seweragesystems in 1965, the lowest percentage in the CACIM area. The investmentschedule proposed, however, would raise this to 53.5 percent by 1970,slightly in excess of the average for the area (Table 10), but still shortof the Punta del Este goal which would not be attained until around 1974at the planned rate of investmient which, however, is more than three times

the average for the area on a per capita basis.

81. In Managua, the present sewerage system is not adequate; itserves only 60 percent of the presently developed area and less than25 percent of the present population or, 5 percent of the populationexpected in 1995. The system is overloaded and lines in the centerof the city being too small are usually under pressure. By dischargingdirectly to the lake beaeh in the center of the city, the system con-tributes materially to the health risks of the population, as well asinterferes with sound development of the lake frontfor civic andtouristic purposes. The lake front of Lake Managua may be difficult

to exploit if a safe and sightly solution for sewage disposal isnot reached. A master plan has been developed by consultants, envisag-ing a three-stage solution culminating in 1986 with collection andtreatment of all sewage and industrial waste and discharge into LakeManagua at a location which should minimize the effects of pollution.The first stage, as proposed, would cost CA$9.5 million. To financethis, the consultants proposed a foreign loan of $7 million to beserviced from proceeds of a sewer service charge - still to be

authorized and instituted - and an investment of $2.0 millioneouivalent by the National District, which is to be obtained

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by an allocation from real estate taxes. The District Public WorksDepartment would probably be responsible for such a project. Prepara-tion of the project for external financing will probably not be readybefore 1968. The authorities propose that the second stage would beconstructed immediately after completion of the first stage because ofthe need to avoid pollution problems which will begin to develop at thelake front shortly after completion of stage one. Final design andconstruction of the third stage would begin after 1980 and be completedin 1986. Given the lapse of time, this phase should be reviewed andrestudied after 1980.

82. Nine other cities have sewerage systems which serve only 8 percentof the urban population outside: of Managua. Only one of these systems,serving lMatagalpa, is considered to be fairly complete and efficient.

Hospitals and Health FacilitieE

83. On the basis of average population served by each health facilityother than hospitals, Nicaragua appears to be better provided with healthcenters and similar prevent;ive health centers than the rest of the CACMarea (Table 11). Only 40 percE!nt of the national territory has availablesome type of health service facility providing preventive-curative atten-tion. Approximately 50 percent of all the deaths in the country occurwithout any medical attention.

84. Nicaragua has now 38 hospitals with a total of almost 3,900beds serving a population of 1,700,000 or, an average of 2.3 beds per1,000 population. This ratio is about the same as in 1960 as additionalbeds provided since 1960 has merely kept up with the increase in popula-tion. The national plan for the period 1965-1969 (which has not been heldto) contemplated increasingf the total beds to 5,670 by 1969 which wouldprovide 2.9 beds per 1,000 population. This would still be short of thegoal of 5.0 beds per 1,000, the achievement of which has been postponed bythe Government until 1974 because of the Government's preference forinvestment in other public sectors.

85. The distribution of hospital beds, with 6.7 available per 1,000population in Managua and 1.5 per 1,000 population available in the restof' the country (where 53 percent of the population resides) leaves muchto be desired since the concentration of hospitals in Managua makes themless accessible to many residenats of remote rural areas than if the hospi-tals were more amply distributed among the cities.

1/86. A recent survey indicated a need for many changes in the organi-zation of the hospitalization services on a national basis, along with

1/ Verdugo Binimelis, Dr. Dario: Problemas de Atencion Hospitalaria enNicaragua, Informe, Managua, D.N. Marzo de 1966. Report of a studymade with joint support of OMS and OEA.

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improvement of the physical facilities and better utilization of theavailable professional personrel and facilities.

Engineering and M4edical Manpower

87. Although the country is currently credited with having onlytwo sanitary engineers (Table 17), there were some 278 civil engineersaccording to a May 1963 censu;, with an estimated 700 to be trained atthe National University by 19?5, of which some should be available forfurther training as sanitary engineers. The need for sanitary engineersis great and requires that opportunities for advanced sanitary engineeringtraining be made competitively attractive.

88. Although Nicaragua appears to be better supplied with physiciansthan any other part of the area, it needs more than can be trained atthe present rate (Table 15). Required service by newly graduated physiciansin rural health centers is not likely to fill the need for professionalstaff as the nurtber of these zenters is increased.

89. There are not enouga trained public health nurses or even graduatenurses an(d Nicaragua, like other CACM countries, uses nursing auxiliaries,many of whom are "practical" nurse auxiliaries with little or no formaltraining.

90. To help correct the deficiency in the field of health servicesthe government proposes a ten-year program of construction to establish100 health posts and centers located principally in the rural areas. Onlya few of these are now served by intermittent visits by mobile sanitaryunits (PU1AR) or by improvised arrangements in rented buildings notdesigned for the purpose. A proposal to improve the situation has beendeveloped and calls for a total investment in ten years of approximately$2,000,000.

91. Planned expenditures for hospitals and health centers per capitain Nicaragua are the second hLighest in the region. The level of expen-ditures ..proe-<2sto be as high as can be justified at this time, in viewof the need for other health related investments in preventive servicefacilities. Even so, it seenis likely that the realizable outlays for watersupply and health in the period 1966-1970, as estimated by the mission,would amount to CA$18.7 mill-ion, rising from CA$2.0 million in 1966 toCA$5.7 million in 1970.

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E. Costa Rica

92. Preventable water-borne diseases are still the leading causeof death and acccount for a high proportion of disability.

93. Total expenditures by the government for public health have beenincreasing in absolute terms but decreasing in proportion to other govern-ment expnditures. The proportion of the expenditures allocated forpreventive medicine has been decreasing while expenditures for curativemedicine have increased proportionally. Allocations to water supply andsewerage have steadily increased in proportion to total expenditures.

T;Yater Supply and Sewerage

9t... The Servicio Nacional de Acueductos y Alcantarillado (SNAA)which was created on April L, 1961, was charged with responsibility forall matters related to the water supplies and sewerage systems in the entirecountry.

95. Ten water supply systems constructed by the Ministry of PubliclWorks were turned over to SNAA on December 31, 1961, together with 18other systems still under corstruction. Also turned over were a number ofrequests for new systems under study, as well as the responsibility ofproviding for the water supply needs of the metropolitan area of San Jose.

96. A plan for improvement of the water supply for the San Jose metro-politan area (The Rio 3lanco Project) was evolved by SNAA, including anemergency plan, both of which were formalized in September 1961. The firststep of this latter project ras financed with the help of an Eximbankloan signed in December 1961 for $L.5 million and in January 1962, AIDgranted a loan for $3.5 million to finance local costs of the system.Detailed design studies ior the Rio Blanco Project were begun in May 1962with a completion date expected early in 1965. During 1962, an emergencyprogram of design and construction was commenced to partially relieve thescarcity of water in San Jose in advance of the completion ofthe Rio ElancoProject. However, the eruption of Irazu Volvano beginning in March 1963had, by August, resulted in a condition of emergency, with conditionsdetermined later to be insuperable obstacles to the development of the RioHlanco Project as planned. A study of an alternate source - Puente deiIulas - with the assistance of engineering and geophysical consultants wascompleted in 1966 and this project is being carried forward with the helpof funds from the loans for lthe Rio Blanco Project.

97. Prior to the creat-Lon of SNAA, there had been constructed manywater supplies but few, if any, of these were extended as needed forindustry and the increasing population, nor were they aperated to furnish

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a dependable, continous, safe and adequate supply. During 1962 and1963, additional wTater supplies were completed and their operation broughtunder the management of SNAA. Preliminary engineering plans and limitedengineering studies were made for:

(a) sewerage of t:ae metropolitan area;

(b) water supplies and sewerage of major cities(population exceeding 10,000);

(c) water supplies and sewerage for smaller urbanpopulations; and

(d) water supplies for rural areas.

98. Although figures ottained by the mission show that by the endof 1965 piped water was being supplied through house connections to 100percent of the urban population (communities with over 2,000 inhabitants),there is reason to believe that the number is actually considerably belowthis level, since even the mcst developed countries do not show this per-centage of connections. In the rural areas, a figure of 43 percent isshown for the population served by water into the house. In most instances,both quantity and quality of water distributed are deficient. New cons-truction is planned on a. scale to meet population increases by 1970,but is likely to fall behind schedule because of financial limitations.In 1961, only 29 percent of the urban population was served by seweragesystems, or, about 10 percent of the total population of the country.

99. Rates were established in the metropolitan area for water supplyand sewerage services accord"Lng to a schedule by categories of connectionand volume used. In existing water supply systems outside the metropolitanarea, rates were established according to a schedule applying to allsystems administered by SINAA, and based on costs of new systems that SNAAwould construct or improve in the future. In general, the rates are adequateto cover operation, maintenance, and administration, but not depreciationor recovery of investment, e;specially for supplies in rural areas. This isclearly inadequate, but unless rates are increased to increase cash flow,needed investment will be ca:rried out at too slow a pace.

100. Programs for water and sewer improvements have not proceededat the pace planned, for a number of reasons, some of which are:

(a) eruption of Irazu Volcano, making necessary a re-studyand redesign of the Rio Blanco Project;

(b) delays in securing authorized allocations of loanmoney;

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(c) slowness in completing plans and specificationsrequired before construction could begin;

(d) failure of the Central Government to allocate alllegally authorized appropriations; and

(e) failure oi sorie municipalities to accept the author-ity of SNAA to assume direction of the local watersupply and sewierage system, including management ofthe systern of service fees.

101. These delays, in effect, have put the SNAA approximately one totwo years behind the schedule set in 1961. Even with a build-up of staffwhich is needed, the prospects are that achievement of SNAA's goals for1972 will be delayed. Their annual outlays are likely to be somewhat lessthan planned, and the program will extend over a longer period, with totalc:osts somewhat higher than anticipated.

Hospitals and Health Centers

102. The number of persons covered -/ by the Social Security Schemeincreased from 82,200 in 1951 to 29h,4800 in 1963, and 422,372 or 29 percentof the total population by the end of 1965. The cost of curative medicineais practiced by Social Securi-ty is almost three times the national averageas measured on a per capita basis.

;Ianpower and Investment

103. The number of qualified sanitary engineers in the country is notyet sufficient to handle water supply and sewerage planning, design, andconstruction of the projected programs. It is necessary to call upon con-Sulting sanitary engineers from outside the country. The small number ofengineers in the employ of SNAA makes it difficult for any of them to obtainadditional advanced specialized training in water supply and sewerage. Thenumber should be at least doubled. In public health, half again as manyphysicians, twice as many nurses, and triple the number of auxiliaries andnutritionists as at present are needed, as well as lesser increases inthe number of other categories of para-medical personnel. To supply the

1/ Insurance coverage includes medical care and hospitalization formembers and their families.

- 26 -

personnel requirements, an expanded program of training is needed toprovide the total new personnel in the above mentioned categories duringeach of the next ten years.

lo4. The program of expenditures planned for hospitals during theperiod 1966-1970 appears to be! based on an arbitrary ratio of bedcapacity to population rather than on a demonstrated need, taking intoaccount all possible methods of better utilizing the presently availablefacilities. The program of e!xpenditures for preventive public healthfacilities appears too low in proportion to planned expenditures for cura-tive medicine, but is probably realistic in terms of the capability ofstaffing new facilities with competent professionals. Total investmentexpenditures in health and sanitation for 1966-1970 were planned by theauthorities in CA$35 million or, an annual average of CA$7 million ascompared with an annual average of about CA$3.5 million, from 1962 to1.965. The mission estimates that such outlays, given limitations ofproject preparation and execution, are likely to be about CA$24 millionfor 1966-1970.

S'TATI'STICAL APPENDIX

TableNo.

1 Percent of Rural Population to Total Population by Countries:Estimated Actual for 1950, 1960, 1961, 1963, 1964, and 1965:and Projected for 1966-1970 and 197h

2 Estimated Hiid-year Populations Estimated and Projected forCACM Countries in Years 1965-1970 and 1974

3 Life Expectancy, Dea-hs by Age Group and by Cause, and Births,by Countries in Recent Years

4 Reported Cases and Deaths from Typhoid Fever, by Countries,1961-1965

5 Deaths from Gastriti.s, Enteritis, etc. by Countries, 1959-1960and 1964

6 Maternal Deaths by Countries, 1960-1964

7 Investment Expenditures for V'ater Supplies (1961-1965 and 1966-1970)and Population Affected, Urban

8 Investment Expenditures for Water Supplies (1961-1965 and 1966-1970)and population affected, Rural

9 I[nvestment Expenditures for Water Supplies (1961-1965 and 1966-1970)and Total Population Affected

LO Investment Expenditures for Sewerage and Total Population(1961-1965 and 1966-1970) Affected

11 Total Population and INumber of Health and Hospital Facilitiesby Countries, 1963-196)

12 Number of Hospitals by Type and by Country, about 1964

:13 Hospital Beds Reported and Planned by Governments, by Countries

14 Selected Indicators of Public Health and Sanitation Services,by Countries

15 Schools of Medicine and Medical Graduates, Number of Physiciansand Ratios to Total Population and Large Cities, by Countries

16 Number of Nurses and Nursing Auxiliaries and Ratios per 10,000of Total Population, by Countries

TableNo.

17 Health Personnel by Countries, in Recent Years

18 Fellowships Awarded ty Country of Origin of Students, Type ofTraining, and Field cf Study, 1958-1961 (A) and 1962-1965 (B)

19 Expenditures for Hea].th and Sanitation, by Countries

20 Per Capita Investment Expenditures for Health and Sanitation1961-1965, and Planned by Government 1966-1970, by Countries

21 Per Capita Investment; Expenditures for Health and Sanitation1961-1965 and Plannecd by Government, by Countries 1966-70

22 Guatemala: Investment Expenditures for Health and Sanitation,by Categories of Programs, for 1960-1965 and for 1966-1970

23 Guatemala: Public Investment in Health and Sanitation, Actualfor 1961-1965 and Planned by Government for 1966-1970

24 El Salvador: Investrient Expenditures for Health and Sanitationby Categories of Programs for 1960-1965 and Planned by Governmentfor 1966-1970

25 El Salvador: Public Investment in Health and Sanitation 1961-1965and Planned for 1966-1970

26 Honduras: Inves-tmen-t Expenditures for Health and Sanitation byCategories of Programs, Actual for 1960-65 and Planned for 1966-70

27 Honduras: Public Investment in Health and Sanitation, Actual1961-1965 and Planned 1966-1970

28 Nicaragua: Investment Expenditures for Health and Sanitation,by Categories of Programs, for 1960-65 and Planned for 1966-70

29 Nlicaragua: Investment in Health and Sanitation, Actual 1961-1965and Planned by Government 1966-1970

30 Costa Rica: Investment Expenditures for Health and Sanitation,by Categories of Programs, Actual for 1960-1965 and Planned byGovernment for 1966-1970

31 Costa Rica: Public Investment in Health and Sanitation, Actual1960-1965 and Planned by Government, 1966-1970

Table 1: CETTRAL APERICA: PERCENT OF RURAL PCPULATICO' TOf TOTAL POPULATION BY OOLT'TPIES: ESTIMAT`D ACTUALFOR 1950, 1960, 1961, 1963, 1964, AND 1955; AND PROJECTED FOR 1965-1070 AND 1974

.stimated Projected

1950 1960 1961 1963 196 4 1965 1966S 1967 1968 1969 1970 197

Guatemala 68 67 67 67 67 67 67 67 67

1l Salvador 64 59 62 61 61 61 61 61 60

Honduras 77 75 74 7)4 73 72 72 71 68

iiicaragua 65 57 591 59 58 57 57 56 56 53 52

Costa Rica 67 66 65 65.1 65 65 65 64

Central Jimerica 67 67 66 66 65 65 65 65 64 63

*/ Ministerio de Salubridad Publica; Nicaragua: Prioridades en los Problemas de Salud en Nicaragua, 1955

Source: PAtJ A'FIC, :Iealth Conditions in the Americas 1961-1965) Scientific Publication Nolo. 138;

-iission estimates, 1966-1974

Table 2: CENTRAL AMERICA: ESTIMATED MID-YEAR POPULATIONS ESTIMATED AND PROJECTEDFOR CACM COUNTRIES IN YEARS 1965-1970 AND 1974

(in thousands)

Total PopulationCountry 1965 1966 1967 1966 1969 1970 19774

Guatemala 4,438 4,508 4,645 4,786 4,929 5,083 5,737El Salvador 2,928 3,008 3,090 3,175 3,262 3,351 3,737Honduras 2,284 2,320 2,401 2,483 2,565 2,647 3,028Nicaragua 1,655 1,710 1,768 1,827 1,889 1,953 2,237Costa Rica 1,433 1,486 1,541 1,598 1,657 1,718 2,099

Total 12,738 13,032 13,445 13,869 14,302 14,752 16,838

Urban Population

Guatemala 1,445 1,097 1,5LL 1,592 1,641 1,696 1,924El Salvador 1,127 1,164 1,202 1,242 1,253 1,325 1,509Honduras 587 612 651 690 731 773 981Nicaragua 695 729 765 802 841 882 1,068Costa Rica 496 517 539 562 586 611 806

Total 4,353 4,519 4,701 4,888 5,082 5,287 6,203Percent of Total 34.2 34.7 .0 35.2 35.5 35.8 -- 6.8

Rural Population

Guatemala 2,990 3,011 3,101 3,194 3,288 3,387 3,813El Salvador 1,801 1,8W1 1,888 1,933 1,979 2,026 2,228Honduras 1,697 1,707 1,750 1,793 1,834 1,874 2,047M\licaragua 960 981 1,003 1,025 1,048 1,071 1,169Costa Rica 937 969 1,002 1,036 1,071 1,107 1,293

Total 8,385 8,512 8,744 8,981 9,220 9,465 10, 522Percent of total -6.8 65.3 64.0 T.8 6).5 6T.2 65.2

Source: Population for 1966 and future years projected using growth rates shown in Table 11, Rural andUrban population computed using percentages shown in Table 1.

Table 3: CENITTRaJ AEERICA: LIFE aPECTANCY, DEATHS BY AG'E GRCUP KI1,D BY CAUS', AiD BIRTHS, BY C)CUITRIES IllRECENT YEAR3

DeathsUnder Percent of Deaths ENaternal Live

Deaths per 1 Year from From Deaths Births15000 Po-,ulation ner Infective Gastritis per Der

Life Year All 1 - 4 Under 1,000 and Enteritis 1,000 1,000Expectancy of Aiges Years 1 yr. Live Parasitic etc. Live Popula-

Country Date Years Data 3irths Diseases Dix U- tian

Guatemala 1964 49.4 196h 15.9 33.6 91.6 92.3 25.2 13.4 - h.4

El Salvador 1963 60.5 1960 11.7 15.9 65.3 67.8 10.9 5.5 0.9 47.0

rIonduras 1961 60.9 1961 9.5 12.09 45.4 - 8.5 7.3 1.98.1

'icara2aua 1964 69.4 1963 7.2 7.2 L9.7 19.7 14.8 12.0 1.3 41.9

Costa Rica 1963 65.3 1963 8.5 6.7 75.2 75.2 9.0 15.5 1.3 h6.8

Central 1America 56.0 19.11 70.0

Source: PAlCt./mG, Health Conditions in the Americas, 1961-1964, Scientific ?ublication Nc. 138, August 1966

Table 4: CENTRAL AMERICA: REPORTED CASES AND DEATHS FROM TYPHOID FEVER, BY COUNTRIES, 1961-1965

CASES DEATHS--------------- Number--------------- ---------------- Rate ---------------- --------------- Number-------------- ------------- Rate! ------

Country 1961 1962 193 2 1965 961 1962 19623 1 1261 192 1963 L964 1 1961 1962 1963 1964 1965

Costa Rica 99 5° °5 77 53 8.i 4.6 6.j 5.6 3.7 7 ; 12 i2 - 0-G 0 ^° ^. .9

El Salvador 909- 1353- 1116 1279 1153 61.7 89.4 L1.0 45.3 39.4 30 49 169 - - 1.2 1.9 6.2 -

Guatemala 887 732 879 1115 1082 22.6 18.1 21.0 25.9 24.4 348 290 351 - - 8.9 7.2 8. -

Honduras 411 368- 646- - 1027- 753 21.7 38.7 64.6 82.4 45.5 90 61 58 82 - 4.7 3.1 2.9 3.9

Nicaragua 291 286 335 174 51 20.0 19.1 21.7 10.9 2.4 151 110 98 79 - 10.4 7.4 6.4 4.9Central America 2597 2797 3061 3672 3092 23.5 24.5 25.9 30.1 24.5 626 520 688 173 - 5.7 4.6 5.8 1. -

1/ Per 100,000 population

2/ Reporting area for case data

3/ Case data include paratyphoid fever

Source: Health Conditions in the Americas 1961 - 1965, PAHOAWHO, Scientific Publication No. 138

Table 5: CENTRAL !ANIERICA: DEATHS FRlC;- GASTRITIS, EDNTERITIS, STC. BY C0;UTRIIS, 1959,1960AND 19 14

--r cent, of Ceat!is

Number Rate__ from all causes

Country 1959 1960 1964 1959 1960 1964 1959 1960 1964

Costa Rica 13814 1408 1893 122.0 120.2 136.8 13.6 14.0 15.5

El Salvador 2370 1714 1642- 99.3 65.6 60.3 7.9 5.9 5.5

2/ 1/2/E-uatemala 8518 7000- °'561-/ 230.5 183.7- 229.0 13.5 10.6- 13.4

Hionduras 468 3C00 1504 26.3 16.3- 71.9 2.6 1.7- 7.3

iicaragua 1458 1482 1400 106.4 100.3 87.7 12.2 12.4 12.0

Central 14198 1190Lt- 16005 137.1 111.14 131.1 11.0 8.8 - 11.3Ame rica

1/ Rate per 100,000 population, 1963

2/ Estimated

Source.s : 1Iealth Conditions in the Anericas 1961 - 1964, PAIi&/JHCv Scientific PublicationiKo. 138

Table 6: CIE-TRAL AiERICA: 1!.-'LFJ.. DEATI-IS DE CCUIqTRT', 1960 - 196L

iPlumber of Deaths Rate per 1000 live birthsCountry 1960 1961 1962 1963 1964 1960 1961 1962 1963 1964

Costa Rica 74 96 90 77 82 1.3 1.6 1.4 1.2 1.3

L,1 Salvador 210 186 171 157 118 1.7 1.5 1.3 1.2 0.9

Guatemala 433 488 h57 L,o6 - 2.3 2.5 2.4 2.1 -

H:onduras 255 236 215 212 188 3.1 2.7 2.7 2.3 1.9

iicaragua 103 117 115 88 84 1.7 2.0 1.9 1. 1.3

Central 1075 1123 1073 gLo L72 2.1 2.1 2.0 1.7 1.3America

Sources: PARO/U-AHeC Scientific Publication No. 138

Table 7: CIATRMAL AXERICA: TMVES3TI!iENT EXPEUDITURES - FGR -WATER SUPPLIES(1961-1965 ANID 1966-1970) ANDPOPULATIUN2 - A-FFECTED, URBAN

Guatemala El Salvador Honduras Nicaragua Costs Rica Total Area

Population - Urban - 1960 1235. 1007. 415. 492. 404. 3553.Urban population served in 1960 36. 483. 176. 207; 393. 1605.Percent of urban population served in 1960 28. 48. 42. 12. 97. 45.investment Expenditures 1961-1965 12.9 14. 1 1. R A 1 2 28.21Population benefited 266. 649. 51. 43. 103. 1112.Percent of 1965 urban population benefited 18.3 57.5 8.8 6.2 20.8 25.5

Population - Urban - 1965 1448. 1127. 587. 695. 496. 4353.

Urban population served in 1965 413. 722. 227. 282. 496. 2140.Percent of urban population served in 1965 28.6 64. 38.7 41. 100. 49.Investment EXpenditures 1966-70 18.4 8.1 2.8 9.18 11.3 49.78Population to be benefited 348. 308. 117. 280. 103. 1156.Percent of population to be benefited 20.5 23.2 15.2 31.6 16.8 22.

Population - Urban - 1970 1696. 1325. 773. 882. 611. 5287.Urban population to be served in 1970 780. 1244. 314. 530. 599. 3b97.Percent of urban population to be served in 1970 46. 94. 44. 60. 98. 66.Urban population unserved in 1970 916. 81. 1429. 352. 12. 1790.Percent of urban population unserved in 1970 54. 6. 56. 40. 2. 34.

1/ ilillions of C.A. pesosT/ In thousandsSources: PAHOADHt-: Quadrennial Report of the Director 1958-1961. Official Docum.ent No. 43, July 1962.

Table 7: CDITRAL MIEERICA: -PEL.§iY.L-. xPENDITURES 1- FCR .iAiER SUPPLIES(1961-1965 AND 1966-1970) ANDPCPULATICEN 2/ AFFECTED, URBAN.

Sources: (con't.)

PAH(T.HC: Summary of Four-Year Reports on Hlealth Conditions in the Aiericas 1957-1960.

Scientific Publications No. 64, July 1962.PAIICA/H1HC: Health Goals in the Charter oa Punta del Este. Facts uoi Frogzess, liscellaneGusPublication, No. 81, harch 1966.SAldNiAA: Programa de Inversiones y Gastos del Servicio Autonomo Hlacional de Acueductos y

Alcantarillados (SANkk) para el Quinouenio 1965-1969. Inversiones Publicas Sector Salud.

Tegucigalpa, D.C., Honduras, C.A. August 1965.Secretaria General de Consejo Nacional de Planificacion Economnica: Programa de Salud Publica

para la Republica de Guatemala (1965-1969). Guatemala, July 1965.

Consejo Nacional de Economia Oficina de Planificacion: Plan iNacional de Desarrollo Economico

y Social de NIicaragua, 1965-1969, IV Inversions Publicas en Salud, 1965-1969.

Table 8: C1TTRAL AiERICtA: INVEST1EDT EXPENDITURFS - FOR 1IATER SUPPLIES(1961-1965 AND 1966-1970) iji\TD- 2C2ULATI0tT t/ PU A7FFECTED, RURAL

Guatemala El Salvador Hlonduras Nicaragua Costa Rica Total Area

Population - aural - 1960 2576.0 1L447.0 1422.0 919.0 767.0 7131.0Rural population served in 1960 105.0 13.0 34.0 3.0 215.0 400.0Percent of rural population served in 1960 4.1 3.0 2.4 0.3 28.0 5.6Investment expenditures 1961-1965 0.3 2.4 0.25 0.07 0.2 3.22Population benefitted 130.0 547.0 79.0 8.0 185.0 94f9.0Percent of 1965 rural population benefitted h.35 30.3 4.71 0.83 19.7 11.3

Population - Rural - 1965 2990.0 1801.0 1697.0 960.0 937 ,0 8385.0Rural nonulation served in 1965 236.0 590.0 113.0 20.0 b00.0 13b9.0Percent of rural population served in 1965 7.9 32.8 G C.l L/ '6.1Investment expenditures 1966-1970 7.4 18.2 2.45 1.25 2.7 32.0Rural population to be benefitted 380.0 580.0 128.0 102.0 75.0 1265.0Percent of 1970 rural population to be benefitted 11.2 28.6 6.8 9.5 6.8 1344

Population - Rural - 1970 3387.0 2026.0 187)4.0 1071.0 1107.0 94X65.0Rural population to be served in 1970 615.0 1170.0 2)41.0 113.0 475.0 2611.0Percent of rural population to be served in 1970 18.2 57.7 12.9 10.5 )42.9 27.6Percent population unserved in 1970 2772.0 856.0 1633.0 958.0 632.0 6851.0Percent of rural population unserved in 1970 81.8 )42.3 87.1 89.5 57.1 72.4

1/ Millions of CA Pesos2/ In thousands

Source: PAKC/AiHG: Hlealth Goals in the Charter of Punta del Este, Facts on Progress.Iiiscellaneous Publication l,o. 81, Mlarch 1966.PAHOA'THO: -Summary of four-year Reports on HSealth Conditions in the Americas 1957-1960.Scientific Publication No. 6)4, July 1962.Secretaria General de Consejo Nacional de Planificacion Economica: Programa de Salud Publica para

la aepublica de Guatemala (1965 - 1969). Guatemala, Julio de 1965.Consejo N,acional de Economia, Cficina de Planificacion: Plan Nacional de Desarrollo Economico y Social

de Hicaragua, 1965-1969, IV Inversiones Publicas en Salud, 1965-1969.-AH(~/Jh. Q O~uadrennial Report of the Director 1958-1961i. Official Document :Jo. 43 July 1962.

Table 9: CTNTRLAL AMIERICA: INVESTTEIT E[PENDITURES 1/ FOR lATER SUPPLIES(1961-1965 AND 1966-1970) AND TOTAL

POPULATICMi' 2/ iZFECTED

Guatemala Ei Salvador Honduras Nicaragua Costa Rica Total Area

Population - 1960 3811.0 2454.0 1837.0 1411.0 1171.0 10,684.0

Population served in 1960 451.0 526.0 210.0 210.0 608.0 2,005.0

Percent of population served in 1960 11.9 21.5 11.4 14.8 51.9 18.8

Investment expenditures 1961-1965 13.2 6.8 1.65 8.38 1.4 31-43

Population benefitted 1961-1965 197.0 1196.0 130.0 51.0 288.0 1,862.0

Percent of 1965 population benefitted 4.4 40.0 5.7 3.1 20.1 1h.6

Po1pu4lat-i4on - 1965 )h38.0 2928.0 2281,.0 1655.0 1L33.0 12,738.0Population served in 1965 6)48.0 1722.0 340.0 261.0 896.0 3,L57.0Percent o, populatinVr scrved - 16°_65_ 1R.7 ?1.1 15.8 62.5 27.2

Investment expenditures 1966-70 25.8 26.3 5.30 l0.h3 1.0 81.83

Population to be benefitted 1966-1970 7L7.0 888.0 245.0 382.0 178.0 2,440.0

Percent of 1970 population benefitted 1966-1970 1.7 26.4 9.2 19.6 10.4 18.0

Population - 1970 5083.0 3351.0 26147.0 1953.0 1718.0 14,752.0

Population to be served in 1970 1395.0 2610.0 585.0 6 43.0 1074.0 6,111.0Percent of population served - 1970 27.4 77.9 22.1 33.0 62.5 1.4Population unserved - 1970 3688.0 74162.62.0 1310.0 644.0 8,641.0Percent of population unserved - 1970 72.6 22.1 77.9 67.0 37.5 58.6

Per capita expenditure 3/ on basis of benefittedpopulation - 1961-1965 66.50 5.68 12.70 164.60 h.86 16.88

1966-70 3L.60 29.7 21.62 27.40 78.70 33.601961-1970 41.40 15.9 18.50 43.50 33.05 26.ho

Per capita ex;penditure 3/ on basis of total popula-

tion end of period1961-1965 2.96 2.32 0.72 5.o6 0.98 2.46

1965-1970 5.o8 7.87 2.00 5.35 8.15 5.551961-1970 7.65 9.89 2.62 9.65 8.97 7.68

1/ I!illions of CiA Pesos

2/ In thousands3/ U.S. dollars eauivalent

1/Table 10: CE!rTrPL AMERICA: INIVEST ENT vPE`7DI`UPT,S FOR 'Q,7 7ERAGE

AND TOTAL POPULATION (1961-1965 AND 1966-1970)2,/ AFFECTED

Guatemala El Salvador Hlonduras Nicaragua Costa Rica Total Area

Population - Urban - 1960 1235.0 1007.0 415.0 492.0 404.0 3553.0Urban population served in 1960 155.0 29).0 87.0 90.0 90.0 716.0Percent urban population served in 1960 12.6 29.2 21.0 18.3 22.3 20.0Investment expenditures 1961-1965 6.5 3.4 0.2 10.97 0.2 21.27Population benefitted 1961-1965 30.0 349.0 143.0 12.0 175.0 709.0Percent 1065 urban population benfitted 2.1 32t 7 1.7 35.3 16.3

Population - Urauii - 1965 1)58.0 119?47 58eO 695.0 b96.0 410.0Urban population served in 1965 185.0 643.0 230.0 102.0 265.0 1425.oPercent of urban population served in 1965 12.8 57.0 39.7 14.7 53.5 32.8Investment expenditures 1966-1970 12.7 2.3 1.25 24.2) 9.h b9.89

(mil2ion U.S,.$)Population to be benefitted 1966-1970 198.0 357.0 140.0 308.0 177.0 1180.0Percent of 1970 urban population to be benefitted 11.7 27.0 18.1 35.0 29.0 22.3

Population - Urban - 1970 1696.0 1325.0 773.0 882.0 611.0 5287.0TUrban population to be served in 1970 383.0 1000.0 370.0 410.0 442.0 2605.0Percent of urbcn population to be served in 1970 22.6 75.5 h7.8 46.5 72.5 19.2Urban populatioit unserved in 1970 1313.0 325.0 403.0 472.0 169.0 2682.0Percent of urban population unserved in 1970 77.4 24.4 52.2 53.5 27.5 50.8

Per capita expenditure on 1961-1965 217.0 9.75 1.40 915.0 1.14 30.10Basis of benefitted 1966-1970 64.20 6.45 8.94 78.80 53.0 42.30Population 1961-1970 84.20 8.o6 5.14 110.0 27.30 37.70

Per capita expenditure on 1961-1965 1.17 1.47 0.09 6.6)4 0.14 1.67Basis of total popula-

tion 1966-1970 2.50 2.50 0.47 12.41 5.48 3.38At end of period 1961-1970 3.78 3.78 0.55 18.0 5.59 b.84

1/ In millions of CA pesos

2/ In thousands

Table li: CENTRAL AiMERICA: TuTAL POPULATION AND INU114133ER OF I-EALTH AND HOSPITAL FACILITIESBY COUNTRIES, 1963-1964

Number of LocalAnnual Health Facilities Average PopulationGrowth / (thousands)Rate 2/ Population Year Total- Hospitals2- Other3/Served by Facilities

Country in 195U's (thousands) (est.) Other than Hospitals 4/2/

Guatemala 4,396 196h 212 46 166 26.5

El Salvador 2.8 2.82)4 1963 - 51 23 122.01964 74 - -

2/Honduras 3.0 2,092 1964 82 32 50 41.8

Nicaragua 2.6 1,584 1963 163 - - -1964 - 39 2 124 12.8

CoEta Rica 4.0 1,391 1963 134 - - -1964 - 49 85 16.3

Sources:

1/ PAHO/WHO: Administration of Medical Care Services. Pcientific Publication N. 129, June 1966.2/ PAHOPITHO: Health Conditions in the Americas 1961-1965, Scientific Publication No. 138, August 1966.3/ Estimated by difference.El Mission Estimate.

Table 12: CENTRAL AI4ERICA: NUNBER OF HOSPITALS BY TYPE AND BY COUNTRhY, ABOUT 1964

Hospitals Other HospitalsIH-ater- Pedi- Tuber- Mental

Country Year Total Total General nity atrics Other Total culosis Leprosy Diseases Other

Guatemala 1964 h6 37 27 4 a 2 9 5 1 1 2

El Salvador 1963 51 hL 39 h 1 - 7 4 - 2 1

Honduras 1964 32 29 29 - - - 3 2 - 1 -

Nicaragua 1965 39 36 36 - - - 3 1 1 1 -

Costa Rica 1964 49 45 42 2 1 - 4 2 1 1 -

Total 217 191 173 10 6 2 26 14 3 6 3

Sources: PAHO - Number of Hozpital bed- by type of hoFpital 7,ith rates per 1,000 population, by countries, 1961.PAHOATHO - Health ConditionF in the Americas 1961-1965, Scientific Publication No. 138, August 1966.

Table 13: CENTRAL AYiERICA: HOSPITAL BEDS REPCRTED Ai-TD PLATh,ED BY GOVEPM-iENTS, BY a UITRIES

Country 1962 1963 1964 1965 1966 1967 1968 1969 1970

Guatemala 10,250 - 1l,o53 13,339 14,563 15,389 16,384 17,351 -12,907 l/11,19 -r

1 __l<.TaAor - 6.375 6.l951/ 129 -

londuras - - 4,155 - - 4- - 1,921

Costa Rica - 6,186 4,184 6,183 - - - 7,600+ 300

Nicaragua - 2,9L8 3,0214 3,753 h,119 14,119 4,119 4,1533,673 1 3,88 2

3,773 3/ 4,239 3/ 4,703 3/ 5,1701/ 5,670 3/

1/Central America - - 31,702 - - - -

Sources:1/ Draft PA!iCt,'HC:, Some indices of health conditions in Latin America for recent years.2/ Verdugo Binimelis, Dr. Dario: Problemas de iAtencion 'Iospitalari-a en ivicaragua. Informe N;anagua,D.N.,

Ilarzo de 1966. (CmsS/CQX)3/ Consejo Nacional de Economia, Cficina de Planificacion: Plan Nacional de Desarrollo Lconomico y

Social de Nicaragua, 1965-1969, IV Inversiones Publicas en Salud, 1965-1969

Table 14: CENTRAL AMERICA: SELECTED INDICATORS OF PUBLIC HEALTHAND SANITATION SERVICES, BY COUNTRIES

Hospital Beds Physicians Ratio to Physicians1964 per 1L000 oov. per 10,000 pop. Nursing

Population Total Riral Total Rural Personnel Nurses

Guatamala 4,305 2.6 1.4 2.5 0.5 2.6 0.5

El Salvador 2,824 2.3 1.4 2.2 1.0 3.8 1.1

Honduras 2,092 2.0 0.9 1.6 - 4.2 0.5

Costa Rica 1,387 4.5 2.6 4.7 2.0 4.1 1.0

Nicaragua 1,597 2.3 - 4.2 - 2.0 0.5

CentralAmerica 12,205 2.6 2.7

Source: PAHO indices of health conditions in Latin America for recent years;not yet published.

Table 15: COITRAL AMiERICA: SCHOOLS CF NEDICINE AND lEDICAL GRADUATES, NUNER CF PHYSICIANS AND RATIOS TOTOTAL POPULATIONI AND LARGE CITIES, BY COUTRIES

Physicians and Ratios to PopulationCapitals

liedical Schools Entire Country and Large Citie e) Remainder of CountryNumber Graduates Mumber Per 10,000 N4umber Per 10,000 Number Per 10,000

Country Year Per Ylear population Population population

Guatemala 1958 1 (i) 59 (i) 730 (i) 2.1 (i) 571 (b) 10.1 (b) 159 (b) 0.5 (b)1961 719 (j) 565 (b) 8.6 (j) 148 (j) 2.2 (j)1962 1 (a) 35 (a) 954 (a) 2.4 (a)1964 1 (f) o9 (f) 1,066 (f) 2.5 (f)1965 12 (j) 9781967 60 (j) 1,0021969 1,026

El Salvador 1960 1 (i) 26 (i) 483 (i) 1.8 (i) 329 (b) 7.3 (b) 176 (b) 0.9 (b)1961 1 (a) 29 (a) 526 (a) 2.1 (a)1963 352 (g) 7.0 (g) 229 (g) 1.0 (g)1964 1 (f) 410 (f) 625 (f) 2.2 (f)1965 725 (c)

Honduras 1957 1 (a) 34 (a) 365 (a) 2.2 (a)-1960 1 (i) 365 (i) 2.1 (i)1965 1 (f) 13 (f) 341 (f) 1.6 (f) 188 (g) 5.8 (g) 153 (g) 0.8 (g)

Nicaragua 1960 1 (a) 22 (a) 524 (a)(i)3.5 (a)(i)246(b) 9.0 (b) 278 (b) 2.3 (b)1965 1 (f) 22 (f) 698 (f)(h)4.2 (f) 315 (h) 11.5 (h) 209 (h) 4.0 (h)

Costa Rica 1960 1 1458 (i) 3.9 (i) L58 3.91962 1 (a) 30 (d) 575 (a) 4i.5 (a) 408 (b)(g) 9.3 (b)(g)167 (b)(g) 2.0 (b)(g)1963 1 (f) 634 (f) 4.7 (f)1964 1 622

Central Most 5 (a) 194 (d) 3,452 (d)America Recent

Sources (Table 15):

(a) PAHO/NTHO: Scientific Publication klo. 129. Administration of Nledical

Care Services, June 1966 (Table 8, p. 98).

(b) Ibid: (Table 9, p. 99).

(c) Depto. de Planificacion y Coordinacion, Depto. de Estadistica,Direccion General de Salud: Diagnostico de Consultas y Egresosde p acientes Atendidos pcr los Establecimientos del I[inisteriode Salud Publica y Asistencia Social, 1965, San Salvador, ElSalvador, C. A.

(d) Computed from data for mcst recent year.

(e) Includes federal districts, capital cities or departmentswith capital city and. other cities of at least 500,000population or departnents with the city of 500,000 populationor more.

(f) PAiHOAM'O: Hiealth Conditions in the Americas 1961-1965, ScientificPublication No. 138, August 1966 (Table 2, p. 121).

(,) Ibid: (Table 3, p. 122).

(h) `Ninisterio de Salubridad Publica: Prioridades en los Problemas deSalud en Nicaragua, 1965.

(:L) PA1CAMJHC: Summary of Four Year Reports on HIealth Conditions in theAmericas 1957-1960. Scientific Publication No. 6L, July 1962(Table 66 page 89).

(j) Secretario General del Consejo Nacional de Planificacion Economica:

Programa de Salud Publica para la Republica de tuatemala (1965-1969),Guaternala, Julio de 1965.

Table 16: CENTRAL AMERICA: NiUMBER OF NURSES AND NURSING AUXILIARIESAND RATIOS PER 10,000 0]? TOTAL POFULATION, BY COUNTRIES

Nuhmber Number per 10,000 PopulationNursing Nursing

Country Year Nurses Auxiliaries Nurses Auxiliaries

Guatemala 1961 831(c)1962 466(a) 1672(b) 1.2 4.2(b)1965 496(or 1712(or 1.1(e) 5-2(e)

491(e)) 2289(e))Projescted 1967 526 1752Projected 1969 556 1792

El Salvador 1962 500(a) 1333(a) 1.9(a) 5.1(a)-~ 1965 490(c) 1346(c)

715(e) 1680(e) 2.4(e) 5.7(e)

Honduras 1963 161 982(a) 0.8(a) 4.9(a)1965 179(e) 1253(e) 0.8(e) 5.8(e)

Nicaragua 1962 263 868(a) 1.7(a) 5-5(a)1965 (d) 900(d)

353(e) 1047(e) 2.1(e) 6.3(e)

Costa Rica 1962 411(a) 1233(a) 3-2(a) 9.7(a)1965 616(e) 2000(e) 4.3(e) 14.O(e)

Sources and notes:

(a) PAHO/ATIO: Scientific Publicaltion No. 129, Administration of MedicalCare Services, June 1966. (Table 10, p. 102)

(b) 1960(c) Secretaria General del Consejo Nacional de Planificacion Economica: Programa de

Salud Publica para la Republica de Guatemala (1965-1969) Guatemala, Julio de1965.

(d) 900 includes both nurses and nursing auxiliaries with 34 total produced eachyear.

(e) PAHOA/HO: Hlealth Conditions in the Americas 1961-1965, Scientific PublicationNo. 138, Table 7, ). 125.

Table 17: CENTRAL AMERICA: HEALTH PERSONNEL BY COUNTRIES, IN RECENT YEARS

SanitaryEngineers

About 1963 Sanitary Veteri- Pharma- Laboratory art-Ray Physio-Country 1960 or 1964 Inspectors narians cists Technicians Technicians Therapists

Guatemala 1 15 121 40 159 n.a. 60 402/

I'l Salvador 12 7 123 1 155 72 20 -1/

1onduras 57 1 72 1 4 63 25 -3/ )l/ 4I 4 / 14/ 4/

N'icaragua 12 2 170 3 37 13 6 25/ 6/

Costa Rica 107 18 89 18 450 142 31 -7/ 7/ 7/ 7/ 7/ 7/ 7/

Central America 43 575 63 805 290 1h2 42

Sources and Notes:

1/ Government service only.2/ Ministry of Health only.3/ Ministeric de Salubridad Publica: Plan Nacional de Salud, 1965-1974, Nicaragua, Diciembre 1964.17/ Estimated from data on "Otros" in Pag. I, Anexos, Ref. 3/5/ PAHO/WHO: Summary of Four-Year Reports on Health Conditions in the Americas 1957-1960;

Scientific Publication TNo. 64, July 1962, Table 70, page 93.6/ Employed in hospitals.7/ Computed by totaling for area.

Table 18: CENTRAL AMERICA: FELLOUTSHIPS AWARDED BY COUNTRY OF ORIGIN OF STUDENTS, TYPE OF TRAINING,AND FITTn OF 1T Y 1958-1961 (A) AM!D 1962-1965 (B)

Persons Attend-ing Water Supply

Type of Trainina Field of Study Program CoursesCourses Organized or Regular Public Sanitation Nursing and SeminarsAssisted by PAHOA/THO Academic Travel Health Num- % of Nun- % of Num- % of

Country Total Special Academic Courses Grants Admin. ber Total ber Total ber Total

Guatemala (A) 85 4 15 18 8 6 18 21 23. 27 10 12

E1 Salvador (A) )46 22 3 X 17 6 9 20 2 L 5 11

Horrn r r i (A 5L 20 8 13 13 8 6 11 6 11 6 11(B) 14 3 4 7 - 4 29 2 14

Nicaragua (A) 48 24 3 13 8 1 1 2 13 27 6 13

Costa Rica (A) 12 20 7 7 8 1 2 5 10 24 5 12

Central America (A) 275 130 36 55 51) 22 36 13 54 20 32 12(B) 14 3 4 7 4 29 2 1i

Source: PAHO/EHO

Table 19: CENTRAL AlERICA: EXPENDITURES FOR HEALTH AND SANITATION, BY COUNTRIES(in millions of CA pesos)

(A) (B) (C) (D) (E)Percentage of Investments as

Health PercentageTotal Health Expenditures Investment of Total Health

Health Outlays tc Total in Health & ExpendituresCountry Year Outlays Per Capita Governmeint Sanitation (D to A)

Guatemala 1963-64 15.0 3.54 18.5 5.0 33

El Salvador 1963 10.8 3.97 17.8 1.5 14

Honduras 1963 5.0 2.47 12.0 0.9 18

Nicaragua 1965 5.6 3.38 9.0 6.3 1/

Costa Rica 1963 18.6 7.4 25.1 2.6 1h

1/ Unexplained discrepancy between column A and column E.

Source: PAHOAkTHO: Health Conditions in the Americas, 1961-1965, Scientific Publication No. 138 - August 1966,Table 1, p. 82 and Tables 22-31.

Table 20: CENTRAL AMERICA: PER CAPITA INVESTNENT EXPENDITURES FOR HEALTH AND SANITATION 1961-1965,AND PLANNED BY GOVER DNT 1966-1970, BY COUNTRIES

(in millions of CA pesos)

1961 1962 1963 1964 1965 1966 1967 1968 1969 1970

Total Investment for Health and Sanitation

Guatemala 0.66 0.81 1.20 1.16 1.94 2.02 2.32 2.26 2.23 2.22El Salvador 0.24 0.65 0.65 1.84 1.71 2.36 2.20 2.34 1.81 2.74Honduras 0.48 0.56 0.44 0.18 0.83 1.34 1.25 1.29 1.09 0.87Nicaragua 3.10 3.40 4.21 5.06 3.80 4.04 4.01 4.65 6.40 6.14Costa Rica 2.04 1.65 1.93 2.31 2.79 3.77 5-25 5.56 h.59 2.74Central America 1.11 1.33 1.65 2.19 2.58 3.18 3.58 3.88 3.94 3.95

Total Investment for WJater Supplies, Sewerage and Excreta Disposal

Guatemala 0.61 0.74 1.10 0.93 1.22 1.62 1.40 1.27 1.18 1.06El Salvador -- 0.42 0.40 1.77 1.02 1.26 1.36 1.73 1.81 2.74Honduras -- -- 0.05 0.05 0.70 0.91 0.62 0.44 0.51 0.42Nicaragua 1.58 1.94 2.27 3.25 3.38 2.74 2.77 3.45 5.14 5.26Costa Rica 0.90 0.63 0.82 0.143 0.91 2.02 3.50 3.88 3.02 2.27Central America 0.53 0.68 o.88 1.21 1.33 1.60 1.67 1.82 1.94 2.03

Total Investment for Hospitals and Health Centers

Guatemala 0.05 0.07 0.10 0.23 0.72 0.40 0.93 0.98 1.06 1.16El Salvador 0.25 0.23 0.15 0.07 0.68 1.10 0.84 0.60 -- --Honduras 0.48 0.56 0.39 0.11 0.13 0.43 O.62 0.85 0.58 0.45Nicaragua 1.51 1.h7 1.95 1.81 0.42 1.29 1.24 1.21 1.27 0.87Costa Rica 1.114 1.02 1.11 1.87 1.89 1.75 1.75 1.69 1.57 0.47Central America 0.48 O.h8 0.52 0.61 0.70 0.84 0.99 0.98 0.82 0.65

Sources: Tables 2, 23, 25, 27, 29, and 31.

Table 21: CENTRAL AviERICA: PER CAPITA !NVESTIVIENT EXPE-IDITURES FOR HEALTH AND SANITATION 1961-65AND PLANTED BY GOVERNMENT, BY COUNTRIES 1966-70

(in CA pesos)

1961-1965 Planned 1966-1970Hospitals W!ater supply, Hospitals Water supply,and Health Sewer, Excreta and Health Sewer, Excreta

Country Total Centers Disposal Total Centers disposal

Guatemala 5,55 1.08 4.46 10.43 2.76 7.68

El Salvador 4.77 1.29 3.48 10.90 2.36 8.55

Hndsurulas 2sJ .3 1.48 n.83 2.Q5 0.36 2 .X9

Nicaragua 18.h5 6.71 11.75 23.90 5.52 18.40

Costa Rica 7.73 6.62 1.11 20.30 6.64 13.61

Central America 6.71 2.56 1.15 12.10 3.05 9.05

Sources: 1961-1965 calculations based upon population given for 1965 in Table 2.1966-70 calculations based upon eypected population i.n 1970 as given in Table 2.Tables 22-31.

Table 22: GUATEMAIA: INVESTMENT EXPENDITURES FOR HEALTH AND SANITATION,BY CATEGORIES OF PROGRAMS, FOR 1960-1965 AND FOR 1966-1970

Millions of CA Pesos

1960-1965 1966-1970

UJrban water supplies 12.9 18.4

Rural water supplies 0.3 7.4

lJrban sewerage 6.5 12.7

Latrine Program 0.1 0.5

Hospitals 2.6 7.3

Health Centers 1.3 1.9

Other health structures 0.9 t4.8

TOTAL 24.6 53.0

Source: Table 23

Table 23: GUATEMALA: PUBLIC INVESTVIENT IN HEALTH APND SAMITATION, ACTUAL FOR 1961-1965AND PLANNED BY GOVERNMENT FO 1966-1970

(in millions of CA pe3os)

Realized Amounts Projected Amounts1961 1962 1963 1964 1965 JI7J 1967 1968 1969 1970

Expenditures by:

a) City of GuatemalaWater Supply and Sewerage 1.5 2.4 2.1 1.7 2.7 3.6 4.3 3.8 3.2

b) D.G. de O.P. - A.y D.Urban Water aii seweage CJ.7 2. .c 4.G 2.9 1.08 .u 2.2

c) M.S.P.A.S.Hospitals, Health Centers,Posts, and other .2 .3 .4 1.0 2.9 1.8 4.3 4.7 5.2 5.9

d) I.G.S.S.Ho spitals .3

Total 2.6 3.3 5.0 5.0 8.6 9.1 10.8 10.8 11.0 11.3

Miosion EFtimate 3.0 3.0 4.0 5.0 5.0

Source: Agencies listed (X) - (d), planning Office and NiFsion ectimates.

Table 24: EL SALVADOR: INIVESTMENT EXPENDITURES FOR HEALTH AND SANITATIONBY CA.TEGORIS OF PROGRAMS FOR 1960-1965 AND PLANIED BY GOVERNMENT FOR 1966-1970

(In MJJ.llions CA Pesos)

Category 1960 to 1965 1966 to 1970(Actual) (Government Plan)

Urban water supplies 4.4 8.1

Rural water supplies 2.4 18.2

Sewerage 3.4 2.3

Health posts and units 1.0

Hospitals 1.4 5.6

Other buildings and equipment 0.9

Supervision of investments 0.4

TPotal 11.6 36.5

Source: Table 25

Table 25: EL SALVADOR: PuBLIC IN-vSTMENT IN I9ALTH AND SANITPTION 1961-19 6AND PLANNED FOR 1966-1970(millions of Ck pesos)

Realized Amounts Projected Amounts1961 1962 1963 196h 1965 1966 1967 1968 1969 1970

Expenditures by:

a) MSPAS .6 .6 .2 .6 1.9 2.6 1.9

b) ANDA 1.1 1.1 5.0 3.0 3.8 4.2 5.5 5.9 9.2

c) ISSS 1.4 1.4

Total .6 1.7 1.5 5.2 5.0 7.1 6.8 8.J 5.9 9.2

Mission Estimate 8.o 6.4 8.6 7.5 7.5

Source: Planning Office and Ministry of Finance.

Table 26: HONDURAS - INVESTPXENT EXPENDITURES FOR HEALTH AND SANITATION BYCATEGORIES OF PROG]RAMS, ACTUAL FOR 1960-65 AND PLIANED FOR 1966-1970

(in millions of CA pesos)

1960 to 1965 1966 to 1970(Actual) (Governmenit Plans)

Urban water supplies 1.4 2.85

Rural water supplies 0.25 2.45

Urban sewqerage 0.2 1.25

Latrines 0.05 0.05

Hospitals 3.35 12.9

Health centers and posts 0.05 1.2

Other

Total 5.3 20.70

Source: Planning Office

Table 27: HONDURAS: PUBLIC INVESTMENT IN HEALTH AND SANITATION, ACTUAL 1961-1965 AND PLANNED 1966-1970(millions of CA pesos)

Actual Planned by Government1961 1962 1963 196b4 1965 1966 1967 1968 1969 1970

ExpTenditures by:1/

a) SANAA 0.1 0.1 1.6 2.1 1.5 1.1 1.3 1.12/ 3/ 4/ 5/

b) MSPA , PANI , IHSS , JNBS 0.9 1.1 0.8 0.3 0.3 2.3 3.5 3.7 3.5 3 0

Total 0.9 1.1 0.9 0.h 1.9 L- 5n )1 R .1

Mission Estimate 2.4 3.3 3.0 3.5 3.5

1/ Servicio Autonomo Nacional de Acueductos y Alcantarillados2/ Ministerio de Salud Publica y Asistencia Social3i/ Patronato Nacional de la Infancia47/ Instituto Hondureno de Seguridad Socialg'/ Junta Nacional de Bienestar Social

Source: Planning Office.

Table 28: NICARAGUA: INVESTMENT EXPENDITURES FOR HEALTH AND SANITATION,BY CATEGORIES OF PROGRA1S, FOR 196o-1965 AND PLANNED FOR 1966-1970

(in mil:lions of CA pesos)

1960 to 1965 1966 to 1970(Actual) Government Plan)

Urban water supplies 8.3 9.14irianagua 7Other than Managua 3.80 6.5

Rura:L water supplies 0.07 1.23

Water resources study -- 1.13

Seve:rage 10.97 24.24Managua 10.97 237FOOther than Managua -- 0.44

Lat,rines 0.08 0.23

Ho-lpitals 8.18 9.57

Health centers and posts 2.93 1.19

Total 30.54 46.73

Source: Planning Office and Ministry of Finance.

Table 29: NICARAGUA: INVESTI'IENT IN HEALTH AND SANITATION, ACTUAL 1961-1965AND PLANNED BY GOVEFNMENT 1966-1970

(in millions of CA pesos)

Actual Planned1961 1962 1963 19616 1965 1966 1967 196d 1969 1970

Expenditures by:

a) Ministerio de Salubridad 0.6 0.6 1.0 0.5 0.2 0.4 0.4 0.6 0.7 0.6b) J.N.A.P.S. 0.3 1.3 1.3 1.3 1.3 1.14c) i.N.S.S. 1.6 1.7 2.0 2.4 0.3 0 Y o.8 0.7 0.5d) Distrito Nacional 1.7 1.9 2.2 2.4 2.8 2.8 3.1 3.9 7.0 6.9e) Servicios Municipales 0.6 0.9 0.7 0.8 0.9 0.5 0.9 1.4 1.7 2.2f) Empresa Aguadora de Managua 0.01 0.01 .6 2.0 1.9 0.9 0.3 0.3 0.3 0.9g) National Geological Survey 0.2 0.3 0.3 0.3

Total 4.5 5.1 6.5 8.1 6. 4 6.8 7.1 8.5 12.1 12.0

Mission Estimate 2.0 2.0 3.5 5.5 5.7

Source: Planning Office and MiniFtry of Finance.

Table 30: COSTA RICA: INVESTENT EXPENDITURES FOR HEALTH AND SANITATION, BY CATEGORIES OF PROGRAIIS,ACTUAL FOR 1960-1965 AND PLANNED BY GOVERNMENT FOR 1966-1970

(in millions of CA pesos)

1960 to 1965 1966 to 1970Category (Actual) (Governlent Plan)

Urban water supplies 1.2 11.3

Rural water supplies 0.2 2.7

Sewerage 1.1 8.5

Hospitals and Health Centers 9.5 11.4

Total 12.0 33.9

Source: Table 31.

Table 31: COSTA RICA: PUBLIC INVESTIIENT IN HEALTH AND SANITATION, ACTUAL 1960-1965AND PLANNED BY GOVERNIffENT, 1966-1970

(in millions of CA pesos)

Actual Planned1960 1961 1962 196 -1F9W 1965 1966 1967 1965 1969 1970

Ehxpenditures by:

a) SAnilAA 0.5 1.1 0.8 1.1 0.6 1.3 3.0 5.4 6.2 5.0 3.9

b Se -vi ; JL vS

Asistenciales 1.3 1.4 1.3 1.5 2.6 2.7 2.6 2.7 2.7 2.6 0.8

Total 1.8 2.5 2.1 2.6 3.2 4.0 5.6 8.1 8.1 7.6 h.7

Mission Estimate 6.0 4.0 h.0 5.0 5.0

.Source: Planning Office end MIini'-try of Finence.