The Guatemalan public hospital system Niels Ketelhöhn a, ⁎, Rodrigo Arévalo b, ⁎⁎ a INCAE Business School, Managua, Nicaragua b Cardiovascular Unit of Guatemala, Guatemala abstract article info Article history: Received 1 June 2015 Received in revised form 1 September 2015 Accepted 1 November 2015 Available online 29 April 2016 This case takes the perspective of a Minister of Health, who oversees the capacity restrictions and balance of the national healthcare system. This case addresses one of the most common and important issues in healthcare in Latin America: coping with increasing demand of a larger and aging population, with severely constrained capac- ity. The case describes a situation faced by Guatemala's Minister of Health in April of 2015, when he is forced to redefine the priority level of hospital infrastructure projects. The case provides information on regional healthcare infrastructure and describes the route followed by patients to reach the highest level of medical atten- tion. The reader is usually surprised to find out that the Ministry's plans to expand hospital capacity seldom con- sider regional needs. These decisions are often guided by political criteria. The reader can solve the case by defining a strategy to expand system's capacity redefining patient's logistics, and elaborating a new pitch for mul- tilateral finance institutions. © 2016 Elsevier Inc. All rights reserved. Keywords: Ministry of Health National healthcare system Healthcare delivery capacity National healthcare system Sub-national health indicators On April 7, 2015, the front-page headline of the Guatemalan news- paper Prensa Libre read, “A broken promise: Six hospitals will not be built.” In 2013, Dr. Jorge Villavicencio, then Guatemala's Minister of Health, announced the construction of seven new hospitals to help mitigate the country's healthcare crisis. In September 2014, the Presi- dent of Guatemala asked Dr. Villavicencio to step down. Luis Enrique Monterroso, an economist, became the new Minister of Health. Seven months later, the Vice-Minister in charge of public hospitals held a press conference and announced that the construction of six of these seven hospitals would be put on hold due to financial problems and de- lays of private contractors (La Prensa Libre, 2015). In 2015, Guatemala was experiencing an extremely complex healthcare situation. The two national referral hospitals were overwhelmed. Demand was such that these centers were regularly forced to close outpatient and emergency services due to capacity con- straints. Public hospitals were underfunded, short-staffed and faced with acute issues of input shortages. A human rights attorney stated that the crisis had “no precedent in Guatemala's history” (El Periódico, 2015). To confront these problems, Mr. Monterroso had to act quickly by identifying the geographical areas experiencing the most intense problems, and by defining a new investment plan. 1. Guatemala's healthcare system In 2015, the Guatemalan population received healthcare services through four major sub-systems. Private hospitals were used by the high-income social strata representing 8% of the population (Instituto Nacional de Salud Pública, 2011). The Guatemalan Institute for Social Security (IGSS) covered formally employed individuals and their fami- lies, representing 17.5% of the population (Instituto Guatenalteco de Seguridad Socail, 2008). Members of the armed forces, the national civil police and their families, representing 0.5% of the national popula- tion, received medical services from the military system. Between 65% and 75% of the population (Panamerican Health Organization, 2007) was served by the Ministry of Public Health and Social Assistance (MSPAS for its initials in Spanish). Guatemalan law stipulated that any citizen had the right to medical care at any of the healthcare facilities run by MSPAS. Additionally, certain rural populations received healthcare services from Non-Government Organizations (NGOs), which in the aggregate, represented up to 18% of the population (MSPAS, 2011). Additionally, the 2009 National Report on Human Development pointed out that 6% of the population had not received any sort of formal healthcare service. 2. The public hospital network MSPAS had the functions of regulating, managing and delivering healthcare services. To fulfill the latter, MSPAS relied on a network of 1011 primary health centers, 346 primary care clinics and 44 hospitals distributed throughout the national territory. Fig. 1 shows the size of Journal of Business Research 69 (2016) 3900–3904 ⁎ Correspondence to: N. Ketelhöhn, INCAE Business School, K.m. 15.5 c Sur, Managua, Nicaragua. ⁎⁎ Correspondence to: R. Arévalo, Cardiovascular Unit of Guatemala, 2da. Avenida, Calle Vivero el Paraíso, 0–15, Zona 2 de San Lucas Sacatepequez, Guatemala. E-mail addresses: niels.ketelhohn@incae.edu (N. Ketelhöhn), rodrigo.arevalo.alvarado@gmail.com (R. Arévalo). http://dx.doi.org/10.1016/j.jbusres.2015.11.022 0148-2963/© 2016 Elsevier Inc. All rights reserved. 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