Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 8, Number 1, 2003

Las manzaneras are like "health vendors." And yes, they make house calls.

Esther Ballivián (right), a volunteer manzanera, discusses tuberculosis treatment with her newly acquired "son," 16-year-old Ramiro.

For the last year, Ballivián has been a soldier in an army of neighborhood health promoters known as las manzaneras in the city of El Alto, in the department of La Paz, Bolivia. Each of the 800 mostly female volunteers is responsible for monitoring the health of the inhabitants of a given manzana (about 1.5 acres) of the city’s residential area. In door-to-door visits, the manzaneras encourage residents to use community health services and, when appropriate, refer potential patients— particularly pregnant women and children under 5—to nearby hospitals and health centers. Their task is not only to offer practical health information but also to boost awareness of and demand for health services, somewhat like "health vendors," says Fernando Amado, a Pan American Health Organization (PAHO) consultant in La Paz.

Patient shortage

In its less than two decades of existence, El Alto—situated 13,000 feet above sea level—has become one of the fastest growing cities not only in Bolivia, but in South America. If the current rate of growth continues, the city’s population will double in just 14 years. The continuing growth represents a kind of time bomb, as basic services have failed to keep pace with the population expansion. Twenty percent of the city’s 629,000 inhabitants lack access to drinking water, electricity and sewerage services. Health officials say the shortfall contributes significantly to high mortality rates for mothers, 390 per 100,000, and among children, 89 per 1,000 under age 5.

But another part of the problem is that many people do not take advantage of available health services, according to city officials. Some local public health providers could handle twice as many patients as they do now.

"People feel mistreated and misunderstood by health workers, so they don’t seek their services," explains El Alto Mayor José Luis Paredes.

It was at the start of Paredes’ term as mayor, in January 2000, that the manzaneras initiative began to take shape, with the primary goal of ending the "patient shortage." It has become one of the most successful neighborhood health promotion projects in all of Bolivia’s 313 municipal districts.

The project started officially in early 2001 as part of El Alto’s Social Network Program, a health promotion effort sponsored by the Ministry of Health. From the outset being a manzanera has been strictly a voluntary undertaking. More recently, a new and important element has been added: Each manzanera (or manzanero— about 10 percent of the volunteers are male) is now elected by a neighborhood council, making the experience not only voluntary but also democratic and representative.

"Before, many avoided signing up because they felt the work was too solitary," says Johnny Tórrez, who heads the program.

"Today, every manzanera has the support of her own neighbors, and she feels accountable to them because she was democratically elected."

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