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.

It’s been five months now that Esther Ballivián has had a new son. She met him by chance one day, and since then she has visited him every day of the week after lunch. She only sees 16-year-old Ramiro long enough to watch him take his tuberculosis medication, making sure that the disease that claimed his father’s life doesn’t kill the son. Despite their limited time together, Ballivián sees her relationship with Ramiro as anything but short term.

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."

Like having a doctor

A manzanera makes her rounds carrying her own baby from house to house. The volunteers’ job is to promote healthy practices and encourage residents to utilize available health services.

While the program is considered a success, it has a high turnover rate. In 2001 the number of volunteers peaked at 1,600, but by January of this year there were fewer than 800 to cover the five to 40 manzanas in each of El Alto’s six health districts.

“Volunteers go through a cycle,” says Sarah Arnez, one of the program’s founders and a member of El Alto’s city council. “People burn out and leave, but they leave with the advantage of having been trained and sensitized.”

PAHO’s Amado agrees, although he believes that the program should offer more incentives for the manzaneras— for example, providing them with more educational materials. Each volunteer now receives only the special green jacket that allows neighborhood residents to identify her.

“You cannot pay the volunteers,” Amado says. “This is voluntary work and must continue to be so. Otherwise it loses its reason for being.”

Once a volunteer has been elected and trained, her first task is to take a census of the manzana where she will “market” health services door to door.

She then begins her work of providing health education to residents, including telling them about the warning signs of health problems in pregnant women and children under 5. She tells mothers-to-be what to do in case of bleeding during pregnancy, prolonged labor and childbirth, or a high fever after giving birth. She tells parents what to do if a child has diarrhea or if there is a foul odor around a newborn’s navel. She also provides detailed explanations of childhood vaccination schedules.

Each manzanera decides when she will visit her manzana, although most make their visits at mid-morning or in the early afternoon, after feeding their own families.

“First we cook for our spouses and our children, then we can leave to do our rounds,” explains Susana Quispe, a manzanera from Health District III, also known as the Centennial District in honor of the 100th anniversary PAHO celebrated in 2002.

Quispe’s manzana has 20 houses, all two- or three-room adobe-and-brick structures packed closely together along dirt and cobblestone alleyways. One of these is home to 21-year-old Lizet Silva, who has relied on Quispe throughout her first pregnancy and with whom she made her first visit to a health center. “It’s like having a doctor at home,” says Silva.

For El Alto’s health authorities, the manzaneras have achieved what traditional strategies have failed to produce: a lower risk of death from complications of pregnancy and childbirth, and a higher number of institutional or attended deliveries. How have they done it? By restoring “power to the people,” says Tórrez and other supporters of the program, and by drawing on the natural social inclination for neighbors to want to help one another—both strongly rooted cultural features dating back to Bolivia’s precolonial Quechua and Aymara cultures, and still passed on from generation to generation.

Abdel Padilla is a reporter for the Bolivian daily newspaper La Prensa.

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