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—from Epidemiological
Bulletin , Vol. 25 No. 3, September 2004—
Country Profiles: Venezuela
General situation and trends
The Bolivarian Republic of Venezuela, located in the north of South America,
has 23 states, a capital district and federal dependencies.
It has a land area of 916,446 km2, a population estimated at 24,896,379 inhabitants
in 2000; 33.2% of the population is under the age of 15 and 6.5% is over 60
(Figure 1). The annual demographic growth rate was 2% from 1996-1999. In 1999,
the general mortality rate was 4.7 per 1,000 population. The birth rate dropped
gradually from 25.6 per 1,000 population in 1996 to 24.3 per 1,000 population
in 1999. The total fertility rate fell slightly, from 3 children per woman
in 1996 to 2.8 in 1999. Net migration was positive in 1996 (74,099) and negative
the following two years, with figures of -306,574 and-730,107, respectively.
According to the last census of the indigenous population (1992) and forecasts
for 2000, the indigenous population numbered 371,815 people (1.5% of the total
population).
Figure 1. Population structure, by age and sex, Venezuela, 2000.
Economic performance over the last decade has been slow in terms of growth,
marked by a recurrence of inflationary recessive episodes. GDP was estimated
in US$ 2,647 per capita in 1998 (adjusted for purchasing power parity); Figure
2 shows the GDP annual growth. 30% of the national budget was earmarked to
pay the foreign debt. The population living in poverty, according to the index
of unmet basic needs, stood at 49% between 1996 and 2000, and the percentage
of the population living in extreme poverty, at 21.7%. The global unemployment
rate fell from 14.5% in the second semester of 1999 to 13.2% during the same
period of 2000; male unemployment in the same semester and years fell from
16.1% to 14.4%, while female unemployment fell from 13.6% to 12.5%. Formal
employment slid from 50.1% in the second semester of 1998 to 47.0% in the same
semester of 2000. Lack of security for citizens and petty crime are priority
problems for the Government and society alike. In 2000, 7,908 people died due
to assaults. In 1997, Venezuela ranked 48th in the human development index,
and 61st in 1999. Life expectancy was of 74.7 years for women and 68.9 years
for men in the period 1990-1995, and in 1995-2000, it was 75.7 and 69.9, respectively.
In 1998, there was a difference of nearly 10 years of life expectancy between
the most developed and the least developed states (73.6 in the Federal District
and 63.9 in Amazonas). A political, legal, economic, and social transition
was initiated in 1999, aimed at implementing a new development model intended
to strengthen the democratic system, create a fairer society, and consolidate
an efficient economy within the framework of globalization.
Figure 2. Gross domestic product, annual growth (%), Venezuela, 1990-2000.
Only 25% of the eligible population is enrolled in intermediate, diversified,
and professional education. Illiteracy among people over 10 years of age in
1998 was 6.2% (5.5% for males and 7.0% for females).
From 1995-1999, the mortality rate by broad groups of causes was 162.3 per
100,000 population for diseases of the circulatory system, 63.8 per 100,000
for malignant neoplasms, 55.3 per 100,000 for external causes, 53.6 per 100,000
for communicable diseases, and 22.4 per 100,000 for certain conditions originating
in the perinatal period. Figure 3 shows the estimated mortality by groups of
causes and sex.
Figure 3. Estimated mortality, by groups of causes and sex, Venezuela, 1995-2000.
Specific health problems
Analysis by population group
Health of children (0-4 years): Infant mortality is on a downward trend: from
121.7 per 1,000 live births in 1940 to 17.3 per 1,000 in 2000, though the rate
of decrease was slower in the 1990s. The leading causes of mortality recorded
in 1999 were: perinatal diseases (57%), birth defects (15%), and intestinal
disorders (12%). In 1999, 12 % of children had low birth weight. In children
under 3, a high prevalence of anemia (around 50%) was recorded.
Health of adults (20-59 years): Maternal mortality declined between 1940 and
2000, dropping from 172.4 per 100,000 live births to 59.0 per 100,000 in 2000.
Nevertheless, the 1980s saw a reversal in the maternal mortality trend. The
most important causes of death were complications of pregnancy, childbirth,
and the puerperium (50%); edema, proteinuria, and hypertensive disorders (35%),
and pregnancy ending in abortion (14%). Most of the causes are avoidable, considering
that over 90% of deliveries occur in institutional settings.
Health of the elderly (60 years and older): This population accounted for
6.5% (46% men) of the total population in 2000. The population in this group
is expected to triple by 2025. In 1998, the leading causes of mortality in
this group were heart diseases (32%), malignant neoplasms (18%), cerebrovascular
diseases (12%), and diabetes (8%). The risk of death due to these causes is
higher in men, except in the case of diabetes.
Health of the workers: Occupational hazards in the 1990s have increased as
a direct result of informal employment, the use of inadequate premises, and
because homes are used as centers of production. The most frequent occupational
diseases are industrial deafness (work-related hypoacusis), and other conditions
associated with noise and vibrations, chemical poisoning, and musculoskeletal
disorders. It is estimated that 10% of the population has some degree of physical
or mental disability or handicap.
Health of indigenous groups: The indigenous peoples live in conditions of
vulnerability, social exclusion, and extreme poverty. In 1992, more than 50%
of these communities lacked potable water and excreta disposal services; 65%
lacked access to schools and 72.8% of the rural outpatient ambulatory services
in the indigenous villages had no physician. The leading conditions are tuberculosis,
malaria, parasitosis, malnutrition, diarrheal and respiratory disorders.
Analysis by type of health problem
Natural disasters: The disasters with greatest impact (earthquakes, floods,
mudslides) have occurred mainly in the northern coastal region, which is
the most densely populated. There have been technological disasters of chemical
origin, mainly in the petroleum and petrochemical sector. In 1999, torrential
rain and mudslides caused a national tragedy that revealed the inadequacies
of the country’s urban planning and the limitations of its institutional
response capacity.
Vector-borne diseases: The malaria transmission zone covers 23 % of the country’s
surface area. It is inhabited by 720,000 people. In 2000, 30,234 autochthonous
cases of malaria were reported, 38.3% more than in 1996 (21,852). They were
primarily concentrated in Sucre, Bolivar and Amazonas states, which accounted
for 91.5% of the cases. Classic dengue and hemorrhagic dengue fever behaved
endemo-epidemically nationwide. Serotypes 1, 2, and 4, have circulated simultaneously
in recent years; serotype 3 has circulated since 2000. The highest incidence
was recorded in 1998 with 37,586 cases reported; in the following years the
number of cases gradually declined reaching 21,101 cases in 2000 (18,915 dengue
classic and 2,186 hemorrhagic dengue fever). In 2000, indices of infestation
by Aedes aegypti in dwellings and warehouses remained high (20.7% and 10.3%,
respectively). No cases of yellow fever between 1980 and 1997 were reported.
However, in 1998; there was an outbreak in a Yanomami village that led to 15
cases and four deaths. Chagas disease is considered a risk for some 6 million
people living in 198 municipalities in 14 federal entities, in a territory
of 101,488 km2. Insecticide application and improved dwellings conditions reduced
the prevalence of Chagas disease, which was around 45% in the 1950s, to less
than 10% in the 1990s. Some 18.3% of the population at risk of contracting
onchocerciasis in the Region lives in Venezuela, which is the country with
the third highest incidence of the disease. Cutaneous leishmaniasis is endemic
throughout the country, and is more frequent in male agricultural workers aged
15-44 years. In 2000, 92% of the 2,528 cases recorded were the localized cutaneous
form.
Diseases preventable by immunization: The last confirmed case of poliomyelitis
was reported in 1989, and immunization against polio achieved coverage of 86%
in 2000 (Figure 4). Although no cases of measles had been recorded since 1997,
in 2000, an outbreak was reported in Zulia state with 22 confirmed cases. In
2000, 12,609 cases of rubella and 6,044 of mumps were reported. In 2000, an
84 % coverage was attained in children under 1 year of age with the MMR (against
measles, mumps and rubella) vaccine.
Figure 4. Vaccination coverage among the population under 1 year of age, by
vaccine, and tetanus toxoid coverage among women of childbearing age, Venezuela,
2000.
Intestinal infectious diseases: In 1997, there was a Cholera epidemic with
2,551 cases, for an incidence rate of 11.2 per 100,000 population. In 1988,
the incidence dropped to 1.3 per 100,000 population and, in 1999, it was 1.6
per 100,000 population.
Chronic communicable diseases: Bacillary pulmonary tuberculosis and the other
forms of tuberculosis have varied little in recent years. The respective rates
recorded were 15.6 and 26.1 per 100,000 population in 1991 and 15.0 and 25.2
per 100,000 in 2000, respectively. Leprosy ceased to be a public health problem
in 1997. Its prevalence in 2000 was 0.6 per 10,000 population. The problem
persists in Cojedes, Portuguesa, Barinas, Apure, and Trujillo states.
Zoonoses: Between 1991 and 2000, the annual average of human rabies cases
dropped from three to one case. The cases recorded in those years occurred
in the metropolitan area of Maracaibo.
HIV/AIDS: During 1983-1999, 8,047 cases and 4,726 deaths were reported, and
underreporting was estimated at around 80%. According to information from UNAIDS,
62,000 people throughout the country were HIV carriers in 1999. In analyzing
the cumulative incidence, clearly the most frequent mode of transmission is
sexual, which account for 90.3% of the cases, followed by transmission by blood,
accounting for 4.3%. There is a marked predominance of HIV/AIDS cases among
males, although the proportion of females is rising.
Nutritional and metabolic disorders: The groups most affected by general malnutrition
in 2000 were children under two years of age (11.7%), 2-6 years (22.4%) and
7-14 years (24.4%). Twenty-four percent of the preschool-age children attending
public schools have a nutritional deficit. The prevalence of overweight in
the population under 15 years of age rose from 8.5% in 1990 to 11.3% in 2000.
The prevalence of iron deficiency anemia in pregnant women was 41% and in children
under 3 years it was 51%. Mortality due to nutritional deficiencies affected
the age group of children under 1 year the most, at a rate of 60.3 per 100,000
live births. In 1999, Diabetes mellitus was the fifth leading cause of death
overall (5.5%), but fourth (7.4%) for women. The mortality rate that year was
23.8 per 100,000 population (22.9 for males and 26.9 for females).
Diseases of the circulatory system: Diseases of the circulatory system were
the leading cause of death in 1999 (21%); over half were due to acute myocardial
infarction. One in 10 deaths was due to hypertensive diseases. Ischemic diseases
have been increasing. The highest-risk group is 40 to 60 years old.
Malignant neoplasms: Malignant neoplasms were the second leading cause of
death in 1999 (14.3%), with malignant neoplasms of the digestive system, mainly
the stomach, predominating in both sexes. In women, cervical cancer is the
second leading cause (13.1 per 100,000 females), and the highest risk is in
women aged 25-64 years (202.6 per 100,000 females). The second leading cause
is breast cancer (8.8 per 100,000 females). In men, cancer of the bronchus
and lung ranked second (11.4 per 100,000 males), followed by prostate cancer
(11.0 per 100,000 male).
Accidents and violence: In 1999, accidents and violence accounted for 12.5%
of total deaths. Accidents (all types) were the fourth leading cause of death
(7.5%) that year, with a rate of 32.8 per 100,000 population (51.0 for males
and 16.1 for females), including 60% of motor vehicle accidents. In 1999, 5%
of deaths were due to suicides and homicides, making them seventh in general
mortality and fourth for males. Mortality due to this cause is increasing,
mostly due to homicides (16.9 per 100,000 population in 2000).
Foodborne diseases: Between 1996 and 2000, a 63% increase could be seen in
the number of outbreaks, and foodborne cases of diseases quadrupled. In 56.4%
of cases, the contaminating agent was identified (Staphylococcus aureus in
72.8% of cases and high levels of histamine in 14.7% of cases). In 2000, half
the cases occurred in homes and 22.8% in schools.
Response of the health system
Policies and national health plans
The legal framework established by the Constitution has led to the drafting
of a Health Bill, which is awaiting approval by the National Assembly. It contains
policy guidelines and establishes the standards for their institutionalization.
Government policy, and health policy in particular, is implemented by the specific
government agencies and the Federal Council of Government, the entity in charge
of planning and coordinating policies and actions aimed at decentralizing and
transferring the competencies of the central government to the states and municipalities.
A process was initiated in 1990 to decentralize the then Ministry of Health
and Social Welfare to the states; at the end of 2001, 17 federal entities had
been decentralized. In 1999, the Ministry of Health and Social Welfare was
merged with the Ministry of Family Services, and the Ministry of Health and
Social Development was created. This new Ministry is the body governing the
health sector and its functions include regulation, formulation, design, evaluation,
control and monitoring of health and social development policies; programs,
and plans; integration of sources of financing and allocation of the resources
of the National Public Health System; comprehensive health care for all sectors
of the population, especially low-income groups, and promotion of citizen participation.
Health sector reform
With a view to promoting social development, comprehensive health, and citizen
participation, in particular by socially excluded groups, funding for 2001
was directed at several areas. The priorities are maternal and child health
care, disease control and eradication; and accessibility to hospital services,
social infrastructure, and care during social emergencies. The goal of the
Health Bill is to expand and enforce the constitutional right to health.
It states that in order to guarantee the constitutional right to health,
the National Public Health System must be governed by the following principles:
universality; equity; solidarity; uniqueness and social integration; services
free of charge; participation; comprehensiveness; cultural and linguistic
pertinence; quality, efficacy and efficiency.
Health system
The public health sector is composed of the Ministry of Health and Social Development
(MSyDS), the Venezuelan Social Security Institute (IVSS), the Social Welfare
Institute of the Ministry of Education, the Armed Forces Institute of Social
Welfare, and the Central Mayoralty (formerly the office of the Federal District
Governor). The network of public health establishments has different levels
of care and operates throughout the country. In Venezuela, more than 2,400
institutions work in the area of health. They belong to the public as well
as the private sectors, including nongovernmental organizations. The public
sector bears the greatest responsibility for providing health services to
the general population. There are serious shortcomings in health services
coverage and the network ability to respond to health care is insufficient.
The Constitution lays the groundwork for improving the legal nature and organizational
model of the health sector. Article 83 states that health is a fundamental
social right and an obligation of the State that must be guaranteed. To that
end, Article 84 stipulates the creation of a National Public Health System,
under the leadership of the Ministry of Health and Social Development, which
will be intersectoral, decentralized, and participatory; integrated with
the social security system; and governed by the principles of universality,
comprehensiveness, equity, and social integration and solidarity, as well
as being free of charge. In 1997, 65% of the population had some kind of
insurance. The IVSS provides the broadest coverage (57% of the insured population,
including those directly insured and beneficiaries). The MSyDS and the federal
entities are obliged to protect those population groups that lack any other
kind of public insurance (35%); however, in practice, the Ministry’s
outpatient network serves approximately 80% of the population.
Organization of the sanitary regulation actions
Importation, manufacture, processing, transportation, storage, marketing, and
supply, even donated regulated goods, comes under the control of the MSyDS
as far as matters regarding the safeguarding of collective health are concern.
Protection, being responsible for the analysis and evaluation of the quality
and safety of foods, drugs, cosmetics, reagents, and materials for diagnosis
and treatment purposes, and of any other product of human consumption, with
a potential effect on health.
Organization of the public health services
Environmental health surveillance is incipient and must be strengthened, as
it lacks sufficient capacity in the area of laboratories, trained human resources,
and research. The national health information system gathers and analyzes
information on epidemiology, health programs, and services, costs, and expenditures.
Potable water coverage increased from 77% in 1996 to 84% in 2000; the areas
not covered are mainly rural, indigenous, and unincorporated urban areas.
However, the quality of the water distributed is questionable. In 2000, 73
% of the population had adequate sewerage services, the deficit being concentrated,
as in the case of potable water, in the rural, indigenous, and unincorporated
urban areas. Only 10% of the estimated 76 m3/sec of total sewerage dumped
is treated. Annual public investment in the sector has not exceeded 0.2%
of GDP in the last five years. By 2001, with additional resources in the
order of US$ 88.9 million, which amounted to a budget increase of 26.7% for
the sector, the National Sanitation Plan was consolidated. Seventy-two percent
of the municipalities have no solid waste disposal infrastructure and the
country has no safe landfills for hazardous materials, including hospital
waste.
Organization and operation of the individual health care services
All the public health establishments must be part of a network. The outpatient
and hospital establishments belonging to the National Public Health System
are organized according to their level of complexity and problem-solving
capacity. At the primary level there are 4,804 public outpatient establishments,
96% of which belong to the MSyDS. There are 296 hospitals in the network
of public establishments and 344 hospitals in the private sector (315 for-profit
institutions and 29 charitable foundations). In 2000, there were 40,675 public
hospital beds in the governmental sector (17.6 beds per 10,000 population).
Health supplies
National drug production as a percentage of total supply dropped from 95% in
1995 to 45% in 2000. Total spending on drugs increased in recent years, from
US$ 1,200 million in 1998 to US$ 1,600 million in 2000.
Human resources:
In 1999, there were 19.7 physicians and 7.9 nurses per 10,000 population.
Research and health technology
The National Council for Scientific and Technological Research (CONICYT) coordinates
scientific and technological promotion and management at the national level.
Science and technology foundations that operate in 10 states come under CONICYT
but are autonomously managed.
Health sector expenditure and financing
The National Public Health System financing is provided through national, state,
and municipal fiscal budgets for health, states and municipal revenues earmarked
for health, transfers from other social security subsystems, specific tariffs,
resources obtained from costs recovery for registration services, and the
Comptroller for Public Health. Public spending on health’s share of
the national budget increased from 8.6% in 1995 to 11.6% in 2000. Total spending
on health as a percentage of GDP was 3.0% in 2000 and public spending per
capita was US$ 62.2 in 2000. The MSyDS was assigned 6.6% (US$ 2,108,150,100)
of the Nation’s Fiscal Budget for 2001.
External technical and financial cooperation in
health
The total contribution of external cooperation to the health budget in 2001
was US$ 82.6 million, equivalent to 3.9% of the MSyDS budget; of that, US$
72.3 million (88%) loans and US$ 10.3 million (12%) donations and multilateral
cooperation, specifically from the United Nations and Inter-American System.
The loans were for modernizing and strengthening the health sector, supporting
the social management initiative (IDB), reforming health services, and strengthening
and modernization of the health sector in Caracas (World Bank), investment
and social development (Andean Development Corporation), hospital waste handling
(Plan Hispano- Venezolano), and social investment and urban development (Foreign
Debt Bonds). Contributions from multilateral cooperation in 2001 amounted
to US$ 10.3 million, to which the United Nations contributed US$ 9.3 million.
Return to index
Epidemiological
Bulletin , Vol. 25 No. 3, September 2004
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