Socioeconomic, Political, and Demographic Overview
Venezuela has a land area of 916,445 km2. It is comprised of 22 states, a Federal District, and federal dependencies (a group of islands in the Caribbean Sea). The states and the Federal District are divided into 330 municipios, which are the basic autonomous political units within the national system. The municipios, in turn, are divided into parishes and capital municipios. In December 1995 the third election was held.
During 19931996, the country experienced uneven economic growth. GDP grew in 1993 (0.4%) and 1995 (2.2%) and fell in 1994 (2.8%) and 1996 (1.6%). Inflation was 38.1 % in 1993, and in 1996 reached its highest level ever, 103.2%. Per capita GDP was US$ 2,862 in 1993, $2,371 in 1994, $3,470 in 1995, and $2,804 in 1996. In 1996, the Government launched a fiscal, monetary, and foreign exchange plan of action to lower inflation, balance the budget, restructure and strengthen the financial system, establish a new social security model, transfer resources to the most vulnerable sectors, and transform the structure of the economy and of the framework of legal institutions.
The estimated population in 1996 was 21,377,426, and the population density was 23.8 persons per km2. The Federal District has the highest population density, with 1,181.2 inhabitants per km2. In 1996, 85.4% of the countrys inhabitants lived in urban areas; of this urban population, 72% resided in cities of more than 50,000 inhabitants. The indigenous census of 1992 found 38 indigenous ethnic groups - 1.5% of the countrys population. Of the 38 groups, 28 resided in the border states of Zulia, Amazonas, and Bolívar. Some 34 % of the indigenous population belonged to the Wayuu group, 12.9% to the Warao, and 10.5% to the Pemón.
The total population growth rate was 2.3% in 1992, 2.1% in 1993 and 1994, and 2.0% in 1995. The birth rate declined gradually from 27.4 per 1,000 population in 1992 to 23.8 per 1,000 in 1995. The total fertility rate fell from 3.3 children per 1,000 women in 1992 to 2.9 in 1995. Women 20-29 years old have the highest fertility rate.
The Venezuelan population is young: 12.6% are under 4 years of age; 23.6% are 5-14 years, and 55.5% are under 25. Only 4.1% of the population is 65 or older, but this group is growing faster than the general population. Life expectancy at birth in 1995 was 72.2 years (69.3 for men and 75.1 for women).
Poverty estimates from the Household Survey of the Central Office of Statistics and Information (OCEI) indicate that as of 30 June 1994, 27.3% of the Venezuelan population had unmet basic needs and 21.6% lived in extreme poverty. The states with the most people living in extreme poverty were Apure, Delta Amacuro, Amazonas, and Portuguesa.
The unemployed made up 7.1% of the population in 1992, 10.2 % in 1995, and 12.4% in 1996.
In 1995 the illiteracy rate was 7.2% (6.5% for men and 8.0 % for women). Among persons 10-24 years of age, illiteracy among males was 3.5%, and the rate for females was half that. Illiteracy in the indigenous population over 10 years of age was 41%.
The crude mortality rate has varied little in recent years. In 1992, it was 4.4 per 1,000 population and in 1995 was 4.2. The Latin American Demographic Center estimates underreporting of deaths at 13.2%, which would make the actual mortality rate 5.4 per 1,000 population for the period 19901995.
In 1995, according to mortality rates for five major groups of causes, diseases of the circulatory system ranked first (142.1 per 100,000 population), followed by accidents and other external causes (69.9), tumors (60.9), communicable diseases (46.1), and certain conditions originating in the perinatal period (25.8). In comparison to 1989, cardiovascular diseases remained in first place, with a 7.0 % increase. External causes moved to second place, with a 43.8 % increase, edging tumors, which experienced a 0.3% reduction, to third place. Communicable diseases were in fourth place and had a 17.5% reduction. Certain conditions originating in the perinatal period remained in fifth place, despite a 32.9 % reduction. Symptoms and ill-defined conditions represented 1.5% of the deaths recorded in 1995, similar to 1992 (1.6%).
In 1995, deaths from external causes were five times more frequent in males (115.2 per 100,000 population) than in females. Accidents led external causes (74%), followed by homicides (19%) and suicides (7%). In 1992, 13 men died as a result of homicide for every woman, a number that rose to 16 men for each woman in 1995.
An analysis of mortality by years of potential life lost (YPLL) for 1995 ranked in first, certain conditions originating in the perinatal period and in second, enteritis and other diarrheal diseases, which represented 8.2% of the total YPLL. Traffic accidents ranked third and tumors fourth. Excluding deaths in children under 1 year, traffic accidents account for the greatest number of YPLL. The breakdown of YPLL by sex shows traffic accidents and homicides in second and third place for men, while cancer is second for women and enteritis and other diarrheal diseases is third for them.
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
The infant mortality rate from 1992-1995 was stable - around 23.5 per 1,000 live births. Some 59% of infant mortality is neonatal mortality, which had a rate of 13.4 per 1,000 live births in 1995.
The leading causes of death in children under 1 year of age are hypoxia, asphyxiation, and other respiratory disorders (31.1%), enteritis and other diarrheal diseases (17.9%), and birth defects (11.7%).
No national data are available on low birthweight, but data from the Concepción Palacios Maternity Hospital, indicate children with birthweights under 2,500g fell from 16% to 12 % between 1990-1994.
In 1992-1995 the mortality rate in the 14 age group remained stable, with an age specific rate close to 1.2 per 1,000 population. In this group, enteritis and other diarrheal diseases ranked second behind accidents as a cause of death. In 1994, the leading causes of death in primary-school children were accidents (32%), malignant tumors (15%) and birth defects (12%). In that same year, the most frequent causes of death in the group 10-14 years were also accidents and malignant neoplasms. Among 15-19 years old, homicide was the second leading cause of death. The leading cause of death in males was homicide, and in females was accidents.
The total fertility rate has been declining gradually. The highest rate was recorded in the 2024 age group and then the 2529 age group. However, the states of Barinas, Monagas, Apure, Cojedes, Guárico, Sucre, Portuguesa, and Yaracuy showed comparatively high fertility rates among adolescents. Studies conducted in the country found that illiterate women who live in rural areas have an average of 8 children, while women with a university education average 2.1. Physicians attended 95.3% of all deliveries in 1994.
Mortality from complications related to pregnancy among those aged 15-49 constituted 6.8% of the deaths in the 19931995 period, with rates of 6.2 per 10,000 live births in 1993, 6.9 in 1994, and 6.5 in 1995. Over this period, the leading causes of death were hypertension complicating pregnancy, childbirth, and puerperium (28.5%); prepartum hemorrhage, abruptio placentae, and placenta previa (14.2%); and unspecified abortion (13.6%).
According to OCEI data, in 1990 the population aged 65 and older totaled 717,774, about 3.7% of the population and in 1994, 4.0%, and in 1995, 4.8%. In 1990, 26.5% of older adults said they were employed; 41.3% practiced some trade or profession in the home; 68% of this population helped their families through various activities. Some 73.5% were economically dependent on others. Households with older adults or those headed by older adults had lower per capita incomes.
In 1994, the leading causes of mortality in the 65 and older age group were heart disease (42.5%), cancer (18.6%), cerebrovascular disease (15.5%), and diabetes mellitus (6.7%). Older men had higher mortality rates than older women. The National Institute of Geriatrics and Gerontology indicated that in 1996 the four leading causes of morbidity, by reason for medical consultation, were hypertension (7.3%), arthritis (6.4%), influenza (3.3%), and diabetes mellitus (2.1%).
According to OCEI data, in 1994, 7,903,400 people (5,390,600 men and 2,512,800 women) were economically active, and the unemployment rate was 8.6%. The percentage of women over 15 years of age in the labor force has grown since the 1960s, but in recent years, growth has been most pronounced in the group 25- 44. By law, children under 14 may not work. Those between 14 and 16 need special authorization, may not perform night work or piecework, and may not work more than 6 1/2 hours per day. An increase in working minors has been noted. Between 1981 and 1991, 15-19 years old in the labor market rose from 7.7% to 12.8%, and 10-14 years old rose from 0.8 % to 1.2%.
About 10% of the population is estimated to have some type of disability. This percentage is believed to be increasing due to the aging of the population, accidents, and degenerative diseases. The National Health System serves an estimated 2 % of the disabled population.
Venezuela has a richly diverse and complex Amerindian culture. Indigenous groups are widespread in a number of the border states: in Zulia, in the Páez and Mara municipios and in Delta Amacuro, in the Antonio Díaz and Pedernales municipios. In Amazonas, with the exception of Atures, all the municipios have indigenous populations. The remaining indigenous groups are located in the states of Monagas and Anzoátegui, on the coast. Endemic diseases such as, gastroenteritis and dysentery, malaria, hepatitis B, and onchocerciasis, seriously affect the indigenous populations in Amazonas. Malaria is endemic throughout most of the states of Amazonas and Bolívar and is the leading cause of death (40.1%) among the Yanomamis of Amazonas. Hepatitis B is the third leading cause of death in these Yanomamis, where some 58%-84% of the population becomes infected at some time in their life. Onchocerciasis is found in the Orinoco River basin and extends toward Bolívar State and Brazil. The level of endemicity ranges from 4%-76%. It is hyperendemic in the High Orinoco. The most seriously affected ethnic group is the Yanomami.
In Zulia State, 56 indigenous communities were vaccinated through the hepatitis B control program in 1992-1995. In 1992, the rate of new tuberculosis cases in Zulia State was 27.7 per 100,000 population in the nonindigenous population and 167.9 in the indigenous population. In the 14 age group the rate was 11.5 per 100,000 population in the nonindigenous population and 116.6 in the indigenous population. These figures emphasize the high transmission rate of the disease among the indigenous groups, a situation worsened by the high percentage of patients (18%) who fail to complete treatment.
Analysis by Type of Disease
The transmission area for malaria covers 23% of the land area of the country with an elevation of less than 600 m, and has 713,394 inhabitants at risk. The area where malaria has been eradicated or is in the maintenance phase covers 460,397 km2 (77% of the original area), affecting 16,914,622 inhabitants. The regions in the attack phase include the states of Apure, Barinas, Táchira, and Zulia, where the principal vector is Aedes nuńeztovari, as well as the states of Apure, Bolívar, and Amazonas, which are inhabited by indigenous groups and mine and timber workers and where the principal vector is A. darlingi. Of all infections, 91% were by Plasmodium vivax, 8.4% by P. falciparum, 0.2% by P. malariae, and 0.4% were mixed. In the first six months of 1997, there were 14,610 cases of malaria, an increase of 19.1% over the same period in 1996.
Some three million inhabitants are at risk from Chagas disease. Between January and August 1996, the rate of triatomine infestation found in 18,747 dwellings examined was 0.8%, and the rate of infection by T. cruzi was 13.6%. The rate of human seropositivity was 4.3%. Estimates put the total number of infected people at 800,000.
There were no cases of yellow fever between 1992-1997. Between 1994-1996 vaccination coverage increased by 350%. In 1996, 1.5 million doses were administered.
During 19901996, no cases of human plague were recorded, and the only existing focus at present, located in Aragua State, is inactive.
In 1989 and 1990 there was an increase in dengue cases. Since then, the disease has been endemic. Between 1991-1995 this disease, in both its classical and hemorrhagic forms, was on the rise. The most cases occurred in 1995; the 32,280 cases more than doubled those in 1994. Some 5,380 (17%) were hemorrhagic, with 43 deaths, and 25 cases were laboratory-confirmed. Serotype 4 predominated, unlike previous years, when the predominant serotypes were 1 and 2. Serotype 3 was not identified in samples processed. In 1996, some 9,180 cases of dengue were reported; 18% were hemorrhagic, with 13 deaths. The States with the highest morbidity were Barinas, Amazonas, Aragua, Mérida, and Lara.
In recent years, schistosomiasis transmission has been limited to isolated foci, and prevalence remained below 2%. Between 1990-1996, 2,731 cases were confirmed through serological testing. There are three large endemic foci of onchocerciasis: the northeastern region, where 61% of the countrys cases were recorded; the north-central region, with 39% of the cases; and the southern region. In 1995 there were at least an estimated 70,000 active cases of onchocerciasis.
The last confirmed case of poliomyelitis was recorded on 21 March 1989, and the last compatible case was in 1993. In 1995, 104 cases of acute flaccid paralysis were reported, but none were confirmed. In 1994, 110 cases were reported and all ruled out.
The last case of diphtheria was reported in Zulia State in 1992.
The Measles Elimination Plan, begun in 1994, substantially decreased the number of confirmed cases. In 1995 the reduction was 96%; 172 of 652 suspected cases were confirmed, with 1 death. In 1996, 65 of 681 suspected cases were confirmed.
In 1994, there were 808 cases and 21 deaths from whooping cough; in 1995, 510 cases and 25 deaths; and in 1996, 384 cases and 7 deaths.
The intervention strategy to reduce neonatal tetanus resulted in a decrease from 37 cases in 1991 to 17 cases and 7 deaths in 1995. The states of Apure and Zulia reported cases every year in 1989-1994.
In June 1996, cholera reappeared in the country. The first cases occurred among the Wayuus in Zulia State. The epidemic spread, primarily affecting the inhabitants of the areas with the worst living conditions in the states of Delta Amacuro, Mérida, Aragua, Monagas, and Miranda, and in the Federal District. As of 12 July 1997, 1,972 cases had been reported, with 50 deaths.
The annual risk of infection with tuberculosis is estimated at 0.2%-0.4%, and new reported cases of pulmonary tuberculosis have increased by 14% since 1993. The number of cases under 15 has not increased, but in the 524 age group, the increase was in the bacteriologically unconfirmed pulmonary forms. An increase in new bacteriologically confirmed cases was noted in the 2544 age group. In 1995, 3,056 cases were recorded, and 2,765 were treated. After treatment, 75% of the patients had negative smears. In 1996 there were 3,195 new pulmonary cases and 726 extrapulmonary cases, with 212 relapses.
In 1995, 3,954 cases of leprosy were registered. Of these, more than 65% were expected to be discharged during 1996-1997. In 1996, 564 new cases were reported, a 12 % increase over the 504 new cases detected in 1995 -- a positive fact, since this contributes to the reduction of hidden morbidity, calculated at 500 cases.
Acute respiratory infections are the fifth leading cause of death in children under 1 year and the third in the 14 age group. The mortality rate in these age groups was stable between 1989-1995. The states with the highest risk of death from this cause in the population under 5 are Delta Amacuro, Zulia, and Trujillo. There are an estimated 7-9 episodes per child annually in urban areas and 2-4 in rural areas. These infections account for 40% of outpatient consultations and 40% of pediatric hospitalizations.
In 1994 no cases of human rabies were reported. In 1995 an epidemic began in Zulia State, and five cases were reported. In 1996 there were four reported cases, all from canine bites.
The number of newly reported AIDS cases was 966 in 1993; 1,003 in 1994, 746 in 1995, and 226 in 1996. The annual incidence rate per 1,000,000 population was 46.2 in 1993, 46.9 in 1994 and 34.1 in 1995. The male/female ratio for reported cases of AIDS was 6.0 in 1993, 7.1 in 1994, and 9.2 in 1995. Persons 20-49 years old have the highest risk. The highest number of cases was reported in the Federal District, including the Sucre municipio in Miranda State; followed by, in descending order, the states of Nueva Esparta, Aragua, Mérida, and Bolívar.
From 1993-1995, the gonorrhea rate was 72.8 per 100,000. In 1996 the rate fell to 54.1 per 100,000. The syphilis rate from19931995 was 40 per 100,000 and declined in 1996 to 24.1. It is believed that the decline in 1996 was due to underreporting.
Morbidity from meningitis in the 19901995 period was erratic. It increased from 6.7 per 100,000 population in 1990 to 10.5 in 1993; in 1994 it declined; and in 1995 it was 11.4. An improvement in case reporting has been noted. The states with the highest risk were Mérida, Monagas, and Lara, with average rates of 24.4, 22.0, and 20.8 per 100,000, respectively. In 1995 and 1996, almost 80% of the cases occurred in children under 15, with those at greatest risk children under 5, in particular, children under 1 year of age. In 1995, a rate of 3.4 per 100,000 live births was recorded. The two circulating serotypes are B (18.5%) and C (37.0%) of the serotypes identified in 1995.
In August 1995 the first equine encephalitis epidemic in 20 years began. Some 12,317 cases were registered, with 24 deaths. The states of Zulia, Lara, Falcón, Yaracuy, Carabobo, and Trujillo were affected. Zulia had 90.8% of the cases and 62.5% of the deaths and the Wayuu population was the most affected. Of the recorded cases, 59% were among those 5-24 years of age. At the time of the epidemic, vaccination coverage in horses was very low.
In 1994, 4 cases of Venezuelan hemorrhagic fever were reported; in 1995, there were 8, and in 1996, there were 40 cases and 12 deaths. The 1996 case-fatality rate of 30% was higher than in previous years and most severely impacted was the group aged 15-45 with 70% of the cases. Preliminary findings on potential reservoirs point to the rodent Zygodontomys brevicauda.
The incidence of the cutaneous form of leishmaniasis has remained stable over the past three years, with a rate above 1 per 10,000 population. In 1996, 1,409 cases were reported, with an estimated total of 2,234. It is thought that for each reported case there are one or more unrecorded cases. As of October 1996, 33 cases of visceral leishmaniasis (kala-azar) were recorded. Almost half the cases in the country were recorded in Anzoátegui State, followed by Nueva Esparta.
Noncommunicable Diseases and Other Health-Related Problems
Death from nutritional deficiencies in children under 15 increased from the 19911992 period to 1993; most affected were children under 1 year of age. The states with the highest mortality rates from nutritional deficiencies were Delta Amacuro (20.6 per 100,000 population), Amazonas (17.4), and Monagas (8.3). All three states have high percentages of unmet basic needs.
In 1994 the prevalence of overweight (defined as weight-for-height above the 90th percentile) reported by the FNSS was higher than in 1988 for all age groups.
In National Foundation studies in 1992, the prevalence of iron deficiency, determined by serum ferritin levels in 653 schoolchildren aged 7, 11, and 15 in low-income groups averaged 36%. In 1993, the government made it mandatory to fortify corn flour (50 mg/kg) and wheat flour (20 mg/kg) with iron (ferrous fumarate). A comparative study of Caracas schoolchildren aged 7, 11, and 15 living in critical and extreme poverty showed that one year after fortification of the flours, the prevalence of both iron deficiency (20.4%) and anemia (9.3%) was half the 1992 levels.
Iodine deficiency disorders constitute a public health problem, and the Venezuelan Andean region is considered an endemic area for goiter. Based on a sample of 14,074 schoolchildren 7-14 years of age in the Andean region during 1993-1995, the Institute found a 63.5% prevalence of goiter (grade Ia goiter, 40.1%; grade Ib goiter, 20.7%; and grade II goiter, 2.7%). The prevalence of goiter was 62.4% in urban areas and 65.4% in rural areas.
In 1966, salt iodization was made mandatory. The results of salt iodization for the 19931996 period varied. In 1993, 67% of samples were adequately iodized; in 1995, 85%; and in 1996, 64%. This is related to competition from the clandestine mills and problems in surveillance and control.
Diabetes mellitus is one of the 10 leading causes of death with an estimated prevalence of 1%-6%. It especially affects the 4565 age group and females, and has a significant economic impact due to the high cost of medical care and loss of productivity. A prevention and control program has been implemented in 33 health services in 18 states and in the Federal District.
Cardiovascular diseases are the leading causes of death with ischemic heart disease and hypertension important. Even with underreporting, morbidity from cardiovascular diseases is significant. The prevalence of hypertension in adults is 20%-30% and a high prevalence of risk factors noted in the population.
Malignant neoplasms constitute one of the leading causes of mortality. In 1995 they ranked second, after heart disease. For both men and women, stomach cancer declined up through 1995. Lung cancer is rising steadily, with the trend becoming more pronounced in recent years and more marked in men than women. Prostate cancer is also increasing. Cervical cancer had been decreasing until 1985, when the trend reversed. Breast cancer has also been on the rise in recent years.
Since 1996, metropolitan Caracas has had a surveillance system for injuries resulting from violence. As of June 1997, homicides were the most frequent cause of violent death (69.8%), followed by accidents (23.6%) and suicides (6.5%). Homicides are on the rise and males 10-49 years of age at highest risk. The Federal District is the most affected area.
Smoking control activities are interinstitutional and interprogrammatic, and are aimed at prevention among secondary school students. Protection for nonsmokers is sought through strategies to increase smoke-free spaces, mainly in the work environment. Cigarette consumption has been declining since 1983, when all radio and television advertising was banned and public education campaigns initiated. Annual per capita consumption has dropped from 1,950 in 19901992 to 900 in 19941996.
The National Directorate of Oral Health, utilizing the DMFT (decayed, missing, filled teeth) Index has noted the high prevalence of dental health problems. In the 714 age group, 8 of every 10 children have dental damage, and in those over-35, 9 of every 10. As of December 1995 this had not changed.
The Salt Fluoridation Program was established in 1993 and expanded in 1994 and 1995. In 1994 the countrys five most important salt mines began fluoridating salt, ensuring 85% national coverage.
Earthquakes are the greatest natural hazard in Venezuela, with almost three-quarters of the nations territory in seismic areas. On 9 July 1997, an earthquake of medium intensity rocked the eastern part of the country and, to a lesser extent, the central region. Its greatest impact was felt in the areas of Cariaco, Casanay, and Cumaná in the Sucre State. There were a total of 67 dead and 511 injured, and damage to infrastructure was estimated at US$ 25 million. Storms have also caused considerable damage, but with very few human deaths. Industrial accidents are on the rise, largely because of growth in the petroleum and petrochemical industries. In the 19811995 period, more than 15 major accidents occurred.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The institutional basis, objectives, and guidelines for Venezuelas health policies are contained in the Ninth National Plan - a national economic and social development plan from which the priorities for the Executive Branchs five-year work plan are derived. The principal elements of the health policy are: to reaffirm the right to health and equity and to combat inequalities and social inequities with regard to health, disease, death, and access to goods and services; to improve the efficiency and effectiveness of the health services system; to assign special priority to activities for health promotion and damage and risk prevention; to reaffirm the role of the State in developing health services and to democratize the health structure, with broad societal participation; to ensure the guidance role for the Ministry of Health and Social Welfare in determining policies; managing, coordinating, and regulating the health sector; and establishing appropriate regulations. The Ministry of Health and Social Welfare shares operational coordination and the fulfillment of medical care, social welfare, and environmental sanitation programs with 23 federal entities, as well as mayors offices, municipios, and civil society.
The 19931996 period saw a State reform process that moved ahead in decentralizing the different national sectors, especially the health sector. The principal strategies of reform are the restructuring and decentralization of activities. The Ministry of Health and Social Welfare becomes an agency responsible for generating policies, standards, and techniques and ceases to perform operational functions, which are now transferred to the state or municipal level or to society itself.
It is expected that 10% of the national budget will be allocated to health, which, together with the contributions from other sources, will make it possible to create a collective fund for the benefit of population segments that do not have the ability to pay or access to financial intermediaries. The sources of financing for the health sector are: the central government, through budgetary transfers from sector agencies and from the constitutional allocation of funds to the state governments, insurance companies, and private groups; national resources from the National Health Fund; the state governments, through agreements and contracts with the municipal governments and health service centers and with financing modalities such as, the Social Development Research Fund and others.
Organization of the Health Sector
The health sector is made up of the public, private, and social security sectors. Its most important institutions are the Ministry of Health and Social Welfare, the Venezuelan Social Security Institute, the Social Welfare Institute of the Ministry of Education, the Institute of Social Welfare of the Armed Forces, the Government of the Federal District, and the Municipal Council of Sucre, Miranda State. The private sector has grown without any planning or control, and many of its services are inefficient and costly, which increases inequity in health care.
The Ministry of Health and Social Welfare is charged with health research and surveillance, as well as the promotion, provision, and operation of health services. Since 1996 it has been performing these functions in a dispersed manner in 10 states. In the remaining 13 federal entities, the provision and operation of the services has been transferred to the state governments.
One of the country's health problems is access to drugs. Some believe the lack of development and enforcement of a pharmacological policy backed by legislation to ensure its execution has accentuated this crisis. At present, the country has a modern registration system, mechanisms for inspecting pharmaceutical establishments, official quality control laboratories and advisory groups that ensure the marketing of effective, safe, high-quality drugs.
The sanitary control system has an office in charge of the registration and control of imports and the establishments that distribute them. Quality control of paramedical products is performed in various institutions, including universities, health institutes, and private laboratories accredited for that purpose. Since January 1977, all products entering the country have had to be registered in advance.
There are 125 drinking water treatment plants that guarantee the level of water treatment in urban areas. In the rural areas, water supply is still inadequate, and, in some cases, there are no plants to treat the water that is supplied. An analysis in 1997 found that 80% of urban communities have drinking water service through direct connections. The remaining 20%, located in lower-income areas, receive drinking water by means of tank trucks or public spigots.
There are programs to monitor and evaluate the air in metropolitan and industrial areas, with 14 national sampling stations. The National Government has developed programs to reduce the lead content of the gasolines used in the automotive sector.
Soil contamination from the inappropriate use of pesticides and the presence of solid and liquid wastes has been studied, and there are standards and regulations to correct or prevent it.
The Ministry of Health and Social Welfare regulates the technology in the services according to guidelines that take into account the complexity of the establishments and their geographical and population coverage. In the private sector, state-of-the-art technology has been applied in the most highly developed geographical, population, and social centers. Equipment maintenance problems are becoming worse due to disorganized services, poor supervision and control, inadequate technical information, and the lack of training for personnel.
Health Services and Resources
The Ministry of Health and Social Welfare is promoting the implementation of a new model that increases the autonomy and managerial capacity of the municipios. The Healthy Municipios Strategy, begun in 1994, promotes health at the municipio and parish levels and encourages citizen participation and an intersectoral approach under the leadership of the mayoralties. As of June 1997, 15 activities were implemented in 14 federal entities; including 13 community projects.
Since 1978, the National Institute of Geriatrics and Gerontology, by law, has been responsible for the policies on health care for people aged 60 and over. The Institute has 29 geriatric units throughout the country2 of them psychiatricand offers services to 3,500 elderly people. It provides residential care with medical, social, rehabilitation, and nutrition services. In addition, it offers outpatient consultations for preventive, curative, and odontological care, in 11 metropolitan areas and in 6 states in the interior of the country.
The General Sectoral Bureau of Malariology and Environmental Health is responsible for programs to eradicate malaria and to control Chagas disease, ancylostomiasis and other intestinal parasitic diseases, schistosomiasis, other vector-borne diseases, and Aedes aegypti. The Institute of Biomedicine is responsible for programs to control leprosy, leishmaniasis, onchocerciasis, and other dermatoses. In Amazonas State, responsibility for these programs belongs to the Simón Bolívar Amazon Center for Tropical Disease Research and Control. The Technical Directorate of Programs coordinates activities to prevent and control tuberculosis, cardiovascular diseases, diabetes mellitus, mental disorders, and AIDS and other sexually transmitted diseases. In November 1996, the National Epidemiological Information System began operations, enabling electronic data transmission from the state level to the national level.
The virology laboratory of the Rafael Rangel National Hygiene Institute operates as a national reference center. It performs virological and serological diagnosis of infectious diseases and also manufactures biologicals (vaccines and serums).
Official figures show that drinking water supplied by direct connection reaches 80% of the people in urban areas and 65 % of those in rural areas. Sewerage service coverage of 69% is reported in urban areas, with the remaining 31% using septic tanks or latrines. The percentage of wastewater treated does not exceed 5% of the amount distributed.
The mayoralties are responsible for waste collection and disposal services, and many of them have opened the business to private operators. The major metropolitan areas receive adequate collection and transportation service. Deficiencies are noted at the final disposal sites, which are usually dumps and not sanitary landfills, with the State spending funds to improve these sites for municipal waste.
Decree 2218 governing hospital wastes is being implemented in the country. Its enforcement is critical, since not all health facilities have incinerators to dispose of waste properly.
There are pollution prevention programs backed by specific guidelines and regulations. Decree 2215 establishes standards to control the use of substances that damage the ozone layer. There are projects to control industrial pollution, and other petroleum and petrochemical industry projects. Atmospheric lead levels in metropolitan areas under surveillance are below those called for internationally, except in the El Silencio area of Caracas, where the established limits were exceeded in 1993, 1994, and 1995.
In 1995, the network of public health care establishments consisted of 583 hospitals and 4,027 outpatient centers (662 in urban areas and 3,365 in rural areas). The private sector had 344 hospitals. The average number of beds was 2.4 per 1,000 population. Private health services are concentrated in the large population centers and serve higher-income persons. There is a trend toward emergency care, in both the hospitals and outpatient centers. There are more emergency surgeries than elective ones, and preventive consultations are infrequent.
Blood Banks conduct tests to detect AIDS, hepatitis B and C, Trypanosoma cruzi, and syphilis. The serological reagents used to screen for these diseases are evaluated at the National Institute of Hygiene before their distribution to the blood banks. In 1995, the highest prevalence found from the screening of 202,515 donors was for hepatitis B, with 5.9%, for syphilis, 1.1% for hepatitis C, 0.8%, for T. cruzi, 0.8%; and for HIV, 0.4%.
The coverage of care for the disabled is estimated at 1%-2%. The social welfare benefits are limited to the population covered by the social security system; the rest of the disabled depend on non-governmental organizations and some official entities.
During 1996 and the first half of 1997, 50% of the drugs that were marketed in the country were produced domestically. That amount was 45% less than in 1990, which can be attributed to the globalization of the pharmaceutical industry and to the countrys economic and financial crisis. Domestic production of pharmaceutical products and preparations is broad, and the vast majority of the essential drugs are made in the country. Drug imports are limited to the products that have been registered in the country, except for "orphan drugs" used to treat rare disorders. Narcotics and psychotropics are subject to strict control, and their imports must be reported lot by lot.
The Pharmaceutical Products Review Board establishes guidelines that regulate the production and marketing of drugs. Marketing is carried out through the laboratory/drugstore/pharmacy chain. Other marketing modalities exist for certain types of products, such as anti-cancer drugs or hormones. Patients receive these drugs through nonprofit foundations or institutions. This procedure has increased the availability of drugs for all levels of the population. The value of the Venezuelan drug market is US$ 519 million with $487 million (93.9%) in the private sector and $32 million (6.1%) in the public sector.
Since 1986, the producing laboratories have been subject to inspection for good manufacturing practices. The 62 producing laboratories are evaluated at least once every two years. Quality control is conducted at the government and private levels. The legal base for immunobiologicals is the same as that governing the registration and control of drugs. The National Institute of Hygiene carries out domestic production and produces the DTP vaccine (diphtheria, tetanus, pertussis), the tetanus toxoid, and the human and canine rabies vaccine. There is a production plant and a project under way to produce blood derivatives on an industrial scale. The Institute of Biotechnology of the Central University of Venezuela produces polyvalent anti-venom immune serum for the treatment of snake bite and serum for the treatment of scorpion stings.
Until July 1997, there was no sanitary control of reagents and their domestic production is virtually nil. The Ministry of Energy and Mines controls these substances.
Some 14,676 professional nurses, 53,818 physicians, 8,571 pharmacists, and 13,000 dentists are registered with the Ministry of Health and Social Welfare. There are 31,629 nurses aides who work for the Ministry of Health and Social Welfare. In the health sciences, there are 12 medical schools, 7 dentistry schools, and 3 pharmacy colleges, as well as 7 nursing schools with degree programs. All are public institutions, except for two dentistry schools and one pharmacy school The Ministry of Health and Social Welfare continues to be the principal employer of the different categories of health professionals. Financing for training comes from the Ministry of Health and Social Welfare, with approximately US$ 4.5 million from the regular funds of the Ministry itself, and funds from projects financed by the World Bank and the Inter-American Development Bank.
Public funding resources for the health sector, including contributions to social security, amounted to US$ 1.3 billion in 1993 and $1.2 billion in 1996. Health expenditures represented 10.4% of total expenditures in 1993, 9.6% in 1994, and 9.4% in 1995 and 1996. During that same period, health expenditures as a percentage of gross domestic product decreased from 2.1% in 1993 to 1.9% in 1996. Per capita health expenditures were US$ 59.90 in 1993, $58.60 in 1994, $69.42 in 1995, and $54.10 in 1996. The Ministry of Health and Social Welfare and the Venezuelan Social Security Institute account for 76% of public spending on health, a percentage that climbs to 93% if the state governments are included. Systematized official information on private health sector financing and expenditures is not available and must be inferred from households expenditures for final consumption of goods and services. The expenditures for health and education were US$ 1.3 billion in 1993 and 1994.
The Ministry of Health and Social Welfare is implementing the Project for Modernizing and Strengthening the Health Sector, at a cost of US$ 300 million (of which the IDB contributes 50%). The Ministry of Health and Social Welfare is carrying out the Health Sector Reform Program, for a total of US$ 108 million, 50% of which is financed by the World Bank.
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