Socioeconomic, Political, and Demographic Overview
Bolivia has a land surface of 1,098,581 km2, spread over three distinct topographies: highland plateaus and Andean mountain slopes (25%), valley area (15%), and plains (60%). In terms of population distribution, 45% of Bolivians live in the highland plateaus, 30% in valley areas, and 25% in the countrys eastern plains. Social organization, access to goods and services, and morbidity and mortality profiles vary considerably among the three regions. Although the country is officially divided into nine departments, regional autonomy is still at an incipient stage.
The 1995 estimated population was 7,413,834. Overall population density averaged 5.84 inhabitants per km2, ranging from 0.6 in Pando to 19.9 in Cochabamba. Life expectancy at birth in 1992 was 61 years for women and 58 years for men. That same year, 57.5% of the population was classified as urban (i.e., living in towns of more than 2,000 inhabitants): three metropolitan areas (La Paz, Santa Cruz, and Cochabamba) were home to 36.2% of Bolivias population, with 21.3% living in 112 other cities. Children under 15 years of age accounted for 42% of the population, and people over 64, approximately 4%; for urban areas, these figures were 39% and 4%.
In 1992, 70% of Bolivias 1,322,512 homes lacked adequate access to basic education, health, and housing and were classified as poor (51% of urban homes and 94% of rural homes). Thirty-seven percent of these families lived in conditions of extreme poverty (32% were considered indigent and 5% lived in abject poverty); 13% lived at the poverty threshold, with a minimum level of satisfaction of their basic needs; and only 17% were able to properly meet their basic needs.
Only 20% of deaths were certified by a health professional. The principal causes of hospital mortality in 1993 were diseases of the circulatory system (27%), diseases of the digestive system (14%), diseases of the respiratory system (7%), cerebrovascular disease (4%), diseases of the urinary system (3.5%), certain conditions originating in the perinatal period (3%), injuries (2.5%), malignant neoplasms (1.5%), tuberculosis (0.6%), and endocrine and metabolic diseases and disorders of the immune system (0.6%).
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
Health of Children
According to the ENDSA 94 survey, infant mortality stood at 75 per 1,000 for the period 19901994, down from 99 per 1,000 live births in the period 19841989. For rural areas, the rate was 92 per 1,000 live births, compared with 60 per 1,000 in urban areas; the rates for the period 19841989 were 120 and 80 per 1,000, respectively. Neonatal mortality was calculated at 41 per 1,000 live births, with a postneonatal rate of 34 per 1,000. Mortality in the group aged 1 to 4 dropped from 57 to 44 per 1,000 over the period in question.
Data from ENDSA 94 indicated that 28% of children under 3 years of age suffered from chronic malnutrition (low height-for-age), a figure 10% lower than that reported in ENDSA 89. One of every three rural children and one of every five urban children suffered from chronic malnutrition, which was more prevalent in the highland plateaus (32%) and valley regions (30%) than in the plains (18%). According to the same source, 15% of children whose mothers had completed an intermediate or higher level of education showed stunted growth, compared with 46% of children whose mothers had no formal education. Acute malnutrition (low weight-for-height) was reported among 4.4% of children under 3, higher than the level recorded by ENDSA 89 (1.6%). The high rates of acute malnutrition in Chuquisaca (14.6%) and Potosí (10%) resulted in a higher national average for 1994.
ENDSA 94 data on prevalence and duration of breast-feeding showed that a total of 61% of infants under 2 months of age were exclusively breast-fed; at 4 months of age, that figure was only 25%. At the same time, 80% of children aged 10 to 11 months were still being breast-fed (although not exclusively), and 30% were still being breast-fed at 24 months.
Health of Adolescents
The median age for a womans first childbirth is 21.2 years. Specific fertility rates have declined over the past 30 years for all age groups except the 15-to-19 group (rate unchanged), which, because of its size, has caused the total fertility rate to increase among adolescents. Very few female adolescents used family planning methods (5.7%).
Health of Adults and the Elderly
According to ENDSA 94, fertility dropped 26% during the previous five years; reproduction rates indicated that women had 4.8 children on average, compared with 6.5 in the early 1970s. The use of contraceptives is more prevalent among urban women with higher levels of formal education, especially in the departments of Tarija and Santa Cruz, where roughly 55% of women used contraceptive methods (60% of the methods were modern). Maternal mortality had remained relatively unchanged: 416 deaths per 100,000 live births in the 19841989 period, compared with 390 in the 19901994 period. The principal causes of maternal death are, by order of frequency, hemorrhage, toxemia, infection, and obstructed labor; abortions account for an estimated 27 % to 35% of maternal deaths.
Persons over age 60 represented 6.1% of the population in 1992. The estimated mortality rate among persons over 65 years of age was 7.8 per 100,000 population (8.2 among men and 7.4 among women). There is no explicit government policy on care for the elderly, and health plans and programs for this age group are not assigned priority.
In 1994, the economically active population (EAP)defined as all people 10 years of age or olderrepresented 59% (3,921,236) of the total population; 42% of them worked in the agricultural sector. Women have been increasing their participation in the work force and in 1992 they accounted for 39% of the EAP. An estimated 8% of the EAP is between the ages of 7 and 14. Unemployment oscillates between 9% and 24% of the EAP. Employment activity is not limited to the formal sector; Bolivias National Statistics Bureau estimates that 1,366,060 people work in the informal sector of the economy.
Reliable data on work-related accidents are limited. The occupational hazards of mining and other extractive activities have now been compounded by those of agroindustry and the machine tool, metallurgical, and refining industries (the gas industry, in particular).
Health of Indigenous Populations
In 1994, a census was carried out in Bolivias lowlands (i.e., the Oriente, Chaco, and Amazonia regions) aimed at identifying the countrys indigenous groups on the basis of language, territory, and self-identity. Three major linguistic groups were identifiedthe Aymará, the Quechua, and the Guaraníwhich are further subdivided into 35 ethnic groups, each with its own cultural identity. It is estimated that nine ethnic groups have died out since the beginning of the twentieth century.
The Aymará group represents 23.5% of the population and is located in the departments of La Paz, Oruro, and Potosí.
The Quechua account for 34% of the population and they are the group whose health situation is the most precarious: 9 of Bolivias 10 poorest provinces are located in predominantly Quechua areas.
The Guaraní group comprises 33 different ethnic subgroups spread across the Chaco and Oriente regions, for a total population of 150,483.
These groups are not only highly exposed to communicable diseases, they are also more vulnerable to them. The incidence of tuberculosis was five to eight times greater than the national average, and cholera took a particularly high toll among the Weenhayek (Mataco) and Guaraní communities. Gastrointestinal diseases (acute diarrhea in particular) are the leading cause of death among infants and children under 5 years of age. Vaccine-preventable diseases (especially neonatal tetanus and measles) are also more prevalent among indigenous children, whose vaccination coverage is lower than for children living in urban areas. Indigenous women, too, are at a significantly greater risk of death, because they start bearing children at a younger age, they have larger families, the intervals between their pregnancies are shorter, breast-feed their children during a large part of their reproductive lives, receive inadequate care during delivery, and have limited access to family-planning services.
Analysis by Type of Disease
In 1996, a total of 64,012 cases of malaria were reported in eight of Bolivias nine departments, six of them located in areas at high risk of uninterrupted transmission. Cases involving P. falciparum had increased significantly, from 1,110 in 1991 to 4,164 in 1996. Fourteen hospital deaths involving malaria were reported in 1996. With respect to Chagas disease, the main vectorTriatoma infestanswas present in 60% of the country (six of Bolivias nine departments).
A total of 5,780 leishmaniasis cases were reported in 1996, 40% (2,310) were reported in 1996: 93.2% were the cutaneous form and 6.8% were the mucous form (the only cases of visceral leishmaniasis were reported in 1993, in the yungas).
Since 1975the year when seven cases and two deaths were reported in San Joaquínno other cases where reported until 1993, when a case was found in the province of Mamoré. In 1994, nine cases were reported in the province of Iténez; six of them ended in death. In 1996, there were three nonfatal cases, all in the department of Beni.
Laboratory tests conducted in January 1996 detected the presence of dengue fever in Santa Cruz de la Sierra. The serotypes I and II were in circulation, and a total of 66 cases had been reported as of January 1997. No cases of dengue hemorrhagic fever were reported.
Selvatic yellow fever continues to be a problem. In 1996, 30 cases were reported. The cases occurred in the departments of La Paz, Santa Cruz, Beni, and, in particular, Cochabamba.
In December 1996, there was an outbreak of plague (27 cases) in the town of San Pedro (Apolo, La Paz), with a case fatality rate of 15%.
The last case of clinically confirmed poliomyelitis in Bolivia occurred in 1988. In 1994, the last case considered as polio-compatible was seen. In 1992, there was a major outbreak of measles, the largest Bolivia had seen in 10 years (4,937 cases). An elimination program was launched and succeeded in raising vaccination coverage to 90% in 1997, ultimately bringing down the number of cases to 16 in 1995 and 4 in 1996 (based on clinical diagnosis).
Neonatal tetanus had declined since the 1992 level of 42 reported cases, with only 14 cases reported in 1996.
A seroprevalence of 1.1% was detected for hepatitis B among 13,276 donors screened at blood banks in 1994, rising to 1.5 % based on 13,295 samples screened in 1995.
In 1992, there were 23,862 reported cases of cholera, with a case fatality rate of 1.7%. In 1996, 2,632 cases were reported, with a case-fatality rate of 2.4%.
Chronic Communicable Diseases: Tuberculosis-related care services increased sixfold between 1993 and 1995 and are evidence of the high priority accorded to this disease by the countrys health authorities. Reported cases of tuberculosis (all forms) dropped from 165 to 129 per 100,000 population between 1990 and 1995. Primary resistance was found to be 5.8% for isoniazid, 1.8% for rifampicin, and 4.4% for streptomycin; acquired resistance was reported at 14.7%, 12.6%, and 11.5%, respectively.
Eighty-six new cases of leprosy were detected in 1995, and there were an additional 32 in 1996.
Acute respiratory infections (ARIs) continue to be the leading cause of morbidity and the second most common cause of mortality among children. The ratio of ARI mortality to mortality from pneumonia decreased 30% between 1989 and 1994 (dropping from 28% to 20%).
Eight cases of human rabies were reported in 1995, and an additional three cases in 1996. The predominant form of transmission was by dogs (91%).
The first case of AIDS was reported in 1985; as of 1996, a total of 123 cases had been detected in addition to 111 cases of asymptomatic infection with the human immunodeficiency virus (HIV). Ninety-two percent of the cases were in the 15-to-49 age group, and 75% of the patients were males. The transmission routes were sexual contact (92%), blood transfusions (6%), and perinatal transmission (2%). Cases of HIV/AIDS infection were reported in eight of the countrys nine departments.
The number of reported cases of syphilis (all forms) is on the rise; the rate of incidence per 100,000 population increased from 44 in 1992 to 55 in 1995. Gonorrhea was observed at a rate of 73 cases per 100,000 population in 1995, compared with 30 per 100,000 in 1992. The age group most affected was 20-to-29-year-olds, with 65% of the cases occurring among males.
Noncommunicable Diseases and Other Health-Related Problems
Studies undertaken in 1994 and 1996 by a committee of experts revealed a level of iodized salt consumption calculated at 91.6%, average levels of urinary iodine among the general population at 25.02 µg/dl, and 4.5% prevalence of goiter in schoolchildren. With regard to vitamin A deficiency, a 1991 study of 979 children between the ages of 12 and 71 months found serum retinol levels to be below 20 µg/dl in 11.3% of the cases (19.5% in rural areas of the highland plateaus and 16.5% in the plains area) and below 30 µg/dl in 48.3% of the cases (marginal or subclinical deficiency). A 1992 study by the Bolivian Institute for High-Altitude Biology focusing on highland children between the ages of 6 months and 9 years showed a prevalence of iron deficiency (as manifested by the presence of nutritional anemia) ranging from 14.6% to 42.6 % at an altitude of 3,600 m above sea level and from 23.3% to 67.2% at 4,800 m above sea level; the prevalence of anemia was found to decrease with age.
In June 1995, the then National Health Secretariat conducted a study of 2,666 children between the ages of 6 and 15 in 128 periurban and rural schools; the study revealed an overall index of decayed, missing, or filled teeth (the DMFT index) of 7.6 (9.5 for 6-to-9-year olds and 6.9 for 6-to-15-year olds). The average fluoride content of the water supplyat 0.29 ppmwas below the recommended level. A ministerial resolution was subsequently signed giving high priority to this issue and launching a salt fluoridation program.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The Government of Bolivia has responded to the countrys health situation by passing the Community Involvement Act (Ley de Participación Popular, April 1994). The act transfers ownership of all local service infrastructure to the municipios, allocates funding for this purpose (which would now be apportioned on a population or per capita basis rather than discretionally), and delegates to them all responsibility for the operation, maintenance, and administration of that infrastructure. Under the legislation, the municipios are granted full title to all revenue generated by the sale of such services; they are also required to formulate social and economic development plans (for health actions as well) under a participatory approach that involves the user population. Lastly, the act created a supervisory committee that would be responsible for overseeing activities and the appropriate use of funds. Human resources and countrywide programs would continue to be financed out of the national budget. Subsequent legislation (the Administrative Decentralization Act) transferred human resource administration to the local government level (prefectura) of each department, although funding would continue to come from the national budget.
Organization of the Health Sector
Institutional Organization of the Health Sector
Under the national health model the National Health System comprised all public and private services that are engaged in health-related activities under the aegis of the then National Health Secretariat; these include the public health system, the social security system, private for-profit and not-for-profit entities, religious groups, and traditional medicine.
In 1998, the Ministry of Health and Social Welfare designed a new health model that defines the Bolivian Health System as a universal access system based on primary care and embracing gender and intercultural approaches. In terms of operations, the new model establishes care, management, and financial modalities. The Bolivian Health System is defined as accessible, efficient, and solidary and having sustainable quality and multiple providers.
The public health system is a decentralized, participatory system that is funded out of the national budget. The system is essentially a network of services. This network is organized into three care levels. The first level is formed by the countrys 896 health centers and 1,210 health posts, which provide a total of 2,276 beds for attending to normal deliveries and emergency hospitalization; traditional medicine is included in this level. Basic hospitalization services and specialized consultations make up the second level, represented by 63 district hospitals (a total of 1,717 beds). The third levelhighly specialized consultations and hospital careis made up of the countrys 81 general hospitals (5,277 beds), 29 specialized hospitals (including social security facilities and psychiatric hospitals, for a total of 2,071 beds), and national reference and technical support centers.
The system basically has two kinds of management arrangements: management by sector institutions and management that is exercised jointly with the local community. Management by sector institutions refers to the administration of all actions involved in the definition and administration of policies, plans, and programs for the delivery of health care services. Jointly exercised management refers to the responsibilities assumed in cooperation with the local community to administer health care services in a given municipio.. Nongovernmental organizations (NGOs) and the churches in the country play a significant role in health care delivery. At the national level, a broad-based agreement has been signed by the Ministry of Finance and the National Health Secretariat; at the local level, specific agreements are signed with each local health board allowing NGOs to work directly with local governments. Surveys reveal that the public sector provides health care for about 40% of the national population.
Aside from the coverage provided by the public sector per se, Bolivia has an additional health insurance scheme that covers hourly workers. The funds currently provide coverage to 20 % of the population, but their growth has been very slow or even negative in recent years. There are eight health insurance funds and two special, comprehensive insurance funds; benefits and quality of care vary from one to the next. The largest of these funds is the National Health Insurance, which provides 85% of the countrys social security coverage and whose principal guarantor is the Republic of Bolivia.
The Private Subsector is made up of for-profit and nonprofit, privately run companies and organizations that have their own funding. It is regulated by the National Health Secretariat and other government authorities and agencies, who make sure that services are safe and efficient and that qualified personnel are employed. The private subsector comprises:
Private firms, such as health care providers and suppliers of inputs, diagnostic support services, and drugs. Although the private subsector is perceived to operate efficiently, only 10% of the population is thought to use its services regularly. The subsector is experiencing significant growth in urban areas and is able to respond well to the socioeconomic conditions of the neighborhoods where it operates.
Nonprofit organizations. NGOs are the main participants in this category; there are many of them in Bolivia and their presence locally depends on the area and poverty level of the municipio, as well as on the churches activity. An association of health-related NGOs has been set up to coordinate the work of local and international NGOs in this sphere. Most receive international funding, with very few benefiting from local financing. The majority of these NGOs work in depressed urban areas; a few, mainly those with international financing, are active in extremely poor municipios. NGOs are gradually being incorporated into the public health insurance system and into the revamped structure of the new health model. An estimated 10% of the national population uses these services, chiefly at the primary care level; for health promotion activities, the figure is much higher.
Churches provide important services to the community, especially in areas of extreme poverty and in marginal urban areas. In most cases, work is organized around government-sponsored human resources, the churches infrastructure, and partial financing by users. In some municipios and communities, the churches are the sole service providers.
Traditional medicine is practiced widely, and almost every rural or marginal urban community has some kind of practitioner (e.g., midwives, traditional healers, etc.). The health system is gradually moving to incorporate traditional midwives into local care networks. Demand for these services is high and they are often used in conjunction with other public and private services.
Health Services and Resources
Organization of Services for Care of the Population
Services in this sector fall within the sphere of the National Basic Sanitation Directorate, which is the agency in charge of coordinating the supply of basic sanitation services with the local governments and service providers. Between 1993 and 1995, water supply coverage rose 6.4% and sewerage coverage 2.8%; in 1996, the levels stood at 58.2 % and 44.5% respectively, dropping to 24% and 17% in rural areas. The Basic Rural Environmental Sanitation Program, with support from the World Bank, the United Nations, and PAHO/WHO, hopes to close these gaps by promoting community participation at the municipal level.
In 1996, seven of the nine major cities had effective solid waste collection and disposal services; coverage at the national level was 60%. In 1997, a second phase of activity was launched in seven medium-sized cities, which brought coverage up to 70%.
Programs to control fixed-point and mobile-source emissions have been launched with a view to bettering air quality in two major cities. In 1994, Bolivia enacted Law 1,484, which adhered to international agreements for protecting the ozone layer; in 1996 the Governmental Ozone-Protection Commission was created, and a nationwide calendar was adopted for mandatory phasing-out of chlorofluorocarbon use.
Several major watersheds continue to register high pollution levels, and only four major cities have wastewater treatment plants (in the past four years, only one new treatment plant was opened).
Commercial logging activities in the warm valleys of La Paz and the Chapare area of Cochabamba have left extensive tracts of former forestland bare, and other forest areas have been burned down to clear land for agricultural use. These practices have triggered a serious ecological imbalance that threatens the survival of various species of local flora and fauna. In the department of Tarija, deforestation coupled with drought and strong winds has led to soil erosion and destroyed a unique ecosystem, converting it into desert.
According to the National Fund for Low-Income Housing, 40% of the Bolivian population lacks access to housing. Approximately US$ 80 million is being invested in the construction of 35,000. To solve the quantitative housing deficit, though, some 200,000 homes would need to be built each year, and an estimated half a million existing homes are in need of qualitative improvements. Electricity is available in 87% of urban dwellings
Food surveillance and control is performed at the production, handling, transportation, and storage stages. Any foodstuff that is made available to the public is subject to monitoring by the local Municipal Sanitation Directorate and by the National Health Secretariats Food Control Directorate. The central level maintains a national registry of foods processed in the country and a registry of authorized food importers, and it grants authorization for the sale of imported processed foodstuffs.
Organization and Operation of Personal Health Care Services
As of 1996, Bolivia had 2,279 registered health care establishments (2,007 of them operated by the National Health Secretariat, NGOs, or the churches, and 272 operated by the social security system) and a total of 11,939 beds (8,503 and 3,436 respectively), averaging out to 3,291 persons per establishment and 1.6 beds per 1,000 population. According to 1995 data from the National Health Information System, 56.1 % of the total of 4,764,742 outpatient consultations were performed by the public subsector, 24.3% by the social security system, 10.8% by health NGOs, 6.9% by church-affiliated services, and 2.0% by the private sector that reports.
Diagnostic and therapeutic support services are present at most secondary and tertiary level hospitals, but they are relatively rare in rural areas. According to the National Health Secretariat, Bolivia had 224 working laboratories in 1997.
Inputs for Health
The pharmaceutical market with total annual sales of roughly US$ 70 million (US$ 10 per capita), the pharmaceutical market is supplied by 26 local manufacturers (40%) and by importers (60%). The market is very concentrated: three large laboratories cover about 40% of the domestic market. The National Program for Essential Drugs was launched in 1990, and efforts are under way to strengthen the regulatory framework, shore up the supply of low-cost essential drugs, enhance quality, and promote the rational use of drugs. In the service network, drugs are purchased directly by patients and health establishments.
Bolivia is an active participant in the Expanded Program on Immunization and, accordingly, is able to purchase vaccines of proven effectiveness at stable, affordable prices. The national budget has made the necessary allocations for the purchase of EPI inputs since 1995. Several vaccines, such as those for rabies and malaria, are supplied by friendly governments at low prices or, in some cases, at no cost. EPI vaccinations are administered free of charge throughout the public health services network. Most medical and surgical inputs are procured directly by health establishments from private sources or from NGOs; financing for such purchases comes directly from cost-recovery measures (fees) or local government allocations.
According to 1992 census data, the total staff employed in the public health subsector (21,373), is distributed as follows: 4,011 physicians (1,976 under the National Health Secretariat and 2,035 in the social security system), 1,894 nurses (1,003 and 891), 4,792 nursing auxiliaries (3,134 and 1,658), and 10,541 administrative and support staff (5,808 and 4,733). These resources were concentrated in the countrys economic development corridor (La Paz, Cochabamba, and Santa Cruz); roughly 80% of the countrys specialists worked in tertiary-level facilities located in cities. Twenty percent of Bolivias 311 municipios lack qualified health personnel; in those municipios, health care is provided by lay staff. Training has been provided to midwives, health promoters, and other community resources over the past 20 years with an eye to meeting the populations health demands; over 5,000 of these trained midwives and health promoters are thought to be active in the health system.
Training opportunities for health personnel have expanded dramatically with the founding of private universities. The supply of undergraduate courses in medicine has tripled over the past six years; for nursing and dentistry it has doubled.
Health Care Expenditures and Financing
Factoring together all the contributions from the various subsectors, the countrys total health sector expenditure was reckoned at US$ 323 million for 1995 (4.7% of GDP), equivalent to an annual per capita spending of US$ 44. The main source of financing for national health spending was social security (35%), followed by family contributions (32%), the National Treasury (15%), external cooperation (15%), and, lastly, the municipios (3%). If external cooperation is removed from the equation, the total comes to US$ 275 million per year (4% of GDP), equivalent to US$ 37.50 per capita. The public sectors spending on health (from the National Treasury, municipios, and company contributions to social security) came to US$ 170 million (2.5% of GDP), equivalent to US$ 23 per capita.
External Technical and Financial Cooperation
The past four years have seen a marked increase in technical cooperation between countries, not just in the Andean Subregion and Southern Cone but with other countries in the Region as well. Bolivia has extensive bilateral cooperation arrangements with partners such as the European Economic Community, the United States of America, Japan, and the Scandinavian countries, and it also receives significant cooperation from the United Nations System (PAHO, UNICEF, the World Food Programme, the United Nations Population Fund, United Nations Volunteers) and other agencies. The multilateral development banks (the World Bank and the Inter-American Development Bank) also are lending support to crucial projects to strengthen the countrys service network and health care programs. This category breaks down as follows: 65% in bilateral aid, 20% in technical multilateral aid from the United Nations System, and 15% in aid from development banks. International NGOs, it should be noted, account for a sizable share of technical and financial cooperation in some municipios.
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