Venezuela (Bolivarian Republic of)

Overall Context

The Bolivarian Republic of Venezuela is a federal republic located in the northern part of South America. In addition to a capital district, the country has 23 states, 335 municipalities, and 1,091 parishes; it also includes federal dependencies that comprise 311 islands, islets, and keys. The country extends for 912,446 km2 and is bounded on the north by the Caribbean (where it shares maritime borders with the Dominican Republic; Aruba, Curaçao, and the Dutch municipalities in the Caribbean; Puerto Rico; the Virgin Islands; Martinique; Guadeloupe; Dominica; and Trinidad and Tobago), on the east by Guyana and the Atlantic Ocean, on the south by Brazil and Colombia, and on the west by Colombia. Venezuela’s geography, accounts for the country’s great climate diversity, which includes hot, rainy, dry, tropical, and cold climate zones.

Demographics

The estimated population in 2015 was 30,620,404 (49.9% women), with a population density of 33 persons per km2. Children under the age of 1 year accounted for 1.7% of the population; children under 5 years, 8.9%; women of childbearing age (15 to 49 years), 26.5%; adolescents (10 to 19 years), 18%; and the elderly (65 and older), 9.7%. That year, 66.4% of the population was economically active (15 to 64 years old).

Between 1995 and 2015, the population grew 1.7% annually; the birth rate was 19.7 per 1,000 population (1), and the total death rate was 5.0 per 1,000 population (3.9 for women and 6.1 for men) (2).

Figure 1. Population structure, by age and sex, Venezuela, 1990 and 2015

Between 1990 and 2015, Venezuela’s population grew by 57.8%. In 1990, the population structure had an expansive pyramid shape, with the age groups under 25 years old predominating. By 2015, the pyramid’s expansion had shifted toward age groups older than 25 years of age, with the pyramid showing a more stationary structure for groups under that age. These changes are associated with a decline in fertility and mortality rates, especially in the last 25 years.

Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015.

The Economy

The principal source of the country’s foreign exchange comes from oil exports, which account for more than 85% of total revenues. Since 2012, there has been a progressive decline in international oil prices that has dampened the country’s economic activity, particularly the importation of commodities such as food and medicines, some of which have regulated prices and are subsidized by the government. In 2015, the government augmented its investment in the health sector, which led to an increase in the budget for the Ministry of the People’s Power for Health,¹ to Bs. 148,664,149,225.43² (US$ 23,672,635,226.97), in order to meet the needs of the population. Between 2010 and 2014, total health expenditure as a percentage of GDP increased by 49% (from 4.75% to 7.09%). According to the Banco Central de Venezuela, the cumulative inflation rate from 2015 to February 2016 was 180.9% (3).

Between 1998 and 2011, the country’s poverty rate declined from 49.0% to 27.4%, while the percentage of households in extreme poverty fell from 21.0% to 7.3%. According to a report of the Economic Commission for Latin America and the Caribbean (ECLAC), since 2012 this trend has reversed, with poverty increasing from 25.4% in 2012 to 32.1% in 2013, and extreme poverty rising from 7.1% to 9.8% (4).

Violence and Security

Caracas has one of the highest crime rates in Latin America. In 2015, there were 19,453 reported homicides (63.5 per 100,000 population). Rising violence poses serious problems to the health system, including the many deaths from homicides, overcrowding of emergency services, high expenditure on supplies, impact on mental health, and an increase in the number of persons with disabilities.

Leading Environmental Problems

According to the Venezuelan Seismologic Research Foundation, the main natural hazards are water- and weather-related events, such as heavy rains and flooding; fires, explosions, and spills; and landmass shifts, such as landslides, rock slides, and earthquakes (5). Because nearly 70% of Venezuela’s energy is hydroelectric (6), droughts can affect its availability, causing significant financial and social harm.

In 2011, 88.8% of the Venezuelan population lived in urban areas (1), which translates into high population density in marginalized areas, with a consequent worsening of the quality of life and greater vulnerability during natural disasters. In 2010, for example, heavy rains triggered floods that resulted in 87 deaths and left 60,000 people homeless in many capital districts.

The country’s natural heritage encompasses a rich biodiversity, including an estimated 386 species of mammals, 1,463 species of birds, 377 species of reptiles, 340 species of amphibians, 1,860 species of fish, and 15,636 species of plants. Financial and technical support has been provided to indigenous communities in order to implement 26 socioeconomic projects in the Caroní river basin, State of Bolivar, which will benefit 497 families.

In 2013, official data showed that deforestation had slowed by 43.2%, as a result of environmental policies in place since the late 1990s (7). A comparison of the period 1990 2000 with 2000 2010 reveals that in the first, 247,000 hectares had been deforested, decreasing to 140,296 hectares in the second decade. In 2013, 7.3 million plants were planted, which resulted in the recovery of about 7,462 hectares of land.

Social Determinants of Health

The law known as the 2013-2019 Plan for the Economic and Social Development of the Nation (1) encompasses strategic objectives that address health and quality of life. The health sector’s three key policy guidelines are:

• To strengthen the steering role of the health sector and health subsystems within the framework of the comprehensive community health areas (ASICs, for their Spanish acronym).
• To promote the development of institutional, social, cultural, and environmental determinants aimed at the population’s healthy physical and mental conditions.
• To increase the National Public Health System’s production of medicines, vaccines, and medical supplies, and to enhance the education of health workers to meet demand.

The country has developed policies and interventions aimed at improving social inclusion through certain social initiatives, with strategies aimed at guaranteeing the fundamental rights of the population and at targeting the most marginalized sectors so as to address social inequality. These initiatives have been given extraordinary resources, and are coordinated by various ministries and institutions. The role and active participation of organized communities is at the heart of the planning, conducting, and monitoring of these initiatives. As of this writing, there are many initiatives at work in health, education, food, energy, and housing.

By 2012, progress had been made in addressing the social determinants of health, including a 7.7% reduction in the population living in extreme poverty, a 2.7% reduction in global malnutrition in children under the age of 5 years, and improvements in the coverage of drinking water and wastewater collection (95% and 84%, respectively). Further, access to new technology (e.g., the Internet) increased from 680,000 to 12.56 million users between 1990 and 2014 (8).

Between 2011 and 2015, 1,000,016 homes were built as part of the Misión Vivienda (Housing Mission) initiative, which met 26.7% of the housing needs of 3,742,226 families recorded in the National Housing Registry (9, 10).

As of May 2014, 2,683,126 Venezuelans had benefited from the Robinson Initiative, a social literacy initiative that uses innovative educational material to teach literacy to those who cannot read nor write, no matter their age.

The country’s social security program guarantees old age pensions for those who contributed to the system (starting at age 55 for women and 60 for men); in 2010, this benefit was extended to farmers, fishermen, and indigenous populations aged 50 and older. Between 1998 and 2014, those receiving this pension increased from 19.6% (387,007 pensioners) to 72.6% (2,565,725 pensioners) (11). The government also provides disability pensions to those with occupational diseases and work-related injuries, and to survivors of pensioners.

In regard to gender equity, in 2015, 8 of the 28 ministries and 4 of the 5 public branches of power (legislative, judicial, executive, civil society, and electoral) were led by women. Furthermore, after the 2015 elections, 35 of the 167 national assembly seats were held by women, which more than doubles the number of women elected to the legislature in the previous five-year period (16 women). The employment rate in 2010 2014 remained above 90%, with no significant differences between men and women. Between 2010 2011 and 2012 2013, school enrollment increased by 4.16% at the primary level and by 2.73% at the secondary level (12).

The National Institute of Statistics estimated that social investment rose 60% in the last 15 years, mainly due to initiatives aimed at increasing access to housing, strengthening the electrical power system, addressing public safety, and improving education and health.

The Health System

The National Health System encompasses the public and private subsectors, and is characterized by fragmentation and segmentation. The Ministry of Health, the government’s regulatory agency in health matters, includes the following five vice-ministries: Comprehensive Health; Public Health Networks; Hospitals; Resources, Technology, and Regulation; and Outpatient Health Care Networks.

The public sector encompasses several institutions, including the Venezuelan Social Security Institute (IVSS), the Institute for Social Welfare of the Ministry of Education, the Institute of Social Welfare of the Armed Forces, the Corporación Venezolana de Guayana, and Petróleos de Venezuela S.A., which either have their own health services or contract private services for their enrollees.

The National Constitution of 1999 provides the basis for the National Public Health System, whereby health which is intrinsically linked to quality of life and human development is enshrined as a fundamental social right guaranteed by the State and rests on a single, universal, decentralized, and participatory system that provides free health care. This model, whose essential pillar is primary health care, emphasizes health promotion, disease prevention, and the participation of organized communities, as well as the strengthening of primary care facilities.

The Ministry of Health works to coordinate traditional health facilities and the facilities of the Barrio Adentro strategy in order to achieve a comprehensive and integrated health services network with the comprehensive community health areas (ASICs), the geopolitical and social territories aimed at ensuring a leading role for communities.

In 2016, the Ministry reported that there were a total of 16,909 facilities in the Community Care Network, across 593 ASICs and organized as follows:

• community health clinics 12,904 clinics;
• comprehensive diagnostic centers 571 centers;
• comprehensive rehabilitation centers 587 centers;
• community dental offices 1,923 offices; and
• community opticians 330 offices.

In addition, the hospital network operated by the national public sector (the Ministry of Health, the Venezuelan Social Security Institute, the Corporación Venezolana de Guayana, the Ministry of Defense, and Petróleos de Venezuela S.A. includes 293 hospitals (types I, II, III, and IV) (13).

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Leading Health Challenges

Critical Health Problems

Emerging Diseases

In the first week of December 2015, the first indigenous case of vector-borne Zika virus was reported. There were no reported cases of Guillain-Barré syndrome that year, and the incidence rate remained below 75.4 cases per 100,000 population. In 2016, 59,348 suspected cases of Zika were reported, 894 of which were associated with neurological syndromes, including Guillain-Barré, and 3,435 of these cases were in pregnant women. Another 2,200 cases were confirmed by laboratory, for an incidence rate of 192.9 per 100,000 population. The highest number of cases occurred in the first quarter of 2016 (14, 15).

The first cases of chikungunya disease were reported in 2014. The following year, 16,419 probable cases were reported, for a cumulative incidence rate of 54 cases per 100,000 population. In 2016, 3,471 probable cases were reported throughout the country, with a cumulative average incidence of 11.2 cases per 100,000 population (14, 16).

Between 2011 and 2015, there were 285,960 reported cases of dengue, with the worst outbreak occurring in 2014 (87,447 cases). Evidence shows that four types of dengue virus circulate in Venezuela, with serotype 2 being the most common. Climate phenomena such as rising temperatures and changing precipitation patterns, along with difficulties in vector control strategies, may have created conditions for the colonization and reproduction of Aedes aegypti. In 2015, there were 54,309 reported cases of dengue, with a significant decline in 2016, when there were 29,150 cases. There were 90 deaths from dengue in 2015, and 30 deaths as of November 2016 (14, 17, 18).

The incidence of malaria tripled in just a few years, increasing from 1.58 per 1,000 population in 2011 to 4.45 per 1,000 in 2015, which made it a priority for the country’s health agenda.

Of the 136,402 cases reported in 2015, 1,594 were imported. The states of Amazon, Bolivar, Delta Amacuro, Monagas, and Sucre reported 98.7% of all cases in the country; this pattern continued up to epidemiological week 32 of 2016, when the states of Bolivar (78.3%) and Amazon (13.7%) accounted for 92% of the cases recorded in the national registry. In 2015, a total of eight deaths were reported.

The slide positivity rate also has been rising in recent years, from 16.5% in 2013 to 17.6% in 2014, and 22.1% in 2015. Of the total number of cases reported in 2015, 70% were among 10 39 year olds. The highest incidence occurred in men, primarily among 20 29 year olds (840.9 per 100,000 population).

In 2016, the country reported 240,613 cases, a 76.4% increase compared to the same period a year earlier (n=136,402). Although malaria cases occurred in 16 of the country’s 24 federal states, the State of Bolivar accounted for 74.3% of all cases, where the epidemic outbreak was influenced by a boom in unregulated gold mining that mainly affected the municipality of Domingo Sifontes (14).

Several factors contributed to the increase in the number of malaria cases in the country that year, such as lack of compliance in the treatment and control of vectors, the occurrence of asymptomatic infections, an increase in migration and immigration, and high levels of social insecurity in slums that have grown around mining areas. All these factors significantly challenge prevention and control activities.

Between 2011 and 2016, only one case of human rabies was reported, with two cases in cats and 35 cases in dogs. Zulia was the state with highest risk of suspicious bites (14).

Neglected Diseases and other Infections Related to Poverty

There were 303 new cases of leprosy reported in 2016, 87 in women and 8 in children under the age of 15. The case detection rate decreased by 31.82% between 2010 (0.22 cases per 10,000 population) and 2014 (0.15 cases per 100,000) (19).

Compared to 2010, 2011 showed an increase in intestinal parasitic diseases, from 317,384 reported cases in 2010 to 330,198 cases in 2011, as a consequence of amebiasis. In 2011, there were 174,465 reported cases of helminthiasis, 110,015 cases of amebiasis, and 45,718 cases of giardiasis.

Between 2010 and 2014, transmission foci of schistosomiasis were discovered, affecting two municipalities in the states of Aragua and Carabobo.

Transmission of onchocerciasis persists in the Yanomami indigenous area located on the southern border of Venezuela with northern Brazil. Several factors curtail the necessary actions that would eliminate the disease, such as lack of access issues, the location of affected areas deep in the Amazon jungle, and the nomadic habits of the most vulnerable population. In a focus of the disease in southern Venezuela, treatment coverage exceeded 85%, which remained stable from 2006 to 2015.

Data for 2014 2015 confirm that the transmission of onchocerciasis decreased by 75% in the at-risk Yanomami population. This focus has 276 known endemic communities, 184 of which are hyperendemic, 35 mesoendemic, and 57 hypoendemic The geographic distribution of these communities covers an area of over 80,000 km2, with an at-risk population of 14,212 individuals, mostly in the Yanomami Amerindian group. In two other foci (north-central and northeastern), morbidity was eliminated and transmission was interrupted.

In 2015, 6,796 cases of tuberculosis were reported, with an incidence of 22.19 per 100,000 population and a 5% increase compared to the previous year. Of those cases, 83.6% were pulmonary and 16.4% were extrapulmonary. A higher frequency of cases was observed among men (male/female ratio of 8:1). The 15 34-year age group accounted for 38.9% of total cases, with 2,643 cases reported.

The highest incidence of tuberculosis was seen in the Capital District (68.39 cases per 100,000 population), followed by the states of Delta Amacuro (56.22 per 100,000 population), Amazon (39.89 per 100,000 population), Vargas (34.59 per 100,000 population), and Portuguesa (34.24 per 100,000 population) (20).

Based on statistical models, it is estimated that 108,575 people are living with HIV in Venezuela, 64.7% of them men. More than 60,000 of those living with the disease receive antiretroviral therapy. The age group 30 34 years old is the most affected (18.8%). The prevalence rate is 0.56% in the general population and 5% in the most vulnerable groups, especially men that have sex with men. There were 1,735 reported deaths from AIDS in 2010, and 2,161 deaths in 2012.

Adolescent Pregnancy

Women under the age of 20 account for one of every five pregnancies in Venezuela. According to the Ministry of Health’s Information System (SIS), the percentage of pregnant women aged 10 to 19 years decreased slightly, from 23.99% in 2010 to 22.76% in 2015. According to data from the 2011 National Population and Housing Census, only 28% of all teenage mothers attended school.

Chronic Conditions

In 2013, four of the five leading causes of death were chronic, noncommunicable diseases (NCDs) (51.2% of all causes of death), i.e., heart disease (20.7%), cancer (15.4%), diabetes (7.6%), and cerebrovascular disease (7.5%). The first two causes ranked the same in the previous five-year period, but diabetes moved from 6th to 3rd place.

The link between diabetes mellitus and systemic hypertension contributes to the increase in chronic kidney disease, with a subsequent rise in health costs. Mortality from chronic kidney disease was 6.4 per 100,000 population, and accounts for 1.3% of all causes of death.

Diabetes Mellitus

In 2010, there were 37 comprehensive care centers for diabetic foot patients, which rose to 60 such centers in 2013 (a 62.1% increase). From 2010 to 2013, there were 7,991 reported visits to these centers (16).

Mental Health

Mental health services are structured in three levels: long-term psychiatric facilities, psychiatric hospitals, and mental health clinics. According to a report on Venezuela’s mental health system, 37,531 patients were seen in psychiatric hospitals in 2011, 50% of them women and 7% children or adolescents, with an average stay of 82 days. According to available data, 1% of patients received inpatient treatments in psychiatric hospitals over a period of 5 to 10 years. Of all the users seen at day facilities, 55% were women and 18% were children or adolescents (21).

Human Resources

The strategy for training human resources for primary health care established a National Training Program in Comprehensive Community Medicine in 2005; this training modality is in addition to the traditional training offered at existing national medical schools. The program has demonstrated advances since 2012, when the first cohort of 8,129 comprehensive community physicians graduated (77% women and 23% men). The 2011 law that reformed the practice of medicine permits comprehensive community physicians to practice medicine. According to the Ministry of Health’s Directorate-General for Research and Education, as of 2014 four cohorts of comprehensive community physicians had graduated from the program, for a total of 18,361 professionals. In 2015, 12,020 of these practitioners pursued graduate studies, and 9,469 of them were trained in comprehensive general medicine (2). Between 2010 and 2015, the Ministry granted 5,873 scholarships for undergraduate studies and 8,959 scholarships for graduate studies in health sciences.

In addition, as of the end of 2016, the Dr. Arnoldo Gabaldón Autonomous Institute of Advanced Studies in Public Health had 38 researchers. Of them, 26 conduct medical science research and 12 conduct research in the social sciences; together, they published 86 reports and other documents between 2011 and 2015. In an effort to strengthen the administration of policies, plans, and social programs, in 2015 the institute provided training to 38 professionals and community leaders in various public-health areas.

To improve the decision-making capacity of indigenous populations in the area of health, 1,186 indigenous leaders enrolled in the comprehensive general medicine degree program and became physicians at health facilities in their communities in 2012. Furthermore, 193 training modules were offered in indigenous health for treating leading health problems.

Health Knowledge, Technology, and Information

The Ministry of Health’s health information system includes electronic medical records, a useful tool for epidemiological surveillance. A plan of action for improving vital and health statistics is in place, which helps improve the issuance of birth certificates at birth centers and death certificates at the place of death, ensuring broad coverage, quality, and timeliness.

The Environment and Human Security

Venezuela has one of the highest CO2 emissions in Latin America, due to the high use of fossil fuels (6.5 tons per person) and an average consumption of 420 kilograms of CO2 per barrel of oil. Furthermore, the country is highly sensitive to the effects of climate change, which is causing major floods and severe droughts (22).

According to the 2011 census, 95% of the population has access to safe water, which is supplied to 97.2% of households through various methods (1). Around 80% of waste is sent to sanitary landfills and dumps (regulated or unregulated) and the rest is disposed of in open pits. Barely 2.3% of total waste is recycled, with the most common recycled materials being paper and cardboard (88.9%), plastic (5.5%), glass (4.2%), and iron and aluminum (1.4%) (1).

Aging

According to PAHO/WHO’s Core Indicators for 2016, life expectancy at birth in Venezuela was 74.6 years, 70.6 for men and 78.8 for women (23). In 2010, life expectancy in the state of Delta Amacuro was 66.3 years, 7.8 years less than the national average (1). According to estimates of the National Institute of Statistics, in 2015 there were 1,991,738 people aged 65 or older (1,099,063 of them women), accounting for 7% of the total population, compared to 6% in 2011.

Monitoring the Health System’s Organization, Provision of Care, and Performance

The Ministry of Health’s National Health Plan for 2014 2019 includes the government’s objectives, policies, projects, and strategies to ensure i) health as a universal right; ii) health care as a public good and responsibility of the State; and iii) comprehensive public health care, including promotion, prevention, treatment, and rehabilitation.

The Ministry is responsible for the governance of the health sector and for implementing various programmatic action plans, standards, and protocols, and for putting in place monitoring and evaluation mechanisms to optimize the impact of public health policies.

Between 2010 and 2014, total health spending as a percentage of GDP increased by 49% (from 4.75% to 7.09%).

In recent years, there have been many changes in the health authorities involving a turnover of those in charge of management, planning, and services. This situation has led to a lack of continuity in actions and changes in the implementation of National Health Plan strategies, which has, in turn, affected expected health outcomes.

In 2015 and 2016, economic hardships, aggravated by a decline in foreign exchange at the national level, reduced the availability of certain medicines, supplies, and equipment, as well as logistical distribution capacity. Furthermore, access to food has been hindered by inflation, speculation, and a decline in purchasing power, to the detriment of the health and well-being of the population.

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

Maternal mortality remained stable between 1990 and 2009, with a maternal mortality ratio (MMR) of 60 per 100,000 live births; this ratio increased between 2010 and 2015, to nearly 70 per 100,000 live births. There were 452 maternal deaths recorded in 2015, with an estimated MMR of 95 deaths per 100,000 live births (14).

There were 756 maternal deaths recorded in 2016, a 65.79% increase over the previous year (300 more deaths), with great variations from state to state (14). The current MMR is 139.53 maternal deaths per 100,000 live births (541,833 live births according to National Institute of Statistics projections), practically doubling the average in the previous five-year period; in 10 states, the MMR exceeds the national average (1, 14). Six federal states account for half of all maternal deaths (Zulia, Carabobo, Lara, Bolivar, Capital District, and Anzuategui). Nearly all (98%) deliveries take place in health facilities. In 2015, there were 243,638 attended deliveries and 92,986 cesarean sections in the national public services network.

In 2016, the leading causes of maternal deaths were hemorrhage and hypertensive disorders. According to the classification of maternal deaths, 653 (86.37%) were direct obstetric deaths and 103 (13.62%) were indirect obstetric. Indigenous mothers accounted for 3.17% of total maternal deaths, while African-descendent mothers accounted for 1.85%.

Child Health

Between 1990 and 2015, the infant mortality rate trended downward. An analysis of the 2010 2015 period shows varying trends in the different infant-mortality components: while post-neonatal mortality continues to decline, neonatal mortality has reversed its trend and is now rising, largely driven by early neonatal mortality caused primarily by perinatal disorders and birth defects (24). In 2016, 11,466 deaths were recorded in children under the age of 1 (14), which is reflected by an infant mortality rate of 21.16 per 1,000 live births for that age group (1). Neonatal mortality is the main component of these deaths, especially early neonatal mortality (0 to 6 days of life) (14). Based on official data, chronic malnutrition in children under the age of 5 has trended downward, from 13.4% in 2009 to 3.37% in 2013 (23). According to WHO, Venezuela qualifies as a country with a low rate of malnutrition, ranking fourth in Latin America and the Caribbean in terms of having the lowest child malnutrition. According to official data, the rate of overweight children in the under-5 age group was 4.0% in 2013, compared to 6.4% in 2009.

Health of Schoolchildren (5 to 9 Year Olds)

By 2013, the mortality rate in the 5-9-year age group was 26.9 per 100,000 population. The leading causes of mortality were external causes (especially road traffic accidents), tumors, congenital malformations, and deformations and chromosomal abnormalities (2).

Health of Adolescents

In 2013, mortality among 10 14-year-olds was 33.9 per 100,000 population. External causes, tumors, and diseases of the nervous system were the main causes of mortality in both sexes.

In 15 19-year-olds, the rate rose by 7.4% over the same period (from 167.7 to 180.2 deaths per 100,000 population), with external causes, tumors, and diseases of the nervous system being the leading causes of death. The risk of death for males in this age group was five times higher than for females. This differential is even higher when mortality is disaggregated into external causes, including violent acts (male/female ratio of 17:1) and accidents of all types, where eight males died for every female (2). The specific fertility rate (one of the targets of the Sustainable Development Goals [SDGs]) estimated for 2016 was 79.1 live births per 1,000 females aged 15 to 19 years. This level is much higher than the average in Latin America and the Caribbean (63.0 live births per 1,000 females aged 15 to 19 years) (23), and has a harmful effect on the health, well-being, and plans of this age group, particularly those under the age of 15.

Health of Adults

Mortality in adults in the 20 64 year age group increased from 312.4 per 100,000 population in 2010 to 321.2 in 2013. The leading causes of death were assaults, road traffic accidents (among other external causes), along with diseases of the circulatory system and tumors. Mortality from all causes was three times higher among men than among women. This difference was even greater in terms of assaults (18 men for every woman) and other violent deaths (male/female ratio of 15:1) (2). In 2014 the prevalence of overweight in this group was 62.3%, (63.5% in women and 61.0% in men), exceeding Latin American and Caribbean averages (23).

Health of the Elderly

According to 2016 estimates, people over 65 years of age accounted for 6% of the total population, and life expectancy at birth was 74.6 years–8 years more for women (78.8 years) than for men (70.6 years). From 2000 to 2016, life expectancy at birth in Venezuela increased by 2.2 to 2.8 years. Mortality in the 65 and older age group was 29.8 per 100,000 population in 2013, with no significant changes with respect to 2010. Diseases of the circulatory system, tumors, and diabetes mellitus were the three leading causes of death in this age group, for both men and women. Mortality from all causes was 6.1 points higher in men than in women.

Health of Workers

In 2014, the leading causes of work-related accidents reported to the National Institute for Occupational Prevention, Health, and Safety included contusions or crush injuries, which accounted for 23.6% of the reports, wounds (22.9%), and trauma (20.4%). The parts of the body most frequently affected were the arms (41.6%), the legs (27.2%), and the head and face (13.8%). Injuries were more frequent in men than in women (280 and 90 cases, respectively), with predominance among 34 44-year-olds.

The professions with the highest number of accidents were related to the manufacturing industry (38%), the trade and service sector (13%), social and health services (73%), and mining and quarry activities (6.9%) (25).

Health of Indigenous Peoples

According to the 2011 census, there were 724,592 indigenous people (categorized into 47 groups) in Venezuela that year, representing 2.7% of the country’s total population. That figure represented an increase in the proportion of indigenous peoples compared to 2001 (2.3%); 37% live in rural and border areas, 30.2% are illiterate, and 33.1% do not speak Spanish, which poses cultural and linguistic limitations to the access to health services. Of the 241 hospital facilities in the country, only 14.3% have health services geared to indigenous patients (1).

Health of the Disabled

According to the 2011 census, 1,454,845 people (5.4% of the population) reported having some type of disability (neurological, musculoskeletal, auditory-voice-speech, visual, cardiovascular, respiratory, mental, or intellectual) (1). To meet the needs of this population, the country has 586 rehabilitation clinics throughout the 24 federal states.

Mortality

In 2013, the mortality rate for all causes was 4.93 per 1,000 population. Between 2010 and 2013, the 10 leading causes of death remained the same, with some changes in rank order and magnitude. Heart disease and cancer prevailed as the leading two causes throughout the period; cerebrovascular diseases, diabetes, and accidents of all types round out the five leading causes, with some changes in the individual years. A comparison of data between 2010 and 2013 shows that the crude rates (per 100,000 population) of the 10 leading causes of mortality increased over this period, with the exception of perinatal disorders. In 2013, chronic, noncommunicable diseases (diseases of the circulatory system, cancer, diabetes mellitus, and chronic diseases of the lower respiratory tract) accounted for 46.56% of deaths, while 3.93% of deaths were due to infectious and parasitic diseases, and 19.39% were from external causes. As a result, the burden of mortality in the country is mainly due to chronic diseases, external causes, and infectious diseases (2).

Morbidity

Communicable Diseases

Regarding vector-borne diseases, there were 76 reported cases of oral transmission of Chagas disease in 2011 2015 (26). The visceral form of leishmaniasis is considered endemic in the country (27), with an incidence of 0.05 cases per 100,000 population in 2010, increasing to 0.12 per 100,000 population in 2013. Between 2013 and 2015, the incidence of cutaneous leishmaniasis remained near 7 per 100,000 population. In 2016, there were 2,059 reported cases of cutaneous leishmaniasis, for a rate of 6.64 per 100,000 population, and 34 cases of visceral leishmaniasis, for a rate of 0.11 per 100,000 population.

In January 2011, there were 99 confirmed cases of imported cholera and one work-related case due to lack of compliance with biosafety standards in the reference laboratory. To date, no new cases have been reported (14).

In terms of vaccine-preventable diseases, with the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in 2014, Venezuela’s immunization program now has a series of 12 vaccines that protect against 17 diseases throughout the life course (28). In 2011 2015, coverage rates for the regular program in children up to 1 year of age remained below 95% (except for BCG coverage rates), with similar levels from year to year. In 2016, vaccination coverage in the under-1-year age group was 120.1% for BCG, 47.2% for the second dose of rotavirus, 82.4% for the third dose of poliomyelitis (OPV3), and 83.7% for the third dose of the pentavalent vaccine (Penta3). In 1-year-olds, coverage against measles, mumps, and rubella (MMR) was 88.3%, with 84.0% coverage for yellow fever, and 6.7% for the third dose of PCV1 (29, 30).

Coverage levels varied at the state and municipality levels. Using Penta3 as a tracer vaccine, in 2016 only 20% (5/24) of the federal states achieved a coverage greater than or equal to 95%, and another 20% (5/24) reported under 80% coverage. At the local level, 54% (181/335) of the municipalities had a coverage of less than 95%. These municipalities accounted for 74% (400,086) of the estimated population target for 2016 (541,833), indicating a significant risk of contracting vaccine-preventable diseases.

That same year, there was a 19% dropout rate for Penta1/Penta3, which means that 106,017 children under the age of 1 who started the pentavalent vaccine schedule did not receive the third dose. The last follow-up campaign to eliminate measles, rubella, and congenital rubella syndrome was carried out in 2014, resulting in coverage of 99.5% of children from 1 to 5 years of age. Throughout 2011 2015, the country remained free of polio, rubella, congenital rubella syndrome, yellow fever, and diphtheria, with no reported cases of these diseases. In this same period, seven cases of neonatal tetanus and 68 cases of tetanus were reported in other ages, along with 18 cases of whooping cough, 2,980 cases of mumps, and eight cases of meningitis from Haemophilus influenzae type b. In 2012, the country reported one imported case of measles, with no secondary cases. On 29 November 2016, the Venezuelan national focal point updated PAHO/WHO on the country’s diphtheria situation. From September to December 2016, 6 of the 24 federal states identified suspected or probable cases of diphtheria, and reported 227 suspected cases, 31 laboratory-confirmed cases (through isolation and PCR), and 5 deaths from toxin-producing Corynebacterium diphtheriae. The state of Bolivar was the worst affected (29, 30).

Chronic Noncommunicable Diseases

In 2013, the five most frequent sites of malignant neoplasms (excluding non-melanoma skin cancer) were the prostate, the mammary gland, cervix, lung, and colon-rectum, which together accounted for 54% of the 42,585 neoplasm cases that year, 52.6% of which were found in women. Among men, the most frequent sites were the prostate (51.5 per 100,000 men), lung (18.7 per 100,000 men), colon-rectum and anus (13.5 per 100,000 men), and stomach (10.8 per 100,000 men), which together accounted for 56% of the cases of malignant neoplasms. In women, four sites accounted for 58.7% of the cases: mammary gland (38.1 per 100,000 women); cervix (25.9 per 100,000 women); colon-rectum, anus, and rectosigmoid junction (12.6 per 100,000 women); and lung (11.6 per 100,000 women). With regard to mortality, there were 23,121 certified deaths from neoplasms, and the four leading sites (lung, prostate, breast, and stomach) accounted for 50% of total deaths from cancer for both sexes.

Nutritional Disorders

Between 2008 and 2014, the percentage of malnutrition in children under the age of 5 fell to 3.3%, while energy availability increased from 2,140 calories in 1990 to 3,108 in 2014.

According to the study “Prevalence of overweight, obesity, and exogenous conditioning factors in the population 7 40 years old in 2008 2010,” 38% of the Venezuelan population was overweight, with the highest prevalence seen in the adult population (54.9%), followed by children and adolescents (24.1%) (31).

Accidents and Violence

Deaths from this cause are among the 10 leading causes of death in Venezuela. In 2013, there were 9,720 accident-related deaths, which accounted for 6.51% of all deaths. Of that total, 7,029 (72.31%) were due to road traffic accidents. This leads to a high demand on the health care system: it is estimated that 20% 40% of hospital beds are occupied by patients injured as a result of accidents and violence, further aggravated by the fact that these patients tend to stay in hospital for a lengthy period.

Other Health Problems

In regards to ocular health, in 2010 2014, there were 31,569 reported cases of diabetic retinopathy, for an average of 6,314 patients each year. In 2012 2014, 755 cases of retinopathy of prematurity were reported, and in 2013 2014 there were 7,835 cases of glaucoma (3,409 in 2013). The Misión Milagro, which is under the authority of the Health Programs Directorate, has the tools required to implement an ophthalmology intervention plan. From 2011 to 2014, 664,378 surgeries of different kinds were performed, primarily for cataracts.

Risk and Protective Factors

Regarding tobacco use, the 2010 Global Adult Tobacco Survey showed that in Venezuela 5.6% of the population 13 15 years old and 17.0% of adults were smokers. In 1984 2011, tobacco use decreased by 3.08% each year, with a lower rate of decline among men (2.7%) than among women (3.65%) (32). Finally, the 2012 National Food Consumption Survey, 65.1% of men and 77.8% of women reported that they engaged only in light physical activity (1).

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Prospects

Although the country has advanced in attaining the Millennium Development Goals (MDGs) related to the social determinants of health (poverty, housing, education, and human rights), there have not yet been any significant changes in the MDG targets directly linked to health (infant mortality, maternal mortality, HIV, malaria, and neglected diseases),³ constituting challenges the country must address in the near future in connection with the SDGs.

In the last four years, the decline in the price of oil has forced Venezuela to cut resources allocated to social investment. That, coupled with the current political conditions, has affected the population’s health. Notwithstanding these circumstances, the government continues to strengthen its priority policies, programs, and strategies. As part of that effort, the National Public Health System continues to strengthen and integrate the health network through the 100% Barrio Adentro strategy, in order to achieve quality universal health coverage for the country’s population.

The 100% Barrio Adentro strategy capped the efforts to bring together the traditional public system with the Misión Barrio Adentro into a single network based on primary health care. This included redefining geographical and functional areas (comprehensive community health areas). Professional resources to implement this strategy were provided by the educational agency set up in connection with the National Training Program in Comprehensive Community Medicine launched in 2005. This workforce (comprehensive community physicians) is a significant achievement due to its community focus, which stems not only from the education received, but also from the fact that physicians graduating from this program come from the very communities where they will practice, including some indigenous communities. These doctors’ commitment and their humanitarian and solidarity training is an important step toward attaining universal access to health and universal health coverage in Venezuela, with a focus on primary health care, community participation, and the incorporation of broader approaches based on human and gender rights, equity, and intercultural relationships.

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References

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20. Ministerio del Poder Popular para la Salud (Venezuela). Reporte de tuberculosis, OMS, 2016. Caracas: MPPS; 2016.

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27. Pan American Health Organization. Leishmaniases: epidemiological report in the Americas. (Leishmaniases report #4). Washington, D.C.: PAHO; 2016. Available from: https://www.paho.org/hq/index.php?option=com_topics&view=readall&cid=6721&Itemid=40754&lang=en.

28. Ministerio del Poder Popular para la Salud, Dirección de Inmunizaciones (Venezuela). Archivos 2010-2015. Caracas: MPPS; 2016.

29. Pan American Health Organization. Immunization in the Americas: summaries 2012-2017. Washington, D.C.: PAHO; 2017. Available from: https://www.paho.org/hq/index.php?option=com_content&view=article&id=3573&Itemid=2573&lang=en.

30. World Health Organization. WHO vaccine-preventable diseases: monitoring system [Internet]. Geneva: WHO; 2016. Available from: http://apps.who.int/immunization_monitoring/globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=VEN.

31. Instituto Nacional de Nutrición (Venezuela). Sobrepeso y obesidad en Venezuela: prevalencia y factores condicionantes. Caracas: INN; 2011. Available from: http://www.inn.gob.ve/pdf/libros/sobrepeso.pdf. Accessed on 17 September 2016.

32. Oficina Nacional Antidrogas; Observatorio Venezolano de Drogas (Venezuela). Estudio nacional de drogas en población general 2011. Caracas: ONA; 2011.

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