- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The Plurinational State of Bolivia, located in central-western South America, has a land area measuring 1,098,581 km2. It borders Brazil to the north and east, Argentina to the south, Peru to the west, Paraguay to the southeast, and Chile to the southwest. It has different geographical areas and climates, including three predominant ones: Andean (28% of the territory), sub-Andean (13%), and plains (59%) ().
In 2016, the population was 10,985,059 inhabitants (66% urban and 34% rural), with a population density of 9.7 inhabitants per km². The country is divided into nine departments, 112 provinces, and 339 municipalities. The departments of La Paz, Santa Cruz, and Cochabamba hold 71% of the population (). There are 36 constitutionally recognized nations with their respective languages, and 40.7% of Bolivians say they belong to an indigenous, native, campesino, or Afro-Bolivian nation ().
In 2016, life expectancy at birth was 71.9 years for both sexes (75.3 for women and 68.6 for men).
The population has been growing at 1.5% annually, with a total fertility rate of 2.9 children per woman (). Between 2012 and 2016, the crude birth rate declined from 24.44 to 22.77, the survival rate increased, and the population aged. The population structure expanded at a slower rate, with slow growth in children under age 15, in conjunction with population aging and reduction of fertility and mortality.
In 2016, 32.8% of the total population was under 15 years of age, 58.5% was between 15 and 59 years old, and 8.8% was over 60 years old. Figure 1 shows Bolivia’s population structure in 1990 and 2015.
Figure 1. Population structure, by age and sex, Bolivia, 1990 and 2015
Source: Pan American Health Organization, based on data from the National Statistics Institute of Bolivia (projections from the 2012 Census).
Bolivia is now considered to be a middle-income country, averaging 4.9% annual economic growth since 2006. Strategic resources such as oil and communications have been nationalized, which helping to reduce the fiscal deficits experienced in the country prior to 2008. Macroeconomic policy has been prudent and inflation has remained at moderate levels ().
Productive activities include manufacturing (16.2% of GDP); mining and quarrying (12.5%); and agriculture, forestry, hunting, and fishing (11.9%) (). Since 2006, the current government has implemented economic and social development plans that have fostered economic and social growth based on an economic model of social and community-based production. Industry and employment gained strength, which improved income redistribution and poverty reduction ().
Progress in public safety has been achieved through legislative advances, such as the Comprehensive Law against Trafficking in Persons (2012) and the Comprehensive Law to Ensure Women a Life Free from Violence (Law 348, 9 March 2013); the Law on the National Public Security System for Safe Living (Law 264, 31 June 2012); and the creation of courts to combat violence against women and corruption ().
Health Policies, Plans, and Programs
Noteworthy among health policies is the plan to set up a Unified Intercultural Community and Family Health System (SAFCI).
Since 2015 Bolivia has deployed 2,710 primary care clinics throughout the country, providing access to primary care to 25% of the most vulnerable population. The focus is on prevention, early diagnosis, and the social determinants of health, and includes the direct participation of grassroots organizations. In addition, the Zero Malnutrition Multisectoral Program uses a intersectoral partnership with the ministries of social services and the economy to operate in the municipalities most vulnerable to food insecurity and risk of malnutrition among children under 5 (especially those under 2 years of age) ().
Social Determinants of Health
The economic and social policies implemented in the country, coupled with stronger GDP growth, have brought up employment and income levels. Furthermore, resources have been channeled into the most vulnerable households through conditional cash transfer programs (). Meanwhile, policies that have helped increase the average years of schooling have improved access to more skilled jobs, greater employment possibilities, and social mobility ().
An increase in home construction means that 69.7% of households owned their dwelling in 2012 (88.4% in urban areas and 59.7% in rural areas). Between 2001 and 2014, safe drinking water coverage increased from 72.8% to 83.6% overall, while it was 92.2% in urban areas and 66.2% in rural areas. During that period, basic sewerage and sanitation coverage increased from 41.4% to 56.3% overall (63.1% in urban areas; 42.1% in rural areas) (). Literacy programs have facilitated universal literacy (99.4% in 2014) among the 15-24 year old population ().
Bolivia has made some of the best progress in the Americas in reducing inequalities, but there are still disparities in well-being between rural and urban areas, the different regions, men and women, indigenous and non-indigenous citizens, and even indigenous populations. Only 45% of the indigenous population lives in the countryside, as a result of migration to the cities. There continue to be significant inequities in economic and social status, and in access to and quality of basic social services (). Extreme poverty has gradually declined in Bolivia, from 37.7% in 2007 to 17.3% in 2014.
Similarly, between 2007 and 2014 extreme poverty in rural areas fell from 63.9% to 36.1%. Extreme poverty among women was 1% higher than among men, while extreme poverty in the indigenous population was 27.6% (figure 2) ().
Figure 2. Evolution of extreme urban and rural poverty in Bolivia, 2005-2014
RMM: razón de mortalidad materna; ODM: Objetivos de Desarrollo del Milenio.
Source: Unit for Analysis of Social and Economic Policies. Millennium Development Goals in Bolivia.
Eighth Progress Report; 2015 ().
Between 2001 and 2014, urban unemployment fell from 8.5% to 2.3%, although there are significant differences between departments (). In 2014, some 60% of the working-age population was employed (80% in rural areas and 57% in urban areas) ().
The Health System
The health system consists of multiple public and private sector entities that perform different functions such as leadership, financing, insurance, procurement, and health care delivery.
The public sector includes a public subsector and the short-term social security subsector (). The so-called public subsector is managed at different national levels: the Ministry of Health (MoH) is in charge of policy management at the national level, and the Departmental Health Services (SEDES) manage the sector at the departmental level. Municipal executive authority is recognized as the highest authority responsible for local health management. The municipal health networks have primary and secondary care establishments. For primary care, there are also Mi Salud clinics, co-managed by the Ministry of Health and the corresponding autonomous municipal government. The departmental health networks include several municipal health networks and more specialized hospitals ().
The public subsector primarily covers the population not insured under any entities of the Short- term Compulsory Social Security. Law No. 475 on Comprehensive Health Services is the main social protection policy covering the health of children under age 5, pregnant women, older adults, persons with disabilities, and women of childbearing age (for delivery of sexual and reproductive health services).
The short-term Social Security subsector is comprised of managing entities (health funds) in charge of granting packages of in-kind services (maternity and sick benefits), and monetary benefits (maternity and sick leave, workers compensation, etc.) to subscribed formal workers. Short-term Compulsory Social Security has its own facilities.
The private subsector includes for-profit entities and nonprofit ones (such as churches and nongovernmental organizations) that provide health services. There is an incipient market of private insurers providing health coverage. Finally, Bolivian traditional medicine is an important component of the Sector, and in the past decade it has been recognized and coordinated with the National Health System (9.10).
Leading Health Challenges
Critical Health Problems
The most socially vulnerable groups (especially those living in extreme poverty, indigenous people, and rural populations), continue to experience the most avoidable health problems, such as chronic malnutrition, maternal and child mortality, communicable diseases related to various environmental problems, and noncommunicable chronic diseases. There are also various the physical and mental effects of different types of violence (domestic, sexual, etc.), including gang- and drug-related violence, especially in certain urban areas ().
Endemic diseases (particularly vector-borne diseases and zoonoses) are exacerbated by disasters and climate change, and are concentrated in the most vulnerable groups and the highest-risk areas (poor rural and urban zones).
In Bolivia, noncommunicable chronic diseases cause 59% of deaths ().
Official counts of human resources for health include only personnel in the public subsector. The national supply of physicians is estimated at 8 per 10,000 population. In 2015, this subsector had 8,676 physicians (including specialists and generalists) and 4,254 nurses (4 nurses per 10,000 population). The total supply of physicians and nurses was 14.1 professionals per 10,000 population, ranging from 25 professionals per 10,000 population in Chuquisaca to only 12 professionals per 10,000 population in Santa Cruz. At the national level, there were 12 professionals per 10,000 population, split evenly between urban and rural areas. Of these, 8% were specialized physicians, 16% general practitioners, 4% registered nurses, 8% other health professionals, 24% nursing assistants, 13% service personnel, 10% administrative personnel, and 17% other personnel. Overall, 56% of physicians worked in primary care. As of 2012, 4,456 traditional practitioners had been registered, of whom 1,433 were regarded as traditional naturopaths, 490 as midwives, and 2,535 as traditional doctors (General Directorate of Traditional Medicine and Interculturalism/MoH) ().
Prior to 2014, 77% of physicians in the public sector were in urban areas and 23% were in rural areas. Currently, thanks to the Mi Salud, Bono Juana Azurduy, and ASSO medical residency programs, 65% of physicians are now in urban areas and 35% are in rural areas ().
Health Knowledge, Technology, and Information
Routine health data is collected, processed, analyzed and reported by the National Health Information and Epidemiological Surveillance System (SNIS-SEES).
The Environment and Human Security
In the past three decades, the country has more frequently faced climate-related events such as El Niño and La Niña. Bolivia frequently endures an array of natural disasters, such as floods, landslides, droughts, snowstorms, hurricane-force winds, hailstorms, and forest fires. At the same time that these events cause flooding, reservoirs for drinking and irrigation become exhausted, thousands of hectares are damaged, thousands of families are displaced, and there are epidemic outbreaks (malaria, dengue, diarrheal and acute respiratory disease), and even deaths ().
Poor and rural populations often migrate to the cities such as Santa Cruz and establish settlements in places at high risk for flooding and landslides (). In the last five decades, 45% of deaths from disasters were caused by floods, 16% by landslides, 8% by earthquakes, and 1% by wind storms.
The greatest vulnerability is found in the highland areas of La Paz, Oruro, and Potosí departments, and the inter-Andean valleys of Cochabamba, Potosí, and Chuquisaca (). Law 300 “Framework Law on Mother Earth and Comprehensive Development to Live Well” was enacted in 2012, and in 2013 its regulations entered into force (DS 1 696) ().
The country has banned the importation of ozone-depleting substances, and 17% of the national territory is protected area ().
Higher temperatures and increased rains favor the spread of mosquito habitats such as anopheles (malaria vector) and Aedes aegypti (dengue, chikungunya, Zika, and yellow fever vector), which are now appearing in places with high numbers of susceptible people, including urban areas with inadequate sanitation ().
60% of Bolivia’s land area is tropical rainforest or plains. Since 1990, soybean and livestock production have been encroaching on native forests ().
The National Pandemic Influenza and Avian Influenza Plan has been in place since 2005, including an influenza surveillance system. And in 2014, the World Organization for Animal Health certified all of Bolivian territory as free of foot-and-mouth disease ().
In 2015, 90% of the population had improved water supply (84% with running water in the home), and almost universal coverage was reported in urban areas (97%), with majority coverage in rural areas (76%) (). In 2015, 50% of the population had improved sanitation facilities: 61% in urban areas, but only 28% in rural ones. Total solid waste generated was reported at 4.8 tons daily. Finally, the Plurinational Program for Comprehensive Solid Waste Management has been prepared for the 2011-2015 period ().
Older persons are not a uniform group. They have inequalities related to socioeconomic status, income level, sex, age, ethnicity, residence in an urban or rural area, and geographical region ().
Three laws have been enacted that show legislative progress: Law 1886 on Protection of the Rights and Privileges of Older Adults; Law 475 on Comprehensive Care and Benefits for Older Adults; and Law 3791 on Income Dignity—a noncontributory universal pension. However, there are still no structural standards or conditions allowing for more effective implementation of this legislative progress, or to meet the health needs of older adults—a sizable population group that will continue to grow in number (). In this vein, we note the addition of the “Carmelo” program to provide nutritional support to older adults through Supreme Decree 1984.
In recent decades, there has been internal migration primarily toward the main areas of economic production and in multiple directions: toward the large cities of La Paz, Cochabamba, and Santa Cruz; and toward the rural lowlands, especially Chapare (Cochabamba), San Julián (Santa Cruz), and Yucumo-Rurrenaque (Beni) (). Between 2001 and 2012, an estimated 562,000 Bolivians migrated to different countries: 41% to Argentina, 20% to Spain, 9.6% to Brazil, 5.7% to Chile, and 3.2% to the United States ().
Monitoring of the Health System’s Organization, Provision of Care, and Performance
National leadership and governance is provided by the Ministry of Health. Improvement of the health sector is addressed in the 2016-2020 Economic and Social Development Plan, particularly “Pillar 3: Health, Education, and Sports”, whose objective is to provide comprehensive and universal health care, as well as education that is “decolonizing”, eliminates patriarchy, is liberating, and is intra- and inter-cultural, community-based, critical, and transforming; and to offer universal access to a full array of sports activities to produce healthy men and women.
The Unified Intercultural Community and Family Health System (SAFCI) is a linchpin of health policies. It seeks to eliminate social exclusion in health, boost society’s participation in health management, bring services closer to individuals, families, and communities, boost traditional medicine, thus helping to improve the living conditions of the population ().
The national health system is heterogeneous for the various sectors and participating entities. The SACFI Unified System strives to smooth these differences primarily in the public subsector, to reduce the impact that segmentation and fragmentation has on universal access, particularly for people who need it the most and who lack insurance coverage.
In 2014, total expenditures on health (current + capital) represented 6.7% of GDP, or US$206 per inhabitant. Public spending accounted for 70.8% of total health expenditures (44.9% for the public subsector and 25.9% for social security).
The national policy for development of human resources in health has been in effect since 2009, in accordance with national and sectoral health policies. In 2011, there were 81 university degree programs in health sciences, primarily in medicine, dentistry, and nursing (). Health care in the public subsector is organized through a network of centers at different levels according to complexity and service coverage.
A municipal service network has primary care centers and secondary care hospitals in the most populated municipalities. Departmental health networks have greater integration and different levels, as they include municipal networks and tertiary care establishments. In this type of organization, each primary care center is connected to more complex referral centers. As of November 2016, Bolivia had 3,874 health facilities, 3,857 of them in primary care (12 blood banks, 25 centers with unique characteristics, 1,067 ambulatory health centers, 838 centers with inpatient facilities, 145 comprehensive care centers, 300 health centers, 15 polyclinics, 33 polyclinic practices, and 1,152 health posts), 221 secondary care hospitals, and 66 general and tertiary care hospitals.
Some 83% of facilities are run by the public sector, 6% by social security, 3% by nongovernmental organizations, and 8% by the private sector. Each public and private subsystem covers a different population group, with differences in socioeconomic level, insurance capacity, and payment at time of service ().
In 2015, the social security sector covered 37% of the population of the country, while the public subsector covered 28% (General Directorate of Health Insurances). It is estimated that the traditional medicine sector serves approximately 10% of the population, particularly in rural areas (not to the exclusion of other coverage) ().
From 2009 to 2016, the Bono Juana Azurduy program benefited 1,706,401 people, of whom 723,511 were pregnant women and 982,890 were children under 2, for a total investment of BOB870,358,060 (US$ 138,152,073).
Since 2006, the country has received health care support from the Cuban Medical Cooperation mission—health teams comprised of physicians, nurses, and technical personnel who work in primary and secondary care hospitals. They performed 63.4 million specialized consultations; 179,300 surgeries; delivered 45,700 babies; and saved 86,983 Bolivian lives (patients treated in acute stages of disease). In addition, through the Operación Milagro initiative of the governments of Bolivia, Venezuela, and Cuba, ophthalmological surgery was provided to 671,171 patients by November 2016, including 547,294 Bolivians, 44,000 Argentines, 25,000 Peruvians, 300 Paraguayans, and other nationals ().
The Mi Salud project, established by the Ministry of Health to strengthen primary care, has a presence in 307 of the 339 municipalities and 25 indigenous communities in the country through promotion and prevention activities at the individual and community level. The project saw 9,701,071 patients between 2013 and 2016, with the support of 2,710 physicians, closing the gap in access to health care for the neediest people.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
According to the 2011 National Study of Maternal Mortality, the maternal mortality ratio was 160 per 100,000 live births—14.4% lower than in 2000 (186 deaths per 100,000 live births). At the departmental level in 2011, maternal mortality ranged from 286 to 60 deaths per 100,000 population, in La Paz and Santa Cruz, respectively () (figure 3). The main causes of maternal mortality are hemorrhage (59%), pregnancy-induced hypertension (19%), miscarriage (13%), and infection (7%).
Figure 3. Maternal mortality ratio, by department, Bolivia, 2000 and 2011
Between 1996 and 2015, the institutional birth rate increased from 33% to 87.51%, while this past year, 75% of pregnant women received four or more prenatal check-ups with trained personnel ().
In December 2016 the Ministry of Health began estimating post-2011 maternal mortality ratios to determine the impact of interventions introduced that year: enlistment of hospitals to provide emergency care, conditional cash transfer programs (Bono Juana Azurduy and Juancito Pinto), increased prenatal check-ups, and increased access to primary care through the Mi Salud program.
In 2013, the infant mortality rate was 44 deaths per 1,000 live births, reflecting a 46.3% reduction since 1989 (when infant mortality was 81.9 deaths per 1,000 live births) (figure 4) ().
Figure 4. Evolution of infant mortality in urban and rural areas, Bolivia, 1989-2012
That same year, mortality for children under age 5 was 51.5 deaths per 1,000 live births, with fluctuations between 42.2 and 73.6 deaths in Tarija and Potosí, respectively ().
Between 1989 and 2013, under-5 mortality fell from 129 to 56 per 1,000 live births. In 2014, coverage with a third dose of pentavalent vaccine reached 86% among children under 1 year of age ().
Between 1989 and 2012, the prevalence of chronic malnutrition (low height-for-age) in children under 3 fell from 41.7% to 18.5%, while global malnutrition (low weight-for-age) in children under 5 fell from 8.3% to 3.6% (figure 5).
Figure 5. Evolution of the prevalence of chronic malnutrition in children under 3, Bolivia, 1989-2012
Health of Adolescents
In 2016, 23% of the population was in the 10 to 19 year old age group (). In 2008, 17.9% of girls and adolescents in this age group had a history of pregnancy, with a higher proportion in rural areas (25%) and in the poorest quintile (31%). Among adolescents 13 to 17 years of age, 22.5% were overweight and 4.7% were obese ().
It is estimated that only 24% of females and 28% of males have comprehensive knowledge of HIV/AIDS. Only about 8.7% of women with primary schooling understand HIV/AIDS, compared with almost half (49.9%) of those with higher levels of education ().
Health of the Elderly
In 2016, people over 60 years of age represented 8.8% of the national population (). These people have lower income levels than the other age groups, while 20.7% have no income at all. That means one out of five is completely dependent. The poverty rate for this age group is high, since 34.5% of people over 60 live below the poverty line, while 37.2% live below the indigence line compared to the population as a whole (). Social security coverage is still low, which encourages people over 60 to continue working. 28.5% of older persons are enrolled in the Comprehensive Health System, Law 475 ().
Health of Indigenous Populations
Creation of the Plurinational State has resulted in great progress in the recognition and exercise of the rights of indigenous populations, and in their development. However, there are still vulnerable indigenous populations at greater risk of disease and death, especially in the Bolivian Amazon region ().
Health of the Disabled
3.8% of the population have a permanent disability, of which 20% are very severe, 48% severe, 27% moderate, and 5% mild. The prevalence of disability varies greatly between departments, ranging from 5.2% to 0.6% in Oruro and Beni, respectively (4.19). These include physical (37%), intellectual (30%), and multiple (13%) disabilities. Physical disabilities include visual impairment (even with glasses), impaired motor function of the lower limbs, and hearing impairment (even with hearing aids) ().
The National Statistics Institute is currently (February 2017) processing the Demographic and Health Survey (EDSA). The previously estimated crude death rate for 2017 was 5.98 deaths per 1,000 population, according to projections from the 2012 Population and Housing Census ().
According to WHO estimates, in 2012 proportional mortality was 24% from cardiovascular diseases; 28% from maternal, child, and nutritional conditions; 18%, other noncommunicable chronic diseases; 13%, injuries; 10%, cancer; 4%, diabetes; and 3%, chronic respiratory diseases ().
Conditions favorable to vector reproduction and reservoirs of disease (in tropical areas) are responsible for the persistence and outbreak of various vector-borne diseases and zoonoses, including malaria, dengue, chikungunya, Zika, yellow fever, Chagas disease, leishmaniasis, viral hemorrhagic fevers, hantavirus, and leptospirosis.
During the 2000-2010 period, the country reduced malaria cases by 56%, thanks to the introduction of artemisinin-based combination therapy (ACT) and the large-scale use of insecticide impregnated mosquito nets, which allowed Bolivia to enter the phase of P. falciparum elimination ().
From 2008 to 2014, no deaths were attributed to malaria, although there were 13,769 cases in 2010 (). The process of certifying elimination of the disease began in December 2016.
In 2014, there were 22,846 suspected cases of dengue were reported in 2014 in the departments of Santa Cruz (70%), Beni (9%), and Tarija (8%) ().
In regards to Chagas disease, throughout 2016, entomological evaluation and household spraying was conducted in 114 municipalities, of which 28.9% reported a household infestation index above 3% for Triatoma infestans. Since 2006, when the Chagas Disease Law (No. 3374) was enacted, institutional entomological surveillance has been stepped up, with community participation and municipalities providing technical personnel in the 154 municipalities of the endemic area. In 2011 and 2012, in the endemic parts of La Paz and Potosí departments, the INCOSUR Intergovernmental Commission of Experts on Chagas Disease, with the participation of PAHO/WHO, evaluated indicators of vector infestation in dwellings and the prevalence of Chagas disease in the populations of endemic areas. This led to certification of the interruption of intradomicile vector-borne transmission of Trypanosoma cruzi to the population at risk ()
The first two cases of Zika virus infection occurred in December 2015. As of November 2016, 156 confirmed cases were recorded: 144 in Santa Cruz, eight in Pando, three in Beni and one in Chuquisaca (). Thirteen cases of congenital Zika syndrome were also recorded.
In 2010, seven of the country’s nine departments recorded a total of 1,810 cases of cutaneous leishmaniasis, with a rate of 17.4 cases per 100,000 population. That same year, in the Department of La Paz, 867 cases were recorded; 85% were in communities with populations below 1,000 inhabitants, and 55% were in three of the municipalities. In 2014, 1,739 cases of this illness were reported, and 58% of patients completed treatment. In 2016 human and canine cases of visceral leishmaniasis were reported ().
An upsurge in the incidence of pertussis began in 2013, especially among infants younger than 6 months of age. A measles and rubella follow-up campaign was conducted among children from 2 to 4 years old in 2015, with coverage of 72.6%. The pneumococcal vaccine was introduced in 2014, with 56.9% coverage. And in 2015, 89% coverage was recorded for polio and pentavalent vaccines.
The human papillomavirus vaccine was introduced in 2016 and there are plans to vaccinate girls 10 to 12 years of age starting in 2017 (). In 2010, vaccination coverage for children under 1 year of age included: BCG (90.75%), third dose of the pentavalent vaccine (80.60%), the third dose of polio (80.22%), and the triple viral vaccine (79.62%). In 2015, coverage for children under 1 year included: BCG (98.72%), third dose of the pentavalent vaccine (88.41%), third dose of polio (88.10%), and the triple viral vaccine (94.38%) ().
There have been no confirmed cases of measles since 2006, the last recorded case of rubella was in 2006, and the last reported polio case was in 1989. In 2010 four cases of diphtheria were confirmed in the departments of Tarija and La Paz.
In 2015 canine vaccination coverage was 86%, with 268 reported cases of canine rabies. In 2014 719 snake bite cases were treated, and three cases of arachnid stings were treated, including one that was fatal ().
Since 2006 there has been mass administration of triclabendazole (TCZ) in groups at-risk for fascioliasis living around Lake Titicaca (107,000 people in 2010) ().
In 2010, a study of hydatidosis in a community in Potosí found 4.1% of 1,268 ultrasound studies to be positive, as were 23.9% of 264 canine fecal samples ().
In 2009, 22 cases of hantavirus were recorded, with four deaths and a case-fatality rate of 18%. In 2010, 14 cases were reported with four deaths (28% case-fatality rate) in the departments of Santa Cruz, Cochabamba, and Tarija. In 2014 there were 34 cases with a case-fatality rate of 11.5% ().
In 2007, there were 20 suspected cases of the Machupo virus, which causes Bolivian hemorrhagic fever (FHB), and two positive cases died. In 2012, 17 cases were reported; in 2013 four were reported, and none were reported in 2014 ().
In 2010, 49 cases of leptospirosis were recorded in seven of the country’s nine departments ().
A study conducted in the Guaraní population of the Gran Chaco, yielded positive results for different types of soil transmited helminths in 84% of those tested ().
HIV/AIDS and other Sexually Transmitted Infections
In 2014, the estimated prevalence of HIV carriers was 1.5 per 1,000 population. As of December 2014, 13,180 cases had been reported, with 19% in the AIDS stage. However, due to estimated 17.6% underreporting of cases, there may be 16,000 people with HIV/AIDS (). Transmission is mainly sexual (96%), with 3% vertical transmission and 1% blood transmission. In 2014, there were 116 AIDS cases per million population. The prevalence of HIV that had not reached the AIDS stage was eight times greater than the prevalence of AIDS. The distribution of reported cases was 1.7 times higher in men, and more than half of the population with HIV/AIDS was between 20 and 34 years old. In 2014 2,510 cases of HIV at the AIDS stage were recorded, with 86.9% located in the central part of the country: Santa Cruz, Cochabamba, and La Paz. In 2007, the prevalence of chlamydia was 10.5%, trichomoniasis 4.6%, syphilis 2.6%, and gonorrhea 0.5%. Syphilis affects 7.2% of pregnant women, and 11 per 1,000 newborns ().
In 2014, the incidence of TB was 70.8 cases per 100,000 population, with more cases in the departments of Santa Cruz (83.0 cases per 100,000 population), Beni (56.9 per 100,000 population), and Tarija (56.7 per 100,000 population). The rest of the departments recorded incidence rates below 50 cases per 100,000 population. In 2013, 84.4% of TB patients were cured. In 2014, 51% were in the 15-34 year old age group, and men were affected 1.5 times more than women. General resistance was estimated at 16.2%. In 2015 62 cases of multi-drug resistant TB () were reported. In 2009, 51% of known HIV/TB co-infected persons received treatment ().
Chronic, Noncommunicable Diseases
WHO estimates that these diseases affect 59% of the population, and people in the 30-70 year old age group have an 18% probability of dying from them ().
In 2012, the incidence rate of cancer in adults was 185 per 100,000 men and of 323 per 100,000 women. In 2008, mortality from neoplasms was 57.4 for men and of 89.7 for women per 100,000 population. Cancer of the prostate was the most common type in men (17.0%), and cervical and uterine cancer (21.2%), followed by breast cancer (7.5%), were the most common cancers in women ().
From 1989 to 2012, chronic malnutrition (low height-for-age) in children under 3 fell from 41.7% to 18.5%; in 2012 it was greater in rural areas (25.9%) than in urban ones (14.6%). This past year, global malnutrition (low weight-for-age) in children under 5 stood at 3.6% throughout the country (2.8% in urban areas and 5.0% in rural ones). In 2008, the prevalence of low-height-for-age among children whose mothers had less schooling was 50.9%, while it was just 9.2% for children of mothers with more schooling. In the poorest quintile, the prevalence of chronic malnutrition was 46.0%, while in the least poor quintile it was (6.5%) (). In 2012, 8.5% of children under 5 were overweight or obese, as were 49.7% of non-pregnant women of childbearing age. In 2012, the prevalence of anemia in boys and girls from 6-59 months of age was 60.8%––higher in the 6 to 23 month old age group (63%) than in the 24 to 59 month old group (59.7%). The national prevalence of anemia in children from 3 to 59 months old was 60%: 0.6% severe, 12.4% moderate, and 47.1% mild. The breakdown by age group shows that among children from 3 to 5 months old, the prevalence of anemia was 42.5%, for children 6 to 23 months old it was 63%, and for children 24 to 59 months old it was 59.7%. There is a significant gap in anemia prevalence between urban and rural areas, which report rates of 53.1% and 73.1% respectively. These differences are found in all age groups ().
Accidents and Violence
In 2007, road injuries caused 16.7 deaths per 100,000 population; 59% of victims were drivers or passengers in four-wheel vehicles, and 35% were pedestrians. In 2013, 36,512 traffic crashes were recorded, leaving 171.6 wounded persons per 10,000 population (). Between 2006 and 2010 there was an increase in homicides, with a rate of 8.7 deaths per 100,000 population this past year. Furthermore, an average of nine femicides per month was recorded. The most frequent forms of violence were child abuse and domestic violence; 83% of girls, boys, and adolescents suffered violence in their own homes or schools, while 88% of the educational community acknowledged the existence of physical, psychological, or sexual violence in schools ().
Risk and Protective Factors
WHO estimates that in 2011 30% of the population smoked (42% of men and 18% of women), while annual per capita consumption of alcohol was 5.9 liters (9.1 liters for men and 2.7 liters for women) (). Marijuana was one of the most frequently used drugs in the country, consumed by 3.8% of the population in 2010. In 2008, obesity affected 17.9% of the population (9.6% of men and 25.9% of women), while hypertension affected 24.4% of the population (27.8% of men and 21.2% of women) ().
Bolivia stands out as a low-income country that has transitioned to medium-income status and proceeded to eliminate various kinds of inequality. It has made remarkable strides in its human, economic, social, and health development. This is reflected in the achievement of some MDGs, such as: reducing extreme poverty and chronic malnutrition, expanding institutional birth coverage, and reducing malaria incidence to elimination levels. Progress must continue in maternal and child health, tuberculosis, HIV/AIDS, Chagas disease, and health information systems. Given the way the Plurinational State functions, and its comprehensive approach to development and equity issues, the country has paved the way for tackling the sustainable development agenda. Noteworthy is the national proposal to achieve universal health coverage, in accordance with the SDG 3 health targets, which the country intends to achieve by unifying the health system.
The current challenge facing Bolivia is to maintain the positive trends and ensure the sustainability of the economic and social progress made. It must ensure that the productive economy helps create better jobs and greater social well-being, while protecting the environment, in keeping with the Sustainable Development Goals (SDGs). This effort includes protecting the population from the effects of climate change and natural disasters. Also, the 2016-2020 Economic and Social Development Plan for Living Well (PDES) establishes health targets and actions ().
It is important to gradually consolidate health, economic, and social policies, in accordance with the legal reforms and progress made since 2006. Consolidation of the Family, Community, and Intercultural Health policy through support and consolidation of the Mi Salud program is critical. The principles of prevention, quality care, and citizen participation in the Mi Salud program should be extended to all stakeholders in the health networks. The training of human resources in health––with equal opportunities for marginalized populations, and based on principles of ethics and solidarity––is indispensable for ensuring geographical coverage and good patient care. The use of patients, drug prescriptions, and technology merely for monetary gain should be eradicated. On this last point, the State Agency on Drugs and Health Technologies (AGEMED) has been created to consolidate the efforts of the Plurinational State to exercise leadership in the production and marketing of drugs.
All the components described above have been considered in the 2016-2020 Sectoral Plan for Integral Development ().
1. Bolivia, Instituto Nacional de Estadísticas. Anuario Estadístico 2012 [Internet]; 2016. Available from: en:http://www.ine.gob.bo/html/visualizadorHtml.aspx?ah=Aspectos_Geograficos.htm. [cited: 2016 Nov 12].
2. Bolivia, Instituto Nacional de Estadísticas. Proyecciones de población e Indicadores demográficos por años Calendario, 2012- 2020. [Population Projections and Demographic Indicators by Calendar Year, 2012-2020] [Internet]; 2014. Available from: http://www.ine.gob.bo/indice/visualizador.aspx?ah=PC20104.HTM. [cited: 2016 Oct 20].
3. United Nations Development Program. Cambio climático y el desafío de la salud en Bolivia 2013 [Climate Change and Health Challenges in Bolivia 2013] [Internet]; 2013. Available from: http://cambioclimatico-pnud.org.bo/paginas/admin/uploaded/EA_Salud.pdf [cited: 2016 Nov 2].
4. Bolivia, Instituto Nacional de Estadística. Principales Indicadores. [Internet]; 2016. Available from: http://www.ine.gob.bo/default.aspx. [cited: 2016 Sep 27].
5. Unidad de Análisis de Políticas Sociales y Económicas. UDAPE. Objetivos de Desarrollo del Milenio en Bolivia. Octavo Informe de Progreso 2015. [Internet]; 2015. Available from: http://www.udape.gob.bo/portales_html/ODM/Documentos/InfProgreso/8vo%20Informe%20de%20progreso.pdf. [cited: 2016 Aug 1].
6. Estado Plurinacional de Bolivia. Ministerio de Salud. Plan Sectorial de Desarrollo Integral 2016-2020. [Internet]; 2016. Available from: https://www.minsalud.gob.bo/8-institucional/880-normas-de-la-direccion-general-de-planificacion.
7. United Nations Development Program. Informe Nacional sobre Desarrollo Humano en Bolivia: El nuevo rostro de Bolivia [Human Development Report, Bolivia: the New Face of Bolivia] [Internet]; 2016. Available from: http://idh.pnud.bo/content/informe-nacional-sobre-desarrollo-humano-en-bolivia-el-nuevo-rostro-de-bolivia. [cited: 2016 Nov 2].
8. United Nations Development Program. Informe Nacional sobre Desarrollo Humano en Bolivia: Los cambios detrás del cambio [Human Development Report, Bolivia: The Changes behind the Change] [Internet]; 2010. Available from: http://idh.pnud.bo/content/los-cambios-detr%C3%A1s-del-cambio [cited: 2016 Nov 2].
9. Ledo C. Sistema de salud de Bolivia. Salud Pública de México. 2011; 53(2). [Internet]; 2011. Available from: http://bvs.insp.mx/rsp/_files/File/2011/vol%2053%20suplemento%202/7Bolivia.pdf [cited: 2016 Nov 2].
10. Bolivia, Ministerio de Salud y Deportes. Anuario Estadístico de Salud 2009. (Serie Documentos Técnicos Normativos No. 192) [Internet]; 2010. Available from: http://www.ops.org.bo/textocompleto/nest31645.pdf [cited: 2011 Oct 20].
11. Autoridad Plurinacional De La Madre Tierra. Compendio Normativo de la Madre Tierra. [Internet]; 2014. Available from: http://www.madretierra.gob.bo/apmtv2/images/archivos/compendio_apmt.pdf. [cited: 2016 Aug 2].
12. Food and Agriculture Organization of the United Nations. Transboundary animal diseases. [Internet]; 2016. Available from: http://www.fao.org/emergencies/emergency-types/transboundary-animal-diseases/en/ [cited: 2016 Nov 22].
13. Bolivia, Ministerio de Medio Ambiente y Agua. Programa Plurinacional de Gestión Integral de Residuos Sólidos. Bolivia. [Internet]; 2012. Available from: http://www.mmaya.gob.bo/redcompostaje/files/biblioteca/05%20PLANIF%20NORMATIVA/01%20PNGIRS.pdf. [cited: 2016 Nov 2].
14. Salazar C., Castro M.D. y Medinaceli M. Personas adultas, desiguales y diversas. Políticas públicas y envejecimiento en Bolivia. Cuaderno de futuro 29. Informe sobre Desarrollo Humano PNUD. Bolivia agosto de 2011. [Internet]; 2011. Available from: http://www.bo.undp.org/content/bolivia/es/home/library/poverty/_-cuaderno-del-futuro-no-29–personas-adultas-mayores–desiguale.html [cited: 2016 Nov 3].
15. Brigada Médico Cubana. La Colaboración de la Brigada Médico Cubana en Bolivia. http://www.bmcbolivia.com.bo/ [cited: 2017 Feb 13].
16. Bolivia, Ministerio de Salud y Deportes. Estudio Nacional de Mortalidad Materna 2011 Bolivia. [Internet]; 2016. Available from: http://www.ninezbolivia.org.bo/estacion/images/OMMN/EstudiosInvestigaciones/Nacional/PDFnacional/EstudioNacionaldeMortalidadMaterna2011Resumenejecutivo.pdf [cited: 2016 Oct 10].
17. Bolivia, Ministerio de Salud y Deportes. Revista epidemiológica. [Internet]; 2015. Available from: https://www.minsalud.gob.bo/images/Libros/epidemio/Revista-Epidemiologica_opt.pdf. [cited: 2016 Oct 10].
18. UNICEF Bolivia 2012. Guía de Transversalización de la Interculturalidad en Proyectos de Desarrollo: Salud, higiene y protección contra la violencia. UNICEF Bolivia 2012 [Internet]; 2012. Available from: https://www.unicef.org/bolivia/Guia_intercultural_resumen.pdf [cited: 2017 Feb 13].
19. Bolivia, Presidencia de Bolivia. Ley General para Personas con Discapacidad, 2 de marzo de 2012. [Internet]; 2012. Available from: http://www.lexivox.org/norms/BO-L-N223.xhtml [cited: 2016 Nov 21].
20. Pan American Health Organization/World Health Organization. Misión Internacional de evaluación epidemiológica y de control de la enfermedad de Chagas en Bolivia, 2011. [Internet]; 2014. Available from: http://www.ops.org.bo/textocompleto/nchagas32348.pdf. [cited: 2016 Nov 2] 35.60.
21. Ministerio de Salud – Sistema Nacional de Información en Salud y Vigilancia Epidemiológica, 2016 PRINCIPALES INDICADORES, Available from: http://snis.minsalud.gob.bo/principales-indicadores-en-salud. [cited: 2016 Dec 13-14].
22. Bolivia, Ministerio de Salud y Deportes. Guía técnica de vigilancia epidemiológica, prevención y control de fasciolosis e hidatidosis. Publicación 159. 2012. [Internet]; 2012. Available from: https://www.minsalud.gob.bo/images/Documentacion/dgss/Epidemiologia/ZOONOSIS/5.guia%20fasciola.pdf [cited: 2016 Nov 2].
23. Villena F. Fortalecimiento de la cooperación técnica para mejorar el control de la hidatidosis en Bolivia. [Internet]; 2011. OMS/OPS Bolivia. Available from: http://www.ops.org.bo/textocompleto/hida32356.pdf [cited: 2011 Oct 16].
24. United Nations HIV/AIDS Program (UNAIDS). Bolivia: Informe nacional de progresos en la respuesta al VIH/Sida, 2014. [Internet]; 2014. Available from: http://www.unaids.org/sites/default/files/country/documents//file%2C94420%2Ces..pdf [cited: 2016 Nov 20].
25. Bolivia, Ministerio de Salud y Deportes. Día Mundial de la Lucha Contra el Cáncer. [Internet]; 2014. Available from: https://www.minsalud.gob.bo/index.php/384-dia-mundial-de-la-lucha-contra-el-cancer.pdf [cited: 2016 Sep 30].
26. World Health Organization. Bolivia. Cancer country profiles, 2014. Internet]; 2014. Available from: http://www.who.int/cancer/country-profiles/bol_en.pdf [cited: 2016 Nov 18].
27. Bolivia, Ministerio de Salud y Deportes. Encuesta de evaluación de salud y nutrición 2012. [Internet]; 2014. Available from: http://www.udape.gob.bo/portales_html/docsociales/Libroesnut.pdf [cited: 2016 Oct 10].
28. Estado Plurinacional de Bolivia. Decreto Supremo Nº 2079, Aprueba el “Plan Nacional de Seguridad Vial 2014 – 2018”. [Internet]; 2014. Available from: http://www.lexivox.org/norms/BO-DS-N2079.xhtml [cited: 2016 Aug 17].
29. Defensoría del Pueblo. Información relevante sobre niñez y adolescencia en el Estado Plurinacional de Bolivia, 2012. [Internet]; 2012. Available from: http://www.defensoria.gob.bo/sp/datos_ninas_ninos_adolescentes.asp [cited: 2016 Nov 2].