Pan American Health Organization

Bolivia

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
Page 1 of 5

Overall Context

Flag of BoliviaThe 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%) ().

Demographics

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).

The Economy

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 ().

Vulnerable Populations

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).

Chronic Conditions

In Bolivia, noncommunicable chronic diseases cause 59% of deaths ().

Human Resources

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 ().

Aging

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.

Migration

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.

Prospects

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 ().

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