Bolivia: Bolivia Health Profile 2011

Social safety nets are fragmented, and coverage is not distributed equally. In recent years, the government has tried to address all three of the principal problems of the country’s mechanisms of social provision: modernizing the theoretically well-developed, but highly inefficient traditional system of social security, particularly in the mines, in industry and urban employment; extending coverage to the great majority of people who are not yet included, most of them in rural areas; and fighting poverty among the lower-paid strata of workers (formal and informal) and marginal self-employed. In 2006, the Morales government tripled the minimum wage and set aside additional funds from its increased gas revenues for anti-poverty programs, schools and grants for students. In January 2008, further changes were introduced by presidential decree: the minimum wage was set at 575 bolivianos ($76), and the minimum pension at 566 bolivianos. For those whose individual contributions to the pension funds did not add up to this minimum monthly payment, the government made up the difference. The requirement of minimum contributions was repealed, the minimum retirement age was lowered from 65 to 60, and new groups such as migrant agricultural workers were made eligible for the pension scheme. In addition, a tax-financed, non-contributive state pension of 200 bolivianos for all citizens over 60 years of age (renta dignidad) was introduced, replacing the universal Bonosol scheme established in 2002. Most of this new system was to be financed (according to a 2007 decree) by funds subtracted from transfers to regional authorities, with the funds coming originally from the tax revenue on hydrocarbons production (IDH) (as decreed in July 2007). This measure has intensified conflicts between the government and the departments.

Despite the government’s rhetoric, the private pension funds which emerged after 1997 in the previous process of social security privatization, with catastrophic consequences for many of the insured, were not (yet) abolished. It was not until August 2008 that the government, under pressure by the unions of the COB, announced that it would take over responsibility for pension funds from companies which lost a considerable proportion of shares in the nationalization of gas and oil. In addition, the government confiscated $10 million from accounts run by private pension managers for coverage of professional and accidental risk insurance, applying these funds toward the new pension benefits. It also made a 10% deduction from the pensions of the highest-paid workers, using the money to fill a pension solidarity fund, and proposed a new income tax for the highest-paid workers to raise funds for the renta dignidad. These measures, which affected only 0.1% of the population, turned out to be rather insignificant, but were seen as political instruments and intensified the conflicts between the government and the opposition. The idea of a new fuel tax for pension funds seems so far to have been abandoned. In late 2008, at the end of a three-year campaign for literacy drawing on funds provided by Venezuela’s Chávez government, Morales stated that more than 820,000 people had learned to read and write, and that there was practically no more illiteracy in Bolivia (only 3% as compared to 14% in 2001). The land reform measures have provided some land for poor landless farmers. Public expenditure on health remained constant at a low level (4.3% of GDP) between 2003 and 2005. Bolivia still cannot combat poverty systematically on its own.

Equal opportunity There are a number of domestic and international institutions and programs aimed at compensating for gross social inequality. Programs have been ongoing for some time in the context of the HIPC, the PRSP and Millennium Development Goals, as well as on the part of participatory social movements with communitarian and indigenous traditions. The number of agencies promoting the cause of women has increased. In urban areas, women (like men) have significantly better access to education than in rural areas. As many women are not aware of their legal rights, campaigns aimed at raising this awareness have multiplied. The MAS government has given stronger support to these activities and launched additional programs, aimed particularly at improving opportunities for the disadvantaged and previously excluded indigenous minorities. The new constitution, in addition to recognizing the right of self-determination for 36 indigenous peoples, has set high standards. However, legislation and government programs have been showing more exclusionary biases against non-indigenous citizens (white and cholo) than before, so that in the end the net inclusion rate may not have advanced much. In 2005, the adult literacy rate’s female-to-male ratio was 0.87, and the female-to-male ratios derived from the gross primary and secondary education enrollment rates were respectively 1.00 and 0.97. On the whole, structurally embedded unequal opportunities continue. World Bank data has shown that existing programs compensating for major social differences have not had much impact on the gap between indigenous and non-indigenous poverty rates.
 

Population : 64.4% of it urban and 35.6% rural.  According to the 2001 census, 31% of the population identified itself as Quechua, 25% as Aymara, and 6% as Guarani and other Amazonian ethnic minorities, while 38% did not identify with any particular ethnic group. Bolivia’s population is very young: 60% is under 25, and only 7% over 65. The average annual population growth rate is 2.7%. According to the 2001 census, 64% of the population did not bring in enough income to meet its basic needs. Projections indicate that the incidence of poverty in 2006 will be on the order of 63%, with 35% of this group living in extreme poverty. This mainly Quechua and Aymara population is concentrated in municipalities located in the Andean valleys and the Altiplano (high plain) region. Poverty is also found in the flatlands, the Chaco region, and the country’s major cities, owing to migration. In 2003, the average per capita income was US$ 900. However, an examination of the distribution of that income reveals that, on average, the income of the wealthiest 20% of the population is 13 times higher than that of the poorest 20%. The indigenous population is marginalized and lacks access to health care and basic services. In a study of 50 municipalities (of the country’s 327) with high levels of extreme poverty, where the monolingual native population lives, infant mortality is twice as high as in the 138 municipalities where poverty is the lowest.

Life expectancy at birth rose from 63 years (2001) to 65 years (2005). This low rate of increase is attributable to high infant mortality, 54 per 1,000 live births, and this in turn to neonatal mortality. The crude birth rate remains high (28.5 births per 1000 population). This is due to the large population of young adults, high fertility rates (3.7 children per woman), and women’s lack of autonomy in decision-making and consequent inability to exert their sexual and reproductive rights. The birth and death dynamic indicates that Bolivia is growing the way the developed countries did in the 1950s and 1960s.

According to the information reported, the current distribution of mortality reveals a predominance of cardiovascular causes (40%), followed by communicable diseases (13%) and external causes (12%). Mortality is higher in men than in women (1,102 versus 897 per 100 000).
In 2003, 27% of children suffered from chronic malnutrition, and of these, 8% from severe malnutrition.
Only 26% of the population is covered by the health insurance system, and over half the population practices traditional medicine. The private sector meets only 5 to 10% of the demand for services, which means that the remaining 70% of the population must be covered by the public sector. Limitations on access to the system leads to the conclusion that only half the population that should be served by the public sector actually has access to it, leaving the remaining 35 to 40% of the country’s population without coverage.

OPPORTUNITIES

• New government with a solid base in the indigenous and native populations and a mandate for social change in health, coinciding with the principles of Alma-Ata
• National Development Plan that recognizes the intrinsic link between social determinants and
• heath inequities and contains a rights approach
• A participatory constitutional process that involves the creation of a new model for assigning responsibilities, with the Ministry exercising the steering role in the sector
• Allocation of new fiscal resources for health, based on the strategy of redistributing wealth to the local level
• Adoption of the principle of health sovereignty, which implies recognition and strengthening of the Ministry’s steering role vis-à-vis international cooperation.
• Appreciation of PAHO/WHO support in the participatory transformation of the State
• Retooling of PAHO/WHO’s role in cooperation, particularly with priority countries

CHALLENGES

• Participating and providing technical and policy assistance for the constitutive process
• Strengthening the steering role and institutional capacity of the Ministry in the exercise of health sovereignty
• Strengthening mechanism for channeling the demands of excluded groups to decisionmakers
• Identifying and strengthening the institutional capacities of PAHO/WHO within the context of the country’s transformation
• Balancing regional mandates with the country’s new priorities
• dentifying, systematizing, and sharing good practices and lessons learned at the global, regional, and national level
• Clearly defining PAHO/WHO’s role with respect to the new modalities and actors in international
• cooperation
• Considering current national priorities in the preparation of PAHO/WHO cooperation instruments (country BPB, subregional Biennial Proposed Budget (BPB), Technical Cooperation among Countries (TCC) projects, mobilization of other resources)