Health first in Bolivia

"Health first" in Bolivia Ramon Granados, Angel Valencia and Juan Sotelo JF or many years, the focus of Bolivia's health services was on hospitalisation and treatment, with little or no part being played at the local level. But, starting in 1982, an integrated programme of health care by local authorities began to take shape, with the emphasis on basic health services, the use of modern technology, and grassroots involve- ment in health care and hygiene. These are now the principal methods used to effect radical changes in this sector and to make them more efficient and widely available. The new methods stress involving social institu- tions in health care, and seeking the cooperation of the various segments of Bolivian society. In short, "Health for all" means that all are responsible. Since 1986, the main emphasis has been on restructuring the prevailing regional systems and giving them more decision-making powers. By 1987, the expansion of public health services in Bolivia meant that health facilities were available to most of the population. @ But the development of local health § systems on a district and regional level ~ has led to a more efficient adminis- . tration and better use of human and ~ financial resources. The end result is ~ that health care has become more ~ accessible to all classes of society. The transformation of the nation's health systems began with experiments in selected areas in order to gain experience in these new techniques, make the necessary adjustments and use them on a national scale. Two experiments show that they are indeed capable of providing effective health care for all. The Caranavi district Caranavi lies in the Department of La Paz, some 175 kilometres from the capital and much nearer sea level. Its climate is tropical and what roads there are leave many remote villages very hard to reach. The district has a population of 92,000, grouped into 780 communes over an area of 14,000 square kilo- metres. Its economy is largely farming and - on the social and economic level - it is a depressed area. The principal health problems are infectious parasitic and nutritional ailments, acute diar- 14 rhoea and respiratory diseases as well as tuberculosis, leishmaniasis, parasit- oses, malnutrition and goitre. The Caranavi experiment, launched in October 1986, focused on the integration of health facilities, so the involvement of the district community groups, agrarian trade unions and leading figures in the community was enlisted. The trade unions took an active part in improving health facilities and eventually, acting through agents elected by the community, were able to operate as people's health centres. The health centres are supported by the clinics and their medical staff. They developed their activities in four main areas - public education, supplies of medication and other items required for treatment, obtaining statistical data on community health, and logging background information on patients. Salt fortified with added iodine is a preventive measure against the iodine- deficiency disease goitre. The personnel of the health centres are selected by the social organizations in the different communities. As a result of the gradual transfer of tech- nology and the acquisition of skills and experience, the experiment has been a considerable success. Public health committees have cooperated with the health clinics in all sectors of com- munity life, and assist the medical staff in planning and evaluating health campaigns. Much effort has gone into training the staff at these clinics. The training programme initiated under the new system first concentrated on control measures for tuberculosis, a widely prevalent disease in the Caranavi district. It provided an excellent starting point for the clinic staff and a model for public education, information, background on patients and, generally speaking, a model for other health programmes. Where tuberculosis is concerned, the improved methods in diagnosis and treatment have paid off handsomely. This experience has been extended to other prevention and control pro- grammes such as those for acute diarrhoea, respiratory infections, para- sitoses, goitre and anaemia of preg- nancy. These methods can now be further applied this year to such prob- lems as mental disorders and psycho- motor disturbances. The successful collaboration with local health services means that early diagnosis and treatment can be encouraged in other areas: for example, women's com- mittees have now been set up not only to improve nutritional and educational standards but also to foster irrigation projects. Two years on, the Caranavi exper- iment has demonstrated the value and vast potential of grassroots involve- ment in the health sector, its effectiveness in raising health stan- dards in deprived areas, and the success of health programmes when the whole community is involved. It has shown the results that can be obtained through district health centres involving community participa- tion, and how effective the actions of the community can be when its own social organizations and institutions play an active role. The Caranavi district is now cooperating with non- governmental agencies to obtain medical supplies and even communi- cation systems. The experiment has also revealed certain weaknesses, among them a lack of qualifications in the health clinic staff. But conversely, the professionals have played a major role in motivating personnel to acquire the necessary skills and experience. The Sorata district Sorata is also situated in the Depart- ment of La Paz, and lies 153 kilo- metres from the capital with which it is linked by road - except in the rainy season. Within an area of 300 square kilometres it has a population of 22,800 people spread over 171 communes. This is a mountainous WOR LD HEALTH, May 1989 region with valleys and plains ranging from 1200 to 2600 metres above sea level. The climate is temperate and access is usually difficult. The most prevalent diseases are diarrhoea, acute respiratory infections, parasitoses, scabies, tuberculosis, malaria and endemic goitre. Accidents are also frequent although no statistics on the mortality rate are available. The "health first" campaign exper- iment was launched in March 1987 with the aim of expanding it at a later date. Stress was laid on regional cooperation, teamwork, community involvement and the training of human resources. The ultimate aim was to focus public attention on methods of prevention via publicity campaigns, and to reduce the mortality rate among high-risk groups. Much emphasis was placed on teamwork and eo-responsibility by the community services through improved standards of medical treatment and hygiene. Previously attitudes towards health needs had been somewhat passive, but now positive steps were taken to identify the sick and those at risk A district health programme was drawn up which called for closer cooperation between doctors and nursing personnel. Staff training at the health centres was a key ingredient of the programme, since much of its W OR LD HEALTH . May 1989 success in the remote countryside depended on qualified personnel. Also basic to the efficacy of the programme were regular visits to the local com- munities by doctors and nurses. The medical team conducted a population census and did a preliminary survey of health conditions in the various communes, thus gaining a clearer picture of the epidemiological situation and the risk potential. Data on births and deaths The experiment has involved a pro- found restructuring of the medical services and personnel which support the existing district services. A number of people's health centres have been set up so as to make medical attention accessible to all . Now the Sorata district has a capability for the exchange of information on patients between the local clinics and the central hospital. As a result, data are now available on births, deaths and the incidence of disease. Moreover, health care can now be provided in remote areas which were hitherto far outside the scope of normal medical services. Today, the newly-established medical teams are actively engaged in raising hygiene standards, in collaboration with the district clinics. The Sorata experiment has also led to stricter control of endemic diseases in the region, increased health care of The whole community takes an interest in Bolivia's campaign against goitre. Extending medical care through grass- roots participation has enormous potential for the improved health of the nation. women and children, better immuniz- ation programmes and a closer watch on fluoride levels. The programmes are tailored to local realities, and the clinics and people's health centres have even mobilised the churches and educational authorities as valuable collaborators in the joint effort. Not all the problems have been solved. There is still inadequate coordi- nation between the new methods and the old systems. But both the Caranavi experiment and, to a lesser extent, that in Sorata are highly encouraging. The lessons learned reveal that "health comes first" is a sound strategy that can be applied at all levels, including district ones. In the Bolivian context, the exten- sion of medical care through grass- roots participation has enormous potential for the improved health of the nation. The two experiments show that simple basic methods using trained personnel can be incorporated into more complex health systems, thus raising health standards at all levels of society. • 15