ACHIEVING MDGS 4 & 5: BOLIVIA’S PROGRESS ON MATERNAL AND CHILD HEALTH

Rafael Cortez, Fernando Lavadenz, Seemeen Saadat, and Andre Medici

August 2014

Health, Nutrition and Population Global Practice

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Knowledge Brief

Introduction

Bolivia is a lower-middle income country, but one of the poorest in South America, with a per capita GNI of US$ 5,750 in 2013 and an average GNI growth rate of 4.4 percent during the last ten years. Nearly 36 percent of its population of 10.6 million (2013) are aged 0 to 14 years and one third live in rural areas. The country has a multi-ethnic society and 62 percent of the population self-identify as indigenous people. Bolivia ranks 108th out of 186 countries in the Human Development Index and 97th out of 186 countries on the Gender Inequality Index.

Bolivia has made considerable progress in improving maternal and child health. Child-mortality (under 5 years old) declined from 123 to 41 deaths per 1,000 live births between 1990 and 2012. In addition, maternal mortality more than halved from 510 to 200 deaths per 100,000 live births between 1990 and 2013 - a 61 percent decline.

This note explores the key maternal and child health policies and programs that have been implemented since 1990.

Maternal and Child Health Policies

Key health policies and legal provisions have created space for improving access and expanding provision of maternal and child health services. These include the National Plan for child Survival and Maternal Health (1989-93); Plan Vida (1993-97); and more recently, Salud Familiar Comunitaria Intercultural (SAFCI, Intercultural Family and Community Health) in 2008. Provisions in the 2009 Constitution also guarantee the healthcare including reproductive health.

Transformation of Health Delivery Model

Maternal and child health programs re-focused attention

KEY MESSAGES: Bolivia has made considerable gains in reducing maternal and child mortality from 1990 to date. The maternal mortality

ratio declined from 510 to 200 deaths per 100,000 live births between 1990 and 2013, and under-five mortality also declined from 120 to 41 deaths per 1,000 live births from1990 to 2011. Bolivia also reduced its under-2 child mortality rate due to severe malnutrition by 80 percent in the same period.

The three key drivers of this reduction are: (i) structural reforms in the health delivery model, including changes in programs and health systems governance, new health infrastructure, and policies for expanding coverage from 1990 to 2003; (ii) financial protection reforms with a pro-poor provision of free maternal and child services through the creation of a public health insurance program, using results based financing to pay providers since 1996, and (iii) cultural adaptation to ensure greater access to and acceptance of health services by the indigenous population.

Over the last five years, progress has stagnated and Bolivia needs to continue working on three strategic lines to achieve the next round of gains. These lines are: (a) the health delivery model that will need to improve quality and address shortages of staff, (b) improving facilities and equipment in remote areas, and (c) financial protection that requires changes in payment mechanisms aimed at increasing the quality of MCH services for the indigenous population.

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HNPGP Knowledge Brief

on primary health care in the 1990s, expanding the public health system in rural and peri-urban areas, with (i) the construction of more than 300 primary health care facilities in around 100 defined networks during a ten years period; and (ii) prioritizing key programmatic interventions:

Maternal and Child Health Programs IMMUNIZATION: Under the health sector reform (1996), the Expanded Program of Immunization (EPI) was revamped and expanded as EPI II. It included the penta-valent vaccine, a combination of five vaccines: diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenza type b (the bacteria that causes meningitis, pneumonia and otitis). Health facilities were responsible for directing the vaccination operations for the population living within a 5-kilometer radius. A new complete health cold chain was developed, and the new vaccines were included as reimbursed services in the portfolio of the maternal and child health insurance (1996). Between 1989 (date of the first EPI launch) and 2008, the percentage of fully immunized children increased from 18.8 percent with 5 vaccines to around 79 percent with 8 vaccines.

CHILDHOOD ILLNESSES: Two key programs, the National Acute Diarrhea Program (NADP) and the Acute Lower Respiratory Infection Program (ALRI), were also revamped. These programs focused on leading causes of post-neonatal mortality (children between 28 days of life to 1 year old). Distribution of oral rehydration therapy by professional personnel at health facilities, and by volunteers of the People’s Health Committees at the community level, was key to the success of the NADP. The ALRI adapted culturally acceptable practices for the treatment of respiratory infections. Both programs were incorporated into the Integrated Management of Childhood Illness (IMCI) Strategy in 1996, which focused on the care of children between 0-5 years. Between 1999 and 2000 almost 80 percent of rural and peri-urban health personnel were trained to implement the IMCI Strategy. The training involved integrating the best health measures available to promote healthy lifestyles, prevent sickness, as well as timely detection and effective treatment of the most prevalent childhood illnesses.

MATERNAL HEALTH: Since 1983, the Ministry of Health

(MOH) has supported the WHO recommended “risk approach” for pregnancy screening along with the promotion of prenatal and delivery care and postpartum care. Ministerial Resolution 0496 updated maternal and child health services by adopting 18 evidence-based best practices for maternal and newborn care. Emphasis has also shifted from training traditional birth attendants to training skilled birth attendants at health facilities.

FAMILY PLANNING: Public health facilities began providing family planning services in 1989 under the Plan

for Child Survival and Maternal Health. Prior to that, these services were not widely available. Since 1998, family planning has been one of the services provided through maternal and child health insurance.

ZERO MALNUTRITION PROGRAM: To reduce

malnutrition among children, the program focuses on (a) food fortification; (b) literacy and provision of information to mothers, education and communication activities; (c) development of Rural Integral Nutritional Networks (RINN); and (d) expanding access to drinking water and sanitation. Between 2007 and 2010, the program helped to reduce under-2 child mortality due to severe malnutrition by 80 percent.

Health System Improvements DECENTRALIZATION: In 1994, the Popular Participation

Law transferred 20 percent of central government revenues to the municipalities, which became responsible for the provision of health services (Figure 1 presents health expenditures for 1995–2012). Management of human resources for health was made the responsibility of the sub-national autonomous administrations. Between 1995 and 2012, data show a doubling of health expenditure per capita (Figure 1). Changes in governance from 1997 to 2003 increased accountability, with the use of performance agreements between National and sub-national authorities for achieving results in exchange of additional funds.

Source: World Development Indicators and Ministry of Health

EXPANSION OF COVERAGE - EXTENSA: Launched in

2002, the EXTENSA program aimed to expand coverage of essential health services to rural and remote areas through mobile health teams (under SBS and SUMI – discussed later). A hundred mobile health brigades (BRISAS) helped to reduce the geographical barrier of access to services for dispersed indigenous communities situated along rivers of the amazons, and in the highest mountains in the Andes. By 2007, EXTENSA was providing services to over 300,000 people in these areas.

FINANCIAL PROTECTION REFORMS - MATERNAL AND CHILD HEALTH INSURANCE: Since 1996, Bolivia

has provided free maternal and child health services to underserved communities through three insurance programs aimed at reducing economic barriers to health

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services. The use of results-based financing, reimbursing providers based on results with autonomous utilization of resources and free access to health facilities was the core objective of the three health insurance programs:

Seguro Nacional de Maternidad y Niñez (SNMN): Introduced in 1996, SNMN was Latin America’s first public health insurance scheme, providing coverage for 32 basic interventions including: (a) prenatal emergency obstetric and newborn care; and (b) treatment of diarrhea, pneumonia, and respiratory infections in children under five. Prenatal visits increased by 39 percent and births at facilities increased by 50 percent, especially among the poor and the youth in the first 18 months of implementation.

Seguro Básico Salud (SBS): In 1998 the SNMN was replaced by a broader health insurance program known as SBS, with support from the World Bank. SBS

increased the portfolio of available services to 92, including coverage of certain endemic diseases linked to poverty such as tuberculosis for the general population. Between 1998 and 2003, the percentage of mothers utilizing health services through the public insurance grew from 3.6 percent to 53.4 percent. Both SNMN and SBS focused on first and second levels of care and led to the rapid decline in maternal and child mortality.

Seguro Universal Materno Infantil (SUMI) (2003): Introduced with support from the World Bank, the Universal

Mother and Child Health Insurance (SUMI) added insurance coverage for tertiary care, and continued the focus on pregnancy-related care and under-five child health. While more than 500 services were financed, some services covered under the SBS such as endemic pathogens were eliminated This was a strategic decision to maintain focus on reducing maternal and child mortality. By 2004, SUMI had reached 74 percent of its targeted population. In

Figure 2. Bolivia: Timeline of MDG 4 and 5 Interventions

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DPT Measles U5MR

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MDG 5: Maternal Mortality

Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio

1979–1990

1979: Expanded Program of

Immunization (EPI)

1980s: National Program to Combat

Diarrhea and Acute Lower Respiratory Infection Programs

1983: “Risk approach” adopted for

maternal health

1989–93: National Plan for Child,

Survival and Development and Maternal Health

1991–2001

1993–97: Plan Vida/Life Plan

1994: Law of Popular Participation

1994: Education Reform Act

1996: Integrated Management of

Childhood Illness strategy

1996–98: Seguro Nacional de

Maternidad y Niñez (SNMN)

1998–2003: Seguro Básico Salud (SBS)

1999: Epidemiological Shield

2001: Indigenous Health Insurance

2002–2013

2002–07: EXTENSA Program

2003: Universal Mother and Child

Health Insurance (SUMI).

2006: Zero Malnutrition Program

2008: Salud Familiar Comunitaria

Intercultural (SAFCI) Policy

2009: Bono Juan Azurduy;

Constitutional guarantee on health and reproductive health rights;

National Strategic Plan for the Improvement of Maternal, Perinatal and Newborn Health;

National Sexual and Reproductive Health Strategic Plan

2013: Prestaciones de Servicios de Salud Integral (Law 475, Dec. 2013)

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HNPGP Knowledge Brief

2006, the program was expanded to cover additional 27 reproductive health care services including family planning and screening and prevention of cervical cancer for women up to age 60. However, some services, such as dental care for mothers and children, diluted the potential impact of SUMI while adding transactional costs. While institutional deliveries increased from 57.1 percent 67.5 percent between 2003 and 2008, Demographic and Health Survey (DHS) estimates show that maternal mortality increased during this time. This suggests that maternal mortality is driven by the quality of care, and is a matter of health system efficiency.

Prestaciones de Servicios de Salud Integral (Law 345, December 30, 2013) / Benefits of Comprehensive Health

Services, establish and regulate the financial protection in health for the beneficiary population and lays the groundwork for universal comprehensive health care. This law unifies all existing health insurances (SUMI, SPAM (Special Insurance for seniors), and Disability Insurance) for targeted population.

Cultural adaptation of health services

INDIGENOUS HEALTH INSURANCE (2001): Created by the Ministry of Health Resolution 26350 of 2001, the program was aimed at improving indigenous populations’ access to health facilities during the SBS period. It included an additional portfolio of ten services that adapted maternal health services to indigenous traditions, such as “soul rescue” by a traditional practitioner, devolution of placentae, painting facilities yellow, rather than white, which is associated with death among indigenous communities, and creating “wilaqunas” or indigenous health defenders. Provision of rural health services increased in coverage by 15 percent within one year. However, with the creation of SUMI, the next government ended this indigenous insurance program.

BONO JUANA AZURDUY (2009): This is a conditional cash transfer program aimed at improving maternal, newborn, and child health. The program pays a stipend of US$ 260 in installments to each pregnant woman for regular prenatal visits, skilled birth attendance, and postnatal visits for children until they are two years old. This is another effort to ensure cultural adaptation, as an incentive to increase demand for health services.

Creating an Enabling Environment

Besides health sector interventions, empowerment and equity were key to achieve better health outcomes. Broad support for improved equality in gender and education is evidenced by a number of policies and initiatives including

the following:

CONSTITUTIONAL RIGHTS: The 2009 constitution guarantees all Bolivians, the right to health, the right to reproductive and sexual rights, and the right to gender and cultural equality.

WOMEN’S EMPOWERMENT: The 1994 Popular Participation Law promoted women’s and men’s participation in municipal development plans; and the Supreme Decree 26350 established the following key policies on gender: the National Gender Equity Plan (the first gender mainstreaming plan), the National Plan for the Prevention and Eradication of Gender-related Violence, and the Program for the Reduction of Poverty in Women (2001–2003).

EDUCATION: The Educational Reform Act of 1994 promotes gender and multicultural/multiethnic equality, focusing on bilingual education. Figure 3 shows a timeline of MDGs 4 and 5 interventions.

Future Challenges

Although Bolivia has made considerable improvements in maternal and child health outcomes, this progress has slowed down in recent years. One of the main challenges is to improve the quality and focus of SUMI and reinforce the health delivery model, reducing the shortage of staff in rural areas, and improving the management of health networks. Addressing supply side issues is critical to accelerating progress on MCH. On the demand side, communal decision making is central to the culture as well as providing culturally appropriate services and improving access to information. These actions will reduce unsafe abortions accounting for a significant number of maternal deaths.

Bolivia is among the countries with the highest rate of teen pregnancies in Latin America, with over 17 percent of girls aged 15 to 19 having had a pregnancy (DHS 2008). Provision of youth-friendly services, elimination of financial, physical, and social barriers to services and appropriate information are important in reaching this population.

This HNP Knowledge Brief highlights the key findings from a study by the World Bank on “Maternal and Child Survival: Findings from Five Countries’ Experience in Addressing Maternal and Child Health Challenges” by Rafael Cortez, Seemeen Saadat, Sadia Chowdhury, and Intissar Sarker (forthcoming).

The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions.. For more information on this topic, go to: www.worldbank.org/health.