Bolivia: Maternal Health Inequalities and Recommendations
Bolivia is a country located in the southern part of America with its total population of about 8,324,700 people and the population density of about 7.6 people per square kilometre. However, the country is an assortment of administrative departments comprising of nine which are further divided into 112 provinces within which 314 municipalities are being obtained. Due to this complex administrative unit, the country continues to experience some changes in administration as a result of modernization policies which have been developed. Among such policies there are such as: the Community Involvement Act and the subsequent reforms that were implemented in the National Constitution in 1994. Following the amendment and the resultant passage of various acts, the sense of democracy in participation in national matters has increased through the devolution of power from the municipalities to the autonomous government agencies. The population growth has been considerably high with a triple rise in the population size within the last 50 years. However, this increment is relatively small and accompanied with the intensive urbanization. Consequently, this aspect has seen a decline in the rural population by 30 percent between 1950 and 2000. The population of Bolivia comprises of a huge population of young people being below 25 years old that comprised of 25 years old in 2000. In this regard, the fertility rate remained relatively high between 1995 and 2000 (UNICEF, 2006).
The health situation of Bolivia is also inspired by the economy of the country, particularly a rising fertility rate despite some challenges that this paper seeks to address concerning the administration of treatments, particularly in the maternal health contexts. In this regard, there has been an indication of population growth of the country between the year 1990 and 1998. This posted a positive growth of 4.3 per cent and a per capita income of US $1,010. However, the average rate of inflation in the country remained and continues to pose a significant challenge recording 3.1 percent in 1999. At that time, there was an improvement from the 10 percent of the 1990. A good economic performance was also attributable to the declining rate of unemployment. Furthermore, the incidences of poverty by virtue of the income generation were also reported to drop significantly over the same period. In general, there has been a general rise in the social welfare of the people in Bolivia. This has been indicatively the factors leading to the improved lifestyle including the upscale of literacy level over the period aforementioned despite the parity among the school going males and female children (Bicego & Boerma, 1990).
In conclusion, the state of health has also not been left behind despite a number of challenges in the administration of treatment. The country recorded 9 out of every thousand people in crude death between 1995 and 2000. However, it is eminent that the country still lags behind in the development of systems of recording the important statistical inferences, especially on the matters to do with health. Consequently, there has been an estimated total of about 63 percent of mortality incidences that escape recording due to poor recording systems .They have also crippled the improvement measures that would be put in place. Besides that, the country also records a low life expectancy at the birth of 61.4 years (Green, 2008).
According to the health survey done in 2000, it indicates that the main causes of mortality are circulatory infections and communicable diseases that account for 30.3 and 12.0 percent respectively. Other causes accounted for about 10.7 percent. However, despite many challenges that are eminently perceived in the Bolivian health systems, including but not limited to the inadequacy of recording systems, this paper seeks to conduct a detailed analysis of discrepancies or inequalities that subsists in the administration of maternal health in the Bolivian state. From the aforementioned, it is clear that the population is a main contributor and plays a central role in defining the economic, political and cultural destination of a country. However, the population is also cantered on the maternal health and, therefore, is a key to the development in the respective country (Hickler, 2001).
The health inequality in maternal discipline has been a major challenge to the country. Consequently, this has led to downplay of the entire health performance of the country as opposed to the majority expectations. Despite the fact that the public and child health, in particular, has improved over the recent past, there has been a post-existing parity in the health. For instance, since the drop of the children mortality from 89 to 55 for every 1000 live births both 1998 and 2000 respectively, the statistical records show that an infant mortality rate in the rural settings remains above 80 with early neonatal mortality rates leading a cause of death with 57 percent. The issue of maternal health inequality has been on the rise, thus, leading to the increased need of developing mechanisms to combat it if the good health is to be achieved. In line with these efforts, various programs have been developed to spearhead the initiative both at the federal and civil society levels. Among such programs there is a FOCAL health program. The main aim of this program is to inject the culture of using analytical tools for the production of fact-based evidence with respect to the extent of health and maternal health, in particular. The main focus in this program, however, is the marginalized population which includes the Afro-descendants of Bolivia and Peru as well as indigenous citizens of the state. Indeed, the implementation of the program is one of the initiatives that will help in the detection of a policy gap. It exists regarding the development and exchanges on relatively accurate policies within the discipline of health (Pan American Health Organization & World Health Organization, 2002).
Indeed, the issue of maternal health inequality is a hyper-sensitive problem in the health domain of the Bolivian state while the child mortality rates remain alarming and highest recorded in Latin America. This, therefore, presents the country with an immense challenge of having a balanced population guarded by good health through the improved medical care for all. In an effort to counter the spread of health inequality, particularly among mothers and children, the government of Bolivia has set forth three major insurance policies towards implemented since 1994 on a free basis. These policies include: the Basic Health Insurance; National Maternal and Child Insurance as well as the Universal Maternal and Child Insurance. They are all geared towards breaching a gap between the access to public health for both the modernized population and the marginalized ones lagging behind in the rural areas. In this regard, the National Maternal Health with regard to infants has indicated a considerable improvement in the maternal health situation with the due implementation of the National Maternal and Child Insurance policy (Fretes et al., 2008).
The inequality in maternal health remains an incredible challenge that the Bolivians are yet to solve amicably since it remains far below the targeted level in the 2015 Millennium Development Goals of the United Nations. In particular, there has been a low performance in maternal health of both rural citizens and indigenous. It comprises 37 and 60 percent by a population size of Bolivia. However, there has been a prolonged go-slow in the implementation of some policies except for the Basic Insurance that has seen a relatively greater impact. One of main contributors of ineffectiveness in the implementation of such insurance includes the pre-existing historical gaps of the ineffective public policies driven by impartiality. The Basic Insurance has, however, demonstrated the ability to significantly inspire a great improvement in dealing with both neonatal and maternal mortality. These ones have consequently declined as a result. This, therefore, shows the incredible significance of bridging the historical gap and the entire infant mortality being particularly fatal in the rural and indigenous communities of the Bolivian state (Organization for Economic Co-operation and Development, 2010).
There have been the tremendous advances in the performance of public health in the period of the past two decades. However, according to the Demographic Health Surveys (DHS) of the entire health performance of Bolivia, the country continues to record one of the badly hit health indicators within entire Latin America. Indeed, the record on maternal as well as infant mortality is indicatively the second highest in the region starting from Haiti. In essence, Bolivia is currently undergoing through an epidemiological transition in which case, chronic infections have been increasingly recorded, thus, putting a downward push on the already weak health situation. In addition to that, the further disparities in maternal health are exhibited due to the high population, accounting for 65 percent, living below the poverty level. This further widens the gap in the unequal distribution of medical care in Bolivia. Socioeconomic indicators further denote that the poverty level is also overwhelming among the indigenous categories of citizens which, thus, indicate the high frequency of uncontrolled maternal health. This has resulted to a rising health inequality within rural areas (Silva & Batista, 2010).
Indeed, despite the presence of public health facilities in rural areas, the latter one does not adequately meet the medical needs of the poor rural communities, which are perhaps the most sidelined groups in sharing the states’ resources, unlike the situation in urban areas. This marks one of the discrete foundations of disparity and inequality in health within the Bolivian state. The reports from the study on the Bolivian’s state of health by the Pan American Health Organization (PAHO) have indicated the following. Rural Bolivians experience the impact of inequality by virtue of discriminations through both exogenous and endogenous factors respect to the health care system. The exogenous factors include poverty, gender parity and geographical instincts among others. Furthermore, the citizens also experience discrimination on the basis of historical variables. These factors account for approximately 60 percent of a health inequality problem. On the other hand, the communities are further discriminated through endogenous factors which include a limited reach out by medical services as well as systemic inadequacies. Systemic inadequacy entails such aspects as the lack of technical and professional capacity to solve a health problem and, therefore, a harmful result of the perpetuated ill-health. The latter one may also entail the high tendency of changes in health care providers and conflicting cultural perception towards the quality of healthcare provided. Certainly, the endogenous factors can be easily controlled by both recipients and health care providers, while the exogenous variables are often beyond control of either (Pan American Health Organization & World Health Organization, 2002).
The health care systems of Bolivia comprises of three main health care providers namely: social security, public as well as the private sectors. In particular, the public sector is responsible for offering the medical care on mothers, infants as well as the aged population. However, it has a limited capacity to adequately offer such services. In essence, the sector experiences an acute shortage in the human resource personnel and, therefore, the incapability. In the same tone, there exists the acute disparity in the distribution of such limited personnel. According to the National Health Information systems of 2007, for instance, the urban community is allocated ‘3.6’ doctors per ten thousand people, while the rural community allocates only ‘1.3’ doctors for every ten thousand population group. On the other hand, the other health services’ body, social security only caters for the population employed within the precincts of a formal sector, thus, discriminating the population of poor which forms the majority within the informal sector. Finally, in this context, the private sector comprises of a small population that basically comprises of churches and non-profit organizations as main administrators. In this category, there are the traditional herbalists, which form a major component of the health care provider in Bolivia (Savage, Chilingerian, & Powell, 2005).
Health care in Bolivia is further classified into three distinct categories with regard to the complexity of services. These are: basic facilities (50.5 %), preventative care as well as health centres which comprise of 42.4 %. Indeed, this level accounts for virtually all the services offered in rural areas, accounting for 93 percent of the health care services in Bolivia. In the urban areas, we have the other category that offers general the medical care besides other four specific services namely: traumatology, gynaecology, paediatrics and general surgery. As a result, the rural communities remain marginalized in absolute terms and cannot access such specialized services besides accessing the low profile services. The last category comprises of general and specialized medical care centres located in the capital city of every Bolivian department. This may include psychiatry and urology among others. Indeed, this adds up to the further expanding tag of disparity and the overall inequality in the health coverage of Bolivians where they badly hit the population remains the rural often indigenous communities. These ones do not have an access to both the second and third categories of medical care and the maternal health, in particular. This is the case because the mothers and children are badly hit as they experience some hardships in accessing health in a distance location in urban regions, while, at the same time, the poverty-laden community cannot bear up medical charges neither (Haagh & Helgø, 2002).
Above all, maternal health in Bolivia remains eminently high in the region. The records from the DHS indicate that there were a recorded total of 416 maternal deaths of live births in 1989. The country, however, sought to reduce this number to 104 for the mortality rates by 2015 projection of the Millennium Development Goal. However, despite the measures that have been taken through the implementation of three main insurance policies in all state departments, there remains a huge challenge in the process and clear enough that the fateful achievement of the MDG may not be possible unless some acute and drastic measures are taken to combat the mortality deaths. Similarly, it has also been indicated that the neonatal mortality rates also assume the same trend with 27 deaths per thousand live births. This, however, continues to rise in all state departments with the exemption of Oruro and Chuquisaca only.
Besides that, the indigenous groups are indicatively exhibiting 200 percent of neonatal deaths relatively to non-indigenous groups; while the gap between urban and rural precincts continues to widen as recorded in 2008. The results above clearly indicates the aspect of inequality in access to health care and the absolute coverage between the indigenous and non-indigenous communities as well as the urban and rural communities, which adds up to the overall inequality. Contrary to the expectations of the majority, it has been noted that the gap between infant mortality rates of urban and rural communities increased in the course of implementation of the insurance plan except for the case of the Basic Insurance Plan. Its effect led to a considerable improvement in the maternal health situation of the country (Holtz, 2008).
Due to a protracting level of the maternal health disparity, the Bolivian governments in conjunction with health authorities have set forth the designated three insurance models targeting to improve the health situation of the population. These plans are a basis upon which various policies have been developed with a view to reduction of the gap between rural and urban communities. Thus, there was the reduction in inequalities. However, despite the investment by the government in offering the free insurance through some underlying policies, a lot remains to be done if the health inequality is to be solved substantially. However, the three policy development has seen the improvement of the health distribution to the aged and poor people, women and children, particularly in the marginalized regions of the country. The biggest of them all there has been the Basic Health Insurance attributed to the biggest positive health impact on the indigenous citizens, particularly women and kids (Giuffrida, 2007).
Indeed, the above measures have been some of public health strategies targeting the marginalized population. However, the overall output has been negligible as there was very little if any improvement in maternal health situation. The ineffectiveness can, however, be attributed to the approach that the Bolivian government accords the strategic measures and the direction it gives to its strategic intervention through a regional placement of attached facilities. In order to improve the performance of the public health and maternal health, in particular, the government should involve the civil society and improve the access to major health care through uniformity of services and the subsidization of medical care. This could make it relatively affordable for all citizens. In order to define the particular conclusive point of view, the government should conduct a national-wide economic survey in order to understand the citizens’ standards of living and the level of health services vital to its citizens and affordable by virtually all besides improving the national-wide population’s growth by virtue of the equitable growth (Fretes et al., 2008).
Besides that, the policies that are developed in the view of combating the situation of maternal health inequality and the general national health should also target the main players namely: the rural and indigenous communities. In this regard, with the scarcity of a resource endowment, the country should focus its resources on the indigenous groups in order to narrow the gap between them and the non-indigenous ones. This would, therefore, minimize the overall health inequalities in a long-run. Besides that, the health insurance plans should be ones focused towards the prevention, cure and health promotions towards the health problems facing the marginalized groups. Furthermore, the gender disparity can also be factored in the determination of effectiveness of policies and the subsequent implementation. In addition, before the execution of any viable health policies or any insurance, the federal government should particularly raise the level and supply within the regions facing some acute shortages in health facilities. Finally, the government should avail reproductive health services within neonatal as well as lower maternal mortalities (Sojo, 2006).
Gender disparity should also be incorporated in the evaluation of effectiveness of policies in order to determine the viability of one policy over another. Consequently, the government should consider the demographic feature of its population with respect to gender in the determination of the most articulated and viable placements of requisite public facilities with respect to the services offered. For instance, the availability of maternal hospitals and paediatrics in the regions where the majority of the population resides and the simultaneous recognition of the vast majority in the scarcely populated rural areas that perhaps comprises of a group of low income earners and subsequent low level living standards. Such can also be revamped through the improvement of feeder roads that would also beef up the access to such services and minimize the disparity (Razavi & Hassim, 2006).
Finally, the overall situation of health in Bolivia is a function of big mismanagement of the country resources. It has resulted into an ‘abnormal’ distribution. In essence, the country also experiences a poor policy development that results in minimal if any achievement of the set target perpetuates the status quo. As a result, the country’s health system lacks competitiveness and efficiency due to the lack of contextualization of the targeted population. Despite the huge investments into public policies such as the free medical insurance cover, there has been a minimal achievement due to fraud in the implementation of the latter.