Health for All: Alma Ata is Alive and Well in Venezuela

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Social Medicine (www.socialmedicine.info)

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Volume 3 Number 4, November 2008

EDITORIAL

Health for All:Alma Ata is Alive and Well in Venezuela

Joan E. Paluzzi and Fernando Arribas García

In 1978 the Declaration of Alma Ata assertedthat health is a fundamental human right and“Primary health care is the key to attaining thistarget as part of development in the spirit of social justice.” Thirty years later we find the partnershipbetween the Venezuelan and the Cubangovernments realizing the promise of “Health forAll” for the people of Venezuela. For this reason,we are honored to serve as the guest editors for thisspecial edition of the journal

Social Medicine/Medicina Social

examining the robusthealth sector reform that has been underway inVenezuela since 2003. As an example of a “counter-reform” which explicitly challenges the prevailingpolicies and organizational practices in globalhealth, the events in Venezuela have internationalsignificance.

Misión Barrio Adentro

is one of the manywidespread social sector programs (Missions)developed within the framework of the ongoingBolivarian Revolution and initiated following theelection of President Hugo Chávez in 1998.

Barrio Adentro

can be translated “inside theneighborhood”, a concept which establishes the‘street credentials’ of the Venezuelan reform as alegitimate exemplar of an engaged model for socialmedicine in the 21

st

century.

Barrio Adentro

is heirto the tradition that many, including physician/ anthropologist Howard Waitzkin and hiscolleagues

1

,refer to as the “Golden Age of SocialMedicine.” Social medicine flourished in 1930sLatin America, propelled by pioneers like Max

1

H. Waitzkin, C. Iriart, A. Estrada, and S. Lamadrid2001. Social medicine then and now: Lessons fromLatin America.

American Journal of Public Health

91 (10):1592–1601.

Westenhofer and Salvador Allende Gossens of Chile. The direct line of descent for this uniquelyVenezuelan version of social medicine can be tracedthrough the Cuban public health system upon whichmuch of it has been modeled.In a period of 5 years the

Misión

has created ahealth system – ranging from primary to tertiarycare – that is both free and accessible to allVenezuelans. Traveling across Venezuela duringtwo successive summers, we were repeatedly struck by just how pervasive

Barrio Adentro

has becomewithin a relatively short period of time. At everystop along the way, in large cities and tiny rural

pueblos

, anyone on the street or along the road whowas stopped and asked for directions to the nearest

Barrio Adentro

neighborhood clinic respondedwithout hesitation.One of the most important elements of thisreform is its actualization of the concept of health asa fundamental human right. As further indication of the Venezuelan commitment to this principle, theobligation of the State to assure the full realizationof this right has been explicitly encoded intoVenezuela’s national constitution. Additionally, thisreform has established an example of a nationalpublic health system that has supported andmobilized focused political will and widespreadcommunity engagement to rapidly create a nationalhealth system that is characterized by broadaccessibility across a large, geographically andculturally diverse nation.

Corresponding Author:Joan E. Paluzzi, Ph.D.Anthropology DepartmentUniversity of North Carolina Greensboro.E-mail: jepaluzz@uncg.eduConflict of Interest: none declared

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Volume 3 Number 4, November 2008

The Venezuelan example holds great promise forcountries struggling to develop sustainable primaryhealth services. The concept of health as afundamental right provides a notable contrast to thethoroughly privatized system in the United Stateswhere the discussion of health as a human rightrarely finds its way into the ongoing and as of yet,ineffective, political debate on “the health carecrisis”. These two themes are related in that theunquestioned acceptance of market-regulatedhealthcare in the US has worked its way intointernational policy vis-à-vis the influence of the USgovernment in setting international development andfinancial policy. Lack of educational, health, andother basic infrastructures are just some of thebarriers to large-scale and rapid development of primary systems in many of the poorest countries of the world. The continued imposition of theneoliberal ‘Washington Consensus’ developmentmodel with its intractable ‘one-size-fits-all’

modusoperandi

constrains the ability of many heavilyindebted, poor countries to prioritize the socialsector reforms that are essential to reverse decadesof imposed neglect.With healthcare as its “product”, privatizationinevitably and thoroughly commodifies healthservices. The services, supplies, and medicinesneeded to maintain health become situated withinthe market and are therefore vulnerable to themanipulations of market dynamics, transformingthem from basic necessities into profitablecommodities. With this commodification andthrough the reproduction of existing socio-economichierarchies, ultimately health itself is commodifiedby making accessibility and often quality of basichealthcare dependent upon an individual’s access tocash. For decades, many of the countries in LatinAmerica, including Venezuela, experiencedrepeated waves of neoliberal structural adjustmentsthat have been characterized by widespreadprivatization of human services, includinghealthcare. This in turn has exacerbated the existingand significant inequalities within these societiesand created new opportunities for their expressionwithin essential social sectors such as health andeducation

2

.The lucrative profits assure that thesmall minority that benefit from the healthcaremarket will continue to be invested in maintaining(or reasserting) privatization. In Venezuela, it maybe inevitable that the vested interests who wish tomaintain the primacy of the market model willcontinue to directly and indirectly challenge thecurrent reform.Unlike the prioritization of primary,neighborhood-based healthcare services inVenezuela, the current international healthdevelopment model promotes vertical, disease-specific programs. On the one hand, they serve animportant function in addressing the most visibleand, in some cases, the most lethal health issues inplaces like sub-Saharan Africa. On the other hand,these highly focused programs are also uniquelysuited to current international development policieswhich reflect the priorities of wealthy donorcountries and to a system where policy is dictated byhealth economists from the rich countries rather thanhealth providers from the poor ones. The cost of avertical program is easily quantifiable per “unit”(the full treatment regimen for a single patient); it isrelatively simple to control access to the programs;and there is a relatively narrow, easily manageablerange of accountability for administration andfunding oversight. Yet this apparent rationality isutterly myopic.Without accessible primary health services,many, if not most of the people who contract HIV,TB, and malaria do not have a mechanism throughwhich they can be diagnosed and referred into theseprograms for treatment. Further, poverty createsvulnerability to a wide range of health issues; the

2

See for example: N . Homedes, A . Ugalde. 2005. Why neoliberal health reforms have failed in Latin America .

Health Policy

71 (1): 83 – 96; T.L. Karl.2003. The vicious cycle of inequality in Latin America in T.P. Wickham-Crowley and S.E. Eckstein(eds.)

What justice? Whose justice? Fighting for fairness in Latin America.

University of CaliforniaPress: Berkeley CA.; J.P. Unger, P. De Paepe, G.Solimano Cantuarias, O. Arteaga Herrera. 2008.Chile’s Neoliberal Health Reform: An Assessmentand a Critique.

PLoS Medicine

, 5(4): 542-547;

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Volume 3 Number 4, November 2008

current priorities in international public health havecreated a situation in which hundreds of millions of impoverished people in the world may or may nothave access to a treatment program for one of threemajor infectious diseases (TB, malaria and AIDS)but have absolutely no recourse for the diagnosisand treatment of other life-threatening conditions,acute injuries and illnesses, or chronic diseases.Curing someone of their TB is a hollow victory if they subsequently die of tetanus, diabetes, cholera,work-related injuries or one of the other myriad,treatable conditions whose incidences areconditioned by the impact of poverty on humanhealth.Combining (across organizational andinstitutional borders) the resources currentlydedicated to the major infectious diseases,eliminating duplication of services, and endingcompetition for resources would provide the fiscalmeans to begin ‘planting’ the disease-specificvertical programs within comprehensive primarysystems. This would require a paradigm shift at thetop levels of international health and among donorswhere territorialism, competition, and instantgratification in terms of quantifiable outcomes havedominated for decades. Comprehensive anduniversal primary care and the societal advantages itconfers may require careful analysis acrossgenerations to fully appreciate its long-term impacton illness outcomes, disease prevention, and thehealth and development of children. Ultimately, themost significant collective advantage conferred byuniversal access to healthcare will emerge from theability of healthy citizens to contribute to the growthand development of their society. This holisticvision of health and human experience is ill-suitedto the narrow quantification of the cost/benefit ratioanalysis which continues to be the current gold-standard of assessment within internationalhealthcare capitalism.Listening to members of communities acrossVenezuela describe the positive and immediateimpact of accessible primary and secondary healthservices on the quality of their and theircommunities’ lives provided us with a glimpse of what an alternative, more comprehensive systems-assessment model that seeks to incorporate bothqualitative and quantitative information might look like. For example, the assessment process, like thebasic tenets of the social medicine system it seeks toevaluate, should incorporate the fact that individualhealth issues cannot be completely understood oraddressed without contextualizing health and illnessexperience within the larger social, economic, andecological environment in which people live andwork.The contributing authors in this edition includean international group of physicians, public healthspecialists and other scholars, many of them directlyinvolved in the design, implementation, andassessment of Venezuela’s new national health caresystem and the development of its concurrenteducational infrastructure. The significance of

Barrio Adentro

as a counter-reform in relation to thecurrent international public health system paradigmis underscored by the fact that all of these authorsexplicitly contextualize the emergence of

Barrio Adentro

as a deliberate and reasoned alternative tothe neoliberal privatized model that has existed fordecades in Venezuela.Carles Muntaner and his colleagues provide uswith a brief history of public health in Venezuela,the impact of structural adjustment on the system,and the formation, organization, and expansion of

Misión Barrio Adentro

. Due to the short amount of time (less than 5 years) that the program has beenoperating on a national scale, there is a limitedamount of data available to perform impactassessments. However, utilizing surveys obtained in2004-2005 they present a quantitative system-development profile that illustrates the rapid scale-up of the new system as well as early butnonetheless promising changes in epidemiologicalpatterns that may indicate its positive impact.One of the great constraints on health systemsthroughout the world is the lack of trainedpersonnel. There are multiple reasons for thishowever, it is no coincidence that, in many of thepoorest countries in the world, structural adjustmenthas also had a negative impact on the educationalsectors with standard neoliberal tactics such asprivatization, cutbacks in government spending oneducation and the initiation of user fees that positioneven primary education beyond the reach of millionsof poor children. Comprehensive healthcarecoverage requires large numbers of educated

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