Venezuela´s Barrio Adentro: participatory democracy, south-south cooperation and health care for all

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Social Medicine (www.socialmedicine.info)

- 232 -

Volume 3 Number 4, November 2008

VENEZUELAN HEALTH REFORMS

Venezuela's

Barrio Adentro:

ParticipatoryDemocracy, South-South Cooperation andHealth Care forAll

Carles Muntaner, MD, PhD

,1,2

, Francisco Armada, MD, PhD

2

, Haejoo Chung, RPh,PhD

2

, Rosicar Mata

3

, Leslie Williams-Brennan, Bsc, BScN, RN

2

and Joan Benach, MD, PhD

4

Preface

In the 1990s Latin American countries, with theexception of Cuba, undertook reforms in theirhealth systems. In general, they followed a patternsimilar to that adopted in other parts of the worldby pursuing a neoliberal agenda that included thepromotion of changes designed to achieve greaterparticipation of the private sector in the fundingand delivery of health services. Despite thedifferent modes of reform, all strengthened theview of health as a consumer commodity andfavored abandonment of the concept of health careas a right guaranteed by the state. Most of thechanges implemented corresponded to the policiesof structural adjustment, in accordance with theneoliberal paradigm recommended byinternational financial institutions with the aim of guaranteeing payments of the external debt (1-4).After several years of application, the negativeimpact of neoliberal health policies has beendemonstrated by its inability to improve coverageor access to health services. These consequencescoincide with the general failure of neoliberalismto improve quality of life; thus, Latin Americaremains the region of the world with the greatestinequalities between social classes.These persistent inequalities have motivated avariety of political responses in Latin America,including proposals advocated by liberal left-wingsectors in various countries of the region that arecontrary to neoliberalism and include thepromotion of policies to reverse privatization of health care while asserting it as a right guaranteedby the state. The amendments to the Venezuelanhealth system are one of the earliest examples of this type of reform. From 1999 onward, after adecade of implementing neoliberal policies, amarked adjustment in the health system wasinitiated to establish health as a fundamental rightguaranteed by the state in a context of broadparticipation of organized communities andinternational (“South-South”) cooperation.This article describes the primary health carereforms in Venezuela, formalized as “

Misión Barrio Adentro

” (Inside the Neighborhood) from2003 onwards. We begin with an analysis of theneoliberal model that existed in Venezuela at thetime changes in health policy were initiated. Thisis followed by an explication of

Barrio Adentro

inits historical, political, and social context, pointingto the central role played by popular resistance toneoliberalism. We continue with a description of its operation, consolidation, analysis of the firstindicators of the program’s impact on health, andthe discussion of the main challenges to aguarantee of sustainability. We conclude by

From the:

1

Centre for Addictions and Mental Health, Canada

2

University of Toronto, Canada

3

Ministerio Del Poder Popular Para La Salud,Caracas Venezuela

4

Universitat Pompeu Fabra, SpainCorresponding Author: Dr. Carles MuntanerEmail:carles.muntanerb@gmail.comConflicts of Interest: None declared.

Social Medicine (www.socialmedicine.info)

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Volume 3 Number 4, November 2008

suggesting that

Barrio Adentro

not only provides amodel for health care reform in other countries of the region, but that it also offers important lessonsfor countries throughout the world, including thosewith the most powerful economies.In conducting this study, a variety of politicalactors were interviewed who had been involved inthe development of the health system in bothVenezuela and Cuba. This included patients,officials from the Venezuelan Ministry of Health,doctors, and members of community healthcommittees. A review of the Venezuelan press,legislation passed by the government’s NationalExecutive, grey literature from the Ministry of Health, and official epidemiological registries wasalso performed. Finally, two of the authors of thisarticle also participated in the implementation of

Barrio Adentro

.Without a doubt, the different political,economic and cultural contexts of Latin Americancountries have influenced the recent developmentof their social policies. This would explain whythe development of social security systems,including health care, from the end of the SecondWorld War until the early eighties, was related tothe struggle and gradual organization of urbanindustrial workers (5, 6). It also helps in under-standing the impact of the various crises of globalcapitalism on the social policies of the continent,from the crisis generated by the breaking of theBretton Woods agreement to the mandates of structural adjustment policies imposed bymultilateral financial organizations (principally theWorld Bank, the International Monetary Fund, andthe Inter-American Development Bank) (5).

1

Structural adjustment programs, despite thelack of scientific evidence (7), were fundamentalin determining the changes carried out in healthsystems in the region during the 1990s. Financialorganizations promoted structural adjustmentprograms as an attempt to rectify the perceivedfailure of the State as guarantor of social protect-—————

1

See (10) (pg. 113-116) for a detailed discussion onthe political economy of Latin American descentinto indebtedness.

tion through the substitution of the free market asthe best mechanism to achieve economic andsocial prosperity (3). Reductions in stateexpenditures on health and the subsequentdeterioration of health services during the 1980swere drastic (1, 8), which justified the presen-tation in the 1990s of privately managed anddelivered services as the only viable option forhealth systems. It was in this context that theWorld Bank published the

World Development Report: Investing in Health

(9) in 1993 wherein itdefines the two main strategies for improvinghealth in countries with medium and low incomes:1) limit state investment in health care to reducecosts in order to form a macroeconomicenvironment beneficial for private sectorinvestments that facilitate economic growth, whichin turn should plausibly increase householdincome and subsequently reduce poverty; 2)promote competition and diversity in the fundingand delivery of health services by facilitatingincreased incorporation of the private sector. Thispublication constituted much more than anacademic exercise given the enormous politicaland financial influence of the World Bank in theformulation of public policies in the countries of the region and its role in directly funding healthreforms (4).The reforms introduced a variety of mechanisms for the administration and funding of health services and other areas of social protection,particularly pensions and attention to occupationalrisks. Furthermore, decentralization was promotedas a mechanism for abating the nationalgovernments’ involvement in efforts to facilitateprivatization. Numerous private entitiesmaterialized to administer resources for health,and there was an enormous increase in theparticipation of private sector in the delivery of health care services. The negative effects of theseneoliberal health reforms have been widelyreported (8, 10-13) and illustrate the fact that theonly beneficiaries have been transnationalcorporations based in Europe and North Americain alliance with the local elites involved in the

Social Medicine (www.socialmedicine.info)

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Volume 3 Number 4, November 2008

administration and delivery of health services andother aspects of social security (2, 3, 14).Although following different trajectories, theneoliberal reforms in health were implemented inthe majority of Latin American countries (4).Venezuela was no exception, and it is preciselyfrom this context, as described below, that a set of changes in health policy was initiated.

Policy Modifications and Neoliberalization of Health in Venezuela

2

Venezuela joined the neoliberal movement inLatin America relatively late, which some authorsattribute to the strength of its dominant oileconomy (15). In any case, apart from oil, Vene-zuela followed a pattern of deepening externaldebt between the end of the 1970s and the mid-1980s. The failure of policies intended to promoteequitable distribution of oil-generated earnings,the increase in the national debt and a decline inoil revenues during the 1980s contributed to thesocioeconomic crisis, which reduced 54 percent of the population to extreme or critical poverty by theend of 1989. That year, the Social Democrat,Carlos Andrés Pérez was elected president for thesecond time following a campaign in which hepromised the return of the economic boomexperienced in the 1960s, during his firstpresidency (15, 16).

3

Following the dictates of the dominantneoliberal ideology and using the justification of combating growing poverty, Peréz embarked onthe execution of a plan in agreement withrecommendations prescribed for the region by theWorld Bank and the International Monetary Fund.The plan, nicknamed

El Paquete

(The Package),involved profound reductions in publicexpenditure, privatization of public enterprises,increased opportunity for oil exploitation byforeign parties, liberalization of commerce and apoverty reduction program (16, 17). The initial—————

2

See analyses of the implementation of neoliberalism in Venezuela (14)

3

This was Pérez’s second presidency. His firstperiod in office was during the mid 1970s oil boom.

enthusiasm for the implementation of thesereforms soon faded; the policy quickly facedextensive popular opposition and Pérez wassubsequently removed from power in 1993following a trial for corruption(18). In terms of health care, this period saw the decentralization of a broad network of existing public services, withcontrol passing from the national government tosome regional governments. This accentuated theexisting fragmentation of providers and publicfunders of health services and accelerated theirdeterioration.After a transition government lastingapproximately one year, Rafael Caldera, aChristian democrat, won the 1993 electionspromising to discontinue the neoliberal policies. Inpractice, however, the opposite happened, with thefocus on a plan known as

Agenda Venezuela

,which followed the neoliberal recipe. TheVenezuelan government obtained two substantialloans for health reforms, one from the World Bankand the other from the Inter-AmericanDevelopment Bank (19, 20). Both sought to facil-itate a re-structuring of health-sector funding,preferably giving an increased role to privatefunding.The decentralization of high-demand healthservices, combined with the fiscal austerity of theearly 1990s, left the responsibility for themanagement of poorly equipped health facilitiesto regional governments, who indirectly favoredprivatization of many services through a variety of mechanisms, principally through “cost recovery”;in other words, users pay for services rendered(21-23). By 1997, 73 percent of healthexpenditures in Venezuela was private (21). Theclearly apparent deterioration of public healthservices was presented as an irrefutable rationalefor the initiation of radical reform of the healthsystem towards the end of that presidential period.The plan copied the Chilean and Colombianmodels of separating funding and delivery of services as well as tackling individual health careand population-based health care and promotionseparately. This stimulated private investment inhealth care by promoting capitalist competition

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