The Politics of Social Determinants of Health

The Case of Venezuela
Carles Muntaner, Joan Benach, María Páez Victor,
Edwin Ng, and Haejoo Chung

In 1999, newly-elected Venezuelan President Hugo Chávez initiated a farreaching social movement as part of a political project known as the
Bolivarian Revolution. Inspired by the democratic ideologies of Simón
Bolívar, this movement was committed to reducing intractable inequalities
that defined Venezuela’s Fourth Republic (1958-1998). Given the ambitious
scope of these reforms, Venezuela serves as an instructive example to understand the political context of social inequalities and population health. In
this article, we provide a brief overview of the impact of egalitarian policies
in Venezuela, stressing: (a) the socialist reforms and social class changes
initiated by the Bolivarian Movement; (b) the impact of these reforms and
changes on poverty and social determinants of health; (c) the sustainability
of economic growth to continue pro-poor policies; and (d) the implications of
egalitarian policies for other Latin American countries. The significance
and implications of Chávez’s achievements are now further underscored
given his recent passing, leading one to ask whether political support for
Bolivarianism will continue without its revolutionary leader.

In recent years, a growing body of research has begun to investigate the political
context of population health and health inequalities (1-4). These contributions
tend to focus on wealthy nations in North America, Europe, and Australia,
use comparative methods to contrast welfare regimes or welfare expenditures,
and evaluate the health effects of countries transitioning into democratic states
and capitalist economies. As a preliminary general statement, findings indicate
that social democratic countries are often most advantaged in absolute health
International Journal of Health Services, Volume 43, Number 3, Pages 537–549, 2013
© 2013, Baywood Publishing Co., Inc.


g. a recent literature review among 73 empirical studies on politics and health found that less than 15 percent of reviewed studies had conceptualized political traditions and dynamics as macro-social determinants of health (2).g. (c) the sustainability of economic growth to continue pro-poor policies. and arrangements of social class power (e. Given the dearth of attention that has been paid to power politics.g. corruption.538 / Muntaner et al. and transitions into capitalist and neoliberal economies are associated with increases in health inequalities (1). Although case studies are an underused research design in comparative social epidemiology. welfare and democratic states) as opposed to ideological and power relations (e. With this said.g. this unit-specific approach allows us to move beyond asking whether politics and health are related. working-. outcomes. the judicial system. affect social inequalities in health. and revolutionary forms of power. the historical importance of understanding Venezuela’s social and public health achievements as accurately as possible has gained added significance since Hugo Chávez. for example. state versus private ownership of means of production). an under-researched theme in extant literature is the effect of political traditions and dynamics. the movement’s central figure. on social inequalities and population health. Brazil). and (d) the implications of the Bolivarian Movement for other Latin American countries. increases in welfare expenditures correspond with improvements in health outcomes (3). strong leftist political parties and trade unions facilitate the development of strong welfare states). advanced and liberal democracies tend to be healthier than non-democratic states (2). In this article.. 2013. Although politics is essentially about power. participatory democracy and socialism versus liberal democracy and neoliberalism). understood as left-right ideologies. We do not analyze here the shortcomings of the Bolivarian process. we use a case study approach to describe the possible effectiveness of egalitarian policies in reducing inequalities and improving health in Venezuela circa 1999. consumerism... to consider how political movements and configurations unfold to reorganize social structures and institutions that. given that they have been widely covered in the media and academic literature (including. violent crime in Caracas. we provide a brief overview of the impact of egalitarian policies in Venezuela. more work is needed to understand the social and health consequences of different political systems and ideologies (e..g. forms of productive ownership (e. but not necessarily in terms of health inequalities (2).g. To this end. . and middle-class versus uppermiddle-class/capitalist class coalitions).. most politicallyoriented research focuses on institutionalized systems (e. and urban planning). lower-.. mass movements. Argentina. (b) parallel changes in poverty levels and social determinants of health. For example. stressing: (a) the socialist reforms and social class changes initiated by the Bolivarian Movement. in turn. passed away on March 5. Despite these contributions. It is also important to note that some of the social progress attributed to the Bolivarian Revolution has also been experienced by other Latin American countries in recent years (e.

nutritious. hospital services. progressive reforms ranged from education (e. Bolivarian Missiones were largescale investments designed to increase the availability and quality of social determinants of health to the poorest and most marginalized individuals in Venezuela.” emphasizing state ownership of private factories and the establishment of co-operatives.g. Even though governmental pledges to reduce poverty are . Chávez set forth a political agenda grounded in the idea of “21st-century socialism.g. housed.. and organic food) to economic development (e.g. In doing so.. and increasing access to postsecondary training) and food and nutrition (e. by his Bolivarian government’s commitment to and effectiveness in reducing absolute and relative forms of deprivation. Comprehensive in scope and ambitious in design. ensuring functional and numerical literacy among adults.. Chávez and his government sought to redress the inequalities that characterized Venezuela’s Fourth Republic (1958-1998). reorienting economic productivity to first meet the social and welfare needs of the marginalized) and health care (e. and educated to improve their living conditions and well-being). on the other hand. the poor are fed. The decision for Chávez to use his political power to increase the state’s role in the economy and to invest government revenues to reduce inequality signified a radical shift from the modus operandi of previous administrations. At its core. Through a number of socialist reforms. could be approached and rectified through state interventions (e.. Chávez changed in fundamental ways how social inequalities.g. the poor are left to their own devices to secure an acceptable standard of living) and how these social injustices. however. in large part. his popularity soared in Venezuela and soured in Washington... RESTRUCTURING PRODUCTIVE ENTERPRISES FOR THE PUBLIC GOOD RATHER THAN PRIVATE GAIN Chávez’s popularity can be explained. has yet to be properly recognized or understood by the media or the public. supporting high school dropouts. Less acknowledged are the underlying reasons for Chávez’s repeated landslide victories and continued popularity over the past decade. which favored the private market as the primary arbiter of public goods. First elected as president in 1999. safe. and preventive resources). providing free community health care. on one hand. known as Bolivarian Missiones. Chávez still won by an impressive 11 points.g. As Chávez re-prioritized the human needs of the marginalized before the wants of the privileged. despite receiving waves of media criticism from both sides of the Atlantic. Sick with cancer and assailed by the media. were generated and reproduced through market mechanisms (e. The election’s significance. Hugo Chávez and his Bolivarian government were re-elected for a historic fourth term.g.Egalitarian Policies in Bolivarian Venezuela / 539 THE BOLIVARIAN REVOLUTION AND “21ST-CENTURY SOCIALISM” Last year. improving access to high-quality.

S. By owning this productive property. controlled. the Bolivarian government has increased social spending by an impressive 60. most initiatives fall well short of elevating a significant number of individuals. profits were earmarked for the purpose of reducing unfair and avoidable inequalities. for example. Johnson’s “War on Poverty” legislation in 1964 or U. and food security) and their beneficial impact on various health outcomes. commonplace (e. and benefited from Venezuela’s most productive enterprises. .. as previous governments had done. Next. and communities out of poverty. we provide a descriptive review using the best available data on the equalizing effects of egalitarian policies (e. the Venezuelan government was able to use abundant oil revenues for the benefit of its people. and health services. education..g.K. increasing access to education or health care) is partly explained by the fact that these measures. President Lyndon B. education. In 2003. which have reduced poverty and improved health by increasing the availability and quality of social determinants of health. It follows that for inequalities and poverty to be significantly reduced. U.A. REDUCING POVERTY AND IMPROVING HEALTH THROUGH SOCIAL DETERMINANTS OF HEALTH Poverty and health. income transfers.. Rather than allowing profits to benefit a small class of elite renters. while well-intentioned. income inequality and poverty. families. the Bolivarian Revolution in Venezuela set in motion a sequence of social processes.g. to what degree are workers treated as market commodities.540 / Muntaner et al. changes are needed in terms of who exercises control over productive enterprises.6 percent. In this respect. are often disconnected from political and economic institutions that unevenly distribute power to some at the expense of others. 6). Over the past decade. in that poverty and health are determined by a series of social processes. a total of US$772 billion (5. respectively. the state assumed ownership of Petróleos de Venezuela. one of the world’s largest and most profitable oil and national gas companies.g. such as building essential infrastructures and investing in social. are not solely defined by a lack of income or the absence of illness. Prime Minister Tony Blair’s 1999 commitment to halve and eliminate child poverty by 2010 and 2020). Income Inequality and Poverty The effectiveness of Venezuela’s anti-poverty reforms is evidenced by the fact that it has the most narrow income distribution. The ineffectiveness of conventional anti-poverty measures (e.. Chávez was able to significantly reduce poverty by changing who owned. Both are correlated and multi-factorial. rising from less than US$10 a barrel in 1999 to more than US$100 this year. as measured by the Gini coefficient. and how valuable resources are distributed between social classes. S. The value of oil has also increased during the tenure of the Bolivarian government. Within this context.

rates of poverty and extreme poverty have seen large declines during the Bolivarian Revolution (8.5 million seniors received an old-age pension. by 49. Since tuition-free education was made available from daycare to university. Food Security While 21 percent of the Venezuelan population was malnourished before the Bolivarian government took office in 1998. in terms of the proportion of students enrolled in post-secondary institutions (16).7 percent. Income Transfers for Seniors. the number of Venezuelan seniors on state pension rolls was 387. extreme poverty declined from 16. the state pension system grew by more than 600 percent. Extreme poverty follows the same trend. the decline has been 70 percent (7). poverty has fallen from 42.8 percent of households to 26. In 2011.7 percent (10).6 percent to 7. Since 2004.6 percent decline. respectively.0 percent. through the country’s social security institute (12). By 2012. malnutrition dropped to 6 percent in 2007 (17) and to less than 3 percent in 2012 (14). adjusted to the country’s minimum wage. approximately 20 million Venezuelans have benefited from various anti-poverty programs (11). school enrollment has exploded: 72 percent of children attend public daycares and 85 percent of schoolaged children are enrolled in school. In addition. representing a 57. representing a 37. To date. child malnutrition . education spending now accounts for 10 percent of Venezuela’s gross domestic product (GDP) (13). Since 2004.Egalitarian Policies in Bolivarian Venezuela / 541 among all Latin American nations. Venezuela’s Gini coefficient fell to 0. when the Chávez government took control of the oil industry. The number of new or refurbished schools has reached the thousands. From 1999 to 2011. and Disabled People Prior to 1999. unemployed women and disabled individuals began receiving income transfers equivalent to 80 percent of the minimum wage to ensure acceptable standards of living among those most socially excluded in Venezuela (14).5 million Venezuelans basic literacy skills (14) and have elevated Venezuela to third place in the region in terms of reading frequency (15). Under Chávez’s egalitarian tenure. the poverty rate fell even faster. educational reforms known as the Misión Robinson I have taught 1. 2. As a result. Since 1999.000. Consistent with the United Nations Educational.8 percent decline. Similarly. 9). Venezuela now ranks second and fifth in Latin America and the world. Education The Bolivarian government identified education as a major determinant of both poverty and health.39 (7). Similarly. including 23 new post-secondary institutions. Scientific and Cultural Organization’s call to further reduce illiteracy. Women.

dropping from a high of 90 percent in 1980 to a current low of 30 percent. osteoporosis. from 7. and 6. a primary health care program.000 live births in 1990 to 13 per 1. several important agrarian reforms have empowered agricultural producers to increase the overall domestic supply of food.000 farmers have joined the program (20). A review of extant literature provides preliminary support for the link between egalitarian policies and various public health outcomes. which represents a 41 percent increase from 1999 to 2012 (24). an important question is whether these investments have resulted in improved health outcomes. Venezuela’s commitment to establish a network of subsidized food systems has increased the overall accessibility and affordability of healthy foods in grocery stores and supermarkets. has saved more than 1. . including cancer. including 4 million children in schools. 3 million hectares of farming land have been redistributed (14). • The density of physicians increased 400 percent. Since the launch of Misión Agro-Venezuela in 2011.081 health clinics. Misión Barrio Adentro.2 percent in 2010 (18).5 million lives (25) and carried out 534 million medical consultations (14).000 food kitchens feed 900. an increase of 169. has decreased by 58. AIDS.000 population in 2010 (14). As a result. • While previous Venezuelan governments took four decades to build 5.5 percent.000 people (21). • National supplies of clean drinking water are now available to 96 percent of the population. and more than 150. the Bolivarian government has built 13. • Since Chávez came into power in 1999. • Over the course of nine years. Moreover. approximately 650. from 20 doctors per 100. schizophrenia.721 health clinics in 13 years.542 / Muntaner et al.7 percent in 1990 to 3.000 live births in 2010 (23). The effectiveness of these food security measures was acknowledged by the World Health Organization in its recognition that Venezuela has been the most successful country in Latin America and the Caribbean in eradicating hunger (22). the country’s production of staple crops and the amount of land under production have both increased (19).000 patients have received expensive medications for free to treat 119 pathological conditions. Subsidizing food production has significantly reduced the amount of food imports.6 percent (22).000 population in 1999 to 80 per 100. Public Health and Health Care As Venezuela has devoted a larger share of its economic resources to meeting the social and welfare needs of its population. Improved outcomes include but are not limited to the following: • Infant mortality rates dropped from 25 per 1. and other serious ailments (26). 5 million Venezuelans now receive free food.

500 billion barrels). To the extent that Venezuelans supported Chávez’s socialist agenda. the forming of 30. • Misión Milagro. POPULAR DEMOCRACY AND ECONOMIC RESTRUCTURING An integral part of understanding Venezuela’s commitment to increased social spending and improved public health infrastructure involves the intense political participation that characterizes the country’s democratic institutions and systems. and therapies for malaria and Chagas.e.000 people homeless. an eye care program developed in 2004.g. and empowering individuals to be active agents in bringing about desired changes (31). 33). In 2011. 24.5 million Venezuelans suffering from cataracts or other eye diseases (30). similar dire predictions . Western economists. This includes. such as insulin.. they shared a strong ideological preference to use government resources to improve the living conditions of low-income and marginalized populations. repeat ad nauseam that Venezuela’s economic development is unsustainable and will stagnate once oil revenues cease. these individuals were sheltered temporarily in all manner of public buildings and hotels (32. high crime rates). building 346. antibiotics.000 homeless adults and children have received essential services through a specialized anti-homeless program known as Misión Negra Hipólita (27). with 46 beds. who oppose Chávez. Strong institutions and councils have increased the Bolivarian government’s willingness and responsiveness in serving its citizens. the Bolivarian government launched a comprehensive housing program. and a large amount of savings. heavy tropical rains left a staggering 100. • Essential medications. high petroleum reserves. overseeing progress. has restored sight to 1. Not unlike other democratic states. However.000 homes in 18 months to address this housing shortage (34). In the short term.000 communal councils. are heavily subsidized below market value and made available through a network of public drugstores (29). which are charged with determining local needs. what differentiates Venezuela is that its citizens recognized that the actions of the Bolivarian government were intended to benefit the marginalized and not a small group of elites. Although Venezuela’s economy is characterized by low debts.. In the long term. Venezuelans who were socially excluded in the past were engaged to be active participants in the country’s democratic process and social development. The Bolivarian government’s commitment to egalitarianism has raised concerns about the economic sustainability of redressing deep inequalities.Egalitarian Policies in Bolivarian Venezuela / 543 • Over the past seven years. for example. Chávez and his socialist government have far from eradicated social problems in Venezuela (e. 32 for adults and 14 for children (28). Despite the fact that Venezuela boasts one of the largest oil reserves in the world (i. • Venezuela now boasts the largest intensive care unit in Latin America. for example.

is misguided.5 percent of GDP. the country’s GDP per person has grown by an average of 2. In 2011. Given that the average external debt among European Union nations is 82.7%) and total public debt (30. Since the state strengthened its capacity to collect taxes.7% of gross national product to 14. Venezuela’s economy under Chávez has benefited from the improved infrastructure. Another development that reflects the sustainability of Venezuela’s economy can be seen in its increasing diversification in generating revenues. Often missing from these critical appraisals is the fact that the Bolivarian government has built a new industrial and agricultural infrastructure since Chávez came into power.3 percent of GDP.406 million bolívares.6 percent in the first half of 2012.3% to 7. Such economic figures would arouse envy among any Organisation for Economic Co-operation and Development country in North America or Europe. which accounted for more than the petroleum income (35). Critics are also quick to argue that investing oil revenues to achieve social goals. Even The Wall Street Journal reports that Venezuela’s stock exchange is among the best-performing stock markets in the world. which has contributed to steady economic growth even during the current global financial crisis (10). an endemic problem for many decades. Because previous administrations had neglected such foundational investments. have repeatedly proven wrong … Venezuela’s current economic growth is sustainable and could continue at the current pace or higher for many years. Economic milestones during the Bolivarian Revolution include significant reductions in the national unemployment rate (11.” According to Global Finance. which amounts to 396. the Venezuelan economy defied most forecasts by growing 4. Venezuela’s economic burden in 2012 was 51. reaching .3% of gross national product) (36).2 percent and was up 5. It has a debt-to-GDP ratio comfortably below the United States and most European nations. In terms of external debt. balance of payments or debt crises and other gloomy prognostications. but also created new opportunities to distribute income and wealth more equally among social classes. and its overall GDP has increased by an impressive 24 percent (37).7 percent in 2012. the main source of income in the 2013 national budget. has fallen to a four-year low of 13. as well as many economic forecasts along the way. Venezuelan co-operatives have grown in number and have been strengthened by local. Diversifying revenues not only increased the nation’s wealth.544 / Muntaner et al.5 percent annually (10). wasteful. was derived from non-oil and gas sources. Venezuela’s economy appears to be comparatively stable (37). According to Weisbrot and Johnson (10): “[t]he predictions of economic collapse. Since 1999. and unproductive. as opposed to profit-driven capitalist ones. Its inflation rate. it now generates revenue from tax collection in addition to the sale of oil. are not levied against other oil-rich economies such as Canada or Saudi Arabia. Venezuela’s unemployment rate is 8 percent. endogenous economies (38). Since 2004. In fact.

D. has channeled US$100 million to opposition groups in Venezuela.. and TELESUR. Nevertheless. In concrete terms. Questions abound. leaving the future of the Bolivarian Revolution in serious doubt. whether his political party.S. UNITING LATIN AMERICA AND CURBING THE INFLUENCE OF WASHINGTON The socialist politics of Chávez’s government have not only spearheaded radical change in Venezuela. Ecuador.g.or long-term future of Bolivarianism. In this sense. and Bolivia) to elect progressive governments. The tide of progressive change unfolding among Latin American nations is collectively building the necessary infrastructure for a genuinely independent South America.. UNASUR. Although it is too soon to predict the short. THE FUTURE OF BOLIVARIANISM WITHOUT CHÁVEZ During the preparation of this manuscript. MERCOSUR. the example of Venezuela since 1999 carries a heightened sense of importance given its achievements to date and its uncertain future. will maintain its popular support. Chávez and his Bolivarian government have invested heavily in the social determinants of health. With support from political integration organizations such as the Bank of the South. Nicaragua. Chávez passed away on March 5. disregarding the negative rhetoric that was disseminated through Venezuela’s 95 percent privately-owned. PETROCARIBE. CELAC. and what direction “21st-century socialism” will head toward under new leadership. the Fifth Republic Movement. the example of Venezuela demonstrates to the rest of the world that there are real and feasible alternatives to instituting more equality and developing economically in the 21st century (41). including who will succeed Chávez as president. Following a different model of economic development that diverges from the finance capitalist-led austerity economics in Europe. 2013. Chávez was still able to be re-elected last year despite the enormous financial and strategic help that U. Washington. agencies and their allies gave to opposition parties and the right-leaning media. the egalitarian ideals that Chávez championed are far too significant to end with his passing. Since 2002. PETROSUR. which have . Growing support and backing for leftist movements in this region is somewhat unexpected given the extent of foreign interests and influence. For example. The political and social changes that have taken place in Venezuela are neither abstract nor intangible. while Venezuela’s bonds are some of the best performers in emerging markets (9). the majority of voters still supported Chávez. but have also inspired other Latin American nations (e. anti-Chávez media (40). US$40 million to US$50 million of which was distributed last year alone (39).C. Venezuela and other Latin American nations have been able to grow steadily and invest in social equality while lowering debt levels.Egalitarian Policies in Bolivarian Venezuela / 545 an all-time high in October 2012. ALBA.

The Economist. by a National Research Foundation of Korea grant funded by the Korean government (MEST) No. Rev. This new model of development has had a phenomenal impact all over Latin America. . It has become cliché for academics to implicate a “lack of political will” as the explanation for why effective policies or interventions are not implemented to reduce social inequalities in health. At the same time. J. Epi + demos + cracy: Linking political systems and priorities to the magnitude of health inequities—evidence. Acknowledgments — An abridged version of this article was originally published in Counterpunch. Paying more attention to the past achievements of the Bolivarian Revolution will augment our understanding of how egalitarian politics has the power to transform unequal societies into more equal ones. 2009. Applying a neoliberal lens to understand the experience of Venezuela does nothing to dispute the facts of reduced poverty and improved public health. December 14-16.546 / Muntaner et al. preferring instead to repeatedly predict the imminent collapse of its economy. we have a unique and current example of what happens when political will is present and policies committed to alleviating human suffering are implemented in a short timeframe. However. El Pais. including Colombia of late. 2012S1A5A8022889.000 protesters were slaughtered for voicing dissent against austerity measures in Caracas). decidedly ignores stories about trends toward greater equality and better health. given that progress has been achieved. Beckfield. and the left-of-center governments that are now the majority in the region see in Venezuela the catalyst that has brought more democracy. This work was supported.. N. national sovereignty. Unresolved debates on whether the Bolivarian Revolution is guided by socialism or whether Chávez’s movement is revolutionary or reformist are moot discussions at the end of the day. For example. and Krieger. it is widely accepted that taking real action on the social determinants of health is often thwarted by insufficient levels of political will. 2012. The Spanish publication. 31(1):152–177. Epidemiol. and economic and social progress (43). Instead. dramatically improved the living conditions of many Venezuelans. gaps. the supposedly “objective” and “empiricist” magazine. it devotes its pages to anti-Chávez diatribes by a journalist who served as one of the main architects of the Caracazo (in 1989. REFERENCES 1. has not and will not publicize data that speak to Venezuela’s achievements. in part. 3. This is exactly what infuriates critics within Venezuela and detractors from neocolonialist countries. Although a solid knowledge base on why some people are healthy and others are not has been established. Chávez successfully and dynamically engaged Venezuelans to actively participate in the political process to achieve the country’s egalitarian goals (42). and a research agenda. in the case of Venezuela.

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