Bolivia - Health and Social Security

Health and social security

From the mid-1970s to the mid-1980s, Bolivia made slow but steady progress in improving the health conditions of its population. Life expectancy rose from forty-seven years in 1975 to nearly fifty-one years in 1985. During the same period, the mortality rate dropped from 18.4 to 15.9 per 1,000 population, while the infant mortality rate dropped from 147.3 to 124.4 per 1,000 live births. The mortality rate in children one to four years of age dropped from 14.6 per 1,000 population in 1975 to 10.9 per 1,000 by 1980. Despite these improvements, however, in the mid-1980s Bolivia's health indicators were among the worst in the Western Hemisphere. Its life expectancy was the lowest in the Western Hemisphere, and its infant mortality rate was third after that of Peru and Haiti. An estimated 70 percent of the population suffered nutritional deficiencies. Only 43 percent had access to a safe water supply. Barely 24 percent could avail themselves of adequate sanitary facilities.

Health conditions varied significantly across regions and, within regions, by urban or rural residence. For example, disaggregated infant and childhood mortality rates for the mid1970s revealed significant regional and urban/rural disparities. Infants in the rural parts of the Altiplano, valleys, and Yungas had a far greater probability of dying than those in the urban lowlands. Mortality rates for children up to the age of five in the departments of Potos� and Chuquisaca were nearly double those found in the departments of Santa Cruz and Beni. Analysts also noted disparities in rates among ethnic groups. Rates were highest among children of mothers who spoke only an indigenous language, intermediate among bilingual mothers, and lowest among monolingual Spanish-speaking mothers.

Gastrointestinal diseases, measles, and respiratory infections caused 80 percent of infant mortality. An ambitious vaccination program in the early 1980s brought a significant decline in the number of cases of poliomyelitis, whooping cough, tetanus, and measles. The number of cases of diphtheria climbed, however, during the early 1980s.

Bolivian health specialists also confronted a variety of diseases that affected the general population. A national survey in the early 1980s revealed the presence of the vector responsible for Chagas' disease in the homes of 26 percent of the population. The number of cases of malaria--primarily found in Beni, Santa Cruz, Tarija, and Chuquisaca departments--rose from 9,800 in 1981 to 16,400 in 1984. In 1984 the government organized a mass campaign in an effort to deal with a malaria epidemic in Beni Department. In 1983 the government also organized a major yellow fever vaccination program; the number of cases of jungle yellow fever declined from 102 in 1981 to 5 in 1984. Pulmonary tuberculosis remained a serious concern; over 9,400 cases were reported in 1981. In addition, during the 1970s over 360 miners per year died from silicosis. Finally, as of 1987 Bolivia reported six cases of acquired immune deficiency syndrome (AIDS).

In the mid-1980s, the government was restructuring its health care system to allow for a more effective delivery of services. Bolivia's health network traditionally had been characterized by a high degree of fragmentation and duplication of services. Although the Ministry of Social Services and Public Health had overall responsibility for the system, ten separate social security funds offered health services to members insured through their place of employment. In addition to wasting scarce resources, this approach had a heavy urban bias. The new approach called for a unified system under the control of the Ministry of Social Services and Public Health, with emphasis on preventive rather than curative medicine.

The total fertility rate (the number of children a woman expected to bear during her reproductive life) was 6.0, and the crude birth rate (per 1,000 population) was 43 in the late 1980s. Both had declined but remained higher than those of neighboring countries. Fertility was highest among rural women, non-Spanish speakers, and women with little or no education. Roughly onequarter of all married couples were using some form of family planning.

Bolivia's booming cocaine industry was also spawning serious health problems for Bolivian youth. In the 1980s, Bolivia became a drug-consuming country, as well as a principal exporter of cocaine. Addiction to coca paste, a cocaine by-product in the form of a cigarette called pitillo, was spreading rapidly among city youths. Pitillos were abundantly available in schools and at social gatherings. Other youths who worked as coca-leaf stompers (pisadores), dancing all night on kerosene and acid-soaked leaves, also commonly became addicted. The pitillo addict suffered from serious physical and psychological side-effects caused by highly toxic impurities contained in the unrefined coca paste. Coca-paste addiction statistics were unavailable, and drug treatment centers were practically nonexistent.

Social security coverage began in the early twentieth century when legislation created pension funds for teachers, the military, bank employees, and civil servants. The prototype for modern coverage came in the late 1940s and early 1950s with laws covering such benefits as disability insurance, maternity care, medical care, pensions, and funeral benefits. The Social Security Code of 1956 provided assistance for sickness, maternity, occupational risks, long- and short-term disability, pensions, and survivors' benefits.

In the late 1980s, social security programs only covered roughly 20 percent of the population (counting families of insured workers). Agricultural workers and the self-employed--a significant portion of the working class--were excluded. The percentage of the population covered was highest in the mining department of Oruro (43 percent) and lowest in the departments of eastern Bolivia.

Worker and employer contributions financed most benefits. Taxes provided additional money for some of the smaller funds. Since the mid-1960s, retired workers in many industries had established complementary pension funds to help protect their retirement benefits from the effects of inflation.

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[Basic health security in Bolivia. Interview with the