Mission Barrio Adentro - Pan American Health …experiment in primary health care (PHC) strategy....

Mission Barrio Adentro: The Right to Health and Social Inclusion

In Venezuela

Pan American Health Organization

Caracas, Venezuela. July 2006

Center for Documentation and Information. PAHO Venezuela. Cataloguing in source.

Mission Barrio Adentro: The Right to Health and Social Inclusion in Venezuela. Caracas: PAHO/Venezuela, 2006.

1. Primary health care 2. Venezuela

© Pan American Health Organization, 2006

The material included in this publication may be cited or reproduced without restriction as long as the source and ISBN number are mentioned.

Address: OPS/OMS, 6ª Av. entre 5ª y 6ª transversal, Altamira. Caracas, Venezuela. Telephone: (0212) 206 5022Fax: (0212) 261 6069E-mail: [email protected]: http:/www.ops-oms.org.ve

Editorial committee:

Arachu Castro (Harvard University)Renato d'A. Gusmão (Pan American Health Organization)María Esperanza Martínez (Central University of Venezuela)Sarai Vivas (Central University of Venezuela)

Authors and authors:

Carlos Alvarado (Ministry of Health)César Arismendi (Ministry of Health)Francisco Armada (Ministry of Health)Gustavo Bergonzoli (Pan American Health Organization)Radamés Borroto (Cuban Medical Mission)Pedro Luis Castellanos (Pan American Health Organization)Arachu Castro (Harvard University)Pablo Feal (Cuban Medical Mission)José Manuel García (Ministry of Health)Renato d'A. Gusmão (Pan American Health Organization)Silvino Hernández (Cuban Medical Mission)María Esperanza Martínez (Central University of Venezuela)Edgar Medina (Ministry of Health)Wolfram Metzger (University of Tübingen)Carles Muntaner (University of Toronto)Aldo Muñoz (Cuban Medical Mission)Standard Núñez (Ministry of Health)Juan Carlos Pérez (Cuban Medical Mission)Sarai Live (Central University of Venezuela)

Cover photo: Cuban medical equipment in Caricuao, Caracas. April 2006. Photographer (cover and inside): Arachu Castro.

ISBN: 980-6678-02-8

Legal Deposit: lf645200663283Caracas, Venezuela. July 2006.

Foreword

The volume you have in your hand and are about to read - Mission Barrio

Adentro: The Right to Health and Social Inclusion in Venezuela- is a much-

needed, stimulating, and challenging book. It is also an enjoyable book. I recommend

it enthusiastically.

This book is needed because, despite the stories that abound, there still is a

fair amount of ignorance about the Barrio Adentro experience. Although it has been

the topic of much conversation, little is really known. The book comes at a propitious

time to fill the gap in knowledge about this interesting and important Venezuelan

initiative to extend the benefits of health protection to all the country's citizens. In

simple and direct language, it offers an appropriate balance between exposition and

testimony, between technical analysis and political rationale, and between the

initiative's background, growth, and achievements, on the one hand, and, on the

other, the challenges that have had to be addressed in the course of this new

experiment in primary health care (PHC) strategy.

Mission Barrio Adentro is primary health care in its essential form. It is a

strategy for restructuring and transforming the entire health system. It is primary

health care as conceived by Halfdan Mahler and David Tejada the leaders behind

the conference at Alma-Ata. Barrio Adentro was born exactly 25 years after that

seminal gathering.

Although Barrio Adentro is a Venezuelan phenomenon, I see it as the

culmination of 25 years of experience in Latin America and the rest of the world in

transforming health systems through the primary health care strategy. It has been

built on the achievements and failures of many countries working toward the goal of

Health for All. The story of this 25-year effort in our Region has been captured in a

critical review prepared in 2005 by the countries of the Americas with the support of

the Pan American Health Organization (PAHO).

The 25-year trajectory since Alma-Ata have has certainly been dynamic,

though not always in the sense of progress toward achieving the goal of Health for All.

The “missing decade” of the 1980s, the foreign debt crisis, military dictatorships and

the struggle to recapture democracy, dominance of the free-market mentality and its

Organización Panamericana de la Salud. Renovación de la Atención Primaria de la Salud. Documento de posición de la OPS/OMS, Washington DC. Diciembre 2005.

1

1

Foreword

neoliberal structural reforms these trends and events have formed the backdrop

against which our peoples have struggled to improve their level of health through

social justice and the building of a newly empowered citizenry.

In our Region, primary health care has gone through the same vicissitudes as

the countries themselves. Even so, the public health sector has upheld the banner of

Health for All, and now, with the support of PAHO, a number of countries have

succeeded in integrating the primary health care model into their social and political

processes. Examples are health sector reforms in Brazil and Costa Rica, re-

establishment of a unified health service in Chile, the Cuban system with its many

strengths, the conference on health and life in Ecuador, numerous national public

health conferences, the Central American initiative “Health: A Bridge to Peace,” the

development of legal frameworks to facilitate citizen participation, decentralization

and empowerment of local health systems in many countries, community-based

rehabilitation, healthy municipios, and many other experiences. Mission Barrio

Adentro is an in this same tradition which has involved both the State and the people.

While in some regions of the world the primary health care strategy may be

faltering, in Latin America and the Caribbean, with the persistence of PAHO and its

supporters, its value is recognized and the momentum remains strong. Our regional

consultation on primary health care affirmed that building health systems based on

this strategy is the essential condition for achieving equity and universality, extending

social protection in health, and ultimately, guaranteeing Health for All. Within this

framework, Mission Barrio Adentro is an innovation and a very important

contribution.

This is a stimulating book because its statements and practices are new and

bold. For example, this experiment in bilateral cooperation between two sister

countries on an unprecedented scale shows us what can and is being done to

address some of the challenges that are faced by almost all our countries: to create a

comprehensive care model that emphasizes both health promotion and disease

prevention; to implement broad-scale primary health care in urban areas; to form

integrated service networks, and to develop an innovative infrastructure of

establishments that is capable of supporting the PHC strategy, new mass human

resources education programs, and modalities and dynamics for citizen participation

in building the missions and also capable of ensuring the viability and continued

growth of this experiment. Barrio Adentro is already a recognized reference point for

those seeking innovative social approaches for improving access to large-scale

services in the short term using the primary health care strategy. Barrio Adentro

shows that a number of different objectives can be achieved through political will and

citizen support, that financial resources derived from national wealth can be invested

quickly and appropriately in improving the life of the population, and that significant

change can be brought about in the operation of health systems.

This is a challenging book that will fuel greatly needed debate for two reasons.

First, because it is the product and reflection of a different political and social

experience, an alternative to current conventional approaches that specifically

challenges free-market fundamentalism. And second, because Barrio Adentro is an

original experiment, framed outside the conventional textbooks on social and public

health policy. The book highlights this difference and invites healthy and needed

debate. It is a book for discussion, and I am sure it will be discussed vociferously in

schools of public health. The novelty of the approach, the scale of the experience, its

political roots, its technical assumptions all these aspects inspire scientific debate.

This book is welcome because brings some fresh air to the cloisters of the schools of

health sciences and public health and why not? the academic programs on health

administration and health economics.

And last but not least, it is an enjoyable book and a good companion. It is an

easy read, and the language is sincere, with a touch of urgency. I enjoyed reading it,

and I am certain of that many others will find it enjoyable as well. I found that reading it

was a useful exercise, and I hope that this opinion will be shared by politicians

responsible for deciding on the health of the populations, public health specialists,

health workers, and citizens in general who live inside, behind, above, and at the

deep core of … Barrio Adentro!!

Mirta Roses Periago

Director, Pan American Health Organization

Regional Office of the

World Health Organization

Foreword

Contents

Introduction .................................................................................................................................... 3

Chapter 1 ......................................................................................................................................... 6

Venezuelan Health Care Models and Social Exclusion ................................................................. 6

THE HEALTH OF VENEZUELANS PRIOR TO MISSION BARRIO ADENTRO ................................. 7

REVERSAL OF EXCLUSION IN THE HEALTH SECTOR: FIRST STEPS

AND PRELIMINARY RESULTS ...................................................................................................... 16

THE SPIRIT OF ALMA-ATA IN VENEZUELA ................................................................................... 19

Chapter 2 ....................................................................................................................................... 23

Origin of Barrio Adentro and Citizen Participation ...................................................................... 23

CRISIS IN THE VENEZUELAN HEALTH SYSTEM ......................................................................... 24

ARRIVAL OF THE FIRST CUBAN PHYSICIANS IN BARRIO ADENTRO ........................................ 25

THE FIRST OBSTACLES ENCOUNTERED BY BARRIO ADENTRO ............................................. 31

EXPANSION OF BARRIO ADENTRO: TOWARD COMPREHENSIVE HEALTH CARE .................. 33

BARRIO ADENTRO AS A RESPONSE BY THE STATE AND ORGANIZED SOCIETY .................... 35

CITIZEN PARTICIPATION AND THE HEALTH COMMITTEES ....................................................... 36

Chapter 3 ....................................................................................................................................... 45

Development of New Networks within the National Public Health System ................................ 45

BARRIO ADENTRO IN PRACTICE ................................................................................................. 46

TOWARD THE NEW NATIONAL PUBLIC HEALTH SYSTEM ......................................................... 49

Network of Outpatient Care and Popular Clinics .............................................................................. 50

Popular Medical Dispensaries and Consultation Points ................................................................... 53

Rural and Urban Outpatient Care Services ...................................................................................... 57

Popular Clinics ................................................................................................................................ 57

Diagnostic Centers ......................................................................................................................... 58

Rehabilitation Centers .................................................................................................................... 59

Dental Clinics .................................................................................................................................. 60

Popular Pharmacies ....................................................................................................................... 60

Vaccination Points ........................................................................................................................... 61

Optical Centers ............................................................................................................................... 62

Emergency Network ....................................................................................................................... 62

Hospital Network ............................................................................................................................. 62

COORDINATION OF BARRIO ADENTRO WITH OTHER SOCIAL MISSIONS ............................... 63

Contents

Chapter 4

Lasting Legacy of Barrio Adentro and Human Resources Development .................................. 71

TRAINING IN COMPREHENSIVE COMMUNITY MEDICINE ......................................................... 72

TRAINING IN STOMATOLOGY AND COMPREHENSIVE GENERAL DENTISTRY ....................... 79

TRAINING IN COMPREHENSIVE COMMUNITY NURSING .......................................................... 80

Chapter 5

Impact of Barrio Adentro .............................................................................................................. 83

ACCESSIBILITY OF CARE UNDER BARRIO ADENTRO ............................................................... 85

DISTRIBUTION OF PRIMARY HEALTH CARE PROFESSIONALS ............................................... 87

HEALTH PROMOTION ................................................................................................................... 90

Training of Health Promoters ........................................................................................................... 91

Training and Operation of Specific Groups or “Clubs” ....................................................................... 94

Health Promotion Activities ............................................................................................................. 99

PRENATAL AND CHILD CARE ..................................................................................................... 102

CHRONIC DISEASE CARE .......................................................................................................... 102

Hypertension ................................................................................................................................ 105

Diabetes ....................................................................................................................................... 106

Ischemic Heart Disease and Cerebrovascular Disease ................................................................. 108

Bronchial asthma .......................................................................................................................... 109

DENTAL CARE ............................................................................................................................. 110

OPHTHALMOLOGIC CARE ......................................................................................................... 112

CHILDHOOD ILLNESS ................................................................................................................. 114

List of Tables ............................................................................................................................... 124

List of Figures ............................................................................................................................. 126

References .................................................................................................................................. 127

Introduction

Mission Barrio Adentro is a key element in the proposal for social inclusion

embodied in the 1999 Constitution of the Bolivarian Republic of Venezuela (go to

annex 1) [1]. Although the Mission started out originally in 2003 as a humanitarian

medical and health care project undertaken in cooperation with the Republic of Cuba

in a limited neighborhood of Caracas, it grew to become a national public health

program committed to wiping out the national health care deficit. The dizzying

increase in health care coverage achieved in the space of less than a year was

possible thanks to the incorporation of thousands of Cuban physicians, technical

personnel, ophthalmologists, and dentists into this community health initiative. The

new model, based on responding to needs and the demand for services, offers an

alternative to the predominant models that are based on market competition and the

availability of services. After three years, it can be said that the Venezuelan

population previously excluded from the health system now has access to

comprehensive health care.

It is a policy of the Venezuelan State to enlist public health as a tool for social

transformation. From the beginning, Mission Barrio Adentro has captured the interest

of public health professionals, social scientists, and journalists around the world.

Barrio Adentro was created within the context of social transformation initiated in

Venezuela in 1998, the new corporate structure of which is reflected in the

Constitution of 1999. It includes a ban on the privatization of natural resources and

public services in the areas of health and education, the development of Social

Missions, equal access to learning, an endogenous development model, protection

of the environment, food security, and agrarian reform.

In terms of international economics, Venezuela favors a multipolar system; opposes

the premises of neoliberalism (considered to be a process that weakens the State);

and proposes the Bolivarian Alternative for the Americas (ALBA), a process for

integrating and strengthening the States as guarantors of the people's rights, as well

as trade agreements between nations aimed at reducing poverty, ensuring fair trade,

and promoting increased economic development [2]. The Bolivarian proposal for

integration and regional and international trade is based on solidarity and

01Introduction

02

cooperation [3] and egalitarian policies for social insertion that also tend to benefit to

public health [4].

Barrio Adentro is part of a larger exchange between Venezuela and Cuba, and

it represents a health care alternative for all the countries. Many proposals aimed at

improving access to health care and the quality thereof emphasize self-management

and the transfer of responsibility from the State to so-called “civil society,” which

justifies the reduction of public financing [4,5,6]. However, Barrio Adentro proposes a

new way of interaction between the State and its citizens in which the State takes on

the guarantee of social rights in co-responsibility with them.

This book reviews how Mission Barrio Adentro originated, how it was

implemented at the national level, how it works, and what it has achieved in 2004-

2005. It has been a joint project of the Venezuelan Ministry of Health, the Cuban

Medical Mission in Venezuela, and the Representative Office of the Pan American

Health Organization in Aruba, the Netherlands Antilles, and Venezuela. In addition,

assistance was provided by the National Commission on Cooperation with UNESCO

of the Venezuelan Ministry of Foreign Affairs. The information was gathered between

March and July 2006 based on a review of available reports and other documents, an

analysis of epidemiological data, and interviews with men and women from Barrio

Adentro, ranging from people in the communities who have participated in the

process to health professionals who have been involved since its inception. The data

were analyzed using epidemiological methods and qualitative data analysis. We are

sincerely grateful to all the people who participated in the interviews, both from the

health committees and from the Cuban Medical Mission.

The first chapter gives the technical and sociopolitical background that

characterized the global context in which the Bolivarian government took its initial

steps in public health up to the conception and implementation of Mission Barrio

Adentro. The second chapter reviews the origin of the Mission and how high citizen

participation was achieved. The third chapter tells how Mission Barrio Adentro made

it possible to catalyze formation of the new National Public Health System (SPNS) in

Venezuela. The fourth chapter describes the measures that have been taken to

guarantee the permanence of this new health care model, with emphasis on the

training of health professionals throughout the country. And finally, the last chapter

reviews the health achievements of Mission Barrio Adentro since its inception.

1

Venezuelan Health Care Models and Social Exclusion

Photo 1: Sucre Parish, Libertador Municipio, Caracas. April 2006.

Chapter 1

04Venezuelan Health Care Models and Social Exclusion

05

THE HEALTH OF VENEZUELANS PRIOR TO MISSION BARRIO

ADENTRO

Since its establishment in 1936, the Ministry of Health and Social Welfare

(MSAS), successor to the Ministry of Health, Agriculture, and Livestock, had made

important progress in controlling the main health problems of the Venezuelan

population, such as infant mortality, malaria, and tuberculosis [7,8]. The development

of the public health system reflected the needs of the rural population and was based

on an economic model that envisaged expansion of the agricultural frontier. Starting

in 1948, health posts and rural medical dispensaries called medicaturas were set up

and equipped throughout the country, followed by hospitals in almost all the large

cities of the interior. At around the same time, the MSAS Division of Malariology

inaugurated its Rural Housing Program, which included educational activities and

encouraged community participation. Under this program a total of 5,670 rural homes

were built [9]. In 1956 Venezuela was the first country in Latin America to announce

the elimination of smallpox [9].

The year 1961 saw creation of the Simplified Medicine Program. Under this

initiative, people in rural communities were given three months of training to work as

nursing auxiliaries in the rural dispensaries and handle simple health problems in the

areas of the interior where there were no physicians [7]. The program produced

tangible results in the control of endemic communicable diseases. That same year,

Venezuela was recognized by the World Health Organization (WHO) as the first

country to eliminate malaria in two-thirds of its national territory [9].

Venezuela has enjoyed uninterrupted democracy since 1958 (¡Error! No se

encuentra el origen de la referencia.). During the first three decades of this period,

social programs were cast in broad terms. In theory, the entire population had the

right to free health care, education, public safety, and social protection, and it was the

obligation of the State to provide these benefits [10]. In practice, however, access to

social programs was contingent on belonging to certain groups for example, a given

political party, an important workers' union, the armed forces, or the population of

salaried employees. It also favored those living in urban areas or near nodes in the

public service network [11].

Chapter 1

06

Public investment in health services began to decline in the 1960s [12,13],

undermining the effectiveness of prevention programs and control of the priority

health problems associated with rural poverty, as well as curtailing the development

of new programs to address living conditions in the burgeoning marginal urban

populations (Table 1).

Table 1: Urban-rural distribution of the Venezuelan population, 1950 to 2001

censuses (percentage) [14]

At the same time, private medical services were expanding in response to the

population's unmet health needs. For example, the number of public hospital beds

dropped from 3.46 per 1,000 population in 1963 to 3.06 in 1973 while during in the

same period beds in private hospitals increased from 0.43 to 0.46 per 1,000

population [12]. The delivery of public health services became increasingly

fragmented. In the 1970s, public health agencies proliferated to the point that there

were more than a hundred, including the MSAS, the Venezuelan Institute of the

Social Insurance, the Military Health Services, the Government of the Federal

District, and the Institute of Social Welfare under the Ministry of Education.

During the 1960s and 1970s the proportion of poor population kept growing. In

1970, 23 percent of Venezuelan urban families had a monthly income of less than Bs.

500, and 70 percent were receiving less than Bs. 1,500 [15]. At the same time, the

Ministry of Health and Social Welfare was estimating that minimum family

subsistence required a monthly income of Bs. 1,400 to Bs. 1,600 [16], an estimate

that was consistent with independent research [17]. The combination of public

underfunding and increased poverty had created such an impact on health that by

Urbana Rural

1971 72,8 27,2

1990 84,1 15,9

1961 62,1 37,9

1981 80,3 19,7

2001 87,7 12,3

47,41950 52,6


07

the early 1970s it was estimated that at least 30 percent of all the country's children

under 5 years old were suffering from some degree of malnutrition [18]. Between

1968 and 1973, infant mortality rose from 46.7 to 53.7 per 1,000 registered live births.

In the city of Valencia, center of the refining industry, infant mortality rate reached

94.6 per 1,000 live births, almost double the national average, and in its marginal

urban areas the rate was four times higher than in the city's upper income

neighborhoods [19]. In Ciudad Guayana, heart of the country's iron and steel and

aluminum industries, diarrhea became the leading cause of general mortality and the

number one reason for adult consultations at urban outpatient medical services [20].

As in many other countries of Latin America [4,21,22], at the beginning of the 1980s

the health services system in Venezuela was characterized by acute underfunding

(Figure 1), direct and indirect privatization (based on fees-for-services or requests for

donations from users), cutbacks in the maintenance of infrastructure, and

fragmentation and lack of articulation between multiple participants responsible for

regulation, financing, insurance, service delivery, etc. [21] (Table 2).

Figure 1: Government budget for health as a percentage of the national budget.

Venezuela, 19701999 [23]

Chapter 1

08

Table 2: Characteristics of the Venezuelan health system prior to Mission

Barrio Adentro.

During the 1980s and the 1990s the public health sector saw very little growth

compared with the rapid expansion of its private counterpart. For example, only 50

new public health facilities were established in the 20-year period versus some 400

new private clinics [24]. This trend ruled out any aspirations for universal delivery of

public health services, and social programs ceased to be proposed in terms of

achieving broad social reforms (or the reduction of inequities). Instead, objectives

were trimmed to more limited targets as a partial response to the funding crisis and

the negative impact of economic adjustment programs. The more transcendent

� Social underfunding

� Direct and indirect privatization

� Healthmarket relationship

� Predominance of curative care

� Growth of private establishments

� Deterioration of public infrastructure

� Lack of preventive maintenance

� Organization of the work to comply with professional associations

and unions

� Overall lack of articulation, fragmentation of the health system

� Abandonment of diagnosis and treatment protocols

� Abandonment of the first level of care

� Health workers being trained to respond within the prevailing

model

� Growth of the population not matched by expansion of the public

network

� Hiring freeze

� Reduced schedules

� Low wages

� Private insurance for hospitalization, surgery, and maternity

� Obsolete medical equipment


09

aspirations, such as equity and the redistribution of income, were postponed [11].

Public investment in health, which had been 13.3 percent of the national budget in

1970, fell to 9.3 percent in 1990 and 7.89 percent in 1996, representing only 1.73

percent of the gross domestic product (GDP) [25].

The cost recovery system, promoted in response to the budget cuts, became

a major barrier for access to outpatient clinics and public hospitals, since patients

were required to provide “voluntary assistance” in the form of money or a contribution

of medical or surgical supplies [26]. With poverty on the rise, this barrier was affecting

an increasing proportion of the population. In 1990, 32 percent of the nation's homes

were without piped water. In 1996, according to the official definition of extreme

poverty, 42.5 percent of the population was living below that line. Inflation that year

peaked at 106 percent, and it hovered around 30 percent for the decade as a whole.

All these trends had a critical effect on the capacity of poor families to meet their food

and health care needs [27].

Public health was being managed from the medical perspective, based on a

disease-oriented model for the management, organization, and delivery of care, with

somewhat less emphasis on health promotion and quality of lifecontrary to the

principles of primary health care. As a result, care delivery was configured in terms of

the limited capacity to provide services; it was haphazard and unproductive; it was

organized around hospital and curative care; coverage was low; primary care was

virtually nonexistent; schedules were irregular; and consultation systems were

haphazard all of this contributing to reduced quality, access, and timeliness of

response. It was a care model similar to those that had predominated in many

European countries in the twentieth century and were later replaced by free universal

public health systems [28,29,30].

Since the 1960s, the number of public hospitals in Venezuela has remained

unchanged except for one new establishment built in the 1980s. In all, there are 296

hospitals, distributed as follows: 214, Ministry of Health or other government entities;

33, Venezuelan Social Security Institute; 13, Armed Forces Social Welfare Institute;

3, Petróleos de Venezuela, S.A. (PDVSA); 29, National Geriatric Institute; 2,

Venezuelan Corporation of Guayana; 1, Miranda City Administration; and 1, Caracas

State Police [31]. Many of these hospitals were without needed supplies or unable to

function because of failure to fill professional and technical positions, lack of

Chapter 1

10

maintenance, inadequate infrastructure, lack of official oversight and supervision,

union bureaucracy at all levels, and virtual abandonment of personnel even when

they were under contract to perform certain hours of work. A study conducted in

Caracas in 1983 pointed to several difficulties that people could have in gaining

access to health care: distance from the service, service not organized around the

population's needs, no counter-referral, predominance of a curative rather than a

preventive approach, and care provided by recent medical graduates with little

experience [32]. In 1999, 55 percent of all physicians had incomes in the top quintile

in 24 states [33]. A total of 4,804 public outpatient facilities were available to serve a

population of 23,867,393 throughout the country [34].

Table 3: Reasons for not consulting a physician, by household income

quintile, Venezuela, 1998 [35]

World Health Organization reports on the health situation in Venezuela point

out that during 1990-1998 the impoverished population had less access to drugs

because of cost-recovery policies [36]. Drugs were sold through a network of private

pharmacies, with the exception of certain very expensive treatments such as cancer

drugs, antiretrovirals, and hormones, which patients had the option of obtaining

through private nonprofit foundations. All Venezuelans were ensured access to a

basic list of drugs through the Venezuelan Social Security Institute, but because of

lack of progressive public funding of the Institute itself, availability was also very

limited. A census of public sector hospital beds taken in 2000 showed a total of 40,675

(1.76 beds per 1,000 population), and 50 percent of these were located either in the

Income

quintile

Not necessary,

problem did not

justify a medical

consultation

Not enough

money to pay

for visit,

medicines,

examinations

Health service

too far away

Other

reasons

1

2

3

4

5

TOTAL 8,3

49,3 35,3

64,9

85,4

81,4

69,6

70,1

25,9

11,1

7,7

13,1

19,4

5,9

0,6

0,6

2,6

0,5

2,2

9,5

8,7

2,9

8,4

16,8


11

Capital District or in the capitals of the most developed states [31]. Deep social

inequities had been introduced into access to health care and drugs.

During the 1990s, the response capacity [37] of the health care network was

critically insufficient [21]. There were long waiting lists for surgery and specialized

outpatient care, and often there were not enough essential supplies to provide the

care needed. The network did not have plans for preparing for or mitigating

emergencies and disasters. This situation, created by public underfunding, led to the

decision to privatize the health services and relieve the State of full responsibility for

guaranteeing the right to health.

Figure 2: Political map of Venezuela and its 24 states

Chapter 1

12

REVERSAL OF EXCLUSION IN THE HEALTH SECTOR: FIRST

STEPS AND PRELIMINARY RESULTS

The Venezuelan government, working within the framework of the

Constitution of 1999, has embarked on an economic policy that is changing the

course of the Venezuelan health system. By using the nation's oil wealth to seed [38]

social investment in the health system, it has been able to halt the process of

privatization of health care. This oil “seed money” is being used to finance not only

direct health care (Tables 4 and 5) but also the Social Missions (US$ 5 billion

invested in 2005 in the Social Missions, including Barrio Adentro [39], in addition to

the regular Ministry of Health budget) to improve conditions and quality of life as the

recognized determinants of the health and disease situation in the Venezuelan

population. Improvements in the delivery of health care to the population are serving

to undermine the dominance of the curative over the preventive approach, which

previously had led to abandonment of first-level health care services, discontinuation

of pre-hospital support, and elimination of diagnostic and treatment protocols.

In 2004, the Presidency of the Republic announced 10 social strategies for

consolidation of the new stage of Venezuelan development [40]. The changes in public

health already being seen in Mission Barrio Adentro are part of this strategic plan for the

nation. To start building the new social structure, the State recognizes its responsibility

to develop strategies for making social rights universal, fighting social inequity,

eradicating poverty, combating exclusion, improving the efficiency of the

comprehensive public health system, and promoting disease prevention. Among the

main strategies for achieving these objectives are reforming the social security system,

strengthening and consolidating the Social Missions, improving statistical knowledge

on living conditions, participating in a diagnosis of the conditions that contribute to

poverty in the municipios, and promoting local mechanisms for monitoring the

development of Social Missions. Emphasis is being placed on becoming organized to

make a progressive contribution toward increasing the social capacity to involve the

actors concerned and on identifying new needs, such as giving people the power to

become involved in changing the situations that need to be changed. This emphasis on

establishing a democracy that is not only representative but direct is the spirit that

underlies the Constitution of 1999 and Mission Barrio Adentro.


13

Table 4: Public investment in health, Venezuela, 2000-2006.

(millions of Bs.)

Note: The regular Ministry of Health budget for 2006 does not yet include the additional credits.

FONDEN: National Development Fund.

Table 5: Public investment in health as a percentage of national budget and

gross domestic product, Venezuela, 2000-2006

Note: The regular Ministry of Health budget for 2006 does not yet include the additional credits.

2000 1.435.273

2001 1.729.247

2002 2.096.070

Regular Ministry of Health

budget [41]

Regular Ministry of Health budget

Extrabudgetary contributionsfrom PDVSA,

FONDEN, and other sources

Regular Ministry of Health budget

Extrabudgetary contributionsfrom PDVSA,

FONDEN, and other sources

Budget for Mission Barrio Adentro [42]

Budget for Mission Milagro [42]

2003 122.0212.644.873

2004 519.000671.5323.910.674

2005 2.435.000 4.500475.9654.862.989

2006 1.130.459 1.50035.000226.5385.010.740

2000 23.553.561 6,09

2001 28.079.214 6,16

2002 31.687.452 6,61

2003 41.613.125 6,36

2004 60.505.058 6,46

2005 81.805.297 5,94

2006 87.029.741 5,76

National budget [41]

Regular health budget

as % of the national budget

1,801,80

2,171,94

2,631,94

3,471,97

5,561,88

9,171,85

7,711,75

79.655.692

88.945.596

107.840.166

134.217.306

207.599.608

262.984.000

285.624.000

6,09

7,34

8,90

11,75

18,81

31,00

26,08

Regular health budget plus

extra-budgetary contributions as % of the

national budget

Gross domestic

product [41]

Health budget as % of gross

domestic product

Regular health budget plus

extra-budgetary contributions as % of gross

domestic product

Chapter 1

14

The principles of right and social justice that form the basis of Venezuelan

social policy are enshrined in the National Economic and Social Development Plan

for 2001-2007 (PNDES) [43]. The Plan's chapter on social balance affirms that social

inclusion is the most important strategy for achieving social justice, especially for

those sectors that have traditionally been excluded: children, adolescents, women,

indigenous groups, the rural population, and those living in extreme poverty. This

point of departure for achieving development and social balance assumes that the

fight against social inequality and poverty is also economically efficient. The

principles underlying the PNDES hold that social participation favors self-

development, generates co-responsibility, and promotes citizen activism the pillars

of an equal, collective, and democratic society (¡Error! No se encuentra el origen de

la referencia.).

Barrio Adentro came into being while the world was celebrating the 25th

anniversary of the Declaration of Alma-Ata [44]. This was also a time when steps were

being taken in the Region of the Americas to promote the renewal of primary health care.

In the 1950s, lack of access to medical care on the part of poor rural populations had

prompted the World Health Organization to develop the concepts of essential medical

services and simplified medicine. which incorporated the elements of both preventive

and curative medical care, and these concepts found their way into the Declaration of

Alma-Ata. Some examples of experiences with primary health care prior to Alma-Ata

include cases in Chile [45], Kerala (India) [46], and Sri Lanka [46] in the 1950s; Cuba

[47], Tanzania [48], and China [49] in the 1960s; and Costa Rica in the 1970s [50].

The key points adopted at Alma-Ata called for attaining the goal of Health for

All by enlisting the primary health care strategy [44] and promoting universal

outpatient medical care at the first level of service. However, the rapid transformation

of health care based on these concepts was only successful when it was

accompanied by improvements in social conditions.

Although the Declaration of Alma-Ata was criticized because its concept of

cooperation did not recognize the possibility of conflicts of interest among social

THE SPIRIT OF ALMA-ATA IN VENEZUELA


actors [51], never before had the close tie between health and social change been

emphasized so clearly. The Declaration generated wide debate and created the

opportunity to take a new look at public health problems. Emphasis on the right to

Health for All and the strategic principles of equity, universality, interdisciplinarity,

intersectoralism, social participation, and the development of appropriate and

culturally accepted technologies [44] posed a challenge for health systems in

countries with only average or straitened resources. Nevertheless, they embraced

these postulates with enthusiasm.

Unfortunately, in the decades that followed the Declaration of Alma-Ata a

neoliberal economy of weakened public institutions supplanted this vision

throughout almost the entire world. In less than a decade after the Declaration was

adopted, WHO ceased to be the dominant player in health sector policy-making and

the mantle was passed to the World Bank and the International Monetary Fund (IMF),

especially following the Bank's World Report of 1993 [52].

In Latin America the 1980s and 1990s were a time of growing marginality and

social inequality. Heavy flows of migration from the country to the city due to lost rural

jobs and impoverishment of the countryside, caused by the rise of industrial

monocultures, resulted in rapid urban growth in the metropolises [53]. The concept

and practice of primary health care, increasingly removed of the original spirit of the

Health for All [54], got distorted and priority shifted to the containment of public sector

spending. This influence lent a consistent orientation to health system reform in the

countries of Latin America, including Venezuela, and undermined progress toward

the implementation of primary health care. At the same time, however, despite these

setbacks, the Alma-Ata mandate to reform the medical school curriculum was being

fulfilled in Latin America from 1978 to 1990. During this period the primary health care

movement had strong support in Venezuela's universities [55]. However, support at

the political level was so weak that it was impossible to introduce these changes in

the health institutions or even keep up the spirit and practice through academic

curriculum reforms. Even so, this academic movement continued to spread

throughout Latin America, and each country has its own story to tell. In Venezuela,

with the exception of small pockets where the PHC movement was kept alive, the

techno-scientific medical model was imposed once again and medical studies were

isolated from direct contact with the living conditions of the population.

15Chapter 1

Starting in 1999, Venezuela began to give renewed attention to primary health

care, and this time the impetus came from within the health care delivery system with

introduction of the Comprehensive Care Model (CCM). This initiative coincided with

development of the Strategic Social Plan, which embodied the constitutional

principles of the right to health, equity, and solidarity. The CCM introduced in 1999

was committed to providing both preventive and curative care to all members of a

household at any time they came for consultation, thus eliminating the barriers

imposed by division of labor according to days and specialties in the outpatient health

facilities. As a result, this strategy has reduced missed opportunities and improved

the performance and quality of services.

The renewed vision has restored the spirit of Alma-Ata, and primary health

care has once more become a valid tool for health promotion. Mission Barrio Adentro,

an expression of primary health care, has only been possible because it is backed by

a comprehensive economic and social policy that envisages the full development of

peoples and communities in a setting in which national development is tied to

collective international cooperation.

This undertaking is in same spirit as the Social Charter of the Americas of the

Organization of American States [56], which proposes that:

“All persons have the right to comprehensive health care

and protection, which is understood to be part of the right

to life and thus an human inalienable and

unrenounceable human right.

The States shall assume the firm commitment to ensure

their populations permanent and uninterrupted access to

the national public health system in accordance with the

principles of equity, universality, solidarity, free cost,

quality, and efficiency, leading in turn to the promotion,

protection, conservation, restitution, and rehabilitation of

the complete physical, mental and social well-being of the

human person.

The States recognize their peoples to be co-responsible

actors who participate actively in the planning, execution,

and control of the national public health systems and


accordingly, they assume the commitment to promote

community participation in the development of programs

and services aimed at controlling the biological and social

agents that pose risks for health”.

The Social Missions that have been undertaken in Venezuela correspond to a

comprehensive primary health care strategy and to practical implementation of both

the Ottawa Charter [57] and the more recent Bangkok Charter for Health Promotion

[58], as well as the Millennium Declaration adopted by the United Nations in

September 2000, whose ten Millennium Development Goals [59,60] are at the top of

the world agenda for the twenty-first century.

17Chapter 1

2

Origin of Barrio Adentro and Citizen Participation

Photo 2: Popular medical dispensary in Catia, Libertador, Caracas. April 2006.

Chapter 2

20Origin of Barrio Adentro and Citizen Participation

21

CRISIS IN THE VENEZUELAN HEALTH SYSTEM

Ratification of the new Constitution in 1999 sparked the collective

construction of a new economic and social model. This model is guided, among other

principles, by the affirmation that health is a fundamental social right guaranteed by

the Venezuelan State, based on co-responsibility on the part of all citizens and

guaranteed active participation by organized communities. These are the premises

on which the new health system would be built. In keeping with the Constitution, in

1999 a presidential decree was issued that prohibited the collection of fees in the

country's public establishments [61].

In 2002, the Venezuelan Medical Federation, with the support of the Caracas

Metropolitan City Administration (which served five metropolitan municipios and a

total population of 2,762,759 in 2001 [34]), called for a national work stoppage of the

federation's members [62] in connection with demands for wage-related benefits.

The stoppage shut down the majority of outpatient clinics and public hospitals in

Venezuela, seriously affecting access to health care in the country, especially in the

metropolitan area of Greater Caracas. In the neighborhoods, many of the 81 existing

outpatient clinics under the Caracas Metropolitan District shut their doors, and those

that remained open did so for only a couple of times a week, providing service in

return for a “contribution.”

The Caracas Municipal Institute of Endogenous Development (renamed the

Local Development Institute, or IDEL, in 2003), which was responsible for social

programs in the Mayor's Office of Municipio Libertador, conducted a house-to-house

survey to identify the population's most important needs. Liberator is a

heterogeneous municipio with 22 parishes (the smallest geopolitical and

administrative unit in the national territory), some of them with high levels of extreme

poverty (Antímano, 29 percent; La Vega, 21 percent; Macarao, 31 percent; and

Sucre, 30 percent [34]) and high population densities. Their main concerns turned

out to be lack of transportation to get to a hospital in case of emergency, malnutrition

due to insufficient food, and lack of opportunities for sports [63]. To address these

shortcomings, in January 2003 the mayor of Liberator ran a notice in the press

announcing vacancies for physicians to work in a new program in the neighborhoods.

Chapter 2

22

The objective was to launch a comprehensive health program that would go deep

into the neighborhood and also include an education program and sports activities.

The outcome was not at all what was expected. The Medical Federation put

pressure on its members not to apply for the jobs. Of the 50 Venezuelan physicians

who did respond to the first announcement, 30 refused to work in the neighborhoods,

citing union issues related to hazardous working conditions. Since the remaining 20

were specialists, they were assigned to specialized health care centers [64].

In February 2003, the Liberator Mayor's Office contacted the Embassy of

Cuba in Venezuela and requested the collaboration of the Cuban Medical Mission.

This overture led to the signing of a technical cooperation agreement with Cuba. The

Mission had been working in Venezuela since December 1999, providing

humanitarian aid following a flood in the state of Vargas. Since then, a number of

Cuban physicians had settled into several areas of Venezuela to help develop a

comprehensive health program in places of greatest need.

In mid-March 2003 a team of three Cuban physicians (one woman and two men)

arrived in Caracas to work with IDEL in developing what was then called the Barrio

Adentro Plan. The initial objective was for 50 Cuban physicians to work in 10 parishes of

Libertador Municipio and launch the program as quickly as possible. It was decided to

speak with the neighborhood communities, including the urban land committees

(organizations that participate in surveying the land and grant property titles) [65], to

explore possibilities for housing the doctors and setting up dispensaries in the homes of

people who offered space. The neighborhood communities were organized into groups

that were in a position to support a health committee i.e., a group of neighbors sharing

a dispensary and assisting the physician in his or her preventive and educational

activities. These arrangements were decided on in open neighborhood meetings [26].

The phrase “Barrio Adentro” conveys the idea of penetrating deep into the

community. As explained by the coordinator of a health committee in the Caracas

municipio of Libertador, where one of the first Cuban physicians was received:

ARRIVAL OF THE FIRST CUBAN PHYSICIANS

IN BARRIO ADENTRO


23

I heard that the doctors were coming because some of

them had already arrived and were established deep

inside the neighborhood. A neighbor who was suffering

from asthma said to me “the Cubans are there. Let's go

find them.” So we went looking for them in the heart of the

neighborhood. Of course we were already deep in the

neighborhood, but we went even farther, and we found

them. After I saw the doctor I immediately started to make

contacts and start the necessary steps. That was back in

April 2003.

The Cuban team spent a month visiting the various homes that had offered to

provide lodging for the doctor or provide space for the dispensary. The criterion for

acceptable housing for the doctor was that there be a bed, even if it was in a shared

room, and indoor plumbing. For the clinic, there had to be enough space for a

stretcher, a table and two chairs, and a curtain, and the person donating the space

had to agree that it would be open to any person in the neighborhood regardless of

their social status or political affiliation. One advantage that these neighborhoods

offered was that, despite their poverty, they had access to electric power, water, and

wastewater disposal, in part because in the year 2000 the Water Boards and

technical teams had worked with the communities to make drinking water available.

All Cuban physicians participating in Barrio Adentro had to be specialized in

comprehensive general medicine and have three and a half years of graduate-level

training in internal medicine, pediatrics, obstetrics, and preventive medicine. In

addition, more than 30 percent of those who came had a second specialty (surgery,

traumatology, dermatology, otorhinolaryngology, ophthalmology, neurology, urology,

nephrology, psychiatry) and more than 70 percent had additional certification or

specialization [66]. Most of them came to Venezuela with at least two years' previous

experience with Cuban humanitarian medical missions outside their country. Many

were practicing as family doctors in Cuba when they offered to work in Venezuela.

They averaged 10 years' experience practicing medicine before they joined Barrio

Adentro. All care had to be provided free of charge to the patients.

By the beginning of April, the Cuban team, working closely with IDEL, had

already found space for 50 doctors, who arrived in mid-April. Their impending arrival

had generated a mix of high expectations and skepticism, because the neighborhood

Chapter 2

24

communities could not believe that a promised multi-government initiative would

materialize so quickly. In the words of one of the first Cuban physicians to arrive in

Caracas:

When we arrived in the neighborhoods, people could not

believe that we were there, because [they told us that]

many administrations had come and gone and made

many promises. Everyone had come and promised them

something, and then afterwards nothing had changed.

When they saw us, they couldn't believe their eyes,

because they had assumed that the mission would be just

one more broken promise.

As a result, some of the spaces that had been promised were not even ready

when the physicians arrived. However, the communities mobilized to meet the

challenge, and within a day the housing was arranged. For those with more

confidence in government-related institutions, such as personnel in the Liberator

municipal offices, they were greeted with the open arms. According to one of the first

people to welcome one of the physicians:

They came straight from the airport to our homes. We

were expecting them. We had gone to a lot of trouble to

get everything ready a lot of trouble, but with great

tenderness and care. And they quickly settled in.

The communities that welcomed the first doctors, fearing that they were not

going to stay and knowing that the living conditions they offered were not very grand,

started to look for more opportunities in the neighborhoods to expand the program

and improve the housing and working conditions for the doctors. Some neighbors

donated mattresses, curtains, tables, and other utensils to improve conditions in the

dispensaries without expecting anything in return. The responsibility of feeding the

doctors was shared by the members of the health committees, who started to look for

more formal arrangements. Many other neighbors spontaneously contributed food to

the homes where the doctors were staying. Those who took part in this momentous

effort look back on it as a challenging time but one that led to major achievements in

the claiming the right to health. The Cuban coordinator for Barrio Adentro in the

Caracas metropolitan area had this to say:


25

And how they fight for their doctors! The doctors are no

longer [Cubans], now they belong to the health

committee. To transfer a physician, we have to ask them

for permission.

During the morning and into in the early afternoon the doctors took care of all

the people who came, at first about 80 a day. Later in the afternoon they would go up

into the hills to take a census, one person or household at a time, recording the

prevalent diseases, vaccination histories, and nutritional status; identifying the main

social problems such as illiteracy and overcrowding; verifying the availability of

liquids and solids; and, in the process, seeking out new places to accommodate more

than 150 doctors who were about to arrive. The physicians reported their findings on

a weekly and monthly basis to the Barrio Adentro Coordinating Team, which was

made up of epidemiologists.

This information system made it possible to gain a thorough picture of the

health situation in the neighborhoods up in the hills, about which very little was

known, even by the Health Surveillance System, because the country did not have

complete health care coverage. Some diseases, such as dengue, were subject to

special surveillance. In May 2003, with the information collected over a period of two

months by the Barrio Adentro physicians and with information the from the Social

Security Institute and the Municipal Health Directorate, for the first time it was

possible to undertake an assessment of the health situation in the neighborhoods in

the Caracas hills. The two main social problems that were identified were

malnutrition and illiteracy [66].

The next group of doctors arrived quickly. More than 100 of them came in May

2003. They there were sent to other neighborhoods in the hills of Libertador

Municipio, where the program had originated; to other parts of Caracas, such as

Sucre Municipio (another area of hillside neighborhoods in the state of Miranda); and

to center-city neighborhoods. One of the physicians recalls:

I remember arriving in the neighborhood where I was

going to work, El Recreo Parish, in the center of Caracas.

We got there at night, and the people were holding a

meeting. When they saw that we had actually arrived with

our luggage, they couldn't believe it. It was about nine

o'clock at night, and they wanted to take us through the

Chapter 2

26

entire neighborhood so that everyone could meet us,

even at that late hour.

Up until then, many people in the neighborhoods distrusted the doctors who

took care of them in the emergency rooms of the Caracas public hospitals. Many

others in the neighborhoods had never known a doctor who would go to someone's

home. As the Cuban physicians began to treat the people, their acceptance in the

neighborhoods grew. As they took care of both acute and chronic cases, with tangible

results in the improvement of people's health, the communities began to appreciate

the doctors' abilities. This situation got even better when drugs were made available

in the dispensaries and the patients no longer had to pay for them.

From the outset, the dispensary doctors were available 24 hours a day. The

communities made various arrangements when care had to be given during the

night. In some areas, where the doctor lives in a module, a member of the health

committee agrees to stand watch for emergencies and will escort the person to the

doctor's module. In some modules, the committee has installed an alarm system so

that, if necessary, the doctor can contact the health committee and someone from the

committee can go to the module.

A factor that also contributed to the acceptance of the Cuban physicians was

that they adapted very well to the difficulties of life in the neighborhoods and lived in

the communities alongside everyone else. A nursing auxiliary from Catia comments:

How things have turned upside-down in this country! It

used to be that those who had a bedside doctor were the

rich people. The rich! Now we are the ones who have the

good doctors, and they are not in it for the money. We

have dedicated doctors who are with us day in and day

out, who feel with us, who live with us in poverty. That's

what means so much to us.

As new doctors arrived, they reached deeper into the communities , thus

reducing the population which up to then had been excluded from access to health

care. Within a few months the program was fully established, with fixed working

hours. The number of daily patients was declining, both because of the increased

number of doctors and because the health problems were being taken care of. In

2003, Barrio Adentro handled 9,116,112 patient consultations and performed

4,143,067 health education interventions [67].


27

In December 2003, the Plan Barrio Adentro was established as a permanent

Social Mission under a decree issued by President Hugo Chávez Frías and published

in the Official Gazette a month later [68]. It was then decided to extend Mission Barrio

Adentro to all of Venezuela, to pursue the following objective: “Implement and provide

institutional coordination for the Comprehensive Primary Health Care Delivery

Program; encourage and implement expressions of social economics; and transform

the economic and environmental status of communities through a new management

model based on principles of interdependence, coordination, co-responsibility,

cooperation, and the active participation of organized communities.” In 2004, Mission

Barrio Adentro opened the road to structural change in health care access for millions

of Venezuelans who until then had been excluded. Since then, the Social Missions in

Venezuela have been defined as suprasectoral strategies with extraordinary resources

in which institutions at all levels of the State work together in an articulated manner to

accelerate social inclusion and ensure the universal human rights guaranteed in the

Constitution in the areas of health, education, employment, food, housing and the land,

as well as social, economic, cultural, political, and civil rights, in order to form a

participative democracy for the transformation of Venezuela.

Mission Barrio Adentro gradually became organized into what is now its current

administrative structure, with individuals responsible for coordinating brigades of

physicians by parishes, municipios. and regions in collaboration with the neighborhood

health committees, which participate integrally in the drafting of health policies, plans,

projects, and programs, as well as execution and evaluation of the mission's

management. In 2004, Barrio Adentro reached beyond the metropolitan area of Caracas

to incorporate the state of Zulia; the rest of the municipios in the state of Miranda; the

states of Barinas, Lara, Trujillo, and Vargas; and ultimately the rest of the country.

One of the first obstacles encountered by Barrio Adentro was the mass media

campaign against the presence of Cuban physicians in Venezuela. For many of

these doctors, it was the first time they were not well received abroad by a sector in

the host country. For political reasons, the Venezuelan Medical Federation spread

THE FIRST OBSTACLES ENCOUNTERED BY BARRIO ADENTRO

Chapter 2

28

word in the media that the Cuban physicians were not trained to practice medicine.

However, the signing of an agreement with the Metropolitan District Medical School

in May 2003 gave legal validity to the qualifications of foreign physicians to practice

medicine within the Barrio Adentro framework [69]. The Federation responded by

filing suit, and the Court decided that the Cuban physicians could not practice

medicine in Venezuela. The media announced that the Cuban physicians had to

leave the country [70], but this generated a groundswell of support for Barrio Adentro.

The Metropolitan District Medical School issued an explanation to the effect that the

Cuban physicians were not filling jobs but rather were on a humanitarian mission,

and thus the situation was defused. Because of this campaign, sometimes it was a

challenge for the Cuban physicians to convince patients to trust their diagnosis and

the drugs they were prescribing or their recommendations that surgery was needed.

The second obstacle involved the medical prescriptions. Although the

physicians arrived with a lot of drugs, what they had was not always enough, and

sometimes they had to prescribe drugs for patients to purchase in pharmacies. The

problem was that the Cuban physicians used the generic names of the drugs

whereas the pharmacies were more used to prescriptions with brand names. Also,

some pharmacies did not want to fill the prescription if it bore the municipal and Barrio

Adentro logo. Three weeks after the plan got under way, a more complete supply of

55 essential drugs was received. The municipal office provided a storage area, and

the Cuban physicians themselves took turns packaging them up and distributing

them to every physician who had arrived in Venezuela, along with a stethoscope and

a vaporizer. Since this initial system did not take care of all the needs for drugs,

starting in January 2004, based on the information collected from the first

assessment of the situation, it was decided to provide for a list of 106 drugs from 23

pharmacological groups encompassing the majority of essential drugs (Annex 4).

These drugs are now distributed twice a month to every physician in the entire

country. The Venezuelan Armed Forces provide logistic support.

The third obstacle was the physicians' referrals for diagnosis and hospital

care, since the regular health system was opposed to the initiative. Most of the public

hospitals refused to receive patients referred by Barrio Adentro. At first, the Caracas

Military Hospital was the only one that accepted referrals from Barrio Adentro for

either diagnosis or hospital care. Then the Caracas University Hospital stepped up to

the plate. To expand the referral network, in mid-2003 the National Commission of


29

Venezuelan Physicians (CONAMEV) created a directory of physicians in various

public hospitals who were willing to cooperate with Mission Barrio Adentro and

receive its patients. This extra-institutional network was in the process of being

formalized in October 2004 when a new mayor of Greater Caracas was elected. The

new mayor lent his support to Mission Barrio Adentro and established official links

with the city's Ministry of Health.

From the beginning it was recognized that using private homes to house the

medical personnel and set up the dispensaries was a temporary measure to address the

urgent need to serve the population in the neighborhoods. Hence there was need to

create more stable structures for the development of Venezuela's National Public Health

System. In August 2004 work got under way on the first of the health modules, which are

simple rectangular or octagonal brick structures that fill the dual role of providing space

for the dispensary and housing the medical personnel within the community. The ground

floor of the modules has a waiting room, two consulting rooms, and two bathrooms (one

for patients and the other for medical personnel). The second story has a living-room,

kitchen, bath, and one or two bedrooms. These always accommodate a physician and

one other person, who may be another doctor, a physical therapist, an optics technician,

or a dentist. The modules make it possible to accommodate dentists and opticians, who

up until then had been living in people's homes in the community. The modules were built

with the help of the communities. Their location was chosen so that they would be

available to between 250 and 350 families. As of July 2006, a total of 1,612 modules had

been built and 4,618 were under construction, which means that many of the 23,793

Barrio Adentro health professionals (15,486 of whom are physicians) still live and work in

family homes provided by the community [71].

The scarcity of land and the topography of the hills in the dense urban areas of

the Capital District gave rise to the idea of a two-story octagonal building that

included space for providing medical and/or dental care and also room to house the

physician. This first design, known as the “Barrio Adentro module,” was later modified

EXPANSION OF BARRIO ADENTRO: TOWARD COMPREHENSIVE

HEALTH CARE

Chapter 2

30

and adapted to the special features of the country's varying social terrain. The

decision of where to locate and build them is now based on the following criteria,

among others: capacity to reach 250 to 350 families, existence of basic services

(water, electricity, sanitation, waste disposal), land available within the community,

and safety from physical risks such as landslides and floods.

In the process of building the Barrio Adentro modules, the community, working

together with the Ministry of Health and with Cuban cooperation, got involved in

activities ranging from certification of the land for location of the modules (obtained by

filling out forms and preparing the technical specifications) to approval of the

decisions in town council meetings. The land, which is typically national ejido land, is

usually donated by the community or local government, and construction of the

modules is done by community cooperatives. Some of the clinics have been located

in facilities donated by other governmental institutions. This initiative helps give

concrete expression to the integration of citizens into social networks and the

process of public policy-making and to the development of a culture of ownership and

collective participation in activities that seek solutions to improve the quality of life of

all the people in every community.

During this time, Barrio Adentro has been spreading and gaining momentum.

The first comprehensive diagnostic centers (CDCs) were established in 2003. In the

beginning they were spaces within the communities located in private homes,

abandoned structures, and municipal dispensaries that has been adapted for the

purpose. They were outfitted with clinical laboratory, ultrasound, endoscopy, and

EKG equipment donated by Cuba. Because of climate control problems, it was not

always possible to install radiology equipment.

In order to expand outpatient care capabilities, construction of a network of

new CDCs got under way in early 2005 using a design that made it possible to

accommodate more medical equipment and personnel. The CDCs include imaging,

clinical laboratory, and EKG equipment, and some of them also have intensive care

units or operating rooms, given the challenge that Barrio Adentro patients face in

obtaining hospital care. High-technology centers (HTCs) are being also established

to back up the CDCs with 24-hour monitoring and comprehensive rehabilitation

services (CRSs). Each of these centers and services provides coverage for several

neighborhood clinics, located so that the traveling distance is short and patients can

go there the same day they are referred.


31

Creation of the CDCs reduced the need for diagnostic tests done in hospitals,

but the need for expanded hospital care continued to exist. The Ministry of Health had

begun to create its own popular clinics in Caracas neighborhoods, in Social Security

establishments, and later in new establishments in the rest of the country for the

purpose of strengthening the hospital network under the National Public Health

System (SPNS). From the outset, these clinics have been linked up with Mission

Barrio Adentro. They are centers to which patients can be referred if they need

hospital care. Since 2004, the Ministry of Health has been working on the

interinstitutional integration of the SPNS and coordinating the various components of

the health system.

The contrast between the increasingly evident limitations of the health system

and the needs of the excluded population were coming to pose an intolerable

situation, especially in the context of the people's increasing awareness of their

political and social rights enshrined in the new Constitution and the growing social

movement in support of the Bolivarian process. The social mission approach

promoted by the State is a rapid mass strategy for achieving social inclusion,

especially the most excluded population, based on the organized participation of

communities. Thus, Mission Barrio Adentro was born in the space of interaction

between State and society defined by the new Constitution of the Bolivarian Republic

of Venezuela, and it has become a strategy for building a new health system as part

of the process for creating a new public institutionality in which the people assume a

proactive role.

The Barrio Adentro experience has coordinated readily with development of

the other Missions, which are weaving a fabric of comprehensive social policy aimed

at improving the quality of life of traditionally excluded populations, which have grown

to the point that they are now a majority of the Venezuelan population. Thus, Barrio

Adentro is a strategy of the State and Venezuelan society to affirm their constitutional

rights and duties in the area of health and assert the principles which, according to

BARRIO ADENTRO AS A RESPONSE BY THE STATE

AND ORGANIZED SOCIETY

Chapter 2

32

the Constitution, are supposed to govern development of the SPNS. In this way,

Barrio Adentro becomes a humanitarian mission that is part of the broader overall

process of building a participative democracy and the new approach to supporting

direct citizen participation. This process is taking place in a context of political conflict

promoted by those who would attempt to destabilize the new configuration of the

State. It is part of the effort to build “people power” and lay the groundwork so that

Venezuelan society can begin to move toward more equal forms of economic and

political organization based on socialism.

The expanded application of Barrio Adentro at the national level is supported

by three pillars: organizational experiences that involve community participation in

health, leadership, and the firm political will of the government to promote a new

public institutionality and a new approach to the interaction between State and

society based on preeminence of the people and international solidarity with Cuba.

Since the 1960s, Venezuela has had experience with community participation

in health, in some cases promoted by the Ministry of Health or the state governments

and in other cases by grassroots movements or simplified medicine initiatives.

However, none of these experiences ever succeeded in becoming a national

strategy for transforming the health system, sometimes because they were limited

local experiences and other times because they were conceived and developed as

experiments subordinate to institutionalized government within the framework of

multiple health system reforms. The majority of these experiences either died on the

vine or survived under adverse conditions that prevented their potential from being

realized.

At the beginning of the 1980s the Ministry of Health promoted the formation of

health committees within the framework of what was then referred to as “community

medicine.” In Caracas, for example, some twenty committees were created in

different areas, including what is now the state of Vargas and part of the state

Miranda. This initiative was promoted by the regional health directorates. Health

committees were formed in the respective districts and placed under district

CITIZEN PARTICIPATION AND THE HEALTH COMMITTEES


33

administration, through which they received orientation from the Ministry of Health's

Bureau of Social Welfare. The emphasis of their work was preventive, and they

assisted with activities such as health censuses and vaccination campaigns. In some

cases, especially when there was backing from grassroots or religious organizations,

the committees were assertive in demanding health services and managed to get

local medical dispensaries established with the support of the respective

communities and the Ministry of Health. However, their operation always left much to

be desired, and relations with the medical personnel were problematic, since they

were frequently rotated, often absent, and required special compensation for

working in areas considered to be “at risk.” These experiments failed after a few years

for lack of resources and because of the dispensaries' limited problem-solving

capacity. In some cases they were later absorbed into municipal community projects.

At the end of the 1980s, the Ministry of Health promoted the formation of

social/public health boards, as well as social hospital boards, in the context of health

sector reform and “cost recovery” policies. These boards included representatives of

the Ministry and state governments, on the one hand, and institutional

representatives of the communities, on the other. Their job was to mobilize resources

from within the community and monitor their appropriate use. In a context of growing

deterioration of the service network and a rising deficit in public funding, this measure

led to the development of foundations and other organizational entities that collected

and managed resources contributed by the population in the form of insurance

premiums or fees for services. These payments became a major barrier that

prevented access to health care by people with limited resources. Rather than

promoting social participation, the boards helped to disguise the fact that the State

was evading its responsibility for the health of the people.

The negative impact of privatization policies on the quality of life of the majority

of the population, and the poorest segment in particular, was of such magnitude that it

led to an uprising in February 1989, referred to as El Caracazo [62], which threatened

the very foundations of Venezuelan society. Starting from that landmark event, the

people's anger gradually developed into a broad social movement. Until this process

succeeded in creating an enabling environment, experiments in community

participation in health had not been linked to the process of building citizenship (Table

6). The process of establishing the enabling environment, because of its broad

participative and democratic nature, involved all sectors of Venezuelan society. It

Chapter 2

34

was a process in which communities and their organizations affirmed their social and

political rights and assumed their responsibilities in the construction of the new State.

This expression of popular power through community organization and participation

continued to gain momentum following the political conflicts of 2002 and 2003, and

social mobilization became an essential pillar of national stability. This organized

population base, bound together by awareness of the people's rights and duties, is a

major part of the foundation on which Mission Barrio Adentro has been built.

Table 6: Primary care nuclei

Primary care nuclei (NAPs) were first introduced in the state of Aragua in

1994-1995. To form a nucleus, the people had to organize and participate in

mobilizing basic resources both locally and from elsewhere, as well as

commit to participating in the health programs that were to be developed.

Under to motto “Health for All, with All Participating,” by 2000 the state

government had created 100 nuclei consisting of a physician and a nurse or

nursing auxiliary, each supported by its respective health committee. The

work program for the nuclei included basic curative medical care such as

prevention aimed at high-priority problems, with emphasis on the mother-

child population group. The communities had the option of renewing their

contracts with the medical personnel once a year. Although the target was for

each nucleus to have to capacity to serve 2,500 inhabitants, in reality

universal coverage was not goal, and in one state only one-fourth of the

population had access. Nor were the nuclei coordinated with other levels of

outpatient and hospital care. Instead, they had to struggle to keep going

within a national context of cutbacks in health resources and gradual

deterioration of the public service network. The nuclei eventually succumbed

because of insufficient commitment on the part of the medical personnel,

breakdown of the initially rigorous selection and follow-up processes, lack of

community involvement, and scarcity of resources.


Table 7: History of the current health committees

In 1996, thanks to an initiative of the Sucre state government, an intensive

program of community organization and participation in health got under way

with the creation of 21 health committees. In 2006, there are now 150

registered committees associated with Barrio Adentro and the other Social

Missions. This experiment, aimed at low-income populations, has included

the selection of community promoters by assemblies in the beneficiary

communities. These social promoters have been trained to promote

community development and participative local planning. The health

committees created by the communities are supported in each locality by

teams consisting of a physician, a social worker, and a nurse who are

responsible for a program of work in health promotion and the prevention of

priority health problems. The health committees prepare proposals for health

interventions, which, once approved, are funded by the state government.

In the first quarter of 2006 a total of 8,951 health committees had been elected

by the popular assemblies; certified by local, parish, or municipal authorities; and

included in the Ministry of Health registry. The number of unregistered health

committees associated with the popular medical dispensaries is even greater. Each

committee has an average of eleven members. They are formal or informal leaders

who have been elected by the community. Their mandate is to identify the priority

health problems in the community, prioritize them, and decide on the main actions

that the community should take to address them. They are also responsible for

making arrangements to support the work of their particular popular medical

dispensary and comprehensive diagnostic center. Operation of the health

committees is regulated by the Community Councils Law of 6 April 2006 [72], which

mandates that the health committees work in concert with other community

organizations affiliated with the community council. Among other responsibilities, the

community councils administer the budgets allocated to each community, including

the budgets of the health committees.

35Chapter 2

36

Figure 3: Health committees, Mission Barrio Adentro,

April 2003 May 2006 [67]

This process has not been without conflict and tension, and the experience

has developed leadership skills in the local participants. According to a nursing

auxiliary from Catia, one of the Caracas neighborhoods:

My role changed after the doctors arrived. Thanks to

them, I've learned to perform better. I used to be very shy

about speaking up. It was very painful to speak. We were

all reluctant to speak up, and we didn't know how to speak

in public. Because of all those meetings we had to attend

for Barrio Adentro, and all those workshops, I have

learned to overcome my fear.

Unlike prior Venezuelan experiences with community participation in health,

this initiative was not overshadowed by the Ministry of Health or associated with

predefined plans and programs introduced by the health authorities. Barrio Adentro

promotes new ways of organizing available health care services and programs to

create more and better opportunities for response. One of the first health committee

coordinators in Liberator remarked:

It used to be that here they made all the decisions for us.

We were like puppets. But that's not true any more. Now

we are an organized health committee, which has had to


37

pioneer everything. We are the ones who figured out how

to organize housing construction, the ones who sit on the

land tenure committees. Advice to the community comes

through the land tenure committees. We are going to be

our own advocates in solving our problems. No one is

going to come here and tell us what's going on. Here we

are really going to be heard. The idea isn't to hand the

responsibility over to the president and then attack him.

It's the other way around: he is giving us the tools, and we

have to learn how to use them successfully. We are

strong as long as we are united, and as long as the

organization keeps going, we will continue to see

progress. The health committees and the land tenure

committees meet every week. That's where we are going

to focus our efforts. That's where we are going to see the

challenge and the social work that needs to be done. This

is not an easy task. In the past we have opted to do it the

easy way taken the path of least resistance: letting them

give it to us or do it for us. But that doesn't happen any

more. Now we have the will to fight, the sense of

belonging, the sense that we have to do it, because if we

don't do our share of the work in the community, either in

health or toward the other goals, the job will fall back on

the president again. But here no government agency is

going to come and tell us what's what. We have regular

meetings of the health committee, which has played a

very important role in the community. If it hadn't have

been for the health committee, we would not be 99%

united. It's been great!

While community organizations are pressing for more rapid and effective

development of the new Ministry of Health, a process that entails changes in the law

and the institutional culture, at the same time the health system considers that the

capabilities and organizational capacity of the health committees need to mature.

This is a process that calls for a great deal of creativity, which can not always be

Chapter 2

38

planned or measure up to specific standards and guidelines. It is precisely from this

point of interaction between what the State and the people have to offer that the new

National Public Health System is going to emerge. Based on the

socioepidemiological knowledge acquired in covering an ever-growing percentage

of the population (73 percent of the total population in 2006) (Table 23), it is now

possible to begin planning health care resources based on the needs of the

population rather than the amount of medical care available.

The Ministry of Health has established a National Health Committee

Coordinating Office, and steps are being taken to create similar structures in the

states and municipios. Also, a New Citizenship School has been established in the

Institute for Advanced Public Health Studies under the Ministry of Health. A total of

41,639 community health assemblies were held in the first quarter of 2006, with the

participation of 1,423,815 people.

Among the social rights of Venezuelans, the Constitution firmly establishes

the right to health and the citizen's duty to take an active part in the management of

health. Sharing collectively in political, civil, and community life is considered a duty

of all citizens. The Constitution identifies the Local Public Planning Board as the

forum for citizen participation in planning and local management, and it provides for

the progressive transfer of management of public services to the communities and to

organized local groups, including the health services. Finally, it explicitly calls for the

participation of communities and individual citizens in the preparation of plans and

budgets and in the execution, evaluation, and control of public programs and

services. These rights and duties are the bases for ensuring that participation

ultimately leads to the transfer of power to the communities.

To guarantee the right to health, the Constitution calls for the organization of a

National Public Health System that is free, decentralized, participative, and based on

a set of principles that include universality, comprehensiveness, equity, social and

collective integration, and participation. It is also stipulates that citizens have the right

and the constitutional duty to protect the environment, and it also requires, as an

integral part of education and health policy, that they have access to sports and

recreation. The Constitution specifies the right to health of indigenous populations

under conditions of respect for their culture and for traditional medicine, and it also

affirms that indigenous populations have the right to political participation.


39

The most recent progress toward refining the legal framework to support the

new participative democracy is passage of the Community Councils Law. This law

defines the terms, organizational structure, and duties of the social organizations, as

well as the opportunities for community participation in the branches of government

and in the processes of public policy formulation, execution, and evaluation. This law

recognizes the health committees and other organizational forms of local

participation as part of the each community's Assembly of Citizens. It also defines the

procedures and mechanisms for establishing these assemblies and specifies how

they carry out their duties, thus creating a framework for community organization and

participation in public management as well as for the transfer of functions and

resources to the communities. In addition, this law also sets the bases for the

organization and operation of Village Banks as mechanisms for the strengthening of

community financial management [73].

Mission Barrio Adentro promotes specific actions for the intervention and

participation of community leaders in the design and control of health management.

Citizen participation and “people power” not only provide fundamental support for this

health management platform but have become autonomous forces in and of

themselves, requiring health institutions to adapt to newly identified needs and

opportunities opened up by the State as it progresses in the direction of social

inclusion. Thus, the State is being directed and having demands placed upon it, and it

must account for its actions and work toward the point where community organization

and institutional organization converge, both of them focused on strengthening

opportunities for integration at other levels of the health network and with other

institutional sectors.

Chapter 2

40Origin of Barrio Adentro and Citizen Participation

3

Development of New Networks within the National Public Health System

Photo 3: Intensive Care Unit, Comprehensive Diagnostic Center, Fuerte Tiuna, Caracas. April 2006.

Chapter 3

42Development of New Networks within the National Public Health System

43

BARRIO ADENTRO IN PRACTICE

The organizational principle that has guided the work of Barrio Adentro follows

in line with the strategic planning model for health services. It calls for deliberate

planning of interventions by the various actors or social forces with a view to

achieving the transformation envisioned by society [74]. Mission Barrio Adentro is

growing and expanding in a process of social and institutional transformation aimed

at configuring the new National Public Health System.

The doctors' arrival in the communities was the impetus for organizing the health

committees. Household censuses conducted by the medical personnel and

neighbors in the communities revealed a number of social and health care needs that

led to new decisions, plans, and actions in the area of social policy.

To begin with, there were people of all ages who did not know how to read or

write, and this finding led to the creation of Mission Robinson, devoted to literacy. Its

message “I can do it!” was very powerful at the subjective level. This mission, along

with the other educational missions, was widely received, as reported by members

the health committee in a neighborhood of the Caracas municipio Libertador:

Gradually, after the introduction of Mission Barrio

Adentro, other missions got under way. The founder's

work was supplemented by the efforts of a group of young

people in the community who took training to act as

facilitators. The mission quickly took off. Those who

started with Robinson 1 are now finishing Robinson 2

[primary education].

We submitted a request for teaching materials and got a

response within a week: now we have television sets,

VHS players, films, instructors' manuals.., and it has all

come so quickly. The institutions provided constant

support and supervision.

Here there were both young and older people who had

not finished high school. After hours, the dispensary's

waiting room was turned into a classroom, with Mission

Robinson part of the time and Mission Ribas the rest of

the time.

Chapter 3

Now we need space for Mission Sucre. This is a project

initiated by students in the Mission Ribas program, which

is going to be the basis for our proposal to different

institutions for support. We are looking for space within

the community itself.

In addition, the problem of malnutrition was identified in several very

neglected groups, and this led to setting up feeding homes. Mission Mercal soon

followed, with plans to improve food intake and food security. The feeding homes

were intended to offer “free balanced daily meals (prepared by the community) to

populations in economically depressed areas” [27]. Each feeding home provides

three daily meals to a minimum of 150 people, and priority is given to pregnant

women, children, and older adults. Another member of a Libertador health committee

recalls:

When the doctors' censuses identified food deficiencies,

they decided it was necessary look for ways to provide

supplementary feeding. Soon feeding homes were being

set up in the communities. They are for older adults,

pregnant women, and underweight children. Were used

the Mission Mercal network to set up the feeding homes,

and now have four of them.

In addition, the censuses revealed major social deficits in other key aspects

involved in comprehensive health that needed to be addressed: physical

rehabilitation, vision correction, and dentistry. Thus Mission Barrio Adentro was

expanded in terms of variety, quality, and quantity variety, in the training of health

workers, modalities of service organization, clinics, diagnostic centers, rehabilitation

services, and high-technology centers, and quality, in the sense that the broader

range of services improved the diagnostic and treatment capability being

coordinated with the hospital network. This picture is in sharp contrast to the

traditional concept of service production in which the supply is dictated by technical

and bureaucratic criteria that fail to take the needs of the population into account.

Barrio Adentro has a permanent contact point for families within the

communities namely, the popular medical dispensary. But there is also has another

access point: the emergency facilities in the Comprehensive Diagnostic or High-

Technology Centers. From each of these points a group of services is available at a


different level of complexity. When people come to the network through any of its

nodes, they have access to solutions to their health problems, and they are guided

and regularly followed until their problems are taken care of. This approach avoids

the difficulties generated by the haphazard provision of services in which patients are

on their own to find the care they need and follow-up is limited.

The network operates first and foremost in terms of levels of complexity,

defined according to the capacity of each level to handle specific health needs. The

criteria include: location of the establishment, transportation possibilities, and

distance between the families' homes and the rest of the establishments; profile and

availability of health workers, and resources available, including drugs, supplies,

equipment, and infrastructure.

In the second place, mechanisms are in place to direct the flow of people in the

network, both vertically (between the clinic and the hospital) and horizontally (to

laboratories and optical, dental, rehabilitation, health promotion, first aid, surgery,

birthing, and other services). This flow is based on use of the referral and counter-

referral system, which takes into account the patient's needs, timing, and the

complexity of services required.

The draft bill of the new General Health Law declares that participation and

social control in health is a constitutional right of all citizens and that they have the

right to make decisions, intervene, and exercise direct control, with autonomy and

independence, in all matters related to the formulation, planning, and regulation of

health sector policies, plans, and projects, as well as the evaluation, control, and

monitoring of health sector management and financing all within the paradigm of an

increasingly social, participative, and protagonistic democracy [26].

This law proposes that the health system's service-providing establishments

and programs be organized within a health network model based on the concepts of

comprehensive health, levels of complexity, and response capacity considered in

relation to the possibilities for training and specialization of human resources,

technological capacity, and geographic and population coverage within a given

TOWARD THE NEW NATIONAL PUBLIC HEALTH SYSTEM

45Chapter 3

46

social territory. This model incorporates preexisting State-financed establishments

and adapts them to the needs of the population and geographic criteria. It includes

the services of the Ministry of Health, the Venezuelan Social Security Institute, the

Institute of Welfare and Social Assistance under the Ministry of Education, the Armed

Forces Institute of Social Welfare, and health centers under the jurisdiction of state

and city governments. It also creates cross-cutting medical care networks such as

the emergency network, Mission Milagro, and the oncological care network.

The objective is to organize the delivery of health services into networks,

breaking away from the bureaucratized and medicalized model of medical care

based on the distinction between preventive and curative medicine in which referral

and counter-referral mechanisms are weak, importance is given to normative

criteria, and the hospital is at the center of the system. In the new model, primary

health care is the axis around which the network of popular medical dispensaries is

organized and the integrating force in maintaining the health of the population. This

change was noted by an 80 year-old woman on one of the health committees who is

also a primary-level student in Mission Robinson:

Well, when they began this here and we realized that

Barrio Adentro was coming to our community, we were all

happy because there had never been anything like it.

Before, we had to go to Magallanes [Hospital] or

Periférico [Hospital] and spend a whole day sitting and

waiting. Now they take care of us right away, they give us

the medicines they prescribe right there, and give us

support and all.

The health committees have re-introduced the primary health care structure.

The active participation of these committees is indispensable to placing family

physicians in excluded communities and family homes as consultation points and

providing and transforming these points into permanent popular medical

dispensaries [26].

Configuring the health system into networks is a planning strategy that is key

to social intervention and meeting the health needs of each geographical and social

area. The network takes shape based on feedback from the institutions and health

committees, which are constantly interacting on a timely basis to meet the needs of

individuals and the population, and it is articulated depending on the responsibilities


47

assumed by each participating health worker, unit, service, and institution. The

network is interdisciplinary, its doors are open, and its goals (for example, regarding

diagnosis, planning, and the participatory budget) are decided on in coordination with

society [75]. Mission Barrio Adentro is so far the most important step toward building

a network-based National Public Health System.

This network consists of the Barrio Adentro popular medical dispensaries or

consultation points, the Barrio Adentro diagnostic centers, the Barrio Adentro

rehabilitation services, outpatient rural and urban health posts, the popular clinics,

the Barrio Adentro dental treatment rooms, the people's pharmacies, vaccination

centers, and Barrio Adentro optical services. Each popular medical dispensary is

linked to one of the other health care centers.

Table 8 shows the number of Barrio Adentro establishments that have already

been built or are under construction. Figure 4 shows a map of these establishments

in the state of Amazonas, the state with the lowest population density in Venezuela,

while Figure 5 shows the same for the municipio of Libertador, which in home to more

than half the population of Caracas.

Table 8: Barrio Adentro installations and popular medical dispensaries, July 2006

Built Under construction Total

Popular medical

dispensaries 1,612 4,618 6,230

CDCs 139 461 600

CRCs 151 449 600

HTCs 6 29 35

Popular advanced

care clinics 10 2 12

Note: Of the 139 CDCs in place, 40 have an operating room.

Network of Outpatient Care and Popular Clinics

Chapter 3

Figure 4: Map of Amazonas State and Barrio Adentro health facilities

Figure 5: Map of Libertador Municipio in Caracas and Barrio Adentro health

facilities

Note: The yellow circles on the map are for general reference only; they do not correspond to exact

locations because they have not been built yet.


49

Popular Medical Dispensaries and Consultation Points

Serving as the permanent point of contact between the community and the National

Public Health System, the health modules are physical structures that have been

specifically designed and built with a view to expanding and improving the care

provided to communities. The consultation point popular medical dispensary, is a

physical environment within the community that has been equipped to provide free

medical care for everyone in the area that it serves. Both have at least one physician

on duty who is specialized in comprehensive or family medicine, a health agent, and

a health promoter, and they have a social support organization in the form of a health

committee. The health modules operate on the basis of four fundamental principles:

(a) territorial coverage, in which each health module guarantees access and

coverage to about 250 to 350 families; (b) comprehensive care based on the

comprehensive care model, in which guaranteed care throughout the life cycle is

provided by units that have the capacity to promote health and quality of life through

educational, preventive, curative, and rehabilitation activities that respond to both

immediate health needs and the social determinants that affect the health of

individuals and communities; (c) social participation, in which there is ongoing

participation by the community; and (d) an intersectoral approach, in which the health

modules work is coordinated with the rest of the social policies of the State.

Table 9: Objectives of the popular medical dispensaries

� Promote and provide comprehensive health care for individuals, families, and

communities.

� Identify and practice early diagnosis and provide regular prenatal care for

pregnant woman.

� Practice nutritional surveillance and contribute to the development of proper

eating habits.

� Promote the development of health committees and social networks under

community control.

� Provide opportunities for education in health and basic environmental

sanitation.

Chapter 3

Table 10: Regular activities of the popular medical dispensaries

� In the mornings, Barrio Adentro, patients are seen in the dispensary.

� Afternoon hours are spent in the field (in the community in the local area of

influence).

� Contact is made with the organized community and the health committees,

which serve as bases for the organization of social control.

� The program for the free distribution of 106 commonly used drugs and the

family drug module are administered and monitored as necessary.

The drug module was introduced in April 2003 when the Barrio Adentro

doctors arrived for the distribution of free drugs, as indicated, to patients in the

popular medical dispensaries. At that time the module consisted of 55 drugs, which

corresponded to the main health needs of the Venezuelan population, including

antibiotics, parasiticides, anti-inflammatory and antipyretic agents, collyria,

bronchodilators, antihistamines, creams, antihypertensive drugs, vitamins for

prenatal care, contraceptives, pediculicides, antacids, anesthetics, anti-anemics

and nutrients, hydrating solutions, drugs for emergency use, steroids, drugs for

cardiovascular use, hypoglycemics, antianxiety drugs, and scabicides. In January

2004, in light of the need to introduce new drugs to the module, the list was expanded

to 106 drugs, which include: antiepileptics, muscle relaxants, urinary antiseptics,

antidepressants, specific vitamins for the infant and juvenile population, antifungal

creams, antiviral and cholesterol-reducing drugs, laxatives, and medication for gout,

as well as additional antacids, collyria, parasiticides, antihypertensive drugs, drugs

for cardiovascular use, and anti-inflammatories (Annex 4). To make sure that the

drugs in the module don't run out, there is a biweekly program for distributing them to

the popular medical dispensaries based on orders placed by the medical staff based

on characteristic morbidity in the particular area. This distribution is done by a group

of pharmacists, who are supervised by medical staff. Between April 2003 and May

2006, a total of 5,895.2 metric tons of drugs were distributed at no cost to the

population served by the physicians of Barrio Adentro.

In addition to the drug module for the popular medical dispensaries, the family

drug module was added in 2005. This program reaches 40 selected municipios in 17


51

states (Annex 4), an area that is home to 55 percent of the excluded population in

Venezuela. Accompanied by leaders in each community, a total of 105 physicians

deliver a bag containing the family drug module to each home in the municipio. Each

bag includes a list of its contents, which is tailored to the ages of the family members

(Table 11). The drug module is delivered every three months, and as of July 2006 a

total of six deliveries had been made (Table 12). This is a strategy that has been

widely received by the population. To date, a total of 4,846,948 families have

benefited.

Table 11: Population benefited by the family drug module

In Venezuela, 2005-2006

Table 12: Population benefited by family drug module deliveries

In Venezuela, 2005-2006

Chapter 3

Age Group Drugs and Supplements Distributed

609,819 infants between 6 months and 1 year old1

bottle/month of vitamin A and D2 in drops

4.426.791 children l to 11 years old Multivitamins (1 tablet/day)

343,414 pregnant women, and1,451,182 women of childbearing age

Ferrous fumerate and folic acid (1 tablet/day for all except for 2 tablets/day of ferrous fumerate for women more than 20 weeks pregnant)

429,563 women over 40 years old Calcium gluconate (1 tablet/day)

Beneficiaries

Families

Infants

6 mo to 1 year

Children

1 to 11 years old

Pregnant women

Women

of childbearing age

Women

over 40 years old

Delivery

1st 2nd 3rd 4th 5th 6th Total

1.111.832

123.315

895.555

50.001

490.475

11.950

625.485

128.647

537.170

59.653

104.352

-

653.360

147.128

509.751

57.446

154.939

80.948

688.360

6.747

594.357

56.719

190.647

85.193

692.330

130.918

487.198

60.306

242.617

85.861

1.075.566

73.064

1.402.760

59.289

268.152

165.611

4.846.948

609.819

4.426.791

343.414

1.451.182

429.563

52

Delivery of the family module is accompanied by “Health parties”, a series of

activities carried out by the community including sports, health promotion and

cultural events, with the active participation of various community organizations,

including groups of grandparents, teenagers, pregnant women or alcoholics.

In the municipios and states that are not included in the family module

deliveries, larger supplies of ferrous fumerate and folic acid are distributed to each

popular medical dispensary in order to guarantee free access to these supplements

for all pregnant women and women of childbearing age who go for consultation.

These are the Type I and Type II rural and Type I urban outpatient facilities.

They are part of the Ministry of Health's conventional free service infrastructure. The

operations and equipment in these facilities are undergoing rapid upgrading. The

outpatient services follow the comprehensive care model in order to take advantage

of every opportunity to practice comprehensive care with the population who ask for

care or come to the centers.

Table 13: Frequent types of care given in rural and urban outpatient services

� Sexual and reproductive health

� Oncology and cytology

� Health of children and adolescents

� Immunization

� Visual health

�Mental health and drug dependence

The popular clinics are public establishments whose objective is to promote, protect,

and restore the health through specialized medical care provided on an outpatient

basis. They have the technological capacity to treat medical and surgical cases that

Rural and Urban Outpatient Care Services

Popular Clinics


cannot be handled by other establishments in the network. The new management

model adopted by the popular clinics is based on timely and free quality care and

encourages cooperativism. With the exception of special community areas such as

indigenous communities, they are designed to serve a population of approximately

75,000 people living in reasonably close proximity.

Table 14: Services offered by the popular clinics

� Pediatrics, internal medicine, surgery, obstetrics

� Dentistry: 8 hours

� Emergency service: 24 hours

� Delivery room: 24 hours

� Laboratory: 24 hours

� Radiology: 24 hours

� Observation: average stay of 48 hours

� Operating room: same-day surgery

� Electrocardiography, ultrasound, endoscopy

The diagnostic network that supports the popular medical dispensaries

consists of some 600 comprehensive diagnostic centers (CDCs) and 35 high-

technology centers (HTCs). The CDCs respond to the need to provide diagnostic

support and strengthen the response capacity of the network of consultation points

and popular medical dispensaries based on referral and counter-referral. These

centers have the capacity to provide timely and quality response to meet the needs of

the community, as well as to optimize the human and financial resources of the

comprehensive network. The CDC is a health facility that provides diagnostic support

services, guarantees 24-hour medical emergency care, and also offers intensive

care, and all these services are free of charge to the population. The CDCs also

practice prevention, control and monitoring of diseases of the eye, with referral and

counter-referral of Mission Milagro beneficiaries (Table 18). The objective is for them

to offer advanced technology and serve specific geographical areas of influence and

Diagnostic Centers

53Chapter 3

designated numbers of popular medical dispensaries or outpatient services in the

conventional network. The Barrio Adentro organization anticipates that there will be

one operating room in every four CDCs. The location of CDCs that provide intensive

care gives the population rapid access in the event of a medical emergency (Table

15). There is one CDC for every 10 to 15 popular medical dispensaries.

The high-technology centers perform diagnoses that require highly technical and

complex equipment, again at no cost to the population (Table 15). They receive

patients from other establishments in the health network. Based on the needs

identified during the development of Barrio Adentro, it is proposed to build at least

one CDC and one comprehensive rehabilitation center in each municipio and more

than one in the major municipios located in the state capitals, as well as one HTC in

each state and up to three in the more densely populated states.

Table 15: Services offered by comprehensive diagnostic centers (CDCs) and

high-technology centers (HTCs)

CDCs

� X-ray

� Diagnostic ultrasound

� Endoscopy

� Electrocardiography

� Clinical laboratory

� Ultramicroanalysis

(in CDCs with operating room)

� Clinical ophthalmology

� Emergency, vital support

� Intensive care

� Pathological anatomy

(1 in every 6 CDCs is capable

of carrying out histopathological studies)

� Operating room (1 in every 4 CDCs)


HTCs

� Magnetic resonance imaging

� Computerized

axial tomography

� Tridimensional ultrasound

� Mammography

� Bone densitometry

� Video endoscopy

� Clinical laboratory

� Ultramicroanalysis

� Electrocardiography

55

Rehabilitation Centers

Dental Clinics

Popular Pharmacies

The comprehensive rehabilitation centers (CRCs) are establishments that

offer free services to the population corresponding to the popular medical

dispensaries or CDCs who have been diagnosed with a disability or illness that

requires physical therapy and rehabilitation of the musculoskeletal, gynecological,

urinary, vascular, or nervous systems or the services of a speech therapist. The

objective is to establish a total of 600 CRCs.

Table 16: Services offered by the comprehensive rehabilitation centers

� Electrotherapy, ultrasound, and laser therapy

� Thermotherapy, infrared heat

� Hydrotherapy, hydromassage

� Pediatric gymnasium

� Adult gymnasium

� Occupational therapy

� Natural and traditional medicine

� Speech therapy

� Podiatry

These are physical spaces with completely equipped dental treatment units.

The services are provided at no cost to the population by dentists who give oral

health care. There is one dental clinic for every three or four consultation points or

popular medical dispensaries. As of March 2006, 4,680 dentists were working in

Barrio Adentro and 1,558 in the conventional system [76].

These units sell drugs that are not distributed in the free program from the list

of 106 most commonly used drugs, which are made available with an 85 percent

Chapter 3

subsidy. Examples are complex antibiotics or second-generation anti-hypertensive

drugs. The first 100 popular pharmacies were opened inside the markets of Mission

Mercal. As of mid-2006 there were 270 popular pharmacies throughout the country,

and the aim was to have 300 by the end of year.

These are units that carry out free-of-charge activities to combat vaccine-

preventable diseases. The goal is to improve upon coverage under the Expanded

Program on Immunization (EPI). Starting in 2005, 630 vaccination points were

opened under the umbrella of Barrio Adentro, and it is expected to have a total of

1,881 under Barrio Adentro by the end of 2006, or a total of 5,800 throughout the

country (Table 17).

Table 17: Number of vaccination points in Barrio Adentro

And in the conventional network

Locating the vaccination centers in close proximity to the people helps to

increase the immunized population. It facilitates the monitoring of possible adverse

reactions, tends to eliminate missed opportunities for vaccination, improves the

accuracy of the database on vaccinated persons, and encourages community

participation in prevention activities. The list of EPI vaccines is reviewed on a regular

basis, and new vaccines are added based on recommendations by the public health

sector. As of July 2006, the list included: the pentavalent vaccine, oral polio, triple

bacterial, trivalent viral, double viral, yellow fever, Haemophilus influenza type b,

pediatric hepatitis B, adult hepatitis B, adult TB, BCG, tetanus toxoid, and rotavirus.

Vaccination Points


Year Number of

vaccination points

2004 3.800

2006 5.800

2005 4.600

57

At present the ratio is one vaccination center for every five consultation points or

popular medical dispensaries. They are physically located in a popular medical

dispensary and serve the population in its area of influence.

Optical Centers

These centers provide evaluation services and make glasses available to

people who need them at no charge. They are staffed with personnel trained in

optometry and optics. As of March 2006 there were 441 Optical Centers in the

country under Barrio Adentro and none in the conventional system [24].

This network is the accessory entry point to the National Public Health System

and responds at the site where the emergency occurs, whether en route to a health

center or at the health center itself. It comprises emergency primary care units,

mobile pre-hospital care, non-hospital outpatient emergency centers, hospital

emergency services, and intermediate and intensive care beds. It is tied in with the

other networks in the system for proper follow-up once the emergency is under

control. This network is in the phase of being developed.

This network is made up of institutions that have the capacity to hospitalize

patients, either for complex studies or for medical or surgical interventions [75], and it

includes all the People's Hospitals and specialized public hospitals in the country. As

part of the strategy to strengthen this network, an inventory of public hospitals

conducted in 2005 which identified their priority needs and main deficiencies and

made it possible to set priorities for securing the equipment and personnel needed in

order to run these facilities properly. Infusions of funding were donated to make up

the hospitals' budgetary shortfalls and a new hospital financing and hospital

management model was instituted in which, unlike traditional centralized models,

resources are administered directly by the hospital directors and administrators, with

obligatory participation by community representatives to guarantee the

administrative transparency of these processes.

Emergency Network

Hospital Network

Chapter 3

58

The hospital network also benefited by agreements signed in 2004 with Cuba

[77] and Argentina [78] which gave impetus to the procurement and upgrading of

equipment in the areas of neurology, rehabilitation, cardiology, oncology,

neonatology, and obstetrics. This initiative also made it possible to purchase

elevators, which in many cases had stopped running for lack of maintenance or had

been out of service for more than 20 years. Arrangements are currently being made

to procure equipment for the first 43 people's hospitals in the country.

To reduce the backlog in heart surgery needed for Venezuela's children, the

Dr. Gilberto Rodríguez Ochoa Latin American Children's Cardiology Hospital opened

its doors in August 2006. One of the largest centers of its kind in the world, this center

will provide timely cardiovascular surgical care free of charge, with equity and

universality for all children in the country. Moreover, in fulfillment of the agreements

implicit in the Bolivarian Alternative for the Americas, it will also receive children with

congenital heart disease from other Latin American nations who have no possibility

of receiving such care in their countries of origin. The establishment has capacity for

142 hospital beds (with facilities for one accompanying adult per child) and 33

intensive care beds. It has a total built-up area of 47,326 square meters, 30

consultation offices, 4 operating rooms, 2 hemodynamic stabilization units, 24

additional beds for accompanying family members, and a 169-seat auditorium.

As part of the social policy framework of the Venezuelan State [79], the Social

Missions got under way in mid-2003. These Missions were an original component of

the government management program that promotes the creation of opportunities

for the entire population so that the people will develop their full potential [80]. It

differs from social policies that focus on assistance because it's about progress

toward structural change.

The Missions contribute to the creation of a new social fabric and a new

institutionality of the Venezuelan State. Their action is aimed at the social

determinants that affect health and reduce social exclusion (Table 18).

COORDINATION OF BARRIO ADENTRO WITH OTHER

SOCIAL MISSIONS


59

Table 18: Social Missions that accompany Mission Barrio Adentro

Chapter 3

Social need and area of attention

Eye health

Name ofMission

Objectives

Preschool education

Literacy

Complete primary education

Secondary education

University Education

Training and employment

Land tenure

Inclusion of indigenous peoples

Milagro

Simoncito

Robinson I

Robinson II

Ribas

Sucre

Vuelvan Caras

Zamora

Guaicaipuro

Respond to the backlog of surgery needed for ophthalmological conditions.

Provide preschool education for children 0 to 6 years old.

Provide continuity for literacy program with studies through sixth grade of elementary school.

Provide the opportunity for a high school education.

Guarantee access to university education for all high school graduates who are without a space in the higher education system.

Give land, farming equipment, and technical assistance to rural peasants.

Recognize the rights of native peoples and indigenous communities to the land they occupy, respecting their social and political organization, customs, languages, and religions.

Provide job-related education and training.

Eliminate illiteracy.

Accomplishments

as of May 2006

176,000 patients underwent surgery in Cuba between July 2004 and March 2006, and 2,694 Latin American patients had surgery in Venezuela.

52% preschool coverage in 2003; construction of 10,000 classrooms in 2005.

On 28 October 2005 Venezuela was declared an “Illiteracy-free Land.” 1,482,543 persons taught to read.

1,521,603 persons taught toread and continuing to study.

614,835 persons enrolled; 168,000 graduates; 101,613 studying under scholarships.

216,582 persons enrolled; 20 university villages inaugurated in 13 Venezuelan states.

6,814 cooperatives created; 5,666 cooperatives financed; 130 active endogenous development nuclei established; 264,720 persons graduated in 2005 and 362,819 in 2006.

69,528 agricultural charters awarded; 2,993,543.07 hectares distributed; 48 Mission Zamora farms established with a total of 23,065.44 hectares.

21 collective land titles awarded, corresponding to 6,769 hectares; 32 projects financed.

Culture Cultura Guarantee mass access to culture; disseminate examples of culture of the popular sectors.

30,296 activators enrolled; 288 indigenous activators enrolled.


Housing

Right to identity

Care for children and adults in difficult circumstances

Food markets, feeding homes, and nutritional supplements

Knowledge and technologies for endogenous development and national sovereignty

School feeding programs

Living conditions in mining communities

Sports and recreation

Hábitat

Identidad

Negra Hipólita

Mercal

Ciencia

Programs de AlimentaciónEscolar (PAI)

Pío

Barrio Adentro Deportivo

Guarantee the right to housing.

Grant an identification card to citizens who have been denied this right.

The goal is zero children, older persons, and families in the street.

Guarantee the basic food basket at low prices with no intermediaries (Mercal Protección); guarantee food for highly excluded population (Mercal Máxima Protección).

Generate knowledge and technology; cultivate national talent; make achieve mass use of computer technology.

Guarantee feeding of the school-age population

Improve the quality of life of mining communities by promoting the rational use of resources.

Promote sports in the neighborhoods.

15,921 dwellings delivered in the first quarter of 2006; 110,000 families benefited in 2005; 41,500 urban dwellings constructed in 2005.

1,226,363 cards issued between February and May 2006.

The Mission is just getting under way. Steps have been taken to reintegrate families, give training for jobs, provide health care and food, and treat for substance abuse.

15,722 units established; 12,710,158 persons benefited; 6,075 feeding homes (911,250 persons benefited); 1,040,095 beneficiaries of Mercal Protección.

13,347 professional inventors enrolled; 390 medium and small businesses and cooperatives enrolled in the Mission; 217 networks of innovative producers financed; 1,300 high school teachers updated in the teaching of science; 54,038 students selected for graduate fellowships.

1,483,494 schoolchildren benefited in 2005, corresponding to 22% of all school enrollment.

186 cooperatives created; 110 cooperatives enrolled; 2 projects under way.

9 million persons benefited between 2004 and 2005.

61Chapter 3

There is general consensus about users' satisfaction with Barrio Adentro [81],

Mercal [82], and similar Missions, as well as the extent to which they feel that they are

part of one of the public policies that has had the greatest penetration and received

the most positive feedback in the history of Venezuela [83]. In surveys conducted by

the National Statistics Institute (INE) in Caracas, 97 percent of the respondents said

that they were satisfied or very satisfied with their general medical consultations, and

98 percent said they had little or no difficulty gaining access to health care, while 88.5

percent said that they had had some or considerable difficulty gaining access to

health care prior to Barrio Adentro [81]. In another study conducted by the INE in

Caracas, 89 percent were satisfied or very satisfied with the quality of Mercal

products and 96.5 were satisfied or very satisfied with the prices of the products.

However, some national political segments have pointed out that “despite the

success of Mercal, the socio-productive Missions have not yet had any real impact on

the population, nor have the other social Missions, although this does not mean that

might not do so in the future. These and the other social Missions have not yet made a

clear impact”[83].

Bearing in mind the difficulty of articulating the objectives, goals, and results of

health and social development programs and policies prior to the Missions, it can be

said that they have created the opportunity to improve coordination between State

institutions and their commitment to meeting the needs of the population. The

Missions go beyond sector-based public management and address the provision of

comprehensive care to meet the most keenly felt needs of the population. As the

Missions interrelate, they open doors to inclusion so that citizens can engage in

public arenas of decision-making, generate models of social economy and

endogenous development, and create a system of social and food security. The

coordinator of Mission Sucre in the municipio Urdaneta (in the southern part of the

state of Aragua) made the following comment about rural students getting a

university education:

There is no question that first and foremost the students

have to stay in their municipio, because that is where we

want to engage in endogenous development. We have to

grow from the inside out. Previously, a student had to

move to another city, and the few who had the opportunity

for higher education would graduate and remain in the

62

large cities, leaving their home towns abandoned. The

people thought about migrating as soon as they could. At

the first opportunity, they would move to other cities

where they figured they had better opportunities for

advancement. But now, with all of them studying here

and with all this participation taking place through the

cooperatives, and with the various credits going for

agriculture to strengthen the agricultural sector here in

Venezuela and this is an agricultural area I'm hoping

they will all stay here and take part in the development of

their own community. This is going to have huge impact,

because it is going to bring development.

The Missions operate in specific social territories. The concept of “territory”

has been traditionally linked to administrative authority, or a space determined

basically by politico-administrative divisions and power [84]. However, the concept of

“social territory” makes it possible to coordinate political, technical, and economic

capacity and produce strategies that will promote quality of life [85] and lead to

corresponding outcomes and results. In the area of health, the Missions create the

opportunity for:

� Participation by the people in the definition of strategies that affect quality of life

and health, not just services;

� Trans-sectoral action, with the possibility of bringing together the elements of

knowledge and the responsible sectors to make for improved quality of life and

health;

� Development of social agendas aimed at improving the quality of life and health

as a coordinated effort involving areas of government and society;

� Definition of roles and responsibilities for the care networks, taking into account

populations, territories, and goals, as well as the principle of co-responsibility,

which binds people to a specific context in which they have concrete social

responsibilities in addition to just the provision of services.

Experience is showing that, once people become involved in the dynamics of

the Missions, they cease to be anonymous. In their daily life, they become citizens

who acquire visibility in their own right, who take on projects, and, especially, who

give meaning to their lives by sharing ownership and a way of life with others, not just


63

a passing experience in a particular situation. Mission Barrio Adentro makes an

impact on the day-to-day lives of the people who have built it into their daily routine.

This fact was noted by the coordinator of a Magallanes health committee in Caracas:

Now we have health committees right here doctors,

clinics and there have been plenty. This isn't just one

person doing a single job. It's the work of everyone

pulling together. When one person isn't here, someone

else is. We now have new things to think about, like

creating some kind of community newspaper telling

about the work being done in other neighborhoods. We

have the idea of Community Radio. Starting from a base

in the church, we are going to put speakers in some of the

sectors. We are there, you know, little by little, getting the

idea to ripen, not in a big rush, but step by step, to get it

right. At least we could broadcast announcements in the

area to motivate people and tell them about how much

has been achieved with the government. I tell you,

yesterday I went around talking to people, and I amaze

myself when I tell them: It's true: this government really

makes things happen. It's important to seek people out

and get them motivated. The government isn't going to

give us everything; we have to give something in return.

If Mission Barrio Adentro is thought of as the articulating axis of social policy, this

means that its work needs to be tied in with the educational activities of the Missions;

the effort to provide proper nutrition and food security; endogenous development

nuclei; the organization of credit unions or other access to credit; social organizations

and urban land committees; the local health committees; and clubs for seniors,

mothers, and youth. Health management in Mission Barrio Adentro triggers the

construction of a social network. It is a new paradigm in health management and social

development, reflected in the new National Public Health Service, where health ceases

to be a private asset and becomes a public asset the birthright of all Venezuelans.

Mission Barrio Adentro, as the articulating axis of social policy sets the stage

for specific actions for the intervention and participation of communities in the design

and control of public management by undertaking these activities:

Chapter 3

64

� Responding to the needs of family groups in its area of influence.

� Sharing skills and tools with neighbors, community leaders, and participating

organizations.

� Seeing that institutional management is brought up to date and takes into

account the availability of the community as a resource.

� Working with a holistic approach and a trans-sectoral and cross-disciplinary

perspective that incorporates all areas of knowledge and possible responses to

the needs identified.

� Monitoring on an ongoing basis the socioeconomic and sociopolitical status of

the communities served by Mission Barrio Adentro for the purpose of taking a

social census of the indicators of quality of life and health of the population

served, the data being handled automatically by a computer information center.

On the whole, the Social Missions are the best opportunity that has come

along in Venezuelan history for the impoverished and marginal populations both in

the countryside and in the city, including the indigenous communities, to transform

their quality of life and raise the quality of citizens participating in their country's

sustainable human development.


Chapter 4

4

Lasting Legacy of Barrio Adentro andHuman Resources Development

Photo 4: Students in the Comprehensive Community Medicine Training Program. Barbacoas, Aragua State. April 2006.

66Lasting Legacy of Barrio Adentro and Human Resources Development

Chapter 467

Every year the Venezuelan medical schools graduate about 2,000 physicians.

Most of the new graduates are assigned to replace their predecessors who have

completed their one-year tour of social service duty in the traditional health system's

outpatient urban and rural clinics, as required under Article 8 of the Medical Practice

Law. Even though Venezuelan medical, dental, and nursing personnel are gradually

being incorporated and plans are in place for intensive programs to train new

professionals, without Cuban cooperation it would have been necessary to wait several

years before being able to embark on a social mission of the magnitude and social

impact of Barrio Adentro. The vital experience of Barrio Adentro physicians and other

professionals working together has created a strong demand in the communities to have

Venezuelan physicians with the same level of training and social commitment as the

Cuban personnel.

The goal is to train a total of 20,000 Venezuelan physicians through several

different training programs, all of them with a high degree of social awareness and

professional competence, to work for and with the community and become incorporated

into the new National Public Health System as Mission Barrio Adentro is extended

throughout the country. In addition, in collaboration with the Cuban Medical Mission,

1,823 graduate-level students are pursuing programs in comprehensive general

dentistry, and another 413 high-level nursing technicians [86] are being trained to work in

primary health care.

Along with degrees in medicine and dentistry, the academic schools of medicine

and health are offering basic and advanced level programs to train community health

promoters.

In response to the growing demand, the education program in comprehensive

community medicine (CCM) already has more than 17,000 students who have been

selected by their own communities. The education program in community

comprehensive medicine is coordinated by the Ministry of Higher Education and the

Ministry of Health, and it is part of Mission Sucre. The program is six years long and is

divided into four cycles: the basic, preclinical, and clinical cycles and the internship,

which encourages continuing education for the physician. The axis around which the

program is organized is comprehensive care of the individual, the family, the community,

TRAINING IN COMPREHENSIVE COMMUNITY MEDICINE


and the environment, and the teaching-learning setting is the Barrio Adentro popular

medical dispensary. The aim is for the graduates of this program to have diagnostic and

therapeutic competencies that enable them to provide comprehensive medical care

health promotion, disease prevention, and treatment and rehabilitation of the individual,

the family, the community, and the environment.

The CCM program is a new development which represents a change of

enormous significance for Ministry of Health policies in human resource development.

The curriculum is divided into several phases (Table 19).

Table 19: Curriculum of the comprehensive community medicine program [87]

First year� Community Project I: Community Health Diagnosis� Physiology (I, II, and III)� Communication as a Life Tool � Learning to be a Citizen� Sports, Recreation, and Health� Qualitative and Quantitative Methodology of Participatory Social Research

Second year� Community Project II: Natural History of Health and its Problems� Basic Medical Practice (I and II)� Physiology (I, II, and III)� Therapeutic Workshop (I and II)� Integrated Workshop: Causes of Morbidity and Mortality (I and II)� Sports, Recreation, and Health� Latin American Political Thought

Third year� Community Project III: Collective Approach to Community Problems� Basic Medical Practice III� Rehabilitation� Tropical Endemiology� Integrated Workshop III� Diagnostic Imaging� Therapeutic Workshop III� Primary Health Care Management

Fourth year� Community Project IV: Collective Approach to Community Problems� Integrated Medical Practice I

Fifth year� Community Project V: Collective Approach to Community Problems� Integrated Medical Practice II

Sixth year� Practical internship

69

The community project incorporates research and action, research in the

community, social participation, and the utilization of free time of the students and

community members who visit the popular medical dispensary. A Cuban physician

responsible for three students in the Barbacoas CCM program in a rural area of the

state of Aragua had the following comment to offer about the program:

In my parish I have three students. We have the

opportunity of serving not only as physicians but also as

tutors. This experience is unique. Not only do we

contribute to their education, but they contribute to ours.

The give us constant feedback: we have to try a little

harder every day. They are an inspiration for us to

perform better, to give a better example each day. We

have to inculcate many habits and many values in them

not only professional values but also ethical and

humanitarian ones, and it is usually a very moving

experience. We like very much being able to have this

opportunity, which has been unique for us. It is a new

program, a new style of teaching, that is becoming more

widespread.

At the beginning, the undergraduate CCM program had 2,188 students. After

the signature of agreements between Venezuela and Cuba in 2005, some 17,000

high school graduates were admitted in 2006. This first contingent of students, who

are already attending classes in several different universities (the Armed Forces

National Experimental University (UNEFA), Ezequiel Zamora National Experimental

University in Los Llanos (UNELLEZ), and the Bolivarian University of Venezuela

(UBV)), receive a monthly stipend of Bs. 200,000 a month (the minimum wage in

Venezuela in July 2006 was Bs. 465,000 a month). Two of the CCM students in

Barbacoas explained:

I'm studying medicine because I always liked it. I had tried

before, but I never had enough money. I took advantage

of this opportunity.

I never had the opportunity to study medicine because it's too

expensive. I had to pay my living expenses and everything

else, and I really couldn't cover all those expenses.

Chapter 4

70

The CCM program along with the Mission Sucre higher education program

give this opportunity to young people who otherwise would have been excluded from

higher education. In the words of the Mission Sucre coordinator in a municipio in the

southern part of Aragua State:

Since the beginning of the educational missions and

Mission Barrio Adentro, which are training the new

doctors that the nation needs, a large percentage of the

students, at least in the municipio of Urdaneta, have

been high school graduates who would otherwise have

been excluded from higher education. For the last three

years, a high school graduate from this municipio has

been able to attend university. Before, that would have

been virtually impossible. Today we have the opportunity

to study medicine. We have 200 high school graduates in

our parishes and sections studying higher level education

courses with their Mission Sucre professor. Some are

studying law, and we have a group studying computer

science. Until recently it would have been unimaginable

for them to be studying in a university degree program. In

my area, Mission Sucre is soon going to build a University

Village. We already have the land. We are waiting to start

construction. There is endless support for anything that

has to do with education and making it possible for all

Venezuelans to have the right to education and to build a

better life in peace and health in a human-centered and

participatory context.

In July 2004 the graduate program in comprehensive general medicine

(CGM) was launched with a new Venezuelan pedagogical model based on primary

health care. The teaching-learning setting is the popular medical dispensary, with

TRAINING IN COMPREHENSIVE GENERAL MEDICINE

Lasting Legacy of Barrio Adentro and Human Resources Development

71

rotations in the popular medical dispensaries and the network of hospital

establishments. The residency consists of about 30 full-time months of exclusive

dedication.

CGM education takes place in an integrative, cross-disciplinary setting that

brings together the basic, clinical, social, epidemiological, and humanist sciences,

based on criteria defined by the World Federation for Medical Education (WFME)

[88]. The idea is to offer a work/study setting which from the outset establishes a bond

between the student and the healthy or sick individual at all stages of the life cycle

within the context of the family, the community, and the environment. Emphasis is

placed on the epidemiological and environmental perspective; individual and

collective risk factors; critical thinking, sensitivity, and solidarity with one's fellow

man; and, in general, the life and autonomy of the human being. This is the

background against which correct and prompt solutions are sought, or else the

patient is referred to an appropriate point in the health network on a timely basis.

The need for this type of education emerged within the year after Mission

Barrio Adentro got under way. The initiative was undertaken in coordination with an

interministerial commission headed by the Ministry of Health and the Ministry of

Higher Education with advice from the Cuban Medical Mission. The curriculum,

which meets the criteria for graduate studies in Venezuela, is designed to achieve the

range of professional competencies (knowledge, abilities, skills, attitudes, and

values) needed in order to serve in the National Public Health System's primary

health care facilities. The objective is to guarantee the individual, the family, and the

community protection of their life and their environment; provide health education;

and promote quality of life and health through prevention, early diagnosis, timely

management and treatment of disease, and physical, mental and social

rehabilitation from the sequelae of disease for those who require it. These activities

need to be carried out in coordination the other members of the health team as

everyone works together to implement the epidemiological and environmental health

policies set by the Venezuelan State for the purpose of achieving the highest well-

being of its citizens.

The resident in comprehensive general medicine is at the center of the

education process, while the professor facilitates the self-teaching and self-

development process that continues to evolve throughout the person's life. Every

resident has an assigned tutor who is a specialist in CGM, has experience as a

Chapter 4

72

teacher, and works in a popular medical dispensary. The resident takes care of

urgent cases in the emergency services at hospitals, comprehensive medical

centers, or outpatient clinics, and may be able to make a definitive diagnosis using

equipment available at the high-technology centers. He or she needs to learn to

communicate easily with the individual patient, the family, organized social groups,

and the community; promote health education for all; and communicate with other

entities in the health system. Finally, he or she should learn to develop and carry out

qualitative and formative research on topics related to his or her work, with a view to

understanding it better and taking it in positive directions.

According to the Ministry of Health, there should be one comprehensive

physician providing primary care for every 1,250 to 2,500 inhabitants. This means

that between 10,000 and 20,833 graduates will be needed in order to cover the entire

Venezuelan population. To prepare personnel for these positions, in February 2004

the Ministry of Health invited all the physicians in Venezuela to apply for training in the

CGM specialty as part of its National Training Plan [89], with an initial allocation of

1,000 positions nationwide. In August the program was launched in 23 states with an

enrollment of 1,253 residents. This group is soon to be followed by a second class of

2,008 residents. The first class will graduate in March 2007.

This program, initiated in 2004, is conducted as part of the oral health

program. Comprehensive general dentistry (CGD) provides the health team in the

popular medical dispensaries and clinics with access to dental care. It involves

carrying out actions, with the participation of the community, aimed at the promotion

of oral health, the prevention of oral disease, and treatment and rehabilitation of the

mouth to reduce the incidence of oral disease in the individual, the family, the

community, and the environment with a view to improving the quality of care and

meeting the needs of the population. The main objective is to guarantee

comprehensive primary care for all citizens by offering program actions that include

TRAINING IN STOMATOLOGY AND COMPREHENSIVE

GENERAL DENTISTRY

Lasting Legacy of Barrio Adentro and Human Resources Development

73

local participation and social co-responsibility, so that oral health problems can be

detected and treated effectively and on a timely basis.

The curriculum is cross-disciplinary, and instruction is carried out in an

integrative context. The student is at the center of the educational process, while the

professor facilitates the self-teaching and self-development process, training the

student to keep on learning throughout his or her career.

Work on developing the CGD curriculum began in April 2004, and the

foundation was laid for providing education in this specialty. The program actually

started in October 2004 with 958 residents, and in July 2006 there were 875.

Table 20: Characteristics of the comprehensive general

dentistry teaching process

� The approach integrates instruction, care delivery, research, and

management.

� Teaching and service activities are carried out in integrated community

health areas using a tutorial approach.

� The tutor is specialized in CGD or some other branch of stomatology and is

responsible for the comprehensive formation of the resident.

� On-the-job training is the principle around which the teaching process is

organized.

� The Barrio Adentro popular medical dispensary is the primary educational

setting.

� Four hours a week are devoted to on-site academic activity.

� The curriculum is modular.

When Barrio Adentro first got under way, the people from the communities

who worked alongside the doctors in the clinics performed the tasks of nursing

auxiliary under the supervision of the medical personnel and they were referred to as

“health supporters.” These people were trained to generate community participation

in health promotion and disease prevention activities both in the popular medical

TRAINING IN COMPREHENSIVE COMMUNITY NURSING

Chapter 4

dispensary and elsewhere in the community. After participating in a training course

that ended in June 2006, a total of 5,632 people (Table 21) received an employment

contract from the Ministry of Health under which they receive the national minimum

wage. Health supporters are expected to take the prescribed Ministry of Health

training and also pursue vocational training at their corresponding educational level

(Robinson, Ribas) until they complete their training in the National Comprehensive

Community Nursing Education Program. The work of the health supporters (Table

22) comes under the framework of the Health Supporters Coordination in each

municipio, with which they maintain regular contact to stay abreast of guidelines and

policies being issued by the Ministry of Health.

Table 21: Number of participants in the health supporters training course,

By state: Venezuela, June 2006


AmazonasAnzoáteguiApureAraguaBarinasBolívarCaraboboCojedesDelta AmacuroDistrito CapitalFalcónGuáricoLaraMéridaMirandaMonagasNueva EspartaPortuguesaSucreTáchiraTrujilloVargasYaracuyZuliaTOTAL

72126

54326330197250

7929

21995

192282559342141

66240

34494273291154787

5.632

Table 22: Principal duties of health supporters in the popular

medical dispensaries

� Assist with administrative and operational tasks in the popular medical

dispensary.

� Provide patients with excellent care.

� Record information about users on the forms provided for this purpose.

� Orient users on taking advantage of the care provided, thus facilitating the

work associated with the consultation.

� Under the physician's supervision, follow instructions and provide support

in specific tasks consistent with the training the given by the Ministry of

Health and Mission Sucre under the Comprehensive Community Nursing

Program.

� Participate in planned health promotion and disease prevention activities

conducted in the popular medical dispensary along with the health team

(physician, student, health committee).

� Participate in community projects that support health and life.

� Understand the processes for the transformation of Venezuelan society

and guide communities toward an appreciation of these processes through

specific health and life practices.

� Be informed about the health structure of the Venezuelan State and work

toward developing and consolidating the National Public Health System.

� Understand the institutional policy guidelines that have made Barrio

Adentro the central element and primary focus of the Venezuelan State

health policy.

� Take part in the health management planning process in the popular

medical dispensary.

� Abide by the schedule and consultation times established for the popular

medical dispensary.

� Mornings (8:00 a.m. - 12 noon): Activities in the popular medical dispensary

� Afternoons (1:00 - 5:00 p.m.): Health promotion and disease prevention

activities

75Chapter 4

Chapter 5

5

Photo 5: Members of the Health Committee and participants in the Home Feeding Program, Vista el Mar, Los Magallanes Sector, Sucre Parish,

Libertador Municipio, Caracas. April 2006.

Impact of Barrio Adentro

78Impact of Barrio Adentro

Chapter 579

The first scientific observations of the impact of social and environmental

factors on the development of disease were made in the nineteenth century at the

beginning of the Industrial Revolution in Europe [90]. Since then, researchers have

published myriad studies, based on sophisticated epidemiological and of statistical

methods, that confirm the fatal link between poverty, on the one hand, and more

frequent illness and shorter lives, on the other. It is only logical that the abolition of

poverty will lead to improved health and prolonged life.

Assessing the health impact of a given policy or intervention depends on the

many different factors that can affect health. When health interventions are

undertaken, other social or political factors could have an important influence as well,

thus predisposing the outcome of a specific intervention. Clearly, greater effort is

required to measure the impact of complex interventions on heterogeneous target

populations, However, it may be easier to assess interventions limited to specific

target populations. The complexity of this subject has led to differing and even

controversial opinions on the definition of “evaluation” and the extent to which the

population being evaluated has a participatory role [91,92].

According to the Gothenburg Consensus Paper [93], analysis of the health

impact of a given intervention includes a review of all available evidence;

examination of the opinions, experience, and expectations of the people who may be

affected, and, if necessary, the generation and analysis of new data. However, some

policies, strategies, or policy platforms, programs, or projects may be so broad that

an in-depth analysis is impossible. In such cases, it is recommended to make

estimates that summarize the most significant impact without attempting to

determine the precise effect of specific policies or policy platforms.

Mission Barrio Adentro is one of a series of Social Missions that are aimed at

abolishing poverty. Structurally, it is in the process of being integrated into the

National Public Health Program of Venezuela. Thus, it cannot be analyzed as a

limited intervention; rather, it should be considered part of the health system, which

includes an array of organizations, institutions, and resources devoted to health,

including public health services and intersectoral initiatives [94]. Since January 2004,

the main purpose of Mission Barrio Adentro has been to provide the population with

complete primary health care coverage. The activities carried out in 2003

corresponded to the initial phase and were limited to a few municipios in the country.

In this chapter, data are presented for 2004-2005 and the first quarter of 2006. The


data include indicators of coverage and use as well as epidemiological indicators of

interest for the primary health care network.

Access to primary medical care is the crucial prerequisite to achieving the goal

of Health for All. The basic indicator of access has been defined as "the proportion of

population with access to primary medical care installations " and is measured as a

percentage. The numerator is the number of people who live within a convenient

distance from a primary medical care installation and the denominator is the total

population [95].

The location of a medical care establishment or post within a reasonable

distance is a necessary but insufficient condition for providing medical care to the

entire population. If the existing primary care installation is not functioning properly, if

the quality of care is inadequate, or if it is not financially, socially, or culturally

accessible, the spatial proximity of the health post is of very little value because it is

not being used. Thus, it is important to consider all the following factors: access,

quality, availability, social and cultural acceptance, and utilization [51].

In the Venezuelan context, the target population of Mission Barrio Adentro in

2003 was the population of the country previously excluded from medical care living

primarily in marginal sectors of the large cities. The first goal foreseen in planning the

mission was to attain complete coverage in a short period of time. By 2006, a total of

31,439 professionals, technical personnel, and health technicians were working in

the primary care network. Of these, 15,356 were Cuban physicians in various health

care centers the majority, nearly 13,000, in popular medical dispensaries or

consultation points [67]. Each dispensary takes care of 250 to 350 families. Because

the physicians visit the families under their care at regular intervals, the situation of

patients seeing two or three doctors is reduced to a minimum. This makes it possible

to estimate the spatial coverage of primary medical care in the target population

(Table 23).

ACCESSIBILITY OF CARE UNDER BARRIO ADENTRO

81Chapter 5

Table 23: Coverage of Mission Barrio Adentro

13,000 physicians x 300 families x 5 members per household (est.) =

19,500,000 million inhabitants, or 73 percent of the estimated national

population of 26,579,428 [96].

The Cuban and Venezuelan physicians working in Mission Barrio Adentro

have six years of university education in general medicine and have graduated from

Cuban or Venezuelan universities. In addition, the Cuban physicians have all

completed three years of specialization in comprehensive general medicine. All their

diplomas, certificates, and curriculum vitae are at the disposal of the Venezuelan

Ministry of Health. The Venezuelan physicians working in Mission Barrio Adentro are

enrolled in the graduate-level program in comprehensive general medicine.

All services and treatments are free. The Mission Barrio Adentro doctors were

well received in most of the communities. There were only a few cases in which initial

obstacles were encountered during implementation of the plan (see Chapter 2). To

date, there are no reports of communities that have rejected Mission Barrio Adentro.

On the contrary, the feedback shows that the communities have high regard for the

program. The doctors live in the neighborhoods, and it has even been reported that in

some areas prone to violence where there is no police presence the community

provides them with protection. The Caribbean culture shared by Cuba and

Venezuela helps to make for a warm bond.

In 2004 and 2005 a total of 150,455,332 consultations were provided by the

Barrio Adentro program. This is almost four times the number of consultations in the

conventional outpatient services during the same period. Nearly 40 percent of the

Mission Barrio Adentro consultations (58,863,346) were home visits (

Figure 6).


Figure 6: Total Barrio Adentro consultations in 2004-2005

Note: It is considered that a life was saved when a patient had a condition that was

sufficiently severe to pose imminent threat of death and would definitely have died without

immediate action on the part of the physician.

If it is assumed that the 30 percent of the national population in the higher

income brackets already had access to quality primary medical care, it may be

concluded that the percentage of Venezuelans with access to primary medical care

in 2006 was close to 100 percent.

Historically, one of the problems in securing the right to health in Latin America

has been the inequitable allocation of resources. In 1999, the distribution of

physicians in the region ranged from a high of 58 per 10,000 population in Cuba to

only 3 per 10,000 in some countries of the Caribbean and in Bolivia [97]. To

understand the meaning of this indicator within a country, it is important to look at not

only the number of physicians but also their social distribution. In 1998 Venezuela's

DISTRIBUTION OF PRIMARY HEALTH CARE PROFESSIONALS

Total of Consultations: 150.445.332 (2004-2005)

Saved lives: 18.251

In position91.591.986

(60%)

In address58.863.346

(40%)

83Chapter 5

physicians were concentrated in the cities that had the highest per capita income,

and the inequity was even greater in the distribution of specialized physicians.

According to WHO, in 1999 Venezuela had 19.7 physicians and 5.3 dentists per

10,000 population, with less than 50 percent of them in the outpatient network [98].

With Mission Barrio Adentro, the country's outpatient network now has 15,420

physicians specialized in comprehensive general medicine (66 of them are

responsible for coordination and not assigned to direct health care), plus 1,234

currently studying for graduate specialization in comprehensive general medicine

and 4,864 dentists (1,795 of them Venezuelans), with 1,823 currently studying for

graduate specialization in comprehensive general dentistry [67,76].

The distribution of Mission Barrio Adentro physicians across its many

consultation points tends to reduce inequity. Is possible to analyze this distribution

using the Gini coefficient a measurement of inequality typically used in reference to

income which can also be used to calculate other types of inequality [33]. The Gini

coefficient is a number between 0 and 1, where 0 corresponds to perfect equality and

1 is corresponds to perfect inequality. In 1998 the Gini coefficient for the distribution of

physicians in the states of Venezuela, grouped into five strata in ascending order by

per capita income, was 0.23 [33]. This result reflected the fact that 51 percent of the

physicians were concentrated in the five states with the highest per capita income. By

contrast, in 2005 the Gini coefficient for the distribution of physicians in the popular

medical dispensaries was 0.12, and this distribution is much more equitable. This

index is constructed based on the number of physicians in each state without

reference to population density. Since the lower-income states also have the lowest

population density and a smaller number of physicians, their distribution relative to

the population in those states is more equitable.

According to the human development index (HDI), the 2003 ranking of

Venezuela's states shows that the distribution of physicians in the primary care

network is equitable [99]. By estimating the number of inhabitants per physician,

starting from the premise that the physicians in the conventional and Mission Barrio

Adentro networks cover 70 percent of the population previously excluded from

medical care, 16 of Venezuela's 24 states (67 percent) have a ratio of one physician

to fewer than 1,250 inhabitants. In the states with an HDI of less than 0.7, the average

number of inhabitants per physician is 1,068 and in those with a higher HDI the ratio is

one physician to every 1,236 inhabitants (Table 24).

84

Table 24: Distribution of Cuban and Venezuelan physicians working in

Mission Barrio Adentro, human development index for 2003, and ratio of

inhabitants per physician, by states, Venezuela, March 2006

Note: The HDI for Venezuela as a whole in 2005 was 0.81 [101].

The increase in the availability of medical and dental personnel for primary

care implies a qualitative change, since all the physicians who have been added are

specialists in comprehensive community medicine and are also participating in the

education of a contingent of physicians with the goal all the professionals in this

network will be specialists. This arrangement overcomes the previous situation in


Distrito CapitalAmazonasAnzoáteguiApureAraguaBarinasBolívarCaraboboCojedesDelta AmacuroFalcónGuáricoLaraMéridaMirandaMonagasNueva EspartaPortuguesaSucreTáchiraTrujilloVargasYaracuyZuliaTOTAL

0,710,620,760,620,790,660,770,780,680,580,720,690,740,710,840,710,780,650,660,710,650,660,670,740,76

Population [96]

2.073.768134.594

1.428.269452.369

1.617.333724.331

1.475.5272.155.610

288.168145.586869.269716.896

1.736.983811.655

2.765.442819.197422.668839.881889.141

1.134.710685.442328.293573.726

3.486.85026.577.423

HDI

[99]

70% Population

1.451.63894.216

999.788316.658

1.132.133507.032

1.032.8691.508.927

201.718101.910608.488501.827

1.215.888568.159

1.935.809573.438295.868587.917622.399794.297479.809229.805401.608

2.440.79518.604.196

Cuban

physicians

[100]

1.85595

756270880346847

1.587245106529404667476

1.430485163423414397418213416

1.93415.356

Venezuelan

physicians

[100]

40141439

1294312

18323

53323

1257810

51436102362

040

2731,234

Inhabitants

per

physician

766.04864.37

1.298.431.024.781.122.031.303.421.202.41

852.50752.68918.11

1.082.721.175.241.535.211.025.561.344.311.170.281.671.571.280.861.467.921.891.18

999.601.078.90

880.721.105.931.121.41

85

which these services were being provided by recent medical graduates with weak

supervision.

The term health promotion was used for the first time in 1945, when Henry E.

Sigerist defined the four major tasks of medicine as the promotion of health, the

prevention of illness, the restoration of the sick, and rehabilitation, and stated that

health is promoted by providing decent living conditions, good working conditions,

education, physical culture, and opportunities for recreation and rest, for which he

appealed for the coordinated contribution of politicians, the labor and industrial

sectors, educators, and physicians [102,103,104]. This request was reiterated 40

years later in the Ottawa Charter for Health Promotion [57].

Ever since the health professionals began to arrive from Cuba in 1999, health

promotion has been the key tool for working with the communities in Venezuela.

Steps were taken to organize a system for exchanging information and working

closely with individuals, families, and communities. The First National Workshop on

Health Promotion was held in Caracas in March 2004, with the participation of

representatives from all the states, and guidelines were developed for health

promotion activities throughout the country [105]. A second workshop was held in

April 2005 in the state of Carabobo [106], a third in December 2005 in the state of

Zulia [107], and a fourth in May 2006 in Amacuro Delta [108]. All the workshops

discussed training topics for health promoters, the formation of groups or “clubs”

devoted to specific topics, and health promotion activities.

In the first workshop, plans were laid for the training of health promoters based on a

course developed in Cuba for its Comprehensive Health Program which was used to

train 6,931 health promoters. The next step was to develop an intermediate course

based on the Manual del Promotor [Manual for the Health Promoter] [109], which was

HEALTH PROMOTION

Training of Health Promoters

Chapter 5

86

used to train 48,754 people. A third course focused on the learning needs identified

by health promoters who had already been trained, which led to the preparation of a

training manual for health promoters which has been validated for use in the course

on health promotion for Mission Robinson facilitators. A total of 64,772 promoters

were trained in the third course during 2005 plus another 36,481 through May 2006

(Figure 7)[67].

Figure 7: Training of Mission Barrio Adentro health promoters,

Venezuela, 2003-2006 [67]

The training of health promoters includes regular updating, and for this purpose local

continuing education courses have been created.

Figure 8: Update courses for trained health promoters, Venezuela,

April 2003 to May 2006 [67]


87

Along with this process of training health promoters in the communities, a young

health promoters movement has mobilized youth groups in the communities who are

trained to act as health educators, giving courses for children that take advantage of

their imagination and creativity and tie in sports, culture, recreation, and health. At the

same time, they receive ongoing training about the chief health problems that have

been identified in the particular communities. Each group has an adviser from the local

health committee, a young president and vice president, and an organizer. They do their

work in different ways, depending on what the leaders and the rest of the group decide.

Figure 9: Training of young health promoters, Mission Barrio Adentro,

May 2004 to May 2006 [67]

One of the duties of a young health promoter is to visit families in the community and

share the knowledge they have acquired, making a note of the families that have

received these messages. They also carry out activities at home with their own

families with a view to cultivating desirable health behaviors.

Figure 10: Families visited by young health promoters,

Mission Barrio Adentro, May 2004 to May 2006 [67]

Chapter 5

88

Training and Operation of Specific Groups or “Clubs”

Expectant Mothers' Clubs. These groups are made up of pregnant women who are

being seen at the popular medical dispensary. The objective is to prepare the mother

and father for the arrival of the newborn. Among the activities carried out are physical

exercise, cultural and recreational activities, and study circles on topics of interest to

future parents. They also discuss ensuring the best prenatal care. The clubs have a

president and an adviser from the local health committee.

Figure 11: Membership in Expectant Mothers' Clubs,

Mission Barrio Adentro, April 2003 to May 2006 [67]

These clubs include all infants under 1 year of age in a given health

area and their caregivers. Their fundamental objective is to promote psychomotor

development and socialize the infants. Activities are aimed at teaching parents how

to monitor psychomotor development, and topics of interest to parents on feeding

and hygiene are presented. Each club is led by a mother who is also a health

promoter and has an adviser from the local health committee.

Baby Clubs.


89

Figure 12: Membership in Baby Clubs, Mission Barrio Adentro,

May 2004 to May 2006 [67]

These groups bring together adolescents between 10 and 20 years of

age in a given health area. Their fundamental objective is to prepare adolescents for

the stage they are going through in their development, teach them to understand

themselves, and help them learn how to differentiate desirable behaviors from

undesirable ones. Their objectives include getting youths who have been in gangs,

drug users, and delinquents reintegrated into society. Health messages are

conveyed to these young people through cultural, sports, and recreational activities.

Each club has a president, a vice president, and an organizer.

Figure 13: Membership in Teen Clubs, Mission Barrio Adentro,

April 2003 to May 2006 [67]

Teen Clubs.

Chapter 5

90

Senior’s Clubs: These groups are for adults over 60 years of age, and their

objective is to prepare the members to deal with the problems of old age, explain

about their physical limitations and how to overcome them, and encourage

intellectual development through educational self-improvement. The clubs meet in

various ways and offer educational, cultural, sports, and recreational activities. A

physician closely monitors chronic diseases and risk factors. Each club has a

president, a vice president, an organizer, and a treasurer.

Figure 14: Membership in Seniors' Clubs, Mission Barrio Adentro,

April 2003 to May 2006 [67]

Additional clubs are constantly being organized within the framework of

Mission Barrio Adentro for groups concerned with specific health issues, depending

on their prevalence.

Table 25: Clubs for specific groups, Mission Barrio Adentro,

May 2004 to May 2006 [67]


Specific groups

Patients with hypertension

Diabetics

Asthmatics

Smokers

2004

5.102

1.638

2.438

3.833

2005

5.097

1.683

2.476

3.741

2006

4.894

1.635

2.397

3.189

91

Table 26: Health promotion in the popular medical dispensaries,

2004-2005 [67]

Educational talks, classes on public health, and face-to-face sessions are conducted

by the physicians of Barrio Adentro in collaboration with the health committees. They

deliver health messages to patients, their family members, and the community.

Table 27: Health promotion activities, Mission Barrio Adentro,

April 2003 to May 2006 [67]

Health promotion activities have focused on tie-ins with sports and culture,

such as dance therapy groups, children's street events, and public cleanup days.

Dance therapy. Groups interested in physical exercise meet regularly and

enjoy dancing-related activities.

Street events. Children and their families participate in cultural, sports, and

recreational activities that convey health messages through games. Healthy forms of

recreation are taught.

Health Promotion Activities

Chapter 5

2003

2.333.409

90.798

2004

23.961.876

429.485

2005

13.293.528

496.489

16.960.961

2006

1.212.085

165.096

10.282.748

2004 2005

43.199.964

7.991

106.942

8.126

97.444

6.378

36.108

46.699.477

8.116

105.370

8.474

104.110

6.604

38.601

Health education activities

Teen Clubs

Number of participants

Senior’s Clubs


Expectant Mothers' Clubs


Activities

Talks

Public health classes

Face-to-face sessions

92

Public cleanup days. Neighbors join in and clean up common areas of the

community to help prevent the spread of diseases and improve the appearance of

the environment.

Table 28: Other health promotion activities, Mission Barrio Adentro,

April 2003 to May 2006 [67]

Health promotion activities are reinforced by broadcasting health messages

via community radio and television stations. These messages convey information

about common diseases and how to combat or alleviate them. The radio and

television programs include a validation component.

Figure 15:Number of radio stations carrying health education and promotion

messages and average hours broadcast per week, by state, Venezuela [67]


2003 2004 2005 2006

2.035

1.217

2.732

18.931

6.429

5.752

7.904

45.213

6.845

5.809

7.220

48.979

6.681

2.952

3.965

23.750

Activities

Dance therapy groups

Children's street events

Public cleanup days

Sports

AmazonasAnzoáteguiApureAraguaBarinasBolívarCaraboboCojedesDelta Amacuro

No. of stations

097868

1021

Average No. of hours

07.664563.5136

93

PRENATAL AND CHILD CARE

Care for pregnant women and children is a priority because these populations

are vulnerable and they are of key importance in guaranteeing the right to health for

present and future generations [110]. An analysis of prenatal care coverage shows

an increase from 25 percent in 1997 to 57 percent in 2003, although care during the

first trimester was still below 30 percent and the average number of visits was only

around 4 per pregnancy [111]. Between 2004 and 2005 a total of 769,604 pregnant

women had prenatal checkups, and of these, 146,397 were seen in the popular

medical dispensaries. During these two years, prenatal care coverage reached 70

percent in the country as a whole. In the popular medical dispensaries, coverage with

checkups during the first trimester was 54.5 percent, and there were an average of

10.5 visits per pregnancy. Also during these two years the popular medical

dispensaries saw 106,054 women for a total of 201,512 visits during the puerperium,

and monitoring of 106,233 newborns was initiated [67].

During 2004 and 2005, between the popular medical dispensaries and the

conventional network, a total of 872,624 infants under 1 year old were monitored,

Chapter 5

Distrito CapitalFalcónGuáricoLaraMéridaMirandaMonagasNueva EspartaPortuguesaSucreTáchiraTrujilloVargasYaracuyZuliaTOTAL

13771

1110

02216

1217

13144

950.51190.733013177

87.36

94

representing an annual coverage of 87 percent. Of this total, 63.8 percent of the infants were

seen in the popular medical dispensaries (218,191 in 2004 and 338,333 in 2005). During

these two years, the popular medical dispensaries provided 1,946,640 checkups for healthy

children 1 to 4 years of age and 3,945,920 checkups for children 5 to 14 years old [66].

For an appreciation of morbidity from chronic noncommunicable diseases,

the cumulative totals of cases recorded at the Barrio Adentro clinics in 2004 and 2005

give an idea of the situation during the period when activities were getting under way

at the different consultation points. It should be kept in mind that during this time there

were variations within the network in terms of the dynamics of installing and

regularizing activities in each community.

The data on five chronic noncommunicable diseases of major importance for

the health of the Venezuelan population show significant improvement not only in the

capture of new cases but also in monitoring and follow-up. The five diseases are

hypertension (AHT), diabetes, ischemic heart disease (IHD), cerebrovascular

disease (CVD), and bronchial asthma. For all these diseases there has been a

significant increase in the capture of new cases, which is very important because it

represents the diagnosis of cases in excluded groups that would have been very

difficult to identify prior to Barrio Adentro. In addition to an increase in passive capture

in the clinics, there has also been active case-finding through home visits and field

investigations. In the conventional network, the rate of diagnosis of new cases

remained the same or was slightly higher. However, there were only 1.3

consultations a year for each new case, which is not sufficient for follow-up. This

figure reflects the difficulty of monitoring chronic diseases in Venezuela.

In Barrio Adentro, on the other hand, the average annual number of

consultations for newly diagnosed cases is about 12, or approximately one a month.

The volume of return visits to the popular medical dispensaries shows that the

demand for the care of diagnosed patients is being met. The average number of

consultations indicates that there is much more regular contact with the doctor and

the possibility of monitoring these diseases is greater (Figures 16 and 17).

CHRONIC DISEASE CARE


95

Figure 16: Capture of new cases of chronic diseases, Venezuela 2004-2005

Figure 17: Return visits for chronic diseases, 2004-2005.

Between 2004 and 2005 a total of 1,353,905 new cases of arterial

hypertension were diagnosed in the national outpatient network, and of this number,

408,769 were captured in the Mission Barrio Adentro clinics, representing a 30

percent increase in the diagnosis of new cases. During this early phase of Mission

Barrio Adentro, most of the care given was in response to a high pent up demand in

these communities, which can be seen in the volume of consultations to see

Hypertension

Chapter 5

96

hypertensive patients who had already been diagnosed earlier but, despite being

aware of their condition, had not been followed or controlled for years, if at all.

Between 2004 and 2005 there were a total of 1,528,772 consultations for this

condition in the entire outpatient network, and 88.5 percent of these were in the

popular medical dispensaries. The highest increase was in return visits, for a total of

2,714,439 in the two years, and of this number, 95.1 percent were in the new network

of popular medical dispensaries (Table 29).

Table 29: Capture of new cases and follow-up consultations for hypertension:

conventional network and popular medical dispensaries, 2004-2005 [112]

According to WHO [97], in Latin America and the Caribbean 50 percent of

hypertensive patients are undiagnosed, and only one in every 10 patients manages

to keep bloodpressure levels below 140/90 mmHg. The same source points out that

the rise in diagnosis is directly related to increased access to medical care and the

elimination of missed opportunities.

The biggest problem for Venezuela, as well as many other countries in the

region, in having effective programs for the prevention and control of AHT and the

group of related diseases has been that the available information on this health

problem is incomplete. Mission Barrio Adentro has begun to correct this situation,

and it is expected that in the near future there will be an adequate body of information

on AHT in the Venezuelan population, which will make it possible to deepen and

expand the promotion and prevention actions that are already under way. It has been

shown that this is the way to reduce AHT-related morbidity and mortality and improve

the quality of life of people who suffer from the condition.


Total

69,8%

30,1%

945.136

408.769

1.353.905

4,6%

95,1%

583.636

11.429.438

12.013.074

11,4%

88,5%

1.528.772

11.838.207

13.366.979

Conventional network

Popular medical dispensaries

New

cases

Return

visits

Total

consultations

97

Diabetes

Diabetes is a chronic disease with a long silent evolution, which means that it goes

widely underreported. In Venezuela, underreporting is estimated to average 42.2

percent [113], with the consequent missed opportunities to control the bodily injury it

causes for the people affected. This disease contributes to premature mortality and

higher rates of disability because it increases the risks for heart disease,

nephropathy, blindness, and amputation of lower limbs.

In 2004 and 2005 a total of 312,576 new cases were diagnosed. Of this

number, 31.7 percent were captured in the Mission Barrio Adentro clinical network.

This rate has been rising as the clinics' diagnostic capacity increases with the

creation of more comprehensive diagnostic centers. It is expected to achieve an

optimum level of case-finding in the future, especially among groups for which this

opportunity had been largely unavailable. The rate of return visits to the popular

medical dispensaries is much higher than the rates of case-finding, since in this

group of chronic diseases there has been an enormous number of people who have

been diagnosed but have not have access to follow-up or medical treatment. In the

conventional network, on the other hand, the ratio is inverted: the number of new

cases is always greater than the number of return visits. The total number of return

visits for both networks in 2004 and 2005 was 2,714,439, and 91.9 percent of these

were handled by the Barrio Adentro network (Table 30).

Table 30: Capture of new cases and follow-up consultations for diabetes:

conventional network and popular medical dispensaries, 2004-2005 [112]

Chapter 5

Total

68,2%

31,8%

213.257

99.319

312.576

8,1%

91,9%

218.199

2.496.240

2.714.439

14,3%

85,7%

431.456

2.595.559

3.027.015



New

cases

Return

visits

Total

consultations

98

Even though insulin has been in use since 1921, WHO points out that access

to its use for diabetic patients continues to be a problem in Latin America and the

Caribbean [97]. In Venezuela, it has been distributed at no cost in the popular medical

dispensaries since 2004.

Ischemic Heart Disease and Cerebrovascular Disease

The two main cardiovascular diseases, ischemic heart disease and

cerebrovascular disease, can be effectively prevented if the risk factors are

controlled. These risk factors are the same as for arterial hypertension: namely,

smoking, unhealthy diet, and lack of physical exercise. However, as with any disease

that has a long period of latency, preventive measures must be started very early,

because the case-fatality rate is exceedingly high and in most cases death occurs

soon after the onset of symptoms [114]. The main obstacles to improving the

effectiveness of health actions aimed at reducing morbidity and mortality from these

diseases and their consequences for the lives of those who suffer from them, as well

as their families and communities, are: first, limited access to medical services by

excluded populations where the risk factors are greatest, and second,

underreporting of the problem, which is also highest in low-income groups.

After the implementation of Mission Barrio Adentro, in 2004 and 2005 the popular

medical dispensaries network captured 46.6 percent of all new cases of ischemic heart

disease and 29.7 percent of new cases of cerebrovascular disease. Figures on the

monitoring of these patients show that, of the total number of return visits, 98 percent of

those for ischemic the heart disease and 94.9 percent of those for cerebrovascular

disease took place in the popular medical dispensaries (Table 31 and Table 32). For

these two pathologies, physical rehabilitation was almost nonexistent in the national

public network, whereas in Mission Barrio Adentro it is currently being offered on a full

scale, with comprehensive rehabilitation and therapy offered to all those who need it.

Table 31: Capture of new cases and follow-up consultations for ischemic heart

disease: conventional network and popular medical dispensaries, 2004-2005 [112]


Total

53,3%

46,7%

75.033

65.679

140.712

1,9%

98,1%

20.547

1.048.873

1.069.420

7,9%

92,1%

95.580

1.114.552

1.210.132

Conventional networkPopular medical dispensaries

New cases Return visits Tota consultations

Table 32: Capture of new cases and consultations of control in

`cerebrovascular disease`, conventional network and popular physician's

offices, 2004-2005

In the period 2004-2005, 9.2 percent of the capture of new cases of bronchial

asthma and 89.5 percent of the successive consultations was carried out in the

popular physician's offices. This pathology is among the first ten places as reason for

consultation in the country and is one of the most frequent causes of income to the

emergencies. With the Mission Barrio^Adentro, the communities have resources to

serve this pathology nearly home, including medical care, drugs, vaporizers and

orientations for the prevention of the crises and the improvement of the quality of life

of the and the patient. Thus in these two years the total volume of care paid by

bronchial asthma was of 6,873,858 consultations, of which 70 percent were carried

out in the popular physician's offices (to see Table 33).

Table 33: Capture of new cases and consultations of control in bronchial

asthma, conventional network and popular physician's offices, 2004-2005

Bronchial asthma

99Chapter 5

Total

70,3%

29,7%

37.723

15.971

53.694

5,1%

94,9%

11.668

218.818

230.483

17,4%

82,6%

49.388

234.789

284.177

Conventional networkPopular medical dispensaries

New cases Return visits Tota consultations

Total

90,7%

9,3%

1.501.924

153.980

1.655.904

10,4%

89,6%

544.112

4.673.842

5.217.954

29,8%

70,2%

2.046.036

4.827.822

6.873.858



New

cases

Return

visits

Total

consultations

100

DENTAL CARE

. Has been estimated that almost between 70 and 76 percent of boys and girls

already has caries to the seven years and the probability that to the 12 years have at

least three teeth with caries is very high [118] . The situation is similar of superior ages

and the volume of desdentamiento among 35 and 44 years old reaches the figure of

26.7 percent. These data show the lack of dental care in the population for all the age

groups and suggests the need for offering restorative treatment instead of practicing

the exodontia as only solution and the importance both of preventive actions and of

activities of promotion and education for the health.

In order to attend to this health problem and to consider that oral health is an

important component of the comprehensive health of the person and its

environment, in 1999, through decree of the Ministry of Health and Social Welfare, it

was established that all the salt expended in the national territory should contain

between 200 and 220 fluoride milligrams of potassium by kilogram of salt in order to

combat caries // dental. This measure is so effective as the water fluoridation and has

been applied in other countries as Costa Rica, Colombia, France, Jamaica, Mexico,

and Uruguay.

In 2003, there was launched the National Program of Oral Health of the

Ministry of Health, which guided its policy to the development of strategies of

promotion of healthy lifestyles, disease prevention, and curative treatment, as well as

community participation. However, it is based on the implementation of the Mission

BarrioÂdentro in 2004 when it is possible to expand considerably the coverage of

oral health services. Table 34 shows that 71.4 percent of the total of consultations

carried out in the period 2004-2005 were carried out in popular physician's offices.

This increase has been possible due to the growth of the infrastructure of

BarrioÂdentro, with 1,208 new odontological physician's offices and the provision of

3,018 new odontological armchairs, as well as to the increase of the number of

dentists that work in BarrioÂdentro.


101

Table 34: Number of odontological consultations in Venezuela, 2004-2005

Upon analyzing the data of the odontological registry it is observed that in the

caries treatment is a considerable increase of the total number of caps with respect to

the exodontia for the years studied (Table 35). The index of caps-exodontias in the

conventional network is of 1.84 and in the popular physician's offices is of 4.26, while

the general index is of 3.66. This result reflects an improvement in the quality of

odontological care, since current care preserves more the teeth of the people.

Table 35: Number of obturations and exodontias in the popular physician's

offices and in the conventional network, 2004-2005

Table 36 shows the report of the odontological activities in the popular

physician's offices. For the first time, in the poorer sectors of the population

preventive activities are carried out as the application of lacquer of fluorine, early

detection of ̀ buccal` cancer and activities as the adaptation of dental ̀ prostheses`.

Chapter 5

5.689.949

14.367.331

20.057.280

28,4%

71,6%

100%

Odontological

consultations


Popular physician’s offices

Total

Number Percentage

Total

13.937.361

3.270.701 4,26

1.994.197

1.083.1171,84 1,84

15.931.558

4.353.8183,66 3,66

Popular physician’s offices


Obturations

Exodontias

Obturations

Exodontias

Obturations

Exodontias

Number Obturations-exodontias

index

102

Table 36: Dental care in popular physician's offices, 2004-2005

They point out the activities of education for the health, that include among

others the area of balanced feeding (reduction of sugar), bacterial plate control,

creation of habits of oral hygiene (technique of brushed, use of dental thread and

`buccal` rinse), information on application of fluorine (in order to strengthen the

enamel and diminish the incidence of caries), advisory services for the // care in

diabetic and hypertensive patients, and supply of information on the care of her oral

health and that of her child or daughter to the pregnant mother.

In the popular physician's offices the dentists that participate in graduate-level

one of comprehensive general dentistry are formed, which contributes to the fact that

its formation responds to the oral health needs of the population. The increase of the

access to dental care, the group of preventive actions carried out and the increase in

personnel formed in the area is making it possible to improve the oral health

indicators of the population.

Even though the ophthalmological problems are of importance in the Venezuelan

population, the access to the prevention, the diagnosis, and treatment of these

diseases has been very limited for the majority of the people. , the pathologies

identified as cause of blindness are: cataracts in 66 per one hundred of the cases, 16

per one hundred by retinopathies (included the diabetics) and the `hypertensive

disease`, 16 per one hundred by glaucoma and 7 per one hundred by errors of

refraction. In order to manage to eliminate avoidable blindness, it is necessary a

comprehensive addressing of the risk factors among which the low coverage of

OPHTHALMOLOGIC CARE


4.4481.426

355.06414.089.887

4.256.549216.813

Consultations regarding prosthesisTerminated cases Root canals Health education interventions Examinations for early detection of oral cancer Application of fluoride lacquer

103

ophthalmological services is at the first level. As a consequence of the lack of access

to these services, there exists a cumulative demand for medical-surgical care.

In the network of popular physician's offices of the Mission Barrio^Adentro is

carried out investigation and early detection of the ophthalmological pathologies,

there is given orientation and is channeled the treatment of preventable blindness

and visual deficiencies. When the national plan of literacy with the Mission Robinson

started, there were detected a large number of people with visual deficiencies that

had never had access to glasses corrective. Thus there is incorporated the service of

optics and optometry through which, between 2004 and 2005, 3,529,604 cases have

been taken care of, of which 38 percent were resolved with the delivery of glasses (to

see Table 37).

Table 37: Optometry and optical care provided, 2004-2005

Working alongside Mission Barrio Adentro, Mission Milagro responds to the

backed-up demand for eye surgery throughout Latin America. The integrated

approach includes helping patients to get reincorporated in their families, jobs, and

social life and make maximum possible use of their abilities. During the first phase,

between July 2004 and March 2006, surgeries were performed on 176,000 patients

in Cuba, 79 percent of them for cataracts, 19 percent for pterygium, and 2 percent for

palpebral ptosis. Starting in October 2005, Mission Milagro has been incorporated in

28 hospitals with a total of 37 operating rooms in 15 states of Venezuela (Table 38).

As of May 200, 18,294 interventions had been performed (Table 39) on a total of

17,584 beneficiaries (some of them patients with more than one condition). Of these

patients, 2,694 came from fourteen other Latin American or Caribbean countries

under Mission Milagro International cooperation agreements.

Chapter 5

3.529.6042.843.5753.264.2471.339.163

1.446.108

Cases treated

Cases resolved

Refractions

Eyeglasses provided

Lenses cut and mounted in frames

104

Table 38: Mission Milagro in Venezuelan hospitals and number

of operating rooms

Table 39: Mission Milagro eye surgeries performed in Venezuela,

October 2005 to May 2006


Hospitals

1

5

1

1

8

1

1

1

2

1

1

2

1

1

1

28

Number of

operating rooms

1

5

1

1

16

1

1

1

3

1

1

2

1

1

1

37

Apure

Aragua

Bolívar

Carabobo

Distrito Capital

Guárico

Lara

Miranda

Nueva Esparta

Portuguesa

Sucre

Táchira

Trujillo

Vargas

Zulia

Total

5.389112

7.831531

741

481252

343.616

18.294

Cataracts Ptosis Pterygium Strabismus Myopia Corneal transplant Diabetic retinopathy Glaucoma Detached retina Others Total

105

CARE PROVIDED IN COMPREHENSIVE DIAGNOSTIC CENTERS

(CDCS), COMPREHENSIVE REHABILITATION CENTERS (CRCS)

AND HIGH-TECHNOLOGY CENTERS (HTCS)

The availability of and access to high-quality, free, appropriate technology to

increase the response capacity of the primary health care network throughout the

country has grown significantly in the last two years through the services provided by

the comprehensive diagnostic centers (CDCs) and the high-technology centers

(HTCs). In the CDCs, as of March 2006 the following services had been performed:

5,511,851 clinical laboratory tests, 308,766 electrocardiograms, 969,997 ultrasound

examinations, and 72,456 endoscopies, as well as other examinations (Table 40). In

addition, 4,044 patients received medical treatment in these centers.

Table 40: Number of people seen in the comprehensive diagnostic centers,

1st quarter 2006

The high-technology centers began to operate in February 2006, and initial reports

on the services they provided are shown in Table 41.

Table 41: Number of individuals seen at high-technology centers, February

and March 2006

Chapter 5

933.8214.949

19.9727.411.0295.511.851

446.635308.766

36.622969.997

40.59772.456

Cases seen as emergencies Patients on life support Admissions for observation Tests and examinations performedClinical laboratory testsEmergency services Electrocardiograms Emergency services Ultrasound examinations Emergency services Endoscopies

17.864598

1.09514.362

99036

367169232

Total examinations performedMagnetic resonance imagingAxial tomography Clinical laboratory testsBone densitometry Mammography 3D ultrasound X-rays Video endoscopy

106

The rehabilitation centers (CRCs) are faced with an enormous backed-up

need for rehabilitation in connection with various forms of disability. In March 2006 a

total of 556,370 consultations for rehabilitation involved the administration of

1,744,921 treatments (Table 42).

Table 42: Number of people served in the comprehensive

rehabilitation centers, 1st quarter 2006

Accumulated social debt is reflected in sensitive indicators of a population's quality of

life such as the infant mortality rate (Figure 18). Infant mortality is an indicator that is

associated with the living conditions of the household and access to medical care.

The infant mortality rate in Venezuela began to decline in 1996, and since then it has

shown an overall downward trend. Upticks were seen in 2002 and 2003, along with

sharp drops in all economic and social indicators during those two years because of

the coup d'état and the oil strike, but the decline in infant mortality quickly resumed,

falling from 18.5 per 1,000 live births in 2003 to 15.5 in 2005.

CHILDHOOD ILLNESSES


123.576556.370

1.744.921248.290164.555773.857180.330131.595

Consultations

Consultations for rehabilitation

Treatments administered

Electrotherapy

Thermotherapy

Adult gymnastic therapy

Juvenile gymnastic therapy

Natural and traditional medicine

107

Figure 18: Infant mortality per 1,000 live births [dates?]

Acute diarrheal disease and pneumonia have been among the leading

causes of morbidity and mortality in Venezuela children under 5 years old. However,

between 1990 and 1996 mortality from diarrhea in children under 5 years old fell by

59 percent and mortality from acute respiratory infections by 36 percent [98]. A high

proportion of deaths from these childhood illnesses is preventable. The rates are

influenced by such factors as socioeconomic conditions, breast-feeding, literacy,

female access to education, potable water supply, adequate excreta disposal,

immunization, and administration of vitamin A [120,121]. Other determinants are

access to health services, prompt medical attention, and access to oral rehydration

supplies and drugs. Research on this subject shows that when usage of oral

rehydration therapy is higher than 60 percent in children with acute diarrhea,

mortality can be reduced by up to 15 percent a year [122]. Similarly, the execution of

control programs for acute respiratory infections for at least four consecutive years

results in annual reductions of up to 4 percent [122]. At the same time, however, it has

been a challenge for the countries to study the problem and improve their

epidemiological surveillance because of underreporting and low access to medical

care.

Chapter 5

108

Primary health care coverage increased during the first two years of Mission

Barrio Adentro. There has been a steady increase in the health care network's

response capacity, including health promotion and disease prevention, free delivery

of drugs, and the use of rehydration. Access to potable water increased in Venezuela

from 82 percent in 1999 to 93 percent in 2004, while wastewater collection in areas

covered by the health networks increased from 64 to 79 percent during the same

period [123].

It should be noted that during the same two-year period, reports of morbidity

from diarrhea and pneumonia actually doubled. This higher figure reflects the fact

that previously cases were not being reported in the population without access to

medical care (Figure 19, Figure 21, Figure 22).

Figure 19: Cases and deaths from diarrhea in children under 1 year of age,

1996-2005


109

Figure 20: Cases and deaths from diarrhea in children 1 to 4 years of age,

1996-2005

Figure 21: Cases and deaths from pneumonia in boys and girls under 1 year of

age, 1996-2005

Chapter 5

110

Figure 22: Cases and deaths from pneumonia in children 1 to 4 years of age,

1996-2005

There has been an overall decline in mortality from these two pathologies in

children under 1 year and from 1 to 4 years old. Between 1996 and 2005, mortality

from acute diarrhea in children under 1 year dropped 67.7 percent, and in the group

aged 1 to 4 it was down 48.3 percent. During the same period, mortality from

pneumonia in children under 1 year fell 45.3 percent, and in the group aged 1 to 4 it

declined 41 percent.

Over all, mortality from diarrhea in children under the age of 5 fell 63 percent

during 1996-2005, and mortality from acute respiratory infections declined 44

percent. For the years 2004 and 2005, deaths from diarrhea in this age group were

down 39 percent and 14 percent compared with the previous years, respectively,

together representing a larger decline than the average of 15 percent cited in

connection with interventions to treat childhood illnesses [for what population?]

[124]. Deaths from pneumonia in children under 5 were down 20 percent and 32

percent in 2004 and 2005, respectively, relative to the previous year, which

represents a decline far greater than the average of 4 percent reported in response to

interventions to treat these diseases [124].


111

A look at mortality in all children under 5 years of age from pneumonia,

diarrheal disease, malnutrition, and meningitis all of which are childhood illnesses of

major public health importance shows a similar pattern across the board for the

period 1996-2005. Mortality from all these diseases declined overall between 1996

and 2005: they all showed a steady fall between 1996 and 2002; except for

meningitis, there was an upturn in 2003, when malnutrition and pneumonia returned

to values comparable to 1996; and then they all saw downturns in 2004-2005, falling

to the lowest values ever (Figure 23).

Figure 23: Mortality from diarrhea, pneumonia, meningitis, and malnutrition in

children under 5 years old, per 100,000 population, 1996-2005.

The patterns in these rates between 2002 and 2003 reflect the same phenomenon

seen with the infant mortality rate. The key will be to continue monitoring this

morbidity pattern, even though it is likely to remain high until the pent up demand for

care is stabilized. After that, the rates are expected to continue to fall, which is the

goal. With regard to mortality from diarrhea, with advances in health care,

immunization, delivery of vitamin A, introduction of a vaccine against rotavirus in

Chapter 5

112

2006, elimination of illiteracy, rising rates of schooling, and increased household

connections to potable water, deaths from this disease are expected to decline

steadily.


113

Annexes

Annex 1: Constitution of the Bolivarian Republic of Venezuela and Provisional

Draft of a General Health Law

The Constitution of 1999 defines the model of society that is aspired to. Within

a human-centered framework, it is sought to build a social democracy and a State

based on justice and peace that is co-responsible and guarantees equity, since it has

become evident that the social gaps in Venezuela are impeding the exercise of

democracy. The enabling legislation issued in 1999 and 2000 grant to the Presidency

of the Republic the power to make laws on an exceptional basis. These laws have

been an immediate response to enhance the formal legal framework and create a

more propitious context for the structural changes proposed by the Constitution of

the Bolivarian Republic of Venezuela. They are laws at the State level that regulate

the economic, social, financial, and administrative life of the country. The goal is to

transition from a formal democracy that excludes part of society to a participative,

protagonistic democracy that is socially inclusive.

The Constitution lays the foundations for developing the juridical bases and

organizational structure of the Venezuelan health sector. Article 83 establishes that

health is a fundamental social right and that the State has the obligation to guarantee

it. Accordingly, Article 84 calls for the creation of a National Public Health System

(SPNS) with the Ministry of Health in the steering role. The system is to be

intersectoral, decentralized, and participative in nature; integrated into the social

security system; and governed by the principles of free services, universality,

comprehensiveness, equity, social integration, and solidarity. Article 85, in turn,

states that it is the responsibility of the state to finance the SPNS. Finally, Article 86

confirms that every person has the right to the benefits of social security, which shall

be provided as a nonprofit public service that guarantees health and also protection

against threats thereto.

The legal framework established by the Constitution allows for the formulation

of a draft General Health Law that presents policy guidelines and sets standards for

their institutionalization. The General Health Law defines the National Public Health

Annexes

114

System as a composite of the following: policies, plans, and actions; financial

resources from public sources; and institutions, care networks, and public services

focused on health operating at the national, state, and municipal levels, including all

institutions, networks, and services that receive funding from the State.

The General Health Law does not yet have legal force, although it was

promulgated in 1999. It was given preliminary approval, based on initial discussions,

in 2004, and follow-up discussions were to be held during the first half of 2006 to iron

out the difficulties that had been identified and specify the final steps required for its

execution, pursuant to the Constitution. It is a law that should be capable of governing

the highly complex aspects of planning the SPNS and delivering and controlling

comprehensive services. It should be able to promote a financing regimen and a

participatory model of functional organization. It is a law that involves multiple

interests and pressure groups at the central, regional, and local levels. What is

happening in reality is that the SPNS is being established before this legislation is

ready.

In the Provisional Draft of the General Health Law, the State assumes the

steering role and co-responsibly, together with governments at all levels and the

communities, in an internal restructuring process that will result in the formation,

consolidation, and governance of the SPNS. The State's leadership and steering role

is a clear statement of its active presence of the role in guaranteeing the well-being of

the population. Furthermore, heavy investment in the health sector guarantees that

the population will have free access to the corresponding services. With the SPNS,

the Venezuelan State is creating an equitable structure for social inclusion and

greater governance, which, according to the United Nations Development Program,

is closely correlated with a country's capacity to respond to the accumulated social

debt. It is a structure and a system designed to guarantee all Venezuelans the right to

health and a better quality of life, as provided for in the National Constitution.

The Constitution of the Bolivarian Republic of Venezuela and the draft

General Health Law have identified the pathways for intergovernmental coordination

that will facilitate construction of the SPNS. Health is no longer considered a

marketable commodity; it is a right. The Constitution and the new law put an end to

the liberal and neoliberal bias of the health market and the dominant conceptual

model of the last twenty years, which have been marked by social disinvestment and

consequent deterioration of the service infrastructure as well as obsolescence and

115

failure to maintain supporting technology, thus further curtailing the response

capacity of health establishments.

Along with guaranteeing the right to health as a part of the right to life, the

Constitution establishes an entire system of additional rights that supplement the

conceptualization and extension of the right to health. Among them: every person

has the individual and collective right to enjoy life and a safe, healthy, ecologically

balanced pollution-free environment in which the air, water, soil, climate, and ozone

layer are accorded special protection (Art. 127), and all water belongs to the public

domain, with provision in the law to guarantee its protection, utilization, and recovery

(Art. 304). Water and the air, climate, ozone layer, and environment are the

fundamental context of health. As a necessary means of supporting the proactive

role of the people and communities in working jointly with State entities, Article 62

states that both the State and society are obliged to facilitate conditions that will make

it possible for the proposed objectives to be achieved and for the people to participate

in the formation, execution, and control of policy and public action.

On the political and social level, the 1999 Constitution of the Bolivarian

Republic of Venezuela recognizes and facilitates proactive participation, co-

management, self-management, and cooperativism in other words, any associative

approach to life and work that is guided by the values of reciprocal collaboration,

solidarity, and social productivity. The Constitution, foreseeing the multiplicity of

interests and levels of governmental action that could serve as potential areas for co-

management, establishes planning and coordination mechanisms so that organized

communities can be represented in various governmental entities through the

Federal Council of Government, the Council on Planning and Public Policy

Coordination, Local Public Planning Councils, Community Councils, and the Inter-

territorial Compensation Fund. The Community Councils are the most advanced

organization that the neighbors of a given community can establish in order to

assume their role as actors in the exercise of popular power. The Councils serve as

mediators and articulators for the social programs created to improve the quality of

life of all Venezuelans without discrimination [72].

Annexes

116

Annex 2: The Venezuelan Sociopolitical Context and Background Leading Up

to Barrio Adentro

Representative democracy. From 1958 until 1998, two political movements,

the social-democratically inclined Democratic Action and the Christian-democratic

COPEI governed alternately during a period marked by increasing inequity in

income, deterioration of democratic leadership, rampant corruption, and indifference

on the part of elites to the growing poverty.

Free market economy. During the 1980s and 1990s, the International

Monetary Fund, the World Bank, the Organization for Economic Cooperation and

Development, and the World Trade Organization developed packages of political

and economic measures that governments then imposed on their countries.

First economic adjustment in Venezuela and El Caracazo. A turning point in

the crisis of representative democracy came with the spontaneous uprising of the

population on 27 February 1989, referred to since as “El Caracazo.” The rebellion was a

response to the economic adjustment policy concocted by the government at the time (the

second term of Carlos Andrés Pérez of the Democratic Action party) and the International

Monetary Fund, which included cutbacks in public spending and the liberalization of prices

on goods and services. This popular reaction was violently repressed.

World polarization. While the World Economic Forum, the summit of world

finance elites and representatives of the free market economy held its annual

meeting in Davos (Switzerland) in 1992, that same year the first Alternative World

Social Forum, the antithesis of Davos, was convened in Porto Alegre (Brazil) as an

open meeting of citizens of the world with an agenda to fight social exclusion and

advance the cause of social justice.

Military rebellion of 4 February 1992. This failed uprising, led by Lieutenant

Colonel Hugo Chávez, took place on the return of Venezuela's President Carlos A.

Pérez from the Economic Forum in Davos. Although Hugo Chávez and the rest of the

participants were imprisoned, many people identified with the young military rebels

and the uprising turned into a political movement.

End of the Carlos Andrés Pérez régime. In 1993, Carlos Andrés Pérez was

relieved of his duties by the National Congress. The Supreme Court charged him with

misappropriation of public funds, condemned him to prison and then placed him

under household arrest. He finally left the country.

117

Second attempt at economic adjustment. In 1993 Rafael Caldera was

elected the new president after convincing the electorate that he was going to

develop an economic model that would be an alternative to neoliberalism. However,

in 1996 he decreed a new austerity plan for Venezuela, along with a plan to privatize

oil and the iron and steel industry [125].

Election of 1998. By this time the country was deteriorating rapidly, with an

enormous deficit, a 14-year uncontrolled flight of capital, 20 percent unemployment,

and 85 percent poverty. Hugo Chávez managed to enlist almost all the leftist parties

in the country and a large number of the social movements that had supported the

formation of an anti-neoliberal government, and in December 1998 he won the

election with 56.4 percent of the votes.

Constitutional Assembly. In February 1999 the new government convened

the National Constitutional Assembly. Its members were elected by direct universal

secret vote, and the parties and movements that supported the government won 128

of the 131 seats in the assembly.

Participative democracy. In a referendum, the new Constitution was approved

by a 72 percent vote. During 1999-2001 the framework was developed for a series of

government decisions regarding social rights and the legislation that needed to be

drafted to breathe life into the new Constitution. Free health care and education were

decreed and the collection of any form of fee was prohibited in public establishments

throughout the country. During those three years inflation was reduced from 30 to 12

percent and unemployment fell from 14.5 percent in 1999 to 12.8 percent in 2001.

Infant mortality fell from 21.4 to 17.7 per 1,000 registered live births.

Natural disaster of the state of Vargas and the Cuban Humanitarian

Mission. One of the worst natural disasters in recent Venezuelan history occurred in

December 1999. Massive landslides in the state of Vargas caused some 20,000

deaths. The Cuban Humanitarian Mission that responded to this national

catastrophe was to later play a role in initiating Mission Barrio Adentro.

“Another world is possible.” In the meantime, on the international scene,

representatives of movements throughout the world came together in Seattle in 1999

to protest the Washington Consensus and give voice to the slogan “Another World is

Possible.”

New presidential election. Pursuant to the new Constitution, in May 1999

President Chávez called a new presidential election and won 60 percent of the vote.

Annexes

118

Enabling decree. In 2001 the Congress approved an enabling decree that

granted special powers to the president to approve a series of laws which included

the following: a law on land tenure that promotes agrarian reform as a challenge to

the latifundio, or traditional system of large landholdings, which has been viewed as

one of the country's main problems; a law on hydrocarbons that establishes the

bases for nationalization of the oil industry; and a law on coasts and fishing that offers

incentives for small-scale fishing and disincentives for trawling and also dictates the

use and ownership of coastal and riverbank land.

Business lockout. On 10 December 2001 the Federation of Chambers of

Commerce (FEDECáMARAS), the most important business association in the

country, called a national lockout in protest against the laws on land tenure,

hydrocarbons, and fishing, calling them “communist.”

Coup d'état. In 2002 an internationally supported military/civilian uprising

[126] of all the opposition forces led by the private communications media managed

to take over the government for 48 hours. However, thanks to a massive popular

demonstration of political parties, alternative communications media, and a sector of

the armed forces, the coup failed and President Chávez was returned to power.

National oil strike. From December 2002 to February 2003 the opposition

umbrella group known as the “Democratic Coordinator” consisting of leaders from

the private communications media, middle- and high-ranking military officers,

leaders of the traditional political parties, business associations (FEDECáMARAS),

leaders of the Confederation of Workers of Venezuela, the general management of

the State oil company PDVSA, sectors of the Catholic Church, and sectors of civil

society organized a national oil strike and boycott that caused losses to the country

on the order of [US$?] $13.43 billion, loss of 170,000 jobs, and inflation, which

reached 27.1 percent at the end of 2002.

Medical work stoppage. The Venezuelan Medical Federation called a

national medical work stoppage that kept public health facilities partially closed

between 2001 and 2003.

Recall referendum. At the request of the opposition, pursuant to Article 72 of

the 1999 Constitution, a referendum was held to on 15 August 2004 to consult the

populace on whether or not to recall the president. The mandate of President Chávez

was ratified by 60 percent of the vote. All international observers, including the Carter

Center, certified the transparency of the process [127].

119

Annex 3: Description of the Strategic Plan of the Nation within the National

Sociopolitical Context and the New Role of the State

The National Economic and Social Development Plan (PNDES) favors an

inclusive model of endogenous (autonomous) development and a productive,

diversified, and sustainable economy that strongly encourages agriculture, industry,

trade, tourism, and the building of infrastructure. Its objective is to promote the

creation of decent jobs and to monitor and improve all levels of education, health, and

safety in the national territory as well as the political comportment of citizens. The

PNDES promotes social networks, known in the health sector as “quality of life

promotional networks” [84], as spaces for co-management of the State and society.

These networks operate in the different social territories and call for reorganization of

the delivery of services to meet a standard of timely, regular, integrated, and quality

response to the needs of the population. In the PNDES the Venezuelan State

establishes the need to make structural and political changes within the context of a

new institutionality that will allow for a qualitative and quantitative leap forward in

reducing the accumulated social debt and laying new groundwork for development of

the country. These conditions are essential in order to achieve the desired quality of

life and citizenship within a society of peace in which democracy is defined as

participative and proactive.

The new active institutional role of the State apparatus involves creating ties,

taking action, and prompting network actor-mediators to take action up and down all

the chains of command in order to increase efficiency and transparency and ensure

the smooth operation of the civil service. As one of the main strategies, it is proposed

to identify gaps and counterbalance elements so that it will be possible to evaluate,

restructure, and update public administration and management; control public

spending in order to improve efficiency in the execution of public investment; and

transform the public apparatus with a view to reducing bureaucracy and ensuring

social control over management. The objective is to achieve an effective and

humanly balanced flow in the delivery of services to citizens. The bases for achieving

this goal are active participation, education, and joint establishment of mechanisms

for monitoring and strengthening the role of the State in the fight for respect of human

rights. In all this activity it is proposed to use institutionalization and guaranteed

continuity of the Missions as key tools.

Annexes

120

In the overall picture, the Missions are part of the birth of a new institutional

role for the State. They are emerging structures that give viability to an organizational

change in which several organizations join together and go beyond their exclusive

areas of competence to achieve a common end. The Missions cease to be situation-

based strategies and become building blocks within the social security framework for

bringing about permanent transformations in what were once the main sectors of

social exclusion: education, health, food, housing, access to new technology, and

training for insertion into the productive process.

In this new state institution, the fundamental difference compared with the way

services were planned in the past is the concept of meeting needs as opposed to

looking at the available supply. This is a radical contrast to the economic rationale of

neoliberalism, which is based on available supply and “focused spending,” which,

rather giving priority to quality of life, leads to the inequitable proposal of basic service

packages for the marginalized population. Care is now being made available to the

masses and it is socially inclusive, free to the population, and designed to encourage

the emergence of quality-of-life actors and networks, a healthy environment, and

comprehensive health care for the entire population, regardless of age, gender,

ethnic group, geographical location, or socioeconomic background.

In creating this new role, the State is proposing the collective construction of a

new social model as the basis for its experience in balancing the forces of

multidimensional national development in order to create conditions for general well-

being, create jobs, guarantee the equitable enjoyment of universal social rights,

improve the distribution of income and wealth, promote social participation, and

transfer power to its citizens so that they can exercise it democratically in their

corresponding areas and spaces of public decision-making.

121

Annex 4: List of Drugs in the Barrio Adentro Essential Drug Module

1 Epinephrine ampoule

Avafortan ampoule

Diphenhydramine 20 mg amp.

Furosemide 20 mg ampoule

Furosemide 50 mg ampoule

Cotrimoxazole susp. x 60 ml

Ferrous fumerate suspension

Dimenhydrinate 50 mg amp.

Diazepam 10 mg ampoule

Ampicillin 125 mg susp. vial

Amoxicillin 125 mg vial x 60 susp.

Phenoxymethylpenicillin susp.

Hydrocortisone 100 mg bulb

Amoxicillin 500 mg x 10 cap



Ampicillin 500 mg x 10

Beclomethasone spray

Salbutamol spray

Aminophylline 170 mg x 10 tab.

Mebendazole 100 mg x 6 tab

Folic acid 1 mg x 20

Folic acid 1 mg x 10

Norgestrel x 21 tab

Etinor x 21 tab

Etinor x 63 tab

Trienor x 63 tab

Clotrimazole 100 mg x 6 tab vaginal

Clotrimazole 500 mg x 1 ovule

Clotrimazole 100 mg x 12 tab vaginal

Atenolol 100 mg x 30 tab

ORS x 26.5 g

ORS 7 g

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

28

26

25

24

23

27

29

30

31

32

33

34

Cotrimoxazole x 10 tab

Cotrimoxazole x 20 tab

Ciprofloxacin 250 mg x 10 tab

Ciprofloxacin 500 mg x 6 tab

Tetracycline 250 mg x 12

Paracetamol 500 mg x 10



Diphenhydramine 25 mg x10 tab

Diazepam 5 mg x 10 tab

Diazepam 5 mg x 20 tab

Hydrochlorothiazide 25 mg x 20 tab

Chlorthalidone 25 mg x 20

Dimenhydrinate x 10 tab

Dimenhydrinate x 36 tab

Metoclopramide 10 mg x 20

Dexamethasone 0.75 mg x 20

Prednisone 5 mg x 20 tab

Piroxicam 10 mg x 20 tab

Piroxicam 10 mg x10 tab

Indometacin 25 mg x 20 tab

Ibuprofen 400 mg x 20

Metronidazole 250 mg x 10 tab

Polyvit x 100 tab

Multivitamins x 100

Nutriforte x 100

Glibenclamide 5 mg x 10 tab

Digoxin 0.25 mg x 20 tab

Digoxin 0.25 mg x 24 tab

Digoxin 0.25 mg x 10

Alusil x 30 tab

Alusil x 10 tab

Captopril 25 mg x 20 tab

Annexes

122

Captopril 25 mg x 10 tab

Captopril 50 mg x 30

Omeprazole 20 mg x 14 caps

Salbutamol 0.5% nebulizer sol.

Kanamycin strain x 5 ml

Gentamicin strain 0.3% x 5 ml

Anesthetic collyrium 0.5% vial x 5 ml

Sodium chloride x 500 ml

Sodium chloride x 1,000 ml

Dextrose 5 % x 500 ml

Aminophylline 0.25 g x 10 ml amp.

Lidocaine 2% x 2 ml x amp.

Kanamycin 1g bulb

Benzyl benzoate vial

Paracetamol 120 mg/5 ml vial syrup

Povidone-iodine 10% x 120 ml sol.

Povidone-iodine sol. antiseptic vial

Ketoconazole cream

Clobetasol cream x 25g

Clobetasol ointment

Gentamicin 0.1% x 25 g cream

Silver sulfadiazine

Nitrofurazone tube

Dextrose 5 % ampoule

Metamizol ampoule

Procaine penicillin bulb

Sodium penicillin

Water for injection x 3 ml

Cefazolin 1 g bulb

Cefazolin 500 mg bulb

Metronidazole x 100 ml

Atropine 0.5 mg x 1 ml amp.

Nystatin suspension

Oxacillin x 10 cap

Cefalexin 500 mg x 10 Caps.

46

44

43

42

41

40

39

38

37

36

35

45

47

50

49

48

52

53

54

55

51

57

58

59

60

56

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

Cefalexin 125 mg suspension

Secnidazole 500 mg x 4 tab

Levamisole 150 mg x 1 tab

Amiodarone x 30 tab

Ferrous fumerate x 60 tab

Ferrous fumerate x 10 tab

Calcium carbonate 0.5 g x 10 tab

Nitropental 20 mg x 20 tab

Nitropental 20 mg x 10 tab

Ketoconazole 200 mg x 30 tab

Acyclovir X 20 tab

Acyclovir x 10

Chlorpheniramine x 20 tab

Chlorpheniramine x 10 tab

Spironolactone x 20 tab

Spironolactone x 10 tab

Methyldopa 250 mg x 50 tab

Atropine 0.5 mg X 20 tab

Atropine 0.5 mg X 10 tab

Metronidazole x 6 tab vaginal

Metronidazole x 12 tab vaginal

Naproxen x 50 Tab

Nifedipine 10 mg x 100 tab

Cimetidine x 100 tab

Cimetidine x 10 tab

Folic acid 5 x 20 tab

Folic acid 5 x 10 tab

Isosorbide dinitrate x 10 tab

Carbamazepine 200 mg x 90 tab

Carbamazepine 200 mg x 30 tab

Phenobarbital 100 x 10 tab

Amitriptyline 25 x 10 tab

Clorpromazine 100 x 10 tab

Pyridylcarbinol x 10 tab

Ketotifen 1 mg x 10 tab

123

92

93

94

95

96

98

100

87 Azithromycin x 6 cap

Bisacodyl x 10 tab

Mandelamine x 30 tab

Mephenesin x 30 tab

Silogel x 30 tab

Vitamin C 500 mg x 30 tab

Prednisolone 0.5% collyrium x 5 ml

Benzalkonium 0.05% collyrium

Piperazine 120 ml vial syrup

Metoclopramide drops x 15 ml

Vitamins A and D2 drops

Levamisole 10 mg x 15 ml susp.

Vitamin C drops

Miconazole 2% x 25 g cream

Neomycin cream

Neomycin ointment

Acyclovir cream

Colchicine x 10 tab

Polycosanol (PPG) 10 mg x 10 tab

Diphenhydramine syrup

Insulin

88

89

90

91

97

99

101

102

103

104

105

106

Annexes

124

Annex 5: Table of Municipios Selected to Distribute the Family Drug Module

ESTATES

GRAN CARACAS

ZULIA

CARABOBO

MIRANDA

BOLÍVAR

ARAGUA

ANZOATEGUI

VARGASMONAGASSUCREBARINAS

TÁCHIRAMÉRIDA

PORTUGUESA

FALCONAPURE

MUNICIPIOS

LibertadorSucreBarutaMaracaiboSan FranciscoCabimasLagunillas

ValenciaLibertadorGuacaraGuaicaipuroIndependencia

PlazaAcevedoUrdanetaCaronaHeresGirardotSantiago Mariño

Mario BriceñoRivasSucreLibertadorBolívarSotilloSimón RodríguezVargas

MaturínCumanáBarinasSan CristóbalLibertadorPáezGuanareGuanareMirandaPáez

125List of Tables

List of Tables

Table 1: Urban-rural distribution of the Venezuelan population,

1950 to 2001 censuses (percentage) [14] ............................................................... 8

Table 2: Characteristics of the Venezuelan health system prior

to Mission Barrio Adentro ...................................................................................... 11

Table 3: Reasons for not consulting a physician, by household

income quintile, Venezuela, 1998 [35] ................................................................... 13

Table 4: Public investment in health, Venezuela, 2000-2006 ................................. 17

Table 5: Public investment in health as a percentage of national

budget and gross domestic product, Venezuela, 2000-2006 ............................ 18

Table 6: Primary care nuclei ................................................................................. 39

Table 7: History of the current health committees ................................................. 40

Table 8: Barrio Adentro installations and popular medical dispensaries,

July 2006 .............................................................................................................. 51

Table 9: Objectives of the popular medical dispensaries ....................................... 54

Table 10: Regular activities of the popular medical dispensaries ........................... 54

Table 11: Population benefited by the family drug module in Venezuela,

2005-2006 ............................................................................................................ 56

Table 12: Population benefited by family drug module deliveries in Venezuela,

2005-2006 ............................................................................................................ 56

Table 13: Frequent types of care given in rural and urban outpatient services ........ 57

Table 14: Services offered by the popular clinics ................................................... 58

Table 15: Services offered by comprehensive diagnostic centers (CDCs)

and high-technology centers (HTCs) ..................................................................... 59

Table 16: Services offered by the comprehensive rehabilitation centers ................ 60

Table 17: Number of vaccination points in Barrio Adentro and in

the conventional network ..................................................................................... 61

Table 18: Social Missions that accompany Mission Barrio Adentro ....................... 64

Table 19: Curriculum of the comprehensive community

medicine program [87] ......................................................................................... 74

126

Table 20: Characteristics of the comprehensive general dentistry

teaching process .................................................................................................. 79

Table 21: Number of participants in the health supporters training course,

by state: Venezuela, June 2006 ............................................................................. 81

Table 22: Principal duties of health supporters in the popular medical

Dispensaries ........................................................................................................ 82

Table 23: Coverage of Mission Barrio Adentro ...................................................... 86

Table 24: Distribution of Cuban and Venezuelan physicians

working in Mission Barrio Adentro, human development index

for 2003, and ratio of inhabitants per physician, by states,

Venezuela, March 2006 ........................................................................................ 89

Table 25: Clubs for specific groups, Mission Barrio Adentro,

May 2004 to May 2006 [67] .................................................................................... 98

Table 26: Health promotion in the popular medical dispensaries,

2004-2005 [67] ..................................................................................................... 99

Table 27: Health promotion activities, Mission Barrio Adentro,

April 2003 to May 2006 [67] ................................................................................... 99

Table 28: Other health promotion activities, Mission Barrio Adentro,

April 2003 to May 2006 [67] ................................................................................. 100

Table 29: Capture of new cases and follow-up consultations

for hypertension: conventional network and popular medical

dispensaries, 2004-2005 [112] ............................................................................ 106


for diabetes: conventional network and popular medical

dispensaries, 2004-2005 [112] ............................................................................ 107


for ischemic heart disease: conventional network and popular

medical dispensaries, 2004-2005 [112] ............................................................... 109

127List of Figures

List of Figures

Figure 1: Government budget for health as a percentage of the

national budget. Venezuela, 19701999 [23] .......................................................... 10

Figure 2: Political map of Venezuela and its 24 states ........................................... 15

Figure 3: Health committees, Mission Barrio Adentro, April 2003

May 2006 [67] ....................................................................................................... 41

Figure 4: Map of Amazonas State and Barrio Adentro health facilities ................... 52

Figure 5: Map of Libertador Municipio in Caracas and Barrio Adentro

health facilities ...................................................................................................... 53

Figure 6: Total Barrio Adentro consultations in 2004-2005 ..................................... 87

Figure 7: Training of Mission Barrio Adentro health promoters,

Venezuela, 2003-2006 [67] ................................................................................... 91

Figure 8: Update courses for trained health promoters, Venezuela,

April 2003 to May 2006 [67] ................................................................................... 92

Figure 9: Training of young health promoters, Mission Barrio Adentro,

May 2004 to May 2006 [67] .................................................................................... 93

Figure 10: Families visited by young health promoters, Mission

Barrio Adentro, May 2004 to May 2006 [67] ........................................................... 94

Figure 11: Membership in Expectant Mothers' Clubs, Mission

Barrio Adentro, April 2003 to May 2006 [67] ........................................................... 95

Figure 12: Membership in Baby Clubs, Mission Barrio Adentro,

May 2004 to May 2006 [67] .................................................................................... 96

Figure 13: Membership in Teen Clubs, Mission Barrio Adentro,

April 2003 to May 2006 [67] ................................................................................... 97

Figure 14: Membership in Seniors' Clubs, Mission Barrio Adentro,

April 2003 to May 2006 [67] ................................................................................... 98

Figure 15: Number of radio stations carrying health education

and promotion messages and average hours broadcast per week,

by state, Venezuela [67] ...................................................................................... 101

128

Figure 16: Capture of new cases of chronic diseases,

Venezuela 2004-2005 ......................................................................................... 104

Figure 17: Return visits for chronic diseases, 2004-2005 .................................... 105

129

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139Misprints and Clarifications Barrio Adentro

Misprints and Clarifications Barrio Adentro:

Health Right and social inclusión Venezuela.

p. 11 The last page of the first paragraph must state: ¨Public Health Inversion, in 1970 13.3 percent of the national budget, in 1990 it became 5.8 and 5.1 in 1996, which represents a 0.8 percent of the internal product in 1996.

p. 38 In reference to Table 6: Ministry of Health (2006) National Health Committee Coordination. Caracas: Ministry of Health

p. 52 In reference to Table 8: Ministry of Health (2006) Caracas: Vice-minister of network services

p. 55 The second paragraph must state ̈ see Annex 5¨ where it says ̈ see Annex 4¨p. 56 In reference to Table 11 is number 67.p. 56 In reference to Table 12 is number 67p. 61 In reference to Table 17: Ministry of Health (2006) Caracas: Strategical

Análisis Management and Epidemiology.p. 63 In the last paragraph reference 79 must be deleted.pp. 64-65 The information in Table 18 orginates with official internet pages of social

missions and with the government Bolivarian ministers of Venezuela according to information publicated since july 2006

p. 80 In reference to Table 21: Ministry of Health (2006) Information on the first course training for health lawyers. Caracas: Research Management and Education (Training)

p. 88 In reference to Graphic 6, is number 67.p. 99 Instead of graphic 15, there is a tablep. 101 In reference to Graphic 16 is number 112.p. 102 In reference to Graphic 17, is number 112.p. 108 In reference to Table 34, is number 76.p. 108 In reference to Table 35 is number 76.p. 109 In reference to Table 36, is number 76.p. 110 In reference to Table 37: Ministry of Health (2006) Caracas: Vice-minister of

Network Servicesp. 111 In reference to Table 38: Ministry of health (2006) Caracas: Viceminister of

Network Servicesp. 111 In reference to Table 39: Ministry of health (2006) Caracas: Viceminister of

Network Servicesp. 112 In reference to Table 40 is number 100.

140

p. 112 In reference to Table 41 is number 100.p. 113 In reference to Table 42, is number 100.p. 114 In reference to Graphic 18 is: Ministry of Health (2006) Yearly Vital Statistics

and Epidemiology. Caracas: Ministry of Healthp. 115 In reference to Graphic 19: Ministry of Health (2006) monthly mortality

statement Epi 15 and Yearly Vital Statistics and Epidemiology. Caracas: Ministry of Health.

p. 116 In reference to Graphic 20 is: Ministry of Health (2006) monthly mortality statement Epi 15 and Yearly Vital Statistics and Epidemiology. Caracas: Ministry of Health.

p. 116 In reference to Graphic 21 is : Ministry of Health (2006) monthly mortality statement Epi 15 and Yearly Vital Statistics and Epidemiology. Caracas: Ministry of Health.



p. 130 In reference to Annex 4 is number 67.p. 133 In reference to Annex 5 is number 67.p. 142 Instead of 25, it must state: Nacional Office of Budget and Central Bank of

Venezuela (2005) Public health expenditure as a percentage of PIB. Caracas: ONAPRE and BCV.

p. 146 Must delete reference 79.

141Methodology file on historical building of Barrio Adentro in Venezuela

Methodology file on historical building

of Barrio Adentro in Venezuela

Barrio Adentro: Health right and social inclusion

in Venezuela.

5 Tecnique: Live recorded interviews, copied and photographically registered.5 Field work period: April to July 20065 Selection criterias of areas visited in order to interview and to video record :

To visit all establishments that form part of Barrio Adentro during observation in urban environment and in a rural locality: consulting rooms residing in family housing, consulting rooms for the people, dentist clinics, optician clinics, integral diagnostic centers and integral rehabilitation services.

5 Selection criteria for interviewing people: Interviewing people represented for all devoted acts in the development of Barrio Adentro in an urban environment and in a rural locality: doctors, nurses, health lawyers, Health Committee integrants, Mercal Mission coordinators, Robinson II Mission, Ribas Mission, Sucre Mission, Science Mission, Nutritional home chefs, patients in waiting rooms and in consulting rooms, dentists, optical staff, teachers and pre-med students studying Integral Community Medicine, students studying in Integral Community Medicine, Ministry of Health and the Cuban Medical Mission officials( civil servants).

5 Número total de personas entrevistadas: Aproximadamente 60 personas (entrevistas formales e informales).

5 Description of recorded interviews:

5 Open interview hepl in 19 of april 2006 to 13 physicians to the Misión Médica Cubana were go to Venezuela between march and april 2003 and the management teen of Barrio Adentro: 2 horurs 29 minutes of recording.

5 Open interview help i20 of april 2006 to the cuban physicians teem and venezuelan medical students in Barbacoas, Aragua State: 36 minutes of recording.

5 Open interview held april 2006 in a health comité January 23, Parroquia Sucre, Municipio Libertador: 45 minutes of recording.

5 Public interview held 18 of april 2006 in health committees in Vista el Mar, Los Magallanes sector, Parroquia Sucre, Municipio Libertador: 1 hour and 33 minutes of recording.

5 Análisis methodology of interviews: The interviews are analysed using ethnographic tecniques and quality analysis. The result of the preliminary analysis triangulates with information obtained by written sources and additional interviews.

It is a policy of the Venezuelan State to enlist public health

as a tool for social transformation. From the beginning,

Mission Barrio Adentro has captured the interest of public

health professionals, social scientists, and journalists

around the world. Barrio Adentro was created within the

context of social transformation initiated in Venezuela in

1998, the new corporate structure of which is reflected in

the Constitution of 1999. It includes a ban on the

privatization of natural resources and public services in

the areas of health and education, the development of

Social Missions, equal access to learning, an endogenous

development model, protection of the environment, food

security, and agrarian reform.

This book reviews how Mission Barrio Adentro originated,

how it was implemented at the national level, how it works,

and what it has achieved in 2004-2005. It has been a joint

project of the Venezuelan Ministry of Health, the Cuban

Medical Mission in Venezuela, and the Representative

Office of the Pan American Health Organization in Aruba,

the Netherlands Antilles, and Venezuela. In addition,

assistance was provided by the National Commission on

Cooperation with UNESCO of the Venezuelan Ministry of

Foreign Affairs.

Mission Barrio Adentro - Pan American Health …experiment in primary health care (PHC) strategy....

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