92272 Knowledge Brief Health, Nutrition and Population Global Practice ACHIEVING MDGS 4 & 5: BOLIVIA’S PROGRESS ON MATERNAL AND CHILD HEALTH Rafael Cortez, Fernando Lavadenz, Seemeen Saadat, and Andre Medici August 2014 KEY MESSAGES:  Bolivia has made considerable gains in reducing maternal and child mortality from 1990 to date. The maternal mortality ratio declined from 510 to 200 deaths per 100,000 live births between 1990 and 2013, and under-five mortality also declined from 120 to 41 deaths per 1,000 live births from1990 to 2011. Bolivia also reduced its under-2 child mortality rate due to severe malnutrition by 80 percent in the same period.  The three key drivers of this reduction are: (i) structural reforms in the health delivery model, including changes in programs and health systems governance, new health infrastructure, and policies for expanding coverage from 1990 to 2003; (ii) financial protection reforms with a pro-poor provision of free maternal and child services through the creation of a public health insurance program, using results based financing to pay providers since 1996, and (iii) cultural adaptation to ensure greater access to and acceptance of health services by the indigenous population.  Over the last five years, progress has stagnated and Bolivia needs to continue working on three strategic lines to achieve the next round of gains. These lines are: (a) the health delivery model that will need to improve quality and address shortages of staff, (b) improving facilities and equipment in remote areas, and (c) financial protection that requires changes in payment mechanisms aimed at increasing the quality of MCH services for the indigenous population. Introduction This note explores the key maternal and child health policies and programs that have been implemented since Bolivia is a lower-middle income country, but one of the 1990. poorest in South America, with a per capita GNI of US$ 5,750 in 2013 and an average GNI growth rate of 4.4 percent during the last ten years. Nearly 36 percent of its Maternal and Child Health Policies population of 10.6 million (2013) are aged 0 to 14 years and one third live in rural areas. The country has a multi- Key health policies and legal provisions have created ethnic society and 62 percent of the population self- space for improving access and expanding provision of identify as indigenous people. Bolivia ranks 108th out of maternal and child health services. These include the 186 countries in the Human Development Index and 97th National Plan for child Survival and Maternal Health out of 186 countries on the Gender Inequality Index. (1989-93); Plan Vida (1993-97); and more recently, Salud Familiar Comunitaria Intercultural (SAFCI, Intercultural Family and Community Health) in 2008. Provisions in the Bolivia has made considerable progress in improving 2009 Constitution also guarantee the healthcare including maternal and child health. Child-mortality (under 5 years reproductive health. old) declined from 123 to 41 deaths per 1,000 live births between 1990 and 2012. In addition, maternal mortality more than halved from 510 to 200 deaths per 100,000 live Transformation of Health Delivery Model births between 1990 and 2013 - a 61 percent decline. Maternal and child health programs re-focused attention Page 1 HNPGP Knowledge Brief  on primary health care in the 1990s, expanding the public for Child Survival and Maternal Health. Prior to that, these health system in rural and peri-urban areas, with (i) the services were not widely available. Since 1998, family construction of more than 300 primary health care planning has been one of the services provided through facilities in around 100 defined networks during a ten maternal and child health insurance. years period; and (ii) prioritizing key programmatic interventions: ZERO MALNUTRITION PROGRAM: To reduce malnutrition among children, the program focuses on (a) food fortification; (b) literacy and provision of information Maternal and Child Health Programs to mothers, education and communication activities; (c) development of Rural Integral Nutritional Networks IMMUNIZATION: Under the health sector reform (1996), (RINN); and (d) expanding access to drinking water and the Expanded Program of Immunization (EPI) was sanitation. Between 2007 and 2010, the program helped revamped and expanded as EPI II. It included the penta- to reduce under-2 child mortality due to severe valent vaccine, a combination of five vaccines: diphtheria, malnutrition by 80 percent. tetanus, whooping cough, hepatitis B and Haemophilus influenza type b (the bacteria that causes meningitis, pneumonia and otitis). Health facilities were responsible Health System Improvements for directing the vaccination operations for the population DECENTRALIZATION: In 1994, the Popular Participation living within a 5-kilometer radius. A new complete health Law transferred 20 percent of central government cold chain was developed, and the new vaccines were revenues to the municipalities, which became responsible included as reimbursed services in the portfolio of the for the provision of health services (Figure 1 presents maternal and child health insurance (1996). Between health expenditures for 1995–2012). Management of 1989 (date of the first EPI launch) and 2008, the human resources for health was made the responsibility percentage of fully immunized children increased from of the sub-national autonomous administrations. Between 18.8 percent with 5 vaccines to around 79 percent with 8 1995 and 2012, data show a doubling of health vaccines. expenditure per capita (Figure 1). Changes in governance from 1997 to 2003 increased accountability, with the use CHILDHOOD ILLNESSES: Two key programs, the of performance agreements between National and sub- National Acute Diarrhea Program (NADP) and the Acute national authorities for achieving results in exchange of Lower Respiratory Infection Program (ALRI), were also additional funds. revamped. These programs focused on leading causes of post-neonatal mortality (children between 28 days of life Figure 1: Health expenditure per capita, PPP to 1 year old). Distribution of oral rehydration therapy by (constant 2005 international $) 350 professional personnel at health facilities, and by 305 300 volunteers of the People’s Health Committees at the 250 community level, was key to the success of the NADP. 200 The ALRI adapted culturally acceptable practices for the 150 treatment of respiratory infections. Both programs were 100 incorporated into the Integrated Management of 119 50 Childhood Illness (IMCI) Strategy in 1996, which focused 0 on the care of children between 0-5 years. Between 1999 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 and 2000 almost 80 percent of rural and peri-urban health personnel were trained to implement the IMCI Strategy. The training involved integrating the best health measures Source: World Development Indicators and Ministry of Health available to promote healthy lifestyles, prevent sickness, EXPANSION OF COVERAGE - EXTENSA: Launched in as well as timely detection and effective treatment of the 2002, the EXTENSA program aimed to expand coverage most prevalent childhood illnesses. of essential health services to rural and remote areas MATERNAL HEALTH: Since 1983, the Ministry of Health through mobile health teams (under SBS and SUMI – (MOH) has supported the WHO recommended “risk discussed later). A hundred mobile health brigades approach” for pregnancy screening along with the (BRISAS) helped to reduce the geographical barrier of promotion of prenatal and delivery care and postpartum access to services for dispersed indigenous communities care. Ministerial Resolution 0496 updated maternal and situated along rivers of the amazons, and in the highest child health services by adopting 18 evidence-based best mountains in the Andes. By 2007, EXTENSA was practices for maternal and newborn care. Emphasis has providing services to over 300,000 people in these areas. also shifted from training traditional birth attendants to FINANCIAL PROTECTION REFORMS - MATERNAL training skilled birth attendants at health facilities. AND CHILD HEALTH INSURANCE: Since 1996, Bolivia FAMILY PLANNING: Public health facilities began has provided free maternal and child health services to providing family planning services in 1989 under the Plan underserved communities through three insurance programs aimed at reducing economic barriers to health Page 2 HNPGP Knowledge Brief  services. The use of results-based financing, reimbursing increased the portfolio of available services to 92, providers based on results with autonomous utilization of including coverage of certain endemic diseases linked to resources and free access to health facilities was the core poverty such as tuberculosis for the general population. objective of the three health insurance programs: Between 1998 and 2003, the percentage of mothers utilizing health services through the public insurance grew Seguro Nacional de Maternidad y Niñez (SNMN): from 3.6 percent to 53.4 percent. Both SNMN and SBS Introduced in 1996, SNMN was Latin America’s first public focused on first and second levels of care and led to the health insurance scheme, providing coverage for 32 basic rapid decline in maternal and child mortality. interventions including: (a) prenatal emergency obstetric and newborn care; and (b) treatment of diarrhea, Seguro Universal Materno Infantil (SUMI) (2003): pneumonia, and respiratory infections in children under Introduced with support from the World Bank, the Universal five. Prenatal visits increased by 39 percent and births at Mother and Child Health Insurance (SUMI) added insurance facilities increased by 50 percent, especially among the coverage for tertiary care, and continued the focus on poor and the youth in the first 18 months of pregnancy-related care and under-five child health. While implementation. more than 500 services were financed, some services covered under the SBS such as endemic pathogens were Seguro Básico Salud (SBS): In 1998 the SNMN was eliminated This was a strategic decision to maintain focus replaced by a broader health insurance program known on reducing maternal and child mortality. By 2004, SUMI as SBS, with support from the World Bank. SBS had reached 74 percent of its targeted population. In Figure 2. Bolivia: Timeline of MDG 4 and 5 Interventions MDG 4: Under 5 Mortality 150 200 deaths per 1,000 live births 150 100 169 84 % 100 80 50 13 50 41 0 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 DPT Measles U5MR MDG 5: Maternal Mortality 80 600 deaths per 100,000 live 510 71.1 60 60.6 400 42.6 40 births % 200 20 200 23.6 0 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio 1979–1990 1991–2001 2002–2013 1979: Expanded Program of 1993–97: Plan Vida/Life Plan 2002–07: EXTENSA Program Immunization (EPI) 1994: Law of Popular Participation 2003: Universal Mother and Child 1980s: National Program to Combat 1994: Education Reform Act Health Insurance (SUMI). Diarrhea and Acute Lower Respiratory 2006: Zero Malnutrition Program 1996: Integrated Management of Infection Programs Childhood Illness strategy 2008: Salud Familiar Comunitaria 1983: “Risk approach” adopted for Intercultural (SAFCI) Policy 1996–98: Seguro Nacional de maternal health Maternidad y Niñez (SNMN) 2009: Bono Juan Azurduy; 1989–93: National Plan for Child, Constitutional guarantee on health and 1998–2003: Seguro Básico Salud (SBS) Survival and Development and Maternal reproductive health rights; Health 1999: Epidemiological Shield National Strategic Plan for the 2001: Indigenous Health Insurance Improvement of Maternal, Perinatal and Newborn Health; National Sexual and Reproductive Health Strategic Plan 2013: Prestaciones de Servicios de 3 Page Salud Integral (Law 475, Dec. 2013) HNPGP Knowledge Brief  2006, the program was expanded to cover additional 27 the following: reproductive health care services including family planning and screening and prevention of cervical cancer CONSTITUTIONAL RIGHTS: The 2009 constitution for women up to age 60. However, some services, such guarantees all Bolivians, the right to health, the right to as dental care for mothers and children, diluted the reproductive and sexual rights, and the right to gender potential impact of SUMI while adding transactional costs. and cultural equality. While institutional deliveries increased from 57.1 percent WOMEN’S EMPOWERMENT: The 1994 Popular 67.5 percent between 2003 and 2008, Demographic and Participation Law promoted women’s and men’s Health Survey (DHS) estimates show that maternal mortality increased during this time. This suggests that participation in municipal development plans; and the Supreme Decree 26350 established the following key maternal mortality is driven by the quality of care, and is a policies on gender: the National Gender Equity Plan (the matter of health system efficiency. first gender mainstreaming plan), the National Plan for the Prestaciones de Servicios de Salud Integral (Law 345, Prevention and Eradication of Gender-related Violence, December 30, 2013) / Benefits of Comprehensive Health and the Program for the Reduction of Poverty in Women Services, establish and regulate the financial protection in (2001–2003). health for the beneficiary population and lays the EDUCATION: The Educational Reform Act of 1994 groundwork for universal comprehensive health care. This promotes gender and multicultural/multiethnic equality, law unifies all existing health insurances (SUMI, SPAM focusing on bilingual education. Figure 3 shows a timeline (Special Insurance for seniors), and Disability Insurance) for of MDGs 4 and 5 interventions. targeted population. Cultural adaptation of health services Future Challenges INDIGENOUS HEALTH INSURANCE (2001): Created by Although Bolivia has made considerable improvements in maternal and child health outcomes, this progress has the Ministry of Health Resolution 26350 of 2001, the slowed down in recent years. One of the main challenges program was aimed at improving indigenous populations’ access to health facilities during the SBS period. It is to improve the quality and focus of SUMI and reinforce included an additional portfolio of ten services that the health delivery model, reducing the shortage of staff in rural areas, and improving the management of health adapted maternal health services to indigenous traditions, networks. Addressing supply side issues is critical to such as “soul rescue” by a traditional practitioner, accelerating progress on MCH. On the demand side, devolution of placentae, painting facilities yellow, rather communal decision making is central to the culture as well than white, which is associated with death among indigenous communities, and creating “wilaqunas” or as providing culturally appropriate services and improving indigenous health defenders. Provision of rural health access to information. These actions will reduce unsafe abortions accounting for a significant number of maternal services increased in coverage by 15 percent within one deaths. year. However, with the creation of SUMI, the next government ended this indigenous insurance program. Bolivia is among the countries with the highest rate of BONO JUANA AZURDUY (2009): This is a conditional teen pregnancies in Latin America, with over 17 percent cash transfer program aimed at improving maternal, of girls aged 15 to 19 having had a pregnancy (DHS 2008). Provision of youth-friendly services, elimination of newborn, and child health. The program pays a stipend of financial, physical, and social barriers to services and US$ 260 in installments to each pregnant woman for appropriate information are important in reaching this regular prenatal visits, skilled birth attendance, and population. postnatal visits for children until they are two years old. This is another effort to ensure cultural adaptation, as an incentive to increase demand for health services. This HNP Knowledge Brief highlights the key findings from a Creating an Enabling Environment study by the World Bank on “Maternal and Child Survival: Findings from Five Countries’ Experience in Addressing Besides health sector interventions, empowerment and Maternal and Child Health Challenges” by Rafael Cortez, equity were key to achieve better health outcomes. Broad Seemeen Saadat, Sadia Chowdhury, and Intissar Sarker support for improved equality in gender and education is (forthcoming). evidenced by a number of policies and initiatives including The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP- related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions.. For more information on this topic, go to: www.worldbank.org/health. Page 4