A project funded by the Canadian International Development Agency.

Project goal: to support the Bolivian Ministry of Health in constructing a new health system based on community participation and decentralization by providing model projects in two areas:

Project areas: The municipalities of San Lorenzo-Tarija and Guayaramerin-Beni.

Module 1: Participatory and Comprehensive Health District Management
Module 7: Frames of Reference: SHP's 4 Technical Guidelines

Within this framework, the Bolivian Ministry of Health has formulated a plan to restructure the health sector. Its purpose is to implement a new health system with universal access to primary health care.

Decentralization of health system planning and management is a major focus of the restructuring plan. This requires:

• changing policies at the national level

• providing training and infrastructural support for planning and managing  the health system at the district level

• promoting interdepartmental and intersectoral coordination

• providing training and improving the ability of communities to participate in analysis, planning, design and management of health services

BOLIVIA'S HEALTH INDICATORS

Bolivia's main health problems impact primarily on women and children.

Bolivia's infant mortality rate is 75 per 1,000 live births, with large rural/urban disparities. Leading causes of death in children are acute diarrheal diseases and respiratory infections (primarily pneumonia) associated with poverty and lack of primary health care. There is chronic malnutrition, with more than one-third of school-aged children assessed as being growth-retarded. Vector-borne diseases (malaria, chagas, dengue and leishmaniasis) are highly prevalent.

The average fertility rate of 4.9 children per woman is one of the highest in Latin America. Maternal mortality is very high (390 per 100000) one factor being abortions performed in unsafe conditions.

Recognizing the severity of health problems affecting women and children, the government has made maternal and child health its top health sector priority.

The public health system reaches only 35 per cent of Bolivians and is based largely in urban areas. The present structure, biased in favor of secondary and tertiary care, does not properly address the most common problems of the needy, including the rural and indigenous populations. Improved primary health care is required rather than sophisticated equipment or highly qualified human resources.

CANADA'S INVOLVEMENT THROUGH CSIH

Canada, with its experience in health promotion and community participation, its accessible health care system, as well as the lessons it has learned from its own restructuring process, has been in an ideal position to assist in strengthening the Bolivian health reform strategy.

Through its International Health Education Program and, more recently, a youth internship program, CSIH has been involved since 1983 in sending health sciences students and young professionals overseas to participate in primary health care projects. CSIH has built on this experience in youth programming to involve young professionals in project activities in Bolivia. Special criteria and procedures were developed to manage their participation.

Bolivia has benefited through a transfer of Canadian expertise in key reform areas including policy analysis and formulation, health administration, information management, and development and management of integrated delivery systems, and through development of sustainable institutional linkages with Canadian health organizations.

The project has provided opportunities for a variety of Canadian institutions, including universities and regional health authorities, to learn from another model in decentralization of the health care system and programs, and from different health reform situations, approaches and experiments of potential relevance to the Canadian context. The project will provide opportunities for a variety of Canadian health institutions to strengthen their capacity to work internationally.

The project cost $4.6 million over five years, with $3.2 million in funding provided by the Canadian International Development Agency. Other contributions have come from partner institutions, with in-kind contributions generated by CSIH.

PROJECT TARGET AREAS

San Lorenzo (Department of Tarija) and Guayaramerin (Department of Beni) were chosen for the two model projects, according to specific criteria developed in cooperation with the Ministry of Health. These included the absence of similar programs, and the extreme poverty and poor health status of the areas.

San Lorenzo is a village of 5,000 people in the department of Tarija in southern Bolivia. In its treeless, arid landscape, most of the 13,000 rural population make a meagre living growing potatoes, wheat, fruits and vegetables or herding beef cattle. The average family income in town is US$100 a month; in the rural areas, families survive on about US$25 a month.

Health status in San Lorenzo is among the worst in Bolivia. Infant mortality is 85 per 1,000 live births. Approximately 60 per cent of the population has tested positive for chagas disease which leads to high morbidity and mortality. Although there is a hospital in town, it has no water and no equipment. For care, patients have to travel to Tarija, an expensive 30-minute bus ride away.

Guayaramerin, population of some 35,000, is in the north-east corner of Bolivia on an Amazon river tributary that forms the border with Brazil. Most people make a living from small holdings producing Brazil nuts and rubber. Demand for the latter has fallen sharply, but family income is about US$50 per month, thanks in part to increased trade in lumber with Brazil. Poverty, malaria and leishmaniasis largely account for the high morbidity, mortality, and infant mortality rates. Services are very few. The 20-bed hospital and eight health posts are staffed by auxiliary nurses but they have no medical equipment, supplies or medications.

PROJECT STRUCTURE

The project is staffed by a project director and assistant at CSIH headquarters in Ottawa, Canada, and a field project coordinator and assistant in La Paz, Bolivia, as well as technical assistants in each project area.

An advisory committee operates in each country, with the Bolivian steering committee having a particularly important role. Composed of representatives from government and key Bolivian project partners, as well as CIDA and CSIH, its primary function is to provide advice in the areas of needs identification, selection of Bolivian partners, and project monitoring.

The advisory committee in Canada is composed of CSIH members with expertise and experience in health systems management and reform, and a knowledge of the Latin American context. The committee acts as a sounding board for the project management team, providing advice and expertise on policy and matters related to project design, implementation and monitoring. It is also involved in the selection of Canadian technical advisors recruited by CSIH and partner organizations.

CURRENT STATUS OF PROJECT

The Bolivia health reform project ended in July of 2002. Models for planning, organization, management and governance within the health system have been developed. It is fully expected that these models will be adopted by the Ministry of Health and implemented in other areas of the country, since research has now shown that San Lorenzo and Guayarmerin, the project sites have substantially improved their capacity to deliver health services.

Project staff has developed healthcare models that address local concerns, within the national policy framework. To date, the technical officers in each area have brought together local service providers and non- governmental organizations for workshops to initiate the implementation phase. Follow-up activities have included baseline data collection, capacity development in health systems analysis, management, organization and governance for restructuring health service networks.

Project staff were successful in facilitating community access to a national Social Investment Fund for funds to contract health centers and equip the hospitals to provide adequate health services in both San Lorenzo and Guayaramerin. Completing the health services network has greatly enhanced the capacity to  meet  population needs.