Bolivia Prescribes Solidarity: Health Care Reform under Evo Morales

Much as they do at sites across Bolivia, Cuban doctors work side-by-side with Bolivian physicians at the San Francisco de Asis Hospital in the rural town of Villa Tunari, nestled in the tropical El Chapare region. A Bolivian administrator explains that the hospital staff is comprised of 68 Cubans integrated with the 72 Bolivians who work there. Of the three surgeons, two are Cuban. The government of Cuba covers all of the expenses of their doctors, and they do not charge for services. One of the Cubans on site proudly asserts that in the span of one year his team had seen more than 30,000 patients, and conducted 400 surgeries.

At a national level, Bolivia's TCP-ALBA Coordination Team documented that in 2007 Cuban medical personnel had provided services to around three million Bolivians. The following year, a BBC article reported the number of consultations had surged to nine million. Government figures from 2009 indicate that more than 260,000 Bolivians had undergone eye surgeries through Operación Milagro.

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Under Bolivia's system, the country's elite nets five times more in health care expenditures than those with the lowest incomes. Social security and private health care, which together represent four-fifths of all health care expenditures, are highly regressive. The World Bank found that only around 4% goes to poorest 20% of the population, while almost half is enjoyed by the richest quintile. Rural residents are especially disadvantaged, with many effectively lacking any access to health care services.

While medical solidarity from Cuba, Venezuela and other donor countries has been helpful in confronting Bolivia's uneven health care landscape, it is not a permanent fix. In the end, Bolivians should be seeing Bolivian doctors, a point implicitly acknowledged by the several thousand scholarships provided to Bolivians to study medicine in Cuba and Venezuela.

The Morales government has also initiated a series of domestic programs to increase health services. A newly announced mother-child subsidy called "Juana Azurduy" provides cash payments to pregnant women and mothers with babies through their second year, so long as they maintain pre- and post-natal checkups. Nutritional and vaccination campaigns have been initiated and expanded to combat malnutrition and diseases such as yellow fever and rubéola (measles). And in an effort to transcend the dominance of the "biomedical" model, the newly approved Constitution (January 2009) guarantees and promotes the use of indigenous medicines and "ancestral knowledge and practices."

Although these reforms signify important advances, there remain significant structural, budgetary and ideological challenges fundamental to the design of Bolivia's health care system. Debates over privatized care, unequal access, lack of funds, and the prioritization of biomedical disease treatment over the promotion of health and traditional medicines are by no means unique to Bolivia. Yet they sit uncomfortably at odds with the new Constitution's promise of "universal, free, equitable, intracultural" access to health care for all Bolivians.

Lifting Bolivia from close to the bottom of the hemisphere's health indicators will be a difficult task for Morales, much as it was for his predecessors. The initiatives he has implemented to date provide, at best, partial answers. But while Bolivia awaits more durable solutions, the government's immediate approaches have won accolades from many Bolivians, with the importation of Cuban medical professionals being a particularly popular measure.