A People's Health System

Caracas, Venezuela — “Much of our health problem has to do not so much with economic factors as with the organization of communities,” explains Luis Montiel Araujo, a physician with Venezuela’s Ministry of Health and Social Development (MSDS). “Barrio Adentro was conceived as a way to bring medical services to the excluded, ... to put a physician in every community.”

Barrio Adentro. It is nearly impossible to travel Venezuela without hearing reference to the government’s highly popular and controversial healthcare initiative that invites Cuban doctors to treat, train and live with working-class Venezuelans in communities across the country.

In the indigenous Orinoco delta village of San Francisco de Guayo, some 80 miles from the nearest road, and in the Andean town of Mucuchies, some 10,000 feet above sea level, Cuban doctors operate primary care clinics in cooperation with local volunteers. In the 18 months since Barrio Adentro’s inception, the number of Cuban physicians in Venezuela has grown to more than 13,000, their medical services available to approximately 17 million Venezuelans, or two thirds of the country’s population, according to the Ministry of Health and Social Development. The director of the Pan American Health Organization has praised Venezuela, and President Hugo Chavez in particular, for “combating social exclusion” and demonstrating “new leadership in health.”

Poor Venezuelans say the program means they have access to medical services for the first time. But not, they stress, without their participation. Neighborhoods organize themselves into local health committees (Comités de Salud) to oversee the operations of clinics that the government funds. Barrio Adentro enlists the patient as a partner in the care of his or her health.

The program’s detractors — including leaders of Venezuela’s sizeable opposition coalition and much of the medical establishment — attack Barrio Adentro alternately for skirting established norms of licensing foreign practitioners and for allegedly promoting Cuban-communist ideology. Some criticize the program as unsustainable, relying on a supply of foreign expertise, while others accuse the government of giving away Venezuelan jobs.

Proponents say Barrio Adentro is expressive of the participatory political culture and social justice democracy the Chavez government aims to create in Venezuela.

The challenge to the program is two-fold — to demontrate that it can improve health in Venezuela over the long term and to prove that it can survive the country’s protracted political conflict.

It is a test of the practicality of Venezuela’s “Bolivarian Revolution,” the nonviolent effort to restructure Venezuelan society, named for South American liberator Simon Bolivar.

“A NEW CULTURE OF ACTION”

Since the Movimiento Quinta República (MVR) ascended to power in Venezuela in 1998, with the election of Chavez as president and a subsequent controlling majority of the National Assembly, the government has set out to remake the culture of healthcare in Venezuela, bringing it, in Montiel’s words, “from medical assistance to social and participatory medicine.” The new constitution, approved by popular referendum and enacted in 2000, guarantees all citizens the right to health and forbids the privatization of health services. The government has opened social security administration hospitals and even certain military hospitals to the general public to assure a more efficient and equitable distribution of public health services. But the government’s most ambitious visions lie ahead, in the consolidation of an effective primary care network and the alignment of all public health services under a single ministry.

The Venezuelan health system features private and public sectors, a mixed model the government intends to retain. Because many professional Venezuelans do not trust the public hospitals, and highly specialized services can be comparatively rare in the public system, private clinics retain a significant market. Through 2000, private spending on healthcare still outpaced public spending. But this is changing as the government steps up its efforts.

The public health system has, for years, been divided among several masters, including the Ministry of Health and Social Development, the social security administration (IVSS) and the military, among others. Treatment at public hospitals has always been free, but their services have been limited.

“Health is a luxury,” deadpans Jhonny Madrid, a publicly employed security official. Prior governments “didn’t fund the hospitals. They’ve always had their private clinics.”

Pro-government Venezuelans speak often of the prohibitive costs that once attended special medical needs, from some surgeries to eyeglasses. “Seventy, 80, 100,000 bolivares ($35-70) for a consultation. Five million ($2,500) for an operation,” estimates Elizabeth Bustos Uribe, a Chavista nurse. Such prices are well beyond the means of working Venezuelans. Barrio Adentro now provides some of these services at no charge.

Bustos pulls from her purse the prescription glasses fashioned for her by a Cuban optometrist. “They were free.”

Further resources are flowing into the popular pool via the IVSS social security hospitals, formerly the exclusive domain of pensioned workers. IVSS hospitals are reputed to be better equipped and better funded, with more available specialties. By 2000, 53 percent of Venezuelans worked in the informal sector, and so IVSS was treating a dwindling pool of patients. Its opening to all Venezuelans is much celebrated by government proponents.

But it is unclear how much this particular change will materially affect the health of the public: IVSS hospitals make up only about 11 percent of the national total, and IVSS clinics only account for about 1.6 percent of all public clinics. The balance are overwhelmingly establishments operated by the Ministry of Health, all already open to every Venezuelan before the rise of MVR.

The opening of IVSS hospitals and several military hospitals is symbolically important, but Dr. Montiel says more is at stake.

“What’s important is that these hospitals, as they change classification and become People’s Hospitals, adapt to the real necessities of demand — [the large number] of patients with sicknesses that merit attention with high technology and specialized medicine.” The idea is that opening IVSS hospitals to all Venezuelans will contribute to a streamlined healthcare network, one without the inefficiencies created by limiting access to select branches of a public system.

The planned primary care network envisioned by MSDS would include People’s Hospitals, Popular Clinics and Popular Doctor’s offices, replacing the existing order of hospitals and clinics of divergent ownership and access. The government is also considering constructing a factory to produce its own generic pharmaceuticals.

These projects represent a significant investment in infrastructure, and it is not clear that the government’s projections are realistic. Only six Popular Clinics are thus far complete; the government would like 417. Of 8,500 established Barrio Adentro missions, only 280 operate out of the unique “Consultorio Popular” modules designed specifically for that purpose (560 are under construction, and an additional 3,141 modules have advance funding, out of an estimated 9,503 that will be needed).

Underpinning the quick pace of reform is a widespread mistrust of the politicians who governed Venezuela during the previous regime, many of whom retain influence within the opposition coalition. Some Chavez supporters fear that should leaders of the old guard return to power with newfound allies, they may move to privatize essential services as former governments did the national telephone company, the steel industry and other state assets during the 1990s.

The specific fear that an opposition government would privatize basic health services may not be justified. Basic healthcare, to the extent that it has been available and accessible, has long been free in Venezuela, as government opponents are quick to point out.

But working Venezuelans do have good reason to fear underfunding of the public health sector and creeping marketization. In the 1980s and 1990s, successive administrations inaugurated market reforms, restructuring the system of “retroactive” severance pay, eliminating subsidies on consumer goods and cutting tariffs and social spending. The state petroleum corporation PDVSA ran on self-defined priorities, revenue for the state not among them, as it rebelled against what the firm’s leadership viewed to be a hopelessly corrupt government. Poverty rose from an oil-boom low of 10 percent (1978) to 86 percent (1996) in less than 20 years.

Mindful of popular discontent with market models of governance, and of the popular success of Barrio Adentro, some opposition strategists now state that a new, opposition-backed government would retain the program.

But it seems unlikely that a government unified in part by antipathy for Cuba would maintain the oil-for-expertise exchange presently in place. Anti-government demonstrators cite Chavez’s alleged intent to follow the Cuban government’s model as a principal reason that he should be deposed. Even if moderate forces within the opposition were to advise against it, a government of the present opposition might order the greater part of Cuban doctors from the country.

With the failed promises of the previous regime in mind and an ever-developing political consciousness, working-class neighborhoods have aligned themselves more and more closely with the government since 1998. Many believe that community organizing and community education are their best defense against a return to a politically powerless past. Barrio residents gather in “Bolivarian Circles” to discuss the potential effect of new laws before the national assembly on their community, and to petition for government services or local ordinances.

Healthcare has not stood apart from this process. In the spring of 2003, the MVR government of Libertador district, Caracas began to invite neighborhood representatives to planning meetings for the initial phases of Barrio Adentro. The first Cuban doctors arrived in April.

"THE ESSENCE OF THE REVOLUTION"

In the southern Caracas barrio of Las Malvinas, Judy Moros, mother of three, talks about the clinic that opened in her neighborhood one year ago. She cradles her youngest in her arms.

“It’s marvelous. They open the door at any hour, and treat everyone.”

What about people from outside the community? Or members of the opposition?

“They have treated them just the same.” Moros says that the doctors come by her house as if they were neighbors to check on her daughters. They give her vitamins, and tend to the girls’ occasional fevers.

Moros is married to Franklin Gamboa, a member of the Las Malvinas Health Committee. Arranging for the care of approximately 3,000 residents, the committee is divided into two bodies of about 10 citizens each: one group to support each doctor. Committee co-coordinators Paulina Gomez and Edixon Marquinez attended early city planning meetings for Barrio Adentro.

“We asked for the doctors, and they stayed in my house while the clinic was built,” explains Gomez.

“We [the committee] met to choose the site for the module in our neighborhood,” says Marquinez. The Las Malvinas module looks up a dusty hill to the neighborhood’s tin-roofed, rough and cluttered but brightly colored houses. It follows the uniform design of its 280 companions appearing across Venezuela: two-stories, cylindrical, red brick with cornflower blue trimming. The committee provides volunteers for the modules, security and a nurse for each doctor. The nurses from Las Malvinas learned on the job and are now licensed.

Asked what sort of health problems are common in the barrio, Marquinez replies, “asthma.” Nearby residents nod their agreement. He describes the respiratory problems from which the community suffers, associated with a cement mixing operation adjacent to the neighborhood, and the nebulizing device the doctors employ to treat the sick.

Elizabeth Bustos Uribe works as the Barrio Adentro clinic nurse in Casco Central, Parroquia La Pastora, Caracas. She helps the two Cuban medics in her module administer treatments for parasites, skin allergies, diarrhea and other common ailments. “Barrio Adentro is the essence of the revolution,” she says.

“We treat about 50 patients a day,” Bustos says. The doctors are on call seven days a week. Some days, one doctor remains at the module while the other makes the neighborhood rounds. Occasionally, one will be pulled away to another part of town if their specialty — in this case, dermatology or endocrinology — is needed. The Venezuelan government pays the doctors a monthly stipend of $250, and “the city sends them baskets of food.” The medicine they use — some 103 drugs treating 95 percent of Venezuela’s most prevalent illnesses — comes from Cuba.

A few days before, Bustos recalls, “around 8:30 P.M., someone with an emergency arrived. He was swollen, and his blood pressure was around 220/130.” Far above the normal blood pressure of 120/80, this would put him in imminent danger of a stroke. “We gave him medicine and an injection. ... He took the treatment for three days. If he’d not seen the doctor in Barrio Adentro, he could have been paralyzed.”

The Ministry of Health claims that over 11,000 lives have been saved through Barrio Adentro thus far. The figure is plausible. The presence of clinics in communities brings primary care far closer to people who were, in many cases, accustomed to living without treatment until their illness became an obvious emergency. A national immunization plan has elevated vaccination rates. And the intimate involvement of neighborhood groups in Barrio Adentro significantly improves community health education.

Dr. Juan Carlos Marcano, an adjunct physician with the Health Ministry and a coordinator of the burgeoning primary care network, spent a year and a half traveling from barrio to barrio in preparation for Barrio Adentro’s launch. He says he has seen significant progress in a short period. “I was in El Paraiso, a community of 500 or 600 families. A year ago, there was nothing. Now there’s a mercal (a subsidized food market)

and a doctor’s module.” Renato Gusmao, the Pan American Health Organization’s Venezuela representative, praises the project. “Barrio Adentro permits the planning of a healthcare system based on the demands of the population, not just on how much they have and how much they can afford.”

OPPOSITION

The considerable expense of Venezuela’s healthcare reforms and Barrio Adentro’s reliance on foreign doctors raise questions about the initiative’s sustainability. But criticisms of government healthcare policy extend much further than finance, as healthcare becomes valued high ground in Venezuela’s enduring political conflict.

First and foremost among Barrio Adentro’s opponents is the Venezuelan Medical Federation (FMV), a powerful doctors’ group of 55,000 members. In June 2003, the FMV filed suit to stop Barrio Adentro’s Cuban physicians from practicing in Venezuela, alleging that the doctors were not licensed to practice. On August 21, the First Administrative Court ruled that the Cuban doctors should be replaced by licensed practitioners. The government appealed, and the case is not yet resolved.

The Centro al Servicio de la Accion Popular (CESAP), a privately funded human development and citizen rights group, charges that Barrio Adentro “is not attending to the structural problems of the Venezuelan health system.” CESAP suggests that “resources applied to the Barrio Adentro program could be used to fortify” existing clinics and hospitals.

Similarly, Susanna Ibarrin, vice president of the U.S.-based opposition group Free Venezuela, asks, “If his [Chavez’s] goal is to improve the health system, wouldn’t it make sense to improve the hospitals?”

But the government is investing significantly in the creation of its proposed primary care network. If successful, such a network would significantly ease hospitals’ burden, by treating illnesses before they require hospitalization.

The FMV and the private media also allege that Cuban doctors are incompetent and are spreading “propaganda.”

“Barrio Adentro is nothing more than indoctrination. Many of them are not even doctors. … There is a lot of infiltration by the Cuban security establishment,” says Ibarrin.

But no significant evidence has surfaced to support these claims. Stories of communist infiltration and gross malpractice, which succeeded in scaring potential host communities at first, have lost plausibility as most Venezuelans have either sought treatment or know someone who received competent and professional treatment from a Cuban doctor. Many Cuban doctors have at least one specialty and one year of overseas field experience before joining Barrio Adentro. Even CESAP states that complaints of malpractice have been few “in comparison with the great number of patients they attend.”

The Medical Federation’s President Natera also contends that Venezuela already has more doctors than recommended by international health agencies. This is true. Venezuela boasts one doctor for every 500 people, much better than the 1,200-to-1 minimum ratio recommended by the World Health Organization. Yet many barrio dwellers have never had an attendant physician. Article 8 of the Law of the Exercise of Medicine requires doctors to spend a year after medical school in an underserviced area, but there are many ways to fulfill this requirement without delving deep into the barrio.

CESAP cites the “insecurity of popular areas” as a reason that most Venezuelan doctors avoid barrio service. Working-class Venezuelans view doctors’ avoidance of their neighborhoods as class prejudice. But they are quite aware of potential danger to outsiders walking alone in their neighborhoods. This is why the Comités de Salud charge local volunteers with the protection of Cuban doctors, walking them to and from the clinic and anywhere else they must go. It seems the same protection would be available to any Venezuelan doctor willing to perform the same community service.

In 2002, during the planning phases of Barrio Adentro, the government issued a call for volunteer Venezuelan physicians. “They were not receptive,” says Dr. Montiel. About 50 doctors answered. Until the recent addition of Venezuelan post-graduate medical students, only 29 Venezuelan doctors worked in the popular consultarios of Barrio Adentro. CESAP blames the government for this lack of participation. But the culture of the medical profession in Venezuela may bear responsibility, as well.

Most Venezuelan doctors come from the professional class. The majority grew up in the country’s wealthier neighborhoods, and many are not comfortable in the dirty and crowded neighborhoods of poor Venezuela. It is probably true that more well-meaning physicians would consider working in poor communities if they felt it were truly safe. But it is also true that both class and racial prejudice remain strong in Venezuela.

Dr. Marcano believes that “most students are studying to earn money.” And money is in private clinics and specialties, not in neighborhoods like Las Malvinas. FMV President Natera contends the government should pay its doctors more. Better salaries would likely attract more and better doctors. On the other hand, the $600 monthly stipend offered to Venezuelan physicians in Barrio Adentro, with expenses paid, is a respectable public sector salary in Venezuela, and is already more than twice that afforded the Cuban doctors.

Asked why Venezuelan doctors did not answer the call to serve Venezuelan barrios in greater numbers, Ibarrin says, “They don’t want to bring any political message.”

This opposition of the medical profession leadership to the Bolivarian project will likely prove the most difficult problem the government confronts in implementing its vision for comprehensive care.

While the government could probably continue its oil-for-expertise exchange with Cuba for the foreseeable future, Barrio Adentro coordinators recognize that a sustainable healthcare network must rely primarily on Venezuelan health workers, and they are laying the groundwork for this transition.

CULTURAL CHANGE AND COMMUNITY CARE

In line with Barrio Adentro’s ethic of community care, the Venezuelan government is helping barrio residents attend medical school and return to practice in their own communities.

The first class of 250 Venezuelan students has just graduated from medical school in Cuba. Another 1,000 are in training. The government has already integrated 1,200 Venezuelan post-graduates into Barrio Adentro for two-year residencies, after which the new doctors will have the option to stay on if they so choose.

There are also plans to start a medical school tied to Barrio Adentro within the recently chartered Universidad Bolivariana de Venezuela (UBV) in Caracas, part of an effort to open higher education to the popular class.

Still, “changing the culture of [established] medical schools will be difficult,” confesses Dr. Marcano.

So long as Venezuelan medical culture operates on two antagonistic tracks, the country’s ability to effectively coordinate the medical resources under the control of each will be diminished. Integrating Barrio Adentro and the primary care network with the resources of the medical schools remains a challenge.

Financing is another long-term challenge. Barrio Adentro relies on heavy social spending. The Health Ministry estimates the value of medical services rendered thus far at $1.5 billion. Venezuela, an OPEC nation, is currently reaping the benefits of record high petroleum prices. But these prices may not last, and the Chavez government may have to cut spending in the future.

Barrio Adentro has two advantages that may keep it off the chopping block. First, the program is exceptionally popular. Second, as Dr. Marcano explains, start-up costs and the construction of modules are expensive. But once these initial investments are covered, costs of Barrio Adentro and the primary care network will drop significantly, and confer a cost advantage. “Primary care is cheaper, because you avoid more complicated health problems.”

After just a year-and-a-half of operation, Barrio Adentro has attained near sacred status among working-class Venezuelans. Even those who can afford private clinics are finding that they can save money and receive the same quality of care for basic needs at the program’s modules.

“Any government that would attempt to shut down Barrio Adentro would fall within 24 hours,” declares Marcano. Certainly, such a government would confront dramatic civil unrest. Barrio Adentro was built and is continuously shaped by the same people who benefit from it. From their perspective, Barrio Adentro is not a government program, it is their program — one that belongs to the Venezuelan people — and health is their right.

Social cleavages, procedural challenges and major personnel and infrastructure shortages remain obstacles in the path Venezuela must traverse on its way to access, equity and health. But the perspective of a thrice-confirmed majority of the electorate is summed up in one word by Francisco, a smiling, white-haired Chavista waiter in the Andean town of Apartaderos: “Pa’ lante.”

Forward.