BIBLIOGRAPIC DATA SHEET ONROLNNUMBER 2. SUBJECT CLASSIFICATION (695) PN-AAH- 514 NAOO-0000-G512 3. TITLE AND SUBTITLE (240) Bolivia health sector asses;ment 4. PERSONAL AUTHORS (100) %andry, A. So 5. C'ORPORATE AUTHORS (101) AID/LA/U SAID/Bolivia 6. DOCUMENT DATE (110) 17. NUMBER OF PAGES (120) 8. ARC NUMBFhR (170) 1975 512p. I B.bI4.0984.L262 9. REFERENCE ORGANIZATION (130) Bolivia 10. SUPPLEMENTARY NOTES (500) 1I. ABSTRACT (950) i.DESu'-Rs (92o) 'US. FrOjECr Uviu a (N5UB Sector analysis Infrastructure Bolivia Health Public health Socioezonomic deve].opment 14. CONTRACT NO.(140) 15. CONTRACT Program planning Health services TYPE (140) Socioeconomic status Bolivia 16. TPE oF DOCUMENT (160) 16 AM 5Wo7 (10-79) LAC/DR/RD's copy - please return LA/DR-DAEC/P-7q- 50 Bolivia Health SectorAssessment '9 . n 5._._.._ .46. e.• • .. ., qr" -. K >'.;._, ,. : .. ,. , ,- .. ." . .. .. ... ,, . "" . " - . "' : - * -*.. I . • • qm~i ,. United States AID Mission to BolivaS ..... ... W... .. .... .. .. .... .. ..Janua r y.1 97/5 . ... .... ... .". BOLIVIA HEALTH SECTOR ASSESSMENT .UNITED STATES AID MISSION TO BOLIVIA L%PAZ, JANUARY 1975 PREFACE The ultimate objective of the U.S. technical and financial ance programs assist­ is to help the Republic of Bolivia attain its socio-eco­ nomic development goals. The following Health Sector Assessment one of three* is efforts desig. d to analyze the current status of sector activities in Bolivia and to pcovide guidance for planning future USAID programs. It is the intent of the Mission to provide coordinated, mutually supportive interventions in the agriculture, education and health sectors. A simultaneous review of health problems and programs taken by a specially was under­ convened Interministerial Commission. The Com­ mission included more than 60 government technicians and planners from 12 agencies. The Commission worked for over six months through 11 sub­ commissions, and provided much of the basic data contained in this doc­ ument. The Mission and GOB were assistei by 15 short-term specialist consultants. In addition to providing analytic services and assistance in drafting certain aspects of the report, the consultants spent a considerable amount of their time visiting rural areas gathering rele­ vant information.' We believe, the Assessment process has had the following beneficial outcomes: i) the involvement of Bolivian officials and technical personnel from many agencies in the analysis and initial planning of sector activi.ties; ii) the participation of other donor organizations which should contribute to better coordination of external assistance; iii) the documentation of some baseline data and the provision of a single reference source for health information on Bolivia; * The reader is referred to Education in Bolivia: A Preliminary Sector Assessment (May 1974) and Agricultural Development in Bolivia: A Sector Assessment (August 1974) lii iv) the development of a sector assessment methodology which may be beneficial to similar undertakings by other international assistance agencies. The Assessment is composed of ten chapters, each beginning with a summary statement which should facilitate easy review by the reader. The first four chapters provide background information regarding condi­ tioning factors, health status, socio-economic impact, and the structure of the sector. The following three chapters are analytical; they deal with sector programs, infrastructure and intersectorial activities. The last three chapters describe the various responses to the situation--i. e., GOB plans, international donor activities, and the proposed USAID program. The major limiting factor in carrying out the Assessment was the weak data base for Bolivia. Most significant is the lack of a national cersus since 1950. Health and management information systems also are deficient. Thus, the bulk of the data presented must be considered questionable and based on the "best information available". Due to the nature of the information and the difficult and time-consuming efforts to collect meaningful data, there are significant gaps in the Assessment. These include: i) economic and financial data 'regarding the impact of the health situation in Bolivia and the costs of the various health pro­ grams; ii) quantitative information on the priva. voluntary and tradi­ tional health sub-sectors; and iii) age and disease-specific mortality and morbidity rates and other vital statistics including birth and age-specific fer­ tility rates. While "best available estimates" have been provided, it is recognized that the Assessment will have to be complemented and revised as more accurate information becomes available. The Mission intends to carry out research in these areas over the coming years. The Mission views its three Assessments as a continuing endeavor to be periodicaLly updated as more data become available and changes iv take place in Bolivia. Toward this end, the Mission would appreciate and welcome comments on the contents of this document and observations on errors or oversights herein. Please forward to: Humanitarian Assistance Division USAID/Bolivia Casilla 673 La Paz, Bolivia The U.S.A.I.D. Mission to Bolivia January 24, 1975 ACKN104LEDGEMENTS The Health Sector Assessment was carried out and written by the staff of the Humanitarian Assistance Division of USAID/Bolivia, under the direction of Mr. A. S. Landry, MSFH. He was assisted throughout the process by Mr. James N. Becht who coordinated many of the activities and edited the bulk of the report. The Mission was fortunate to re­ ceive the services of various consultants many of whom had previous working experience in Bolivia. Particular mention should be made of the assistance of the following: Alan G. Austin, Ph.D. Public Administration State University of New York James N. Becht, M.P.H. Health Planning and Coordination Private Consultant John A. Daly, Ph.D. Planning/Information Systems D.H.E.W./O.I.H. H. Robert Douglass, A.I.A. Health Facilities University of Texas,. S.P.H. Oscar Echeverri, M.D. Rural Delivery Systems Universidad del Vall, Colombia James C. Eckroad, M.S. Environmental Sanitation Community Systems Foundation Robert Fisher, M.D., M.P.H. Health Economics D.H.E.W./O.I.H. Julia Elena Fortun, Ph.D. Anthropology/Sociology Ministerio de Bducaci6n, Bolivia Leonard F. Krystynak, Ph.D. Hitman Resources University of Florida Robert H. LeBow, M.D., M.P.H. Rural Health Services U.S. Public Health Service vii Ronald, St.John, M.D. Cormunicable Diseases D.H.E.W./CoD.C. B. Brooks Taylor, M.D., M.P.H. Rural Health Servlces Texas State Health Department Dean Wilson, M.S. Nutrition Community Systems Foundation Roberto Zachmann Pharitaceutical Supplies Community Systems Foundation Dieter K. Zschock, Ph.D. Health Econcmics and Financing State University of New York Finally, the Mission wishes to extend its sincere gratitude to the members of the Bolivian Interministerial Commission, and especially to Dr. Antonio Brown Lema, for their constant c9operation and effective participation in the realization of this project. Administrative and research assistance: Dr. Alberto Gumiel B. Secretarial assistance: Rodolfo Chavez, Ana Maria de Del Castillo, Teresa de Mufloz, Giannina de Lijer6n, Teresa de Silberstein, Teresa Aguirre, Teresa Sainz Photographs: Pg. 82, J.N.Becht; cover and all others, R.H.LeBow viii TABLE OF CONTENTS RE ACE ... ... ... ................ .... ... ... ... ... ... jjj ACKNOWLEDGEMENTS .................................... vii TABLE OF CONTENTS " ix LIST OF TABLES ............................. xvii LIST OF FIGURES ........................ xxv LIST OF ANNEXES . xxvii CHAPTER I - THE SETTING - FACTORS CONTRIBUTING TO HEALTH STATUS ... 1 A. Summary ...... ........... 1 B. Geographic Characteristics ....... ....................... 3 1. Physiography and climate ..... • • • ... ............. 3 2. Natural resources , ... .. .. .... .............. 10 3 Communications and transportation ....... 15 4. Geography and health ................... "............. 20 C. Demographic Characteristics ......... a.......... 22 1. Population distribution .................... 22 2. Migration patterns ..... .. ... ......... 27 3.. Family size and housing .................. 32 4. Educational and economic patterns ......... ...... 36 5. Demography and health .. ......... .... .. .. .... 40 .D. Socio-Cultural Characteristics ......... 0.49........ 45 1. Ethnic groups and languages .nn, .................... 45 2. Several aspects of social organization .................. 50 3. Indigenous health practices .................... .. 51 E. Consumer and Provider Attitudes Towards Health and Health Programs ............... ... I • .. ....... a a a & • .. 53 1. Health development and behavioral change ....... 53 2. Selected attitudinal studies 55 3. Family planning ....... ................. 56 4. Community organization and health development ........... 57 CHAPTER II - HEALTH STATUS AND MAJOR PROBLEMS ..................... 65 A. Sununary .4eee4*40....4....................................... 65 B. Mortality and Morbidity .... ,, . o.. 69 1. Disease patterns ............. 69 6........... 2. Mortality ......* *.. 4444 . .S 4444 4.. 7 TO 3. Morbidity - hospital discharge data ... .74 T....... 4. Morbidity - outpatient data ....................... T6 5. Significance of mortality and morbidity data , .78 C*C 0ecific Diseases of Importance 78 * v'l. Malnutrition ..... 444444444444 ** T44444448 2. Communics?-le diseases ............. 3. Non-conmruaicable ...... 83 diseases and problems .................