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Venezuela Health Sector Review ReportNo. 10713-VE Venezuela Health SectorReview (In TwoVolumes) VolumeII Public Disclosure Authorized May14, 1993 Populationand Human Resources Operations Division CountryDepartment I LatinAmerica and the Caribbean Regional Office FOR OFFICIAL USEONLY Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Documentof theWorld Bank Thisdocument has a restricteddistribution and may be used by recipients onlyin the performarnceof their official duties. Its contents may not otherwise bedisclosed without World Bank authorization.Report No. 10715-UG A0 FOR OMCIAL USE ONLY VENEZUELAHEALTH SECTORREVIEW VOLUME TWO Contents Annex 1: Endemic Diseases .. ........................................ 1 Annex 2: Child Health and Nutrition.29 Annex 3: Women's ReproductiveHealth .49 Annex 4: Emerging Patterns of Morbidity and Mortality in Venezuela: An Agenda for Chronic Iisease and Injury Prevention .65 Annex 5: Health Financing.95 Annex 6: Human Resources.117 Annex 7: Hospital Organization,Financing and Resource Use .131 LIST OF TABLES AND FIGURES Annex I Table Al-1: Venezuela: DGSSAExpenditures on Endemic Disease Control, 1985-1991 ................. ...................6 Table A1-2: Venezuela: Distributionof State Contributionsto DGSSA Programs, 1989-1990. 6 Table A1-3: Malaria Incidence in Venezuela, 1960-1989.7 Table A1-4: Bolivar and Sucre: Reported Malaria, 1982-89 .................. 8 Table A1-5: Dengue and DengueHemorraghic Fever in Venezuela, 1989-1990 .... .. 12 Table A 1-6: Chagas Disease in Venezuela, 1985-1989 ..................... 14 Table A 1-7: Intestinal Parasite Prevalence in Venezuela, 1976 and 1989 .... ...... 18 Table A1-8: Institute of BiomedicineExpenditures on Endemic Disease Control ............ .......................... 21 Table A 1-9: New Cases of Leprosy in Venezuela, 1980-89 .22 Table Al-10: Cutaneous and MucocutaneousLeishmaniasis in Venezuela, 1955-89 .24 Chart Al-l: OrganizationalChart of the General Health Directorate for EnvironmentalSanitation. 4 Chart Al-2: OrganizationChart of the BiomedicineInstitute .20 Thisdocument has a restricteddistribution and may be used by recipientsonly in the performance of their officialduties. Its contentsmay not otherwisebe disclosedwithout World Bank authorization. ii Annex 2 Table A2-1: Infant MortalityRatio, Neo-nataland Post-neonatalRatio (deaths per 1000 registered live births) 1980-89 .......... ... 38 Table A2-2: Primary Causes of Death, Children Aged 0 to 1, 1980-88.39 Table A2-3: Primary Causes of Death, Children Aged 1 to 4, 1980-1988 .40 Table A2-4: Primary Causes of Death, Ages 5 to 14, 1980-88 .41 Table .42-5: Percent of Low Birth Weight Deliveries in Ministry of Health Hospitals, 1989 ............................ 42 Table A2-6: Vaccinationsof C-hildrenunder 1 Year of Age: 1980-1990 (Measles, Polio, and Triple Dose) ....... .............. 43 Table A2-7: Neo-natalMortality by Primary Causes, 1980-88 ..... ........... 44 Table A2-8: Main Causes of Post-neonatalMortality, 1980-88 ..... ........... 45 Table A2-9: Mortality by Age Group in Different Countries, 1988 ..... ........ 46 Table A2-10: Proportion of Total Mortality from Children Under 5, Age Standardized,by State, 1988 ......... ................ 47 Box A2-1: MSAS Health Programs Linked with PAMI ..................... 34 Annex 3 Table A3-1: Maternal MortalityRatio ............................... 52 Table A3-2: MaternalDeaths by Cause and Age Group, 1988 ................ 53 Table A3-3: Married Women aged 15-44 Currently Using Contraception, by Residence and MethodUsed, 1977(percent).... .......... 56 Table A34: Source of Oral Contraceptives,by Residence, for Current Users 1977 (percent) ........................ 57 Table A3-5: Planning Status of Most Recent Pregnancy, by Selected Characteristicsof Mother, 1988 (percent) ................. 58 Box A3-1: Risk Factors for Maternal Morbidity and Mortality ................. 54 Annex 4 Table A4-1: Number of Deaths by Cause and Age, 1988 .................... 80 Table A4-2: Comparisonof Mortality by Selected Causes in Venezuela, Puerto Rico, and the United States, 1988, Standardized on the Age Structure of the VenezuelaPopulation .... ........ 80 Table A4-3: Cancer Incidenceby Sex and Type, 1988 ..................... 81 Table A4-4: Personal Risk, Highway Risk, and MotorizationIndex in Venezuela and Other Countries in the Americas .................... 82 Table A4-5: Cost Effectivenessof SelectedChronic Disease Intervontions .... ..... 82 Table A4-6: Sample Componentsof a NationalTobacco Control Program ApproximateEffect and Cost ......................... 83 Table A4-7: Sample Program Priorities for Control of Injury Due to Motor Vehicle Collisions ........................... 84 Figure A4-1: Leading Causes of Death, Selected Years ...................... 85 iii Figure A4-2: 10 Leading Causes of Death, 1988 ......................... 86 Figure A4-3: 10 Leading Causes of Death, Children Aged 1-4, 1988 .86 Figure A4-4: 10 Leading Ciwusesof Death, Children Aged 5-14, 1988 ........... 87 Figure A4-5: 10 Leading Causes o0 Death for Age Group 15-24, 1988 ........... 87 Figure A4-6: 10 Leading Causes of Death for Age Group 25-44, 1988 ........... 88 Figure A4-7: 10 Leading Causes of Death for Age Group 45-64, 1988 ........... 88 Figure A4-8: 10 Leading Causes of Death for Age Group 65-74, 1988 ........... 89 Figure A4-9: 10 Leading Causes of Death for Aged Group 75 and above, 1988 .89 Figure A4-10: MortalityRa:es from Cancer by Age Groups, 1988 .... ........... 90 Figure A4-11: MortalityRates from Heart Disease by Age Groups, 1988 .90 Figure A4-12: Mortality Rates from Injuries by Age Groiup, 1988 .91 Figure A4-13: Mortality Rates from Homicideby Age Groups, 1988 .91 Figure A4-14: Mortality'Rates from Suicide by Age Groups, 1988 .92 Box A4-1: The Ascardio Program .................................. 72 Annex 5 Table A5-1: Public Spendingon Health, by Level of Government, 1983-90 .... .... 97 Table A5-2: Health Expendituresby MW:ASand IVSS, Selected Years .... ....... 98 Table A5-3: Ministry of Health Expenditures,by Budget Category Excluding Support to Other Institutions .................. 99 Table A5-4: Inflows and Outflowsof IVSS by Fund, 1980-90 .... ........... 100 Table A5-5: Ministry of Health Spending, by Category, 1980-1990 .... ......... 102 Table A5-6: Ministry of Health Budgetary Support to Institutionsand Foundations, 1980-90 ....... .................... 103 Table A5-7: MINDUR Investmentin Health Infrastructure, Selected Years .... .... 104 Table A5-8: Distributionof MSAS Spendingby Programs ................... 105 Table A5-9: Ministry of Health Expendituresby Health Services Facility and Category, 1980-90 ............................ 107 Table A5-10: IVSS Expenditureon Health Facilities by Category, 1990 .... ....... 109 Table A5-11: IVSS Expen6ituresby State, 1990 .......................... 109 Table A5-12: ConsolidatedMSAS, IVSS, and State Spendingfor Medical Services at the State Level, 1990 ...................... 111 Table A5-13: Economicand AdministrativeIssues in Setting User Fees .... ....... 113 Table A5-14: Health Care Expendituresas Percent of Gross Domestic Product per Capita, Selected Countries, 1987 ....... ............. 113 Table A5-15: Public Expendituresas a Percent of Total Health Spending Selected OECD Countries, 1987 ......... .............. 114 Table A5-16: Strategies to Control Health Care Expenditure and Encourage Quality . 115 Annex 6 Table A6-1: Human Resources in Health, 1970-88 ....................... 119 Table A6-: Distributionof Health Manpowerby State, 1980-88 ............... 120 Table A6-3: Public Sector Personnel and Personnel in Health, by Institution, 1983, 1986, and 1989 ............................. 121 Table A6-4: Positionsby Program and Level, Ministry of Health, 1982-1991 .... ... 123 iv Table A6-5: Distribut.on of Health Manpower by Category, IVSS and MSAS, 1981, 1984 and 1990 .............................. 124 Table A6-6: Selected Unions in the Health Field and Membership, 1991 .... ...... 126 Table A6-7: IVSS Outpatient Visits per Physician Hour by Type of Service ... ..... 127 Table A6-8: Public Administration Salary Scales, 1982-1989, Various Positions ..... 128 Figure A6-1: Profile of Health Service Employees, IVSS, 1988 ................ 125 Annex 7 Table A7-1: Distribution of Public and Private Hospitals and Hospital Beds, 1990, by State ........................ 132 Table A7-2: Hospitals and Beds by Institution, 1986 ...................... 133 Table A7-3: MSAS Hospitals and Budgeted Hospital Beds by Specialty, 1990 .... ... 134 Table A7-4: Distribution of IVSS Facilities by State, 1990 .................. 135 Table A7-5: Comparison of Hospital Statistics: MSAS (1987) and IVSS (1988) ..... 138 Table A7-6: Comparison of Hospital Statistics Across Selected OECD Countries ..... 139 Table A7-7: Comparison of Hospital Statistics Across Selected Developing Countries ............................. 140 Table A7-8: Management, Administrative and Financing Characteristics of MSAS and IVSS Hospitals .......................... 142 Table A7-9: Summary of Changes Needed to Improve Public Hospital Performance ............................. 145 ANNEX I ENDEMIC DISEASES IN VENEZUELAI' 1. This annex examinesthe major tropical diseases in Venezuela and disease control programs of the Genera4Health Sector Directorate for EnvironmentalSanitation (DGSSA) and the Institute of Biomedicine,both of which are part of the Ministry of Health and Social Assistance. The report provides a profile of the disease situation, summarizesmajor
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