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 Supportto 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 Supportto 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 problems and issues, and offers recommendationsin regard to the possible strengtheningof control activities.

2. Like most of its South American neighbors, Venezuela's major endemic disease problem is malaria. The malaria parasite (primarily Plasmodiumfalcipanm and Plasmodiumvivax) is transmittedby the Anophelesmosquito and causes debiiitatingflu-like symptoms (fever, chills, sweats) that often come in cycles. The parasite attacks and destroys red blood cells and, if untreated, can be fatal (especiallyP. falciparum). The number of malaria cases reported in the 1980srose dramatically from about 4,200 in 1982to nearly 47,000 in 1990. Resurgent malaria in Venezuela is closely associatedwith gold mining and new rainforest settlementwhere humnanactivities result in proliferation of the vector and high human-vectorcontact, in particular, in Bolivar state in the east, in Tachira and Apure states in the southwest, and in Sucre state in the northeast. Malaria control efforts have proven very difficult in the mining and settlementareas where populationsare mobile and where dwellings are precarious. Traditionalcontrol methods, in particular, intradomiciliaryspraying, is less effective under such circumstances. Financial constraints and labor disputes have hampered the consistentexecution of control activities which are frequentlyinterrupted, thus causing the control program to lose ground. Malaria control requires a major investmentof resources: first, to improve and adapt control technologiesto new situationsin the field and second, to improve and strengthen the managementof disease control. Supportfor the continuedtesting of a potential malaria vaccine (being developed by Dr. Patarroyo in Colombia)is also needed. Dengue fever, another mosquito- borne disease, is also found in Venezuelaand was most recently a problem in 1989-90when there were over 12,000 cases (includingthe more severe dengue hemorrhagicfever, for the first time in Venezuela). Over 70 percent of the geographicarea of the country was affected. The most recent epidemicfollows a long period of significantcutbacks (since the last epidemic in 1978) in the clengue control program, which is based on control of the mosquito vector At& aegypti.

3. Intestinal schistosomiasis(Schistosomiasis mansoni), involves an intermediatehost snail (Biomphalariaglabrata) and is found primarily in rural areas of Venezuela's most densely populated region, the center-north, includingthe Federal District and parts of the states of Aragua, Carabobo, Guarico and Miranda. Accordingto DGSSA, about two million people are probably at risk of this debilitatingdisease (in some low-income,rural areas, as much as 40 percent of the populationmay be infected) which over a period of years gradually causes damage to the liver, spleen, and intestines. Surveys of schistosomiasishave traditionallybeen carried out by feces exams. More recently, serologicaldiagnostic methods have been developedand implementedon a limited scale which indicate that prevalence is much higher than was evident from feces exams. A new survey of schistosomiasisis needed to determine if, and where, there is a need for mass treatment campaigns and to assess the feasibilityof eradication. Ascaris and other intestinalparasites (geo-helminths)are also commonamong low-incomepopulations and especiallyaffect children. Mass treatmentthrough

I/ This annex was prepared by John Wilson (consultant). 2 Annex 1

schools and latrine constructionprcgrams have been the primary tools to attack these parasites. Latrine constructionactivities, however, have declined dramatically in recent years and need to be revived.

4. Chagas disease is another parasitic disease in Venezuelawhich, over a period of months or years, causes irreversible damage to the heart, resulting in debilitation and death. Chagas is a vector- borne disease caused by Tyanso_ma cruzi and there is no known cure. It is transmitted by a small blood-suckingtriatomine bug that lives in palm thatch and mud walls of typical houses of poor rural families. The vector and the disease are found in the states of Barinas, Merida, Trujillo, Portuguesa, Lara, Zulia, Yaracuy, Cojedes, Carabobo, Miranda, Anzoateguiand Sucre. In the last five years, there have been an average o. about 1,500 new cases reported per year, but Chagas surveillance activities have been in decline and, given the lengthy asymptomaticstage of the disease, underreportingis probably high.

5. Leprosy (also known as Hansen's disease) is also a problem in Venezuela. It is trapsmitted through prolonged human contact and is caused by a bacterium, Mycobacteriumlepr-e. Over a period of years, leprosy causes severe skin lesions, less of skin sensitivity, nerve lesions leading to muscle weakness and atrophy, especially in the hands and feet, and often has a serious psychological and social impact on the families affected. In January 1991, there were 13,616 registered cases and the states most affected were Merida, Tachira, Trujillo, Barinas, and Apure. Although leprosy is treatable with a new multi-drugtherapy (MDT), and work on immunotherapyand immunoprophylaxis is underway, coverage needs to be improved in Venezuela's more remote areas such as T.F. Amazonas and Bolivar, where the state-levelhealth services are weak.

6. The same is true of to leishmaniasis,a parasitic disease transmitted by sandflies which has two major forms, L. tegumentar (or cutaneous and mucocutaneousleishmaniasis) and L. visceral (Kala-azar). The latter form is not common in Venezuela,but about 50 new cases are reported each year. L. visceral is usually fatal if untreated and is more difficult to treat than other forms of the disease; its symptoms includefever, malaise, weight loss, anemia, and swelling of the spleen, liver and lymph nodes. L. tegumentar is more common in Venezuela; its symptomsmay range from simple skin ulcers to major tissue destruction,especially of the nose and mouth. Some forms can heal by themselves,but often leishmaniasisrequires difficult, expensive, and lengthy chemotherapy. In 1989, there were about 1,900 reported cases of L. tegumentar in Venezuela. However, according to the Instituteof Biomedicine,underneporting of leishmaniasisis very high, perhaps ten to one.

7. Onchocerciasis,which is caused by a filarial parasite transmitted by blackflies, is also found Venezuela. The adult parasites (macrofilariae)form nodulesunder the bkin and produce millionsof offspring (microfilariae)which migrate through the tissues causing severe itching and debilitation. Eventually these microfilariaemay reach the eyes, causing ocular damage and biindness. The impact of the disease is worse in areas where repeated reinfection occurs. The states known to have onchocerciasisare the eastern states of Anzoategui,Monagas, and Sucre, the central states of Aragua, Miranda, Carabobo, Guarico, Cojedes, and Yaracuy, and the southern states of Bolivar and Amazonas. The Instituteof Biomedicineestimates that there were approximately70,000 cases of onchocerciasisin Venezuela in 1990, but a comprehensiveand systematicmapping of the disease, and of the incidenceof onchocercal blindness, has yet to be carried out. There is no vector control program underway or planned, nor are there any mass treatment programs, although an effective microfilaricidaldrug (ivermectin)is now available. 3 Annex 1

8. 'Ihe recent cholera epidemic in South Ame ica spread to Venezuelain 1991, when 14 cases were reported. In the first 10 w:eks of 1992, however, almost 400 cases were reported. The government is therofore comminiled to undertaking whatever measures are necessary to reduce the spread of this lisease and has already begun an intensiveeducation campaignthroughout the country.

GENERALHEALTH DIRECTORATE FOR ENVIRONMENTALSANITATION AND ENDEMICDISEASE CQ,%YROL

9. The General Health Directorate for EnvironmentalSanitation (DGSSA) forms part of tho Ministry of Health and Social Assistance(see Chart Al-1) and its director is appointedby !he Minister. It is headquarteredin Maracay, Aragua. Since its creation in the 1930s it has been responsible for control of the major endemic diseases in Venezuela. DGSSA is comprised of four separate directorates: Rural Endemic Diseases, Rural Housing, Sanitary Engineering, and The Arnaldo Gabaldon School for Malariologyand EnvironmentalSanitation (EMSA). The Rural Endemic Diseases Directorate carries out the major control programs for malaria, Chagas, schistosomiasis,intestinal parasites, dengue, and other vector borne diseases includingyellow fever and Venezuelanequine encephalitis. It is comprised of several divisions: Epidemiology(primarily malaria and Chagas); Vector and Reservoir Control (includesAedes aegypti); and Intestinal Parasites (includesschistosomiasis control) The Rural Housing Directorate executes housing and housing improvementprograms which are intendedto support Chagas control and the intestinalparasite control program. It also executesrural water supply and sewer projects. The Sanitary Engineering Directorate is responsiblefor a broad range of activitiesfor the control of air, water and ground contamination. It has programs for control of solid wastes, rodents, pesticides, construction,occupa- tional health, waste water treatment, air pollution control and others. The EMSA is an especially valued part of the DGSSA. Over the years, EMSA has trained almost all of the professionals, inspectors and laboratory techniciansthat have worked in endemic disease control in Venezuela, as well as many others throughoutLatin America. It is also responsiblefor carrying out major research projects relevant to the control programs. EMSA is the object of great pride as an internationally recognized institutionand it is an importantprofessional point of reference among the managers and techniciansof DGSSA.

10. The DGSSAprograms are verticallyorganized. The primary functionsof the central level are to establishpolicy, norms, and control strategies, provide training and in-service training, manage acquisitionand supply, supervise control activities, and undertake operational research. Execution of the control programs is delegated in each state and federal territory to the zone chief aefe de zona) and his service chiefs aefes de servicio) for Rural EndemicDiseases, Sanitary Engineering, and Rural Housing, Sewers, and Aqueducts. The activities in each state and territory are generally determined by the diseases found there and each is divided into smaller "demarcations"most of which have a strategicallylocated base of operations. The demarcationis the actual implementingunit and the base of operations for the spraymen, house visitors, laboratorypersonnel, and others. The different control programs may or may not share the same demarcations,depending on the local epidemiologicalsituation. 4 Annex I

OrganizationChart of the GeneralSoetoral Dlnmctorate for E-nvironmentalSanitaffon

Ministry of Hlealthand Social Asaistanno

LGSSSA'"

TechnicalCoordination .Planning,- Budget and and ScWreirat Office nformatiOn Systems -LoaI Office @ aNonmTn Planningand Budget -Supportand TOOhnical L InformationSystems Assiteance

Administrative - - PersonnelOffice ServicesOffio -Administration - Financing Laborers - Maintenance -Administratin - Goods and Servic Smployoes ......

Autonomous Rural ' EndemicDisea Sniiuy Engineering Arnaido Gabaidon Housing Directorate Directorate Dircorat Malialoogy School * Financing - Malari, Chagasand - Ground Sanitation GraduateTraining - Rural Aqueducts Other Metaxenic - WatWSanitatin j Research Rural Housing Di_sas - Air Sanitaton L TechnicalTraining Rural Swore - Vector Control

DGS;SSAState-Level Regional Services 5 Annex 1 DGSSA expenditures on endemic diqsese control

11. DGSSA has several sources of funding: (i) dheMinistry of Health and Social Assistance (MSAS), (ii) the Guayana RegionalDevelopment Corporation (CVG - a parastatal coinpany in Bolivar state); and (iii) the state govwrnments.As shown in Table Al-1, state level governments have played a large role in financingDGSSA programs, in particular, rural housing, aqueducts and sewers (see also Table A1-2). The central government,thrGogh MSAS, finances -mostof the remainder of DGSSA's activities, i.e. the specificdisease control campaigns(malaria, schistosomiaisis,Chagas, etc.), administration,and the EMSA. In addition, CVG has been providing a significant financial assistance to DGSSA activities in Bolivar state, primarily malaria control. Total DGSSA expenditures declined over 30 percent, in real terms, between 1985 and 1990. However, projected spending for 1991 shows an increase of 43 percent over 1990, which would bring expendituresclose to their 1985 level. Over half of this projected increase is due to higher funding from the state governments, for housing, aqueducts, and sewers. In MSAS as a whole, there has been a trend towards increasing personnel expendituresas a percentageof total expenditures. However, no significanttrend of this nature is discernible in DGSSA expenditures:in 1987 personnelexpenditures represented 47 percent of total expenditures- in 1990, personnel expendituresrepresented 40 percent of total expenditures.

12. The DGSSA has a staff of about 5,600 persons includingsenior managers (7), professionals and technicians (717), administrativesupport (1,505), and workers (3,383). The latter include spraymen, house visitors, and other field workers. In the malaria program in Bolivar state, DGSSA also has the support of resident volunteer helpers who take blood slides, deliver them to local DGSSA laboratories and distribute anti-malarialdrugs to suspectedcases.

Malaria

Disease Situation

13. Malaria incidence has risen explosivelyin recent years from 4,269 reported cases in 1982 to nearly 47,000 reported cases in 1990 (see Table A'1-3), the highest number of cases ever recorded in Venezuela. Malaria is caused by a parasite transmittedby she bite of infected mosquitos. In Venezuela, both the Plasmodiumfalciparum and Plasmodiumvivax species of the malaria parasite are found. The principal vectors of malaria in Venezuelaare the mosquito species Anophelesdarlingi, A. nuneztovari, A. albimanus, and &.X.> al. 2 Malaria is an acute, debilitatingillness that begins with flu-like symptoms includingfever, chills, and drenching sweats that can often come in cycles. The malaria parasite attacks and destroys the red blood cells. Untreated, malaria can be fatal, particularly infectionscaused by P. falciparum. Persons with no previous exposure to the disease are especially vulnerable. Death may occur, in particular, when infected red blood cells block blood vessels in the brain (this is known as cerebral malaria). Malaria mortality, however, is low in Venezuela - about 52 malaria deaths were reported in 1990, comparedto 47,000 reported cases.

2/ Different anophelinevectors in different areas have been shown to have specific behavioral characteristics. Some, for example, includingA. aguasalis, A. darlingi and A. nuneztovari have been known to feed and rest out of doors, thus evading the effects of intradomiciliaryspraying. 6 Annex I

Table Al-l, Venezuela:DGSSA Expenditureson Endemic Disease Control, 1985 - 1991 (1990 Bs$ millions)

Year MSAS a/ States b/ CVG Total Total (US$ millions) 1985 1,522.8 1,796.7 0 3,319.6 '70.1 1986 1,581.6 1,746.3 0 3,32&.4 70.2 1987 1,293.4 1,342.3 0 2,63S.8 55.5 1988 1,161.7 1,282.4 0 2,444.1 51.5 1989 891.9 730.0 139.1 1,761.1 37.1 1990 763.9 1,397.8 102.0 2,263.7 47.8 1991 1,345.3 2,109.6 164.6 3,619.5 68.3 a. Does not includeRural Housing, Aqueductsand Sewers. The MOH contribution to the latter programs was Bs$2,032.1 million in 1990 and Bs$2,927.1 in 1991 b. Includes Rural Housing, Aqueductsand Sewers. c. Note: 1991 figures converted at exchangerate of 53/1

Table Al-2. Distributionof State Contribuons to DGSSA Programs, 1989 - 1990 (1990 Bs$ millions)

1989 1990 Central Administration 7.0 26.5 Endemic Disease Control 2.8 66.8 Rural Housing 686.9 1,295.2 Sanitary Engineering 3.2 9.4 Total 730.0 1,397.9

Source: General Health Director-;;: for EnvironmentalSanitation 7 Annex 1

TableAI -3. Malaria Incidence In Venezuela,1960-1989

Year Cea ars 1960 1,674 1976 4,768 1961 1,754 1977 5,304 1962 1,210 1978 5,105 1963 2,853 1979 4,722 1964 5,884 1980 3,901 1965 5,263 1981 3,377 1966 5,481 1982 4,269 1967 5,257 1983 8,400 1968 5,735 1984 12,242 1969 8,740 1985 14,305 1970 15,288 1986 14,365 1971 23,626 1987 !7,988 1972 18,062 1988 46,279 1973 11,687 1989 44,627 1974 7,648 1990 46,910 1975 5,952

Source: General Health Directorate for EnvironmentalSanitation

14. Since the 1960s malaria incidencehas fluctuated in response to changes in the level of control efforts undertakenand to the appearanceof colonizationor mining activities in highly "receptive' areas where the conditionsare favorableto malaria transmission. During the 1960s, colonizationin rainforest areas of Tachira, Ba:iaas, and Zulia states, where the vector was already present, was accompaniedby a significant increasein malaria transmission. Later, between 1970 and 1973, there was a sharp increase in malaria in the state of Bolivar following the discovery of a major diamond deposit and the rapid in-migrationof miners and others. The vector, A. darlingi, was already present and the arrival of infected migrants from other areas quickly led to an epidemic. A similar situation occurred in Bolivar in early 1983 with the discoveryof new gold deposits in the municipalityof El Dorado. Again there was a massive in-migrationof miners from other parts of the country, as well as from other countries such as Brazil, Guyana, and the DominicanRepublic. By tlk late 1980s, there were an estimated 80,000 persons in the gold mining areas of Bolivar. Table A1-4 illustrates the associatedrise in malaria.

15. These gold miners are a highly mobile, almost nomadic, group and tend to stay in the mhnng camps for brief periods of three to six weeks, after which they return to their home communitiqs. Malaria is thereby exported to other parts of the country includingareas which may be highly susceptibleto renewed transmission,given the presence of the vector and non-immunepopulations. New foci of transmissionthus emerge and spread; Sucre state, for example, was free of malaria for 15 years but became reinfected in late 1983 due to in-migrationof infected miners from Bolivar state. Table A1-4 illustrates the violent rise in malaria in Sucre in recent years. In the past, vector control in Sucre has been especiallydifficult due to the exophilic behavior of the primary vector in this area, A. auasalis which prefers to rest outdoors after feeding, thus escaping the effects of intradomiciliary spraying. Altogether,the Bolivar mines have resulted in the reinfectionof an area of about 100,000 km2 in the states of Bolivar, Sucre, and Monagas, increasingthe risk of an even wider spread of 8 Annex 1

transmission in the country. Gold and diamond mining activities in the territory of Amazonashave also been associatedwith an increase in malaria. Reported cases in Amazonasdoubled from 1,305 in 1988 to 2,896 in 1989.

16. Malaria transmissionin the mining areas has specific characteristics: (1) it is highly focalized (2) it is difficult to control with traditionalmeasures such as house spraying due to the lack of sprayable surfaces, or with mass chemotherapybecause of the nomadic habits of the miners; (3) it is difficult to control by use of aerial fogging because the mines are often located in the middle of dense forest where the vector can easily seek shelter; (4) the chloroquineresistant P. falcigarum strains of the parasite are common; and (5) malaria can spread quickly to other areas, where the ecological conditionsfor renewed transmissionare favorable,through the migration of miners.

17. Malaria transmissionhas also risen in recent years, though less dramatically, in the western part of the country,in the states of Apure, Tachira, and Barinas. Transmission in this area is primarily associatedwith new colonizationactivities in Apure state and is also affected by the importationof cases from Bolivar. Malaria transmissionin Apure state is focalized in the new settlementareas. Living conditionsthere are precarious and difficult physical access and guerilla activity (by Colombianrebels) have also complicatedcontrol efforts. Fortunately, local transmission appears to be limited to P. vivax, which (unlike P. falciparum_has not presented problems of resistanceto anti-malarialdrugs.

TableA 14. Bolivar and Sucre: Reported Malaria, 1982-89

Year Cases Bolivar Sucre

1982 20 0 1983 505 8 1984 3,585 271 1985 3,225 4,522 1986 3,689 5,302 1987 8,887 2,190 198C 31,083 4,995 1989 27,735 5,513

Source: General Health Directorate for EnvironmentalSanitation

18. The DGSSA in Tachira state reported 1,280 cases of malaria in 1990 and has identifiedseveral problems: (1) the malaria situationis strongly affected by the imported malaria, especially from Apure state; (2) malaria is easily diffused throughoutthe state because of its good roads; (3) climatic conditionsare highly favorableto mosquitobreeding; and (4) there is a high density of the vector A, nuneztovari which is less susceptibleto intradomiciliaryspraying because of its outdoor feeding and 9 Annex 1 resting habits. Although malaria in Tachira averagedaround 1,000 to 1,500 cases per year since 1985, local officials are concernedthat the number of known local (autocthonous)transmission sites increasedfrom 21 in 1989 to 54 in 1990. If the number of local transmissionsites continues to grow in this way, malaria incidence is also likely to grow. At the same time, control program activities have fallen far short of objectives: house spraying and fogging activitiesreached only 60 percent and 40 percent, respectively, of planned coverage in 1990, largely due to labor strikes and to lack of vehicles, fuel, and supplies.

Control Activities

19. Early malaria control efforts in Venezuelasought to control morbidity and transmissionby eliminatingbreeding sites (source reduction)and through mass chemoprophylaxis,using quinine. Objectivesshifted to eradication in the early 1950s with the introductionof DDT for intradomiciliary spraying. This method of interruptingthe transmissioncycle involves spraying interior walls of houses and associated structures with DDT, a residual action pesticide lasting for several months, in order to kill mosquitosthat land on the walls after feeding. Between 1945 and 1960, malaria transmission was eliminatedfrom three-fourthsof the country. After this initial period of success, the country was stratified into "attack" phase and "maintenance"phase areas. The maintenancearea is presently comprised of 536 municipalities(460,000 km2) with a populationof 15 million or 76 percent of the total populationof Venezuela(approximately 20 million in 1990). The attack area is comprised of 34 municipalities(140,000 km2) with a populationof 670,000 or three percent of the total population. -' However, the disease situationhas changed dramatically since the original stratificationwas made in the 1960s. In 1990, the incidenceof malaria in the maintenancearea was four times higher than in the attack area. This reflects the significantreinfection of areas where malaria was once brought under control and underscoresthe need to update the old epidemiological stratification.

20. The goals of the current anti-malariacampaign are to: (1) maintain successes achieved in areas still free of malaria, and (2) to reduce existingtransmission to such a level that it is no longer a major public health problem. The principal activitiesto achieve these objectives are, ideally: (1) intradomiciliaryspraying with DDT and fenitrothion; (2) aerial spraying (fogging)with Malathion; (3) treatment of confirmedcases; (4) mass chemoprophylaxis,or suppressivetreatment, in some high risk areas; (5) epidemiologicalsurveillance through active case detection (visitinghouses to take blood samples in high transmissionareas) or passive case detection (taking blood samples from febrile patients seeking assistanceat DGSSA laboratories,health centers, hospitals, volunteer notification posts, etc.); (6) entomologicalsurveillance to study vector distributionand density, behavior, and susceptibilityto pesticides; and (7) educationactivities to gain communityparticipation in control efforts. The control program could have the greatest impact on transmission by undertakingall of the above activities. However, resource constraints have limited actual practice in most areas to intradomiciliaryspraying, fogging, and passive case detection and treatment. In particular, education to promote personal protection (use of netting and repellents)and communityinvolvement in the detection and eliminationof mosquito breeding sites would be a valuable complementto present

I/ About one third of the country is classified as "originallywithout malaria" and has an estimated populationof 4 million or 20 percent of the total population. Although imported cases are found in this area (955 in 1989), known local transmissionhas been minimal- only eight cases in 1989. 10 Annex 1

activities. Active case detection could also help to reduce the reservoir of infection in the population, includingasymptomatic carriers, and thus help reduce the intensityof transmission.

21. The basic administrativeexecuting unit is the "demarcation"headed kJ an inspector. The demarcations in each state report to the zone service chief. Malaria controAactivities are executed in the field by teams of spraymen (rociadores)and house visitors (visitadores). There are two types of spraymen teams: one which undertakes the intradomiciliaryspraying and another which operates the aerial fogging machines (either truck-mountedor portable). The malaria control program is principally executed by the teams in the field which undertake the spraying and fogging. The house visitors carry out active case detection (in some areas), administertreatment, and collect the blood samples that have been taken by volunteer notificationposts for analysis at the DGSSA field laboratories. Visitors and spraymen are supervised by team leaders who are supervisedby inspectors. There are three levels of inspector, depending on the amount of training they have received.

Major Issues in Malaria Control

22. Reinforcementof Resourcesfor Malaria Control. An intensifiedcampaign to reinforce malaria control is urgently required in order to reduce malaria transmissionin the mining camps and halt the spread of malaria to other, highly receptive areas. Without such a program it is likely that the numerous malaria cases will continueto increase. As the malaria problem has grown, so have the costs of basic inputs includingfuel and labor costs. At the same time, the DGSSA budget for malaria control has not increasedaccordingly. Instead, additional funds have been used from other programs, thereby impoverishingand seriouslycompromising other important disease control efforts.

23. The CollectiveLabor Contract. In 1990 and 1991 there have been frequent work stoppages due to the non-complianceby the Ministry of Health in the payment of benefits and field allowances to workers, as specified in their most recent 'collective labor contract." In January and February 1991, DGSSA workers in Bolivar were on strike and malaria control activities were essentiallyhalted. Fortunately, some activities were continuedsince part of the labor force is contracted under an agreement (convenio)with a parastatal regional developmentcorporation (CVG) and payments to these workers were not interrupted. Neither malaria control, nor any other endemic disease control program, can be effectivelycarried out if activities are continually interruptedby labor strikes. The Ministry's non-compliancewith the labor contract under the present circumstancesis due to tde fact that an increase in the basic field allowance(from 60 to 468 Bolivares per day) was agreed to without a correspondingincrease in the budget. Therefore, DGSSA field offices do not have the funds to pay all of the field allowancesdue the workers. Most of the workers in Bolivar state are still waiting for seven months worth of field allowancesfrom 1990. Workers in Tachira state were owed four months of field allowances. However, the work ethic in the institutionis still very strong and, despite these problems, most of the spraymen, visitors, and other laborers continueto go to work.

24. Administratve Problems. Administrativeproblems seriously hamper the acquisitionof supplies and maintenanceof vehicles. For example, throughout the country, DGSSA is distributing Primaquine for which the manufacturersexpiration date has expired. In Tachira and Apure, some DGSSAofficials suspect that as a result the product is no longer effective. They received the primaquine from Maracay in April 1991 stamped with an expiration date of November 1990. The drugs are centrally purchased by Maracay headquarters, which keeps a large reserve stock, and are distributed to the field offices on request. The period of validity indicated on the product is three years. Samples of the product have been recently sent for testing to local laboratories and the results 11 Annex 1

are forthcoming. In addition, there are shortages in the field of basic supplies such as microlancets fcr taking of blood samples, lightbulbsfor microscopes,and replacementparts for spraying equipment. Also, even in the most critical areas, field operations are slowed by lack of vehicles - disabled vehicles sit idle for monthsdue to lack of petty cash funds to undertake small repairs.

25. Adjustnent of Malaria Control Strategy. DGSSA has added fogging with Malathionto intradomiciliaryspraying and treatmentof cases in its malaria control activities for miningareas in Bolivar. It has also added fogging to its activitiesin Tachira and Apure. Malaria incidence, however, continues to rise in both areas. DGSSA needs to undertakean intensiveeffort to seek out innovative, appropriatestrategies for these problem areas. This can only be done with an investment of resources in operationalresearch and In the formation of epidemiologiststo analyze the changing epidemiologicalsituations and factors, and to adapt control technologiesto local conditions. An important first step would be to reassess the present epidemiologicalstratification and revise the maintenanceand attack areas based on current patterns of transmissionand incidence.

26. DGSSA is initiatinga study of risk factors for malaria transmissionin Bolivar state with support from the WHO/UNDP/WorldBank Special Programme for Research and Training in Tropical Diseases C(DR). This study should yield important informationto guide adjustmentsin strategy. Also, the malaria control program is experimentingwith the use of lambda cyhalotrin impregnated bednets, also in Bolivar state, in selected indigenouscommunities that are affectedby contact with mining populations.. These activities are important efforts towards finding better approachesto new problems.

Dengue

Disease Situation

27. Dengue is caused by an arbovirus which is transmitted to humans by the mosquito vector Aedes gy=i. This vector is amply distributed in Venezuelabreeding almost exclusivelyin man- made containers such as flower pots, water barrels, and discarded tires within or around the household. Since 1950, there have been several epidemic outbreaks of dengue in Venezuela, the most significantoccurring in 1964 (about 18,000 cases), 1966 (8,000 cases), and 1978 (1,200 cases). The most recent outbreak occurred between October 1989 and January 1990 and affected 70 percent of the area of the country. More than 12,000 cases were reported, and over 2,600 of these were dengue hemorrhagic fever (the first time this more violent form of the disease has been seen in Venezuela). There were 74 fatalities. The distributionof cases by state is shown in Table Al-5.

4/ Regular bednets have been recognizedfor many years as an effective means of reducing man- vector contact. Pesticide impregnatedbednets are a promising improvementon this tactic. Since direct contact with the net may not be necessaryto kill mosquitosentering a room, the use of these bednets could also help in reducing vector density. 12 Annex 1

TableAl-5. Dengue and Dengue HemorraghicFever In Venezuela,1989-90

Dengue Dengue Hemorraghic Fever

Federal District 3,185 724 Zulia 1,068 224 Miranda 1,024 150 Aragua 827 827 Falcon 568 71 Carabobo 532 127 Apure 431 17 Trujillo 324 30 Barinas 273 116 Portuguesa 189 54 Lara 182 4 Yaracuy 173 3 Anzoategui 156 18 Cojedes 112 17 Monagas 68 14 Guarico 58 12 Merida 62 1 T.F. Amazonas 46 2 Nueva Esparta 28 0 Bolivar 23 0 T.F.Delta Amacuro 7 0 Tachira 0 0 Sucre 0 0

Subtotal 9,392 2,634 Total 12,026

Source: General Health Directorate for EnvironmentalSanitation.

Control Activities

28. The Aedes aegypti control program which began in 1947 as an eradicationprogram, is carried out by the Vector and Reservoir Control Division of the Rural Endemic Disease Control Directorate of DGSSA. The 1989-90 outbreak was clearly associatedwith a major decline in MM aegypti control in 1988-89 which occurred when resources were shifted to malaria control. Furthermore, the coverage of the A. aegypti control program has been in decline since the late 1970s. In 1976, for example, DGSSA carried out over 5)00,000house inspectionsand treated over 120,000 houses. By 1980, only 59,000 houses were inspectedand 9,700 treated. By 1989, only 11,700 houses were inspectedand 5,500 treated. 13 Annex 1

29. During the most recent outbreak the Minister of Health set up and headed a National Committeeto Combat Dengue comprised of representativesfrom MSAS and other national agencies to coordinatethe dengue control effort. In addition, regional committeeswere set up in each state, headed by state governors and comprised of the Regional MSAS Director, the Regional MSAS Epidemiologist,the DGSSA Zone Chief, local mayors, business persons and other community leaders, to direct, facilitate and evaluate the campaign. Dengue control activities included: environmentalsanitation, health education, entomologicalsurveillance, and vector control (of both adult and larval forms) through aerial fogging and treatmentof breeding sites. Despite this major outbreak, there are still no vector control teams dedicated exclusivelyto Aedes aegypti control.

Major Needs

30. In order to improve dengue control, the DGSSAshould follow the recommendationsof a recent DGSSA report which proposed the creation of a new section under the Directorate for Rural Endemic Diseases to be responsibleexclusively for dengue and other vector-borne diseases. This would enable DGSSAto better prevent outbreaks of dengue and to respond rapidly and effectivelyto emergency dengue situationswith personnel and equipmentdedicated exclusivelyto this task. Such a section is also needed to undertake the following activities: (1) revise the Manual of Activitiesof the Aedes EradicationProgram to bring it up to date and make it appropriate to a "control" (as opposed to eradication)program; (2) entomologicalsurveillance (using larvae and egg traps) to map the distributionof Aedes aegyjti and other possible vectors of yellow fever and dengue; (3) taxonomic identificationof different vector species of yellow fever and dengue, and carry out studies of habitats and factors favoring vector proliferation; (4) monitor biting rates and vector susceptibilityto pesticides in use; (5) maintain contact with other disease control programs in neighboringcountries; (6) training in entomologicalsurveillance and vector control; (7) define the equipmentand insecticides needed for emergency and preventive action; (8) maintainports and airports free of Aedes aegypti; and (9) health educationgeared to increasingcommunity participation in eliminatingbreeding sites.

Chagas Disease

Disease Situation

31. Chagas disease is caused by Inanosomn cruzi which is transmitted by two triatomine insect vectors: Rhodniusprolixus and Triatoma maculata. Rabbits, small rodents and other small mammals can serve as reservoirs of T. cruzi. R. prolixus is found in 79 percent of the country (590 of 746 municipalities,covering 714,572 km2) and T. maculata is found in seven percent of the national territory (55 municipalitiescovering 63,7'3 km2). The populationof this area is an estimated 14.2 million, however, the actual populationat risk is limitedto low-incomehouseholds, since the vectors shelter in palm thatch used in walls and roofs, and in the cracks of mud walls (a more precise estimate of populationat risk is not available). At night, the triatomine bugs defecate on the skin while feeding on human blood and subsequentscratching of the irritated bite introduces the insect's feces, which carries the Chagas parasite, into the human bloodstream. The early stage of infection may look like malaria, with fever and swollen lymph nodes. This acute phase is on rare occasions fatal, but usually the patient survives and goes through a symptomlessphase lasting many months or years. During this period, the parasites invade and severely damage internal organs, especially the heart. There is no cure for Chagas disease, which is usually detected only after major damage has been done. The patient becomes progressivelyweaker and may eventuallydie of heart failure. 14 Annex 1

32. In Venezuela, Chagas is found in a belt which runs across the states of Barinas, Merida, Trujillo, Portuguesa, Lara, Zulia, Yaracuy, Cojedes, Carabobo, Miranda, Anzoateguiand Sucre. The states known to be most affected are Lara, Portuguesa,Trujillo and Carabobo. In most of the area, the population at risk lives in small and dispersed rural settlements. Table A1-6 shows reported cases of Chagas disease in recent years. The percent of exams testing positive shows a decline from 28% in 1985 to 14% in 1989. However, Chagas surveillancehas deteriorated during this period and it is probable that underreportingof Chagas disease is high.

TableA 1-6. Chagas Disease in Venezuela,1985-1989

Year Total Exams Tested Positive

1985 8,536 2,433 1986 8,295 1,684 1987 11,794 2,417 1988 4,988 962 1989* 6,509 913

('*to August only) Source: General Health Directorate for EnviromnentalSanitation

Control Activities

33. The objectives of the Chagas control nrogram are to interrupt transmissionof the disease through vector control (intradomiciliaryspraying), constructionand improvementof rural dwellings (to eliminate the habitat of the vector in the home), and health education. In the past, Chagas control has benefitted indirectly from intradomiciliaryspraying of DDT for malaria control. The first epidemiologicalsurveys specificallyfor Chagas control were begun in 1961. At present the program covers 14 states. As Table A1-6 shows, coverage in terms of blood samples taken for epidemiologicalsurveillance has fluctuated considerablyin recent years. In a number of states (e.g. Monagas, Anzoategui,Guarico, Sucre, and Portuguesa),however, Chagas control is paralyzed since all resources have been allocatedto malaria and dengue control. Plans for control activities in six additional states exist but have not been realized due to lack of resources.

34. Chagas control activities begin with house visits to insf, t for the presence of the vector. This is carried out by an inspector. If a house is found to be infested with the vector a team of spraymen treat the dwelling and associatedstructures on a four by four month cycle using dieldrin and other pesticides. In addition, house visitors (visitadores)will visit to take blood samples. If positive cases are found they are followed up with an EKG exam (portable EKG equipment is taken to the field) to determine if the victim has heart damage. Inspectorsalso are responsiblefor community education. They explain the disease and its transmissionand the importanceof eliminatingthatch construction material and of sealing crevices in walls by covering mud walls with plaster.

35. Poverty plays a central role in the continuedtransmission of Chagas disease and for this reason the DGSSAhas sought to integrate Chagas control with the National Program for Housing 15 Annex 1 Improvements(MIVICA), run by the Directorate for Rural Housing of DGSSA. Housing improvementis a logical complementto vector control through residual spraying. However, the MIVICA program is very limited in scope with programs in only three states, Falcon, Portuguesa, and Lara. Although the Chagas control program does provide MIVICA with the epidemiological informationto target its activities, MIVICA tends to operate more in areas where the building materials can be readily transported. Thus, the housingneeds of areas which are more remote, and usually more affected by Chagas disease, are generally unattended.

Major Needs

36. Underfinancingand Coverage. Resurgent malaria and the recent epidemic of dengue fever have had a serious impact on Chagas control activitiesin 1990. In the state of Portuguesa, for example, almost no vector control was carried out in 1990, since the Chagas program dependson the same spraymen and equipmentthat are used for malaria and dengue control. In recent years the level of activity in Chagas control has fluctuated considerably,depending on the availabilityof resources. On the whole, the Chagas control program is underfinancedand requires a major infusion of human and financial resources in order to achieve a reasonablelevel of coverage. As noted above, there are six states which are known to be areas of transmissionand which should have control programs but do not due only to lack of funds.

37. Chagas Controland Housing Improvement. Integrationof disease control and housing improvement is an important and worthwhilegoal and shouldbe pursued. However, both the Chagas control program and MIVICA program would require greater funding to achieve a significant and productive collaboration.

Intestinal Schistosomiasis (Bilharzia)

Disease Situation

38. Intestinal schistosomiasisis caused by the parasite Schistosomamansoni. F' In water, the larval form of the schistosomes(cercaria) are shed from infected snails and penetrate the skin of people who enter the water to swim, wash, or fish. The snails are infected by another stage of the schistosome(miracidia) which hatch from eggs passed in the stools of infected persons. In the human host, the adult male and female forms of the parasite live in the blood vessels of different organs and release eggs that are passed out in stools or that becomelodged in the tissues. Schistosomaldisease progresses slowly, as a reaction to these eggs in the tissues. It is characterizedby progressive enlargementof the liver and spleen and damage to the intestine resultingfrom lesions around the eggs and hypertension of the abdominalblood vessels. Repeated bleeding from these vessels can be fatal. The data from coprologicalexams in Venezuela show that persons over ten years of age are slightly more affected than persons under 10, but recent serologicalstudies suggest that not enough is known about schistosomiasisin Venezuelato say which, if any, populationgroup is most affected.

39. Based on the coprologicaldata, and on knowledgeof the distributionof infected snail populations, S. mansoni is known to be endemic in Venezuela's most densely populated region, the

S/ Another major form of schistosomiasisfound in South America, but not in Venezuela, is urinary schistosomiasiscaused by S. haematobuim. 16 Annex 1

center-north. The endemic area covers an estimated 15,000 km2 or 1.6 percent of the country, and includes the Federal District and parts of the states of Aragua, Carabobo, Guarico and Miranda. The population of this area is approximatelyseven million, of which an estimated two million people are actually at risk. The presently known distributionof the disease corresponds to the distribution of the snail intermediatehost, Biomphalariaglabrata. .' The socio-economicconditions and habits of the populationin the endemic area are generally amenable to the persistenceof this disease. In some areas (e.g. Aragua and Carabobo)the problem is aggravatedby brick manufacturerswho are extracting clay and leaving behind huge water-filledpits that are soon infested by B. glabrata. These flooded clay pits are often adjacent to poor, crowded barrios and are inevitably used by the population. Other problem areas includenew low-incomeneighborhoods that have appeared in low- lying peri-urban areas of the cities of Maracay and Valencia.

40. Surveillanceof schistosomiasisir Venezuelahas varied greatly since 1943 when surveillance activities began. Between 1943 and 1960, DGSSA made 87,639 feces exams of which 12,851 or 15 percent were positive for S. mansoni. Between 1986 and 1989, DGSSA made 125,062 feces exams of which 719 or 0.6 percent were positive. These data suggest that schistosomiasiscontrol activities, mainly mollusciciding,have been very effective over the years in reducing prevalence of the disease.

41. However, the introductionof new serological diagnosticmethods have raised some important questions. In 1989, DGSSA collected2,062 serologicalsamples in Carabobo state, and found 789 or 38 percent to be positive for S. mansoni. Another 1,350 blood samples were examined in 1990 of which 358 or 26 percent were positive. Thus, it seems that actual prevalence of schistosomiasismay be much higher than previouslyestimated. It may be that lighter infectionsdo not show up in the coprological exams but do show up in the serologicaltests. The implicationfor control is that, with the more sensitive serologicaldiagnostic tool, the schistosomiasiscontrol program could identify and treat a much larger percentage of infected individualsand significantlystrengthen efforts to eliminate the disease.

Control Activities

42. Since 1943, schistosomiasiscontrol has used a polyvalent strategy attacking the major points in the transmissioncycle: the intermediatehost through mollusciciding,the parasite through chemotherapy(using Oxamniquineor Praziquantel), and the human reservoir through education. Control activitieshave includedepidemiological surveys, hydrographic studies, malacological(snail) surveillance, molluscicidingin infested waters, biological control through introductionof competing snail species, drainage works, constructionof sidewalks, washing places (lavaderos), public baths and latrines, treatment of cases, and health education.

43. As in malaria control, each state where the schistosomiasiscontrol program operates is divided into demarcations. The principal control activitiesfor schistosomiasisin Venezuelaunderway today are snail control, epidemiologicalsurveillance and treatment, and communityeducation. Snail control activities are carried out by specializedteams of workers: some workers clear the underbrush along water courses so that others, followingbehind, can use small nets to capture snails. When infested

§/ S. mansoni has sometimesbeen found in two other potential snail intermediatehosts, B. straminea and B. havanensis, which are distributed over most of Venezuela. 17 Annex 1

bodies of water are found, capturedsnails are taken to Maracay for testing. The infested waters are treated by the same teams with molluscicide(primarily biiy1ucid,but also sodium pentachlorophenate, copper sulfate, Frescon, and sodiumcitrate). The worker teams are supervised by an inspector. In 1989, 10.4 million linear meters of water courses were inspected. The program p'anned to treat 981,000 linear meters but due to increasingcosts and insufficienttransport and personnel, covered only 50 percent of this goal (441,000 linear meters).

44. Epidemiologicalsurveillance is carried out by inspectors in areas where infected snails are found by collectingfeces samples for diagnostictesting (.nainly at the DGSSA laboratory in Maracay). This is followedup by treatmentof positive cases. There is a new plan, however, which has yet to be financed, which would train inspectors and workers to take blood samples for a new schistosomiasissurveillance system based on serological surveys.

45. Communityeducation is carried out by the inspectors with assistance from specialists from DGSSA Maracay headquarters. The focus of communityeducation is on changing the human role in the transmission cycle, i.e. to avoid defecating or urinating in or near bodies of water so as not to transmit S. mansoni eggs to the intermediatehost.

46. Operationalresearch on biological control is being carried out in collaborationwith the School for AdvancedStudies of the Universityof Perpignan (France) and the Guadaluupe Island Hospital Center. The objective of the project is to examine the impact on B. glabrata of the introductionof a competitor snail, Thiara tuberculata.

47. The SchistosomiasisResearch Group was formed in 198A,to help orient the activitiesof the schistosomiasiscontrol program, which is comprised of the head schistosomiasiscontrol program and representativesfrom the Bilharzia Laboratoryof the Tropical MedicineInstitute of the Central University of Venezuela, the Departmentof Parasitologyof the Universityof Carabobo, and the SchistosomiasisLaboratory of the Center for Microbiologyand Cellular Biologyof the Institute for Scientific Investigation(IVIC). The objective of the group is to work together towards improving diagnosis, treatment and control of schistosomiasisin Venezuela.

Major Needs

48. The schistosomiasiscontrol program needs to reassess the epidemiologicalsituation, based on serological surveys, and to develop a control or eradicationstrategy, accordingly. To do so, greater investmentin schistosomiasiscontrol will be needed since, for several years, resources for schistosomiasiscontrol have been used to help combat resurgent malaria. In addition, schistosomiasis control suffered a major setback in 1990 due to the transfer of its manpower to the dengue control effort. Field activities have slowed due to labor strikes and lack of funds to pay field allowances. The schistosomiasisprogram requires basic transport of its own to achieve adequate coverage, and resources are needed to undertake small drainage works, especially in new peri-urban areas where the risk of intensifiedtransmission is high. Coordinationwith state and municipal authorities to encourage such works and to maintain existingdrainage canals is also needed. Laboratory space and equipment, new supplies, and re-training of personnel are urgently needed and the program would also benefit greatly from computerizationof the its informationsystem to manage the epidemiological and snail surveillancesystems. 19 Annex 1

Intestinal Parasites

Disease Situation

49. The prevalence of helminthicinfections is a consequenceof poor living standards and, specifically,of the inadequatedisposal of human wastes. The most recent epidemiolo?icalsurvey of intestinalparasites in Venezuelabegan in 1989 after a lapse of 13 years since the previous survey of 1976. The new survey, which should be completed by late 1991, adds informationon parasite load and covers the same localities studied in 1976 in order to allow an analysis of the impact of control measures applied. Thus far, 33,457 samples from 15 states have been processed with.the results shown in Table Al-7. These preliminary data appear to indicate that the anti-helminthcampaign of the last 13 years has resulted in a significantdecline in prevalence.

Table Al-7. Intestinal Parasite Pre'alence In Venezuela,1976 and 1989

% Positive Parasite Species 1976 1989

T.trichiura 83.3 35.0 A.lumbricoides 41.1 29.1 Ancylostoma 29.6 5.7

Control Activities

50. The objective of the control program for intestinalhelminths is to reduce infection to a level that no longer constitutesa public health problem. The program is carried throughout most of the country and targets the principal geo-helminths:Ascaris lumbricoides, Trichuris trichiur, Ancylostomiases(Necator americanusand Anylostoma duodenal, and Enterobius vermicularis. The principal activitiesof the control program, which are executed by the Zone Service personnel based at the state level, include: (1) Epidemiologicalsurveillance to determine parasite indices and health/sanitationsurveys of households and communities;(2) Education campaignsin the schools and in the community;(3) Latrine constructionwith participationof beneficiariesin constructionand provision of materials; and (4) Mass anti-helminthtreatment through schools and communities(local health centers) with Mebendazole(single dose 500mg preceded by one day with single dose of piperazine). The program has operated best through the schools where treatment is administered twice a year.

Major Problems

51. The program's budget has not kept pace with rising costs and populationgrowth. Coverage has therefore been lower than projected: 34 percent for latrine constructionand 74 percent for antihelminthictreatment (k989). The figures on latrine constructionover the last two decades show a 19 Annex 1

very strong declining trend: only 786 latrines were constructedin 1990 as comparedto an average of 1,496 per year in the period 1985-89, 1,597 in the period 1984-88, 4,220 in the period 1979-83, and 10,376 in the period 1974-78. Until 1990, the Ministry of Health was providing funds to DGSSA to purchase building materials for latrines for needy beneficiaries. This support has been terminated and now beneficiariesmust be able to furnish all the materials. The control program is now experimentingwith innovativelydesigned 'ventilated' latrines (a snail-shapedstructure) using traditionalconstruction materials of clay and wood. This experiment is interesting and deserves to be expanded into some kind of pilot project in selected areas of high disease incidence. It is importantto note that the positive results of a good campaignto reduce intestinalinfestation can be lost in one or two years, if ongoing control programs are not maintained.

52. DGSSAofficials cited lack of transport and funds to pay field allowancesas serious constraints to the effective pursuit of program objectives. In addition, schools visited in April 1991 had not received drugs for distribution. DGSSAofficials (from Maracay headqvarters)cited difficulties in the national drug procurementsystem. Also, surveillanceactivities may be slowed down due to the fact that the central coprologicallaboratory in Maracay closed down in April 1991 due to a lack of equipment and resources. In theory, the Intestinal Parasite Division coordinatesactivities with the Rural Housing Directorate and, in particular, with the Housing ImprovementProgram (MIVICA). While the importance of this coordinationis clear, its realization will depend on the allocationof human and financial resources for materials, logistics, and communitymobilization.

THE INSTITUTEFOR BIOMEDICINE AND THE STATE DERMATOLOGY DEPARTMENTS: LEPROSY, LEISHMANIASIS AND ONCHOCERCIASIS

53. The Institutefor Biomedicine(IB) of the General Health Sector Directorate (DGS) is attached to both the Ministry of Health and Social Assistance(MSAS) and the Central University of Venezuela (UCV) and is responsiblefor the control of leprosy, leishmaniasis,and onchocerciasis(see Chart Al- 2). Control activities for the latter diseases (primarily passive surveillance, and treatment) are all carried out through the structure and personnel of 28 MSAS state-levelDermatology Departments (SDDs). In some areas there is collaborationwith the local rural health services involvinglocal nurses in leprosy and leishmaniasisrelated health education. The principal role of the IB, therefore, is to determine disease control strategy, carry out operational research and, ideally, to supervise control activities in the field. The presence of the IB is strongest in areas where its major research projects are underway (immunoprophylaxisstudies for leishmaniasisand leprosy) and which are supervisedfrequently by Institute staff from Caracas. The Institute itself does not have offices in the field. However, the SDDs are the executing arm of programs planned by the IB, as well as the principal vehicle for applying new diagnostic proceduresdeveloped by the lB. 20 Annex I

Organization Chart of the Biomedicine institute

Ministry of Healthand Social Assistance CentralUniversity of Venezuela I I Departmentof BiomedicineInstitute Dermatology_I

Directorate Administration k ;_ _ - ~~~~~Secretariat *ULbrary Maintenance State-LevelDermatology | Sterilization/ Services L_ Cleaning

IImatlonal Collaboration |Sectons| TrainingPrograms I I . I - PAHOIntemational Center - Clinic - GraduateCourse for Researchand Training - Immunology In Dermatology in Leprosyand Tropical - Immunology11 - Short CourseIn Diseases - Histochemistry Derrnatology - WHO/PAHOFellowship - Fislopathology * Undergraduate Program - Leprologyand Training - WHOCollaborating Experimental * GraduateCoume Referenceand Research Pathology In Microbiology Centerfor M. Laprae - Mlcology - GraduateTheses - Biochemistry - Dermopathology - Microbiology - Statisticsand Computing - Hybridomas - Genetic Engineering - MolecularBiology - Immunochemistry - Epidemiology - ElectronMicroscopy - Immunohematology I Veterinary/Bloterium 21 Annex 1 54. The IB is financedprimarily by two institutions,MSAS and the Central University of Venezuela (UCV). (In addition, USAID has supportedonchocerciasis treatment in the Yanomami area and NIH and Rotary Club have supported some IB research projects.) As shown in Table Al-8, IB expenditureshave declined in recent years, primarily as a result of declining MSAS contributions.

Table Al-8. Insdtute of BiomedicineExpenditures on Endemic Disease Control

Year MSAS a/ UCV b/ subtotal c/ d/ Total Total (1990 US$ m) (1990 Bs)

1986 493,300 194,200 687,500 178,400 100,000 965,900 45,783,660 1987 443,600 199,200 642,800 121,700 100,000 864,500 40,977,300 1988 445,400 196,600 642,000 87,100 100,000 829,100 39,299,340 1989 369,100 189,100 558,200 132,200 100,000 790,400 37,424,960 1990 352,0^ ) 197,400 549,400 130,000 120,000 799,400 37,891,560

a. Expenditureson personnel for all control programs. b. Expenditureson personnel for all research and training activities. c. Supportfor the Leprosy Multidrug therapy program from AMERICARES(drugs and field expenses). d. Support for Immunoprophylaxisfor Leishmaniasis(vaccine production and field expenses)financed by WHO/UNDP/WorldBank special Prcgramme for Research and Training in Tropical Diseases (TDR).

Leprosy

Disease Situation

55. Leprosy (als, known as Hansen's disease) is caused by a slow growing bacterium, Mycobacteriumlep-ra, which grows mainly in nerve cells and macrophagecells in the skin. The clinical course of leprosy varies from asymptomaticinfections to severe disfiguring disease. Skin lesions may appear and heal spontaneously. As the disease progresses, usually over many years, the skin lesions may become more frequent. These lesions range from depigmentedpatches, usually with loss of skin sensitivity,to multiplenodules with extensiveskin thickeningand folding. Loss of sensitivityin the skin often results in unnoticedburns or ulcers. Lesions of the nerves can lead to muscle weakness and atrophy resulting in deformities, especially of the hands and feet. The disease leads to disfigurementand disability due to injuries resulting from loss of nerve sensation. The mode of transmissionis not clearly known but it is generally accepted that prolonged and intimate contact with the source of infectionis necessary. The bacterium is believed to be transmitted mainly from the nasal discharge of infected people, but may also be transmitted by skin contact.

56. In 1991, Venezuelahad 13,616 registered cases of leprosy. The number of new cases reported in the last decade is summarizedin Table Al-9. The increasednumber of new cases detected does not indicate a worseningsituation, but reflects improvementsin surveillance. The IB estimates that over the last 40 years, the incidenceof leprosy has actually declined from 16/100,000 in 1951 to 1/100,000 in 1990. In 1981, the IB stratifiedthe country into three areas: (1) the high 22 Annex I

prevalence area, with greater than two cases per 1,000 population, comprised the states of Merida, Tachira, Trujillo, Barinas, and Apure; (2) the mediumprevalence area with between 1/1,000 and 2/1,000, comprised the states of Nueva Esparta, the Federal District, Portuguesa, and Guarico; and (3) the low prevalence area with less than 1/1,000, comprised the rest of Venezuela.

TableA 1-9. New Cases of Leprosy In Venezuela,19-89

Year New Cases

1980 333 1981 365 1982 375 1983 357 1984 372 1985 411 1986 455 1987 438 1988 490 1989 419

Source: Instituteof Biomedicine

Control Activities

57. The principal activity in control of leprosy is epidemiologicalsurveillance of patients and their contacts, and supervised treatment in order to Interrupt transmissionby reducing incidence. This is carried out at the state level by the SDDs. The latter are, ideally, but not always, staffed with a doctor, nurse, field inspector, and social worker (all of them do have a doctor, however). In addition, the leprosy program carries out health educationgeared to changing attitudes about the disease, focusingon its curability, low infectivity,and the benefits of immunoprophylaxis. Rehabilitationactivities are also undertaken in some areas to reduce incapacitationin patients who lose sensitivity, especially in the hands and feet (such patients tend to injure themselvesin routine activities).

58. For many years the only treatment for leprosy was dapsone, a drug which halts the multiplicationof the bacterium. Treatmentwas le,rthy, sometimeslife-long, there was risk of relapse, and resistanceto dapsone was appearing in many areas. However, a newly developedmulti- drug therapy (MDT) has been in use in Venezuelasince 1985. MDT combines dapsone, rifampicin and clofazimine. A total of 5,445 patients have received MDT (a coverage of 87 percent) of which 1,980 cases (36 percent) have successfullycompleted treatment. MDT is implementedin all states except Tachira, Apure, and Merida (where immunoprophylaxisis being tested) and Bolivar, due to difficulty of access and other problems associatedwith such frontier regions. The IB is also working on immunotherapy,using the same compoundwhich is being tested as a vaccine, described below. 23 Annex I

So far, the IB is encouragedby the results of immunotherapy,claiming that 90 percent of patients treated have respondedpositively.

59. Venezuelais one of several countries now working on preventionof leprosy through vaccination. The objective is to reduce prevalence and incidenceby protecting high risk contacts. As areas of high prevalence, Apure, Tachira, and part of Merida were selected for an immunoprophylaxisstudy which is testing a vaccine made of dead M. Ipa and a compoundcalled B.C.G. At the beginningof the study, an epidemiologicalsurvey was conducted:2,294 cases were registeredand their 64,572 contacts (people at highest riak of contracting the disease) were identified. Of these contacts, 29,116 received the vaccine. The contactsare examinedannually. 2' So far, the IB is encouragedby the results and hopes to expand the program to all endemic areas in the country.

Major Needs

60. The Institute for Biomedicineneeds to undertake a comprehensiveevaluation of the leprosy control program in all states and territories. Based on such a review, surveillance and treatment activitiesshould be strengthenedin areas which are presently underserved (especiallymore remote areas with weaker health infrastructuresuch as Amazonasand Bolivar). In addition, the results of the immunoprophylaxisand immunotherapystudie3 now underway should be evaluated as soon as possible with a view to determining whether these studies should be expanded, in order to make these alternativetherapies ava.lable to leprosy patients and contacts throughoutthe country.

Leishmaniasis

Disease Situation

61. Leishmaniasisis caused by a parasite transmitted by infected sandflies (genus Lutzomyia in Venezuela)which breed in moist soils, for example, in forest areas, caves or burrow of small rodents. Several species and subspeciesinfect man, leading to symptomsranging from simple self-healingskin ulcers to life-threateningdisease. Small mammals includingrodents and dogs, serve as reservoir hosts of infectionand may play an importantpart in the epidemiologyof the disease. In Venezuela, two forms of leishmaniasisare found: L. tgumentar (also called cutaneous and mucocutaneous leishmaniasis)and L. visceral or Kala-Azar. The former is more common and its symptomsmay range from simple skin ulcers to major tissue destruction, especially of the nose and mouth. Visceral leishmaniasisis a more serious form of the disease and usually fatal if untreated - its symptoms include fever, malaise, weight loss and then anemia, and swelling of spleen, liver and lymph nodes. Simple cutaneous leishmaniasiscan heal by itself without medical intervention, leaving the person immune to further infection from that particular form of the disease. However, some cases of mucocutaneousleishmaniasis (as well as visceral leishmaniasis)are extremely difficult to treat and may require a long course of pentavalentantimony drugs (Glucantimeor Pentostam) and sometimes the antibiotic amphotericinB.

2/ The study is supported by the WHO/UNDP/WorldBank Research and Training Program for Tropical Diseases (TDR), the VenezuelanGovernment, and the Pan AmericanHealth Organization. 24 Annex 1

62. Cutaneous and mucocutaneousleishmaniasis have been reported in nearly all states in Venezuela with the exceptionof Nueva Esparta and T.F Delta Amacuro. Underreporting is high and there may be as many as ten cases unreported for every reported case. Table Al-10 summarizesthe reported cases of cutaneous and mucocutaneousleishmaniasis in Venezuelasince 1955. The IB has classified the different states where transmissionoccurs into active foci: Lara, Tachira, Merida, Trujillo, Barinas, Miranda, Anzoategui,Sucre, T.F. Amazonas, and Zulia; and slightly active foci: Bolivar, Cojedes, Falcon, Monagas, and the Federal District. A few small foci of L. visceral have been found in flve states: Lara, Guarico, Sucre, Anzoateguiand the Federal District. Incidenceof visceral leishmaniasishas been about 50 new cases per year. Leishmaniasisis often associated with certain occupationsin Venezuela(lumber, bark, and chide extraction, road construction, mining and petroleum exploration)because they result in greater contact between people and the disease vector in or near forest areas.

Control Activities

63. Several activities are being carried out by the SDDs and IB in an effort to interrupt transmissionand reduce prevalence of the leishmaniasesin Venezuela including: (1) passive case detection and some active case detection (in Tachira, for example, the SDD visits the householdand neighborhoodof patients who seek treatmentto undertake active case detection among the patient's family and neighbors); (2) treatment of cases with antimonials(in all states except Tachira); (3) in Tachira, experimentalimmunotherapy, using a "vaccine" composedof dead Leishmania and B.C.G.

Table Al-JO. Cutaneousand MucocutaneousLeishmaniasis in Venezuela,1955-1989

Year Cases

1955 to 1980 16,728 1981 1,203 1982 1,507 1983 1,640 1984 2,100 1985 2,557 1986 2,677 1987 2,486 1988 2,664 1989 1,899

Total 35,461

Source: Institute of Biomedicine 25 Annex 1

(modeled after the vaccine under developmentfor leprosy), which appears to be as effective as Glucantime, without the serious side effects11; (4) immunoprophylaxisstudies in Lara state, using the same vaccine as above; and (5) educationactivities are carried out in high risk areas focusing on measures to avoid the vector such as use of bednets and Insect repellents (e.g. fumigation coils). Presently, there is no vector control for leishmaniasisthough it is theoretically part of the responsibilityof the Vector Control division of the Rural Endemic Diseases Directorate of the DGSSA.

Major Needs

64. EpidemiologicalSurveillance. An active case detection system is needed in order to definitivelymap the location and level of leishmaniasistransmission in the country, given the suspectedhigh level of underreporting. Also, given the encouragingresults with immunotherapyand immunoprophylaxis,support for these activitiesshould be increased. Both of the above would require a considerable investmentof resources.

65. Assessmentof Vector Control. Research on the vector, non-humanreservoirs of infection, and vector/reservoir control as an additional means of interrupting leishmaniasistransmission, is also needed.

Onchocerciasis

Disease Situation

66. Onchocerciasis(pronounced on-ko-sir-kai-a-sis) is caused by a thread-like worm, Onchoce _olvulus,which is spread by the bite of the female blackfly (Simuliummealicam, Simulium exiguum, SimuliumEjptgj, and SimuliumGuasisanguineum in Venezuela). Victims of onchocerciasis suffer severe debilitationand itching due to the proliferation of millions of infant worms (microfilariae)produced by adult worms (macrofllariae)located in nodulesunder the skin. Years of repeated reinfection and eventual microfilarial migrationto the eyes will lead to severe ocular damage and blindness(hence, onchocerciasisis known as River blindnessin Africa). In Venezuela, onchocerciasisis found in the eastern states of Anzoategui,Monagas, and Sucre, the central states of Aragua, Miranda, Carabobo, Guarico, Cojedes, and Yaracuy, and the southern states of Bolivar and Amazonas. The IB estimates that there are approximately80,000 cases of onchocerciasisin Venezuela. However, a complete and systematic mapping of onchocerciasisin Venezuelais still needed, includingan assessmentof the extent of blindnessdue to onchocerciasis.

Control Activities

67. Onchocerciasiscontrol activitiesare limitedto passive surveillanceand treatmentof cases with ivermectin (Mectizan), an effective microfilaricidein use since 1987. Ivermectintreatments must be administered yearly for the lifespan of the adult parasite (11 to 14 years) since ivermectindoes not kill the adult worm. Studies in West Africa of ivermectinas a control tool indicate that, without some form of vector control, it is probably not effective in interruptingtransmission. In Venezuela,

A/ In 1990, the IB signed an agreement with the Rafael Rangel NationalInstitute of Hygiene which agreed to assist in production of the vaccine. 26 Annex 1

vector control was attemptedfor a short period between 1959 and 1965. The effort was halted, however, because of its high cost and because it did not have a significant impact on vector density.

Major Needs

68. EpMdemlologicalSurveilan,ce and Treatment. Effective control of onchocerciasisin Venezuela would require an active epidemiologicalsurveillance system, as well as a program for mass ivermectin treatment in importantfoci across the country.

69. Vector Control. The IB and DGSSA could explore again the options in blackfly control, given new technologiesthat were not available in 1965.

CONCLUSIONS AND RECOMMENDATIONS2 '

70. Although there have been promising advances in the treatmentof leprosy, leishmaniasis, onchocerciasis,and schistosomiasis,and while importantsteps are being made towards immunoprophylaxisfor leprosy, leishmaniasisand even malaria, on the whole, efforts to control the tropical diseases in Venezuelahave been deterioratingor stagnatingduring the last decade. Chagas is still an incurable disease affectingthousands of people each year, which could be prevented through better vector control, rural housing improvement,and education. The real magnitude of schistosomiasis,onchocerciasis, leishmaniasis and leprosy in Venezuelais not known because epidemiologicalsurveillance activitieshave not achieved or maintaineda complete coverageof the country. Resurgent malaria is a growing problem not only due to technical problems that need innovativesolutions but also because control efforts are hampered by insufficientrebources to cover field expenses resulting in labor conflictsand strikes. These are problems that can be addressed through better management,greater investment,and operational research.

Epideniological Assessment

71. The DGSSA and IB need to undertake a comprehensiveevaluation of the epidemiological situation and the adequacyof control measures now underway or planned for each of the major endemic diseases. They should take stock of what they are doing and why; for several years, disease control activitieshave been determined not on the basis of epidemiologicalrealities but on the basis of fiscal constraints. There are now significantgaps in the epidemiologicalprofile. Onchocerciasis, leishmaniasis,and schistosomiasis,in particular, should be surveyed carefully and completely. Studies are needed, however, on all of the endemic diseases, includingmalaria, with special attention to: (1) epidemiologicalpatterns, and the determining factors in disease transmission; (2) development and experimentationwith new control technologies;and (3) adaptationof existing control technologies to local conditions.

2/These recommendationsare now being incorporatedinto the design of the Endemic Disease Control EPrjecin preparation. 27 Annex 1 Greater Investment In Endemic Disease Control

72. Endemic disease control in Venezuelarequires a major investmentof capital in order to re- anchor programs tiiat are losing ground. In the medium-term,the DGSSA and the IB will have to grow in size and increase spending in order to expand coverage to an appropriatelevel. An institutionaldevelopment program could be designed to help guide this growth. Such a program could focus, in particular, on strengtheningseveral areas: human resources, management,information systems, operational research, and infrastructure.

Human Resources

73. Training of field personnel and local technicalpersonnel needs to be strengthenedto permit expanded coverage and to prepare the states for planned decentralizationof health services. Also, more epidemiologistsare needed at the central and state level to increase local capacity to assess epidemiologicalpatterns and continuallyevaluate the impact and appropriatenessof control activities. Training of technical specialists in all relevant areas needs to be expanded. Career development planning and opportunitiesare needed to strengthenthe future human resource base for disease control. In addition to strengtheninglocal training capacity, the disease control institutionscould invest in sending their own professinals abroad to strengthen their qualificationsin key areas (such as public health administration,epidemiology, and entomology)and to learn from the experiencesof other disease control programs. Both the DGSSA and the IB have strong training traditions and can build on existing foundationsto better meet their human resource needs for effective disease control.

Management

74. The fact that resurgent malaria has led to the cannibalizationof DGSSA's other disease control programs is a strong argument for a review of managementproblems in the institution; improvements can be made in the managementof how the institutiongenerates resources to sustain its programs. There are also many smaller problems, at the local level, that indicate the need to review management systemsand increase efficiency and flexibilityin solving day-to-dayproblems. For example, field personnel complainof long delays in acquiringsupplies, shortagesof critical supplies like microlancetsand spare parts for manual sprayers, and lack of petty cash to solve minor problems includingbasic maintenanceof vehicles. The DGSSA and the IB could undertake an evaluation of program management(using outside specialistsif necessary) in order to identify problem areas and possible solutions.

Information Systems

75. Collectingand manipulatinginformation is a key activity in effectivelymanaging endemic disease control. Both DGSSA and IB have strong traditions in manuallycollecting and processing data from the field. At the central level, computerizationof administrativetasks and some epidemiologicalanalysis is already underway. There is considerableinterest in utilizingcomputers at the field level as well, especially for processingepidemiological data for malaria and schistosomiasis. The DGSSA and IB could survey their informationprocessing needs, administrativeand epidemiological,and identifythe equipment, software, and training programs that would be needed to upgrade and automate their informationsystems. 28 Annex 1 Infrastructure

76. DGSSA lacks basic infrastructurein some critical areas. In Bolivar, for example, more field bases are needed in strategic locationsin order to reduce fuel and transport costs. Living quarters for field personnel (especially for those working in the more remote areas) and deposits for pesticidesand other supplies are also needed. TlheDGSSA could undertakea complete survey of its existing infrastructurefor each of its programs and identify its needs in this regard.

Operational Research

77. Operationalresearch is a valhzableinvestment and should be considered an integral part of any disease control program. Both the DGSSA and IB carry out operational research, sometimes with support from other institutionsincluding the World Health Organization,the Pan AmericanHealth Organization, pharmaceuticalcompanies, and universities. The IB's work on immunotherapyand immunoprophylaxisof leprosy and leishmaniasisis important and needs strengtheningand expansion. A research agenda for onchocerciasisto design and activate an onchocerciasiscontrol program in Venezuela is urgently needed. The DGSSA is also pursuing immunologicalstudies, on malaria in Bolivar state, in collaborationwith Dr. Patarroyo of Colombia. It is also conductingother operationallyrelevant studies: a comparativestudy of alternativepesticides and applicationmethods for malaria control (includingthe testing of pesticide impregnatedbednets and the use of Bacillus thuringensis)and a study of risk factors in malaria transmissionin Bolivar state. More operational research is needed, however, on all of the endemicdiseases to better understandthe epidemiological situation, and the major factors in disease transmission. Research is also need on the adaptationof control technologiesto the special epidemiologicalcharacteristics in different areas. 29 Annex 2

ANNEX 2

CHILD HEALTH AND NUTRITIONW'

1. Approximately40 percent of Venezuelansare under fifteen years of age. Despite the country's fairly high per-capita income, child welfare indicators are poorer than might be expected: Venezuela's official infant mortalityrate (25/1000 in 1989) is higher than that of several countries in the region with lower per-capita income, includingCosta Rica, Chile, and Jamaica. Much of Venezuela's poor performance in improvingchild health has been attributed to problems identified within the health sector, includingpoor coordination,lack of targeting, and an emphasis on curative, rather than preventativecare. In additionto these problems, Venezuelaunderwent a serious economic crisis in the 1980s, during which per-capita governmentexpenditures on health fell by approximately 55 percent in real terms over the decade (see Annex 5). Althoughfirm conclusionsare hamperedby a lack of reliable data, there are some indicationsthat child health and nutrition worsened during the decade of the 1980s.

2. Since 1989, the governmenthas initiatedor expanded targeted interventionsin both health and nutrition, includingthe Programa AlimentarioMaterno Infantil (PAMI) which distributesfood to pregnant and lactating mothers, as well as children under six. Food distributionunder PAMI was to be accompaniedby a strengtheningof maternal-childhealth services through the Ministry of Health and Social Services (MSAS), but this part of the program has lagged behind the food distribution component. While the expansionof PAMI and other programs has the potential to improve the overall health status of Venezuelanchildren, for the most part it is too early to judge the results of these programs from existingmortality and morbidity statistics. This annex reviews what is currently known about the health status of V -'utan children, progress and problems in implementingnew or existinggovernment programs aimed a iimprovingchildren's health, and options for further addressingproblems in the area.

CHILD MORTALITY

3. The infant mortality rate (IMR) in Venezuelahas fallen over the last three decades. Improvementslowed, however, during the economic crisis of the 1980s. According to MSAS statistics, the IMR fell from about 32 per 1,000 live births in 1980, to about 23/1000 in 1988 and 25/1000 in 1989 (see Table A2-1.) Data also show large variations in the infant and child mortality rate by region, with the Federal Territories of Delta Amacuro and Amazonashaving among the highest rates, and the Distrito Federal having among the lowest. Data quality across regions, however, is quite variable; rural areas are particularly prone to under-reporting.

4. For infants from zero to one year of age, the principal causes of death in 1988 in order of importance were: 1) hypoxia and other respiratory disorders; 2) gastroenteritis and other diarrhea-

1/ This annex was written by Kate Hovde (Worid Bank), drawing heavily on backgroundpapers prepared by Fernando Vio (consultant). 30 Annex 2 associatedillnesses; 3) congenitalabnormalities; 4) other problems of newborns; 5) respiratory illness; 6) lesions and other complicationsresulting from the birthing process; 7) accidents; 8) septicemia; 9) immaturity;and 10) meningitis(Table A2-2). Diarrhea-relateddeaths for this age- group have fallen during the 1980s, but still remain quite high. Official registries in 1990also recorded a significantjump in the numbersof diarrhea-relateddeaths, from 1,548 in 1989 to 2,087 in 1990. This jump may in part be attributableto improvementsin the reporting system, although it probably also reflects a decline in the overall standard of living.

5. For children from one JQfo yes of age, the primary causes of death in 1988 were 1) accidents; 2) pneumonia; 3) gastroenteritis and other diarrhea-relateddiseases. Also within the top ten causes of death (occupyingvarious places throughout the 1980s) are measles, and malnutrition. Deaths registered as malnutritionhave fluctuatedduring the 1980s: moving from the eighth most importantcause of death in 1984to the fourth in 1987and then back to sixth in 1988 (see Table A2- 3).

6. For children from five to fourteen years of age, the primary causes of death in 1988 continuedto be accidents, over half associatedwith automobiles. Other violent forms of death (suicide and homicide)also take on increasingimportance as the fifth most importantcause of death. Cancer is the second most importantcause of death, with pneumoniathe third, and gastroenteritisand diarrhea related-diseasesin eighth. Congenitalanomalies, heart diseases, meningitis and epilepsy also appear as importantcauses of death at this age (see Table A2-4).

7. Particularly striking about the principal causes of death of Venezuelanchildren is how many of them are, in fact, preventable. Diarrhea, measles, malnutrition,and respiratory infectionsare all illnesses that can either be avoided (as through vaccinations)or treated at relativelylow-ost in the home, neighborhood,or local health center. Access to pre-natal care, in turn, can help reduce the risk of many neo-natal problems.

RISK FACTORS

Hospital Births

& Most Venezuelanchildren are born in hospitals, which reduces the chances that mother or child will die or be injured during the birth. MSASdata from 1989 show a total of 94 percent of all births in either MSAS hospitals or clinics - 85 percent in MSAS facilitiesand 9.0 percent in private facilities. Of total births, 6 percent are registeredas "other." Across the different states, the proportion of births attended by physiciansis lowest in the states of Apure (60 percent), Barinas (72 percent), and the Federal Territories (64 percent for Amazonasand 73 percent for Delta Amacuro.)

Low Birth Weight

9. Among proximate causes of infant mortalityand malnutritionis low birth weight, which is in turn related to many factors, especially low maternal weight gain during pregnancy. Low birth weight statistics are collectedby MSAS, but their reliability is not known. It is also difficult to infer trends from these statistics, because the completenessof reporting could vary over time. According the official statistics (see Table A2-5), the proportionof low birth weight babies in Ministry of Health 31 Annex 2 hospitals was highest in the states of Apure (42 percent), Cojedes (37 percent), and Falcon (23 percent). Rates were reported to be lowest in Portuguesa(1 percent) and Nueva Esparta (4 percent), but as these rates are abnormallylow, they are more likely due to poor quality data. If service statistics were improved, these indicatorscould be used to monitor infant health over time. In the largest maternity in the country, MaternidadConcepcion Palacios, the proportion of low birth weight babies increasedfrom a range of 12 to 13 percent over the period 1986to 1989, to 16 percent in 1990. Given the high quality of this hospital's data, the increase of about one-third signals a problem, perhaps reflecting the economic conditionsof the low-incomepopulation in 1989 and early 1990. This same institutionregistered 33% of low income patients in 1990as having had no pre- natal care. Interventionsto reduce the prevalenceof low birth weight babies includetargeted programs of food and iron supplementationduring pregnancy, improved pre-natal care and nutrition education.

Breast Feeding Practices

10. As has been extensivelydocumented, breast feeding helps protect children from the risks of dying from infectiousdisease. Exclusivefeeding of breast milk to infants from zero to six monthsof age is also considered an importantfactor in reducing the risk of dying from infectiousdisease, mainly from infant diarrhea (currentlyvery high in Venezuela)and assuring adequate nutrition. In addition, breast feeding contributesto a longer period of amenorrheafor the mother, reducing the risk of inadequatespacing between pregnancies. Unfortunately,little current data exists on breast feeding practices among Venezuelanwomen, trends over time, or differencesamong sub-groupsof the population. Questionson breast feeding practices have been included in the 1991-92Household Social Survey, which should also allow for more robust estimatesof the total fertility rate and contraceptiveprevalence. Breast feeding promotionis includedin the health services part of the PAMI program, but no informationcurrently exists on the extent to which such education is taking place.

Fertility Rates and Family Plarnning

11. Inadequatebirth-spacing, as well as early or late childbearing, raises risks of low birth weight and other complicationsfor both mother and child. Nonetheless,coverage of women of childbearing age under the MSAS family planningprogram remains quite low: estimatesfor 1990were coverage of 13 percent of women of childbearingage (see Annex 3).

Sanitation

12. Diarrhea continues to be an importantcause of sickness and death for childrenunder five. Most often, this is a disease related to the availabilityof potable drinking water, inadequatesanitation, and the mishandlingof food. Informationsources differ considerablyas to the status of access to water and sewage systems, and the qualityof the services provided in Venezuela. Accordingto the 1989 Household Social Survey, only 15 percent and extremely poor urban householdswere without some type of sewage disposal, compared to 4 percent of non-poor households. Yet a 1987study showed that 50 percent of the urban populationwas without sewer services, and 25 percent had no

2/ World Bank. VenezuelaPoverty Study: From GeneralizedSubsidies to Targeted Programs, Washington, 1991, p. 39. 32 Annex 2 potable water..' Amongthe extremelypoor living in rural areas, these percentages are likely to be much higher.

13. Adequate sewage disposalsystems are also critical in reducing the prevalence of intestinal parasites, especially in children. While intestinalparasites are seldom fatal, they do weaken children's resistance to other diseases and can exacerbate malnutrition. Preliminary results from a recent MSAS survey indicate a significantfall in intestinalparasite prevalence over the last 15 years, but to what extent this is due to improvementsin sanitationversus treatment campaignsis not known (see Annex 1).

Immunization

14. The persistenceof measles within the top ten causes of death for children ages one to four is no doubt in large part due to the inadequacyof Venezuela's immunizationprogram over the decade of the 1980s. According to MSAS estimates, in 1989, meas;es vaccinationonly reached 50 percent of children under one year who shouldhave gotten the vaccine, with a low of 24 percent in the Federal Territory of Amazonasand a high of 76 percent in the state of Trujillo. Third polio dosage for children under one year of age fell from 93 percent in 1980to 67 percent in 1989. In same year, coverage for the third dose of DPT was 55 percent (see Table A2-6.) Problems identified include functioningof the vaccine cold chain, lack of syringes, lack of paper for registration, work stoppages, and limited ambulatory hours. Governmentefforts to improve immunizationcoverage rates in 1990 did produce results: coverage of children under one year with the third dose of polio increasedto 72 percent, third dose of DPT increasedto 62% and measles to 62 percent. Most of the increases were registered in routine, rather than campaignbased vaccinations.

Nutrition

15. AlthoughVenezuela does keep nutrition-relatedrecords on childrenusing primary health care facilities (throughthe Sistemade Vigilancia Alimentariay Nutricional- SISVANWthe available data do not permit generalizableconclusions over time or across regions, because the sub-samplesare not representativeY Nationallyrepresentative anthropometric data will, however, be collected on an ongoing basis in the NationalHousehold Social Survey, which was begun in 1991 (data analysis should be completed in 1992). Earlier small scale surveys have establishedthat differences in caloric intake in Venezuelaare marked between the rural and urban regions, low caloric intake being more severe in rural areas.5 Principal deficienciesalso seem to be caloric, rather than protein.

16. Experience in many countries indicatesthat micronutrientdeficiencies, especially insufficient vitamin A, iron, and calcium are a commonproblem, and poor maternal iron status in particular is considered a risk factor for infant mortality. The only estimates of deficienciesin these micronutrients in Venezuela at a national level are based on Food and Agriculture Organization

3/ Genatios, Eduardo. "La Cuidad y sus Servicios," Caracas, 1987.

4/ The SISVANsample is not representative,as it includes only children attending a sub-group of MSAS health facilities.

I/ World Bank, VenzuelaPoverty Report, 1991, p. 32. 33 Annex 2

(FAO) food balance sheets: no survey of actual prevalencehas been done to date. Some work has been done on iodine deficiencies. A 1981 survey estimated endemic goiter resulting from iodine deficiencyto be affecting approximately21.9 percent of the populationin some parts of the Andean regions; Venezueladoes currently have a salt iodizationprogram, although it has experienced problems with compliance.0' Further work to determine prevalence of micronutrientdeficiencies, especially iron, is needed.

GOVERNMENTCHILD HEALTHAND NUTRTON PROGRAMS

17. Most of Venezuela's child health and nutrition programs in the 1980s have been run under Ministry of Health and Social Services (MSAS) and an affiliate organization, the National Nutrition Institute (INN). The INN is the principal nutrition research and policy agency in the country, but over the last decade became heavily involved in food distribution. The INN also runs state centers for the recuperation of the severely malnourished(serving approximately220 patients, mostly children, in 1990).Z'

The PAMI Program

18. In 1989, as part of its new poverty alleviationplan, the government institutedthe Programa Alimentario Materno Infantil, or PAMI (Box A2-1). The purpose of the PAMI program was to expand the very low coverage of both INN and MSASprograms oriented toward the health and nutrition of pregnant and lactatingmothers and children under six. This was to be done by linking the distributionof food (primarilydried milk) to the provision of basic health services includingpre- natal care, health promotion, immunization,well baby care, nutritionalsurveillance and supplementation,breast feeding promotion, and cancer screening. Food is distributed at local health centers, and women and children must be enrolled in primary health care services in order to receive the food. Rather than continuingunder the INN, the food distributioncomponent of PAMI has been relegated to a separate foundation affiliated with the MSAS (the Fundaci6n PAMI), while the health programs associatedwith the PAMI initiativehave continuedunder the MSAS.

19. Begun in December 1989 in state of Trujillo, the food distributior.component of PAMI covered 18 states or federal territories by the end of 1991Y The program's overall goal is to reach 50 percent of the population from 0-23 months, 30 percent of the populationfrom 24 months tc 6 years, and 50 percent of pregnant and lactatingmothers with both food supplements and primary health programs by the end of 1992. In this first phase of the program, milk and a soy-based product (LACTOVISOY)are being distributedto the entire target group with differing amounts given

6/ Comisi6n Presidencialpor Los Derechos del Niflo. Programa Nacional de Acci6n, December 1991, p. 18.

7/ World Bank. VenezuelaPQverty Report, 1991, p. 79.

1/ Garcia, Haydee and Levy, Alberto. Venezuela: Revisi6n del Programa Alimentario Materno Infantil (PAMI). November, 1991. 34 Annex2

Box A2-1. MSAS Heaith Programs inked with PAMI --the ImmunizationProgramd m a or PmA AsS. mentionedearlier in thiurptimnunization X.verge has'been :slippiig over the past decade,and wasparticularly disappoitig in 1989. In respose, te:PAl programhas increasedthe numberof singleay vaccinationap agn,: an.'dhas'beeb tawkig advantageof the PAM1program to increaserogutine v.acnatio s.Results improved in 1991,although problems with'the cold chainand supp ies Continue.

-the DiarrhoeaDisease Control Program Iraub.-:.OWR " . -. Enfermedades wbarreicas}F-iQhi,ch:.monitorsandinfluences goverment policiesto .expand basc sanitationsystems. Ontheicurative side, the' SAS'hastsw paaceutical lab that producesOral RehydrationTherapy..: (OR1)formula i.n: read yvto-mii.envelopes (SUERORAL)that are then distributedto healthIcenters.' 'This laborty functionsat approximately10 percent.of capacity,however, and produces.only'2. millionenielopes a yeardespite the fact that actualdemand is estimatedat 9.millio per year. 'ORT'salts are frequendyunavailable at localclinics. --the acute Respiratory:Infection. Program (ub-Programa IIe i6Respi ratorias Aiudas fIRA. Tiis program.wascreated in 1987and was a,ied .ateu.c,ingthe morbidity-and mortality of children.underS fromrespiratory infeti . Pr coveragehas sufferedin part due to a sho'rtageof medicines.withf *hich to-'trea infections.

-the PerinatologyProgram Prrama e Pe inatogloia>.isdesign topoveaystYn^-- of follow-upattention for new.-bon,'par.ticularl y'tose' classifeasig-risk. Te. ,program.sobjectives also- incudea. porooinducationathe

-the MaternalCare ProgramfProia de Ateneid -ate . o o V.` includea reductionin maternaland ifiant morbidityand 'mortality,beast fei: promotion,and breastand ceWicalcancer screeni"g. ,

dependingon classificationof beneficiariesas high-or low-risk. Oncethe programis better established,food distributionis to be limitedto thosewho fulfillmore specificbiological, economic, or nutritionalrisk criteria(by 1993).9'

2/ Risksare currentlybeing evaluated using the followingguidelines: high-risk pre-natal is definedas over 35 and/orilliterate, and/or parity greater than 4; high risk youngchildren are definedas having a low birth weight,or low weightfor age; high-riskpre-schoolers are definedby heightand weight criteria,an illiteratemother, or the headof householdunemployed. 35 Annex 2

20. According to the Fundacidn PAMI, food distributionreached a total of 1,930,147 beneficiaries in 1991, with a total of 17,523,965 kilos of milk and 13,922,094 kilos of LACTOVISOY. Of total recipients, 25 percent were pregnant women, 33 percent were lactatingwomen, and 42 percent were children under six. Distributionof milk and LACTOVISOYis being contracted privately, a system which has been working well so far and has managedto keep overhead low. A recent evaluation of the program estimated that out of a monthlycost-per-beneficiary of approximately$Bs. 889.93 (about US$ 15), direct food costs ran $Bs. 862, or approximately97 percent.-LI

21. Preliminaryevaluations indicate that the PAMI program is doing an excellentjob in both food distributionand in the creation of demand for basic health services. Far less successful, however, has been the ability of the existing health centers to cope with the expansionof demand. Many local health centers are simply non-operational. Those that are functioningoften suffer from inadequate staffing (particularlyof nurses), equipment, and supplies. Beneficiariesmust see a doctor or health professionalbefore receiving their monthlysupply of milk, and there are long waits for appointments. Health service workers in turn complain the decline in quality of care prompted by rapid expansion: in some regions of the -ountry health workers are attendingan average of 12 patients and hour.'" Concerns have also been expressed regarding the provisionof dried milk to children and mothers, should the choice of food distributeddiscourage breast feeding practices.

22. In addition to the PAMI program, several other government 'rograms are directed toward school-age children. These include:

The Beca Alimentaria Program

23. Like the PAMI program the Beca Alimentaria,or Nutritional Grant program, was initiated in 1989 as part of the government's poverty alleviationplan and is run through the Ministry of Education. Despite the name, this is a cash transfer program, designed to aid the families of students attendingpre-schools and elementaryschools located in poor or marginal areas. The program was begun in the poorest states in the country, and by Septemberof 1991, had become operative in all 23 federal entities. In addition to the cash transfers to families, the program now includes the distribution of coupons for purchase of milk and cereals (the Bono Lacteo and the Bono de Cereales). Total beneficiariesfor 1991 consistedof approximately2.3 million students, or about 55 percent of all students attendingpre- and primary schools up to the sixth grade for the same year.2

24. Administrativecosts for the Beca program have been kept low, and are estimated at about 4 percent of total program costs. Indicationsare also that the program is managingto transfer both money and coupons tc. beneficiariesin a timely fashion. No formal evaluationshave been done on either the nutritional impact of the program or the targeting to the poorest families, but the fact that

LQ/Garcia and Levy. "Venezuela: Revisi6nded Programa Alimentario Materno Infantil (PAMI)", 1991, p.2 0 .

.I/ Ibid, p.12.

12/ Garcia, Haydee and Levy, Alberto. "Venezuela: Revision de la Beca Alimentaria". November 1991. 36 Annex 2

55 percent of all children are now covered suggests a substantialamount of "leakage"to families In lesser need of benefits.

The SchoolHealth Program

25. T'hisprogram is run by the MSAS, and aims to provide access to basic medical coverageto school-age children. While nutrition programs run by the NationalInstitute of :;utrition (INN) achieve reasonably good coverageof this age group, the coverage of the health program is estimated to be low.

INN Programs

26. The NationalInstittite of Nutritionruns three major programs oriented to children 7-14 years of age. The School Lunch program provides hot luncliesto primary school children, while the Snack Program provides arepas and other snacks and/or Lactovisoy. Lunches are free to students screened by the school nutritionistat the beginningof the year, and selection is made on the basis of economic factors as well as deflcient growth or anthropomorphicmeasurements. The Glass of Milk program, which in recent years has constitutedapproximately 25 percent of the total INN programs, consists in the provision of free, fresh milk in cartons to all students, regardless of nutritional status.)'

27. As with the Beca Alimentariaprogram, the targeting and nutritionalimpact of INN programs is not sufficientlymonitored or known. In addition, with the exception of the school lunch program, programs tend to be targeted by type of population, rather than by economicor nutritionalcriteria within target groups. Lack of other targeting criteria, in turn, can lead to significant "leakage" of program benefits to those who need them least. Of all INN programs, the least targeted and one of the most inefficientis the Glass of Milk program, because only perhaps 50 percent of milk purchased by the program actually reaches beneficiaries,due to extensivespoilage and diversions. This is also probably the program with the fewest nutritionalbenefits, since the principal nutritionaldeficiency in Venezuela is in calories rather than protein. Nonetheless,the Glass of Milk program continues to be the largest program in terms of beneficiaries,with an expanded target of 2,000,000 school children in 1992. While the greatest contributorto caloric consumptionis the school meal program, it is also the program sviththe highest cost-per-beneficiary: school snack programs, in contrast, provide the greatest nutritionalbenefit per Bolivar.

CONCLUSIONS AND RECOMMENDATIONS

28. Despite the growing importanceof chronic and degenerativediseases in Venezue'.a'shealth profile, child health continues to be an area wh re "old" diseases such as diarrhoea, iiinections,and endemic diseases are taking a heavy toll. Recent patterns of health expenditure have exacerbatedthe situation, as resources have shifted away from basic preventive care and disease control. While overall spendingon nutrition programs is probably sufficientto meet the country's needs, better coordination,targeting, and monitoringof existingprograms is needed.

jl/ Comisi6nPresidencial por los Derechos del Niffo. Programa Nacionalde Acci6n, 1991. 37 Annex 2

29. In health, the PAMI program could represent a major step forward in expanding coverage of basic health services and nutrition monitoringto pregnant and lactating mothers and children under six - a portion of the populationconsidered most at-risk for nutrition-relatedand other illnesses. Nonetheless,many of the planned health aspects of PAMI are lagging behind the food distribution component. Moreover, the explosionof demand for health services resulting from the food distributioncomponent is putting a serious strain on existinghuman resources, equipment, and materials at the level of the health center. The MSAS needs to move quickly on the allocationof resources to this level if the objectivesof the PAMI program are to be achieved.

30. The PAMI program has probably contributedto an increase in routine vaccinations,but as mentioned earlier in the report, the vaccinationprogram is still fraught with problems relating to supplies, work stoppages, and the functioningof the cold chain. A concerted effort in the area of immunization,particularly for measles, is warranted, given an increase in the level of outbreaks in 1991, and the high proportion of children between the ages of one and four who have never had a measles vaccination.

31. The continuingimportance of diarrhea as a cause of child morbidityand mortality also requires increased governmentalattention both on the curative and the preventativeside. Curative- oriented actions should include: 1) increasedavailability of Oral RehydrationSalts; 2) training of health workers in Oral RehydrationTherapy (ORT) and 3) the implantationof Oral RehydrationUnits and communitybased ORT resource people in communitiesand states accordingto epidemiological indicators. Preventiveefforts should encompass 1) increasedinvestment in maintenanceof existing water and sewage systems; 2) an increasedepidemiological focus on the part of MSAS in monitoring sources of illness; 3) increased coordinationwith other agenciesto solve identified problemrs;and 4) promotionof communityeducation centering on basic health and hygiene, and in particular, breast feeding. The recent cholera epidemic in neighboringcountries has fostered the creation of a joint communityeducation project between the MSAS and the Ministryof Education focussing on the preventionof transmissionof food-bornediseases, and it is to be hoped that such efforts also help in the reductionof incidenceof more common forms of diarrhea)A'

32. In nutrition, even more than health, there is a chronic need to improve monitoringsystems and the quality of informationavailable for decision-making. More regular nutrition surveys and investigationinto micronutrientdeficiencies would be useful beginnings. Because of the number of ministries and agenciesinvolved in the study, planning, and execution of nutrition programs (Ministry of Agriculture, Ministry of the Family, Ministry of Education, and Ministry of Health; the Institute FUNDACREDESA,and others), there is also a great need to have a single agency coordinating available information, proposals and decision making related to nutrition. One option would be the re-formulationof the Nacional Instituteof Nutrition (INN) to take on an increasinglypolicy-oriented role.

33. With regard to existing nutritionprograms, improvedtargeting may be based on covering high-risk age groups (childrenunder six and pregnant/lactatingmothers) and/or geographical, economic, or nutritionalcriteria. Once stabilized, for example, the PAMI program is expected to target nutritionalbenefits to a specific group based on additional needs criteria. An up-to-date nutrition survey and a "poverty map" are needed in order to better target many of the school-based

L4/Vio, 1991, p. 15. 38 Annex2 prograisis,since manyof thesedo DOtdiscrimina betweenstudent on additionalneed criteria. School-basedprograms should also be monitoredand eauat on thebais of their oveal efficiency in deliveringnutritional benefits: resourcoscurendy spet on the Gi of Milkprogram, for example,might yield greater benefits if spenton school cb in underserved areas. 34. It shouldbe noted,however, that despitethe impotnce of tageting benefitson nutritional, economic,and efficiencygrounds, nutrition program oftenhave multiplefvnetons. If it is found that a widerdistribution of schoolsnack programs helps keop more childrenin whool, or that use of basic healthservices by pregnantmothers drops off everly whenadditional targeting criteria are applied,then these are considemionsthat policy nake ms also weighin choosingwhich programs deservesupport.

TableA2-1. IWfant,Neo-natal wad Post-neonatal MortaliyRate (deathsper 1000regitered live bhrhs)19M89 Year InfantMortality Neo-natal Post-nonatal 1980 31.7 16.7 IS.0 1981 35.2 16.8 18.4 1982 29.8 16.7 13.1 1983 27.4 15.2 12.3 1984 28.4 IS.7 12.8 1985 26.9 15.3 11.6 1986 25.8 15.3 10.6 1987 24.8 14.5 10.3 1988 22.7 13.8 9.0 1989 24.9 14.6 10.3 Source: MSASStatistics 39 Annex2

TableA2-2 Mnay Cau, oufDat,C drn AgOd tol, 190-88

Cause-SpecificInfant MortalityRates (Per 1,000Live Registered Births) Causeof Death 1980 1981 1982 1983 1984 1985 1986 1987 1988

Hypoxiaand Other Reapiratoy Problems 7.0 6.3 61 5.5 5.9 6.5 6.8 7.0 7.1 Gastroenteritisand Diafrhea 4.4 5S 4.4 3.8 3.8 3.0 3.0 3.0 24 CongenitalAbnormalit 2.3 2.4 25 25 2.7 2.4 2.7 2.6 2.6 Immaturity 1.6 2.0 2.4 2.1 13 1.0 0.9 0.7 0.6 Other Problemsof Newbors 2.6 2.5 2.0 1.8 2.3 2.6 2.5 2.3 2.1 RespiratoryDisease 2.0 3.0 2.0 1.6 1.6 1.6 1.5 1.6 1.3 Septicemia 1.1 1.4 13 1.4 1.5 1.1 0.9 0.8 0.7 Lesionsand other Complicationsof Births 1.4 13 1.1 1.0 1.0 1.2 1.1 1.2 0.9 Injuries(all types) 0.7 0.8 0.8 09 0. 0.9 1.0 0.8 0.8 Meningitis 0.7 09 07 06 0.5 0.5 0.5 0.5 0.4

Sowme. MSASAnnual Statistical Update I

40 Annex2

TableA2-3. PiimaiyCausw of Deatk, Cildren Aged 1 to 4,1980-88

MortalityRate (Per 100,000Children Aged I to 4) Causeof Death 1980 1981 1982 1983 1984 1985 1986 1987 1988

Injuries(all types) 30.2 33.4 32.8 30.5 27.5 23.9 28.2 25.6 24.4 Automobile 10.0 11.9 11.3 124 93 72 07 8.2 8.2 Gastroenteritisand Diarrhea 293 35.3 21.9 19.9 21.6 14.9 15.6 18.9 13.6 Pneumonia 25.2 38.0 24.5 21.2 20.3 18.2 16.0 18.4 15.7 CongenitalAbnormalities 6.7 7.0 6.9 5.5 7.6 6.5 7.9 5.7 8.0 Septicemia 5.7 8.9 6.0 7.0 6.3 5.7 3.2 4.8 2.7 Cancer 7.7 6.3 5.4 5.2 6.3 5.7 5.3 5.0 5.5 Meningitis 5.9 3.1 4.6 3.2 4.5 3.0 3.0 4.0 3.2 Malnutrition 10.3 5.5 5.6 2.8 4.3 4.8 5.0 5.8 5.0 Measles 3.3 15.8 4.0 4.0 3.6 7.7 3.1 3.6 1.9 Heart Disease 3.9 3.7 2.9 3.9 2.7 2.0 1.7 2.2 1.7 Asthma 1.9 3A 4.3 2.9 2.7 2.1 2.7 2.4 2.1

Source: MSASAnnual Statistical Updates 41 Annex2

TableA2-4. PrimaryCausesof Death,Ages 5-14, 1980-88

MortalityRate (Per 100,000Children Aged 5-14) Causeof Death 1980 1981 1982 1983 1984 1985 1986 1987 1988

Injuries(all types) 23.1 215 20.9 19.1 17.6 17.5 18.0 17.1 16.4 AutomobileAccidents 12.0 104 10.7 19.1 8.8 8.2 85 8.4 86 Cancer 4.1 4.9 4.3 4.2 4.1 4.6 4.3 4.6 4.6 Pneumonia 2.8 3.0 2.8 2.A 2.0 2.4 2.3 2.2 2.2 Suicides/Homicides 1.0 0.8 1.1 1.0 1.6 0.9 1.0 0.6 1.5 CongenitalAbnormalities 1.A 1.5 1.9 1.7 1.4 1.8 1.4 1A 1.7 Heart Disease 1A 1.3 1.3 1.7 1.3 1.0 1.0 i.1 1.0 Septicemia 0.6 0.7 1.0 0.9 0.8 0.8 0.6 0.6 0.7 Nephritis 1.1 0.4 0.4 0.6 0.7 0.8 0.7 0.4 0.7 Gastroenteritis/Diarrhea 0.9 0.0 1.0 0.9 0.6 0.7 0.5 0.7 0.7 Meningitis 1.1 0.8 0.8 0.9 0.6 0.7 0.6 0.5 0.7 Anemias 0.8 1.1 0.5 0.5 0.5 0.6 0.6 0.5 0.4 BenignTumors 0.6 0.6 0.7 0.6 0.3 0.5 0.6 0.4 0.4 Cerebral-vascular 0.5 0.6 N.I. N.I. 0.2 0.6 0.5 0.5 0.5

Source: MSASAnnual Statistical Updates 42 Annex 2 Table A2-5. Percent of Low Birth Weight DeliveriesIn Ministry of Health Hospitals, 1989

Percent Low Birth Weight Deliveries a/

Anzoategui 17.7% Apure 41.7 Aragua 20.6 Barinas 6.6 Bolfvar 14.6 Carabobo 19.6 Cojedes 36.7 Falc6n 23.4 Gugrico 12.5 Lara 19.8 Merida 18.2 Miranda 21.1 Monagas 17.4 Nueva Esparta 4.1 Portuguesa 1.1 Sucre 15.2 Tachira 14.5 Trujillo 3.4 Yaracuy 18.6 Zulia 17.0 Zona Metopolitana 10.4 T.F. Amazonas 6.7 T.F. Delta Amacuro N.A.

Total 15.6 a/ Deliveries under 2,500 grams. Note: Based on a total of 383,280 deliveries. Source: MSAS, Maternal-ChildHealth Division 43 Annex2

Table A2-6. Vaccinationsof CWUdrenuwder 1 Year of Age: 1980 - 1990 (Measles,Polio, and TIple Dose)

Target Year PopulationThird Dose Polio Third Doa Triple Meases 1980 493,000 93 55 49 1981 497,270 74 53 43 1982 510,532 75 53 44 1983 514,381 77 S7 42 1984 503,973 67 38 44 1985 502,329 65 62 61 1986 504,278 64 61 49 1987 516,773 61 57 59 1988 527,661 74 56 51 1989 531,549 67 55 S0 1990 534,458 72 63 62

Source: MSAS Statistics. 44 Annex 2

TableA2-7. Neo-natalMortalityRatebyPrimaryCauses, 190-88

Dfaths within 28 Days of Birth Pe- 1,000Live Births Cause of Death 1980 1981 1982 1983 1984 1985 1986 1987 1988

Hypoxia and Other Respiratory Problems 6.9 63 6.0 5.5 5.8 6.5 6.7 6.9 7.1 Other Problems of Newborns 2.5 2.4 1.9 1.8 2.2 2.5 2.4 2.2 2.0 Congenital Abnormalities 1.4 1.5 1.6 1.6 1.8 1.5 1.7 1.6 1.5 Lesions and other complicationsof birth 13 13 0.9 1.0 1.0 1.2 1.1 1.2 0.9 Immaturity 1.6 2.0 2.4 2.0 1.7 '.0 0.9 0.7 0.6 Gastroenterities and Diarrhea 0.5 0.6 0.9 0.6 0.6 u.4 0.4 03 0.2 Septicemia 0.3 0.3 0.5 0.6 0.5 0.4 0.3 0.2 0.2 Respiratory Disease 0.3 0.4 0.3 0.3 0.4 0.4 0.3 0.3 0.3 Injuries 0.1 0.1 0.1 0.2 0.1 0.2 0.2 0.1 0.1 Meningitis 0.1 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1

Source: MSAS Annual StatisticalUpdates 45 Annex 2

Table A2-8. Main Causes ofPost-neonatalMortalit,j 1980-88

Deaths from 28 Days to within 11 Months of Birth Per 1,000Registered Live Births Cause of Death 1980 1981 1982 1983 1984 1985 1986 1987 1988

Enteritis and Diarrhea 3.9 5.2 3.5 3.2 3.2 2.6 2.6 2.6 2.2 Respiratory Disease 1.7 2.7 1.7 1.3 1.3 1.3 1.2 1.3 1.1 Congenital Abnormalities 0.9 0.9 0.9 0.9 0.9 0.9 1.0 1.0 1.1 Septicemia 0.8 1.0 0.8 0.8 1.0 0.8 0.4 0.6 0.5 Accidents 0.6 0.7 0.6 0.7 0.6 0.7 0.3 0.6 0.6 Meningitis 0.6 0.7 0.6 0.5 0.4 0.4 0.6 0.4 0.4 Malnutrition 0.5 0.3 0.3 0.1 0.3 0.3 0.3 0.3 0.3 Other Problems with Newborns 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Measles 0.1 0.3 0.1 0.1 0.1 0.2 0.1 0.1 0.1

Source: MSAS Annual Statistical Updates 46 Annex2

TableA2-9. Mortafityby Ae Groupin Different Countzic4198

Cause-SpecificInfant MortalityRate a/ Cause of Death Venezuela Costa Rica Cuba

InfectiousDisease 332.5 84.8 109.6 Diarrhea 238.7 62.7 47.4 Cancer 3.5 12.3 4.3 Malnutrition-Related 28.5 23.3 0.5 Pneumonia 126.0 145.0 97.4 Injuries 79.0 22.1 44.2 PerinatalHealth Problems 1076.0 661.4 514.6 CongenitalAbnormalities 255.7 392.0 303.0

Cause-SpecificMortality Rate, ChildrenAged 1-4 b/ Cause of Death Venezuela Costa Rica Cuba

InfectiousDisease 23.1 12.2 12.0 Diarrhea 13.5 7.8 2.0 Cancer 4.9 8.1 6.9 Malnutrition-Related 4.9 0.6 0.2 Heart Disease 1.7 2.8 2.5 Pneumonia 16.1 8.1 5.5 Injuries 26.0 16.2 26.4 CongenitalAbnormalities 8.0 14.0 11.8 a. per 100,000registered live births. b. per 100,000members of age group.

Source: Comisi6nPresidencial por los Derechosdel Nifto,Programa Nacional de Accion1991. MSASand Pan-American Health OrganizationStatistical Data 47 Annex2

TableA2-ia Proportionof TotalMortalityFrm ChildrenUnder s, Age Standardized,by State, 1988

State %

Merida 23.0 T.F. Delta Amacuro 223 T.F. Amazonas 22.2 Zulia 21.5 Trujillo 20.7 Bolfvar 18.6 Portuguesa 18.4 Guarico 18.0 Lara 17.9 Distrito Federal 17.4 Tichira 17.4 Yaracuy 17.2 Barinas 17.0 Sucre 16.5 Nueva Esparta 163 Apure 16.0 Cojedes 15.4 Aragua 14.8 Carabobo 14.1 Falc6n 13.8 Miranda 10.5 Anzoitegui 8.8 Monagas 7.0

Source: Comisi6nPresidencial por los Derechbsdel Nifio, ProgramaNacional de Acci6n1991. 49 Annex 3

ANNEX 3

WOMEN'S REPRODUCTIVE HEALTH

1. Women of reproductiveage make up about one-quarterof the Venezuelanpopulation. The major reproductive health needs of this populationencompass care during pregnancy, delivery, and postpartum; prevention and treatmentof cervical cancer and breast cancer, sexually transmitted diseases, and reproductivetract infections; and family planning informationand services. There is little national-levelinformation available to monitor women's reproductivehealth status in Venezuela- information such as the proportion of pregnanciesthat receive prenatal care, the coverage of the populationwith cervical cancer screening, and the quality of and access to family planning services. Ministry of Health service statistics are of uneven quality and in additiononly report a subgroup of the populationthat use Ministry of Health facilities. Many countries rely in part on national household surveys to estimate dermographicdata and to monitor health status, health risks, and health service use. However, very little relevant nationalhousehold survey data were collectedin the decade of the 1980s on health in general and on women's health more sp:cifically in Venezuela. This situation was changed recently by the introductionof the National Household Social Survey which was fielded in late 1991. When analyzed, the results will provide very important benchmark informationon health in Venezuelawhich will be useful for analyzinghealth risks, access to health services, and health indicators.

2. Existing information points to problems in several areas. Cervical c:anceris the number one cause of cancer in women, and much more could be done to detect this conditionearly when long term survival rates following treatmentare virtually 100 percent. The number of adolescent pregnanciesis significant--a=out18 percent of all pregnanciesoccur to women under age 20. Adolescentpregnancies are of concern from a health viewpointbecause adolescentpregnancies tend to be at higher risk for some complications. Prenatal care coverageof adolescentpregnancies and birthweighttend to be lower. Both the quality and coverageof prenatal care for all age groups could be improved in order to decrease the risk of maternal morbidityand mortality and decrease infant mortality. The total fertility rate" has fallen steadily over the past 40 years and was estimated at 3.6 in 1988. Most of this decline is due to increaseduse of contraceptivesand, secondarily, increases in age at first marriage. Nonetheless,family planning services, especiallyfor lower income women, are limited and the range of methodsoffered is narrow. Ministry of Health and Social Assistance (MSAS) facilities do not have steady suppliesof contraceptives. Many users purchase oral contraceptivesin private pharmacies at relativelyhigh prices comparedto internationalprices. This cost could present a prohibitive financial constraintto using family planning for some women. Abortion is one of the major reasons for hospitalizationof womenduring their reproductiveyears, and are a significant source of maternal mortality.

DATA

3. There is little solid informationon women's reproductivehealth status in Venezuela. The Ministry of Health collects service statisticsfro.m ambulatory ce:nters and from hospitals on prenatal

1/ Average number of children born to a woman during her lifetime.

I 0 I SO Annex 3

care, pap smears, and family planning services. The quality of this informationvaries greatly by health facility and its reliability !s not known. In addition to data reliability questions, service statistics reflect health service use only for the populationusing Ministry of Health facilities.

4. In additionto service statistics, vital statistics record births and deaths nationwide. Maternal mortality from vital statistics is underreportedin Venezuela, as it is in almost every country, because the cause of death is often not recognizedas pregnancy-related,or the cause of death is omitted. Birth registration is almost complete in Venezuela, but problems in the timeliness of registrationmake it difficult to interpret birth trends from year to year from civil registries.

5. Apart from service statistics and vital statistics, the other major source of reproductivehealth informationis traditionally from population-basedsurveys. The 1977 National Fertility Survey which was carried out as part of the World Fertility Survey, provides informationabout marriage, fertility, knowledge and use of contraceptivesand well as other maternal child health information. No national-levelfollow up demographicand health surveys were conductedfollowing the 1977 survey.Y The just-completedNational Household Social Survey will be an important source of informationon health in general and maternal-childhealth in particular. The survey is a new initiativeto systematicallycollct informationon living standards. The first round of the survey was carried out in late 1991, and preliminary results are expectedshortly. The survey included questions on sickness and accidents in the last month, use of medical services, pregnancies,prenatal care, live births, child mortality, contraceptiveuse, breastfeeding,oral rehydrationtreatment for childhood diarrhea, vaccinations,participation in the Expanded Maternal Child Health Program (PAMI), distance to health centers. This first round will be followed by subsequentrounds in which different modules can be added or removed. Therefore it can offer an importantpotential source of health informationrelevant to program design, evaluation and policy making.

PRENATALCARE, BIRTH AND POSPARTUM CARE

6. Good t_.lity prenatal care is an essentialpart of maintainingthe health of the mother and fetus, preventing compli-ations, and identifyingand treating high-risk pregnancies. It is difficult to assess the quality and coverageof service delivery in Venezuela. The Ministry of Health estimated that about 26 percent of pregnant women were enrolled in Ministryof Health prenatal care programs in 1989. In the public sector, prenatal care is offered not only at MSAS health centers and outpatient departmentsof hospitals, but also at Instituto Venezolanode Seguro Social (IVSS) ambulatoriesand hospitals and by the Instituto de Previsi6ny AsistenciaSocial del Ministeriode Educacion (IPASME) and other public providers. But MSAS is the largest single provider. MSAS prenatal enrollment is lowest in the states of Aragua, u'le Distrito Federal, Zulia, Lara, and Territorio Federal Delta Amacuro. Of those pregnant women who do seek prenatal care, MSAS estimates that only about one- quarter enroll according to program norms in the first three monthsof the pregnancy. These numbers are difficult to interpret because only a few states have good service statistics on prenatal care. Even less is known about the quality of services provided, such as whether basic diagnostictests are

2/ A householdsurvey was carried out however in Caracas in 1991 that collected informationon women's reproductivehealth status. 51 Annex 3

performed (blood pressu,4 measurement,urinalysis, tests for syphilis, etc.) and whether high risk pregnanciesare adequately treated.

7. Accordingto MSAS statistics, about 94 percent of all births are attended by physicians. This ranges from almost all births in the metropolitanarea of Caracas to much less in states like Apure (see Annex 2, Table A2-S). Low birthweightstatistics sre also collectedby MSAS, but again their reliability is not known. It is also difficult to infer trends from these statistics because the completenessof reporting could vary over time. Accordingto the official statistics, the proportion of low birthweightbabies in Ministry of Health hospitalswas highest in the states of Apure (42 percent), Cojedes (37 percent), and Falcon (23 percent) (see Annex 2, Table A2-4). Rates were reported to be lowest in Portuguesa (1 percent) and Nueva Esparta (4 percent). Both the case of Portuguesa and Nueva Esparta are examplesof poor data qualiy because these numbers are absurdly low. If service statisticswere improved, these indicatorscould be used to monitor infant health over time, because low birthweight is a major risk factor for infant mortalityand morbidity. In the largest maternity hospital in the country, the Hospital MaternidadConcepcion Palacios in Caracas, the proportion of low birthweightbabies increased from a range of 12 to 13 percent over the period 1986 to 1989to 16 percent in 1990. Given the high qual:ty of this hospital's data, this increase of about one-third is a signal of a problem, perhaps reflecting the economic conditionsof the low-incomepopulation in 1989 and early 1990.

8. In part to reduce the risk of poor weight gain of the mother and fetus, and in part to increase the facilitiesand demand for prenatal care, the ExpandedMaternal Child Health Program (PAM!) was initiated in late 1989. It offers two kilos of dried milk2'to pregnant and postnatal women as well as young children in conjunctionwith primary care through health centers. Women receive milk for an average of six months after the birth. In 1991, the PAMI foundation reported that 478,097 pregnant women and 638,878 postnatal(check) women were enrolled in the program.s The program first started in the state of Trujillo in December 1989and was expanded rapidly to other states. In 1992 the program goal is to reach full state coveragethrough expansionto the Distrito Federal, and the remaining states of Miranda and Carabobo and part of Zulia. A total of 1,094 health centers are planned to be covered by the end of 1992. The food supplementationprogram has not been accompaniedby adequate efforts to improve the quality and coverage of primary care in health clinics. This needs to be the major focus of the PAMI program over the short to medium term.

Cesarean Sections

9. Cesarean section deliveries can be a life-savingmeasure in certain circumstances. They can also be used excessively, for example, in cases where they are done for convenienceor because the physician is not prepared to handle complicatedvaginal deliveries. If done unnecessarily,they pose additionalhealth risks and are financiallycosdy. The proportion of cesarean deliveries in Ministry of Health facilitiesis estimated at about 9 percent in 1988. For the purposes of comparison, rates were 10 percent in England and Wales, 8 percent in Belgium, 11 percent in the Netherlands, and 20

l/ In September, 1991the program also introducedlactovisoy.

4/ These numbers could represent double countingof individualwomen, because women could pass from one status to another in a given year. 52 Annex 3

percent in the United States in 1983.Y'Interestingly, rates are more than double in IVSS facilities, and are creeping up slowly. The cesareanrate in IVSS facilities was 17 percent in 1984, and increased each year to 21 percent in 1988. In 1989, reported rates in IVSShospitals varied markedly and beg an explanation. In the metropolitanregion of Caracas, rates varied from about 14 percent in Hospital Luis Salazar Dominguezto 32 percent in Hospital Miguel Perez Carrefio.Y

Maternal Mortality

10. Maternal mortality is usually defined as death while a woman is pregnant or within 42 days followingthe pregnancy, related to or aggravatedby the pregnancy, or by measures taken due to the pregnancy. The maternal mortalityratios presented in Table A3-1 are the official estimates of the number of maternal deaths per 100,000 live births. This ratio is underreportedin all countries, because death certificatesoften fail to note that the woman was pregnant, in childbirth, or had recently given birth. Death certificatesalso often fail to note maternal deaths occurring early in pregnancy. Official estimatesof maternal mortalityare about 55 deaths per 100,000 live births in 1986. In contrast, this ratio averages about 10 in industrializedcountries.

Table AJ-L. Maternal Mortality Ratio al

1982 50.5 1983 54.3 1984 60.8 1985 57.9 1986 54.6 a/ Number of maternal deaths per 100,000 live births. Source: Direcci6nde Planificaci6ny Estatfstic%,MSAS

11. Table A3-2 presents maternal mortalityby cause for 1988. Abortion, sepsis, toxemia, and hemorrhageare major causes of maternal mortality. Risk factors for maternal morbidity and mortalityare presented in Box A3-1. Good quality pregnancy managementis key, as well family planning services to prevent unwanted pregnancies(and therefore reduce the risk of abortion).

Abortion

12. Abortion and obstetric complicationsare the third main cause of death for women aged 15-24, falling into fifth place for women aged 24-44. Abortion is legal in Venezuelaonly if pregnancy threatens the life of the woman. Unsafe abortions are extremely dangerous, and can carry high social and economic costs: mortality, morbidity,long run sequelae, hospitalizationcosts, loss of time at

4/ F.Z. Notzon, P.J. Placek, and S.M. Taffel, "Comparisonof NationalCesarean Section Rates," The New England Jouinal of Medicine, 316, no. 7, February 12, 1987, pp 386-9.

§/ IVSS Statistics 53 Annex 3

work, etc. Because of its illicit nature, it is extremely difficult to estimate the 'Aumberof abortions in Venezuela. Pacheco estimatedthat the total might range from between 210,000 to 270,000 in 1980.2' The most immediateaction that can be taken to reduce the risk of unsafe abortions, short of increasingthe safety of the procedure through easing legal restrictions is to make

Table A3-2. MaternalDeaths by Cause and Age Group, 1988

Deaths, under age 19 or Deaths, ages Cause of Death over age 35 20 to 34 Total Percent

Direct Abortion 17 35 52 19 Toxemia 39 33 72 26 Hemorrhage 19 24 43 15 Sepsis 8 13 21 7 Other Complications 19 52 71 25

Indirect 9 13 22 8

Total 111 170 281 100

Source: Programa Nacional de Acci6n, Comisi6nPresidencial por los Derechos del Niho, Venezuela, December 1991, from Ministry of Health statistics. good quality family planning services widely accessibleto all womenof reproductiveage, including adolescents, women in rural areas, and low incomewomen in order to minimizethe risks of unwanted pregnancies.

FAMILY PLANNING SERVICES

13. Family planning for women who wish to delay or end childbearingis fundamentalto any reproductivehealth program because of the very large health benefits, both for women and young children. The main benefit to women is the reduced risk of morbidityand mortalityfrom pregnancy and childbirth.&'In addition, too many closely spaced births seem to cause "maternaldepletion

7/ Edilberto Pacheco, El Aborto en Venezuela: Problema de Salud Piblica. expresion de la Desigualdad Social, (Caracas: Fondo Editorial Carlos Aponte, 1986).

8/ Most contraceptivemethods also entail health benefits and risks unrelated to contraception. For example, the pill is associatedwith increasedrisk of stroke myocardial infarction, but reduced risk of anemia and ovarian cancer. 54 Annex 3

Box:A3-4 Risk Factors.for Matern Mo bidity d Mortalty

Prepregnancy Dgmggra_h$c -FActo :isk Under.age 2O or over age 34. Low socioeconomicstatus/unmarried. Medical Risk Factors Number of children born.(noneor more than four). Low maternal-weight for-height. Certain diseases such as diabetes and chronie hypertension. Poor obstetric history (includingprevious low birth weight, infant/maternal morbidity, multiple spontaneousabortions, and infertilitytreatment). Gynecologicabnormalities such: as small pelvis,-uterine, ldise;s, tubl scarring secondary to sexually transmitted diseasesand potentally leading.to ectopic pregnancies.

Pregnancy Medical Risk Factors Poor weight gain (of mother and fetus). Anemia/abnormalhemoglobin. Infections includingmalaria, streptococcus(group B), and sexually transmitted diseases such as syphilis, AIDS, gonorrhea, chlamydia, mycoplasma,and herpes. Induced abortion, especiallyif illegally. Ectopic pregnancy. Hypertension/preeclampsialtoxemia. Placental abnormalitiessuch as placenta previa and abruptio placenta. Behavioral and EnvironmentalRhk Eactors. Unwantedpregnancy. Absent or inadequateprenatal care.

Delivery Inadequateobstetric care.

Postpartum Period Inadequatecare for the mother.

Source: Adapted from Walsh et al., "Maternaland Perinatal Health Problems" in kHahlz Sector Priorities Review, The World Bank, Draft, April 1989. 55 Annex 3 syndrome"-a general decline in health and nutritionalstatus. Closely spaced births can also affect the health of young children.

14. The transition from high fertility levels to low fertility levels is well underway in Venezuela. The Oficina Central de Estad(sticase Informatica (OCEI) estimatesthat the total fertility rate fell from about 6.5 births per woman in 1950 to about 3.6 in 1988. Almost of this decline is due to increased use of contraceptionand increases in the age of first marriage.

History of Family Planning Services

15. The introductionof family planning programs in the 1960s and 1970s was at times quite controversial. The first family planning programs in Venezuelastarted in two public hospitals in Caracas in about 1962. Three years later, the Ministry of Health created a division of population and the Congress on Public Health in 1966 resolved that public services should offer family planning. At the end of the 1960s, a group of physicians formed the Asociaci6nVenezolana de Planificacion Familiar (AVPF) which eventually set up 132 service centers throughoutthe country to provide family planning informationand services. AVPF received funding from the InternationalPlanned ParenthoodFederation. There was much controversy in the 1970sover the perception that foreign interests might be promoting 'population control' through AVPF, because of its foreign funding and because of statementsby leaders in other countries about the need for "birth control" in Latin America. The VenezuelanMedical Federation resolved to prohibit physiciansfrom working in family planningunless the program was managed by the public sector. Because of this controversy, AVPF closed in 1976 and transferred its service centers to the public sector. Nongovernmental(NGO) groups did not reappear until the Asociaci6nVenezolana para una Educaci6a Sexual Alternativa (AVESA) was created in 1984.

ContraceptivePrevalence Patterns

16. The most recent national picture of contraceptiveprevalence and patterns is fairly out-of-date- from the 1977 NationalFertility Survey. This survey interviewed4,361 women aged 15-44 years of age. At that time, 46.4 percent of all currently married women in their reproductive years (ages 15- 44) were using contraception(Cable A3-3). As observed in many countries, there were marked differences in prevalence between urban (51 percent) and rural areas (28 percent). Oral contraceptiveswere the most important method, followed by IUDs and sterilization (Table A3-3). About 65 percent of oral contraceptiveusers obtained their supplies directly from the private sector, either from pharmacies or clinics.

Unmet Need

17. Unmet need, defined as women who report not wanting any more children, but who are exposed to the risk of conception(married, in their reproductiveyears, but not using contraception) was estimated at 8.5 percent of all married women. The problem of unmet need was greatest in rural areas (18 percent) versus urban (7 percent). This measure of unmet need can be considered a minimum figure, because it does not includewomen not using contraceptionwho would prefer to space their births. Given the high levels of unmet need in rural areas, the survey results indicate problems with access to family planning services in rural areas in 1977. This percentage of women in need of family planningservices increases with parity (numberof children) and is inversely related 56 Annex 3

to education. Accordingto survey results, the risk of the last pregnancy being unplanned is high in rural areas (37 percent). Unplannedpregnancies are positively associatedwith the mother's age, parity, and is negatively associatedwith educationallevel (Table A3-5).

TableA3-3. Married Women aged 15-44 CurrentlyUsing Contraception, by Residence and Method Used, 1977 (percent)

Method Total Urban Rural

Currently Using Oral Contraceptives 15.3 16.3 10.8 Sterilization 7.7 8.6 3.6 IUD 8.6 9.7 3.6 RJhythm 4.0 4.3 2.9 Condom 4.8 5.6 1.4 Withdrawal 4.7 4.8 4.6 Other Methods a/ 1.3 1.3 1.0 1otal 46.4 50.6 27.8

Not Currently Using 53.6 49.4 72.2

Total 100.0 100.0 100.0

Number of Cases 2,280 1,863 417 a/ Includes injection, diaphragm, and vaginal methods. Source: Calculationsfrom 1977 National Fertility Survey by Centers for Disease Control, Atlanta, Georgia.

Public Family Planning Services

18. The Ministry of Health's family planning program includes the following methods: condoms, oral contraceptives,and IUDs. Sterilization,a major method of family planning throughout the world, is not included in the Ministry's program, although some Ministry facilities offer this procedure. Accordingto Ministry of Health statistics, oral contraceptivesand IUDs are the most common methods supplied. MSAS estimatesthat 13 percent of women of reproductive age were covered by the Ministry's family planning program in 1989. No estimateshave been made of coverage through other public providers and from private providers. National householdsurvey data are needed to get a more representativepicture of contraceptiveprevalence patterns and to identify what groups have the most problems with access to services.

19. The Ministry of Health family planning program has been plagued by irregular supplies, low budgets, lack of trained manpower, lack of equipmentand materials, little outreach and dissemination activity, and poor monitoringand supervision. From 1988 to 1990 the Ministry of Health did not 57 Annex 3 Table A3-4. Source of Oral Contraceptives,by Residence, for Current Users 1977 (percent)

Source Total Urban Rural

Hospital 11.8 10.5 20.0 Health Center 18.6 19.4 13.3 Beneficiencia 2.6 2.9 2.2 IVSS 0.9 1.0 0.0 Private Clinic or Physician 3.2 3.6 0.0 Pharmacy 61.3 60.9 64.4 Other 1.7 2.0 0.0

Total 100.0 100.0 100.0 Number of Cases 349 304 45

Source: Calculationsfrom 1977 National Fertility Survey by Centers for Disease Control, Atlanta, Georgia.

purchase any contraceptives,although the maternal-childhealth progran. Lequestedsupplies. Its only source of supply was the United Nations Fund for PopulationActivities (UNFPA) and national labs which donated pills, IUDs and condoms. These donated supplies did not meet the demand in health centers.

20. The Ministry has established norms for the methodsprovided in the official family planning program. Althoughdemand is high among adolescents,the program norms prohibit the provision of family planningservices to women under the age of 18, unless they are accompaniedby their legal representative. In 1988 according to OCEI, about 18 percent of all births were to adolescents(under age 20). This segment of the populationshould not be ignored in terms of family planning needs. In fact, special outreach programs are needed to reach this subgroup of the population, at risk of high- risk and unwantedpregnancies.

Sterilization

21. Sterilizationis not openly supported as a means of family planning in the Ministry of Health. The code of medical ethics states that procedures to end childbearingpermanently may only be practiced when the pregnancy carries with it a threat against the health of the woman, or when the product of conception would most likely be born with serious deformities. Despite the lack of support in the medical ethics code, sterilization is a very common method in Venezuela. In 1977, it was the third major method, and, if trends in Venezuelaconform to those in many other Latin American countries, it may have risen to second place today. It is popular because it is effective and safe. It is a method that must be guided by well developed clinical norms and patient counseling guidelines as informed consent is extremely importantgiven the permanent nature of the procedure. Despite its exclusion from the family planning program, sterilization is performed at some Ministry of Health facilities, IVSS facilities, and at the Hospital MaternidadConcepci6n Palacios in Caracas, the 58 Annex3 largestmaternity hospital in the country. Accessto this serviceis very uneven. The Hospital MaternidadConcepci6n Palacios offers sterilization postpartum, in conjunctionwith cesarean sections, and "interval"sterilization (done more than six weeksafter delivery). Accessto intervalsterilization is importantso that womenneed not becomepregnant first or undergoa cesareansection in order to be sterilizedto end their childbearing.The HospitalMaternidad Concepcidn Palacios plans to introduceminilaparotomy, done as an outpatientprocedure, soon.

Table A3-5. Planning Status of Most Recent Pregnancy, by Selected Oharacteristicsof Mother, 1977 (percent) Last Pregnancy Characteristic Unplanned

Total 29.6 Residence Urban 27.9 Rural 36.8 Age 15-19 8.5 20-24 17.1 25-29 25.4 30-34 35.4 35-39 40.4 40-44 48.1 Paritya/ 0 7.0 1 6.3 2 13.0 3 30.5 4 37.8 5 44.1 6 56.6 Education None 45.7 Less thanFull Primary 35.3 Primary 26.4 Less than Full Secondary 17.3 Secondaryor more 18.8 a/ Numberof children. Source: Calculationsfrom 1977National Fertility Survey by Centersfor DiseaseControl, Atlanta, Georgia. 59 Annex 3 Private Family Planning Services

22. Family planningservices are also availablefrom nongovernmental,or private sources, includingfor profit and not for profit providers. Private pharmaciesare major sources of contraceptivesupplies, and private clinics and physicians as well as nongovernmentalorganizations such as PLAFAM and AVESA are importantproviders of services.

Pharmacies

23. In 1977, pharmacies were the major source of oral contraceptivesupplies. This probably holds true today as well given the supply problems in Ministry of Health facilities. According to trade data, sales of oral contraceptivestotalled about 4.2 million cycles in 1986, climbingto 6.5 million in 1988 and falling to 5.0 million in 1990. Sales appear to be fairly price and income sensitive. Part of the decline in sales in 1990 could be due to increases in prices: From 1988to 1990, the price of the brand Triquilar increased63 percent in real terms; the price of Nordette increased 54 percent. Price appears to be a major constraintto access to oral contraceptives. Retail prices are relatively high comparedto other Latin American countries such as Brazil. Pharmaceutical imports are restricted if similar production occurs in the country. As a result, currently all oral contraceptivesare manufactured in Venezuela(mixing of imported raw materials, putting into pill form and packaging). There is not strong competitionin supply. Two large companiescontrol about 85 percent of the market, with a third company controllingmost of the remaining 15 percent. High retail prices could be explainedby lack of competitionin supply, and/or by the structure of retail markieting. There is a small black market with productssmuggled from Colombia because of the large price differentials between Venezuela and Colombia. Privatelypurchased oral contraceptives could well be prohibitive in cost to low income women. In 1991 the cost of a cycle of oral contraceptiveswas estimated to range between XX and YYY of a minimummonthly salary. (Mention in Brazil prices as low as 50c per cycle). In order to bring down consumer prices, the governmentcould consider how to best stimulatecompetition in supply. At the same time, subsidized supplies should be available in health centers for very low incomewomen.

NongovernmentalProviders

24. Nongovernmental(NGO) groups active in women's reproductivehealth services are dominated by two groups, AVESA and the Asociacidnde Planificaci6nFamiliar (PLAFAM). AVESA, founded in 1984, supports a wide range of activitiesin the area of reproductivehealth rights. It supports sex education, victims of sexual violence, adolescentreproductive health (unwantedpregnancies, sexually transmitteddiseases, prostitutionand violence). AVESA actively works with other organizations, such as the metropolitanpolice force of Caracas, the Ministry of the Family, and the Universidad Central de Venezuela. AVESA is based in Caracas, and has limited geographiccoverage with its service programs. It has tried to extend its influenceby developing reproductivehealth service models that can serve as a reference for other initiatives.

25. PLAFAM, founded in 1986, is the other major nongovernmentalgroup active in women's reproductive health. It is also based in Caracas, and has as its goal to work in areas where the Ministry of Health is not active. It provides both temporary methods of family planning and male and female sterilization. One dimensionof service quality is the range of method choice provided in family planning. The PLAFAM program is a modelprogram in that regard because it gives couples a wide choice of methods: oral contraceptives,condoms, spermicide, IUDs, diaphragms, male and 60 Annex 3

female sterilization, and natural family planning. Female sterilizationand oral contraceptivesare the most popular methods among PLAFAM's clientele. Of the approximately3,500 new users in 1990 served by PLAFAM, 36 percent chose female sterilization, followedby 24 percent with oral contraceptives,23 percent with IUDs, and 15 percent with condoms. PLAFAM is probably the biggest single provider of sterilizationsin Venezuela,followed by the Hospital Maternidad Concepci6nPalacios and the UniversityHospital of Caracas. About 38 percent of total inflows in 1990 were from user charges. The remainder of funding comes from national foundations, charges for training programs, and intemational donations. PLAFAM plans to expand its operations by opening periphery clinics in the metropolitanarea of Caracas and then later into the interior.

Private Health Insurance

26. Private health insurance policies cover only hospitalization,surgery, and deliveries in Venezuela;they do not cover outpatient services, includingfamily planning. Female sterilization is not covered as well. In order to obtain a sterilization, some women seek cesarean sections, which usually are covered by insurance, in order to obtain a sterilizationat the same time. This distortion in services has both economicand health costs. Cesarean sections are more expensivethan vaginal deliveries. In addition, while not commonlyrecognized, electivecesareans are more risky both for the mother and the baby, and for that reason shouldbe discouraged.2'

Conclusions

27. Much improvementis needed in improvingthe access and quality of services for low income women, either through public provision of services, or through publicly financedprivately provided services. The Ministry of Health family planning program is weak. It offers a limited set of methods, supplies are erratic, outreach activities are almost nonexistent,and program supervisionand evaluation is weak. In addition, the program does not openly support what has become the most popular method world-wide,sterilization. The legal status of sterilizationneeds to be reviewed and decisions made about whether it should be offered openly in official family planning programs, with well developedinformed consent procedures. If male and female sterilizationare to be included, a major training and equipmentprogram would be needed so that vasectomies,postpartum and interval female sterilization could be offered in the appropriate-levelhealth facilities. Supplies in MSAS facilitiesfor such methods as oral contraceptivesare erratic, and most users probably purchase pills at pharmacies as they did at the time of the 1977 National Fertility Survey. The retail price of pills is high in Venezuelaand the price could present a significantfinancial constraint to low income women. There are two main NGO groups that offer family planning in Venezuela, both located in Caracas. Program quality appears to be much higher than in public facilities. While they meet the needs of some low income women, their coverageis limited. Considerationcould be given to publicly- financingan expansion of these two groups' activities in underservedareas. Given the high number of teenage pregnancies, considerationcould also be given to revampingregulations that restrict the access of those under 18 to public family planning services, as well as developingspecial outreach programs for adolescents.

2/ Cesarean section poses two major risks for the newborn, premature interruption of pregnancy as a result of incorrect estimationof gestational age, and greater likelihood of respiratory distress. The mother faces greater risks from the use of anesthesiaand from infection. 61 Annex 3 CERVICAL AND BREASTCANCER

28. Cervical and breast cancers are two of the four leading causes of death from cancer for Venezuelanwomen. Cervical cancer is the leading cause of cancer mortality, followed by stomach (which also affects men), breast, and lung cancer. Lung and stomach cancers are not specific to women, and are discussed in Annex 4. Breast cancer is the most commoncancer in women worldwide, followed by cancers of the cervix and stomach. In Venezuela,however, cervical cancer is the most common cause of death from cancer, because of higher risk factors (such as poverty) and inadequatescreening and treatment programs. There is considerableopportunity for reducing mortality from cervical cancer through increased screening with follow-upservices. Recognizingthis, the Ministry of Health is supportingan aggressive screening program for cervical cancer. With strong support for this program, cervical cancer rates can be expected to drop significantlyover the next 10 years.&' As with cervical cancer, screening for breast cancer is an important control strategy, althoughscreening exams (breast self-examination,examination by medical personnel, and mammography)are less effective than the pap smear and, in the case of mammography,much more expensive.

Cervical Cancer

29. Cervical cancer is the number one cause of cancer among women of reproductiveage because of high risk factors (poverty) and inadequatescreening and treatment programs. Deaths increasedin absolute terms from 771 cases in 1981to 1,075 cases in 1988. Invasive cancer of the cervix is preceded by dysplasia and carcinoma in situ. Both conditionsare detectable for many years and treatable before becoming invasive. The pap test is the establishedscreening method for cervical cancer, and can be provided as part of regular gynecologicalexams, or through special communijy outreach activities.

Cost Effectivenessof Cervical Cancer Screening Programs

30. For middle income countries, WHO recommendstat women between the ages of 35 and 55 years be screened for cervical cancer every five years. Because of the long gestation period for the cancer, when frequency of screening increases to more than every three vears, the cost-effectiveness declines rapidly. Approximatelythe same benefits are achiieved,but at a higher cost. The Ministry of Health has a very active control program. It establish-d a more aggressiveprotocol than the WHO recommendations,with screening every three years after three annual negative pap smears. The target population for this screening is women aged 25 to 64 years of age. Screening is carried out in Rural Health Centers Type II and Urban Health Centers Type I and Il.L'YHospitals also provide this exam. Approximately590,000 pap smears were processed in 1990 by the Ministry of Health or

10/ In industrializedcountries, cervical cancer rates (standardizedfor age structure and population size) dropped about 30 percent from 1960to 1980; much of the decline was due to the widespread use of the pap smear test to screen for cervical cancer.

11/ Rural health centers type 1 serve rural populationsof over 1,000 and are staffed with a physician. Urban health centers type 1 are staffed with general physicians;type 2 also are staffed with specializedphysicians. 62 Annex 3

zbout 15 percent of the target female populationW. Coverage by other public institutionsand the private sector is not known.

31. Physiciansare the only personnel permitted to carry out the pi "mear, although the Medical Federation is reviewing a proposal to permit middle-levelpersonnel to varry out the exam. In order to expand the program further, training programs, material and equipmentpurchase, laboratory capacity and quality, and communityoutreach programs to subgroupsof the populationat highest risk will have to be expanded and improved.

Breast Cancer

32. Breast cancer mortality rates have increasedsteadily over the past decade. Deaths increased from 356 in 1981 to 589 in 1988. The Ministry of Health's breast cancer program goals are to educate women on the importanceof breast self-examination,include physical exams in all gynecologicalconsults, and referral of women in high-risk categoriesly or with breast lumps to more specializedcare. The program is also trying to improve the nationalbreast cancer registry for the purpose of epidemiologicalsurveillance and program desigr and evaluation.

Cost Effectiveness of Screening

33. The effectivenessof breast self-examinationfor reducing mortality has not been well- established,but it appears to have importantadvantages: it is simple, inexpensive, and non-invasive. It encourages women to play a more active role in monitoringtheir own health-an attitude that may have much broader benefits. Physical examinationby medical personnel in combinationwith mammography(x-ray examination)has been shown to reduce breast cancer mortalityby about 20 to 30 percentLY,but at a high cost, as the cost of a mammogramis between US$50 and US$150. As a result, the setting of national guidelinesfor using mammographyto screen asymptomaticwomen and the appropriatefrequency and age group covered remain highly controversial''.

12/ These numbers were approximately570,000 in 1986, 610 in 1987, 590,000 in 1988, and 460,000 in 1989 (Source: OncologyDivision, MSAS). la/ Known risk factors for breast cancer include exposure to radiation, a family history of breast cancer, nulliparity, early menarche and late menopause, and childbearingat older ages. 14/ W. Venet Shapiro et al., "Ten to Fourteen Year Effect of Screening on Breast Cancer Mortality," Journal of the NationalCancer Institute, 69 (1982): 349-355; L. Tabar et al., "Reductionin Breast Cancer Mortalityfrom Breast Cancer after Mass Screening with Mammography," Lance, I (1985): 829-832.

Dj5IIngvar Andersson et al., "MammographicScreening and Mortality from Breast Cancer: The Malmo MammographicScreening Trial," British MedicalJournal, 297,no. 6654 (October 15, 1988): 943-947. 63 Annex 3 SEXUALLY TRANSMITIED DISEASES AND AIDS

34. Sexuallytransmitted diseases (STDs) are serious because they can cause sterility, blindness, brain damage, cancer and even death. Infections during pregnancy can result in premature rupture of the membranes,spontaneous abortion, stillbirth, premature delivery, and low birthweight. An infected mother can pass the infectionto the newborn child, and this infection can produce pneumonia, mental retardation and congenitalanomalies. In addition, there is strong evidencethat STDs that cause lesions or inflammationscan greatly increase the risk of contractingthe AIDS virus, HIV, from sexual contact. The Ministry of Health keeps a registry of sexually transmitteddiseases and AIDS cases in the Departmentof SexuallyTransmitted Diseases. The figures indicate that a global decrease in sexually transmitteddiseases occurred in the 1980s.'J Some of this decline could well be due to changed behavior (greater use of condoms, reduction in general of risky sexual behavior) resultingfrom the fear of contracting AIDS. On the other :tand, the decline or at least a componentof the decline may be completelyillusory, reflecting a number of factors, includinga fall in diagnosticexams, treatmentof cases and follow-upof contactsdue to strikes among physicians, nurses, laboratorytechnicians, public health inspectorsand other workers involved in the S'i'D control program and a lackrof materials for diagnosticexams. Over the period 1988-90, the Department registered approximately55,000 cases each of gonorrhea and non gonoca. A uretbritis, and about 26,000 cases of syphilis as the leading three sexually transmitteddiseases (reported cases refer to men and women). In4idence of chlamydia is not known and t0 diagnostictest is not widely available. Designingcontrol strategies for these diseases, especiall ince many of these diseases produce few symptoms in their early stages, is difficult. It wouldb :.ul to conduct communitysurveys and detailed studies to establishlevels of prevalence and the consequencesof these infectionsin order to design appropriate preventionand treatmentstrategies. AIDS

35. Venezueladoes not appear to have as serious an AIDS problem as many nearby countries. Reported rates in Brazil and many of the Caribbeancountries are much higher. The total number of AIDS cases reported to the World Health Organizationfor Venezuelaas of the end of 1990equalled 1,061. New cases fell from 326 in 1989 to 214 in 1990. Again, this fall could sign.1 an improvementin the AIDS situation in Venezuela,or reflect a fall in the efforts for diagnosis and reporting. It has been clearly shown that many STDs facilitate transmissionof the AIDS virus, HIV, so that STD control is an importantcontrol measure. Thus it is important that STDs and AIDS programs be closely coordinated, as they are in Venezuela. Other interventionsthat are widely recognized as important include educationprograms to encouragefewer sexual partners and safe-sex practices, promotionand distribution of condoms,drug abuse treatment programs and access to clean needles, HIV screening for blood transfusionand the use of clean needles in medical treatment, and the use of multiplecommunication channels for delivering educationalmessages. 27'

16/ Ministryof Health and Social Assistance,Memoria y Cuenta 1990, Republic of Venezuela, PublicationsDepartment, Caracas, Venezuela, 1991, pp 86-93.

17/ Malcolm Potts, Roy Anderson, and Marie-ClaudeBoily, "Slowingthe Spread of Human ImmunodeficiencyVirus in DevelopingCountries," The Lancet, 338 (September7, 1991):pp. 608- 13. 64 Annex 3 RECOMMENDATIONS

36. Access to good quality reproductivehealth services, especially by poor women, is a problem in Venezuela. While impeovingthe coverage of womenwith prenatal care, family planning services, and cervical cancer screening is planned under the PAMI program, implementationof these services has been slow. Strengtheningthis coverageeither through public health centers or through NGOs is an immediatepriority. For prenatal care, coverageneeds to increase, women need to get into prenatal care earlier in their pregnancy, and care needs to include a minimum package of services. Increases in medicallysupervised deliveries should be a priority for states where this is well below the national average. In addition, the governmentcould consider how to expand the range of contraceptivemethods included in its family planningprogram, includingmale and female sterilization, and explore options to bring down the price of contraceptivesin pharmaciesby policies to promote competitionin supply, such as opening up the market for imports.

37. Monitoringand evaluating reproductivehealth status and programs is difficult because of the lack of good quality data. The just-completedNational Household Social Survey will be a valuable source of information. The survey is intendedto be periodic, and modules can be added and removed as needed over time. As health services are decentralized,the Ministry of Health will increasingly restrict its role to regulation, norm setting, and monitoringand evaluation. At present little informationis collectedon programs outside of the Ministry of Health. It is importantfor the Ministry to include within its mandate monitoringaccess to services not just in all levels of the public sector but also in the private sector. 65 Annex 4

ANNEX 4

EMERGING PATTERNS OF MORBIDITY AND MORTALITY IN VENEZUJELA: AN AGENDA FOR CHRONIC DISEASE AND INJURY i-REVENTIONY'

1. Chronic degenerativediseases and injuries were responsiblefor six of the 10 leading causes of death in Venezuela in 1988Y Like many other middle-incomedeveloping countries, Venezuela's epidemiologicalprofile has shifted over the last few decades. While the mortalityrates for pneumonia, enteritis, and peri-natal diseases fell, rates for injuries, cancers, and heart disease increased (Figure A4-1). In large part this shift reflects a host of other changes, including increased urbanization and industrialization,changes in personal behavior patterns (such as smoking), improvementsin sanitation, and declines in both mortality and fertility.

2. The combinedeffect of these changes is a shift in causes of mortalitythat has major consequencesfor the organizationand delivery of health services. Increasingly,the health system is having to meet demands on two fronts: preventionand curative care of infectiousdiseases, particularlythose of childhood, and the rapidly growing importance of chronic diseases and injuries. Given limited resources and growing demands, resourceswill have to carefully targeted to the most cost-effectiveinterventions. This annex examinesthe importanceof chronic diseases and injuries in Venezuela, considersthe effectivenessof governmentand non-governmentprograms aimed at prevention and cure, and makes additionalrecommendations on measures to be taken to meet the growing demands of these problems on the health system.

MORTALITY IN VENEZUELA

Patterns of Mortality in 1988

3. The 10 leading causes of death in Venezuelain 1988 for males and females were in order of importance:heart disease; malignantneoplasms (cancers); injuries; diseases of the peri-natal period; cerebrovasculardisease (stroke); infectiousdiseases such as pneumonias;diabetes; homicide and suicide; enteritis and other diarrheal diseases; and congenitalanomalies (Figure A4-2). These causes

1/ This annex is based on a report by Luis Escobedo(U.S. Departmentof Health and Human Services, Centers for Disease Control), with contributionsfrom Kate Hovde (World Lank) and Michael Dalmat (U.S. Departmentof Health and Human Services, Centers for Disease Control).

2/ The mortalitydata presented in this report are based on statistics availablefrom the Ministry of Health and Social Assistance. Cause of death is based on the internationalclassification of death certificates. In interpreting the annex findings, one should keep in mind that 1) classificationon death certificatescan be highly unreliable even in relatively well-developedsystems; and 2) the international classificationsunderwent a change in 1979, so that changes in rates for any particular cause of death from 1978 to 1979 may in fact reflect this classificationchange. 66 Annex 4

of death and their relative order in Venezuela is similar to that of industrializedcountries, with the notably higher rankir,g of perinatal diseases and diarrheal diseasesY

4. Injuries are an importantdeath for childrenand adolescents. In pre-school age children one to four years of age, injuries are the most common cause of death, although childhood infectious diseases, mainly pneumonia, enteritis, and other diarrheal diseases are also prominentin this age group (Figure A4-3). In children five to fourteen years of age, the importanceof injuries as a cause of death increases. Rates from malignant cancers and childhood diseases are lower in this age group than in younger groups (Figure A4-4). In adolescentsand young adult males and females 15 to 24 years of age, injuries, suicides, and homicidesfigure prominently as the leading causes of death (Figure A4-5).

5. Chronic diseases begin to gain importanceamong adult males and femalesfrom about 25 years of age onwards. Rates of cancer and diseasesof the heart are high enough to be among the 10 leading causes of death for the 25 tQ4 age group (Figure A4-6). However, injuries are the primary cause of mortality; homicidesand suicides rank third. The mortalityrate from chronic diseases figures most prominently for older age groups. In adult males and females 45 to years of age chronic diseases such as heart disease, malignant cancers, and cerebrovasculardiseases, ) are the leadingcauses of death. Injuries, diabetes, cirrhosis of the liver, and suicide and homicide follow (Figure A4-7). Infectiouc'and endemic diseases (pneumoniaand Chagas disease) rank eight and ninth.

6. In adult males and females65 to 74 years of age chronic diseases continue as the leading causes of death (Figure A4-8). Mortality for this age group is similar compared with 45 to 64 year- olds, except for the greater number of deaths in this older age group. Chronic respiratory diseases also become evident among 65 to 74 year-olds (Figure A4-9). Chronic diseases continueto figure prominently in the oldest group (those 75 years of age and older). Deaths from injuries, pneumonia, and Chagas disease occur less often (Figure A4-9).

7. Comparing age-standardizedmortality rates in Venezuelato those in Puerto Rico and the United States, one observes that mortalityrates for cerebrovasculardisease (stroke) and motor vehicle collisionsare higher for Venezuelathan for the other two countries. Mortality rates in Venezuelafor heart disease and suicide, in turn, are slightly lower than in Puerto Rico and the U.S. (Cable A4-2).!'

I/ National Center for Health Statistics. Health. United States. 1990. Hyattsville, Maryland: Public Health Service. 1991.

4/ For this analysis, death certificate data from the Division of StatisticalSystems (of the Ministry of Health in Venezuela), the Office of Health Statistics(of the Ministry of Health in Puerto Rico), and Health. United States. 1990, a publicationof the United States NationalCenter for Health Statistics were analyzed. Mortality rates for Puerto Rico and the United States were standardizedto the age distributionof Venezuelaby the method of direct standardization. 67 Annex 4

Age-Burden of Mortality

8. Much of the burden of mortalityfrom chronic diseases and injuries in Venezuelafalls upon the young and middle-aged (Table A4-1). Age-specificdeath rates from cancer, for example, are relatively low for age group 25-44, (Figure A4-10) but the burden in terms of deaths is still fairly high given the young age structure of the population.

9. Just as mortalityrates from cancers are higher with increasingage, so are mortality rates from heart disease. Wnen the number of heart disease cases are considered by age group, the burden of heart diseases is still higher for older than younger age groups, though less dramatic than when age- specific mortalityrates are compared(Figure A4-11).

10. Mortality rates from injuries are high during childhood and increase slightly with age; these rates are particularly high in the elderly (75+ years of age). The rates vary approximatelybetween 25 and 60 deaths per 100,000population in each age group until 64 years of age. When considering the numbers of deaths by age, however, the burden of deaths from injuries falls largely on adolescents and young adults (Figure A4-12).

11. Homicide is a public health problem among all age groups, though the highest rates are among 15 to 24 and 25 to 44 year-olds. Mortality rates from homicide are also notably high among persons more than 75 years of age (Figure A4-13).

12. Deaths from suicide first become an important cause of death during adolescence, and mortality rates increase slightly with increasingage. As with injuries, when consideringthe number of deaths by age, the greatest number of suicides occur during adolescenceand young adulthood (Figure A4-14).

13. The societal burden of early mortalitycan be estimated by calculatingthe number of ;'potentialyears of life lost" between death and the average life expectancy. Given the high burden of chronic diseases and injuries on younger age groups and the fact that deaths from perinatal disease and diarrhea were also among the 10 leading causes of death in Venezuelain 1988, the current mortality patterns in Venezuelacan be assumed to result in a high rates of "potentialyears lost" for chronic diseases, injuries and perinatal conditions.

Risk Factors and Trends

CardiovascularDiseases

14. Accordingto 1988 data, "heart disease" was the first and "cerebral-vasculardiseases" or stroke, the fifth most important causes of death for the entire population. Both types of diseases can be classifiedwithin the general rubric of "cardiovasculardisease," which comprises a broad range of disorders of the circulatory system. Within Venezuela, "ischemic' diseases are comparativelymore important than hypertensiveones.Y Mor,ality rates for heart disease have remained relatively stable since 1975; there is little reliable informationregarding morbidity for these illnesses in Venezuela, or the cost of cardiovasculardisease-associated hospitalizations.

5/ Ischemic heart disease refers to build up of fatty and fibrous tissue in major arteries. 68 Annex 4

15. Risk factors vary for different types of cardiovasculardisease: Chagas disease, for example, can cause or contribute to one type of heart problem, while personal behavioral traits such as smoking may contribute to anotherY Four of the main types of cardiovasculardisease - coronary heart disease, stroke, peripheral vascular disease and hypertensiveheart disease -- do, however, share many risk factors, among them smoking, a sedentary lifestyle, stress, hypertension, age, gender, and a diet high in saturated fat, sodium, and cholesterol. Some of these, like age, are non-modifiable,while others, like diet or hypertensioncan be altered through a combinationof medical supervision,public education and personal effort. A significantrisk factor for cardiovasculardiseases is diabetes, which in Venezuelahas been climbing in importance as a cause of death from the twenty-secondmost important cause of death in 1955, to the seventh most important in 1988. The current prevalence of diabetes in Venezuelais unknown. However in developed countries the prevalence tends to be about four percent.2'

Cancers

16. Like th- term "cardiovasculardisease", "cancer" is a blanket term for over 100 distinct diseases, all cd iracterizedby an uncontrolledproliferation of cells and invasion of other tissues. In its broad definition, cancer is currently the second leadingcause of death in Venezuela. The Directorshipof Oncologyof the Ministryof Health makes estimateson the incidence of specific cancers based on the number of deaths (from the central cancer registry) and case fatality for that cancer.F' These calculationsshow that the 10 most common cancers (by sex or in both males and females) are, by location and in descendingorder: cervix; stomach; lung, trachea, and bronchial tubes; breast; prostate; colon and rectum; leukemia;lymphoma; liver; and mouth/pharynx(Table A4- 3). The relative importanceof these cancers has been shifting since 1975, with a notable decrease in the mortality rates for stomach cancer, and slight increases in the rates for breast, prostate, lung and tracheal cancer. Despite some fluctuation, mortalityrates for uterine cancers, colon and rectal cancers have been basicallystable.

17. As with cardiovasculardiseases, risk factors vary for different types of cancers. The drop in mortality rates for stomach cancer in Venezuela since 1975 is perhaps related to increased use of refrigeration: consumptionof poorly preserved food is considereda possible risk factor for stomach cancer. Increases in mortality rates for lung and tracheal cancer, on the other hard, are likely due to increasing use of tobacco. The Ministry of Health has sponsoredsurveys to determine the prevalence of cigarette smoking in various populationsettings in Venezuela. These surveys have indicated that the prevalence of smoking (the percentageof the population who smoke) was 38 percent for the country in 1984, 42 percent for Caracas in 1986, 36 percent for Caracas in 1989, and 34 percent for

§/ By "risk factor" we mean a factor (behavioral, environmental,etc.) which research has shown to contribute to the likelihoodof developinga particular disease.

7/ Kuller LH, LaPorte RE, and Orchard TJ, "Diabetes", In: Last JN (ed.) Public Health and Preventive Medicine. Norwalk, Conn.: Appleton, Century-Crofts, 1986.

8/ Capote Negrin Luis G. "Incidenciade cancer en Venezuela". OncologyDirectorate, Ministry of Health and Social Assistance. 69 Annex 4 women of childbearing age for the country in 1987.2' These figures suggest that cigarette smoking is as common in Venezuelaas it is in industrializedcountries. In addition, these data also suggest that smoking is on the decline in Caracas, though smokingappears to be a significant public health problem among women of childbearing age.

18. Several cancers, includingliver and cervical cancer, are associatedwith viruses. In the case of cervical cancer, early sexual activity, multiplepartners, and poor hygiene increase the risk of contractinghuman papilloma virus. The risk of liver cancer (and liver cirrhosis which is a leading cause of death in Venezuelaamong 25-14 year olds), in turn, is increasedby infection with hepatitis B. The seroprevalenceof hepatitis B infectionin Venezuela is 2 percent for the country and 8 percent for Amazon areas, based on data from the country's blood banks.'0 In the earlv 1980s, an outbreak of delta hepatitis occurred among the Yucpa, an indigenousgroup which resides in the Perija Mountainsnear Colombia.W These data indicate that transmissionof hepatitis B (and of the delta agent) is a problem in Venezuela, especially in the Amazonand Andean areas. Recent data gathered by Dr. Dalia Rivero (of the Pan-AmericanHealth Organization)indicate high rates of infection in the regions of Portuguesa, Barinas, Trujillo, and Merida, especially among pregnant women (1.1 percent) and women in Merida (4.8 percent). As a result, various studies (screening, biochemical, epidemiological)and vaccinatioiAprograms have been conductedin select populationsin Venezuela (especiallyamong the newborn and children younger than 10 years of age).

Injuries

19. Injuries are the third most importantcause of death in the population at large, and the leading cause of death from the age of I to 44. Mortality rates for injuries increasedsteadily from 1941 to about 1980, but declined during the 1980s. The determiningfactor in this decline was a drop in mortalitydue to motor vehicle collisions,perhaps due in turn to increased familiarity of the populationwith traffic flow patterns, fewer cars on the road during the economic crisis of the 1980s, and/or success of government and other programs in promotingroad safety. Despite this decline, motor vehicle injuries continue to be the leading cause of death within the category of accidents, followed by drowning, falls, and injuries involvingfirearms.

20. To quantify and compare vehicle density and vehicle-relatedinjuries in Venezuela with that of other countries in the Americas, indicatorsof motorizationand personal and highway risk for death are presented in Table A4-4. The personal risk index is defined as the number of deaths per 100,000 population;the highwayrisk index as the number of deaths per 10,000 vehicles; and the motorization

2/ Centers for Disease Control. Smokingin the Americas--areport of the Surgeon General. Rockville, Maryland: US Departmentof Health and Human Services, Public Health Service, 1991 (in press).

LQ/OH Fay and the Latin American RegionalStudy Group. "HepatitisB in Latin America: epidemiologicalpatterns and eradicationstrategy". Vaccine 8 (supplement);S100-6:1990).

I1/ Hadler SC, et al. Delta Virus Infectionand Severe Hepatitis. Annals of Internal Medicine. 100;339-44:1984. 70 Annex4

index as the number of vehicles per 1,000 population.2 High indices for personal and highway risk suggesta large number of traffic deaths per populationor vehicles, respectively.

21. The indices for Venezuelawere compared with those that have been published r the United States, Chile, Costa Rica, and Colombia. Of these countries, Venezuelahas the highest ih.Oicesof personal and highway risk, and the highest index of motorizationin Latin America (able As ' Beyond these broad indicatorsof risk, there is little informationabout behavioral traits that affect traffic mortality, for example, use of seat belts, compliancewith speed limits, alcohol consumption, and so forth.

Suicide and Homicide

22. Increasingly,both homicide and suicide are being recognizedas public health problems, although perhaps not ones the health system is well-equippedto handle from the standpointof prevention. Both are important causes of death in Venezuela,particularly among teenagers and young adults. Mortalityfrom both causes is also much higher for men than for women.

23. Mortality rates for suicide and homicide registeredslight increases from 1978to 1983, after which they fell slightly and then stabilized. The increase in the mortality rates for 1979, however, coincides with the revision of the InternationalSystem of Classificationof Diseases (ICD), so part of the 1978 to 1983increase may in fact be due to classificaitionchanges. Respiratory Diseases

24. Cause-specificmortality from respiratory diseases changed in Venezuelain the period between 1975 and 1988. Nfortalityrates from pneumoniaand influenzadeclined substantially,whereas mortality rates from chronic respiratory diseases increasedslightly. Although mortality rates from pneumoniaand influenzaare still greater thanthose from chronic respiratory diseases, these differenceshave diminishedappreciably.

AIDS and Cholera

25. Neither of AIDS nor Cholera has yet had an important impact in Venezuelain terms of mortality, but both are potentiallyserious problems and need to be planned for accordingly. The first AIDS case was diagnosed in 1983, and as of the end of 1989 the number of cases had climbed to 715 with 356 deaths.) The bulk of cases were found in the Federal District and more developed states. The prevalence of HIV among specific groups or the populationat large is not known. The cholera epidemic which hit Peru in 1991has slowly been spreadingto the rest of Latin America. Venezuela's first cases were identified in early 1992.

12/ Trinca GW, Johnston IR, Campbell BJ, et al. "Traffic Injury T ' .. In: Trinca GW et. al. (eds.), Reducin"gTraffic Injury: A Global Challenee. Melbourne, Aus.-4!:: A. H. & Massina Co. 1988.

13/ Vio, Fernando. "La SituacionEpidemiologica y Programasdel Sector Salud en 'enezuela". November, 1990, page 21. 71 Annex 4

CURRENT ACTIVITES FOR THE PREVENTION OF CHRONIC DISEASES AND INJURIES IN VENEZUELA

Organizational Structure

26. Within the Ministry of Health, the functions related to the prevention of chronic diseases and injuries subsumed under the General Directorshipof Health are found in the following sub- Directorships: the Directorshipof Oncology, the Directorshipof Epidemiologyand Health Programs, and the Directorshipof Health Promotion. The Directorship of Oncology consistsof an office, an institute, a center, and two divisions (office of administrativeservices, the Luis Razetti Oncology Institute, and the medical care, and teaching and research divisions). Two of the seven divisions in the Directorshipof Epidemiologyand Health Program are devoted to chronic disease preventionand for safety and injury prevention.

27. Other Ministries with functionsrelated to the prevention of chronic diseases and injuries includethe Ministry of Transportationand Communication(for vehicle-relatedinjuries) and the Ministryof the Family (for health promotion). Foundationsand private corporations also carry out programs related to the preventionof chronic diseases and injuries; among these are the ASCARDIO program for cardiovasculardiseases, FESVIAL (for motor vehicle crashes), and oil companies(for occupationalhealth).

Activities for the Prevention of Cardiovascular Diseases

28. The Program for the Control of CardiovascularDiseases was established in 1959, in response to the growing importanceof cardiovasculardisease as a cause of mortality. The Departmentof CardiovascularDisease has about 100 employees, slightlyunder half of whom are cardiologists. A handful of cardiologistswork in the Central Departmentin Caracas, with the rest working in different cardiologyunits in Caracas and elsewhere in Venezuela. The program aims to increase knowledge regarding cardiovasculardisease in Venezuela, reduce those risk-factorsthat are modifiable, and provide adequate treatment to those affected by cardiovasculardiseases. A major focus of program activities are training courses for physiciansand nurses at various levels of care.

29. No systematicevaluation of the cardiovasculardisease control program has been done, but the overall functioninghas been subject to problems affecting the sector as a whole, includingover- centralization,insufficient resources, equipment,and an overemphasison curative care. The program has also been criticized for lack of precision regarding specific objectivesand types of cardiovascular diseases on which to focus.

30. The CardiovascularDisease Departmenthas been quite successful, however, in fostering a number of collaborativeprojects with other private and public institutions, includingthe ASCARDIO program. Plans have also been underwayfor a program to reduce the prevalence of personal lifestyles linked to chronic diseases (mainly cardiovasculardisease and cancer) in Baruta, a communitynear Caracas. This effort is the product of collaborationamong the Division of Chronic Diseases of the Ministry of Health, the Pan-AmericanHealth Organization, and the communityof Baruta through the Mayor's office. This program may stimulatethe creation of expert professionals in chronic disease interventionmethodologies and in identifyingstrategies that are appropriate for Venezuela. 72 Annex 4

BOX A4.1 TIE ASCARDIOPROGRAM

One of the most dynamicVenezuelan examples of a public-privatepartnership in health is the ASCARDIOprogram. ASCARDIOis a not-for-profitfoundation establishedby the Cardiovascular Disease Departmentof the MSAS to serve the state of Lara. Founded in 1976 to help support the growing4demandfor cardiovascularservices and information, ASCARDIOhas grown from an organizatinn of three employeesto an organizationemploying over 310.

Thefoundation provides a wide range of services includingpublic education on health nissu,itpatient cardiology services, rental and maintenanceof cardiology equipment, a private 24-hour ambulance service, laboratory services, and a specializedlibrary. Allservice units within ASCARDIOare considered cost centers and are self-supportingthrough fees'for service. Fees for service are charged on a sliding scale (indigentpatients do not pay), and together with membershipfees, insurance-typefees, and contributionsfrom private industric! make up 85 percent of ASCARDIOs budget. In addition to its service provision functions, the foundation is also engaged in applied research on cardiovasculardisease and behavioral risk factors.

ASCARDIO'ssuccess is attributablein large part to a well-developedadministrative model, which includes the followingbasic precepts:

1) Managementof human resources through careful selection, financial incentive, and sanctions; training of staff to see their functions in support of system objectives;

2) Strong communityparticipation, includingfostering the organizationof health committeesand respondingto communityrequests;

3) Developmentand use of an informationsystem as a basis for decision making;

4) Developmentof activitiesthat integrate health promotionand cardiovasculardisealse prevention; applied research as a means of improvingthe system; and

5) Universal access to the system; cost-recoveryfrom users of the system but services provided free of charge when needed.

National Diabetes Program

31. The National Diabetes Program has a very small staff within the MSAS. Staff responsibilities includepatient care in one of the largest diabetes units in the country, training of healthcareproviders 73 Annex 4

in prevention and early detection of diabetes, and the aggregationof statistics on the disease provided by participating units. In 1990, the program had 16,000 patients enrolled. Between 1975 and 1980, an average of about 3,000 hospital dischargesper year were attributed to diabetics, with an average hospital stay of 21 days.

32. The current strategy of the program is to expand program coverage by establishinga network of diabetes service units throughout the country at primary, secondary, and tertiary levels of care. As of Ap.ril 1991, the program had established29 service units in 14 states, with the distributionof units heavily weighted toward hospitals. In recent years, the program has not been able to buy insulin in sufficient quantitiesto provide it free of charge, and patients are being asked to purchase it as a form of rationing.

Cancer Prevention Activities

33. The OncologyDirectorate of the MSAS was establishedin 1976 and has as its main thrust the secondaryprevention (screening, early detection, and treatment) of cancer patients. There is an Oncologycoordinator in almost every state or sub-region, and the cancer program is implementedin coordinationwith other programs (such as gynecology and pediatrics) at all levels of the health system. The cancer prevention and screening programs concentrateon cervical, breast, stomach, and lung cancers.

Cervical Cancer

34. Given the high incidence of cervical cancer in relation to other cancers, prevention and screening of cervical cancer was designatedas the number one cancer priority in Venezuelain 1987. The goal of the Cervical Cancer program is to screen 80 percent of all women 25-64 years of age who have not had a hysterectomy,are sexually active, and who have not had a Pap smear within the last three years. Pap smears are done at all levels of the health system, and slides are processed at regional cytology laboratories.

35. As of 1990 (three years after the beginningof the campaign), the program estimated having processed pap smears for approximately64 percent of the women eligible for screening accordingto the risk criteria. While this is a remarkable accomplishment,ongoing problems identified include the absence of adequate treatment centers, variable quality of laboratory analysis, and low coverageof high-risk groups (for example, the extremely poor). Coverage under both the cervical and breast cancer screening programs may increase through their linkage with the PAMI nutrition program, although logisticalproblems of equipmentand materials are likely to persist over the short term.A

Breast Cancer

36. The Breast Cancer screening program was establishedin 1976, and has five main components:(1) screening by physical examinationand history by nurses, social workers, and

14/ The PAMI program was initiatedin 1989 as part of the Government's targeted poverty alleviation strategy. PAMI distributesmilk and enriched soy-productsthrough local health centers to pregnant and nursing mothers and children under six, who must be enrolled in health programs in order to receive the food. 74 Annex 4

physiciansduring primary care consultations;(2) referral of suspectedcases to oncologists at the secondary and tertiary ievels of the health system for further testing; (3) community and clinic educationto promote breast self-examination;(4) maintenanceof records and registries for breast cancer that contain certain risk factor, clinical, and pathologicaldata; and (5) training of health personnel to support the above-mentionedactions. Neither coverage nor effect of the program on early detection and mortality rates is known.

Stomach and Other Cancers

37. With respect to cancers of the stomach, prostate, leukemia, colon, and others, secondary preventionstrategies are being developedwithin the contextof the Cancer Screening Project under the Directorshipof Oncology. The goal of this project is to establish cancer screening units in each health district to which women 25 and older and men 35 and older can come for a cancer evaluation (all types). The Directorship of Oncologyhas participatedsince 1983 in a large scale stomach cancer screening program in the state of Tachira, which has the highest rates of stomach cancer in Venezuela. This project has been done in conjunctionwith the governmentof Japan. The Directorship also supports various activitiesin the country for the preventionof cancer, including operation of the central cancer registry in collaborationwith several of the country's hospitals, and narticipationin the country's anti-tobaccocampaign.

Anti-Tobacco Campaign

38. In 1984, the anti-tobaccocampaign in Venezuela was formalizedwith the establishmentof a National Committeeto coordinatetobacco preventionactivities and formulatehealth policies for the preventionof smoking. The committeeconsists of representativesof the Ministries of Health and Social Assistance, Agriculture, Work, Transportationand Communications,Justice, Environment and Natural Resources, Informationand Tourism, and Education; the VenezuelanInstitute of Social Security; the National Academyof Medicine; the AnticancerSociety; and the VenezuelanMedical Federation. The OncologyDirectorate recommendsthat each state or region establish an anti-tobacco coordinatorwho will participate in the Committeeand help implementits guidelinesand directives.

39. Among activitiesundertaken by the NationalAnti-Tobacco Committee have been assessments of the prevalence of smoking in Venezuela, formulationand promotion of anti-smokinglegislation, incorporatinganti-tobacco education into integrated school health education curricula, promotionof restrictions on smoking in the workplace, and investigationof different smokingcessation techniques. The Ministry of Health has also publisheda manual on stoppingsmoking, and cigarette advertisingon television was recently banned by Presidential decree.

Activities for the Prevention of Injuries

40. The prevention of injuries in Venezuela is still in its infancy and lacks adequate resources, infrastructure, information, and administration(national, state, or local) to address this prevention issue effectively. Nonetheless, a small cadre of pioneer professionalsdedicated to injury prevention does exist in the public and private sectors of Venezuela. The Divisionof Safety and Prevention of Injuries of the Ministry of Health was establishedin 1980, and consists of two professionalswho have initiatedefforts to prevent injuries by defining epidemiologicalaspects of injuries in Venezuela. Their work has been the basis for educationalstrategies to prevent injuries in local communities. The primary focus has been on road safety and education, since motor vehicle collisionsare responsible 75 Annex 4

for half of all injury-relateddeaths. On the state level, the program is assistedby regional epidemiologistsand health inspectors.

41. Members of the Road Safety and EducationFoundation (FESVIAL)are also dedicated to preventing car crashes through education and communityaction. FESVIAL was founded in 1987, and received a grant of approximatelyUS$69,000 from the governmentof Venezuelafor the first year of operation. In additionto governmentsupport, the foundationalso receives private contributionsfrom corporations and individuals. The foundation attemptsto increase knowledgeand compliancewith traffic laws by implementingvarious educationalcampaigns for children and adults. They have expended a large portion of their budget in the creation of traffic obedienceclinics for children in an effort to initiate a life-longrespect for traffic laws. FESVIAL relies heavily on volunteer professionals,but due to budget restrictionsit has not been possible for the foundation to expand its activities.

Occupational Health

42. Responsibilityfor occupationalhealth and safety is currently shared between the Venezuelan Institute for Social Security (IVSS), which offers occupationalhealth services, the MSAS, which regulates businesses related to food handling, and the Ministry of Labor. A 1986 Occupational Environmentand AccidentPrevention Law gave the governmentsubstantial purview in regulation and enforcement of safety codes; however, the institutionalarrangements necessary to operationalizethe law have not been implemented.

43. Existingdata suggest that there has been progress made on reducing the frequency and severity of occupationalinjuries and deaths. Accordingto MSASdata, the incidence of occupational injuries fell from 76 injuries per one million person-hoursworked in 1941-1945,to six injuries per one million person-hours worked in 1981-1985. Little is known, however, about existing programs to promote worker safety. The IVSS works with some businesseson a voluntary basis, but is has limited ability to levy fines for businessesthat do not conform to existingcodes. The oil industryhas implementedprograms to ensure occupationalsafety and health for its workers. The Occupational Health Department of LAGOVEN, one of the major oil corporations in Venezuela, coordinates delivery of preventiveand curative medical services, and supports other public health initiatives in the country (such as the anti-tobaccocampaign).

A CHRONIC DISEASE AND INJURY PREVENTION PROGRAM FOR VENEZUELA

General Conclusions

44. Chronic diseases and injuries are increasinglyimportant causes of death and morbidity in Venezuela, affecting a large proportion of the populationat an early age. While Venezueladoes not have data that permit correlation of mortalityto socio-economicstatus, research in other countries also suggests that many of these "new" diseases, like the 'older" infectiousdiseases, disproportionatelyaffect the poor. Disability and loss of life resulting from chronic diseases and injuries represent a heavy economicburden for the country, as well as a financial strain on the public health system. Treatment of cardiovasculardisease, cancers, trauma, and other chronic diseases and 76 Annex 4

injuries tends to be expensive, and is likely a primary reason for the dramatic increases in public sector expenditureson health in countries such as Brazil over the last 20 years.J1'

45. Although Venezuelahas establisheda number of programs to prevent chronic diseases and injuries, strengthening,expanding, and in some cases re-directing the programs is needed if the public health sector is to successfullycope with the growing demands on resources. In order to make such adjustments,policy makers will need both additional informationand a conceptual framework for prioritizing interventions. Successfulimplementation of chronic diseases and injury prevention programs in Venezuelawill also be contingentupon strengtheningthe administrativeinfrastructure of the various governmentagencies involved in deliveringpreventive and curative services. These administrativeissues, however, are discussed in other portions of this report.

Epidemiologic Surveillance and Studies

46. Collectionof epidemiologicdata is the initial step in the surveillanceprocess, from which analysis, interpretation,and public health action follow. Surveillanceof chronic diseases is made difficult by the chronicityand repeat visits associatedwith them. If data are hospital-based,the hospital catchmentarea needs to be defined to calculate rates of morbidity. In addition, failure to consider repeat visits results in artificially high incidence rates associated with these diseases. Because defining the hospital catchmentarea and identifyingrepeat visits can be difficult, Venezuela's current use of existing death certificate data may be a second best alternative to establishinga surveillancesystem for chronic diseases. Nonetheless,the central cancer registry, the existing vehicle-relatedinjury data, and other data-gatheringefforts shouldbe strengthenedto supply reliable morbiditydata.

47. Data about vehicle-relatedinjuries and deaths compiledby the Ministry of Transportation and Communicationscan be a model for gathering data about other injuries such as falls, drownings, homicides, and suicides. Such data can be useful in understandingtime, location, socio-demographic, and other circumstancesassociated with these injuries. Surveillancedata can highlight important characteristicsabout injuries that are useful in planning prevention programs. For example, falls, which have high incidenceand low fatality, may require different interventionstrategies than poisonings,whichx have low incidenceand high fatality, or motor vehicle-relatedinjuries, which have high incidence and fatality.

48. Aside from small-scalecommunity surveys such as those done by the ASCARDIOprogram, little is known about personal risk factors (personal behaviors and lifestyles that are associatedwith a high incidenceof chronic diseases and injuries) in Venezuela. Communityor populationsurveys to determine the prevalence of those personal beikaviorsknown to be associatedwith chronic diseases and injuries (tobaccouse, sedentarism, ingestionof animal fat, nonuse of car seatbelts, etc.) are crucial to targeted preventionstrategies. One mechanismto gather such informationon a larger scale would be to include questionson personal behavior patterns, as well as on morbidity and disability, days lost, out-of-pockethealth expenditures,service use by provider, etc. in the National Household Social Survey. This survey is done on a periodic basis in Venezuela, and data are rapidly available.

15/ Brazil: The New Challenge of Adult Health, 1991, World Bank. 77 Annex 4 49. To better understandbasic determinantsof chronic diseases and injuries and to support programmaticinitiatives, current epidemiologicalstudies and services should be expanded to include important aspects of chronic diseases and injuries. In addition, additional positions for epidemiologistswith experience and interest in chronic diseases and injuries should be availableto study issues related z chronic disease and injury in local communities.

Cost EffectivenessAnalysis and Evaluation

50. While strengthenedepidemiological surveillance is needed to be able to design appropriate preventionprograms, cost-effectivenessanalysis can be useful in evaluatingtrade-offs between different programs and types of interventions. Using this method, econoinic cost (discountedto present value of a given currency) and benefits (also discounted to the present values of a currency) associatedwith a given public health program are calculated. The cost per discountedhealthy life years gained associatedwith various public health programs can then be used as a unit of comparison between programs.

51. Cost effectivenessmethodology was recently used as the basis for a review of the major diseases in developingcountries and the cost and effectivenessof availabletechnologies for their preventionand case management.-L'According to this report, one of the lowest costs per discountedhealthy life year gained was for measles preventionprograms (two to 15 dollars per discounted healthy life year gained dependingupon case fatality rates and the cost of the measles portion of the immunizationprogram), and one of the highest costs was for coronary bypass operations (over $5,000 per discountedhealthy life year gained). Becausethe report is based on cost- data and assumptionsfrom OECD countries, the findingsare not universallytransferrable to Venezuela; however, the overall prioritizationof interventionsis useful, and underlies the recommendationsin this annex (Table A4-5).

52. In addition to determining what interventionsare (theoretically)most cost-effectivein preventing mortality and morbidity, it is also importantto evaluate the efficiency of existing programs. This is an area in which Venezuelashould and could do much r. ore. Although some anecdotal informationabout the chronic disease and injury prevention programs exists, few if any have undergone a thorough evaluadon.

Strategies for Chronic Disease Prevention

53. According to the findings in Disease Control Priorities in Developing CountrWes,one of the mos: cost-effectiveinterventions for lowering the risk of chronic disease is an anti-smokingprogram. Venezuelahas already taken a number of positive steps to limit smoking: the anti-tobaccodrive is perhaps one of the most active in Latin America, and appears to be using a range of strategies to combat the problem. Some limits on cigarette advertisinghave already been imposed;further limits and measures such as package warning labels should be investigated. Sales taxes on cigarettes are usually an effective deterrent, as well as a source of *evenuefor government. Unfortunately,high sales taxes on cigarettes in Venezuelahave led to a recent increase of smugglingof cigarettes into the

16/ Jamison DT and Mosley WH with BobadillaJL and MeashamAR (editors). Disease Control Priorities in Developing Countries. New York: Oxford UniversityPress for the World Bank, forthcoming. 78 Annex 4

country. While the current sales tax may be partially effective in reducing smoking, the loss of revenue from smugglinghas prompted the governmentto consider reducing the tax.

54. A number of companies(notably Lagoven) have taken steps to limit smoking in the workplace. Such policies and local ordinances can be inexpensiveand very effective, as much for their educationalaspect as for their role in limitingthe risks of passive smoking. With the new authority given to municipal governmentsto enact local laws and collect local taxes, encouraging mayors to consider ordinances to prohibit smokingin public and private establishments(schools, restaurants, offices, hospitals, industries, buses, etc.) could be fruitful. On the national level, public education campaignsshould be used to target specific risk groups, such as adolescentsand women of childbearingage. Education campaignsshould involve prominent persons in a range of communities, includingphysicians, politicians, business people, and entertainers. Anti-tobaccoactivities should target different populationsettings (the ,workplace,rural communities,slums, public schools, medical offices, hospitals, etc.). Finally, health professionalsshould be prepared to serve as a model (by not smokingthemselves) as well as to provide smoking cessation services upon request. A checklist of componentsin a national tobacco program with an evaluationof their effectivenessappears in Table A4-6.

55. A second high-priority interventionis screening for cervical cancer in women. Althoughthe Department of Oncologyhas already establishedcervical cancer screening as a top priority, progress still needs to be made on integratingscret .ing services for cervical cancer into the primary care setting, and strengtheninglaboratory and coordinationcapacities to process results of specimens. Cervical cancer screening does fall within the health componentof the PAMI program, which is aimed at expanding the health coverageprovided to pregnant and nursing women and children under six. Efforts should be made to make sure that educationon both cervical and breast cancer and screening of women participating in the PAMI program is done on a routine basis.

56. Given that diabetes is within the top 10 causes of death as well as a contributingfactor to cardiovasculardisease, strengtheningof the diabetes program is warranted. Treatment of insulin- dependent diabetes in particular is consideredreasonably cost-effective. The MSAS should ensure adequate funding for the purchase of insulin, although it may wish recover some of this cost through charging fees on a sliding scale. For non-insulindiabetes, promotinglifestyles that reduce the risk of heart disease (through diet and physical activity) will reduce the risk of complicationsin non-insulin dependentdiabetics. Strengtheningof hepatitis B vaccinationprograms in areas and groups at high risk for hepatitis should also receive high priority.

57. Unless caught at an extremely early stage, treatmentfor stomach cancer is not generally effective. In areas where stomach cancer rates are high, however, screening programs like the one Venezuela has developed in the state of Tachira do make sense. Although risk factors for this cancer are not well known in Venezuela, epidemiologicalstudies in the state of Tachira could provide useful information in the near future. For now, educationon food preparation (to avoid the consumptionof spoiled food) by means of health education, and inspectionand refrigeration of food items may be useful alternatives.

58. Policies at the national and local level need to be articulatedto promote lifestylesthat reduce the likelihoodof heart disease and cancer (promotionof physical activity, reductions in the intake of animal fat and red meat, and promotionof the intake of fruits and vegetables). Nutritional education using radio, print, and television media may be helpful, as well as communitynutrition education 79 Annex 4

through neighborhoodclubs, factories, and,churches. To assess which educationtechnologies are most effective at changinglifestyle in Venezuela,efforts of the Ministry of Health to initiate communityinterventions at the local level should be supported. The interventionsplanned for the communityof Raruta may help to define the most appropriateeducation strategies for Venezuela. Strategies for Injury Prevention

59. Reduction in disalbilityand mortality resultingfrom motor-vehiclerelated injuries needs to be a major public health priority in Venezuela. Findings in this study suggest that motorization, driver/occupantrisk, and highway risk are critically important factors in Venezuelato understanding motor vehicle crashes. Furthermore, the decline in mortality associatedwith motor-vehiclecollisions in the 1980s may have been partly due to increased alternativesto driving (the constructionof the Metro system in Caracas) and the loss of purchasingpower brough, on by the economic crisis. Increases hi the price of gasoline wouldlikely reduce-motor vehicle driving density, and improving the bus transportation system could also help to expand alternativesto driving.

60. Improving the driver's environmentis usually considered a cost-effectivemeans of reducing motor vehicle-relatedinjuries. Basic traffic control signals are few for the number of motor vehicles in Caracas and in nearby highways. Traffic control and law enforcementofficers are also noticeably few for the existing traffic. As a result, traffic patterns are chaotic throughout the city, nearby communities,and major highways. For the moment, basic traffic control and enforcement should have a high priority (Table A4-7).

61. Longer-term legislativestrategies to reduce injuriescould include laws to ensure that children are secured with seatbelts could be imposed, as well as heavy fines for drunk driving and for ignoring traffic laws. In contrast to economic incentivessuch as taxes, legislativestrategies must usually be accompaniedby educationand enforcementto be successful. To establishthese measures, collaborationwith law enforcementofficers, the country's legislators, and independentorganizations such as FESVIAL will be needed. Althoughrelevant data are not availablein Venezuela,research in many countries has also determinedthat alcoholplays a significantrole in motor vehicle-related injuries, falls and other injuries, domesticviolence, and homicide. Increased taxes on the price of alcohol and stricter control on advertisingcould help reduce injuries in these categories. Stricter control of tirearms sales (throughtaxes and regulation)could also reduce the incidence of homicides. 80 Annex 4 Table A4-1. Number of Deaths by Cause and Age, 1988

Number by Cause Age Group Cancer Heart Disease Accidents Suicide

0-4 132 112 911 0 5-14 211 48 754 24 15-24 219 137 1,613 232 25-44 1,236 R35 2,464 330 45-64 3,524 3, 91 1,178 174 65-74 2,318 3,647 426 49 75+ 2,200 6,064 491 34

Source: Data from Central Cancer Registry and MSAS Statistics Division.

Table A4-2. Comparison of Mortality by Selected Causes in Venezuela, Puerto Rico, and the United States, 1988 Standardized on the Age Structure of the Venezuela Population

Age Standardized Deaths per 1.000 inhabitants Cause Venezuela Puerto Rico United States

Heart Disease 79.2 81.5 98.6 Cerebrovascular Disease 28.7 15.2 18.2 Cancer 52.5 53.9 75.9 Traffic Accidents 23.6 17.0 18.5 Suicides 4.5 7.5 9.2 Homicides 8.7 17.4 8.5 81 Annex 4 Table A4-3. Cancer Incidence by Sex and Site, 1988

Rates Type a/ Total bl Men b/ Women b/ Cervical N.A. N.A. 27.8 Stomach 9.0 10.9 7.0 Lungs, Trachea and Bronchial Tubes 7.4 9.7 5.1 Breast 7.2 0.02 14.6 Prostrate N.A. 13.1 N.A. Colon and Rectum 5.0 4.7 5.3 Leukemia 3.8 4.0 3.6 Lymphoma 3.2 3.7 2.7 Liver 3.0 3.2 2.8 Mouth and Pharynx 2.8 3.5 2.0 Larnyx 2.1 3.3 0.8 Skin 2.0 2.0 2.0 Pancreas 1.9 1.9 1.9 Bladder 1.6 2.0 1.3 Kidney 1.5 1.6 1.4 Ovarian N.A. N.A. 3.0 Brain 1.3 1.4 1.1 Gall bladder 1.2 0.6 1.8 Esophagus 1.1 1.4 0.7 Uterine N.A. N.A. 1.8 TIhyroidGland 0.8 u.4 1.3 Bones and Cartilidge 0.7 0.9 0.5 Multiple Melanoma 0.6 0.7 0.6 Testicles N.A. 0.6 N.A. Penile N.A. 0.6 N.A.

N.A.= not applicable a/ In decending order of incidence in the total population. b; Per 100,000population and 100,000men and women, respectively. Source: Data from Central Cancer Registry and Statistics Division,MSAS. 82 Annex4 TableA4-4. PersonalRisk, HighwayRisk,and MotorizationIndex in Venezuelaand Other Countriesin the Americas

Personal Highway Motorization Countrya/ Year Risk b/ Risk c/ Index d/ United States 1985 19.1 2.7 711 Venezuela 1983 30.2 26.0 116 Chile 1983 13.3 17.9 74 Costa Rica 1983 8.2 12.0 68 Colombia 1981 8.9 25.7 35 a. In descendingorder of motorizationindex. b. Personal risk definedas deathsdue to traffic accidentsper 100,000inhabitants. c. Highwayrisk definedas deaths due to traffic accidentsper 10,(iOO vehicles. Autos and commercialvehicles included; motorcycles excluded. d. Motorizationindex defined as vehiclesper 1,000inhabitants. Autos and commerical vehiclesincluded; motorcycles excluded. Source: Data on number of vehiclesin Venezuelafrom the DireccionGeneral Sectorial de TransporteTerrestre. Data on number of deathsin Venezuelafrom StatisticsDivision, MSAS. All other data from Trinca,G.W. et al., 'ReducingTraffic Injury A GlobalChallenge".

TableA4-S. CostEffectivenessof SelectedChronicDiseaseInterventions

Interventionspotentially=ting lessthan US$25per discountedhealthlv life year gained Smokingprevention (antismoking campaigns with tobacco taxes) Interventionspotentially costing between US$75 and $250per discountedhealthly life year gained Publicpreventive campaigns to preventcardiovascular disease (mass education and individual counselingto effectbehavior change, and screeningand referralto those at highrisk) Insulin managementof diabetes(provision of injectedinsulin and health educationfor insulin-dependent diabetics) Medicalmanagement of stableangina Screeningfor cervicalcancer (pap smear) Interventionsprobably costing over $250per discountedhealthly life year gained Medicalmanagement of hypertension Medicalmanagement of hypercholesterolemia Source: Dean T. Jamisonand W. HenryMosley with Jose Luis Bobadillaand AnthonyR. Measham(editors), Disease Control Priorities in DevelopingCountries. New York: OxfordUniversity Press for the WorldBank, forthcoming. 83 Annex 4 Table A4-6. Sample Components of a National Tobacco Control Program Approxmate Effect and Cast

Effectiveness a/ Costs b/ Legislation and Restrictive Measures - Increasing taxation on tobacco + ++ $ products and other economic measures

- Ban on tobacco advertising ++ +

- Placing of health warnings on tobacco + $ product packages and advertisements

- Protecting the rights of nonsmokers + + $ (e.g., public transport, restaurants, worksite)

- Protecting minors + + $

Education and Information - Informingleaders and key social groups ++ S about the extent of the *'baccot -'ilem and what should be done

- Encouragingmedical personnel and public * + + S figures to take leadership roles

- Encouraging the public especially school children +++ SSS never to adapt tobacco habit

- Encouraging people who use tobacco to stop + SSS or at least decrease use

- Encouraging workers in high-risk industries ++ $$ and pregnant women to stop any tobacco habit

National Program Organization - Establishing a national agency specially + + SS responsible for planning and coordinating the program a. + Marginally effective, + + moderately effective, + + + very effective b. $ Relatively inexpensive,SS moderately expensive, $$S requires considerable expense (costs are determined from the point of view of an agency charged with planning and running a national tobacco control program).

Source: Adapted from: Stanley, Kenneth, 'Control of Tobacco Production and Use" in Jamison, D.T. and Mosely, W.H. with Bobadilla, JL and Measham, A.R. (eds.) Disease Control Priorities in Developing Countries, New York: Oxford University Press for the World Bank, forthcoming. Table A4- . SampleProgram Priorities for Controlof InjuryDue to Motor VehicleCollisions Phase SampleIntervention Priorityin termsof: Overall __._._. Impact AcceptabilityFeasibility Cost Prioriq * Adopt the 1975UN guidelinesfor the issue and vailidityof driving + + + + + + + + 3 permits,with periodic visual screening of drivers. PRE- * Initiate vehicle registration requirements,with F odic inspection + + ++ EVENT for safetyfeatures. + + + + 3 * limit dangerous vehicles(e.g. motorcyclesover 250 c.c.) through +++ .+.++. +.+ + taxationor importrestrictions. + +.+ + + 2 * Control imports of vehiclesto require padded dashboards, anti- + + + + + + + + I lacerativewindshields. + + + + + + + + I

* Establishamd enforcespeed limits. ++++ ++ +++ ++ 2 * Identify and improve "blackspotsor hazards;divide highways. + + + + + + + + + + + + + + 1 * Create pedestrian and bicycle-segregated traffic areas. + ++ + + + + + + ++ 3 ' Modifyroadways through towns to ensure slowingof traffic. + + + + ++ + + + + EVENT * Improve roadside lighting. 3 ++ ++++ + + * Mandate and enforce the use 4 of seatbelts and child restraint ++ + + +.+ + + + systemsin passengervehicles. + +.+ 2 * Mandate and enforce the useof crash helmets and daytime ++++ +++ +++ headlightsfor motorcycles. +++ 2

* Provide basi: emergencycare training for police, public tansport ++ + + +.+ + +.+ + + +.+ + 2 driversand otherslikely to be first at scene. * Train primary health cre workers in injury diagnosis and primary ++ + + +.+.+.++ + + +.+ + 1 POSIT- management,includiPg use of localmaterials for collars,splints EVENT and stretchers. * Coordinate local communicationsand transport resources to + + + + + + + ++ + + + 2 provideemergency transport to traumacenters. * Regionalize and upgrade trauma care in urban centers. +++ ++.+ + +.+ + + 2 * Improve or develop community- based rehabilitation services, ++ + + +.+ +.+ +.+ + +++ 2 includingtraining and referral resources at regional trauma centers.

Notes: 1 HighestPriority, + + + + Highest,++ + High,++ Medium,+ Lowest Source: Stanfield,Smith, and McGreevey, lInjuries"in Jamison, D.T. and MoselyW.H. with Bobadilla,J.L and Measham, DiseaseControl Priorities in Developing A.R. (eds.) Countries. NewYork: OxfordUniversity Press for the WorldBank, forthcoming. 85 Annex 4 EYgureA4-1. Leading Causesof Death,Selected Years

120

100 _

1980 1- X 11941 180~~~~~~~~~~~~~~~~~~~~~~~~~181961 ~~~~~~~~~~~198S ~60-

I ~~~~~~~~901961

1 AL1i980gl 40

Oastmeutcgids Perinala MonaLity Pneumonia Hemt Deas Im"uu Camer

Source: Ronald Evaws "Notas Sobre el Pasado el Presente y el Futuro de la Acci6n Sanitaria en Venezuela" from Ministry of Health Data 86 Annex 4 FigureA4-2. 1OLeadingCaUSS of Death, 1988

90

80 _ Heat Disease(79)

70-

0 X | 1 Cancer(53)

a'50 Injuries(42)

4nv _2 _~~~~~~~~Fe4nW

Problet4 _ - (30) Cfreb,rova (29)

20 - ~~~~~~~~~~~~~~~Pneumonoia(16) SUId. aNW Diabetes (14) Ho (icide1d iarbea- Cani

10 Related (10) Ab1o_o_ai_es(9)

0L Source: Ministry of Health and SocialAssistance, Statistics Division

Figure A4-3. 1OLeading Causes of Death, Children Aged 1-4, 1988

30

23 Iijunies(24)

20

0A M Prseumonia(16) Diafrbea Related (14)

A ~~~~~~~~~~~~Abmoomalities(6) Caaoer(6) Malauteidon(S)

Meningitis(3) septimmia(3) o*A. PsnAsthma(2) h

0 Source. Ministryof Health and SocialAssistance, Statistics Division ff~~~~~e >g P W F t. t Deo Rne ProO, Popuat

I~~ I# l i

0 0,

II .. .._ 88 Annex 4 FigureA4-6. 1OLeading Causes of Death forAge Group 25-44,1988 60.

SO_ Injuries(49)

(40

B30- Cacer (25) Suicie md

Homcide (2' 20 _- HeartDiwsea (17)

10 _ 10 - - - VUSOUlarCerebro-(8) ~~~~~~~~~~~~~Abortionand Obeteric __mplicaLtio (4) Pneumonia(4) Cfrrois (4) Duabetes (3) Nephirtis (3)

0 Source: Ministry of Health and Social Assistance, Statistics Division

FigureA4-7. 1OLeadingCausesofDeathforAgeGroup45-64,1988 210

2m -HewtDiseae(192)

Cancr (170)

a._

A ~~~~~~~~~Cerebro-

so Diabetes(44)

C 1 ~Suicideand cliaasu Homicide(17) PoemHonat(15) Soc(12) NepAstlnI (0)

Sou4rce: Ministryof Health and SocialAssistance, Statistics Division 89 Annex 4 FigureA4-8. IOLeading Causes of Death forAge Group 65-74, 1988

900

Heart Disease(806)

700

iF CCncer(512)

1400 2s00_ rG00 Cetmbro- W30 vasCuar(273)

C

Source: MinistryofHelhand Social Assistance, Statistics -D-visionI.

Figure A4-9. 10OLeadingCause of Death for Aged Group 75 and above, 1988

Heart Diseaue(2,625)

ev ccl(1,091)_ C9).hrni

So _ l _ Pneumonia Cktis(62 Disease(56)Dis 53)Nephrneumonia(502) _l ~~~~~~~Diabetes(339) Chronic _ _ _ _ In 1) (177) l~~~~~~~~~~~~~~endion (108) Disease(103)

0 Soure: Ministry of Health and Social Assistance, Statistics Division ~~I DI wI I lo S

I- II

_S D ;E~~~~~~~~~~~~~~~~~~~~m

e + I v 91 Annex 4 FigureA4-12. AfortalityRatesfrom InjtwriesbyAge Group,1988

250

200 ISO

ASoo

Iso

Source: Mfinistryof Health and Social Assistance, Statistics Division

S FigureA4 -13. MortalityRates from Homicideby Age Groups,1988

20

- o

0-4 5-14 15-24 2S-44 43-64 6-475+ Source: Ministry of Health and Social Assistance, Statistics Division 92 Annex 4 FigureA4-14. MortalityRatesfrom Suicideby Age Groups,1988

20

l.. 10 s

0 f l d a S 5 - source. Ministry of Health and Social Assistance, Statistics Division 93 Annex 4

BIBLIOGRAPHY

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AntonovskyA. 1967. Social Class. Life Expectancyand Overall Mortality. Milbank Mem Fund Q 45:31-73. Bailar J, Smith E. 1986. "Progress Against Cancer?" NEIM. 314:1227. Bale GS, Entmacher PS. 1977. "ExpectedLife Expectancyof Diabetics." Diabetes. 26:434-8. Black D, Smith C, Townsend P. 1982. Inequalitiesand Health: The Black Report. New York: Penguin Bools, p. 67. Bray GA. 1979. "Obesity in America: An Overviewof the Second Fogarty InternationalCen.er Conference on Obesity." InternaticnalJournal of Obesity. 3:363-75. Capote Negrin Luis G. "Incidenciade Cancer en Venezuela." Direccion de Oncologia. Castelli WP et al. Circulation 1977. HDL Cholesteroland Other Lipids in Coronary Heart Disease: The CooperativeLipoprotein PhenotypingStudy. 55:767-72. Centers for Disease Control. 1991. Smokingin the Americas-a Report of the Surgeon General. US Departmentof Health and Human Services, Public Health Service, Rockville, Maryland. (in press). Centers for Disease Control. 1988. "Trends in Years of Potential Life Lost Due to Infant Mortalityand Perinatal Conditions, 1980-1983and 1984-1985." MMWR. 37: 249-50, 255-6. Centerwall BS. 1984. "Race, Socioecononic Status, and Domestic Homicide." Atlqnta, 1971-72. A,JPH. 74:813-5. Chorba TL, Reinfurt D, Hulka BS. 1988. "Efficacy of MandatorySeat Belt Use Legislation: The North Carolina Experience from 1983 through 1987." JAMA. 260:3593-7. Dawber TR. 1980. The FraminghamStudy. Cambridge: Harvard U. Press. Epstein AM, Stem RS, Weissman JS. 1990. "Do the Poor Cost More? A MultihospitalStudy of Patient's SocioeconomicStatus and Use of Hospital Resources." NEJM. 322:1122-8. Evans L. 1986. "The Effectivenessof Seat Belts in PreventingFatalities." Accid Anal Prtv. 18:22941. Evans R. 1989. Notas Sobre El Pasado, El Presente y El Futuro de la Accion Sanitaria en Venezuela. Edicion FundacionGual y Espana Farquhar JW et al. 1985. "The StanfordFive-city Project: Design and Methods." American Journal of Epidemology. 122:323-34. Farquhar JW. 1978. "The Community-basedModel of Life Style InterventionTrials." American Journal of Epidemology. 108:103-111. Fay, OH and the Latin AmericanRegional Study Group. 1990. "Hepatitis B in Latin America: EpidemiologicalPatterns and EradicationStrategy." Vaccine 8 (supplement!.S100-6. Fortmann SP et al. 1982. Does Dietary Health EducationReach Only the Privileged? 66:77-82. Fortmann SP, et al. 1986. "CommunitySurveillance of CardiovascularDiseases in the Stanford Five-City Project: Methods and Initial Experience". AmericanJournal of Epidemology. 123:656-69. Hadler SC, et al. 1984. "Delta Virus Infectionand Severe Hepatitis." Annals of Internal Medicine. 100;339-44. Hubert HB et al. Circulation 1983. Obesity as an IndependentRisk Factor for Cardiovascular 94 Annex 4

Disease: A 26-year Follow-upof Pricipats in the Fringham Heat Study." 67:968-77. Jamison DT and Mosley WH with BobadillaJL and Measham AR (editors). Disese Cont1rQ Priorities in Developing Countries. New York: Oxford University Press for the World Bank, forthcoming. Kannel WB, Sorlie P. 1979. "Some Health Benefitsof Physical Activity: The FraminghamStudy." Arch Int Med. 139:857-61. Kannel WB. 1983. "Chapter 1: An overviewof the Risk Factors for CardiovascularDisease." Kaplan NM and Stamler J (eds.): Prevention of Coronary Heart Disease. WB Saunders, Philadelphia,PA. Kircher T, Nelson J, Burdo H. 1985. "The Autopsy as a Measure of Accuracy of the Death Certificate." NEJIM. 313:1263-9. McKeown T. 1973. The Modern Rise of Ponulation. New York, Wiley. Ministeriode Transporte y Comunicaciones.1987. Resumen Estadistico. Murray DM et al. 1986. "SystematicRisk Factor Screeningand Education: A community-wide Approach to Prevention of Coronary Heart Disease." Preventive Medicine. 15:661-72. NationalCenter for Health Statistics. 1990. Health 1991. Public Health Service. Hyattsville, Maryland, USA. NationalPublic Health Laboratoryof Finland. 1981. CommunilyControl of Cardiovascular Dismes. World Health OrganizationRegional Office for Europe, Copenhagen. Nieman D. The Sports MedicineFitness Course. Bull PublishingCompany, Palo Alto, Calif. Omran AR. 1980. "EpidemiologicTransition in the United States: The Health Factor in PopulationChange." Po2ulationBulletin 32:1-44. RobertsonLS. 1977. "Motor-vehicleInjuries: Causes and amelioration." Public Health Reviews 6:25-35. StansfieldSK, Smith GS, McGreeveyW. "Injury." JamisonDT. MosleyWH. (eds), Disease Control Priorities in DevelopingCountries. Population, Health and Nutrition Division, The World Bank). Syme SL, Berkman LF. 1976. "Social Class, Susceptibilityand Sickness." AmericanJournal of Epidemology. 104:1-8. Trinca GW, Johnston IR, Campbel BJ, et al. 1988. "Traffic Injury Today." Trinca GW eL..L (eds.). Reducing Traffic Iniury: A Global Challenge. Melbourne, Australia: A. H. & Massina Co. Voller R, Strong WB. 1981. "PediatricAspects of Atherosclerosis." American Heart Journal. 101:87. Wilson PW, McGee DL, Kannel WB. 1981. "Obesity, Very Low density Lipoproteins, and Glucose Intolerance Over Fourteen Years: The FraminghamStudy." AmericanJournal of EpVdemology.114:697-704. World Bank. 1991. Brazil: The New Challengeof Adult Health. World Health Organization. 1974. Suicideand AttemptedSuicide. Geneva. WHO Public Health Parers. No. 58). World Health Organization. 1982, 1983, 1984. World Health StatisticsAnnual. Geneva. 95 Annex 5

ANNEX S

HEALTH FINANCING1 '

1. The health system in Venezuelais largely a public system: about 77 percent of all hospital beds are public, and about 74 percent of all physicians work for public providers. Public health spendingis highly centralizedat the federal level, through the Ministry of Health and Social Assistance(MSAS) and the VenezuelanSocial Security Institute (IVSS). This concentrationof spendingfeeds a highly centralizedhealth services system that lacks appropriate incentivesfor the delivery of efficient high quality services. There is little or no link of financingto production, and accountabilityby providers on cost and quality is low. The allocationof public resources has neglected several highly cost-effectivehealth interventions. The public system also appears to be inequitable. Per capita spending on health varies widely by state. Private spending does not appear to compensatefor this variation.

2. Households,government (in terms of privately-providedhealth benefits for public employees) and private companiesare the main sources of financing for the smaller private sector. Most private sector providers (hospitals and clinics) are organizedon a for-profit basis. The health insurance sector appears to be dynamic, growing rapidly (albeit from a small base) throughout the 1980s. Private health insurance and private providers have the potential to serve as a significantsource of growth in the hiealthsector over the mediumto long term.

3. Public financing for health is highly dependenton oil revenues and, as a result, is unstable. The contraction in the Venezuelaneconomy in the 1980s was accompaniedby a significantdrop in public spendingper capita on health. Data are lacking on private spending on health, but private financing probably did not increase sufficientlyto compensatefor the drop in public spending. Spending cuts did not affect all program categories and types of expendituresequally. Social security health spendingfell less than Ministryof Health spending. Within the Ministry of Health, its support to autonomousinstitutes was relativelymore protected than expendituresfor directly administered programs. By the end of the decade, total public resources allocated to health were low in absolute terms-amounting to about 1.2 percent of GDP.

4. This annex reviews public and private health financing trends over the 1980s, and examines resource allocation, efficiency, and equity aspects of the health system. As the epidemiological profile changes (with a greater disease burden from chronic and degenerativediseases) and incomes grow, demands on health services can be expected to increase. Major efforts are needed to: (1) improve low incomegroups' access to health care, (2) increase allocativeefficiency by directing more resources to neglected, but highly cost effective interventions,and (3) improve technicalefficiency of the production of health services. In tandem with improvingallocative and technical efficiency, considerationshould be given to increasingthe sources of financing for health care beyond the federal

1/ This annex draws heavily from Haydee Garcia, "ComportamientoFinanciero del Sector Piblico de Salud," Caracas, November, 1991. 96 Annex 5

government, includingsuch means as user fees, private insurance, and municipal and state governmentrevenues.

AVAILABLE DATA ON HEALTH EXPENDITURES

5. There are two main sources of informationon health financing: the Central Bank of Venezuelaand the Central Budget Office (OCEPRE). Neither data source makes estimates of private spending. The Central Bank defines the category "health" as health services delivered directly by public health facilities. It exc'ldes programs directed at environmentalhealth and support to institutionsunder the Ministry of Health that are not directly related to health services.

6. The methodologyused by OCEPREdiffers from that used by the Central Bank. OCEPRE calculates expenditureson health made by a heterogenousmix of institutions, including all of the autonomousinstitutes of the Ministry of Health, whether they provide health services or not. However, OCE!PREdoes not include social security health expendituresmade by IVSS. These expendituresfall under their budget category "social security." Public sector expenditureson health insurance for public sector employeesalso do not appear in the "health" account in OCEPREdata. Instead, these expendituresappear under personnel expenditures.

7. OCEPRE enumerationspresent other peculiaritiesthat make any financial analysis difficult. First, data on personnel expendituresare presented for "budgeted" not "actual" positions. There is no way to determine the actual number of employeesfrom the budget. Second, salary expendituresare not consolidatedin the budget, but are divided under several categories. These include "General Services" for negotiatedsalary increases, "CollectiveContracts", and each program in the "Personnel Expenditure" category. The dispersionin salary informationmakes it difficult to determine how much each program spends in salary costs. In addition, there are categories such as "transfers" and "financialdisbursements," sometimes quite substantial, that do not detail well the uses of funds.

8. Data on IVSS health expendituresare also difficult to interpret. Expendituresare reported from published accounts of the use of their three funds: Administration,Medical Assistance, and Pensions. However, the AdministrationFund provides support to health services (investmentand operating expenses)that cannot be disaggregatedfrom the published data. Thus, one cannot establish the total expenditureson health from IVSS.

9. Good data on private expenditureson health are not available. The national account data do not estimate total (public and private) spending on health, and national household surveys have not generated this information. Data are availableon total spendingfor private health insurance, which is a significant componentof private spendingon health. The other componentsfor which data do not exist include direct payments by individualsfor drugs and health services, and direct payments by companiesfor drugs and health services.

EVOLUTIONOF PUBLICEXPENDITURES OVER TIME

10. Public resources for health fell dramaticallyover the 1980s. Accordingto the Central Bank of Venezuela, consolidatedpublic spendingon health fell in real terms by about 55 percent per capita 97 Annex 5

over the period 1983 to 1990. In absolute terms, the fall was from about US$112 per capita in 1983 to US$49 per capita (1991 dollars) in 19901 The Central Bank estimatesthat overall public spending on health amounted to about 1.2 percent of GDP in 1989. Most of this spending was at the federal level, accountingfor 85 to 90 percent of all public spending between the central government and IVSS (Table A5-1). The high concentrationof financingat the federal level is accompaniedby a highly centralized organizationof health services.

Table A5-1. Public Spending on Health, byLevel of Governments 1983-90 (1984 & per capita)

Level of Government 1983 1984 1985 1988 1989 1990

Total 564.1 500.0 512.1 274.8 249.0 253.4 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Central Government a/ 262.9 244.2 246.9 101.9 115.5 104.2 46.6% 48.8% 48.2% 37.1% 46.4% 41.1% Social Security 176.4 143.0 144.7 127.1 104.3 124.1 31.3% 28.6% 28.3% 46.3% 41.9% 49.0% Decentralized bi 71.6 58.7 61.4 35.4 21.6 18.6 12.7% 11.7% 12.0% 12.9% 8.7% 7.3% Regional Government 37.4 40.1 43.7 6.6 4.9 4.6 6.6% 8.0% 8.5% 2.4% 2.0% 1.8% Municipal Government 15.8 14.0 15.4 3.8 2.6 1.9 2.8% 2.8% 3.0% 1.4% 1.0% 0.7%

1991 US$ per capita level of Government 1983 1984 1985 1988 1989 1990

Total $112.8 $100.0 $102.4 $54.9 $49.8 $50.7 Central Government a/ $52.6 $48.8 $49.4 $20.4 $23.1 $20.8 Social Security $35.3 $28.6 $28.9 $25.4 $20.8 $24.8 Decentralized b/ $14.3 $11.7 $12.3 $7.1 $4.3 $3.7 Regional Government $7.5 $8.0 $8.7 $1.3 $1.0 $0.9 Municipal Government $3.2 $2.8 $3.1 $0.8 $0.5 $0.4

a. Excludes MSAS spending on environmental sanitation. b. Includes MSAS transfers to institutes and foundations.

Source: Haydee Garcia, "Comportamiento Financiero del Sector Publico de Salud," November, 1991, from Banco Central de Venezuela and Anuario de Cuentas Nacionales.

Z/ These data are incomplete,because they do not include all of the Ministry of Health expenditures for autonomousinstitutes. However, they are useful in analyzingtrends. 98 Annex 5

11. At the central level, the Ministry of Health and IVSS are the two largest financiers of health services (Table A5-2). The Ministry of Health is funded by general revenue, and the IVSS is funded by payroll taxes. Minhstryof Health spending is more than double that of the IVSS Medical AssistanceFund. Over the decade, NVSSfunding for medical services was more stable year-to-year than Ministry of Health funding, in part because the MedicalAssistance Fund has the option of running a deficit (drawingon other funds). At the same time, the proportion of the Ministry of Health budget for its autonomousinstitutes grew significantlyfrom only 18 percent in 1980 to 37 percent in 1990. Ministry of Health sriendingon direct administration,which includes all health services, declined by 24 percent in real terms over the decade. Most of the decline was over the period 1988 to 1990 (see Table A5-3). In contrast, IVSS Medical AssistanceFund expenditures declinei by 13 percent in real terms. In order to maintain iLsgreater stability, the IVSS Medical AssistanceFund ran a large deficit (rable A5-4), reaching 3,127 million nominal Bs in 1989, or US$66 million. In 1990, the deficit was eliminatedtemporarily by an increase in payroll tax deductions.

Table A5-2. Health Expendituresby MSAS and IVSS, Selected Years (millionsof 1984 ConstantBs) 1980 1985 1990 Ministry of Health, Total 5,169 5,760 5,036 Ministry of Health Support to Institutes 954 1,415 1,852 Ministry of Health Direct Administration 4,215 4,345 3,184 IVSS(Medical AssistanceFund Only) 2,478 2,068 2,168

RESOURCE ALLOCATION AND TECHNICAL EFFICIENCY

Ministry of Health

12. The Ministry of Health is financedfrom the national budget. Its potential beneficiariesare the entire populationof Venezuela. Services are financedprimarily by central governmentrevenue, however state and local governments contributea small part to the operation of Ministry of Health facilities,usually in the form of personnel expenditures. Some Ministry of Health facilities recover costs from patients, and/or have foundationsassociated with them that receive private contributions.

13. Expendituresby category. With approximately100,000 employeesin 1990, the largest single budget category is personnel expenditures,averaging about 70 percent of total spending from

3/ The increase over the decade is due to the creation of new institutes,as well as the large expansion of the Expanded Maternal Child Health Program (PAMI) in 1990. TableAS-3. MinistryofHealth Expenditures, byBudget CategoryBEludingSupportto OtherInstitiions (00(W,'X1984 Bs)

Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

Total 4215 5528 4772 4321 4072.5 4345 4633 4698 3788 3944 3184 100% 100% 100% 100% 100% 100% 100%/o100% 100% 100% 100%

PersonnelExpenditues a/ 25187 3561.4 3224.9 3204.7 2832.9 3397.8 3771.0 3360.6 2826.1 2543.8 1931.1 60% 64% 68% 74% 70% 78% 81% 72% 75% 64% 61%

Materia 672.5 765. 826.5 500A 541.8 621.8 438 913 724.7 844.6 621.6 16% 14% 17% 12% 13% 14% 11% 19% 19% 21% 20%

DebtServie 67.5 8.5 7.8 1.7 1.5 24 19.6 100 24 445 38 2% 0% 0% 0% 0% 1% 0% 2% 0% 1% 1%

Purchaseof Equipment& Furniture 20.2 32.5 48.9 17.1 24.8 35 44.7 54.6 27.3 19.3 15.1 0% 1% 1% 0% 1% 1% 1% 1% 1% 0% 0WC

Investmentb/ 420.8 265A 267.7 53.7 113.3 1012 121.0 114.5 37.4 452 116.8 10% 5% 6% 1% 3% 2% 3% 2% 1% 1% 4%

Transfers 151. 182.9 172.7 167 158.6 162.8 186.6 153.4 164.5 101 107A 4% 3% 4% 4% 4% 4% 4% 3% 4% 3% 3%

SpeciaUEmergencyPrograms cl 364.0 '711.6 223.6 376A 399.6 2.3 2.1 2.1 5.5 346.1 354.4 9% 13% 5% 9% I 0YO%ve 0% 0% 0%it 9% 11% a. Includessalary increases and bonusesfrom budget category financialdisbursements." b. Includesexpansion of healthfacilities and equipmentmaintenance from budget category 'rfiancial disbursements., c. Exludes moniesfor personneland investment. Sowre: Compiledfrom MSAS data and presentedin HaydeeGarcia, 'Comportamiento Financierodel SectorPublico,' November 1991. 100 Annex 5

Table A5-4. Inflows and Outflows of IVSS by Fund, 1980-90 (MILions of Current Bs)

Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Total Inflows 4643 5275 5557 5196 5320 5803 7178 8414 11167 15719 43104 Medical Assistance Fund 1648 1773 1839 1739 1891 1837 2164 2790 3654 5438 13816 Pensions 2045 2502 2654 2412 2455 2859 3683 4123 5530 6516 23687 IndemnizacionesDiarias 332 356 367 344 394 329 387 497 628 637 1806 Administration 618 644 697 702 580 779 945 1004 1355 3127 3795 Total Outflows 3286 3915 4125 4537 4587 5000 6423 7541 9224 14876 25673 MedicalAssistance Fund 1633 1840 1823 1908 2002 2304 3339 3885 5130 8565 11608 Pensions 1037 1194 1398 1596 1796 1847 2077 2445 2468 2878 9186 Indemnizaciones Diarias 255 243 239 249 209 213 225 249 280 229 1083 Administration 361 638 665 783 580 636 782 962 1347 3204 3795 Balance, Outflows Less Inflows Total 1357 1360 1432 660 733 803 754 873 1942 843 17431 MedicalAssistanceFund 16 -67 16 -169 -111 -467 -1176 -1096 -1476 -3'27 2208 Pensions 1008 1309 1256 815 659 1012 1606 1679 3062 3638 14500 IndemnizacionesDiarias 76 113 129 95 185 115 162 248 348 409 722 Administration 258 6 31 -81 0 143 163 42 9 -77 0

(Millions of 1984 Constant Bs) Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Total Inflows 7046 6904 6631 5832 5320 5209 5774 5282 5415 4131 8051 MedicalAssistance Fund 2501 2320 2194 1952 1891 1649 1741 1751 1772 1429 2581 Pensions 3103 3275 3167 2707 2455 2566 2963 2588 2682 1713 4424 IndemnizacionesDiarias 503 466 438 386 394 295 311 312 304 167 337 Administration 938 843 831 788 580 699 760 630 657 822 709

Total Outflows 4987 5124 4922 5092 4587 4488 5168 4734 4473 3909 4795 MedicalAssistance Fund 2478 2408 2176 2142 2002 2068 2687 2439 2488 2251 2168 Pensions 1574 1562 1668 1791 1796 1658 1671 1535 1197 756 1716 IndemnizacionesDiarias 388 318 285 279 209 192 181 157 136 60 202 Administration 547 835 794 879 580 571 629 604 653 842 709

Balance, Outflows Less Mflows Total 2059 1781 1709 740 733 721 607 548 942 222 3256 MedicalAssistance Fund 24 -87 19 -190 -111 -419 -946 -688 -716 -822 412 Pensions 1529 1713 1499 915 659 908 1292 1054 1485 956 2708 IndemnizacionesDiarias 115 147 154 106 185 103 130 155 169 107 135 Administration 391 8 37 -91 0 128 131 26 4 -20 0

Source: I.V.S.S. Memoria y Cuenta. 101 Annex 5

1980 to 1989 (Table A5-5) when support to other institutionsis excluded4' While the Ministry was facing severe budget constraints in the 1980s, it added approximately22,600 new employeepositions to its rolls&'. The next most importantallocation is support to associatedinstitutions,such as the National NutritionInstitute, the University Hospital of Caracas, the NationalInstitute of Hygiene, ?nd the Rural Housing Program (Table A5-6). Supportto foundations made up about 25 percent of MSAS expendituresover the 1980s. The NationalNutrition Institute absorbed the most resources of all the Institutes in the 1980s, although its programs were sharply cutback in 1989 and 1990, and more funds went to a new p:ogram, the Programa AlimentarioMaterno Infantil (PAMI) Foundation, which was created in 1990. The other major category is material, accountingfor approximately16 percent of total MSAS expenditures.

14. The physical investmnentportion of the direct budget is small, averaging under 3 percent of the total. Since the early 1980s, most investmentin new health facilitieshas been handled outside of MSAS, by the Ministry of Development(MINDUR), as shown in Table A5-7. In October 1987 the Fundaci6n para el Mantenimientode la InfraestructuraMedico Asistencialpara la Salud P iblica (Foundationfor Medical Services Infrastructureor FIMA) was establishedwith the mandate of providing equipmentand maintenancefor major medical equipment. FIMA is an autonomous institute under MSAS. FIMA's expendituresare for equipmentpurchase, physical renovations necessary to install equipment, and equipmentmaintenance.

15. Expendituresby program. MSAS budget data are not organized in a manner that permits analysis of expendituretrends by program. Significantportions of total expendituresare not allocated to health service programs. These expendituresare designatedfor collectivelabor contracts and central services and administration. Expendituresfor collective labor contracts varied from 20 percent to as much as 41 percent of MSAS expendituresduring the 1980s (see Table A5-8). Allocationsto central services ard administrationvaried from 5 percent to 42 percent of all expenditures. This large fluctuationwas caused by labor expenditures(negotiated salary increases) and other budget line items that are not disaggregz.edby program.

16. Expenditureson health services include epidemiologyand health promotion, communityhealth education, health services, and rural endemic diseases and sanitation. Spendingon the largest program, health services, fell by 50 percent in real terms from 1980 to 1990. Of the remaining smaller programs, the fall in expenditureson rural endemic diseases and sanitationof about 63 percent from 1980 to 1990 is striking, especiallygiven the increases in incidence of malaria in Venezuelaover the period. Subprogramexpenditure data are not presented, so it is difficult to determine resource flows to key subprograms such as immunization,farnily planning, injury prevention programs, child health, etc.

17. Expendituresby type of healthfacility. Expenditureson medical services sharply declined in real terms over the 1980s. Since no major initiativeswere introducedto improve efficiency at the same time, this drop in expendituresmust have had a big impact on service quality. Hospital services

4/ Autonomousinstitutes are excluded from the calculationbecause of the difficulty in estimatingtheir personal expenditures.

I/ Positions are reported in the budget, not the actual number of employees. 102 Annex 5 accoun!tedfor about 80 percentof all spndin oa health svncins over most of the period, although this droppedin 1989 and 1990to about 70 percat (CableAS-9).

TableA--5. .WinistryofHIc@t Speada&gbyCatgq, 195O-195a/ ('0o,oXo1984 Es)

Year 1960 1961 19g 1963 1964 1965 1986 197 1968 1989 1990

Total MSASSpcng S1169.0 7001.0 5757.7 5207.4 4700 7602 6171.8 6929.0 591S.1 S37S.i S036.5 PersonnelExpenditurea b/ 25187 356. 3224.9 3204.7 285. 3397.8 3771.0 3360.6 282' 2543.8 1931.1 Material 672.5 765.8 O.54 54 541.8 6218 488 913 724.7 844.6 621.6 Purchaseof Equipment,Fuaiture 202 325 489 17.1 24.8 35 44.7 54.6 273 193 15.1 Support to Other Institutions 9S39 14723 985.6 64 897.5 141S3 1S38.8 2230.8 21272 1430.6 1352.2 Invetsmentc/ 420.8 265.4 267.7 53.7 1133 101.2 121.0 114.5 37.4 452 116.8 Other d/ 5W29 903.o 404.1 545. 559.7 169.1 2063 255.5 172.4 491.6 499.8

Total MSASSpending 100% 100% 100% 100* 100* 100% 100% 100% 100% 100% 100% PersonnelExpenditures b' 49% $I% 56% 6Z% 57% 59% 61% 49% 48% 47% 38% Material 13% 11% 14% 10% 11% 11% 8% 13% 12% 16% 12% Purchaseof Equipment,FutnItur 0% 0% 1% 0% 0% 1% 1% 1% 0% 0% 0% Support to Other Institutions 18% 21% 17% 17% 18% 25% 25% 32% 36% 27% 37% InvestmentC/ 8% 4% 5% 1% 2% 2% 2% 2% 1% 1% 2% Otherd/ 11% 13% 7% 10% 11% 3% 3% 4% 3% 9% 10%

TotalMSAS Spendin& Ewmludlng Support to other Institution 100% 100% 100% 10*% 100% 100% 100% 100% 100% 100% 100% Personr.nlExpenditures b/ 60% 44% % 74% 70% 78% 81* 72% 75% 64% 61% Material 16% 14% 17% 12U 13% 14% 11% 19% 19% 21% 20% Purchaseof Equipment,Furnitue 0% 1% 1S 0% 1% 1% 1* 1% 1% 0% 0% Investmentc/ 10% 5% 6% 1% 3% 2% 3% 2% 1% 1% 4% Other dl 14% 16* 8% 13% 14% 4% 4% S% 5% 12% 16% a. Excludessanitation expenditurvs. L. Includessalary incrses appeaing in irnacIaldiNbureeals"ategc. c. Includesexpenditures to open oewfaciltie ad equps mainenne in "f-sclal dsbunamente cstgoqy. d. Includesfinancdisbu enwecateg (omiti i eatd dinonteland2)tasnls sddebtserice Souzc: CompiledIhno MSASdt ad pented In Hayde Ola omp m PbanclP odel Sector Pubo November199L Table A5-6. MinistryofHeafth BudgetarySupport to Institutions and Foundations, 1980-90 a! (100X, W 1984 Bs)

Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 TotaLMSAS Spending 5421 7229.9 5946.4 5385.4 5140.8 5925.6 6337.7 7087 6069 5496 5133 Total Supportto other Institutes 953.9 1472.9 985.6 886.4 897.5 14153 1538.8 2230.8 21272 1430.6 1852.2 %of total MSASSpending 18% 20% 17% 16% 17% 24% 24% 31% 35% 26% 36%

Spendingby Institute NationalNutrition Institute 421.1 471.9 359.2 331.1 3779 900.9 1096.4 1695.6 16093 769.1 6733 % of total for Institutes 44.1% 32.0% 36.4% 373% 42.1% 63.6% 713% 76.09% 75.7% 53.8% 36.496 UniversityHospital of Caraca 258.9 197.1 211.1 1T1.7 174.7 188 157.6 174.4 159.2 121.7 1603 % of total for Institutes 27.1% 13.4% 21.4% 20.0% 19.. 133% 102% 7.8% 7.5% 8.5% 8.7% NationalInstitute of Hygiene 273 23.6 203 21.7 173 zO.6 20.7 19.7 21.9 18 30.9 % of total for Institutes 2.9% 1.6% 2.1% 2.4% 1.9% 1.5% 13% 0.9% 1.0%So 13%6 1.7% iVIC 1313 1243 113.4 101 100 993 77.7 94.7 1292 973 85.9 % of total for Institutes 13.8% 8.4% 11.5% 11.4% 11.1% 7.0% 5.0% 4.2% 6.1% 638% 4.6% INAGER 54.6 328.8 280.4 253.9 227.4 206.4 185.8 177.4 150.1 92 92.3 % of total for Institutes 5.7% 22.3% 28.4% 28.6% 253% 14.6% 12.1% 8.0%o 7.1% 6.4% 5.0% ICSs 1.2 1.1 0.2 02 0.6 1.2 % of total for Institutes 0.1% 0.1% 0.0% 0.0% 0.0%/ 0.:% SLAM 110.1 % of total for Institutes 7.7% NationalHousing Institute 60.7 3272 67.8 57.5 % of total for Institutes 6.4% 22.2% 3.0% 2.7% PIMAb/ 71 303 % of total for Institutes 5.0% 16.4% Rural HousingProgram b/ 131.4 440.4 % of total for Institutes 92% 23.3% CVG 11 7.8 % of total for Institutes 08% 0.4% PAMIFoundation 583 % of total for Institutes 3.1% a. Indudes sanitationexpenditures. b. In 1989,these programswere transferredfrom internal Ministry of Healthprograms to autonomonsinstitutes.

Soure: Data fromOCEPRE, as Jeportedin HaydeeGarcia, 'El Comportamientodel Sector Publico de Salud,*November 1991. 104 Annex5

TableAS- 7. MNDUR Investmentin Health Infrastructure,Selected Years ('0 0,o00 1984&)

Year 1981 1984 1986 1988 1989 1990

Total 244.7 44.8 192.7 428.1 58.1 42.8 Hospitals 226.7 48.1 19.3 Health Centers 27.4 4.9 7.5 Clinics 151.8 0.5 9.8 Other 22.2 4.6 6.2

Source: OCEPRE data as reported in Haydee Garcia,"Comportamiento Financiero del SectorPublico de Salud,"November 1991. Table A5-8 Distribuiionof MSAS Spendingby Programs ()000,0001984 s per capita)

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

Total 4,105 5,212 4,449 4,012 3,794 4,057 4,502 4,417 4,019 3,801 2,701 100% 100% 100% 100% 100% 1O00o 100o 100%o 1o0 100l%o10o

Central Services and Administration 465 959 315 183 329 348 1,002 945 1,056 1,612 448 11% 18% 7% 5% 9% 9%1o 22% 21% 26% 42% 17%

Collective Contracts 826 1,561 1,506 1,401 1,334 1,684 1,401 1,240 1,102 756 782 20% 30% 34% 35% 35% 41% 31% 28% 27% 20% 29%

Epidemiologyand Health Promotion a/ 0 120 100 90 101 95 109 107 108 108 134 0% 2% 2% 2% 3% 2% 2% 2% 3% 3% 5%

Community Health Education 42 35 35 26 23 15 9 8 7 4 4 a I % 1% 1% 1% 1% 0% 0% 0% O0o 0O% O "

Health Services b/ 2,420 2,188 2,202 2,057 1,830 1,743 1,790 1,934 1,571 1,171 1,213 59% 42% 49% 51% 48% 43% 40% 44% 39% 31% 45%

AdministrativeSupporttoAbove 99 120 103 77 6 8 25 26 13 29 23 Categories 2% 2% 2% 2% 0% 0%o 1% 1% 1% 1% 1%

Rural Endemic Diseases and Sanitation c/ 210 189 156 149 146 135 138 13 128 104 77 5% 4% 3% 4% 4% 3% 3% 3% 3% 3% 3%

AdministrativeSupporttoAboveCategDry 43 40 33 29 25 30 28 28 26 17 20 1% 1% 1% 1% 1% 1% 1% 1% 1% 0% 1% a. Health promotion includes such activitiesas the immunization program, MvCHprograms, and prevention of chronic disease. b. Includes Budget Categories 9 (Normative Services), 10 (Norms and Supervisionof Health Facilities) and 11 ('Fomento y Restitucion de la Salud") c. Includes Budget Categories 6 (Rural Endemic Diseases), 7 (Rural Sanitation), 12(Sanitary Engineering), and Environmental Control. Source: Haydee Garcia, "CompoAtamientoFinanciero del Sector Publico,"November 1991. 106 Annex 5

18. Expenditureson Inputs. Expenditureson materials, such as drugs and other supplies, are highly variable. Hospital directors report severe problems with supplies. These complementary inputs to labor are essential to delivering services efficiently. It is difficult to separate out the labor componentof hospital and non-hospitalexpenditures. Table A5-9 shows the proportion of expenditureson personnel as reported under that program category (53 percent of hospital expendituresin 1990). However, labor expenditurcsare made from several categories within the Ministry, making any final attributior.of labor spendingby ptogram extremely difficult. We can say that Table A5-9 greatly understateslabor expenditures,as expendituresare also made under the programs "CollectiveContracts" and 'Central Administration." From interviews with hospital directors, the consensus is that labor expendituresmake up a very high proportion of total hospital and ambulatoryexpenditures, crowdingout other expenditureson complementaryinputs.

19. nTebudgetary process. Budgetsfor health facilitiesare generally made on the basis of the previous year's budget. There is no strong link made between the budget 2nd production of services. Some health systems in other countries have adopted measures to tie the budget to production, and give the health facility an incentive to improve its performance. Some systems pay predetermined global fees per medical case, with medical cases grouped by diagnoses that generally consume similar amountsof resources. Other systemsreimburse set rates for services rendered. This has the disadvantageof creating incentivesto produce services, whether or not necessary. Even with this problem, it would be a big advance over the present system that has no explicit link between budgets and production.

VENEZUELAN SOCIAL SECURITY INSTITUTE ('SS)

20. IVSS is financed from contributionsfrom workers, companies, and the state. Full IVSS coverage includes health care as well as pension and other work-relatedbenefits for the workers and their dependents. r'Vsscoverage is fairly low given Venezuela's per capita GDP-fluctuating between 31 to 35 percent of the labor force in recent years. Full coverage (includinghealth care) is even Jower, reaching about 25 percent of the labor force. Partial coverageexcludes health care from the package. Only workers who live in areas without IVSS facilitiesare eligible for partial coverage. In practice, actual users of WVSShealth services are a much larger group. By law, no one can be excluded from an IVSS facility if they are in need of emergency services, and many hospital and health clinic cases are considered emergencies(births, for example). In addition, many facilities do not check IVSS affiliationfor those seeking treatment. IVSS gets no support for its health facilities from user charges and foundations, as facilitiesare prohibitedfrom this activity.

21. Expendituresby type offacility. IVSS expendituredata are not available by program, just by type of facility. Compared to MSAS, a similarly high percentage of health services spendingis directed at hospitals. In 1990, 74 percent of health services spending was on hospitals, with the remaining directed at health centers (note these figures exclude central personnel administration) C(able A5-10). Health center expendituresare dominatedby personnel expenditures(82 percent). Hospitals have a lower proportion of total expenditureson personnel, because of the greater importance of drugs, surgical supplies, and equipment. In both types of facilities, shortagesof drugs and supplies are reported, as well as problems with maintenanceof buildings and equipment. 107 Annex 5

TableAS-P9. Mmistry ofHealth Expdidtures by HaeathSarc Pcilityand Catcgory,1980-90 ('O0,000 1984 lb)

Bft2ypedFwQ. 1980 1961 1912 1983 194 1W 196 1987 1988 1989 1990

T-otalLKediid SW .n btug 1948 1815 1I 1778 1715 1455 1106 13 1299 835 1273 Percentof Total 1009 100% 100% 100* 100% 100% 100* 100% 100% 100% 100% HosviW PAwldlll IS52 U530 1677 1535 1475 1149 915 1164 1048 598 903 Perant otTotal 80% 84% 84% 6% 86* 79% 63% 84% 81% 70% 71% Non-Homolta Exqohnditure 396 285 311 242 240 309 193 218 251 257 370 Pcent of Totd 20% 16% 16* 14% 14% 21% 175 16% 19% 30% 29%

Bvfvve oFacflltvand Bugeet Catear

HosgiAExiueS£DiDlll 1552 130 1677 1535 1475 1149 915 1164 1048 S98 903 Personnel 883 1027 955 965 857 649 776 819 665 395 477 569% 67.1% 57.0% Q.9% 581% 73.9% 84.6% 703% 63.S9 66.1% 52.8% Materil 273 462 515 236 249 2 % 67 253 339 192 313 17.6%6 30.2% 3067% 15.% 16.9% 25.1% 7.3% 21.7% 32.3% 32.1% 34.7% Equipmcent urchau 1 1 1 1 1 0 0 0 0 0 0 0.1% 0.1% 0O0% 0U0* .O% 0.0% 03% 0.0% 0.0% 0.0% 0.0% Tlansfer 29 39 42 40 3# 12 21 0 0 0 0 19S 2.6% 2516 2A*6 23% LO% 23% 0.0% 0.0% 0.0% 0.0% NewFacilitsieaadRnovatbm 336 C 14 9 0 0 51 63 6 0 76 21.6% 0.0% 9.7% 0.6% 0.0% 00% 5.6% .4% 0.6% 0.0% 8.4% Specil Support 30 0 1 6 0 0 0 0 14 1 17 1.9% 0.0% 0.0% 0.4% 0.0% 0.0% 0.% 0.0% 1.3% 02% 1.9% MSAS tasm to mates 0 0 0 219 161 0 0 0 0 0 0 0.0% 0.0% Q0.* 143% 109% 0% 00% 0.0* 0.0% 0.0% 0.0% Other 0 0 1 59 173 0 0 30 24 10 20

Non-Hosnital Expenditures 396 285 311 242 240 30 193 218 2S1 257 370 100% 100% 100% 100% 100% 10% 100% 100% 100% 100% 100% Personnel 80 210 1B5 194 176 165 160 179 151 148 171 20.29 73.6% 59.5% 79 73. 34% O1% 123% 60.3% 57.6% 46.3% MaterIal 6 37 38 36 33 29 4 16 38 38 34 L6S 129% 121% 156% W*% 9A* 2.2% 7.4% 15.0% 14.6% 92% EquipmentPurchae 0 0 0 0 0 0 0 0 0 0 0 00% 0.% 01 0.1% 1% 0.1% u00 0.0% 0.0% 0.0% 0.0% Transfers 0 0 0 0 0 0 2 0 0 0 0 0.0% Q0.% 0% 00% 00% 00% 08*% 0.0% 0.0% 0.0% 0.0% NcwFaciUtleand Renovatlo 2 0 a 0 0 0 27 10 0 0 16 0.6% 0.0% 23.2% 0.0% 0. O0% 13.9 4A% 0.0% 0.0% 42%

Other 307 38 0 11 31 llt 0 13 62 71 149

______C: ______77.6% 114% de8%.1% 4A% 12% 372% 0% 24.7% 27.8% 40.3%

Sam=ce HaydeeOamsra. Cmponamlento Flueadmdel SecorPublicsde uld' KvoMwlb 9L 108 Annex 5

22. Geographiccoverage. IVSS health expendituresare heavily concentratedin the metropolitan area of Caracas. About 58 percent of all IVSS medical expendituresare in the Distrito Federal and the nearby state of Miranda (rable A5-11). Becauseof lack of facilities, IVSS does not have any health expendituresin the states of Merida, Monagas, and Sucre and the federal territories.

Other Public Providers

23. The other major sources of public financingand provision of health services are the Instituto de Previsi6n y Asistencia Social para el Personal del Ministeriode Educaci6n (IPASME) for employeesof the Ministry of Education, the Institutode Previsi6n Social de las Fuerzas Armadas (IPSFA) for the armed services, and local governments. Given the large size of the Ministry of Education, IPASMEcovers about 22 percent of all civil servants in the federal public administration. Those covered includecurrent and retired teachers and administrativestaff of the Ministry of Education. IPASME runs health centers in urban areas throughout the country. IPASME contributes to the employee's hospitalizationcosts through the purchase of private (hospitalization)insurance. Coverage of hospitalizationof family members is limited to obstetric services for the spouse.

24. IPSFA runs health centers and five hospitals for members of the armed services. There is a two-tiered system with different services for professional-levelmembers of the armed services versus non-professionalmembers. Financing comes from payroll deductions and the Ministry of Defense budget.

25. Most states and municipalitiesplay a very small role in health services financingand provision. They often contribute suppliesor personnelto MSAS hospitals. The Distrito Federal has several hospitals run by the local government,including the largest maternity hospital in Venezuela, Hospital MaternidadConcepci6n Palacios. These local governmentfacilities receive only a nominal financial contributionfrom MSAS. Almost all financingis from the local government'sbudget.

ACCESS TO HEALTH CARE: LIMITED INFORMATION

26. It is difficult to assess access to health care from existing information. Informationcould be collected through household surveys (such as the recently initiated National Household Social Survey) on householdexpenditures for health and the use of different providers. These data could then be used to assess the coverageof each subgroup of the population. MSAS provides coverageto the largest populationgroup, but informationon coverageprovided by other actors in the health system-IVSS, other public institutions, and the private sector-is incomplete.

27. A compositepicture of per capita public spendingon health services from three sources, MSAS, IVSS, and the states, is presented in Table A5-12. Based on these data, one can infer that in certain states the populationreceives significantlyfewer health services from the public sector than other states. Not surprisingly, given the high concentrationof public medical facilities and physicians, the Distrito Federal has the highest public spendingon health, at US$65 per capita (1990 US$). Of course, the Distrito Federal serves as a referral center for a larger populationgroup. Overall, the average is US$30 per capita, varying between states from only US$15 in Barinas to US$43 per capita in Trujillo. The states are already makinga small but significant contributionto health expenditures, averaging about 6 percent of total spending on health services. 109 Annex5 TableAS-ia IVSS Expenditureson Health Facilitiesby Category,1990 ('000,0001990a) Expenditures Percent Total a/ 12,057 100 % Hospitals 8,927 74 Health Centers 3,iiO 26 Hospitals 8,927 100 Salaries 5,932 49 Maintenance 258 2 Medicine 190 2 Equipment 393 3 Food 240 2 Other 1,912 16 Health Centers 3,130 100 Salaries 2,579 82 Maintenance 59 2 Medicine 131 4 Equipment 29 1 Food 1 0 Other 330 11 a. Excludescentral administration. Source: IVSSStatistics

TableAS-11. IVSSExpenditures by State, 1990 ('000,000 1990Bs) Expenditures Percent Total 12,057 100.0% DistritoFederal 4,873 40.4 Anzoategui 421 3.5 Apure 18 0.1 Aragua 548 4.5 Barinas 4 0.0 Bolfvar 847 7.0 Carabobo 936 7.8 Cojedes 34 0.3 Falc6n 402 3.3 Guirico 35 0.3 Lara 345 2.9 Miranda 2,078 17.2 Nueva Esparta 98 0.8 Portuguesa 95 0.8 Tachira 257 2.1 Trujillo 410 3.4 Yaracuy 23 0.2 Zulia 633 5.3 Source: IVSSStatistics 110 Annex 5

Private Sector

28. Private sector financing is made up of fee-for-servicepayments by individualsand companies, pharmaceuticalexpenditures, and private health insurance. As mentionedearlier, informationon private sector financingand provision of health care is incomplete. In general, higher income groups are served by the private sector. The income elasticityof demand for health care is high, and higher income consumersdemand more services as well as higher quality care. But all householdsprobably make some use of the private sector. For example, pharmaceuticalexpenditures are frequently a significantproportion of low income families' budgets.

29. Large companiesfrequently provide some sort of direct medical assistanceor private insurance. The petroleum industryw'for example, operates 33 health clinics and 2 hospitalsYl Services provided includebasic health services, physical exams, and treatment of work-related accidents. The petioleum industry has sponsored some innovativehealth promotion programs for its workers. The health facilities are considered necessary in some cases because of the large distance from the work site to MSAS health facilities. In 1990, the petroleum industryprovided some health services coverage to about 50,000 workers, 85,000 family members, and 20,000 contracted workers.

30. The private health insurance industry is another area where some data are available. The private health insurance industry has grown rapidly over the 1980s, and competitionin supply seems robust. While no statisticson the numbers covered by private health insurance policies are available, data on total spending (for insurancepremiums) increasedfrom US$97 million in 1984 to US$164 million in 1989 (1990 constant US$). Private health insurance policies are known as "H.C.M." policies, because they cover, up to certain limits, hospitalization,surgery, and maternity care. These types of policies have been in existence in Venezuelafor about 25 years. In 1989, about 36 firms offered individualpolicies and 41 companiesoffered collectivepolicies. In additionto hospitalization, some policies also cover ambulatoryvisits. Usually the individualinsured pays a portion (a co- payment) for the service provided, and deductibles are often imposed. In order to contain costs, insurance companiesalso set limits on prices that they will reimburse for certain procedures.

31. There is an enormousrange in types of health insurancepolicies offered, ranging from modest reimbursementfor basic hospitalprocedures to generous catastrophiccoverage includingcoverage of organ transplants. Accordingto the Camara de Asegurados, there is a wide range of policies and coverage ranging from a cost of about US$40 per year to US$1,200per year. Group policies are more common than individualpolicies, making up more than twice the total premiums of individual policies.

32. Managed pre-paid health care, also known as health maintenanceorganization arrangements, do not exist in Venezuela, although the Camara de Asegurados(the trade organization for private insurance providers) is planning to undertake technicalstudies on the viabilityof establishinghealth maintenanceorganizations in Venezuela.

6/ Note that this industry could be considered public sector.

7/ According to PDVSA, in 1990: CORPOVENoperated 9 clinics and 1 hospital, INTEVEP had 1 clinic, LAGOVEN had 11 clinics and 1 hospital, MARAVENhad 8 clinics, and PEQUIVEN had 4 clinics. IIl Annex S TableA5-12. ConsolidatedMSAS, IVSS and StateSending forMedical Sen*ea at the StateLeve, 1990

ConsolidatedSpending on Services By Institution: Percent by Institution: Total (1990 Per Capita Per Capita (0W,000 1990Bs) '000,000Bs) (Bs) (USS) MSAS IVSS States MSAS IVSS States Total 25,920 1432 $30 12,380 12,057 1,483 47.8 46.5 5.7 DistritoFederal 6,456 3069 $65 1,584 4,873 0 24.5 75.5 0.0 Anzoategui 1,063 1236 $26 598 421 44 56.2 39.6 4.1 Apure 314 1100 S23 270 18 26 859 5.7 8.4 Aragua 1,228 1096 S23 637 S48 43 519 44.6 3.5 Barinas 302 710 1S 273 4 25 90.4 1.4 8.2 Bolhvar 1,441 1600 $34 SS4 847 40 38.4 58.8 2.8 Carabobo 1,793 1234 S26 784 936 74 43.7 52.2 4.1 Cojedes 262 1441 $30 208 34 21 79.3 12.8 7.9 Falc6n 713 1190 $25 267 402 44 37.5 563 6.2 Guarico 457 934 $20 400 35 21 87.7 7.6 4.7 Lara 1,303 1092 $23 787 345 172 60.4 26.4 132 Mdrida 514 901 $19 466 48 90.7 0.0 9.3 Miranda 2,803 1498 $32 410 2,079 314 14.6 74.2 11.2 Monagas 540 1149 S24 440 101 81.4 0.0 18.6 NuevaEsparta 291 1103 $23 170 98 23 58.4 33.8 7.9 Portuguesa 608 1055 $22 424 9S 89 69.7 15.6 14.7 Sucre 682 1003 S21 657 25 96.4 0.0 3.6 Tachira 911 1128 $24 580 257 73 63.7 28.2 8.0 Trujillo 1,016 2056 $43 550 410 55 54.2 40.4 5.4 Yaracuy 392 1018 $21 327 23 41 83.6 6.0 10.4 Zulia 2,601 1164 $25 1,850 633 118 71.1 24.3 4.5 TF. Amazonas 83 1497 $32 64 19 77.0 0.0 23.0 T.F. Delta Amacuro 150 1775 S37 81 69 54.0 0.0 46.0 Dependendes _- - _ 0.0 Note: .. indicates not available. Source: Haydee Garcia, uComportamiento Financiero del Sector Publico de Salud," November, 1991and MSAS data.

33. The government could consider reviewing its regulation of the private sector with the purpose of finding ways to facilitate or remove unnecessary impedimentsto the growth of private health care, such as pre-paid managed care systems. At the same time, MSAS, in its normative, planning and regulatory role, could begin to systematicallycollect informationabout the activities of the private sector in health care. 112 Annex 5 RESOURCE MOBILIZATION

34. With the poor service quality of public health services and low overall public spending (1.2 percent of GDP in 1989), it is unlikely that public spending is "crowdingout" private spending significantly. Higher incomegroups do not use MSAS and IVSS facilities because they choose to purchase higher quality services from the private sector. In addition, the lower income groups that are served by MSAS and IVSS facilitiesstill make significanthealth expendituresbecause supplies and drugs are frequentlylacking. While the impact of current levels of health spending could be greatly improved through reallocation of resourcesand improvingefficiency of services, over the mediumterm, considerationneeds to be given to methods that could increase the sources of financiing for health care beyond the fiscally constrainedfederal government. More stable financing arrangements also should be sought. The major potentialsources of increasedhealth financing are private insurarce or other private health care arrangements, municipaland state government revenues, and user fees in public facilities.

35. Sources offinancing. The governmentcould review measures in its regulatory framework with the objective of facilitating the growth of efficient private sector services, such as prepaid group practice organizations. With the decentralizationof health services, the proportion of municipaland state governmentrevenues directed at health services will probably grow. Increased user fees are another option. User fees are already in place in some MSAS hospitals. Some hospitals have chosen not to charge fees because they lack the accountingskills to manage the process. While the revenue collected is not large for those hospitals that do charge fees, this revenue can represent an important part of the hospital's discretionarybudget. User fees can fill several objectives: improved efficiency, improved equity, and revenue collection(Table A5-13). In general, fees need to give patients the correct signals for the use of health resources, they should not exclude the poor from services, and they should increase revenue. They also can serve to discourage overconsumption.

36. There is potential for greater resource mobilizationfrom user fees in public facilities in Venezuela, starting first in hospitals, but there will be an accompanyingneed to provide many hospitals with technical assistanceto set up appropriate systems. From experiencesin other countries, there are several factors to consider in establishingcost recovery systems. Fees could be applied only to curative care so as not to discourage preventivehealth care. Fees could be set for those who bypass health centers and go direct.y to hospitals for basic health care in order to discourage this behavior. Fee structures should be kept simple, but set at a proportion of the marginal cost of providing the service. Conside.ationcould be given to introducingcharges for drugs, laboratory tests, and X-rays in public hospitals. Many patients are forced to purchase drugs anyway. Fees need to be indexed to inflation. Fees should continueto be retained by the hospitals.

CONCLUSIONS AND RECOMMENDATIONS

37. Most countries share several health policy goals. Health policies should support universal access to health care by all citizens, control health care costs at a reasonablelevel, use resources 113 Annex 5

TableA5-13. Economic and AdministrativeIssues in Setting User Fees Economic Issues Efficiency of health services (to the extent that revenue raised from user fees cart increase availabilityof necessary inputs) Equity issues (need to have ability to exempt the poor from user fees) Signaling(fees can give consumersappropriate price signals about costs) Administrative Issues Collectionof fees (need for accountingmechanisms, trained personnel, supervision and financial control) Revenue potential (will depend on collectionrate and size of fees) Source: adapted from Charles C. Griffin. "User Charges for Health Care in Principle and Practice", EDI Seminar Paper Number 37, World Bank, Washington,D.C., 1988.

TableA5-14. Health Care Expendituresas Percent of Gross Domestic Productper Capita, Seleaed Countries,1987 1970 1987

Austria 5.3% 8.4% Belgium 4.0 7.2 Denmark 6.1 6.0 France 6.1 8.7 Germany 5.5 8.1 Greece 4.0 5.3 Italy 5.5 6.9 Netherlands 6.0 8.5 Spain 4.1 6.0 Sweden 7.2 9.0 United Kingdom 4.5 6.1 Source: Culyer, A.J. "Cost Containment in Europe," Table 1, in Health Cre Systems in Transition: The Search for Efficiency, OECD Social Policy Studies N.. 7, OECD, Paris, 1990. 114 Annex 5

effectively, and encourage technicaland managerialinnovations.v In many Organizationfor Economic Cooperationand Development(OECD) countries, health care expendituresas a percent of GDP have grown dramaticallyin a short period (Table A5-14). Whereas in 1970most countries in the table were spendingabout 5 percent of GDP on health, this increasedto over 7 percent by 1987. Most OECD systems are financedprimarily through public expendituresas is Venezuela's system (Table A5-15). In most OECD countries about 70 percent of total health spending is public expenditures. Venezuelacould learn from the mistakesand experiencesin other countries in designing an integrated system of financingand organizationof services that can achieve a society's health goals. There are both supply side and demand side measures that can be taken to contain costs and improve the qualityof health care systems.

38. Reinhardt's framework divides cost containmentapproaches into demand side and supply side strategies, and micro managementand macro management(Table A5-16). Most of these approaches could be used by the public or the private sector. Some of these approaches could be considerednow by Venezuela, and others could be introducedover the medium term.

39. On the demand side, user fees can be imposed or health insurance deductiblesto deter overuse of health services and to give patientssignals about resource use. User fees are already in use in some hospitals in Venezuela, but this could be strengthened.

TableA5-15. Public Expendituresas a Percent of Total Health Spending, SelectedOECD Countries, 1987

Australia 70% Belgium 77 Canada 74 Denmark 86 France 75 Germany '78 Greece 75 Italy 79 Japan 73 Portugal 61 Spain 71 United Kingdom 86 United States 41

Source: OECD Secretariat, "Health Care Expenditureand Other Data: An International Compendiumfrom the Organizationfor Economic Cooperationand Development", in Health Care Systems in Transition: The Search for Efficiency, OECD Social Policy Studies No. 7, OECD, Paris, 1990, Tables I and 2.

BI See William C. Hsiao, "What Lessons can Less-DevelopedCountries Learn from the Experiences of Developed Nations About a ComprehensiveHealth FinancingStrategy," InternationalSeminar on ComprehensiveHealth FinancingStrategy, Indonesia, 1990. 115 Annex 5

Table A5-16. Strategiesto Control Health Care Expenditureand EncourageQuality Poss!ble Approaches Micro Management Macro Management Demand Side Strategies Cost sharing with users Predeterminedglobal budgets through deductibles,premiums, for hospitals. user fees.

Managed care systems that superviseor review decisions of clinicians and patients.

Supply Side Strategies Many interventionsto Regionalplanning to make encourage effciency in physical capacity of health production of medical system most suited to "health interventions. Use of needs"--to the epidemiological managementtools, economic profile and to the desired incentives, such as diagnosis- distributionamong regions and related groups as basis for social classes. reimbursement. Measures to minimizeunnecessary and Reallocate resources towards inappropriatecare. neglected, but highly cost- effective interventions.

As examples, manpower planningand controls on purchase of high technology biomedicalequipment.

Source: Uwe E. Reinhardt, "The U.S. Health Care Financing and Delivery System: Its Experience and Lessons for Other Nations," InternationalSymposium on Health Care Systems, December 18-19, 1989, Taiwan, Table 13.

40. On the supply side, there are a multitudeof techniquesthat can be used to encourage efficiency in the production of health interventions,and increase the allocative efficiencyof he resources spent on health. Many of the measures to improve technical efficiency at the hospital level are discussed in Annex 7. They include greater hospitalautonomy and accountability,hospital cost accounting, hospital utilization review, modem materials managementsystems, etc. Many of these measures that have worked successfullyin other countries could be adapted and introduced to Venezuela over the short to medium term. Measures to improve the efficiency of human resource use are desperately needed as well. Economic incentives,such as reimbursing on the basis of diagnosis- related groups, could also be consideredover the medium to long term.

41. More macro-levelsupply side measures need to be introducedbecause the major portion of health spending is supply side driven. Paramount among these measures is better planning to make the physical capacity and health inputs of the health network better suited to the health needs of the population. Government could then use the range of policy instrumentsunder its control (such as 116 Annex 5 subsidizationof higher education, accreditationof medical schools, constructionof new health facilities, tax policy) to influencethe production of health inputs. Better planning could also help address the inequitabledistribution of health facilities in Venezuelaover the medium term.

42. Managed care systems are another alternative. These systemsmanage patient demand by ensuring that patients see their primary care provider before seeking specializedcare and that they are referred to specializedcare in accordance with guidelinesestablished by the managed care system. The decisions of physiciansare reviewed by the system to ensure that resources are being used appropriately. The Venezuelangovernment could try to facilitate the introductionof these types of systems in the private sector over the next few years. Accordingto the Camara de Asegurados, there is interest in these systemson the part of the private sector. In the public sector, better referral and counter referral guidelinesand systemscould help assure patients enter the health system at the appropriatelevel, instead of crowdingresource-intensive hospitals.

43. Demand could also be managed by predeterminedglobal budgets, with the implicit contract to provide a certain amount of services. Global budgeting is already in use in Venezuela, but health facilities have such limited use over their resources that they have little scope for improving efficiency. On global budgeting, greater attention needs to be paid to (1) linking budgets to production, and (2) equitablydistributing resources across states and municipalitiesby using transparent and predictablecriteria. 117 Annex 6

ANNEX 6

HEALTH MANPOWER ISSUES'

1. Human resources are perhaps tk.e most important health services input. in Venezuela they absorb about 70 percent of all public spendingon health. Total numbers of health personnel in the public sector grew rapidly over the 1980s, and by 1989 there were about 173,000 budgeted positions. This amountedto about 17 percent of all public sector employment. There are numerous problems relating to health manpower. As in Latin America in general, there are distortions in the health manpowerpyramid: a high proportion of specialist physiciansrelative to general physicians, a high proportion of physicians relative to nurses, and a high proportion of lower level, untrained manpower relative to paramedicalstaff. There are also distortions in the distributionof personnel geographically. Labor productivityin the public sector is generally viewed as low. This is in part due to strikes, absenteeism,a-id abuse of sick leave policies, and in part to deteriorating salary conditionsover the 1980s. Liw labor productivitycan also be attributed, in part, to lack of complementaryinputs. Managementof the public sector labor force is highly centralized in Caracas, and much of the attention of Ministry of Health (MSAS)and the VenezuelanInstitute for Social Security (IVSS) is devoted to resolving labor disputes, especially in protracted negotiationswith the more than 10 unions that represent health manpower.

2. To address some of these problems, policy instrumentscan influence the numbers and types of medical careers pursued, the geographicdistribution of medical personnel, and the quality of training over the medium to long term so that the profile of health manpower is better suited to the epidemiologicalprofile of the population. Within the public sector, policies affecting work conditions,career structures and remuneration could be restructured in order to improve incentives for productivity and to attract staff to areas of highest priority, such as certain areas of medicine, nursing, geographic areas, and types of facilities. This annex describes the current size and compositionof health manpower, personnelpolicy, productivityand training issues in the public sector. Where informationis available, health manpower in the private sector is discussed.

HUMAN RESOURCES IN THE PUBLIC AND PRIVATE SE7'TOR

Stock and Distribution

Informationon Health Manpower

3. Data on numbers, distribution,and work conditionsof health manpower are found in censuses, householdsurveys, and reports of graduates from educationalprograms such as medical schools. In the public sector, personnel registries and budgets also have staffing information.

1/ The discussionand all of the tables in this annex draw heavily from the background report by Vanessa Cartaya and Maria Helena Jaen, "El Personal de Salud en Venezuela: Evoluci6n y Perspectivas," Caracas, October, 1991. 118 Annex 6

Personnel registries have three limitations. First, as their function is essentially budgetary, data are not organized for the purposes of analyzingstaffing. They lack Informationabout the characteristics of personnel, and are fragmentedorganizationally because they are organized by contractual payments. Second, the data are not disaggregatedin a very useful way. They do not permit analyses by geographicregion or by type of facility (ambulatoryversus hospital). Finally, there are significant discrepanciesbetween the personnel registry and the actual volume and location of personnel. It is difficult to make comparisonsbetween the staffing situation in IVSS and MSAS because of differences in how the data are organized in the two institutions.

4. The number of positions budgeted in a Ministry is often used to estimate total employment. But this must be accompaniedwith several major caveats. First, in additionto positions reported in the budget, there are supernumerarypositions, estimated at between 7 and 10 percent of all personnel employed.-WIn addition, "suplentes"or substitutestafF are used heavily, but it is extremely difficult to quantify the size and compositionof this group of staff. In the case of laborers, the number of workers is only roughly estimated in the budget, because of how their collective contract appears in the budget. For all of these reasons, the number of positionsreported in the budget of MSAS or IVSS should be consideredthe minimumof persons working in that organization. Cartaya estimated that in 1990 the number of those actually working for the Ministry of Health exceededthe number of budgeted positions by about 20 percent. Because of these data limitations, a limited number of quantitativestudies have been done on health manpower.Y

Size and Composition

Trends in the 1980s

5. As in much of the rest of Latin America, there are distortions in the health manpower pyramid: a high proportion of specialistsrelative to general physicians, a high proportion of physicians relative to nurses, and a high proportion of lower level, untrained manpower relative to nurses and other paramedicalstaff. The number of physiciansincreased rapidly in the late 1970s and 1980s, as a result of large increases in medical school enrollmentsin earlier years. The outcome of increase in output over the 1970s and early 1980s is clearly shown in Table A6-1. The number of physiciansper 10,000 inhabitantsalmost doubled, increasingfrom 8.6 per 10,000 inhabitants in 1970 to 16.3 in 1988. The ratio of nurses and nurses aides also increased over the period, but at a less rapid rate. Overall, the number of doctors relative to nurses increased, aggravatingthe existing distortion between these two professions. In 1970, there were 1.7 physicians for every nurse. This increasedto 2.1 physiciansfor every nurse by 1988 (Table A6-1). In contrast to the Venezuelan health manpower profile of more than one physician to every nurse, PAHO recommendsa nurse to physician ratio of between two to four nurses per physician.

2/ Cartaya and Jaen, 1991, p. 50.

3/ See MSAS, Estudios Basicossobre el SistemaNacional de Salud, Caracas, 1974; Quezada, T. y Marta Rodriguez, Recursos Humanos en Salud: El Caso de Venezuela,Informe Final, mimeo, AVEDIS, Caracas, 1987; Andrade, A. Consideracionesacerca de los recursos de personal para el sector salud, MSAS, Caracas, 1984. 119 Annex 6

6. Since 1985, there has been an encouragingincrease in the numbers of graduating nurses and in the ratio of graduatingnurses to physicians, which has shifted from 100 graduatingphysicians to every graduatingnurse in 1986 to approximately14 physiciansper graduatingnurse in 1987 and 13 in 1988. It is still early, however, to evaluate the robustness of this trend, which will in any event take t.;ne to show up in the overall ratio of physiciansto nurses. When middle-levelpersonnel do not exist in sufficientnumbers, doctors (who cost much more to train and to pay) or untrainedpersonnel perform technicianor nursing-leveltasks or these tasks do not get done. As an outcomeof the growing supply of physicians, the decade of the 1980s saw a higher incidence of multiple employment among physicians and a greater incidence of temporaryemployment.

TableA6-1. Human Resourcesin Health, 1970-88

Human Resources per 10,000inhabitants 1970 1980 1982 1984 1986 1987 1988

Total 33.3 49.6 53.5 53.4 54.1 55.3 55.1 Physicians 8.6 10.8 12.1 12.3 13.9 15.5 16.3 Nurses 5.0 7.3 8.1 8.1 7.8 7.7 7.7 Nurses Aides 16.8 21.9 23.4 23.4 22.5 21.9 21.3 Dentists 2.0 3.2 3.3 3.4 3.7 4.0 3.8 Pharmacists .. 2.7 2.9 2.7 2.8 2.8 2.8 Veterinarianw .. 0.1 0.1 0.1 0.1 0.1 0.1 Engineers .. 0.2 0.2 0.2 0.2 0.2 0.2 Sanitary Inspectors 0.9 0.9 1.1 0.8 0.8 0.8 0.8 Nutritionists .. 0.2 0.2 0.2 0.2 0.2 0.2 Dietician .. 0.3 0.6 0.6 0.6 0.6 0.6 Patient History Librarian .. 0.3 0.3 0.2 0.2 0.2 0.1 Librarian's Aide .. 1.4 1.3 1.3 1.2 1.2 1.2

Ratios Doctors to Nurses 1.72 1.49 1.49 1.52 1.75 2.00 2.13 Doctors to Nurses Aides 0.51 0.45 0.52 0.52 0.62 0.71 0.76 Nurse Aides/Nurses 3.36 3.00 2.90 2.90 2.87 2.85 2.77

Note: .. indicates not available Source: MSAS, Anuarios de Epidemiologfa y Estadfstica Vital.

(ieographic Distribution

7. States have wide variation in the number of physiciansper 10,000 inhabitants,from 5.4 in Miranda to 36.7 in the Distrito Federal in 1988 (Table A6-2). Physiciansare most attracted to the Distrito Federal because it offers the most specializedfacilities and the highest concentrationof hospital beds. But the rate of growth of physiciansbetween 1980 and 1988 was the ieast for the Distrito Federal comparedto any other state, probably reflecting the growing underemploymentand unemploymentin the Distrito Federal. The number of physicians per 10,000 inhabitantswas lowest in the states of Barinas, SucrGand Miranda. TabIeA6-ZDk*f-budtkaHe Manpow byStat19O-08 Ratio: Nurse Numberof Physiciam per Ratio: Nurses to Assistants to Beds per 19),000 Physici 10,000iabiants Physicans Physias Inhabianms State 1980 1988 1980 1988 1980 1988 1980 1988 1980 1988 Ditrito Federal 6,174 9,441 273 36.7 0.7 0.4 1.7 1.1 54.6 52.0 Apure 146 335 6.9 13.8 2.5 12 6.5 32 143 14.0 Anzodtegui 476 996 6.9 119 1.1 0.8 5.7 3.1 19.8 22.8 Aragua 569 1,367 6.3 11.0 0.9 0.6 1.1 15 160 12.6 Barinas 189 382 5.5 8.7 OA 09 2.5 1.8 l1.9 10.1 Bolfvar 532 1,087 8.1 11.7 0.9 0.7 2.5 1.9 27.8 18.1 Carabobo 1,034 2,224 9.5 14.9 0.7 0.4 2.0 1.2 30.0 24.4 Cojedes 151 337 11.0 18.3 0.6 0.4 4.3 3.0 169 15.7 LaM 698 1,480 7.3 12.5 0.8 0.6 2.9 2.4 19.9 19.5 M6zida 700 1,317 14.5 22.2 0.5 0.3 1.4 0.7 25.3 21A Miranda 414 1,027 2.9 SA 0.3 0.2 1.7 1.0 13.3 12.2 Monagas 335 591 8.4 12.1 0.6 0.5 2.2 2.0 21A 17.5 Nueva Esparta 185 398 9.6 15.1 0.6 0.6 1.8 1.5 18.6 13.9 Portuguesa 256 654 5.9 11A 0.6 0.5 2.2 1.1 15.6 12.3 Sucre 421 743 7.0 10.3 0.9 0.6 2.4 1.8 21.0 18.7 Tlchira 470 1,090 7.0 133 0.9 0.7 2.3 1A 23.9 26.4 Trujillo 432 820 9.3 15.3 0.5 OA 3.0 1.9 21.6 30.0 Yarmcuy 209 445 6.9 12.2 0.6 0.4 2.2 1.2 32.4 32.0 Zulia 2,095 3,940 11.8 18.6 0.5 OA 13 1.0 33.9 32.9 T.F. 98 223 13.1 12.9 0.5 OA 3.1 1.7 26.8 19.6

Sour: MSAS. Anuario de Epidemiologla y Estadistica VitaL

o% 121 Annex 6 TableA6-3. PublicSector Personnel and Pesonnel in Health, by Institution, 1983,1986, and 1989 (0W of budgetedpositions)

Leveis 1983 1986 1989 Positions Percent Positions Percent Positions Percent

Public Sector Total 895.2 100.0 931.4 100.0 1037.2 100.0

Health Sector Total 128.7 14.4 150.6 16.2 173.2 16.7 MSAS 76.5 8.5 95.1 10.2 102.8 9.9 Autonomous Institutes under MSAS 16.2 1.8 16.8 1.8 18.0 1.7 IVSS, health 29.3 3.3 31.7 3.4 43.4 4.2 IPASME/a 5.3 0.6 6.0 0.6 7.3 0.7 IPSFA/b 1.5 0.2 1.2 0.1 1.8 0.2

Source: OCEPRE, Consolidated Public Sector Budgets. a. Institute for Provision of Social Institute for Ministry of Education Personnel b. Institute for Social Services for Armed Forces

Public/PrivateMix

8. The most recent data that disaggregatepublic and private sector employment in health is for 1987. In that year, 217,400 people were reported to be employedin the ihialth sector, with about 26 percent of the total in the private sector. There are many employmentpatterns. Many physicians hold multiplejobs in the public seetor, or a mix of public and private sector employment. According to a 1988 study of a sample of physiciansin the metropolitanarea of Caracas, only 20 percent of physicians reported that they worked solely in the private sector. About 27 percent reported having both public and private sector employment,leaving 53 percent in the public sector.Y Multiple employmentcan be a problem because it is associatedwith absenteeismin the public sector.

9. Public sector employmentfills an importantsocial and political function in Venezuela. Only in this context can the sharp increase in employmentin the Ministry of Health and IVSS over the period 1982to 1989 be understood, because there was no major expansion in health fcilities over the period. The number of MSAS employeesjumped by 30 percent, or 26,000 employeesover the period. Total IVSS employeesin health rapidly grew by about 60 percent, or 16,000 employees. Table A6-4 presents the number of positions in MSAS from 1982 to 1991 by job category. Laborers figured prominently in new employment. Of the 26,000 new positions created from 1982 to 1989, about 12,000 were laborers, 5,000 were in administrationand the balance were professionals (physicians, nurses, nurses aides and other staff). Public health sector employmentgrew more rapidly than public sector employmentoverall in the public sector in the 1980s, reaching 17 percent of all public sector employment in 1989 (Table A6-3).

4/ AVEDIS, 1988. 122 Annex 6 Staffing Profiles in the Public Sector

10. Of the 173,000 public employeesi'in Jhe health sector in 1989, about 70 percent were direct employeesof the Ministry of Health or employeesof autonomousinstitutes under MSAS, 25 percent were IVSS employees,four percent were IPASMEemployees, and one percent worked for the Armed Forces. These estimates excludeemployment at the state and municipallevel in health. As is true in the public sector overall, employmentis highly centralizedat the federal level. Health employmentat the state and municipallevels is relatively minor, except for local governmentin the metropolitanarea of Caracas (which operates several hospitals and health centers).

11. While further analysis is needed of the staffing profile of the Ministry of Health, it appears that the major increases in staffing in MSAS over the period did not address key problems in the health sector. Overall, about 9i percent of all staff work in health services, the remainder in general administrationand sanitation and endemicdisease control programs. Health facilities appear to have absorbed the bulk of the increase in staff. Laborers figure largely in the increase (making up about 46 percent of the total). It is notablethat despite the increasingproblems from malaria over the period (see Annex 1), and the overall large increases in employmentin MSAS, the number of employeesin sanitation and endemic disease control programs actually declined in absolute terms, from about 8,000 employees in 1982to 6,500 in 1991. Another key area that experienceda loss in personnel was in the area of planning, where the number of staff at the end of the decade was less than half what it wa3 in 1982.

12. The major problems in the size and compositionof health manpower in the public sector are the high volumes of personnel overall (comparedto internationalstandards), the deficit of personnel in certain categories, and the relatively high proportion of laborers to professionalstaff. In the area of health services, approximately70 percent of all staff in both MSAS and IVSS work in hospitals. Physiciansare concentratedin curative medicine specialties. There are relatively few physicians or other staff with training in health planning, epidemiology,health administration,or occupational health. Specialistswell outnumber general medicine (Table A6-5). Paramedicalstaff such as nurses are outnumberedby physicians0,and there are few staff in policy, planning and evaluationpositions. Data are unavailableto estimate total staff per bed in hospitals, but several hospital directors reported ratios of approximatelyfive employeesper bed, which are very high by internationalstandards.

13. Overall, the staff profile in MSAS and IVSS is dominated by laborers and physicians, and middle-levelpersonnel are poorly represented(see Figure A6-1 for IVSS data). If nursing aides are excluded, in MSAS and IVSS there are only about 1.5 professionalstaff for each laborer.

14. Another major problem is the difficulty in rigorously quantifyingthe staffing situation overall in MSAS and IVSS. This is complicatedby the largely manual system of personnel administration, the way laborers are handled in the budget, and the extra staffing from supernumerarypositions and substitutes. It is also difficult to establishthe total numbers of staff working at the level of health facilities from the personnel administrationdata. Not all personnel paid by the facility are working in

5/ Budgeted positions are taken as a proxy for the number of employees. fi/ The nursing division of MSAS estimated that it would need to contract about 6,000 additional nurses in 1991 to cover the deficits in ambulatoryand hospital care at the national level in MSAS. TabieA6-4. Posiionsb.yPrograma and Level, Mwiuiy ofHealth, 1982-1991

Yewr 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991

Totad 76,670 76,466 80,003 83,098 95,093 98,356 100,964 102,8Q4 98,163 100,167 Employees 34,265 33,300 32,569 35,736 46,359 47,231 48,0S8 48,547 43,516 44,230 -Directors 54 64 65 69 60 61 62 63 79 75 -Profesiond Staff 25,674 24,862 24,735 27,189 33,467 34,106 35,541 35,281 30,437 28,205 -Administrative Staff 8,537 8,374 7,769 8,478 12,832 13,064 12,905 13,203 13,000 15,950 Workers 42,405 43,166 47,434 47,362 48,734 51,16S 52,4S6 54,29S 54,677 S5,937

GeneraldAdmunisration 2,889 2,796 2,600 2,96S 2,402 2,056 2,101 2,082 2,052 2,043 Employees 1,948 1,8S5 1,659 1,940 1,772 1,6 1,667 1,661 1,605 1,595 -Direcms 16 16 19 18 22 23 24 25 36 34 -Profeulonal Staff 313 356 372 347 454 648 70S 708 624 456 -AdminimurativeStaff 678 S42 327 550 666 517 S04 507 498 657 Wades 941 941 941 1,025 630 434 434 421 447 448

Health Sevices 66,62 66,189 70,693 73,514 8S,666 8B,962 91,672 93,S32 90,457 92,063 Empos 29,339 28,734 28,534 31,326 41,711 42,482 43,783 43,789 40,497 40,853 -Directors 37 40 38 43 30 30 30 30 3S 33 -Prolesional Staff 23,567 22,909 22,43S 24,928 31,081 31,568 32,32 32,S40 28,S27 27,032 -Administrative Staff S,735 5,78S S881 6,3s5 10,600 10,884 11,221 11,219 11,635 13,788 Worker 37,323 37,45S 42,339 42,188 43,9S5 46,480 47,889 49,743 49,960 S1,210

Sanitation and Endemk Deases 8,060 8,422 7,651 7,644 7,65S 7,694 7,625 7,649 6,130 6,509 Employees 3,919 3,652 3,497 3,49S 3,S06 3,561 3,492 3,518 1,861 2,230 -DIrectors 1 8 8 8 8 8 8 8 8 8 -Professional Staff 1,794 1,597 1,928 1,914 1,932 1,890 2,304 2,033 986 717 -Administrative Staff 2,124 2,047 1,561 1,573 1,566 1,663 1,180 1,477 867 1,505 > Workers 4,141 4,770 4,154 4,149 4,149 4,133 4,133 4,131 4,269 4,279 souro MSASBudgets, various yeami 124 Annex 6

TableA6-5. Distrilbutionof HealthManpowerbyCategoryIVSSandMSAS, 1981,1984 and 1990

1981 1984 1990 Categories MSAS IVSS MSAS IVSS MSAS IVSS

Physicians 7,157 3,994 9,448 5,540 11,394 7,365 - in training 2,735 412 4,033 1,223 4,712 1,744 - general medicine 144 574 207 1,141 992 1,065 - specialists 4,278 3,008 5,208 3,176 5,690 4,556 Nurses 18,679 5,757 23,648 8,351 26,780 13,970 - Graduate 4,679 1,539 6,831 2,398 7,991 4,605 - Aides 14,000 4,218 16,817 5,953 18,789 9,365 Bioanalysts 768 456 1,145 545 1,474 885 Dentists ...... 1,189 915 Pharmacists ...... 159 156 Nutritionists ...... 316 140

Ratios Physicians/Graduate Nurses 1.53 2.60 1.38 2.31 1.43 1.60 Nurses Aides/Graduate Nurses 2.99 2.74 2.46 2.48 2.35 2.03 Physicians in Training/Total Physicians 0.38 0.10 0.43 0.22 0.41 0.24 Specialized Physicians/AllPhysicians 0.60 0.75 0.55 0.57 0.50 0.62

Note: .. indicates not available. Source: Quezada y Rodriguez, 1987,Personnel Registries, 1990.

the facility-they may be assignedto another facility or on extended absences.7' The facility may also have workers paid by another facility, or by the local level government.

Personnel Policies in the Public Secto

15. The legal framework for public administrationconsists of the Ley del Trabajo (Work Law) under the jurisdiction of the Ministryof Labor, that regulatesemployment for laborers, and the Ley de Carrera Administrativo(Administrative Career Law), under the Oficina Central de Personal (Central Personnel Office), for professionallevel public servants. Public employmentis also regulated by collectivecontracts negotiatedbetween unions and the government.

7/ Many absences occur following requests for disability leave or retirement. The procedures to handle these requests are very lengthy, and while the request is in process the worker generally does not report to work. 125 Annex 6

FigureA6-1. Profle of Health SersiceEmployees, IVSS, 1988

12

Laborers 10 _ Physicians Nurse Aides

8

6

Nurses 4

2 - Dentists LabTechnicians Pharmacists Dietkians 0 Source: IVSS, Anuario Estadistico

16. The Oficina Central de Personal has rigid regulationswith respect to job creation. It is difficult if not impossibleto fire non-performingpersonnel. The governmentcan reorganize a Ministry in order to eliminate personnel, but the entire ministry must be restructured and certain positions abolished. Followingthis reorganization,the Oficina Central de Personal has the responsibilityfor redeployingthe people who lost their positions. The IVSS is not as strictlysubject to the Ley de Carrera Administrativabecause it is an autonomousinstitute. This also means that it has more flexibility in job creation.

17. The governmentmust negotiate salary and working conditionswith the many unions and professional associationsthat represent the workers. Table A6-6 lists the ten major unions in the health sector by number of members in 1991. The Federaci6n Medica has carried out collective bargainingon behalf of physicians since 1982. In addition, eaci physician specialty has a professionalassociation representing their interests. The great diversity of regimes and conditionsof work for pub.ic sector workers constituteone of the biggest obstacles for rational personnel management. Between MSAS and IVSS there are 15 collectivecontracts, without includingpersonnel who are financed by the states but work in MSAS establishments.

18. According to the 1982 law governing medicine, physicians are specificallyprohibited from holding more than two positions in public health facilities, except in populationsof under 5,000 126 Annex 6

inhabitants. This law specificallyprohibits holding two jobs with overlappinghours. Nonetheless, the practice of holding several public sector jobs (and holding all jobs only through frequent absences) is believed to continue.

19. It is also difficult to redeploy labor to their most productive uses because union agreements state dhatpersonnel cannot be transferred from one health facility to another, or from one function to another, unless the employee and the union are in agreement. This rigidity means that very often new workers are hired instead of redeployingexisting workers.

Productivity

20. Labor productivity is reduced by strikes, absenteeism,and the abuse of sick leave. It is also frequentlyreduced by interruptions in the availabilityof complementaryinputs such as drugs, materials, and equipment. Absenteeism, disabilityclaims, and abuse of sick leave are commonin MSAS and IVSS. In order to fill absences, health facilitiesuse substitutesto fill in for missing staff.

TableA6-6. Selected Unions in the Health Field and Membership, 1991 Union Numberof Members Federaci6nMedica 25,376 Federaci6n de Bioanalistas Federaci6n de Odont6logos 8,735 Federacidn de Enfermeras 19,655 Federaci6nde Farmaceutas 5,769 FETRASALUD(laborers) SUNEP/SAS 30,000 Asociaci6nAuxiliares de Enfermeria Colegio InspectoresSanitarios 1,868 Colegiode Nutricionistasy Dietistas 1,775 Note: .. indicates not available. Source: Cartaya and Jaen, 1991.

Physician productivity is also considered low. As one measure, IVSS has comparedoutpatient visits per physician hour by type of service and found them to be far from the norm set by the institution (Table A6-7). For example, physicianssee on average two patients an hour in pediatrics while the norm is twice that. Rigorous analysis of the reasons for the discrepancyneeds to be undertaken so that steps can be taken to address the problem.

21. There is no register of time lost to strikes by job category, but frequent strikes in the health sector have had an enormous impact on the efficiency and quality of services and health programs. Strikes and work stoppages of different groups of workers have effects ranging from complete 127 Annex6 TableA6-7. IVSSOutpatient Visits per PhysicianHour by Type of Service,1985 Specialty HealthCenters Hospitals GovernmentNorm GeneralMedicine 3.54 3.83 6 Pediatrics 2.09 3.19 4 Obstetrics-Gyn. 2.47 2.53 4-5 FamilyMedicine 1.83 2.36 OccupationalHealth 1.07 1.22 6 Note: .. indicatesnot available. Source: IVSS,Estadfsticas Mddico Asistenciales, MSAS, Resumen dt Indicese Indicadoresde Atenci6nMedica

paralysisof servicesat the nationallevel to disruptionof particularservices or specifichealth facilities.Three recentstrikes provide examples of the type of impactstrikes can cause. IVSS physiciansheld a six monthstrike during 1990-91over the terms of their collectivecontract. During this longperiod IVSS facilities only attendedemergencies. Another recent strike of lab workersin IVSSfacilities lasted four months. Duringthe periodall IVSSlabs wereclosed. Even emergency serviceswere excluded, and IVSShad to contractout essentiallab work to privatelabs. Endemic diseasecontrol programs which depend critically on continuitywere interrupted by a six weekstrike in 1991related to paymentof per diemstipends.

Pay and Working Conditions

22. Salariesdeclined dramatically in real termsduring the 1980sin the Ministryof Healthand IVSS. Thisdrop is not consistentacross the board, and higherlevel staff have been the most adverselyaffected. Thishas resultedin a narrowingof the differencebetween the lowestand highest paid employees.According to the NationalHousehold Survey, private sector wages declined by about55 percentin real terms from 1982to 1990. In TableA6-8, one can see that the deterioration in wagesin the publicsector was generallyless than in the 55 percentdecline in the privatesector. For higherlevel manpowerin health,such as physiciansand graduatenurses, however, the wage declinewas greater than in the privatesector. In additionto the fall in wages,another demoralizing aspectof salarypolicy is the fact that it is not linkedto individualperformance. 23. Nursesface particularlyunattractive work conditions.As a result,many leave the field over timeto find jobs that are lessdemanding and higherpaid. Graduatenurses are classifiedeither as graduatenurses or nursesaides, depending upon their levelof education. Nurseshave at least a universitydegree and sometimesup to a master'sdegree. Nurseaides have at least nine yearsof education,plus one year of specialtraining. Salarydifferentials are not large betweenthe two categories,despite the diffetencesin qualifications.Formally, nurse aide positionsare classifiedas laborers,and there is no career pathto becomea nurse. 128 Annex 6

TableA6-8. Public AdministrationSalary Scales, 1982-1989, VariousPositions, (f982=100) Job Category 1982 1986 1989 Receptionist 100 101 82 Pharmacist Assistant 100 101 77 Lab Assistant 100 100 62 Nurse Level III 100 81 40 Nurse Chief, IV 100 80 38 Physician, Chief, Level IV 100 86 41 Source: Presidential Decrees, reported in Cartaya, 1991.

24. Managers also face especiallyunfavorable working conditions. A hospital is a very complex institutionand requires a high level of skill to manage well. Yet hospital directors, who are required by law to be physicians, receive low salaries. The positionsare often filled politically, and for this reason are unstable. Managers in the health sector do not have a career path, nor favorable benefits. These positions are frequentlyexempted from overall salary increase decrees, depending instead on less frequent changes in salary scales for managers in public administration. Given the limited number of managers in the public health sector, the financial cost of raising salaries to more attractive levels would not be great. Clear standardswould need to be establishedso that managers with the appropriateexperience and training were selected. Many countries do not require that hospital managers be physicians, but insiw-i h; ;pital administratorswho are then paired with a chief physician who manages the clinical aspects of sit hospital. This model could be considered for Venezuela.

Training Programs

25. In-service training programs do exist in the public health sector, although there are indications that they could be expanded and improved. Civil service training of all types is nominallyunder the National Training System, which is affiliated with the Central Personnel Office of the President. Organizationand implementationof training programs, however, is done by individualgovernment entities. MSAS and IVSS both run in-servicetraining programs for their personnel. Both in coverage of personnel and budgetary allocationsto training, IVSS appears to have the more establishedprogram. In the second half of 1990, IVSS trained a total of 2,086 participants at the technician level, versus a total of 458 participantsin all types of training within MSAS during the same period. This low participationcan be explained in large part by the minimal MSAS training budget, which in 1990 amountedto a total of 7 bolivares per person employed, or about US$ 0.15. There is some cooperationbetween the two institutionsin the training of nurses, nutritionists,dental assistants, and other auxiliary personnel. Within IVSS, however, there is a split between training for doctors, which covers substantiveareas, and training for other personnel, which tends to be predominantlyadministrative and unrelated to substantiveproblems in the health sector. Within MSAS, the Arnaldo Gabald6n School of Malariologyhas developeda fairly integrated training program for personnel working in endemicdisease research and control. 129 Annex 6

26. With the exceptionof a few programs such as those run by the Arnaldo Gabaldon School of Malariologyand the School of Public Health at the Central Universityof Venezuela, most formal graduate education and fellowshipsin health are also heavily oriented toward clinical studies, with low participation in areas such as public heaith, administration,or epidemiology. Fellowship awards appear largely demand-driven,with few defined priorities or criteria as to areas of support.

27. Individuals select training programs and career paths based on many factors, including expected future employmentconditions, training costs, and training quality. All of these factors need to be taken into considerationin developinga strategy for training within a broader strategy of meeting the needs of the health sector. The governmenthas several instrumentsfor affecting the quality and quantity of medical training. It can use its salary policies to affect how attractive certain careers are in the public service. It can grant scholarshipsfor certain types of training, and reduce or eliminate educationalsubsidies for programs where there is oversupply. It can use higher education funding and accreditationto control the growth of enrollmentsin medical schools. It can also use salary policies to attract physiciansto underserved areasY The program at the National School of Public Health could be strengthenedand modernizedto improve training in epidemiology,health services administration,hospital cost accounting,and health policy and planning. Many problems in the profile of health manpower in Venezuela, such as the shortage in number of nurses, cannot be addressed by changing training programs alone. In additionto expanding training opportunities, employmentconditions must be improved so that the career path is more attractive. Additionally, if career opportunitieswere improved, fewer already trained nurses would drop out of the field as well.

28. Some of the problems that should be addressed in a national health manpower program (in concert with measures to change employmentconditions) include:

- the heavy orientation of physician training towards clinical specialties, preparing physicians for curative hospital care, with insufficientatte.ntion to postgraduatetraining in public health and epidemiology. e the shortage of nurses throughout the country.

* geographic distributionproblems in health manpower.

* lack of skilled manpowerin hospital engineering,hospital management(at the top and middle levels), health services administration,hospital finance, nutrition, policy, planning, and evaluation.

CONCLUSIONS AND RECOMMENDATIONS

29. Health manpower in the public sector is characterizedby severe over staffing by international standards in some job categories, and a severe shortage of staff in many others. There are few incentiveslinking salary and performance, and productivityappears to be very low. Complex administrativeprocedures and lengthy collectivebargaining make managementof personnel very difficult, to the detriment to the quality and efficiencyof health services.

A/Venezuela already requires that physiciansserve in rural areas for one year following their medical education. 130 Annex 6 30. In the short term, administrativereforms are needed to simplifypersonnel procedures, computerizebasic administrativeroutines, and decentralize some functionsto the local levels. Personnel policies need to be restructuredto create a system of incentivesto attract personnel into areas of greatest priorities. A key aspect of productivity is control over staff. Health facility managers need greater authority over the use of their staff, and greater accountabilityover outputs (see Annex 7 for a discussionof this in the hospital sector). A human resources training plan needs to be establishedthat will address health manpowerproblems over the mediumto long term-both through medical education and ongoing training programs. This training plan should have as its objective developingmanpower plans that reflect the health care needs of the population, based on (a) the epidemiologicalprofile of the populationand (b) analysis of cost-effectiveinterventions and the personnel best suited to carry out those interventions. These reforms should strive to improve the balance between higher level and middle level personnel, and address the job categories most in deficit, includingepidemiology, hospital administration,public health, and health policy and planning. Over time, measures need to be taken to optimize the numbers of staff across categories by addressing both shortagesand excesses. 131 Annex 7

ANNEX 7

HOSPITAL ORGANIZATION, FINANCING AND RESOURCE USE&

1. In Venezuelathe largest proportion of public spendingfor health services currently goes to hospitals. The public hospital sector is widely perceived as 'in crisis", with very low levels of quality and efficiency. This annex examineshospital financingand resource use in Venezuelain order to suggest ways to increase the internal efficiency and quality of services of hospitals, as well as ways to improve hospital financing. The emphasis is on two largest public providers, the Ministry of Health (MSAS) and the VenezuelanInstitute of Social Security (IVSS); discussionof the private hospital sector is limitedby lack of data.

2. Basic measures of hospital efficiency in public hospitals, such as average length of stay, occupancyrates, and ratios of staff per bed, are poor. Public hospitals have about five staff per bed, well in excess of internationalaverages of between two and four. Hospital directors lack the authority, managementtools, and informationsystems needed to adjust inputs to improve efficiency. Certain personnel categories such as laborers are very uverstaffed;other categories such as nurses and middle-levelmanagers are critically understaffed. Poor quality and inefficiencyalso stem from shortages in inputs such as drugs and materials, and from frequent strikes.

3. To address these problems, major changes in hospital organizationand managementare needed, supportedby increasedautonomy, managementinformation systems, and more assured financing. At the hospital level, more autonomy is needed to hire and fire workers, to increase salary scales for directors and mid-level managers, to managethe budget, and to contract directly for services. Hospitals then need to be held accountablefor their performance.

DESCRIPTION OF THE HOSPfTAL SECTOR

4. Accordingto the 1990 hospitalcensus, there were 608 hospitals in Venezuela. While the private sector accountedfor more than half of all hospitals (344), it representedonly 23 percent of all beds. Overall, there were 2.9 beds per 1000population.- This simple indicator of beds per capita does not mean much alone. The measure of how well the hospitalizationneeds of the population are met depends as much on the age distributionand epidemiologicalcharacteristics of the population as on the characteristicsand use of the existinghospitals (type of hospital and services offered, eligibility of the populationfor hospital services, hospital occupancyrates, mean lengths of stay, etc).

1/ This annex draws heavily on two background papers: Lluis Bohigas, "Los Hospitales en Venezuela", Barcelona, June, 1991, and Joao Urbano, "Analise da Situagio do Sector Hospital na Venezuela: Os Sistemas de Informagao", Lisbon, May, 1991.

2/ This compares with 1.3 for Mexico (1975), 1.7 for Colombia (1980), 3.4 for Costa Rica (1980) and 3.4 for Chile (1980) as reported in Howard Barnum and Joseph Kutzin, Public Hospitals in DevelopingCountries: Resource Use. Cost. Financing (Draft), World Bank, November, 1990. 132 Amex 7

TableA7-1. Distnrbutionof PublicandPriateHospitalsandHospitalecds, 1990,byState

Public Private Percentage Beds 1990 Public Private Hospital Hospital Public 1000 State Population Hospitals Hospitals Beds Beds Beds Population

Federal District 2,103,661 38 103 9,327 4,244 69% 6.5 Anzoategui 859,758 12 22 1,268 470 73% 2.0 Apure 285,412 6 6 372 39 91% 1.4 Aragua 1,120,132 12 16 1,636 248 87% 1.7 Barinas 424,491 7 5 505 76 87% 1.4 Bolfvar 900,310 10 16 1,605 332 83% 2.2 Carabobo 1,453,232 13 16 3,310 397 89% 2.6 Cojedes 182,066 5 1 380 10 97% 2.1 Falc6n 599,185 8 9 1,060 164 87% 2.0 Guirico 488,623 10 16 1,053 708 60% 3.6 Lara 1,193,161 12 19 2,214 507 81% 2.3 Merida 570,215 14 14 1,487 155 91% 2.9 Miranda 1,871,093 14 15 2,503 975 72% 1.9 Monagas 470,157 9 4 894 82 92% 2.1 NuevaEsparta 263,748 5 2 485 39 93% 2.0 Portuguesa 576,435 9 6 857 93 90% 1.6 Sucre 679,595 13 7 1,330 224 86% 2.3 Tachira 807,712 13 16 1,600 647 71% 2.8 Trujillo 493,912 14 7 1,555 159 91% 3.5 Yaracuy 384,536 6 3 7.40 437 63% 3.1 Zulia 2,235,305 31 39 5,339 2,178 71% 3.4 T.F.Amazonas 55,717 1 0 80 0 100% 1.4 T.F.Delta Amacuro 84,564 2 2 190 39 83% 2.7 Federal Dependencies 2,245 0 0 0 0 0% 0.0

Source: Mnistry of Health, HospitalCensus, 1990. 133 Annex 7

5. The availabilityof hospitalbeds varies greatly by state. It is highest in the Distrito Federal, at 6.5 per 1000 population(Table A7-1). This high ratio is partially explainedby the existence of specializedreferral facilities in Caracas serving a broader population, and by the heavy concentration of private sector hospitals in Caracas. States with a relativelyhigh availabilityof beds include Guarico (3.6), Trujillo (3.5), and Zulia (3.4). In coitrast, those with the lowest ratios include Apure (1.4), Barinas (1.4), Portuguesa(1.6).

6. The Ministry of Health is the single largest public hospital service provider, although several other institutionsprovide hospital services (Table A7-2). The Ministry of Health has hospitals in every state, and hospitals ranging from Type I to Type IV. Type I hospitals are the simplest. They are intendedto serve up to 20,000 inhabitantswith primary and secondary medical attention. Type I hospitals have between 20 and 60 beds. They have laboratory and X-ray services and emergency care. 'Type II hospitals have between 60 and 150 beds, and serve between 20,000 and 100,000 inhabitants. They provide primary, secondary, and some tertiary care. Type III hospitals are intendedto serve between 60,000 and 400,000 inhabitants. Type IV hospitals are teaching hospitals for populationsof more than 100,000, with at least 300 beds. MSAS beds are weighted heavily towards the more resource-intensiveType III and IV hospitals: 37 percent of all beds are in Type IV hospitals, and 30 percent of all beds are in Type III hospitals (Table A7-3). SpecializedMSAS hospitals are distributedacross psychiatry, oncology, maternal child health, dermatology, tuberculosis, geriatrics and nutrition.

TableA 7-2. Hospitalsand Beds by Institution, 1986

Number of Total Beds per Hospitals Beds Hospital

MSAS 176 26,42b 150 IVSS 29 5,748 198 Municipalities 17 3,288 193 Ministry of Defense 8 1,106 138 Foundations 24 1,233 51 For Profit Private 287 9,744 34 Total 541 47,535 88

Source: MSAS, Census of Health Facilities, 1988.

7. IVSS hospitals are the second largest public provider of hospital services (Table A7-2). They tend, on average, to be larger than MSAS hospitals, in part because IVSS has proportionatelyless small Type I and II hospitals. IVSS has hospitals in the Distrito Federal and 15 states (Table A74). TableA7-3. M HASHosptalsndBudgetedHstalBedsbySpeciality, 1990

Leveland HosptlTye Number - Sd--Spa------of Beds Genea Psychiatry Onwkg MCHIa/ Dematol T.B. Geriatrics Nutrition Toud

Type4 14 Beds 8,210 14 8,210 Type 3 16 7 1 1 2 1 28 Beds 3,899 2,034 170 177 360 125 6,765 Typc2 30 2 1 3 3 1 Beds 3,048 40 m 100 360 366 150 4,246 Type 1 75 3 2 1 81 Beds 2,551 74 120 20 2,765 <20beds 24 Beds 288 24 288 Total 159 12 2 4 2 4 3 1 187 Beds 17,996 2,330 270 537 360 491 270 20 22,274 a. Maternal-childhealth. Source: Ministryof Health

-J TableA7-4. Distnbutionof IVSSFacilitiesbyState, 1990

Hospitals AmbulatogServices Benefficiaries States Type I Type II TypeIII Type IV Type I Type II Type III

D. Federal 1 4 1 6 7 7 2,041,078 Anzoategui 2 2 Apure 230,946 1 19,550 Aragua 1 1 1 2 437,476 Bolfvar 1 2 1 7 419,707 Carabobo 1 1 3 6 1 698,785 Cojedes 2 36,018 Falc6n 2 1 2 162,803 Guhxico 1 1 50,220 Lara 1 1 1 304,671 Miranda 2 1 1 4 2 1,291,992 N. Eparta 1 1 82,057 Portuguesa 1 70,496 Tachira 1 1 2 149,757 Trujillo 1 1 1 1 91,069 Zulia 2 1 5 2 594,201

Sourc IVSS StatwticsDivision, 1990. 136 Annex 7

8. MSAS manages hospitals constructedby the federal governmentas well as some hospitals that were constructedby states and municipalitiesand later transferred to MSAS.-' Only 17 hospitals are run at the municipalitylevel, and they tend to be large. The private sector is made up of a mix of organizationaltypes. Some are hospitalsbuilt by companiesfor their employees. Others are physician run and are financed by private insurance or direct payments by individuals.

Coverage

9. The majority of the populationhas access only to public hospitals. MSAS hospitals serve the populationnot covered by other public or private systems. They also serve some formal sector workers who are excluded from IVSS health services coveragebecause they live in areas without IVSS facilities, or who have IVSS coverage but still choose to use MSAS facilities for convenience. In theory, IVSS hospitals are only open to formal sector workers who contribute to the system and their dependents. Distinctionssuch as these are blurred in practice. IVSS emergencyservices are open to all, and a high proportion of hospital admissionsare classifiedas emergency. In addition, coverage is not verified, even for elective procedures, in some IVSShospitals and ambulatory facilities. Despite the overlap in coverage, IVSS and MSAS do not coordinateplanning and policy- making. Witi )ut nationally representativehousehold survey data it is difficult to estimate the size of the population served by private hospitals. Probably less than 20 percent of the populationrelies on private hospital services, either through private health insurance, employer-providedservices, or direct payments. In addition, a small proportion of the populationseeks hospitalservices outside of Venezuela.

Hospital Finandng

10. MSAS hospitals are financedprimarily by the federal budget. A small portion of financing also comes from patient contributionseither in kini (purchase of necessary drugs and supplies)or through monetary contributions,contributions from the state, and from hospital foundations(that receive contributionsfrom businesses, the community,and patients). The total value of direct monetary contributionsis not known, but is very small. Nonetheless,the contributioncan be significantgiven the hospitals' very restricted budget for drugs and equipment. Over the course of the 1980s, MSAS hospitals have faced extreme budgetary pressures: absolute levels of financingfell by about 40 percent over the decade (see Annex 5 for a more detailed description.)

11. IVSS hospitals are financed primarily from the social security medical assistance fund which is made up of contributionsfrom employees,employers, and the government. As in MSAS hospitals, patients frequently have to contributeto their medical care by purchasingdrugs and materials. Unlike in MSAS hospitals, IVSS hiospitalsare not permitted to directly recover costs from patients through user fees. They are also not permitted to create affiliatedfoundations to receive communityand business contributionson behalf of the hospital. IVSS health spendingdeclined in real terms by about 12 percent over the decade. Budge..arypressures were alleviatedby the fact that the social security medical assistance fund ran a sizeabledeficit, drawing on payments earmarked for pensions in order to remain solvent.

2/ Many hospitals were originally run at the state and municipal levels. Prior to 1937, for example, the Ministry of Health did not have any hospitals. When growing oil revenues went to the federal level, however, many states and municipalitiestransferred hospitals to the federal level. 137 Annex 7 12. Private hospitals are financedlargely by individualpayment for services and by private hospitalizationinsurance. Data on private hospital expendituresare not available. However, total expenditureson hosritalization insurance amountedto US$164 million in 1989 or about US$9 per capita. Of this, 70 percent was group insurance and 30 percent was individualpolicies.

EFFICIENCY AND QUALITY OF PUBLICHOSPITAL SERVICES

13. There is the widespreadperception in Venezuelathat the public hospital sector, which makes up the vast majority of beds and serves the majority of the population, is "in crisis" and needs fundamental reform. Indeed, quantitativemeasures of hospital efficiency such as average length of stay, number of staff per bed, and occupancyrate, indicate low efficiency (high average lengths of stay and number of staff per bed, low occupancyrates, especially for Type I and II hospitals), both in IVSS and MSAS hospitals. Average length of stay is extendedby problems includingpoor hospital organization, long waits for diagnostictests, lack of operating room availability,supply shortages, and strikes, etc. Quantitativemeasures of quality of services, such as hospital infectionrates and case-adjustedmortality rates, are not available. But quality of service is undoubtedlygreatly affected by factors such as labor strikes, lack of supplies, long waits for diagnostic services and operating rooms, lack of skilled personnel in certain categories and budget problems that frequentlyshut down entire departments of hospitals for extendedperiods of time. Quality is regarded as equally poor across IVSS and MSAS hospitals, althoughIVSS hospitals appear to have less of a problem with interruptionsin drugs and other supplies. Because of inadequatematerials and drugs, most patients in MSAS hospitals directly purchase some or all of the drugs and supplies needed for their treatment. This introduces delays in treatment, and is a difficult burden for very low-incomepatients.

14. Some of the main problems limiting the quality and efficiency of hospital services are: (1) declines in absolute levels of financing, (2) difficulties in substitutionof inputs, (3) lack of financial and administrativeautonomy, (4) lack of managementtools and managementinformation systems, (5) lack of coordinationbetween public providers and between different levels of service, and (6) inefficientprocurement and distributionof drugs and materials.

Indicators of Hospital EMciency

15. Common measures of hospitalefficiency include unit costs of treatmentby diagnosis, mean length of stay adjusted for case mix, hospital occupancyrates, and staffing ratios (number of staff per bed or occupied bed). Because of lack of hospital cost accounting, unit costs are unavailablein public hospitals in Venezuela. Mean length of stay is available and can be comparedby departnent across individualhospitals and between MSAS and IVSS more generally. Table A7-5 presents mean length of stay and occupancyrates in MSAS and IVSS hospitals. Indicators are roughly similar across MSAS and IVSS. MSAS reported an occupancyrate of 78 percent in 1987, and IVSS reported a rate of 69 percent in 1988. While overall length of stay averages about 6.5 to 7 days, the average is very high for departmentsof medicine and surgery. However, there are significant variations across hospitals. Type I and 11hospitals have much lower occupancyrates in

4/ Data compiled by the VenezuelanInsurance Council (Camara de Aseguradoresde Venezuela). 138 Annex 7

Table A7-5. Comparisonof Hospital St:adsrlcs:MSAS (1987) and IVSS (1988)

Mean Length of Stay (days) OccupancyRate Department MSAS IVSS MSAS IVSS

Medicine 14.8 13.7 79% 80% Surgery 11.7 a/ 8.1 75% 68% Traumatology a/ 16.5 a/ 81% Obstetrics 2.8 2.9 78% 77% Pediatrics 6.8 6.1 67% 53%

Overall 6.8 6.5 78% 69%

a. MSAS includes trauma under surgery. Source: MSAS and IVSShospital statistics

both institutionsthan more complex hospitals. In many of these hospitals occupancyrates are less than 50 percent. Mean lengtil of stay also varies greatly and is recognizedas excessive in many instances. Lengths of stay are often prolonged by problems of hospital organization, includinglack of programmingof central services, and shortages in supplies. Hospitalshave difficulties programming operations and diagnostic tests. Almosthalf of all operations are done on an emergency basis, and electiveoperations are difficult to program. Strikes also prolong length of stay by delaying the provision of necessary services.

InternationalComparisons

16. Table A7-6 summarizesselected hospital statistics includingaverage length of stay, occupancy rates, and staffing ratios in several Organizationfor EconomicCooperation and Development (OECD) countries. Table A7-7 presents occupancy rates and staffing ratios for a number of low and middle- income countries. It can be misleadingto compare average length of stay in hospitals across countries, unless appropriate adjustmentsare made for case-mix,and the classificationof patients is comparable. (if a country includes psychiatricpatients and chornic care facility residents in the data, for example, average length of stay will be much higher). Within countries, it is quite striking how average length of stay declined significantlyin almost every OECD country in Table A7-6 from 1970 to 1987. This has been achieved primarily through efforts to improve the organizationof services, to transfer patients to appropriate lower-levelfacilities after acute care has been provided, and to increase the substitutionof inpatient surgery with outpatient surgeryY In Venezuelamean length of stay could be reduced in order to improve efficiency and quaiitf# by addressingsuch issues as poor scheduling, problems in deliveryof diagnostic setvices, the lack of lower level facilities for the

E/ In communityhospitals in the United States, for example, the American Hospital Association reports that more than half of all surgeries in 1991 were done on an outpatientbasis.

{/ Unnecessaryhospital days have both a health cost to the patient as the patient is exposed to the risk of hospital infection without any additionalhealth benefit, as well as a financial cost. 139

TableA7-6. Comparisonof HaspitalStadsties Acros SelectedOECJ Averagelength of sta, ininpatientcareinstitutions sectedyea(da 1970 1980 Australia 9.3 7.7 Canada 11.5 12.9 France 18.3 13.9 Ilaly 18.8 13.1 Portugal 18.4 14.4 Spain 14.8 United Kingdom 25.7 19.1 United States 14.9 10.0

HospitalOrcupancy Rates 1970 198 Australia 75% 80% Canada 79% 83% France 88% 73% Italy 81% 78% Portugal .. 75% Spain 76% 66% United Kingdom 84% 81% United States 80% 79% Numberof Nu Staff per Nurs H-fospitalStaffing Ratios Year OccupiedBed Occu Australia 1986 3.8 Canada 1982 2.1 France 1983 1.4 Italy 1987 1A Portugal 1987 1.7 Spain 1984 1.6 UnitedKingdom 1987 2.6 United States 1985 2.8

Note: Data on staff employedby hospitalsare not completelycompara extent of subcontractingvaries. The definition of nutrsesaso vary Source: Data on averagelength of stay and staffingratios fromlea "Health care Expenditureand other Data: An Intenational Compei Organizationfor EconomicCooperation and Development, Health Health Care FinancingAnnual Supplement1989, Tables 22, 45 and occupancyrates from 'Financingand DeliveringHealth Care: A Co of OECD Countries",OECD SocialPolicy Studies No. 4, Paus, 1IY5 140 Annex7

TableA7-7. Comparison of Hospital Statistics Across Selected Developing Countrics Staff per Bed Number of Occupancy Nurses/ Hospitals Rate Physicians paramedical Other Total in Study Belize Provincial/Midlevel 68% 0.1 0.9 0.1 1.1 1 District/basicsecondary 31% 0.1 0.4 0.0 0.5 6 Colombia Districtto Provincial 68% 0.2 1.4 1.0 2.6 8 DominicanRepublic Central/tertiary .. 0.9 0.8 0.4 2.1 1 Indonesia Central/tertiary 75% 0.6 1.0 1.2 2.8 2 Provincial/Midlevel 68% 0.4 0.9 0.9 2.1 15 District/basicsecondary 54% 0.1 0.6 0.4 1.0 297 Jamaica Central/tertiary 84% 0.2 1.4 0.4 1.9 2 Provincial/Midlevel 87% 0.1 0.7 0.5 1.3 2 District/basicsecondary 80% 0.1 0.9 0.9 1.8 1

SoLuce: Compiled and presented in Howard Barnum and Joseph KutZin, PublicHospitals in DevelopingCountries: ResourceUse. Cost.Financing. The WorldBank, November1990, Table 3.4.

transferof longterm patientsrequiring less intensiveservices, standard treatment protocols, and hospital-acquiredcomplications. Venezuelan hospital directors report in particularthat bottlenecksin operatingroom availability greatly extend length of stay.

17. Occupancyrates of OECDhospitals are, in mostcases, higher for the countriesshown than in Venezuela(Table A7-6). TableA7-7 disaggregates occupancy rate by type of hospitalfor Belize, Colombia,the DominicanRepublic, Indonesia and Jamaica. As is the case in Venezuela,in almost everycountry presented in Table A7-7, occupancyrates are lowerfor lowerlevel hospitals than tertiarylevel facilities. 18. Staffingratios (the numberof staffper occupiedbed) are also presentedin TablesA7-6 and A7-7for OECDcountries and selecteddeveloping countries. Theseratios range from a low of 1.4 staffper occupiedbed to 3.8 for OECDcountries. Nursesfigure heavily in staffingratios, accountingfor between19 and 45 percentof totalstaff. For the developingcountries included in Table A7-7, staffingratios range froma low of .5 to 2.8 staffper bed, or 1.6 to 3.7 per occupied bed. Staffingra:ios increasewith the sophisticationof the hospital. Preciseestimates of saffing ratios are unavailablein Venezuelanhospitals, because of problemsin assessingthe totalnumber of personnel,particularly in the laborercategory, allocated across hospitals. From discussionswith hospitaldirectors in severalJVSS and MSAShospitals, however, one can roughlyestimate that the numberof staffaverages about five in Type IV .iospitals,although one hospitalreported a much 141 Annex 7 higher ratio of ten staff per bed. (The numberswould be even higher if calculatedper occupied bed.) This is obviouslyextremely high by internationalstandards. Furthermore, the proportion of paramedicalstaff in the total staff is low in Venezuela. Again, this number is difficult to estimate precisely, but hospitalpersonnel repeatedly report acute problems from deficits in nursing staff. The shortage of nursing staff is a problem facing the health sector in general in Venezuela.

HOSPITAL AUTONOMY AND ORGANIZATION

19. The degree of financial and administrativeautonomy at the hospital level is important in consideringhow to improve hospital efficiency. Obviouslyefficiency can be improved within the hospital only for those areas under control of the hospital. Major management,administrative, and financing characteristicsof MSAS and IVSS hospitals are outlined in Table A7-8.

20. In Venezuela public hospitals have very limited financial and administrativeautonomy. They are not permitted to hire and fire personnel. Hospitals request personnel by category each year, but the allocationreceived rarely matches that requested. In part this is a problem in the sector, due to a sector-wide scarcity of certain personnel such as graduate nurses. Hospital purchases are restricted almost entirely to drugs and materials; equipment is purchased centrally. Drugs and material are purchased on the basis of price quotes. Hospitalsare not permitted to carry out local competitive bidding. The Ministry of Health has decentralizedthese purchases almost entirely to the hospital level, while IVSS passes on a limited budget for hospitallevel purchases, leaving the bulk of purchasing at the central level. Under both systems, hospitals experience grave shortagesof drugs and materials due to financing constraints. The IVSShospitals are more at the mercy of the central level to meet shortages; the MSAS hospitals are at the mercy of the decentralizedbudget amount. Direct Fees

21. Some MSAS hospitals try to recover a portion of costs from their patients. There is an informal means test involvedfor low-incomepatients. A social worker or other hospital staff member fills out a questionnaireto determine if the patient should be excludedfrom payment. Hospitalshave the liberty to set their own fees and procedures. Fees are very small and vary by hospital.7' About 95 percent of the revenue collectedis retained at the hospital level (five percent is returned to MSAS). It is used to purchase drugs, materials and some equipment. While limited, it is ar. importantsource of funds because it adds to the hospital's small discretionary budget. MSAS hospitals also collect money from small donations, and from selling used X-ray materials. IVSS hospitals, in contrast, are prohibited from recovering costs from patients, arndprohibited from establishingfoundations to collect donations from the community.

7/ For example, fees amountedto Bs 20 in February 1992,or US$.33 for a consultationin the outpatientdepartment of the large 410-bed Hospital Magallanesin Caracas. Hospital personnel stated that almost 100 percent of the patients paid the fee for consultations. Fees are higher for other procedures (US$8.30 for a normal birth, US$25 for a cesarean birth, for example), and less than 50 percent pay. In this particular hospital, the fee level was fixed, and patients either paid or did not. 142 Annex 7 TableA 7-8. Management, Administrativeand FinancingCharacterlsdcs of MSAS and IVSS Hospitals

Characteristics MSAS Hospitals IVSS Hospitals Control over Very limited. Not permittedto hire and fire. Very limited. Not permitted to hire Personnel Hospital submitspersonnel requeststo MSAS. and fire. Hospital makesyearly Allocationsinfrequently mnatch requests. Unions requests for new personnel. impose severe restrictionsof workers' job Allocationsfrequently do not match responsibilities. requests. Unions impose severe restrictionson workers' job responsibilitiesof workers. Budgetary Limited. From the budget provided by MSAS, Very limited. Hospitaldirector has Autonomy the hospital only has control over drug and small budget to meet some of the materialspurchases. However, few restrictions needs for drugs and materials. cn uses of money received from patient contributionsand foundations. Direct User Fairly common, but fees very low. Some Direct user charges not permitted. Charges hospitalsask patients to make donations. No standardizedcharges or guidelinesacross hospitals. Almostall retained at the hospital level. Indirect User Commnon.Patients often purchase their own Common. Patientsoften purchase Charges inputs (drugs, bandages)for their care. inputs (drugs, bandages) for their care. Purchase of Largely decentralized. Restrictionson size of Largely centralized. Hospitalshave Drugs purchase. small budget to purchase drugs directly Purchase of Largely decentralized. Restrictionson purchase Almostentirely purchased in materials size. Caracas Purchase of Centralized(Caracas). Centralized(Caracas). Equipment Subcontractingof Maintenanceof large equipmentoften contracted Contractingout laundry, gardening, Hospital Services out. Contractsmade at the central level, not by food services, security common, as the hospital. well as equipmentmaintenance. Contracts made at the central level, not by the hospital. HospitalCost Extremely limited. Extremely limited. Accounting Contractingout Extremely infrequent. Certain medical services contracted MedicalServices out (about 5% of the budget for health services). 143 Annex 7 Indirect Fees

22. Indirect user fees are very commo-nin both types of hospitals because of the shortage of drugs and materials. A few hospitals have private pharmacieson-sice from which patientsor their families can purchase needed drugs. In most cases, however, the family tnust purchase the drugs and materials outside of the hospital. This introduces treatment delays, and penalizes very low-income fami!ies unfairly. As is the case with direct cost recovery, it is diffiult to estimate the amountof expendituresmade by the direct patient purchase of needed drugs and materials.

Equipmentand EquipmentMaintenance

23. During the years of the petroleum boom, there were large purchases made of hosr; I equipment. These purchaseswere done at the central level by both MSAS and IVSS. tiquipment purchases were generally not well evaluated in terms of cost productivityor vase of maintenance. The result has been great heterogeneityin the brands, models and technolo. *f the equipmentstock. Although the available equipmentrepresents relatively recent technology, major problems exist in its maintenance. Poor maintenanceis a chronic problem because hospitals do not have departmentsof clinical engineering. Maintenanceof major equipment is frequently contracted out. While this in theory could work very well, problems have been identified in the poor supervisionthe hospital provides to these externally-contractedservices. Minor maintenanceis generally left to the direct responsibilityof the hospital, and is very inadequate. Preventive maintenanceis rare. Stocks of spare parts are inadequateand hospitalequipment often lacks technical documentation.

Contracting Out Hospital Services

24. IVSS hospitals make more extensiveuse of contractingout hospital services such as laundry, gardening, food services, and security. Both MSAS and IVSS make use of contracting out for maintenanceof major equipment,such as X-ray machines. Contracts are establishedand financed by the central level, and supervisedat the hospital level. Contractingout can present several benefits. Hospital directors have reported an advantagefrom the fact that contracted out services continue even during labor strikes. Contractingout can also be less costly than publicly provided services if there is strong competitionin supply. In makingthe transition to contracting out services, these savings can be lost, however, if the hospital does not manage to productivelyredeploy or discharge the public workers previously providing the services.

Hospital Cost Accounting

25. Neither IVSS hospitals nor MSAS hospitalshave hospital cost accounting. The Ministry of Health, with the support of the Pan AmericanHealth Organization, is starting to employ a system called "Sistema de InformacidnGerencialN (SIG). This system represents a good start in measuring production and costs. However, over the mediumterm the system could be greatly improved. It is limited in its scope and is conceivedas a largely manual system.F

8/ Joao Urbano,"Analise oa Situacaodo SectorHospital na Venezuela:Os Sistemasde Informaqio", Lisbon,May, 1991. 144 Annex 7

Contracting Out Medical Services

26. IVSS contracts out about 5 percent of its spendingon health services. This is done mainly in the Caracas metropolitanarea, and is for psychiatric and geriatric services and occasionally specializeddiagnostic tests. Contractingout of services is also done in the case of medical emergencies during strikes. The procedures are not systematic, and it is not clear how reimbursement is set for procedures. The Ministry of Health has made no use of contracting out medical services.

IMPROVING HOSPITAL EFFICIENCY

27. Many of the problems in the public hospitalsector are problems with either the health sector or the public sector more generally, and must be addressedoutside the hospital. These types of problems include the fact that: (1) many users bypass health care centers for prinary care attention (because of inconvenienthours or lack of confidence in the care provided) and choose to go directly to hospitals, (2) the various public providers of health care have no coordinatedplanning, (3) MSAS has little planning, policy making, and evaluation capability, (4) there are enormous labor problems in terms of strikes, low salaries, low productivity, and poorly qualified staff, and (5) public funding for health services has been squeezed, dropping by about 40 percent in real terms over the decade of the 1980s.

28. While these systemic problems exist and have effects on the organizationand performanceof the public hospital sector, there are also problems that can be addressedfrom within the subsector that do not depend upon broader solutions. Hospitals need to use the inputs they have in the most efficient manner. This requires managementtools and managementinformation systems to monitor input use and to assign inputs so as to derive the most benefits. It also requires sufficient administrativeand financial autonomy to have control over inputs at the hospital level and the ability to substitutebetween inputs. The major reforms needed to improve hospital performanceare summarized in Table A7-9 and are discussedbelow.

Better Management Tools and Management Information Systems

29. Hospital directors lack the managementtechniques, information, and in many cases the autonomy needed to manage their resources well. No good measures of hospitalperformance exist, and therefore hospital directors cannot be held accountablefor performance. Even if such indicators existed, decision making is so centralizedthat in many areas hospital directors have little financial and administrativecontrol. The issue of hospitalautonomy is discussed further below. Hospital directors are physicians who have some training in hospital management. As a group, diey need much more up-to-date training in hospital management. In addition, given that hospitals are very complex enterprises, salaries of hospitaldirectors need to be raised in order to attract and retain highly qualified managers.

30. An information and managementrevolution has occurred in health care in the past twenty years. Venezuelanpublic hospitals could build on this knowledgeby adapting and implementing 145 Annex 7

TableA 7-9. Sunmary of Changes needed to Improve Public Hospital Perfornance

Within the Hospital: Better managementtools and managementinformation systems. More control over and substitutabilityacross inputs. More use of the private sector if that can enhance quality and efficiency. Improved maintenanceof the physical plant and equipment. Within the Health Better coordinationbetween public providers. Improved Sector: coordinationbetween different levels of the health care system, includingsystematic reference and counter- reference. Improve accessibilityand quality of care in health centers so that they more commonlyserve as the entry point for patient contact. Improved medium to long term strategic planning to improve equity and hospital efficiency, including addressingthe geographic inequitiesof hospital bed distributionover time, convertingsome acute care facilitiesto long term chronic care facilities, increasing the use of outpatient surgery. More use of the private sector if that can enhancequality and efficiency. More hospital autonomy, and with that autonomy, more accountabilityon the part of the hospitaldirector for hospital performance. Address deficits in quantity and quality of training in certain categories of personnel (graduate nurses, hospital engineers, hospital directors). Over medium term, reform of hospital budgeting and financingto link budget with performance. Within the Public Civil service reform (remuneration,career paths, hiring Sector: and firing practices). 146 Annex 7 some of the best ideas developedelsewhere.9Y Information technology can be used to provide clinical and financial informationsystems for planning, management,analysis and evaluation. Industrial engineeringtechniques can be applied to schedule efficiently, purchase meals, laundry and laboratory services on a competitivebasis, analyze the optimum use of support personnel, etc.

31. Several excellentdiagnoses have been made of the informationproblem in public hospitals.) Much data is collected, but little is suitablefor timely managementdecisions. Ministry of Health analyses which aggregate and analyze hospitaldata are several years out of datel' and the results are seldom returned to the hospital level for analysis. If the data reveal a problem, such as low production of services, the informationdoes not support an analysis of causes of the problem. At the same time, other data collection efforts at the hospital level represent duplicationof effort. Data collectionand analysis is generally manual. For all of these reasons, staff at the hospitallevel are not well motivatedto collect information. An integrated clinical and financial information system needs to be introducedthat will address the above mentionedproblems and also generate the appropriate informationto be used at the hospital level to make decisions and at the Ministry of Health level to evaluate and plan.

32. At present, it is impossibleto compare unit costs in public hospitals in Venezuela with each other or across time. Venezuelacould introducea national uniform hospitalcost accountingsystem in order to compare costs per patient for particular types of cases among hospitals, to identify the best medical and managementpractices, and to guide resource allocation. The hospital cost accounting that currently exists in the hospitals is a step in the right direction, but is much too elementaryto serve the above purposes. To serve decision-makingpurposes, cost accountingneeds to be developed by cost centers and needs to includeall expendituresfor hospital services, whether paid by the hospital or not, and whether financial or not.1V Budget line item costs should be attributed to cost centers, which reflect specific hospital departments, includingoverhead, intermediate cost centers, and

2/ See Alain C. Enthoven, "What can Europeans learn from Americans?", in Health Care Systems in Transition: The Search for Efficiency, OECD Social Policy Studies, No. 7, OECD, Paris, 1990.

IQ/ For example, MSAS, "Sistema de Informacion- SituacionActual y Propuesta," 1990, "Proyecto para el Mejoramientode las Estatisticasde Salud," 1990. IVSS, "Proyecto del Subsistemade InformacionEstadistica sobre MorbiletalidadHospitalaria en el Instituto Venezolanode los Seguros Sociales," 1985and "Proyectodel Sistemade Informacionde Mortalidad," 1985.

I/ There is currently a seven year delay in the analysis of some epidemiologicalinformation, and a three year delay in the analysis of some hospital managementinformation at MSAS.

121/Currently many costs are paid at a more centralizedlevel, such as the bulk of drugs and supplies for IVSS hospitals, equipment for MSAS hospitals, and utility bills for MSAS hospitals. Nonfinanc!il costs include depreciationand the value of donated goods and services. 147 Annex 7 final cost centers.2' After all costs are fully allocatedto final cost centers, unit costs can then be compared with utilizationdata.

33. Modem hospital managementtechniques that could be considerad' include:

Patient registration.

* Hospital discharge planning. Systematic, early discharge planning (starting once the patient is admitted) can have an important effect in reducing length of stay. The effectivenessof this measure may be limited in Venezuelagiven the narrow options available (lower level care facilities)for patients with discharge problems (home situationswhere they will not receive adequate care).

* Pharmacy. Informationsystems to analyze rotation rate, drug consumption,and consumptionby service. Systemsto control periods of drug validity and to implement unit drug distribution(Ziis techniquecan reduce losses and also save employeetime).

3 Automatedpersonnel administrationsystems with data on leave plans, absenteeismby cause, normal and overtime work, salary payments, career informationby employee. This should be able to aggregateby employeecategory to report total salary payments by categories, number of days lost to work accidents, and number of hours paid (worked and not worked).

* Materials managementsystems. To identifystocks and items in services, provide analyses by frequency of departure and value, analyze consumptionby service, or article, control periods of delivery from supplier, determine economic quantitiesof stocks, determine rotation rate, and expeditebidding.

* Hospital utilization review. For a random sample of patients, each hospital patient day is analyzedto see whether it is appropriateor inappropriate. If inappropriate,the reason is determined in order to provide informationto managementabout exactly where hospital bottlenecksoccur in order to take action to reduce unnecessarilylong lengths of stay.

* System to program operating room interventions,determine costs by intervention, and study productivity.

* Laboratory management. Systemsfor registrationof requests for exams for each patient, identificationof services and exams provided by patient, registration of collection, transmittalof results, and imputingto cost centers. j13 Overhead cost centers are those that produce services consumedby other departments, for example, administration,housekeeping, and maintenance. Intermediatecost centers are cost centers producing services used by other departmentsand also directly by patients, for example, laboratory tests. Final cost centers produce services directly to patients, not to other departments.

1[I Some of these techniqueshave already been introducedin a few public hospitals. 148 Annex 7 * Patient histories. Managementsystems to attribute patient identificationnumbers to each procedure, permit easy finding of clinical histories, avoid loss of files, code diagnoses, and surgical interventions,and other procedures

* Quality control systems. Organize continuingformal and informal educationprograms for hospitalstaff. Peer review systems.

* Hospital infection control.

* Maintenancesystems.

More Control Over and Substitutability Across Inputs

34. The above mentioned managementtools and informationsystems will be useful only if the hospital can increase its control over the use of hospital inputs. Within the resources the hospital receives, it can only increase technical efficiency if there is substitutabilityacross inputs. Greater administrativeand financial autonomyover drugs, supplies, equipment purchase, and personnel is needed. Currently hospitals do not have the ability to hire and fire labor, and there is not much flexibilityin the use of the existing labor. Greater freedom to substituteacross types of labor has improved hospital efficiency in other countries, for example, substitutingphysician managers with non-physicianmanagers so that the clinical aspects of the hospital are run by physicians, but the financial and administrativeaspects are run by managers.

More Use of the Private Sector if that can Enhance Quality and Effciency

35. Hospitals in many countries contract out hospitalservices such as equipmentmaintenance, laboratoryservices, laundry, meals, etc. Under competitiveconditions and with proper oversight, this can be a useful measure to improve the quality and/or efficiencyof services. IVSS has made much more use of this techniquethan MSAS to date. However, both institutionscould increasetheir us c;f contracting out and consider extendingit to laboratory services.

Improved Ma!ntenance and Equipment Purchase

36. Equipmentpurchasing is centralizedboth for IVSS and MSAS. The technologyavailable in hospitals is relatively reccnt, with the bulk purchasedduring the petroleum boom years. Equipr;ent purchasesdo not undergo a rigorous evaluationof cost effectiveness.

37. The Fundaci6n pars el Mantenimientode la InfraestructuraMedico Asistencial(FIMA) was created in 1987with the goal of maintaininghealth facilities infrastructure. FIMA has established norms for equipmentmaintenance, but maintenanceremains inadequateat the hospital level. The operations of the hospitals are affected by severe problems ranging from inadequate attentionand resources to maintenanceof buildings and equipment. Departmentsof engineeringare needed within hospitals, with adequate salaries to attract qualifiedprofessionals. These departmentscould oversee externally contracted maintenanceagreements for major equipment and carry out systematic preventive maintenanceand minor maintenance. 149 Annex 7 Better Coordination Between Providers

38. Better coordinationis needed between the various public institutionsproviding health services, particularly where the overlap in coverage is high, such as between the IVSS and MSAS, and in the metropolitanarea of Caracas between the Distrito Federal and MSAS and IVSS. Coordinationcould help improve the match of resources used to the neds of the populationserved, and to achieve the appropriate regional concentrationof specializedservices. Coordinationwill be even more important in the decentralizationprocess of transferring responsibilitiesfor operating health facilitiesto the states. This should be done within an agreed upon frinework that clearly defines the roles of all parties in terms of operations, financingand oversight.

Medium to Long Term Strategic Planning

39. Medium to long term planning could be used to improve the equity of health services in Venezuela by addressingthe great variation in the number of hospital beds by state and within the states. Over the medium term, considerationshould be given to diversifyingaway from the acute care hospital model in Venezuela. Most countries have created facilities to provide appropriate care in less costly settings for patients who do not need the resource intense services of an acute care facility. There has been an enormousincrease in the proportion of surgeries performed on an outpatient basis in OECD countries, as well as an increase in the use of home care, nursing homes and chronic care long-term hospitals.

40. Hospital litilizationreview, a techniquementioned earlier, is useful in determining appropriate and inappropriate>osp;sal patient days, and can be used to pinpoint problems in hospitalservices. As averaga length of stay ; reduced over time by reducing the proportion of inappropriatedays of stay, it may be desirable to consider closing wings in hospitalsor convertingthem to less resource intensivelong term stay facilities.

41. Long term measures are needed to improve the quality of care and convenience of care in health centers. Hospital emergencyservices are crowdedby those needing normal ambulatory attentionthat could be provided in health centers.

42. A program of studies would be needed to guide policy on such issues as hospital demand, the role of the private sector, hospital costs, and hospitalreimbursement options.

More Hospital Autonomy and More Accountability for HospitalPerformance

43. Greater administrativeand financial hospital autonomy is fundamentalto improvinghospital quality and efficiency. Optionssuch as transformingthe hospitals into public foundations or public enterprises could be explored. More autonomyis needed in budgeting, hiring and firing, setting salary scales. and making contracts. The excessive interventionof unions in the selection of personnel is a big problem, as well as high absenteeism.

44. Liberalizationof the hospitalmust be accompaniedby measures to hold hospital directors accountablefor the hospital's performanceand by performance indicators. Indicators of hospital quality could include results of routine patient satisfactionsurveys, re-admissionrates, mortality analysis, and hospital-acquiredinfection rates. Indicatorsof hospital efficiency could include unit costs by diagnosis or group of diagnoses, average length of stay by program, and occupancyrates. In 150 Annex 7

addition to an internal system of quality control mentionedpreviously, the Ministry of Health could strengthen its external quality control oversight function.

Address Deficits in Certain Categories

45. Certain categories of health manpower are greatly lacking in hospitals and throughout the health sector in general. Training for nurses, hospital engineers, middle-levelmanagers, and others is urgently needed. In part people are reluctant to enter these professions because of poor salary conditions. Measures must therefore be taken to raise pay levels in these understaffed categories.

Changes in Hospital Budgeting and Financing

46. The current system of budgeting and financingprovides no incentive for efficiency. Budgets are generally based on budgets from the previous year rather than on the basis of costs and hospital production. Personnel costs absorb the bulk of the budget and are basically a fixed cost over which the hospital director has no control.

47. Ideally, the hospital could be reimbursed for its production in a way that generates incentives for technical efficiency without compromisingquality. The directors would need to have the administrativeand financial autonomy to run the hospital efficiently, with the managementtools and informationsystems needed for decision making and monitoring. Alternatively,the hospital could receive a global budget at the beginning of the year with an agreed contract to treat a determined production.

48. The proportion of the budget devoted to personnel expendituresneeds to be progressively reduced in favor of other operatingexpenditures, including drugs, supplies, equipment, and maintenance. Data from personnel administrationcan be used to determine where excess personnel are located.

49. Budget sources could be broadened beyondthe federal budget to include increaseduser fees. Fee structures and exemptionsshould be designed so that they are moderate and consistentwith ability to pay and do not prevent access to essentialbealth care. They should provide correct incentivesfor health care use. Methods of collectionshould be public, transparent and automatic.

Proposals Under Discussion

50. Several hospital reform proposals under discussionin Venezuelaover the past several years have suggested many of the ideas outlined in this annex.& The proposals recognize the importance of integrated informationsystems, managementtools, and hospital autonomy in any serious hospital

IW/ Payment on the basis of diagnosis-relatedgroups is one option a number of countries have chosen. In this system, all inpatient cases are classifiedin one or another of about 470 diagnosis- related groups that are relatively homogeneouswith respect to resource use.

16/ For example, "Plan de Reestructuraci6ndel IVSS", Comisi6n de Reestructuraci6nde la Gesti6n Hospitalaria", and 'Comisidn Presidencialpara la Evaluacidnde la crisis hospitalaria del pafs". 151 Annex 7

reform effort. Pilot reform efforts have been recommendedIn order to gain from the experience of different models. Managementconcessions of hospitals have been discused as one possible model. As proposed, private managers be required to keep the same labor force currently in public hospitals. This seems unworkablegiven the excessive overall levels of staffing in the hospitals. Another consideration is that it would be premature to adopt managementconcessions before having in place a reimbursement system that stimulatesefficiency, and a regulatoryfranework and informationsystem to ensure accountability. IVSS is considering giving hospitals more administrativeand management autonomy. Recommendationshave been made to give those covered by IVSS greater consumer choice in the selection of public or private health insurance.

CONCLUSIONS

51. Problems of poor quality and low efficiency are pervasive in public hospitals in Venezuela, and those who are most affectedby this situationare the poor who cannot afford to purchase services privately. Average length of stay is high, especially fbr surgery. In paft this is caused by bottlenecks in diagnosticservices and therapeuticservices. There is no coordinationamong public providers, and referral across different levels of the health system is poor. Hospitalsare dominated by Type IV (sophisticatedcare) hospitals, and lower level facilitiesfor chronic care patients do not exist. Public hospitals have low productivity, operaing generally only in the morning. Staffing ratios (personnel/bed)are extremely high. Unions intervene in the seecton of personnel. Labor productivity is low, absenteeia,nis high, strikes are common, and salaries are low. There are sharp deficits in the number of staff in certain categories such as nursing, which impacts the quality of services very negatively.

52. A hospital reform program must address these problems by carrying out financial, legal, and organizationalreforms within the hospital, within the health sector, and within the civil service in general. The potentialpayoff is high in terms of improved quality, equity and efficiency of services. Thbisreform program can build on the diverse experienceand lessons learned in many other countries in the past twenty years as those health care systems have incorporatedcost containmentmeasures, managementtechniques, and informationsystems.