Mission Barrio Adentro is a Bolivarian national social welfare program established under current Venezuelan president Hugo Chávez

Hugo Chávez

Hugo Rafael Chávez Frías is the 56th and current President of Venezuela, having held that position since 1999. He was formerly the leader of the Fifth Republic Movement political party from its foundation in 1997 until 2007, when he became the leader of the United Socialist Party of Venezuela...

. The program seeks to provide comprehensive publicly-funded health care

Publicly-funded health care

Publicly funded health care is a form of health care financing designed to meet the cost of all or most health care needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are set down in rules applying to the whole population...

, dental care

Dental care

Dental care is the maintenance of healthy teeth. Forms include:* Oral hygiene, the practice of keeping the mouth and teeth clean in order to prevent cavities , gum disease, and other dental disorders....

, and sports training

Sports medicine

Sports medicine is a branch of medicine that deals with physical fitness, treatment and prevention of injuries related to sports and exercise...

 to poor

Poor

Poor is an adjective related to a state of poverty, low quality or pity.People with the surname Poor:* Charles Henry Poor, a US Navy officer* Charles Lane Poor, an astronomer* Edward Erie Poor, a vice president of the National Park Bank...

 and marginalized communities in Venezuela

Venezuela

Venezuela , officially called the Bolivarian Republic of Venezuela , is a tropical country on the northern coast of South America. It borders Colombia to the west, Guyana to the east, and Brazil to the south...

. Barrio Adentro features the construction of thousands of iconic two-storey medical clinics—consultorios or doctor’s offices—as well as staffing with resident certified medical professionals. Barrio Adentro constitutes an attempt to deliver a de facto

De facto

De facto is a Latin expression that means "concerning fact." In law, it often means "in practice but not necessarily ordained by law" or "in practice or actuality, but not officially established." It is commonly used in contrast to de jure when referring to matters of law, governance, or...

 form of universal healthcare, seeking to guarantee access to quality and cradle-to-grave medical attention for all Venezuelan citizens.

The Latin American branch of the World Health Organization

World Health Organization

The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 and UNICEF both praised the program. According to WHO statistics infant mortality fell from 23 to 20 in males and 19 to 17 in females per 1000 births between 2003 and 2005. http://www.who.int/whr/2004/annex/topic/en/annex_1_en.pdf http://www.who.int/whr/2006/annex/06_annex1_en.pdf In addition, Russian

Russians

The Russian people are an East Slavic ethnic group native to Russia, speaking the Russian language and primarily living in Russia and neighboring countries....

 representatives have visited Venezuelan neighborhoods in order to study Venezuelan public clinics and Russian

Russians

The Russian people are an East Slavic ethnic group native to Russia, speaking the Russian language and primarily living in Russia and neighboring countries....

 officials are considering implementing a similar program in Russia

Russia

Russia or , officially known as both Russia and the Russian Federation , is a country in northern Eurasia. It is a federal semi-presidential republic, comprising 83 federal subjects...

.

Of a planned 8500 Barrio Adentro I centers, 2708 had been built by May, 2007, using an investment of around US$126m, with a further 3284 under construction. As of 2006, the staff included 31,439 professionals, technical personnel, and health technicians, of which 15,356 were Cuban doctors and 1,234 Venezuelan doctors.

Background

The Barrio Adentro program was developed against a background of a public health sector crumbling under long-term financial pressure. As part of the neoliberalisation programme of the early 1990s under President Rafael Caldera

Rafael Caldera

Rafael Antonio Caldera Rodríguez was president of Venezuela from 1969 to 1974 and again from 1994 to 1999.Caldera taught sociology and law at various universities before entering politics. He was a founding member of COPEI, Venezuela's Christian Democratic party...

, a Venezuela struggling with inflation and a low oil price (oil being its primary export) was forced into spending cuts and privatisation in a number of sectors, including healthcare. A 1989 decentralisation law contributed to the trend; from 1993, state governors could request the transfer of public healthcare in their state to their control, and the inability to cope with the new responsibility encouraged cuts and privatisation. Cost recovery became increasingly prevalent through "voluntary" contributions from users. In addition to the problems with the healthcare system, over the course of the decade health problems caused by poverty (infectious and deficiency
diseases) increased. By 1999, 67.7% of the Venezuelan population was living in poverty, from 44.4% in 1990.

In 1999, following the election of Hugo Chavez, the Ministry of Health planned to develop a new National Public Health System, with a particular focus on health promotion, disease prevention, community participation, and the strengthening of the primary health care

Primary health care

Primary health care, often abbreviated as “PHC”, has been defined as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost...

 infrastructure. The 2000/1 annual report by PROVEA highlighted a number of positive features of the new approach, including a wider availability of health services through progressive elimination of users’ fees.

Origins

The Barrio Adentro program is an example of Latin American social medicine (LASM), which became prominent in the 1960s and 70s. Amongst others in Latin America, both Salvador Allende

Salvador Allende

Salvador Allende Gossens was a Chilean physician and politician who is generally considered the first democratically elected Marxist to become president of a country in Latin America....

 in Chile in the early 1970s and Tabaré Vázquez

Tabaré Vázquez

Tabaré Ramón Vázquez Rosas is a former President of Uruguay. A physician by training, he is a member of the leftist Frente Amplo coalition . Vázquez was elected president on October 31, 2004, took office on March 1, 2005, and relinquished the office on March 1, 2010...

 in Uruguay from 2005 have implemented LASM principles. LASM's roots can be traced back to 19th-century European social medicine (particularly the work of social medicine

Social medicine

The field of social medicine seeks to:# understand how social and economic conditions impact health, disease and the practice of medicine and# foster conditions in which this understanding can lead to a healthier society....

 pioneer Rudolf Virchow

Rudolf Virchow

Rudolph Carl Virchow was a German doctor, anthropologist, pathologist, prehistorian, biologist and politician, known for his advancement of public health...

), which was exported to Latin America in the early twentieth century.

LASM emphasises a collective and holistic

Holism

Holism is the idea that all the properties of a given system cannot be determined or explained by its component parts alone...

 approach to healthcare, rather than merely treating the particular symptoms of one individual. Thus the importance of health promotion and disease prevention—informed by the political-economic and social determinants of health—is stressed, over a merely reactive treatment of health problems as they occur. LASM incorporates the concept of primary health care

Primary health care

Primary health care, often abbreviated as “PHC”, has been defined as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost...

 (as defined by the 1978 Alma Ata Declaration

Alma Ata Declaration

The Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care , Almaty , currently in Kazakhstan, 6-12 September 1978. It expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the...

), of which the "simplified healthcare" adopted in rural Venezuela in the 1960s and 70s was one form. More recently, in 2006, Barrio Adentro has been described by the Director of the PAHO as "the culmination of 25 years of experience in Latin America and the rest of the world in transforming health systems through the primary health care strategy."

When Hugo Chávez became President in 1999, he sought to implement LASM principles, beginning with their incorporation into the new 1999 Venezuelan Constitution, in articles 83-85 of Title III. These articles enshrine free and high quality healthcare as a human right guaranteed to all Venezuelan citizens. Notably, Article 84 of Title III follows LASM principles in declaring health promotion and disease prevention a priority; it also describes the healthcare system as "decentralised and participative" and declares that the community has "the right and the duty" to be involved in policy decisions regarding the public health system. In addition Article 85 mandates that the government provide adequate funding for the public healthcare system, while Article 84 explicitly proscribes its privatization

Privatization

Privatization is the incidence or process of transferring ownership of a business, enterprise, agency or public service from the public sector to the private sector or to private non-profit organizations...

.

Initial attempts to transform the Ministry of Health to LASM principles, in the 1999–2003 period, met with little success. The Venezuelan Medical Federation was aligned with the Punto Fijo

Punto Fijo Pact

Punto Fijo Pact was a formal arrangement arrived at between representatives of Venezuela's three main political parties in 1958: Acción Democrática, COPEI and Unión Republicana Democrática, for the acceptance of the 1958 presidential elections, and the preservation of the rising democratic regime.-...

 parties, and many of its members in private health care opposed the new emphasis on the public sector. At the same time that the new policies failed to make much ground within the healthcare system, the traditional top-down way in which the policies were developed and carried out prevented a strong connection with the concerns of the poor.

The origins of a different approach for carrying out LASM lay in the Libertador municipality

Libertador Municipality (Venezuelan Capital District)

The Libertador Bolivarian Municipality is the only administrative division of the Venezuelan Capital District and along with the municipalities of Baruta, Chacao, El Hatillo and Sucre forms the Metropolitan District of Caracas. It is located in the western portion of Caracas. It is landlocked by...

 of Caracas

Caracas

Caracas , officially Santiago de León de Caracas, is the capital and largest city of Venezuela; natives or residents are known as Caraquenians in English . It is located in the northern part of the country, following the contours of the narrow Caracas Valley on the Venezuelan coastal mountain range...

, which in 2003 (under a pro-Chávez mayor, Freddy Bernal

Freddy Bernal

Freddy Bernal is the ex-mayor of the Libertador Municipality in Caracas, Venezuela and a member of the United Socialist Party of Venezuela ....

) set up an Institute for Endogenous Development (IED), broadly intended to improve living conditions through the active participation of the local population. Following a series of discussions between IED and local residents, a proposal was formulated to set up a "Plan Barrio Adentro" using small local clinics to provide free healthcare "inside the neighbourhood" where previously there was none, and to involve residents in the management of the scheme. Bernal then issued a call for doctors, but the Venezuelan Medical Federation put pressure on its members not to apply. Of the 50 Venezuelan doctors who did apply, 30 left on hearing that they would need to live in the barrios; the remaining 20 were specialists and therefore employed in specialist centers and not required to work in the primary health care centers in the barrios. Faced with a lack of willing doctors, Bernal recalled the Cuban doctors who had provided emergency aid following the 1999 mud slides, and discussion with the Cuban Embassy in February 2003 ultimately led to a contingent of 58 Cuban doctors starting the program in April 2003. In the interim, three Cuban physicians spent a month visiting the barrios, examining the homes and clinic spaces offered by the community. By May 2003 another 100 Cuban doctors arrived, and were sent to other parts of Libertador and to other municipalities in and around Caracas. Besides diagnosis and treatment, including the provision of free prescription drugs, the doctors carried out a health census of the barrios, which provided a complete health survey of the Caracas barrios for the first time.

Despite some obstacles (including a refusal by public hospitals to accept referrals for diagnosis and treatment, only gradually and partially overcome during 2003), "Plan Barrio Adentro" became very popular with its constituents. By December 2003, "Plan Barrio Adentro"—having seen over 9m patient consultations and 4m health interventions—was so popular that it was attracting national attention, and President Chávez transformed it into a national program, named "Mission Barrio Adentro" (MBA). It became the first of a series of popular "missions" bypassing existing public institutions.

Barrio Adentro I

"The key aspect of these centers is that they are located within the neighborhood and in the marginalized zones of the large cities," although some facilities were located in higher income areas. "Placement of Barrio Adentro health posts within those neighborhoods that had been most excluded was undertaken at the request of the neighborhood health committees and taking into consideration preexisting health care facilities."

A key part of the national Barrio Adentro scheme, as it was in the original local plan, is the participation of the local community. This takes place through health committees, chosen in an assembly of citizens and typically around 10 people. By 2006, 8951 health committees had been registered (there is one committee for each primary care post). (The total was already 6,241 in 2004.
) A total of 41,639 community health assemblies were held in the first quarter of 2006, with the participation of 1,423,815 people.

The issue of participation goes beyond mere management. As one academic study put it, "the observed role of positive, egalitarian clinical interactions between Cuban physicians and Venezuelan patients and other residents suggests that doctor–patient interactions model power relations between communities and institutions and affect local perceptions and participation." It concluded that developing more positive and egalitarian physician–patient and professional–community relationships "may be one of the easiest, most effective ways" the medical profession can contribute to overcoming health disparities.

Each primary care post covers 250 to 300 families. By 2003, primary medical care coverage was achieved for 70% of the Venezuelan population for whom primary care was previously unavailable, representing over 18m people. By 2007, 3,717 primary care posts had been built and equipped, and a total of 8,633 posts were operational (including those still located in community centers and homes). There were also 4,800 dentists. In 1998 Venezuela had only 1628 staffed primary care posts, and 800 dentists. Between 1998 and 2007 this represents an increase of 530% and 600% respectively.

In addition to the new infrastructure, there are also new outreach programmes. For example, in addition to the drug module for the popular medical dispensaries (which provided free access to 106 essential medicines designed to cover the needs at this level of care), a family drug module was launched in 2005. This programme reaches 40 selected municipalities in 17 states, and every three months delivers drugs and vitamin supplements tailored to the family's needs. Hundreds of thousands of infants, children, and pregnant and elderly women have benefited. Over 150,000 health promoters from local communities were trained in 2004-6 to spread messages relating to ways of improving health.

Barrio Adentro II

After the Barrio Adentro's primary care network went nationwide in 2004, moves to expand beyond primary care soon followed. What became known as "Barrio Adentro I" focused on primary health care. "Barrio Adentro II" focused on secondary care, in three main areas: Comprehensive Diagnosis Centers (for more advanced diagnosis), Comprehensive Rehabilitation Centers (for people with disabilities, another social deficit uncovered by Barrio Adentro I—there were only 78 public sector centers in 1998), and Advanced Technology Centers (for more advanced treatment). Plans were made for 600 each of the first two (each serving a population of approximately 40,000 to 50,000) and 35 of the latter (with at least one in each state).

As of 2007, Barrio Adentro II involved 417 Comprehensive Diagnostic Centers (of 600 planned), 576 Comprehensive Rehabilitation Centers (of 600 planned) and 22 Advanced Technology Centers (of 35 planned). Key modern technology is split between CDCs and ATCs (by 2007 CDCs had 13 of the 19 public sector MRI machines, ATCs 15 of the 26 CT scanners). In 1998, there was only one MRI machine and five CT scanners in the public sector.

Barrio Adentro III and IV

Barrio Adentro III provides care for those cases which cannot be resolved at the two lower levels—major illnesses, palliative and specialist care. Care is available 24 hours a day. Barrio Adentro IV is responsible for the most complicated and specialized medical and surgical needs. These are national and referral facilities where teaching and research is carried out. On 16 November 2006 the Chavez government introduced this phase of the Barrio Adentro project, with a planned 16 hospitals to be built around the country, especially in poor areas. The Dr Gilberto Rodríguez Ochoa Latin American Children’s Cardiology Hospital, inaugurated in 2007, is the most notable example, being one of the largest centers of its kind in the world, with 142 hospital beds and 33 intensive care beds.

Achievements

According to the Ministry of Health, only 50 public health establishments were built in the 1980s and 1990s. Between 2003 and 2007, 4,659 new
comprehensive level I and II health care centers were built and equipped. Services in these centers is provided free of charge. In 2004/5 Barrio Adentro provided 150m consultations, four times as many as the conventional outpatient network; 40% of these were home visits.

"In surveys conducted by the National Statistics Institute (INE) in Caracas, 97 percent of the respondents said that they were satisfied or very satisfied with their general medical consultations, and 98 percent said they had little or no difficulty gaining access to health care, while 88.5 percent said that they had had some or considerable difficulty gaining access to health care prior to Barrio Adentro."

Between 1998 and 2007, extreme poverty was reduced from 20.6% to 9.41%, while the infant mortality rate fell from 21.3/1000 registered births
to 13/1000.

According to one academic study, the successes of the Barrio Adentro program in 2003 and 2004 may have "crucially influenced" Chavez’s 59% to 41% victory in the Venezuelan recall referendum, 2004.

Analysis

The Venezuelan Medical Federation, the largest association of medical doctors in Venezuela, has lobbied vigorously against the use of Cuban doctors in Mission Barrio Adentro, and was in a legal dispute with the Chávez administration over the legitimacy of the Cuban doctors' licensure and practice. In 2003 they obtained a court order preventing Cuban doctors from practicing in Venezuela, on the basis that they were not properly licenced according to the Venezuelan system; a compromise was reached enabling them to continue working in Barrio Adentro.

Creation of related Missions

As the work of the first primary health care Barrio Adentro proceeded, censuses began to reveal "the depth of the social deficits accumulated in these communities." The response was to expand into a number of new areas, creating new missions. Thus under Misión Alimentación, efforts are made to ensure that the vulnerable (children, elderly, etc) receive at least two meals a day. Misión Robinson was created to address illiteracy, which in turn led to Misión Milagro to deal with the revealed deficit of opthalmological care for eye disease.

Defections

In August 2006 the United States under George W. Bush

George W. Bush

George Walker Bush is an American politician who served as the 43rd President of the United States, from 2001 to 2009. Before that, he was the 46th Governor of Texas, having served from 1995 to 2000....

 created the Cuban Medical Professional Parole program, specifically targeting Cuban medical personnel and encouraging them to defect when they are working in a country outside of Cuba. According to a 2007 paper published in The Lancet

The Lancet

The Lancet is a weekly peer-reviewed general medical journal. It is one of the world's best known, oldest, and most respected general medical journals...

 medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the USA". Cuban doctors working abroad are reported to be monitored by "minders" and subject to curfew.

In February 2010 seven Cuban doctors who defected to the US introduced an indictment against the governments of Cuba and Venezuela and the oil company PDVSA for what they considered was a conspiracy to force them to work under conditions of "modern slaves" as payment for the Cuban government' debt.

Abandonment

In July 2007, Douglas León Natera, chairman of The Venezuelan Medical Federation, reported that up to 70% of the modules of Barrio Adentro have been either abandoned or were left unfinished .

In some cases it is said that elected opposition officials have tried to impede or close existing Missions. In 2006 Chávez accused the governor of Zulia state of impeding Barrio Adentro there. In Miranda state in February 2009 the governor was reported to have tried to evict a 25-person Barrio Adentro mission to make room for office space.

External links

• Street Art in Revolutionary Venezuela by Dale Graden, 30 July 2009
• Venezuela slum takes socialism beyond Chavez by Reuters
  Reuters
  Reuters is a news agency headquartered in New York City. Until 2008 the Reuters news agency formed part of a British independent company, Reuters Group plc, which was also a provider of financial market data...