Evaluating the progress of the “Sistema Único de Salud”: Bolivia’s baby steps on the road to Universal Health Coverage

Evaluating the progress of the “Sistema Único de Salud”: Bolivia’s baby steps on the road to Universal Health Coverage


*By Karina Guzmán – Bolivia

Our health is undeniably among the greatest treasures we have. A healthy life is the basis for a high quality of life. And when our health deteriorates, the health services available to us can make all the difference. Unfortunately, half of the world do not have access to essential health services yet [1]. Healthcare provision is particularly challenging when it comes to Latin America and the Caribbean (LAC), one of the most inequitable regions in the world [2]. Nonetheless, a great step towards healthcare for everyone in the region occurred five years ago, when The Strategy Universal Access to Health and Universal Health Coverage (UHC) was approved by the states forming the Pan American Health Organization (PAHO)[3]. This first step forward was reinforced when all UN member states signed the Sustainable Development Goals (SDGs) committing to achieve UHC by 2030 [4].

Bolivia’s health and the region

If we examine the panorama of improvements to healthcare services globally, the World Bank’s report on UHC in LAC simultaneously presents evidence of persisting acute inequities in access to healthcare within countries, leading to unacceptable outcomes (as measured by indices such as life expectancy, infant and maternal mortality and fatality rates of different diseases) in the region and underscores the remarkable progress achieved by some countries in the region [5]. This scenario is particularly evident in Bolivia, the case I will be examining in this blog. On the one hand, the country has dismal health indicators, including one the second worst infant and maternal mortality rate in the region up to 2016 and the highest mortality rate of cervical cancer in the region, with 5 Bolivian women dying daily from the disease [6]. On the other hand, Bolivia had also experienced increasing income in the last decades and consequently has taken a gigantic leap towards UHC by launching the “Sistema Único de Salud” (SUS) on March 2019 that aims to provide integral health services to everyone [5 y 7].

The SUS and its first steps

On May 2019, during the 72nd session of the World Health Assembly at the United Nations (UN) Headquarters in Geneva, Bolivia announced the SUS to the world [8]. The SUS is an amplification of the Law 475 of December 2013, which established integral service and financial protection for its users —pregnant women, children under 5, elderly people, people with disability and women in fertile window regarding sexual and reproductive health— in the process laying the groundwork for the universalization of integral healthcare [9]. In fact, the SUS extends integral health service coverage to
include approximately 1.200 services, encompassing surgeries, complementary exams, prescriptions and hospitalization [10]. The benefactors of this extension are those who currently do not have a healthcare insurance, such as independent workers, union workers, drivers, housekeepers, masons, craftsmen, shoe-shiners and students [11]. In a country where two-thirds of working-aged “adults” (anyone over the age of 10 in Bolivia) work in the informalised commercial or services sectors, this represents a massive leap forward. Now, all Bolivians need to access the healthcare service is a valid ID card and a recent utility bill.

In a recent interview, the flammant Minister of Health Gabriela Montaño reported the successes of the SUS so far, highlighting that in less than two months it has provided over one million of health checks from which more than two-thirds benefited women [12]. In earlier declarations, Minister Montaño affirmed that 3.265 healthcare centres were ready for the start of the SUS implementation and 49 more hospitals will be built [13]. The Bolivian government assigned a budget of 200 M of US dollars for the first operative year of the SUS, which according to Fernando Leanes —the PAHO representative in Bolivia— is considered a reasonable spend for a country initiating in UHC; moreover, Leanes pointed that in 2019 the Bolivian PIB’s spent in healthcare goes up to 5,1% making the Bolivian healthcare budget one of the highest of the region [14].    

Current challenges

However, there is no such thing as a free lunch, and the big question is who is going to pay for all of this. It is no small feat extending a healthcare service to include millions more people overnight. It is doubly difficult in a context were the pre-existing healthcare infrastructure is underfunded and already struggling to provide a quality service [15]. Up until late 2018 the government had a debt of 201M Bolivianos (around 28.9M Us dollars) with the hospitals in the central axis of the country alone —La Paz, Cochabamba and Santa Cruz— for service provision related to the afore mentioned Law 475 and the figure rises if we add the claims from other cities and municipalities [16].

The SUS, understandably, has raised some eyebrows and some protest. The neoliberal right, staunch defenders of the market, decry what they see as overbearing state intervention in the healthcare sector [17]. Doctors, ever a conservative force in Bolivian society have been mobilised in defence of their working conditions (and one feels, commercial interests) [18]. Members of the National Health Fund (CNS), the pot of money taken workers’ pay packets and managed by the workers themselves, remain suspicious of the changes, an understandable fear given previous attempts to extend healthcare provision by the government has rested upon diverting funds from the CNS into then public system [19]. These proposals galvanised a series of protests by the workers and their union central, the COB, over the past decade. In sum, the political landscape surrounding healthcare provision is complex and fraught with difficulties, and the medium- to long-term future of the SUS is far from secure.

To conclude, the SUS represents baby steps towards equity and a better quality of life and an enhanced platform to exercise human rights for all Bolivians. However, the magnitude of the task cannot be overlooked. Beyond the obvious challenges of building adequate infrastructure, training staff and developing an effective stewardship, the political layers and interests involved in this long-term process—I dare say—pose a higher risk to the success of a universal healthcare system than simply providing the budget and people. To ensure a successful healthcare system, the government needs to bring all sectors on board with their plans to provide a solid, material basis for the SUS. Whether they will succeed or not remains to be seen.


REFERENCES

1. World
health Organization. 
Key Facts.  24/01/2019 WHO Available from:
https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)

2. Pan American Health Organization. Strategy for universal access to health and universal health coverage. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2014
Sept. 29–Oct. 3 (CD53/5, Rev. 2). Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=27312&Itemid=270&lang=en.

3. Byanyima W, Barcenas Ibarra A. Latin America is the world’s most unequal region. Here is how to fix it [Internet]; 2016. Available from: https://www.weforum.org/agenda/2016/01/inequality-is-getting-worse-in-latin-america-here-s-how-to-fix-it/.

 4. World Health Organization. Strengthening health systems for universal health
coverage and sustainable development; 07/04/2017. Available from: https://www.who.int/bulletin/volumes/95/7/16-187476/en/

5. The World Bank. Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Selected Countries; 2015.
Available from: http://www.worldbank.org/en/region/lac/publication/toward-universal-health-coverage-and-equity-in-latin-america-and-the-caribbean-evidence-from-selected-countries.

6. Los Tiempos. Bolivia, país con más mortalidad materna en la región: 12/12/2016. Available from: https://www.lostiempos.com/actualidad/nacional/20161212/bolivia-pais-mas-mortalidad-materna-region and ANF. Cuatro a cinco mujeres mueren al día por cáncer de cuello uterino en Bolivia; 03/04/2017. Available from: https://www.paginasiete.bo/sociedad/2017/4/3/cuatro-cinco-mujeres-mueren-cancer-cuello-uterino-bolivia-132981.html

7 y 10. Página Siete. ¿Cómo beneficiarse del SUS? 10 claves para entender este seguro;
02/02/2019. Available from: https://www.paginasiete.bo/sociedad/2019/1/2/como-beneficiarse-del-sus-10-claves-para-entender-este-seguro-204760.html#!

8. OMS/OPS. Bolivia presente en la 72ª Asamblea Mundial de la Salud; 20/05/2019. Available: https://www.paho.org/bol/index.phpoption=com_content&view=article&id=2259:bolivia-presente-en-la-72-asamblea-mundial-de-la-salud&Itemid=481

9. Bolivia (2013) Ley de Prestaciones de Servicios de Salud Integral del Estado Plurinacinoal de Bolivia¦ Law of Provision of Integral Health Services of the Plurinational State of Bolivia. Bolivia.

11 y 13. Valenzuela, Lídice. Estrena Bolivia Sistema Único de Salud (+Infografía);
01/03/2019. Available: http://www.cubahora.cu/del-mundo/estrena-bolivia-sistema-unico-de-salud?fbclid=IwAR2Q1Zb0ly7Nf-VmYrcwLGxskckDfqrt4n-UHkJ6Xt8bpfZoCRvN4ksfjCw

12.  Ministerio de Salud. Bolivia abrió la segunda sesión de la 72ª Asamblea Mundial de la Salud; 21/05/2019. Available:
https://www.minsalud.gob.bo/3784-bolivia-abrio-la-segunda-sesion-de-la-72-asamblea-mundial-de-la-salud

14. OMS/OPS. El SUS en Bolivia arrancará con un presupuesto inicial que está en parámetros razonables; 01/2019. Available: https://www.paho.org/bol/index.php?option=com_content&view=article&id=2194:el-sus-en-bolivia-arrancara-con-un-presupuesto-inicial-que-esta-en-parametros-razonables&Itemid=481

15.  Página Siete. ¿Está Bolivia preparada para el SUS?; 24/02/2019. Available at: https://www.paginasiete.bo/opinion/editorial/2019/2/24/esta-bolivia-preparada-para-el-sus-210057.html

16. Peredo Nelson. Gobierno adeuda más de Bs 200 millones a hospitales de 3 ciudades; 30/11/2018. Available at: https://www.lostiempos.com/actualidad/pais/20181130/gobierno-adeuda-mas-bs-200-millones-hospitales-3-ciudades  

17. Guarachi, Ángel. Médicos ratifican rechazo al SUS y deciden reactivar protestas desde el 6 de marzo; 19/02.2019. Available at: http://www.la-razon.com/sociedad/medicos-movilizaciones-bolivia-rechazo-sus-marzo_0_3096890355.html

18. ANF. COB amenaza a médicos con protestas por el SUS; 19/11/2018. Available
at: https://correodelsur.com/politica/20181119_cob-amenaza-a-medicos-con-protestas-por-el-sus.html

19. Loza, Adriana. ¿Qué es el Sistema Único de Salud y por qué algunos sectores lo
rechazan?; 11/01/2017. Available at: https://abyayala.tv.bo/index.php/2017/01/11/sistema-unico-salud-sectores-lo-rechazan/

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