A People's Health System
Venezuela Works to Bring Healthcare
to the Excluded
by Peter Maybarduk
Multinational Monitor, October
"Much of our health problem has to
do not so much with economic factors as with the organization
of communities," explains Luis Montiel Araujo, a physician
with Venezuela's Ministry of Health and Social Development (MSDS).
"Barrio Adentro was conceived as a way to bring medical services
to the excluded, ... to put a physician in every community."
Barrio Adentro. It is nearly impossible
to travel Venezuela without hearing reference to the government's
highly popular and controversial healthcare initiative that invites
Cuban doctors to treat, train and live with working-class Venezuelans
in communities across the country.
In the indigenous Orinoco delta village
of San Francisco de Guayo, some 80 miles from the nearest road,
and in the Andean town of Mucuchies, some 10,000 feet above sea
level, Cuban doctors operate primary care clinics in cooperation
with local volunteers. In the 18 months since Barrio Adentro's
inception, the number of Cuban physicians in Venezuela has grown
to more than 13,000, their medical services available to approximately
17 million Venezuelans, or two thirds of the country's population,
according to the Ministry of Health and Social Development. The
director of the Pan American Health Organization has praised Venezuela,
and President Hugo Chavez in particular, for "combating social
exclusion" and demonstrating "new leadership in health."
Poor Venezuelans say the program means
they have access to medical services for the first time. But not,
they stress, without their participation. Neighborhoods organize
themselves into local health committees (Comités de Salud)
to oversee the operations of clinics that the government funds.
Barrio Adentro enlists the patient as a partner in the care of
is or her health.
The program's detractors including leaders
of Vènezuela's sizeable opposition coalition and much of
the medical establishment - attack Barrio Adentro alternately
for skirting established norms of licensing foreign practitioners
and for allegedly promoting Cuban-communist ideology. Some criticize
the program as unsustainable, relying on a supply of foreign expertise,
while others accuse the government of giving away Venezuelan jobs.
Proponents say Barrio Adentro is expressive
of the participatory political culture and social justice democracy
the Chavez government aims to create in Venezuela.
The challenge to the program is two-fold
- to demonstrate that it can improve health in Venezuela over
the long term and to prove that it can survive the country's protracted
It is a test of the practicality of Venezuela's
"Bolivarian Revolution," the nonviolent effort to restructure
Venezuelan society, named for South American liberator Simon Bolivar.
"A NEW CULTURE OF ACTION"
Since the Movimiento Quinta Republica
(MVR) ascended to power in Venezuela in 1998, with the election
of Chavez as president and a subsequent controlling majority of
the National Assembly, the government has set out to remake the
culture of healthcare in Venezuela, bringing it, in Montiel's
words, "from medical assistance to social and participatory
medicine." The new constitution, approved by popular referendum
and enacted in 2000, guarantees all citizens / the right to health
and forbids the privatization of health services. The government
has opened social security administration hospitals and even certain
military general hospitals to the general public to assure a -
more efficient and -equitable distribution of public health services.
But the government's most ambitious visions lie ahead, in the
consolidation of an effective primary care network and the alignment
of all public health services under a single ministry.
The Venezuelan health system features
private and public sectors, a mixed model the government intends
to retain. Because many professional Venezuelans do not trust
the public hospitals, and highly specialized services can be comparatively
rare in the public system, private clinics retain a significant
market. Through 2000, private spending on healthcare still outpaced
public spending. But this is changing as the government steps
up its efforts.
The public health system has, for years,
been divided among several masters, including the Ministry of
Health and Social Development, the social security administration
(IVSS) and the military, among others. Treatment at public hospitals
has always been free, but their services have been limited.
"Health is a luxury," deadpans
Jhonny Madrid, a publicly employed security official. Prior governments
"didn't fund the hospitals. They've always had their private
Pro-government Venezuelans speak often
of the prohibitive costs that once attended special medical needs,
from some surgeries to eyeglasses. "Seventy, 80, 100,000
bolivares ($35-70) for a consultation. Five million ($2,500) for
an operation," estimates Elizabeth Bustos Uribe, a Chavista
nurse. Such prices are well beyond the means of working Venezuelans.
Barrio Adentro now provides some of these services at no charge.
Bustos pulls from her purse the prescription
glasses fashioned for her by a Cuban optometrist. "They were
Further resources are flowing into the
popular pool via the IVSS social security hospitals, formerly
the exclusive domain of pensioned workers. IVSS hospitals are
reputed to be better equipped and better funded, with more available
specialties. By 2000, 53 percent of Venezuelans worked in the
informal sector, and so IVSS was treating a dwindling pool of
patients. Its opening to all Venezuelans is much celebrated by
government proponents. J: But it is unclear how much this particular
change will materially affect the health of the public: IVSS hospitals
make up only about 11 percent and IVSS clinics only : account
for about 1.6 percent of all public clinics. The balance are overwhelmingly
establishments operated by the Ministry of Health, all already
open to every
Venezuelan before the rise of MVR. The
opening of IVSS hospitals and several military hospitals is symbolically
important, but Dr. Montiel says more is at stake.
"What's important is that these hospitals,
as they change classification and become People's Hospitals, adapt
to the real necessities of demand - [the large number] of patients
with sicknesses that merit attention with high technology and
specialized medicine." The idea is that opening IVSS hospitals
to all Venezuelans will contribute to a streamlined healthcare
network, one without the inefficiencies created by limiting access
to select branches of a public system.
The planned primary care network envisioned
by MSDS would include People's Hospitals, Popular Clinics and
Popular Doctor's offices, replacing the existing order of hospitals
and clinics of divergent ownership and access. The government
is also considering constructing a factory to produce its own
These projects represent a significant
investment in infrastructure, and it is not clear that the government's
projections are realistic. Only six Popular Clinics are thus far
complete; the government would like 417. Of 8,500 established
Barrio Adentro missions, only 280 operate out of the unique "Consultorio
Popular" modules designed specifically for that purpose (560
are under construction, and an additional 3,141 modules have advance
funding, out of an estimated 9,503 that will be needed).
Underpinning the quick pace of reform
is a widespread mistrust of the politicians who governed Venezuela
during the previous regime, many of whom retain influence within
the opposition coalition. Some Chavez supporters fear that should
leaders of the old guard return to power with newfound allies,
they may move to privatize essential services as former governments
did the national telephone company, the steel industry and other
state assets during the 1990s.
The specific fear that an opposition government
would privatize basic health services may not be justified. Basic
healthcare, to the extent that it has been available and accessible,
has long been free in Venezuela, as government opponents are quick
to point out.
But working Venezuelans do have good reason
to fear underfunding of the public health sector and creeping
marketization. In the 1980s and 1990s, successive administrations
inaugurated market reforms, restructuring the system of "retroactive"
severance pay, eliminating subsidies on consumer goods and cutting
tariffs and social spending. The state petroleum corporation PDVSA
ran on self-defined priorities, revenue for the state not among
them, as it rebelled against what the firm's leadership viewed
to be a hopelessly corrupt government. Poverty rose from an oil-boom
low of 10 percent (1978) to 86 percent (1996) in less than 20
Mindful of popular discontent with market
models of governance, and of the popular success of Barrio Adentro,
some opposition strategists now state that a new, opposition-backed
government would retain the program.
But it seems unlikely that a government
unified in part by antipathy for Cuba would maintain the oil-for-expertise
exchange presently in place. Anti-government demonstrators cite
Chavez's alleged intent to follow the Cuban government's model
as a principal reason that he should be deposed. Even if moderate
forces within the opposition were to advise against it, a government
of the present opposition might order the greater part of Cuban
doctors from the country.
With the failed promises of the previous
regime in mind and an ever-developing political consciousness,
working-class neighborhoods have aligned themselves more and more
closely with the government since 1998. Many believe that community
organizing and community education are their best defense against
a return to a politically powerless past. Barrio residents gather
in "Bolivarian Circles" to discuss the potential effect
of new laws before the national assembly on their community, and
to petition for government services or local ordinances.
Healthcare has not stood apart from this
process. In the spring of 2003, the MVR government of Libertador
district, Caracas began to invite neighborhood representatives
to planning meetings for the initial phases of Barrio Adentro.
The first Cuban doctors arrived in April.
"THE ESSENCE OF THE REVOLUTION"
I n the southern Caracas barrio of Las
Moros, mother of three, talks about the
clinic that opened in her neighborhood one year ago. She cradles
her youngest in her arms.
"It's marvelous. They open the door
at any hour, and treat everyone."
What about people from outside the community?
Or members of the opposition?
"They have treated them just the
same." Moros says that the doctors come by her house as if
they were neighbors to check on her daughters. They give her vitamins,
and tend to the girls' occasional fevers.
Moros is married to Franklin Gamboa, a
member of the Las Malvinas Health Committee. Arranging for the
care of approximately 3,000 residents, the committee is divided
into two bodies of about 10 citizens each: one group to support
each doctor. Committee co-coordinators Paulina Gomez and Edixon
Marquinez attended early city planning meetings for Barrio Adentro.
"We asked for the doctors, and they
stayed in my house while the clinic was built," explains
"We [the committee] met to choose
the site for the module in our neighborhood," says Marquinez.
The Las Malvinas module looks up a dusty hill to the neighborhood's
tin-roofed, rough and cluttered but brightly colored houses. It
follows the uniform design of its 280 companions appearing across
Venezuela: two-stories, cylindrical, red brick with cornflower
blue trimming. The committee provides volunteers for the modules,
security and a nurse for each doctor. The nurses from Las Malvinas
learned on the job and are now licensed.
Asked what sort of health problems are
common in the barrio, Marquinez replies, "asthma." Nearby
residents nod their agreement. He describes the respiratory problems
from which the community suffers, associated with a cement mixing
operation adjacent to the neighborhood, and the nebulizing device
the doctors employ to treat the sick.
Elizabeth Bustos Uribe works as the Barrio
Adentro clinic nurse in Casco Central, Parroquia La Pastora, Caracas.
She helps the two Cuban medics in her module administer treatments
for parasites, skin allergies, diarrhea and other common ailments.
"Barrio Adentro is the essence of the revolution," she
"We treat about 50 patients a day,"
Bustos says. The doctors are on call seven days a week. Some days,
one doctor remains at the module while the other makes the neighborhood
rounds. Occasionally, one will be pulled away to another part
of town if their specialty in this case, dermatology or endocrinology
- is needed. The Venezuelan government pays the doctors a monthly
stipend of $250, and "the city sends them baskets of food."
The medicine they use some 103 drugs treating 95 percent of Venezuela's
most prevalent illnesses - comes from Cuba.
A few days before, Bustos recalls, "around
8:30 P.M., someone with an emergency arrived. He was swollen,
and his blood pressure was around 220/130." Far above the
normal blood pressure of 120/80, this would put him in imminent
danger of a stroke. "We gave him medicine and an injection.
He took the treatment for three days. If he'd not seen the doctor
in Barrio Adentro, he could have been paralyzed."
The Ministry of Health claims that over
11,000 lives have been saved through Barrio Adentro thus far.
The figure is plausible. The presence of clinics in communities
brings primary care far closer to people who were, in many cases,
accustomed to living without treatment until their illness became
an obvious emergency. A national immunization plan has elevated
vaccination rates. And the intimate involvement of neighborhood
groups in Barrio Adentro significantly improves community health
Dr. Juan Carlos Marcano, an adjunct physician
with the Health Ministry and a coordinator of the burgeoning primary
care network, spent a year and a half traveling from barrio to
barrio in preparation for Barrio Adentro's launch. He says he
has seen significant progress in a short period. "I was in
El Paraiso, a community of 500 or 600 families. A year ago, there
was nothing. Now there's a mercal (a subsidized food market) and
a doctor's module."
Renato Gusmao, the Pan American Health
Organization's Venezuela representative, praises the project.
"Barrio Adentro permits the planning of a healthcare system
based on the demands of the population, not just on how much they
have and how much they can afford."
The considerable expense of Venezuela's
healthcare reforms and Barrio Adentro's reliance on foreign doctors
raise questions about the initiative's sustainability. But criticisms
of government healthcare policy extend much further than finance,
as healthcare becomes valued high ground in Venezuela's enduring
First and foremost among Barrio Adentro's
opponents is the Venezuelan Medical Federation (FMV), a powerful
doctors' group of 55,000 members. In June 2003, the FMV filed
suit to stop Barrio Adentro's Cuban physicians from practicing
in Venezuela, alleging that the doctors were not licensed to practice.
On August 21, the First Administrative Court ruled that the Cuban
doctors should be replaced by licensed practitioners. The government
appealed, and the case is not yet resolved.
The Centro al Servicio de la Accion Popular
(CESAP), a privately funded human development and citizen rights
group, charges that Barrio Adentro "is not attending to the
structural problems of the Venezuelan health system." CESAP
suggests that "resources applied to the Barrio Adentro program
could be used to fortify" existing clinics and hospitals.
Similarly, Susanna Ibarrin, vice president
of the U.S.-based opposition group Free Venezuela, asks, "If
his [Chavez's] goal is to improve the health system, wouldn't
it make sense to improve the hospitals?"
But the government is investing significantly
in the creation of its proposed primary care network. If successful,
such a network would significantly ease hospitals' burden, by
treating illnesses before they require hospitalization.
The FMV and the private media also allege
that Cuban doctors are incompetent and are spreading "propaganda."
"Barrio Adentro is nothing more than
indoctrination. Many of them are not even doctors . ... There
is a lot of infiltration by the Cuban security establishment,"
But no significant evidence has surfaced
to support these claims. Stories of communist infiltration and
gross malpractice, which succeeded in scaring potential host communities
at first, have lost plausibility as most Venezuelans have either
sought treatment or know someone who received competent and professional
treatment from a Cuban doctor. Many Cuban doctors have at least
one specialty and one year of overseas field experience before
joining Barrio Adentro. Even CESAP states that complaints of malpractice
have been few "in comparison with the great number of patients
The Medical Federation's President Natera
also contends that Venezuela already has more doctors than recommended
by international health agencies. This is true. Venezuela boasts
one doctor for every 500 people, much better than the 1,200-to-I
minimum ratio recommended by the World Health Organization. Yet
many barrio dwellers have never had an attendant physician. Article
8 of the Law of the Exercise of Medicine requires doctors to spend
a year after medical school in an underserviced area, but there
are many ways to fulfill this requirement without delving deep
into the barrio.
CESAP cites the "insecurity of popular
areas" as a reason that most Venezuelan doctors avoid barrio
service. Working-class Venezuelans view doctors' avoidance of
their neighborhoods as class prejudice. But they are quite aware
of potential danger to outsiders walking alone in their neighborhoods.
This is why the Comités de Salud charge local volunteers
with the protection of Cuban doctors, walking them to and from
the clinic and anywhere else they must go. It seems the same protection
would be available to any Venezuelan doctor willing to perform
the same community service.
In 2002, during the planning phases of
Barrio Adentro, the government issued a call for volunteer Venezuelan
physicians. "They were not receptive," says Dr. Montiel.
About 50 doctors answered. Until the recent addition of Venezuelan
post-graduate medical students, only 29 Venezuelan doctors worked
in the popular consultarios of Barrio Adentro. CESAP blames the
government for this lack of participation. But the culture of
the medical profession in Venezuela may bear responsibility, as
Most Venezuelan doctors come from the
professional class. The majority grew up in the country's wealthier
neighborhoods, and many are not comfortable in the dirty and crowded
neighborhoods of poor Venezuela. It is probably true that more
well-meaning physicians would consider working in poor communities
if they felt it were truly safe. But it is also true that both
class and racial prejudice remain strong in Venezuela.
Dr. Marcano believes that "most students
are studying to earn money." And money is in private clinics
and specialties, not in neighborhoods like Las Malvinas. FMV President
Natera contends the government should pay its doctors more. Better
salaries would likely attract more and better doctors. On the
other hand, the $600 monthly stipend offered to Venezuelan physicians
in Barrio Adentro, with expenses paid, is a respectable public
sector salary in Venezuela, and is already more than twice that
afforded the Cuban doctors.
Asked why Venezuelan doctors did not answer
the call to serve Venezuelan barrios in greater numbers, Ibarrin
says, "They don't want to bring any political message."
This opposition of the medical profession
leadership to the Bolivarian project will likely prove the most
difficult problem the government confronts in implementing its
vision for comprehensive care.
While the government could probably continue
its oil-for-expertise exchange with Cuba for the foreseeable future,
Barrio Adentro coordinators recognize that a sustainable healthcare
network must rely primarily on Venezuelan health workers, and
they are laying the groundwork for this transition.
CULTURAL CHANGE AND COMMUNITY CARE
In line with Barrio Adentro's ethic of
community care, the Venezuelan government is helping barrio residents
attend medical school and return to practice in their own communities.
The first class of 250 Venezuelan students
has just graduated from medical school in Cuba. Another 1,000
are in training. The government has already integrated 1,200 Venezuelan
post-graduates into Barrio Adentro for two-year residencies, after
which the new doctors will have the option to stay on if they
There are also plans to start a medical
school tied to Barrio Adentro within the recently chartered Universidad
Bolivariana de Venezuela (UBV) in Caracas, part of an effort to
open higher education to the popular class. Still, "changing
the culture .4 of [established] medical schools will be difficult,"
confesses Dr. - Marcano. So long as Venezuelan medical culture
operates on two antagonistic tracks, the country's ability to
effectively coordinate the medical resources under the control
of each will be diminished. Integrating Barrio Adentro and the
primary care network with the resources of the medical schools
remains a challenge. Financing is another long-term challenge.
Barrio Adentro relies on heavy social spending.
The Health Ministry estimates the value
of medical services rendered thus far at $1.5 billion. Venezuela,
an OPEC nation, is currently reaping the benefits of record high
petroleum prices. But these prices may not last, and the Chavez
government may have to cut spending in the future.
Barrio Adentro has two advantages that
may keep it off the chopping block. First, the program is exceptionally
popular. Second, as Dr. Marcano explains, start-up costs and the
construction of modules are expensive. But once these initial
investments are covered, costs of Barrio Adentro and the primary
care network will drop significantly, and confer a cost advantage.
"Primary care is cheaper, because you avoid more complicated
After just a year-and-a-half of operation,
Barrio Adentro has attained near sacred status among working-class
Venezuelans. Even those who can afford private clinics are finding
that they can save money and receive the same quality of care
for basic needs at the program's modules.
"Any government that would attempt
to shut down Barrio Adentro would fall within 24 hours,"
declares Marcano. Certainly, such a government would confront
dramatic civil unrest. Barrio Adentro was built and is continuously
shaped by the same people who benefit from it. From their perspective,
Barrio Adentro is not a government program, it is their program
- one that belongs to the Venezuelan people and health is their
Social cleavages, procedural challenges
and major personnel and infrastructure shortages remain obstacles
in the path Venezuela must traverse on its way to access, equity
and health. But the perspective of a thrice-confirmed majority
of the electorate is summed up in one word by Francisco, a smiling,
white-haired Chavista waiter in the Andean town of Apartaderos:
Peter Maybarduk is a freelance writer
and law student at Boalt Hall at the University of California,