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By Modesto Emilio Guerrero
Until 1998, Venezuela was valued for the barrels of crude oil in the world market, its soap operas and the beauty queens that came off its catwalks. Health was one of them.
In Venezuela a new health system is being formed. It constitutes one of the socioeconomic segments with the highest social incidence due to its quantitative value in the human development index. It is undoubtedly the result of the huge public investments since 2002-2003, although the genesis of this new "health" in Venezuela is in the first years of the nationalist political process popularly known as the "Bolivarian revolution."
This new health map is based on the Barrio Adentro Mission, one of the most important social programs in recent national history, if measured by its territorial effects on mass health. Like everything that is done with social mobilization, it does not come alone.
For the establishment of this Mission, political decisions and convictions were linked within and outside of Venezuela (for example, Cuba, which contributed 14,000 doctors and its international experience in primary care). One of the decisive convictions was that of the working-class and poor neighborhoods that supported the program in every way, not only going to be cured, but also defending the modules and their clinicians. This constituted a social mobilization and an ideological battle.
The triumph of Barrio Adentro would be inconceivable, without the deep political mobilization registered in Venezuela since 1998, especially when this mass action acquired a revolutionary character in 2002. To that extent Barrio Adentro and the new Venezuelan health constitute a social conquest.
It's simple, the Barrio Adentro Mission would not have been possible without the powerful Bolivarian social movement that supports Chávez.
Its positive effects are impacting immediately on all segments of the population, in this perspective its action has territorial scope. It has served to help sustain age stability, environmental health balance (individual-city-nature relationship), reduction in morbidity and mortality rates, stability in productive employment, and the state of individual and social happiness. As a social program in full development, it lives trapped in the dialectic of the impact of the new, which is therefore fragile, under the dead weight of the stale.
The most useful of conquests
Until 1998, Venezuela was valued for the barrels of crude oil in the world market, its soap operas and the beauty queens that came off its catwalks. Since the revolutionary action of April 2002, and 11 months later, the conquest of PDVSA, Venezuelan society took a historical leap in the development of its achievements. Health was one of them.
Since then, a radical transformation in the rhythms of construction of the government's nationalist project has been evidenced. What remained asleep woke up abruptly, what was slow accelerated and the indefinite began to contrast, in light of the greatest social mobility and political awareness experienced by Venezuela since the Revolution of January 23, 1958.
If 1999 was the beginning of the political and institutional transformations, April and December 2002 were the spigot for social conquests.
What has been achieved in health, education, oil sovereignty, state sovereignty; More recently, what has begun in land ownership, among other smaller plans, constitute pillars.
But the most useful and transcendent of all the conquests, the one that sustains the social legitimacy of the current Venezuelan process and government, is the political awareness acquired by the population. Without her everything would be volatile.
Between evils, remedies and "doctors"
The quantification of this emerging reality, in the field of health, begins with the data of the population universe served. Between 1999 and 2004, the public health service at the primary level reached more than 12 million people. This, in relation to what was obtained in previous historical cycles, represents a novelty.
We will take two cycles, the one that runs from 1950 to 1980 and the one that begins in 1981.
All the good accumulated in primary health care service, after the Revolution of January 23, until 1980, collapsed between 1981 and 1998.
This is specifically stated by authors such as Augusto Galli and Haydee García, in the book "The Venezuela Case. An Illusion of Harmony" (Chapter 19, "The Health Sector: Radiography of its ills and its remedies." Compilers: Moisés Naim y Ramón Piñango, Ediciones IESA, 2nd Edition Pages 452 to 470. Caracas 1985)
Naim and Piñango had the merit of directing in 1980 the most complete study of the Venezuelan reality, under the ideological and financial orientation of the great neoliberal bourgeoisie of that time. Not by chance, it is the same social group that supported the coup in 2002 and that in 2005 -or 2010 would not matter- anything to see the social missions pulverized: their worst enemies in the long term. In 1981, when they made "The Venezuela Case. An Illusion of Harmony", they had the objective of rebuilding the country that was beginning to get out of hand.
That book was a country project on paper. A project of "doctors". Today, not even that interests them. It would be enough for them to reconquer PDVSA.
The ruin of a vulnerable healthcare system
Everything that was built as a "health system" in Venezuela after World War II was fragile and condemned to decline, because it was not based on the main criterion of massive structural and permanent care. The criteria was the business, the private and the other.
When reviewing the state of health in the three decades from 1950 to 1980, these authors tell in Naim and Piñango's book that "When observing the evolution of health spending, it is appreciated that it has gone from 21 bolivars per capita in 1950, to 398 bolivars in 1980. However, as shown in Table 4, in that same period the percentage of the budget of the Ministry of Health and Social Assistance (MSAS) with respect to the national budget increased from 7.5 percent in 1950, to 6.1 percent in 1980 "(p. 456)
The nominal value of the amount of bolivars per capita invested since 1950, was diluted by inflationary action and lost cumulative value in the development of the health sector, as its global investment historically decreased, falling by 1.4 points while the population multiplied at a rate 2.8 annual average, that is, twice.
Even more serious, the authors indicate that investment in "preventive medicine and environmental sanitation" was cut in half in the period covered. From the 28% reached in 1950, it fell to 14% in 1980. This translated into a serious accumulated deficit of hospital doctor and nurse beds per inhabitant. The Venezuelan drug from that period was the second most expensive on the Latin American continent. Only Peru surpassed Venezuela in the average social cost per drug. A study carried out by the Pan American Health Organization (1984) showed that a price model built with 30 basic primary care drugs gave this result: While in Peru this abstract unit cost the public 3.7 dollars, in Venezuela it cost 3.5 dollars . Both countries were above all others in the Latin American group.
The result was the consolidation of private medicine oriented by individual profit, which in Venezuela grew to the detriment of the public one. 68% of the national health market (medicines, medical supplies and care) was carried out in the private sector.
Following the information in the aforementioned text by Naim and Piñango, it is easy to understand why the health of Venezuelan society was reduced to levels of misery in the 1990s. The development of services was added annually to the reduction in historical social spending. deprived of medical attention and the immunological defenselessness of the inhabitants due to the neglect of prevention.
While the item "Outpatient and preventive service" (from table 5 of the chapter, page 458 in the aforementioned book) occupied 24.1 percent of the percentage spending of the MSAS in 1950, at the height of the Perezjimenista dictatorship, reflecting the Postwar oil revenues , that reality changed in 1980.
This "Service", essential in the health balance, both for defense against infections and for human immune resistance, was reduced to 9.8 in MSAS expenditure. A reduction of almost two thirds.
"The emphasis on the curative and not on the preventive has led to the problem of" disease "being solved with an enormous deployment of resources, which has meant, among other things, the construction of the most modern hospitals equipped of the most modern technology. Meanwhile, the individual and the community have been left out of efforts aimed at "staying healthy" such as disease prevention, and education to take care of themselves and protect their rights to better quality. of life. "(p. 458)
Only one key piece of information was missing in this health equation: food, which in the capitalist way of life depends on a periodic wage income, that is, from work, that is, from the owners of work.
Not only was the disease not prevented, the majority of the population was not cured either, who ended up going to private medicine, waiting months or years for a bed in Social Security ... the most immediate and cheap "health system ", the local healer. With known risks.
There is no better way to measure the disastrous results of Venezuelan capitalism under the administration of the "Fourth Republic, than to know the evolution of the main causes of death. According to the table compiled by the authors referred to so far, 7 of the 10 main causes of death. death in the country in 1972, they had grown in 1980. In other words, all public "investment" in health ended up in something other than the Venezuelan population (Ibid, p. 455, Table 2: Main Causes of Death 1950 -1980)
1981: Second cycle of inexorable decline
A specialist from the Economic Commission of Latin America (ECLAC) determined the causes of the health disaster in Venezuela since 1981. The research and writing of the report was in charge of the specialist Marino J. González R. It was called "Reforms of the health system in Venezuela 1987-1999: Balance and perspectives Edited in Santiago de Chile, June 2001 by the Special Studies Unit, Executive Secretary of ECLAC In this work, Marino reports the following:
"The coverage of the health services of the Venezuelan Social Security Institute (IVSS), especially the FAM, has been estimated at 35% of the total population (including insured workers and their families) in 1998 (D´Elia 2000)"
The author points out a fact: "The coverage of other contributory institutions is not published on a regular basis", a fact that is not less because it concealed two major trends: the drastic reduction of the health service provided by the State and the large legal and illegal businesses that carried out by multinational medicine companies.
The author went to empirical samples that were sufficient as illustrations of the drama. Especially because it distances the reading of the Report from the coldness of the statistics and brings us closer to the common mortal who expresses his social helplessness.
"The 1998 Social Survey (prepared by the Central Office of Statistics and Informatics, OCEI) included social security coverage in one of its questions, but not that of other health systems coverage. Unfortunately, it was not possible to have the base of data that would allow identifying the coverage of at least social security. However, other areas of this survey allow us to contribute some indirect elements (González and Molina 2000)
For example, that "8% of the people who presented acute disorders reported that they went to Social Security services." That "33% of those interviewed stated that they attended private clinics or clinics."
"The rest of the interviewees (just over 60%) reported their attendance at public institutions. In the case of those who reported performing laboratory tests, almost 60% indicated that they went to private or religious centers. This finding is coinciding with the repeated complaints from users about the provision of health centers in the public sector ", highlights the Report.
"It seems that public institutions only meet the demands of laboratory services from a fraction (possibly 50%) of the users who consult for health problems."
More serious is the case of care for chronic health problems. "10% of the patients attended IVSS services, more than 40% of the patients attended private or religious institutions. 40% of the patients were attended in public institutions not dependent on the IVSS."
And the secret of the secrets of human health: "50% of the patients who reported the impossibility of performing complementary tests, indicated that the cause was the lack of economic means. 80% of the patients who reported the impossibility of acquiring medications indicated that it was due to lack of financial means. "
In general, it can be inferred that the real coverage of public services, especially those of the MSDS, is lower in the cases of chronic disorders. More than 50% of patients for these causes are cared for in social security institutions or in the private sector.
In the case of patients consulting for acute ailments, this percentage is slightly lower. "Consequently, it seems that the demand for services in private institutions is higher than what is traditionally accepted."
1987-1998: The Collapse
The extended misery that defined Venezuelan society in 1998 began to take shape in the early 1980s and was implemented en masse between the mid-decade of deficits in social spending and almost the entire decade of the 1990s when those deficits and misappropriation of public money, became a collapse.
The sign of this phenomenon in the field of the class struggle was the insurrection of Caracazo (February 1989), the outbreaks of military insurrection of 1992 and the most intense and extensive list of struggles of all kinds in society that Venezuela has experienced. from 1958-1960 (Margarita, CLACSO, Caracas / Buenos Aires, 2003) The data is known: 82 percent of the Venezuelan population was already living in poverty in 1992.
A grotesque shadow of the collapse of the Venezuelan health until 1999 was the number of laws, decisions and executive decrees that served for everything, especially for state propaganda, but not to cure. More than 10 years of reforms that did not reform anything. This is how researcher Marino J. González shows it in his report to ECLAC:
"Between 1987 and 1999, Venezuela has tried different types of reforms in the health system. In that period, the following reforms occurred: (1) National Health System Law of 1987, (2) decentralization of health services (from 1990), (3) restructuring of the Venezuelan Institute of Social Security (IVSS) in 1992, and (4) approval of the reform proposal of the Social Security Health Subsystem in 1998.
Despite the fact that all these reforms have been materialized in legislative or regulatory instruments, the implementation process has been difficult and unsuccessful in all cases. "
The main effect of this disaster was on the health of the population. The health system that began to develop in 1936 and accumulated some relative successes in the 1960s (See Naim and Piñango, 1982) was destroyed for almost 15 years.
Those who never saw a syringe
Until 1998, the public health network served a little more than 2 million citizens per year, in a historical evolution that began in 1950 with little more than 280,000 people served by the State.
Between mid-2002 and the first half of 2004, the total annual universe served rose to a new annual scale: 11,230,000 people.
From the point of view of care, this data constitutes a revolutionary event, a social achievement. Its beneficiaries understand it politically that way. Only in this way is it understood that the name "Barrio Adentro" is synonymous in Venezuela with health, immediate and free health care. In fact, it replaced health institutions such as IVSS and others in social memory, which for half a century were, in the best of cases, a diffuse reference to this basic service. At worst, IVSS symbolizes in popular memory corruption, inefficiency, anguish.
This radical transformation of the universal primary care service began in 2002, although it had its first initiatives in between 2000 and 2001.
The ECLAC technician reported these precedents in his report: "The health sector has received special attention from the national executive and legislative levels. The National Assembly must legislate in 2001 in the areas of social security and health. The characteristics and consequences of the new legislation will undoubtedly affect the health system in the coming decades. " However, the new health system in Venezuela can only be measured from 2002-2003, with the Barrio Adentro program and investments from 2002-2003.
Two mortality risks
Since June 2003 it has been complemented with the expansion of investments in areas and branches of complex care, such as oncology, AIDS and others.
The new orientation of State investments and its mode of enforceability imposed a radical modification of the forms of insertion. Most decisions and investments in health and care are concentrated in the central government, many at the expense of the useful share accumulated in the Ministry of Health and Social Development (MSDS) and other agencies.
This emerging health system in Venezuela is in the process of development. That very fact forces you to think about the risks that lie in wait.
It is not the first time in our continent that a government or political project advances development plans in health or education. Argentina, Uruguay, Chile and Costa Rica have done so between the 1940s and the 1970s.
The challenge of the new health network in Venezuela is to prevent its decline, corruption and bankruptcy, as has happened in each of the countries mentioned. Of all, the most contracting example is that of Argentina. This country had one of the best health systems in the hemisphere until it was destroyed by privatizations and internal corruption.
Cuba is the only case where the health system gained steps of positive development in primary care and in some branches of complex medicine and did not fall back to the disaster levels of the other countries mentioned. That is because in Cuba health is an integral part of a chain of social conquests governed by the absence of capitalist criteria in health care. Destroying Cuban health would require the simultaneous demolition of all or a good part of the political, economic and social system established by the revolutions of 1959 and 1963.
The "Bolivarian revolution" has not yet reached that level of political and economic deepening. The birth of the new health system is fragile in historical and comparative terms. It will be able to survive and consolidate if it manages to chain itself to other similar transformations in the entire political and economic structure of the State and society.
In this perspective, the new health system created by the "Bolivarian Revolution" contains two inborn risks. The main danger is in the weight gained since 1959 by private health systems, whose ethical, economic and political criteria have as their sole purpose individual profit, not the health care of the population. In this case, health is just one of the commodities of a world system, which is based on the imperialist control of biotechnology, patents and molecules.
The second danger is an epiphenomenon of the previous one, not for that reason less dangerous. It's called corruption. It is born in the private business and ends in the official, not the other way around. It is emerging as the main factor of distortion and danger for the health system that is creating the "Bolivarian revolution."