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PAHO Basic Health Indicator Data Base This is a multidimensional query tool that offers a collection of 108 indicators from 1995 to 2005. The system presents data and indicators on:
- demography
- socioeconomic
- mortality by cause indicators
- morbidity and risk factors
- access, resources and health services coverage.
Selected indicators are disaggregated into age groups, sex and/or urban/rural region. Generated tables can be exported and printed.
The data presented is updated annually with the latest country information.
GENERAL SITUATION AND TRENDS Bolivia is situated in central South America, in an
area of 1,098,581 km2. Its population in 2000 was estimated at 8,328,700 inhabitants,
with a population density of 7.6 inhabitants per km2. The country is divided
administratively into 9 departments, subdivided into 112 provinces, with 314
municipalities. As a consequence of the modernization policies, which included
passing the Community Involvement Act ("Ley de Participación Popular")
and reforming the Constitution in 1994, the degree of participatory democracy
was increased by delegating responsibility for municipal management to autonomous
governments of equal hierarchy under a council and a mayor elected by universal
suffrage.
Demography: In
the last 50 years, Bolivia’s total population has tripled in size. This
increase was accompanied by an intense urbanization process. Between 1950 and
2000, the rural population decreased from 65% to 35% of the national population.
In 2000, 15% of the population was under 5 years of age, 40% under 15 years,
and 59% less than 25 years. The total fertility rate remains high: between 1995
and 2000, women had 4.4 children on average.
Economy:
By 1998, the GDP per capita had risen to US$1,010, posting 4.3% growth between
1990 and 1998. Mean annual inflation was 10%, declining from 18.0% in 1990 to
3.1% in 1999. The open unemployment rate was down by around 4% in 1999; however,
only 48% of the working population in the department capital cities were salaried
workers entitled to social protection benefits. The incidence of poverty, measured
in terms of income, fell from 80% in 1976 to 60% in 1997. The Gini coefficient
for income distribution was 0.53 in 1996 and 0.56 in 1997. In 1997, estimated
national illiteracy was 8% among men and 22% among women over 15 years of age,
reaching 55% and 52% in rural areas of Potosí and Chuquisaca, respectively.
Literacy: In 1996, the average schooling of
the population reached 6.5 years in males and 5.1 years in women.
Mortality: Between
1995 and 2000, the annual crude death rate was estimated at 9 deaths per 1,000
population and life expectancy at birth at 61.4 years. Bolivia has not yet
managed to develop a system to record vital statistics. Estimated national
underregistration of mortality was approximately 63%. In a mortality study
conducted in 2000, it was pointed out that leading broad group causes of mortality
were: diseases of the circulatory system (30.3% of deaths), communicable diseases
(12.0%), and external causes (10.7%). Close to 11% of all deaths were classified
as ill-defined signs and symptoms.
SPECIFIC HEALTH PROBLEMS Analysis by population group Children (0-4 years):The
infant mortality rate has declined steadily, from 89 per 1,000 live births
in 1988 to 55 per 1,000 in 2000, although in some rural areas it still exceeds
80 per 1,000 live births. Neonatal mortality averaged 34 per 1,000 live births:
57% early neonatal mortality and 43% late neonatal mortality. The mortality
rate among children under 5 years declined from 116 per 1,000 live births
in 1993 to 79 per 1,000 live births in 2000. Regarding deaths of children
under 5 years, 40% corresponded to children less than 1 month old, 37% was
attributed to diarrheal diseases, 20% to pneumonias and 16% to perinatal disorders.
Adolescents (10-14 and 15-19 years): In
1994, 37% of adolescent girls were mothers by the time they were 19. In 1998,
this proportion had dropped to 27%. Estimates showed that 14-15-year-old girls
accounted for 69% of abortions.
Adults (20-59 years): The
fertility rate among women with high school or higher education was 2.7 children
per woman, whereas this rate increased to 7.1 among uneducated women. In 1994,
the maternal mortality rate was estimated at 390 per 100,000 live births (274
in urban areas, 524 in rural areas, and 602 in the rural altiplano).
Analysis by type of health problem Diseases preventable by immunization: Between
1998 and 2000, a huge measles outbreak spread across the country, with a total
of 4,751 suspected cases and 2,567 confirmed cases. The under-5 year age group
was the most affected. In 2000, rubella outbreaks behaved in a similar epidemiological
manner to the measles outbreak, and 427 cases were confirmed. In July 2000,
application of the MMR vaccine against measles, mumps, and rubella was included
in the regular EPI scheme for the population aged 12 to 23 months old. Between
1996 and 2000, 5,500 cases of mumps were recorded, of which 2,157 occurred
in 1999 and 680 in 2000. Between 1998 and 2000, the rate of cases of acute
flaccid paralysis (AFP) reported in children under 15 years old, declined
from 11.9 to 7.6 cases per million. In the same period, the indicator for
measuring the acceptability of the stool specimen for AFP increased from 58%
to 72%. In 1999, four cases of diphtheria were reported among the school-age
population and two cases in 2000. The incidence of pertussis has also dropped:
in 1996, 115 cases were reported, whereas, in 2000, 10 cases were reported.
In 2000, two cases of neonatal tetanus were reported and investigated. In
the same year, the national immunization coverage was 94% for BCG among infants
under one year of age, 89% for DPT3 and OPV3 vaccines in infants under one
year of age, and 100% for anti-measles vaccine in children from 12 to 23 months.
HIV/AIDS and sexually transmitted infections: Between
1985 and 2000, there were 605 cases of HIV/AIDS (52% asymptomatic carrier
of HIV). The average annual incidence rate remained around three cases per
million population (1990-1997). The male:female ratio decreased from 5:1 to
2:1, and heterosexual transmission predominates. Sentinel surveillance detected
prevalences of HIV lower than 1% in pregnant women and 5% in populations with
high-risk behavior, and thus the epidemic was classified as incipient. In
1999, incidence rates of gonorrhea, syphilis, and hepatitis B in the general
population were estimated at 74, 55, and 5 per 100,000 population, respectively.
Intestinal infectious diseases:Bolivia saw
40,212 cases of cholera between 1991 and 1995, resulting in 814 deaths. Since
then, there has been a decline in incidence from 2,068 cases in 1996 to 467
in 1998 and no cases in 1999 and 2000.
Vector-borne diseases: In 75% of the national
territory, where half the country’s population live, malaria is actively
transmitted. In 2000, 31,468 P. vivax and 2,536 P. falciparum malaria cases
were reported in contrast with 74,350 and 11,414 cases, respectively, in 1998.
The P. vivax annual parasite index (API) in 2000 was 8.8 per 1,000 habitants,
58% below the figure for 1998. Chagas disease is endemic in 60% of the territory,
where 4.0 million inhabitants are at risk. It is estimated that the prevalence
of infection by Trypanosoma cruzi in the population of the endemic areas is
40%. Between 1996 and 1999, the incidence of jungle yellow fever rose significantly,
from 30 cases reported in 1996 to 68 cases in 1999, and then dropped sharply
with 8 reported in 2000. In the last decade, the case-fatality rate from yellow
fever exceeded 60%. Circulation of dengue virus serotype 1 and occurrence
of cases of classic dengue have been documented in Bolivia since 1987. In
1999 and 2000, 27 and 80 cases of classic dengue were identified, respectively.
No confirmed cases of hemorrhagic dengue were reported. In 2000, 1,735 cases
of leishmaniasis were reported, more than half of these cases in the department
of La Paz. Endemic plague was detected in 2000 in La Paz, Santa Cruz, Chuquisaca,
and Tarija. In the period 1996-1997, there was an outbreak of human plague
in San Pedro Apolo with 17 confirmed cases and 4 deaths. Since then no new
cases have been reported in humans.
Zoonoses: During the last decade, cases of
human rabies followed an interannual cyclical pattern. The incidence of canine
rabies fell from 18.0 per 10 thousand dogs in 1992 to 1.8 in 2000. This drop
was linked to the increase in canine rabies vaccination coverage.
Chronic communicable diseases: In 1999, 9,272
cases of all forms of tuberculosis were reported, 12.6% less than in 1996.
The number of respiratory symptom cases detected fell by 13% between 1996
(71,959 cases) and 1999 (62,371 cases), and the number of diagnostic sputum
smears by 14.1% (from 133,316 to 114,564) in the same period. Ever since the
directly observed treatment, short course strategy (DOTS) was applied in some
areas in 1994, the case-finding coverage has not exceeded 60%. The cure rate
has not exceeded 70% among those who began treatment, with treatment incompletion
rates ranging from 10% to 12%. In the last years, a decline in the number
of prevalent cases of leprosy was observed: from 1,179 in 1993, to 607 in
1997 and 379 in 2000. The prevalence rate of leprosy was 5.3 cases per 100,000
population, with 82 new cases reported (64 males) in 2000.
Nutritional and metabolic diseases:In 1998,
the prevalence of chronic malnutrition in children under three was 26%, but
it was 36% in rural areas, and 44% among children with illiterate mothers.
In the same age-group, the prevalence of anemia was 67%. Iron deficiency is
the main cause of anemia and one of every three women of childbearing age
is anemic. The prevalence of iodine deficiency disorders was reduced from
61% in 1981 to 5% in 1995. In the country’s main cities - La Paz, El
Alto, Santa Cruz and Cochabamba - the prevalence of diabetes mellitus was
7.2% (7.6% in women and 6.8% in males), and as high as 20% in individuals
aged 60-64 years in some cities. In these cities, the prevalence of hypertension
was 18.6%: 16% in women and 21% in males.
Oral health:In 1998, the prevalence of untreated
caries at 12 years of age was 84.6%. The DMFT index at this age was 4.7, with
a caries component of 93%.
Natural disasters: In 1997-98 the most serious
consequences have been linked to the effects of the El Niño phenomenon:
40 (1997) and 75 (1998) deaths, and US$ 1,364 million in economic impact for
both years.
Emerging and re-emerging diseases: The first
confirmed case of hantavirus pulmonary syndrome was reported in 1998 in Tarija,
and the second in 1999 in Santa Cruz. Neither of the two was fatal. In May
2000 in Taruja, there was an outbreak of five cases among men 15-54 years
of age, with four deaths. No Bolivian hemorrhagic fever cases were reported
from 1997 to 1999. In 2000, the only case reported was in Beni and it was
fatal.
RESPONSE OF THE HEALTH SYSTEM National health policies and plans:
The 1997-2000 Strategic Health Plan is designed
to develop the Bolivian health system and ensure universal access through
individual, family, and community primary health; an "epidemiological
shield"; short-term basic and social insurance; and promotion of healthy
municipalities, subject to participation of and control by society. It adopts
the sectoral decentralization guidelines provided for in the 1994 Community
Involvement Act.
Health sector reform strategies and programs: The
main strategy behind the sectorial reform process is the Basic Health Insurance
(BHI), an instrument designed to guarantee all inhabitants permanent access
to a series of promotional, preventive, and curative health benefits, which
are essential to mitigate the consequences of the main causes of disease and
death in the country, at a sustainable cost. This system provides health care
and nutrition for children under 5 years; immunization and promotion of nutrition;
and attention to priority problems in the mortality profile, including diagnosis
and treatment of the country’s principal endemics: tuberculosis, malaria,
cholera and sexually transmitted infections. The debt relief program for heavily
indebted poor countries in which Bolivia participates proposes monitoring four
performance indicator goals: delivery care coverage (69%); coverage for treatment
of acute respiratory infection in children under 5 years old (70%), acute diarrheal
disease in children under 5 years old (56%) and DPT3 immunization coverage in
infants under 1 year of age (85%). By the year 2000, these coverages were 50%,
87%, 36%, and 86%, respectively.
The health system: Bolivia’s health system
comprises public and private for-profit and not-for-profit sectors, and the
social security system. The Ministry of Health and Social Welfare (MSPS) is
responsible for sectoral regulation, and for issuing and applying policies and
national standards. The delivery of health care services is under administrative
responsibility of municipal government. Approximately 43% to 48% of the population
uses the public services of the BHI. Social security funds account for 22% of
coverage, and the private sector for 10%. Between 20% and 25% of the population
lacks access to health services. Organization of public health care services
and programs:
Disease prevention and control:The "epidemiological
shield" strategy vertically integrates the activities of priority programs
for the surveillance, prevention and control of malaria, Chagas disease, tuberculosis,
yellow fever, leishmaniasis and diseases preventable by immunization, and articulates
itself with the BHI. The prevention and control of acute respiratory infection,
acute diarrheal disease, sexually transmitted infections, cervical cancer, other
chronic and degenerative disorders, nutritional disorders, and domestic violence
is part of the national health care program.
Health analysis, epidemiological surveillance and public health laboratory systems:
The National Epidemiological Surveillance and
Health Situation Analysis System was set up in 2000. This system includes mortality,
morbidity, nosocomial infections, risk factors, environmental surveillance and
basic indicator data. The National Institute of Laboratories of Health and the
Center of Tropical Diseases are national referral laboratories that contribute
to the network of the surveillance system which includes 248 clinical analysis
laboratories. The National Health Information Subsystem is a component of the
National Statistical Information System, which prepares information on the production
and productivity of health services in the country.
Potable water and excreta disposal services: In
1999, 72% of the population had access to potable water services (93% urban;
37% rural) and 61% had access to sanitation and excreta disposal services (79%
urban; 33% rural).
Organization of individual health care services: The
country has 3,165 health care establishments of varying complexity and a total
of 12,554 hospital beds that are part of a national health care service network
of the Basic Health Insurance benefit package. In 1999, there were 23,415 blood
units donated in the 60 registered blood banks. A total of 90% of the donations
were replacement donations by family members and 80% were screened. In these
units, positive markers of T. cruzi (17.5%), syphilis (7%), hepatitis C (1.2%),
and hepatitis B (0.5%) were detected. In 1998, Free Medical Insurance for Senior
Citizens was established that guarantees adults over 60 access to public health
services and social security.
Health supplies: In 1999, US$ 98.5 million
equivalent to US$ 12.1 per capita were spent on drugs. In that year, 77.5% of
drug expenditure came from out-of-pocket expenditure. The pharmaceutical sector
is an important segment of the country’s economy, accounting for 1.15%
of GDP. There are 8,293 legally registered drugs, 5,518 of which are marketed.
Of these, 27% are essential drugs and 70% are imported drugs.
Human resources: In 1999, the MSPS had a staff
of 13,850 people: 27% nursing auxiliaries, 26% administrative and service personnel,
18% physicians, 14% technicians, 9% professional nurses and 6% other professionals.
Problems of imbalance persist between human resources available and the tasks
required to solve problems, due to an ‘irrational’ ratio between
administrative and medical personnel, imbalance in types of training, and low
remuneration of medical and paramedical staff.
Health sector expenditures and financing: National
health expenditure amounted to US$ 422 million in 1998. That amount represented
5% of the GDP and was equivalent to US$ 46 per capita per annum. Public health
expenditure accounted for 65% of the national spending on health (42% to social
security; 23% to the public sector). Between 1995 and 1998, the main sources
of sectoral financing are from the country’s companies (45%), consumers
(31%), and government (17%).
External technical cooperation and financing: Through
a loan agreement signed with the Inter American Development Bank, the government
of Bolivia is developing the ‘epidemiological shield’ project and
the 1999-2004 Support for the Reform of the Health Sector Project, equivalent
to US$ 54 million. The country also signed a US$ 28 million loan agreement with
the World Bank for the first phase of the 1999-2001 Support for the Reform of
the Health Sector Project, with the objective to reduce national maternal and
infant mortality rates.
