Although the Bolivian government’s new and improved universal healthcare plan has made a considerable dent in child and maternal mortality numbers, the plan still seems to be more suited for improving statistics than the lives of rural Bolivian women.
With one of highest rates of maternal and child mortality in the Latin America, second only to Haiti, Bolivia remains one of the worst places in the world to give birth, especially in rural areas. Mortality rates have historically totaled to 390 mortalities for every 100,000 live births in central cities (like the capital, La Paz), and reach as high as 887 per 100,00 live births in rural areas, according to UNICEF.
Beginning in 1994, Bolivian government officials centered in La Paz developed a series of free healthcare plans—or, more aptly, three free service packages—intended to keep mothers and children alive past the ordeal of childbirth. The most recent addition to these packages is the “Universal Maternal and Child Heath Insurance plan (SUMI).”
Upon its creation, SUMI was lauded as the symbol of iconic change of fate for Bolivian mothers. Targeted at pregnant women and children under the age of five, the program boasted that it would cover 500 common ailments. Additionally, SUMI was the first Bolivian public health program that did not come from a presidential decree, meaning that it would have longevity through congress even as presidential power shifted.
“The system was created to fight child mortality, to fight that economic barrier that prevented the mother from having proper attention from the start,” said Dr. Dante Ergueta, who works with SUMI at the Bolivian Health Ministry, in an interview with the U.K. Guardian. “It is an icon for Bolivia and I might even say for Latin America.”
Initially, SUMI managed to cut the alarming child mortality statistics. After its introduction, Bolivia saw reduction in infant mortality between 37.7% in urban areas. Even in rural areas, the program saw a 29.9% drop in infant mortality, which, although still less than the drop in metropolitan areas, represented a significant change.
However, the effects of SUMI have been blunted, if not entirely counteracted, since this initial drop.
The seeds for this decline can be found written into SUMI itself. According to a study done by Focal, SUMI’s plan to attack statistics was limited to quick fixes. Every service that SUMI provided was a double-edged sword, all of which left the deep roots of maternal health barriers in Bolivia untouched.
Where SUMI expanded the number of ailments covered by insurance, it also drastically tightened the program’s membership requirements, restricting it to women who had given birth within the past six months and children under the age of five. Previously, Bolivian health insurance had covered all women of childbearing age as well as the general population for endemic disease. SUMI cut the general public endemic disease coverage entirely, along with several family planning services for non-pregnant women.
Focal reports that “health indicators worsened after its [SUMI’s] implementation, particularly in rural areas. Inequity in health outcomes also grew because the services of high complexity that the SUMI plan made available in urban areas never reached the segment of the population [rural, indigenous communities] that needed them most.”
This “icon for Bolivia” is perhaps one of the most stark examples of one of the most common failures in public health: the rush to address startling statistics, instead of attacking underlying socioeconomic, or even cultural, gender-based problems.
According to UNICEF, Bolivian women exist in a culturally persistent subordinate role to men. Their rates of illiteracy are significantly higher, ranging as high as 37.91%, compared to 14.42% of men. This gap also drastically decreases the number of women who are capable of participating in the workforce, giving women less access to employment-based private healthcare options.
These socioeconomic and cultural forces show that the answer to improving Bolivian maternal health is more complicated than implementing a system of health-services handouts. It is not about the number of services the state can provide; it is about changing the situations of people receiving those services.
– Emma Betuel