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By Sergio Ferrari - Bernard Borel
Interview with Nila Heredia, surgeon, internist, community health specialist and professor at the University of La Paz. From the beginning of 2006 to January 2008, he served as Minister of Health of the Government of Evo Morales, participating in the elaboration of the program that the Movement Towards Socialism carried out in view of the 2005 elections.
Bolivia, achievements of a model of change. The new logic of popular health
Nila Heredia is a surgeon, internist, community health specialist, and professor at the University of La Paz. From the beginning of 2006 to January 2008, he served as Minister of Health of the Government of Evo Morales, previously participating in the elaboration of the program that the Movimiento Al Socialismo (MAS) raised in the face of the December 2005 elections. He joined the ranks of the Bolivian Guevarist left (the National Liberation Army), harshly repressed during the military dictatorship. Then he set out on the path of exile to Peru. Upon his return to Bolivia, he did intense work with social, trade union and human rights movements. Holding responsibilities at the head of the Organization of Relatives of Political Prisoners and Disappeared in Latin America.
Q: You served for two years, until January 2008, as Minister of Health of the Bolivian Government. How was the health system when you took office in early 2006?
A: It is important to remember that Bolivia has the health indicators, in terms of maternal and infant mortality and in terms of life expectancy, among the poorest in the entire continent, just behind Haiti. Furthermore, as in all of Latin America, our country has suffered the effects of the structural reform program carried out according to the indications of the World Bank (WB), one of whose objectives is to reduce the State apparatus to the maximum - under the pretext of inefficiency. and corruption - and the privatization of public services, including health.
Q: What concrete impact did this guideline have on public health?
A: The budget of the Ministry of Health was very small and most of its work was carried out with loans from the World Bank and the Inter-American Development Bank. There was, then, a kind of parallel ministries that were directly accountable to those organizations. The programs were promoted according to the United Nations Millennium Goals, which, although it is true that they constitute an important framework, cannot reduce all the work in a specific country like ours. In short, our Ministry had very little to say in those plans promoted from outside and channeled through certain international NGOs and entities.
Q: What did these programs propose to precisely improve the health level of the population?
A: For example, to reduce maternal mortality, the program planned to improve hospital infrastructures and train personnel for deliveries in those centers.
But such a proposal did not really work at the national level for 2 reasons: you had to pay for these services and it did not benefit the women who were most at risk, that is, those who live in the campaign, far from urban centers. It was a very interventionist program. A woman from the rural area does not undress even in front of her husband! Much less will you go to the hospital to give birth!
Q: What were your priorities during the 2 years you were in charge of the ministry?
A: We structure the work based on a National Plan that is based on four main pillars and that were taken up in a general line in the text of the new Constitution of the Republic. Abolish social exclusion by developing a family, community and intercultural health model. Increase the years of healthy life, especially from the zero malnutrition program. Encourage and develop citizen participation. And recover the power of management and direction of the health system.
Q: What were the main difficulties encountered?
A: In the first place, the university discourse in our country is very academic, far from reality and with a vision centered on the commercial logic of profit.
On the other hand, although we managed to regain the leadership of the health system, the departmental directors are appointed by the prefects, among which 6 - of the 9 at the national level - are opponents of Evo Morales. Fact that limits our action, especially in times of economic-social polarization like the current one.
Q: In conclusion ...
A: It can be said that we have gone from a stately, elitist health, with a very weak capacity for leadership on the part of the State, to health based on popular promotion and participation with a coherent national program.
* Interview conducted in La Paz, Bolivia
The four pillars of the Morales Government's health plan
The interview with Nila Heredia allowed to know the essential elements of the National Health Plan that is being implemented today in Bolivia and which includes four essential axes. A fifth aspect, solidarity, appears as a transversal theme.
The abolition of social exclusion it is based on the family, community and intercultural health model. To ensure this, a postgraduate training in this area was created in which 150 Bolivian doctors participate and to which another 50 will be integrated. These resident doctors work in 30% of cases in urban clinics and in 70% in the field. especially in prevention and health promotion tasks. While waiting for a sufficient number of doctors to be trained, the Government of Evo Morales has had the support of Cuba, which in the last two years has sent 1,700 doctors and all the equipment to install 30 rural clinics. At the same time, free assistance has been decreed for those under 21 years of age and those over 60 years of age, as well as benefits related to sexual and reproductive health.
Increasing the years of health. Malnutrition is a major factor in mortality and morbidity. The “zero malnutrition” program seeks to improve nutrition, especially for children under two years of age. This is not only about detecting cases of malnutrition but also ensuring prevention, improving access to a balanced diet and preventing anemia and parasitic contamination.
The promotion of social participation. It seeks to assure communities, municipalities and families the possibility of solving their priority health problems. In this sense, there is an effort by the Ministry of Health to value traditional medicine and establish a treatment registry. When there is a risk of epidemic, as recently happened with the yellow fever that has affected neighboring countries, the workers make themselves available to the municipalities that were in charge, with the support of organized social movements, to ensure that the population is vaccinated on time.
Recovery and planning of the health system by the Government. Credits and loans from the World Bank and the Inter-American Development Bank, like all other foreign aid, pass through government channels in order to develop a coherent health system.
These four axes are totally interdependent and this concept has given strength to the National Plan. It is clear that its comprehensive implementation requires time. It is to be hoped that this process, which takes into account the needs and aspirations of the most disadvantaged sectors for a life "with health" and more dignity, will not be frustrated by a hard, elitist right wing that is willing to use all means to stop or make roll back the ongoing process. (Bernard Borel)
Fragility and potential of today's Bolivia. "The government of social movements." Interview with Nila Heredia, former - Minister of Health
Q: Do you define yourself as a * woman of power *?
A: From the militancy from below. I know the hardships and the interesting aspects of this very particular process that my country is experiencing. A process characterized by the fact that there is no traditional-style political party that wins the elections. Rather, it is the sum of social movements with their respective leaderships, to which some parties join.
Q: It is rare to speak of a government of social movements ...
A: Yes, in a way an unprecedented experience. The movements have a very great weight. They are the expression of the great anger of broad popular sectors against a model of exclusion that dominated Bolivia for years and years. Today's experience is the result of mobilizations, protests, resistance, the water war and the gas war ...
Q: What is the most active sector within these social movements?
A: The labor movement is very weakened. In his time the miners played a leadership role in the Central Obrera Boliviana (COB). Then the national economic life depended on the mines. After its privatization, this sector was significantly reduced. Furthermore, the logic of flexibility in recent years attacked the power of the unions. Many workers saw membership as a threat to their own job stability ...
Hence, in recent years the most dynamic and homogeneous sector has been the peasantry, in a fundamentally rural country.
Q: And in the cities?
A: There are the so-called "unionists", who constitute a very strong informal sector, especially commercial, vendors, artisans. Everyone is organized. In Bolivia there is a huge organizational experience. The unionists are moved by their daily interests: water, the education of their children, health, etc. And they are seeing that certain changes in structure benefit them. Not from the logic of a socialist revolution but from more justice and equity. It is interesting to see that the informal sectors can, in a certain reality, assume progressive attitudes.
Q: How is the general organization of social movements?
A: Very basic, very horizontal and wide. And that is a great strength: no one can be considered more important than the other. But it is also a weakness due to the heterogeneity of social actors. And that is why President Morales makes an enormous effort to relate to all of them, including the organized indigenous people. He exercises undisputed leadership. It is the key that harmonizes very different sectors. His charisma is undeniable. Although it cannot be forgotten that the MAS came to lead the State without any management experience. And it must multiply on many fronts: exercise the central government; ensure parliamentary activity; run various prefectures. Besides having promoted a Constituent Assembly ... A really huge challenge!
* Returning from Bolivia