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BOLIVIA: Wanted – Healthcare Adapted To Indigenous Cultures

Gustavo Capdevila

GENEVA, May 25 2006 (IPS) - The alarming state of health in Bolivia is related to the dominant healthcare model, which ignores the society’s traditional cultures, said Health Minister Nila Heredia, who is attending the World Health Assembly in this Swiss city.

Heredia participated in a debate organised by the Partnership for Maternal, Newborn & Child Health, an international initiative backed by the World Health Organisation (WHO) to help achieve the Millennium Development Goals (MDGs) related to substantially reducing maternal and infant mortality rates by 2015.

Although there have been significant improvements in maternal and child health in the last few years, the most recent figures, from the 2001 census, put Bolivia in next to last place in Latin America – only ahead of Haiti, said the health minister of the leftist government of Evo Morales, Bolivia’s first-ever indigenous president, who took office in January.

The results have failed to live up to expectations, apparently because of the imported healthcare models that have been applied, which take no account of the community’s values and customs, Heredia, a university professor and prominent civil rights activist, said in an interview with IPS.

IPS: What is the difference between the viewpoints applied?

NILA HEREDIA: There are different ways of looking at health. Every culture has a concept of health that is probably different to that of others. In fact, the healthcare model is based on sickness, not health. We are concerned about hospitals, about patients. That is the predominant healthcare model.

In contrast, the general population is more concerned about creating the conditions for health. Many things just come naturally, and are too natural to be forced into a different way of providing healthcare.

IPS: What do you object to in that model?

NH: We have been much concerned with the trend towards humanised childbirth. Sometimes, we think, humanised childbirth is not just about more comfort and convenience for the woman in labour, but means she needs to be attended by a medical professional. But people are afraid because the doctor attends according to his own comfort and convenience, instead of the mother being the one who is made comfortable.

That creates difficulties for medical attention in this situation.

IPS: Are there more deeply-rooted criticisms?

NH: Yes. For instance, in many cultures the placenta has a profound symbolic value. Therefore, it must be kept, and must be buried in the right way, so as to guarantee the survival and life of the child. According to medical logic, the placenta is useless and is thrown away. This creates a huge gulf. And then, the woman won’t go back for medical attention, because a part of her child, a part of its life, has been thrown away.

There are many other criteria, many concepts that require us to look at culture, beyond medical procedures. Even more so when culture has the added value of surrounding the birth of a child, for example, which is an event that belongs to the family, and not to the doctor or the nurse.

IPS: What are the figures from the 2001 census?

NH: The maternal mortality rate stood at 234 per 100,000 live births, one of the highest in Latin America. The under-five mortality rate was 75 per 1,000 live births and the neonatal mortality rate was 31 per 1,000 live births. These statistics are evidence of an alarming health situation.

IPS: How is health care spread out in Bolivia?

NH: Coverage by the universal state maternal and child health insurance scheme, which offers free healthcare to children under five and mothers from pregnancy up to six months post-partum, showed a wide disparity between urban and rural areas.

Neonatal coverage amounted to seven percent in rural areas, and 93 percent in urban areas. In 2004, 51 percent of pregnant women gave birth in hospitals or other healthcare institutions, but most of them were attended in the capital cities of departments (provinces).

IPS: In your presentation to the Partnership for Maternal, Newborn & Child Health, you said “We need every possible ally.” What did you mean?

NH: In this matter, I think that our allies include politicians as well as allies from a more technical and academic point of view. But let me reiterate, childbirth is not a medical procedure, it’s a natural event, something that comes even as a blessing. So, doctors have to ally themselves with that view, and not try to be the lead actors in the birth. The lead actors are the mother, the family.

IPS: Aren’t you afraid that some allies, such as the pharmaceutical industry, might try to shape your policies?

NH: They will certainly try, but they won’t succeed in Bolivia. Obviously, they have influence in the healthcare system, they have their own ways of doing business. But they are not the kind of allies that I would wish to have.

IPS: Why are you so concerned about the training of human resources?

NH: Our human resources continue to be trained within a welfare-based hospital healthcare model that ignores culture and identity, in a country where more than 60 percent of the population is made up of indigenous people. There are over 30 different cultural identities in Bolivia, counting nations and ethnic groups. The main ones are the Aymara, Quechua and Guaraní nations, with their own knowledge, traditions and customs.

Each of them has special characteristics, which requires all of us, and the health system in particular, to review and rethink the training of human resources, because by ignoring culture, identity and customs, we end up training people who aren’t adapted to reality. Many of our personnel can’t speak indigenous languages, so they can’t get close to the people, and neither do the people find it easy to go to the hospitals.

IPS: In your presentation you didn’t mention the question of sexual and reproductive health, unlike the other speakers. Is this not a problem in Bolivia?

NH: It certainly is. We have a problem with the Catholic Church, which is absolutely against any kind of legislation (to decriminalise abortion). I believe it’s an important topic, because with such a narrow view of the meaning of abortion, even therapeutic abortion, and the issue of a woman’s free choice about motherhood, the Church uses all its powers to prevent passage of a law.

In this argument about sexual and reproductive health, there must be a stop to demonising the subject.

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