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BOLIVIA: Cash for Checkups to Slash Maternal Deaths

LA PAZ, Mar 2 2010 (IPS) - A social programme in Bolivia that prevents the deaths of two mothers a day from complications related to pregnancy and childbirth is making headway despite administrative difficulties, and has the potential to cut the alarmingly high maternal mortality rate in this country by up to 80 percent in just five years.

Dr. Walter Soria examines a 10-month-old baby girl. Credit: Franz Chávez/IPS

Dr. Walter Soria examines a 10-month-old baby girl. Credit: Franz Chávez/IPS

“In Bolivia, the risk of dying from causes related to pregnancy, childbirth or the postnatal period is very high. Every year an average of 623 women die from complications during pregnancy,” according to the Health Ministry’s National Strategic Plan for 2009-2015 to improve maternal, perinatal and neonatal health.

The “Juana Azurduy” mother-child subsidy programme introduced eight months ago should reduce the maternal mortality rate in Bolivia, South America’s poorest country, by 80 percent in five years’ time, according to the driving force behind the new strategy, former health minister Ramiro Tapia.

The latest statistics, from 2008, put the rate at 222 maternal deaths per 100,000 live births, the second highest in Latin America and the Caribbean after Haiti.

Tapia, who achieved excellent public health results as minister, but left President Evo Morales’ cabinet in January, told TerraViva he is very pleased that mothers are now attending health centres, encouraged by payments before, during and after childbirth of a subsidy worth a total of 258 dollars.

The subsidy, paid in 17 instalments, is conditional on the mother attending a state health centre for four prenatal check-ups, receiving medical attention during childbirth, and attending 12 postnatal check-ups for the mother and baby until the child is two years old.

The “Juana Azurduy” stipend is complemented by the Health Ministry’s universal mother and child insurance plan (SUMI), which ensures free care for mothers giving birth in any hospital in the country, another healthcare innovation.

A political weapon

The mother-child subsidy was a weapon in the fight for political domination of Bolivia's regions between Morales and the rightwing opposition during the 2009 election campaign.

It was named Juana Azurduy after a woman who is a symbol of Bolivian women's struggle for emancipation. An outstanding indigenous warrior, she attained the rank of lieutenant colonel in the long battle for South America's independence from Spain, in which Bolivia won its freedom in 1825.

In the eastern and southern lowlands provinces of Beni, Santa Cruz and Tarija, controlled by the rightwing opposition, the programme's doctors were initially barred from access to health centres in several municipalities, said national coordinator Nelson Hurtado.

"They were against the doctors because they personified President Morales' cash transfer programmes," he said. But now the subsidy is operational in 98 percent of the country's 325 municipalities.

“The subsidy payment comes in handy for buying milk, diapers, and food for the family,” said Angélica Choque, a mother waiting to be seen at the Alto Miraflores municipal health centre on the outskirts of La Paz, where TerraViva spent a day recently.

Mothers with babes in arms, some pregnant women and a marked shortage of staff could be seen in the health centre, perched on the slopes of a mountain with a view of the eastside of La Paz, and reached by a distressingly steep road.

“We used to see between seven and 10 mothers a day, but now 20 or more are coming in,” explained the person in charge of maintenance, Isaac Valencia, who copes with repairs on the roof to the plumbing in the absence of more staff.

An initial assessment reported that subsidy coverage extended to 98 percent of Bolivian municipalities, and 400,000 people had benefited from the programme, which includes education on family planning and the spacing of births for mothers, Tapia said.

The mother-child subsidy programme is one of the achievements Bolivia is presenting at the Mar. 1-12 meeting of the U.N. Commission on the Status of Women, known as Beijing + 15 as it follows up on the commitments made at the Fourth World Conference on Women held in September 1995 in the Chinese capital.

Improving women’s health by means of specific plans was one of the 12 critical areas of concern included in the Beijing Platform for Action agreed at that conference.

Before leaving the Health Ministry, Tapia received reports that the number of women visiting public health clinics and hospitals had increased from 20 to 120 a day in many cases.

But many of these women undergo great hardship in order to be seen by a doctor. In this case, for example, the mothers and their children have to trek to the distant public health post in Alto Miraflores, arriving at 4:30 AM, in temperatures below freezing. Once they have been given one of the 20 numbered appointments available per day, they still have to wait up to seven hours to be seen.

Prizes and distinctions

In 2009, Ramiro Tapia, then Bolivian health minister, was granted the Americas Award for Excellence in Public Service by CIFAL Atlanta, an international training organisation for government authorities and civil society leaders based in the southeastern U.S. city of Atlanta, Georgia and co-founded by the City of Atlanta and the United Nations Institute for Training and Research (UNITAR).

The mother-child subsidy programme, and Tapia as its leader, were selected from among 140 nominations from 17 countries in the Americas by an assessment committee that included organisations like the U.N. Children's Fund (UNICEF) and the Andean Development Corporation (CAF).

The women here voiced their demands for specialists in gynaecology, paediatrics and general medicine to be assigned to the centre, and complained that the long wait cost them income and time at work. Many of them are self-employed.

The health centre’s only doctor, Walter Soria, has a hectically busy day. He starts work at 8:00 AM, frequently skips lunch and, to fit in more patients, extends his workday by another two hours, without receiving overtime pay.

While he examines a one-year-old girl, he gives medical advice to her mother and writes out prescriptions, but before that he has to fill in a number of forms by hand. He admits that the paperwork is complex, but it is essential in order for the women to be able to claim their subsidies.

“I’m losing a lot of weight, because I should leave work at 2:00 PM, but I stay until I’ve seen my last patient,” he says with a grin, clearly satisfied by his two decades of working as the doctor of Chapuma, as the poor district of Alto Miraflores is known by locals.

The lack of vocation among doctors to practise medicine among people living in rural or semi-rural areas is evident when it comes to filling the 800 vacancies a year.

The national coordinator of the “Juana Azurduy” mother-child subsidy programme, Nelson Hurtado, told TerraViva that in the first year of the programme only 749 doctors were willing to join up.

“They only want to work in cities and don’t want to go into the countryside, but most of the programme’s beneficiaries live in isolated communities and municipalities,” he said.

Under the government programme, a doctor can earn 648 dollars a month, not a bad salary compared to the average for health professionals, according to Hurtado.

The concept of cash payments for mothers tied to obligatory check-ups and hospital births was introduced by the Morales administration. The president, a 50-year-old leftwing indigenous leader, has governed Bolivia since 2006 and began a second term Jan. 22, after being reelected with an unprecedented 63 percent of the vote.

Morales had a particular concern for the problems of Bolivia’s single mothers, most of whom are poor, who face motherhood without any support, Tapia said.

They often have difficulties within their families and communities in a patriarchal and “machista” society like Bolivia, which adds to their vulnerability, he said.

At the moment there is a gap between the good intentions and the day-to-day running of the programme, which will be narrowed by political will, according to Tapia.

Meanwhile Geovana Martínez, five months pregnant, complains she is exhausted by her wait at the Alto Miraflores health centre. “I even feel like not coming back, because claiming the subsidy involves so much paperwork, but I keep coming for my baby’s sake, and for my own,” she says.

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