Caracas Chronicles

Photo: The New York Times, retrieved

With rising child and maternal mortality rates, long-controlled infectious diseases scourging the country and a hospital network where things as simple as running water are a flamboyant luxury, our current situation can only be compared to that of war-torn nations. Actually, in 2007, while petrodollars still kept Chávez’ illusion alive, international health economist and public health advisor, William Newbrander, described fragile states as places where problems like mass migration, terrorism, international crime and reemergence of previously controlled diseases, are common. Sure, he was talking about Congo and Afghanistan, but today he might as well be describing anything we’ve mentioned on our latest posts.

We already know Venezuela is a fragile state, but is there anything we can do to change that?

Good news is, there is! Bad news is, we first need to oust Nicolás Maduro and his cronies out of Miraflores, no real changes will ever be possible with the same criminals ruling the nation. But let’s imagine for a minute that a transition actually happens in the near future; what do we need to turn a chronically dysfunctional health system into something that actually works?

Fragile states as places where problems like mass migration, terrorism, international crime and reemergence of previously controlled diseases, are common.

Well, we must solve the most immediate problems of the starving masses while reshaping the whole system, so development can be achieved in the long term. This is harder than it sounds, but here’s a walkthrough:

1. Gather information

Before we do anything, we need to know the real magnitude of the problems we face. It’s been almost a year since the last time the Venezuelan government published an epidemiological bulletin, and it cost Antonieta Caporale her position as Health Minister. Back then, we had a glimpse of how bad the diphtheria and malaria epidemics were, and we learned that 11,466 children and 756 pregnant women died in 2016. Although we lack recent data, it’s safe to say things are much worse now. We don’t have numbers on things like HIV+ patients in Venezuela (which some claim might be over a million), or how many of them are still receiving their increasingly scarce treatment.

The path to development is very long but without timely and regular epidemiological data, we will never be able to start the journey.

2. Make saving lives a priority

Once we know what’s killing us, and in what numbers, the first six months should focus on tackling the biggest problems using low-cost-high-benefit strategies. This is where long-discussed humanitarian aid comes in hand: the international community, whether by individual-country donations or through multinational institutions such as the World Health Organization (WHO), might guarantee that vaccines and essential drugs arrive at the country in big-enough numbers to stop the dissemination of infectious diseases.

In Venezuela, a large-scale deployment of vaccines to prevent measles, diphtheria, tuberculosis, rotavirus diarrhea, meningitis, pneumonia and yellow fever are urgently needed and could be easily provided through a humanitarian channel. Food packages, infant formulas for HIV+ mothers, condoms and drugs like antibiotics, antiretrovirals, epilepsy medication, antihypertensives, chemotherapy and hormonal treatments could also be delivered in large volumes via humanitarian aid. Surgical material required for emergency operations and reagents to reactivate clinical laboratories in the public sector could also be donated, or subsidized by international programs.

In most cities and towns, these interventions could be delivered in the existing healthcare facilities, but special attention should be pointed at neglected or displaced communities, such as prison inmates and indigenous groups like the Warao, Joti and Wayuu people, where the absence of a hospital network could require the deployment of both national and foreign missions to attend their most urgent needs.

The international community, might guarantee that vaccines and essential drugs arrive at the country in big-enough numbers.

These measures will help decrease child and maternal mortality, and stop most infectious diseases from being transmitted on the very short term, helping stabilize the government in charge. Just remember they’ll be led by donors and the international community, so they won’t actually reflect the government’s effectiveness and, although very positive for the country, these measures won’t be enough to guarantee long-term benefits, since they won’t help rebuild an effective and self-sufficient health system.

3. Medium and long-term response: rebuilding a broken system

Once the hemorrhage is controlled, we can start thinking about how to prevent it from bleeding again. This is the real challenge, the Venezuelan health system won’t do with a little makeup; it needs top to bottom reform and a committed government that makes this a long-term state policy. The objective is to improve regular drug supply while maintaining and expanding the existing infrastructure, to guarantee equity and sustainability in a five-year period.

Many things must be changed for this to happen, but there’s extensive research on the subject, and the ReBUILD consortium, a UKAID-funded organisation, presents a remarkably clear plan to do so. After working in countries like Zimbabwe, Uganda, Sierra Leone and Cambodia, they argue that actions must be pointed in three directions: improving  communities’ access to healthcare, creating incentives for health workers and creating functional institutions that encourage community integration.

Improving communities’ access to healthcare

The structure of human communities, from families to entire towns, is affected, mainly because crisis impoverishes the people through a direct loss of assets or economically-productive individuals. In the African context, this was usually due to an important proportion of the population being killed as a result of conflict, usually young males who provide most of the earnings of households. In Venezuela, this might be important among people living in violent areas, but it’s also a reality for many families split apart by mass migration. Poverty brings disease and, with it, an increased need of health expenses and a reduced ability to work, perpetuating itself in a never-ending cycle. In a post-crisis context, this situation could affect most of the population, making the reduction of healthcare costs a top priority.

This is a challenge we started losing even before Chávez got to power. Back in 1995, we were already one of the countries with the lowest health expense in the region. Out-of-pocket expenses (the money directly paid by users to the health system), on the contrary was among the highest in Latin America; by 2013, and still with high oil prices, things were worse: Only 3,6% of the GDP went to healthcare while out-of-pocket expenses skyrocketed to 65,8%, among the highest in the world. Chavismo made health much more expensive for the average Venezuelan, even before Maduro’s terrible administration.

Poverty brings disease and, with it, an increased need of health expenses and a reduced ability to work, perpetuating itself in a never-ending cycle.

In order to overcome the health crisis currently developing in the country, this must change. The complete destruction of the Venezuelan oil industry makes things harder, but if a new government adopts a strict fiscal policy (backed by international funding), it might be possible for Venezuela to cover most of its people’s health expenses. Pittsburgh-graduate, public policy expert and Universidad Simón Bolívar professor, Dr. Marino González says a good starting point would be redirecting money from low-impact projects (say, some of the government countless misiones) to high impact, more needed areas like the national vaccination or diabetes-hypertension programs. Eliminating the pervasive gas and energy subsidies could also help boost GDP, and public funding of health with it.

This, however, will take time (yes, maybe a long time). We must look for alternatives to help millions of poor people created by the Revolution, a puzzle Cambodia solved: since Cambodian economy can’t sustain universal healthcare coverage, several funding methods are simultaneously used to reduce the money patients must pay for medical services. The most widely available, and arguably the most successful, are health equity funds (HEFs), a scheme mainly financed by several international institutions including USAID, UKAID, the World Bank and, in lesser extent, the Cambodian government.

HEFs are limited to the poorest in the country (around 18% of the population), and grant full coverage of all treatment, meals and transportation fees. Since their implementation in 2000, the percentage of poor people seeking medical attention has increased considerably and, as a consequence, child and maternal mortality rates have reduced.

Bringing back health workers

One of the most critical and complex aspects of rebuilding a health system after a crisis period is the lack of properly trained health workers. In some war-torn African countries, doctors and nurses were targeted by the enemy; in Venezuela, they’re fleeing by the thousands. The effect is the same: entire cities without qualified human resources, a condition especially dramatic in rural areas, where doctors don’t have any incentives to work. The situation is getting so bad that even bigger hospitals have been forced to close emergency services, as there are no doctors to run them.

In Venezuela, this means changing several laws. For instance, the mandatory rural service that doctors must do immediately after graduating in order to practice legally in the country.

Incentives to attract, retain and distribute healthcare professionals must be implemented. This can’t simply include short-term remuneration like higher salaries; incentive packages should include decent housing and working conditions, as well as recognition of the health workers’ roles and achievements.

In Venezuela, this means changing several laws. For instance, the mandatory rural service that doctors must do immediately after graduating in order to practice legally in the country should be revised. If we hope to bring back at least a small part of the highly-qualified professionals who have fled, or prevent more young doctors from leaving, forcing them to work for a lame salary in an isolated town, away from their families for a whole year… well, it sounds bad to me.

Médicos Integrales Comunitarios (MICs), the infamous doctors massively produced in pro-government universities could pose an alternative to this problem. MICs training has consistently been deemed insufficient for standard medical practice, but if their academic program is modified to focus on low-cost, simplified preventive medicine, they could be deployed in small towns around the country, allowing highly-specialized physicians to focus in reference centers. Existing MICs could be trained relatively quick and deployed in a short period of time.

Training Venezuelan doctors in foreign institutions should also be encouraged by the government, to form highly-skilled professionals that will eventually replicate their training in national institutions.

Creating functional institutions

Crisis prompts the formation of community-based organizations as a coping mechanism to solve the inefficiency of the government, and they should take part in the reconstruction of the health system to boost local leadership. The experience in places like Congo has proved that creating committees of respected community figures, working in coordination with local healthcare providers, promotes transparency, efficient management and maintenance of physical infrastructure.

To grant long-term sustainability, external funding will be needed.The International Monetary Fund (IMF) could lend money to the new Venezuelan government…

The Health Ministry could use these organisations and the health providers monitoring them to quickly detect relevant health problems across the country, developing a relatively low-cost and efficient epidemiologic vigilance and medicine-distribution system.

Most of these actions could take advantage of the existing infrastructure, and could be applied simultaneously to those aimed to stabilize the Venezuelan economy. This would allow the new administration to greatly improve quality of life in Venezuela without spending too much money. But to grant long-term sustainability, external funding will be needed.The International Monetary Fund (IMF) could lend money to the new Venezuelan government to help it pay part of the billionaire debt it holds with the pharmaceutical industry, regularizing access to drugs; its support, and the economic reforms it carries, could also increase the number of international donors willing to help, and eventually lead to economic growth, only then should we start building the much needed new hospitals and research centers.

Finally, the rebuilding process would probably extend for decades, but it should allow us to create a health system that reaches most of the population and offers attractive conditions to its workers, while sparing enough resources to form capable personnel, develop an effective disease surveillance system, prevent infectious diseases and sustain itself in the long term. Or in a few words, a system able to do all that we currently can’t.

Special thanks to Dr. Marino González for his contribution and advise in the making of this post.