Bolivia has a history of poor maternal and infant mortality indicators, lagging behind other countries with similar income levels, such as Honduras and Nicaragua. Improving such unsatisfactory health outcomes is critical for improved quality of life and sustained development. At the time of project design, infant mortality in Bolivia was estimated at 67 per 1000 live births (compared to an average of 33 for other lower middle-income countries), and maternal mortality was equally high at 390 per 100,000 live births (compared to 163 in other lower middle-income countries). The picture was even bleaker in rural areas, where infant mortality was 50 percent higher than in urban areas, and in poor households, where 147 out of every 1,000 children were expected to die before age 5.
This project was designed as a countrywide programmatic intervention in several stages (Adaptable Program Loan, or APL). The first two operations were specifically focused on reducing infant and maternal mortality by improving the quality and accessibility of essential maternal and child health services, particularly for low-income groups.
The project yielded improved health outcomes in rapid fashion. It helped reduce the infant mortality rate from 67 deaths per 1,000 live births in 1998 to 54 deaths in 2003. Maternal mortality dropped from 390 per 100,000 live births in the mid-1990s to 234 in 2001.
Highlights:
- The percentage of births attended by trained health personnel increased to 54 percent in 2002 from 42 percent in 1998.
- The number of pneumonia cases in children under 5 attended in health services rose from 81,462 in 1998 to 128,244 in 2002.
- The number of acute diarrhea diseases in children under 5 attended in health services rose from 337,123 in 1998 to 426,697 in 2001.
- The percentage of children who received third doses of DPT/Hib/Hepatitis B vaccines rose from 77 percent in 1998 to 100 percent in 2002.
- The number of municipalities with DPT/Hib/Hepatitis B vaccine coverage below 80 percent was reduced from 171 in 1998 to 53 in 2002.
- The project’s structure is being used to support new government programs. For example, it established mobile health brigades that continue to reach almost 200 of the most vulnerable municipalities in the country. This mechanism has now become the main instrument to implement the current administration’s main strategy in the health sector, Desnutrición 0.
- In addition, this was one of the first projects in the region to focus on clear and measurable results, and its monitoring and evaluation arrangements—including the system of health indicators developed for this operation—are now widely used throughout the World Bank portfolio.
Total project cost was US$26.26 million of which IDA provided US$21.93 million and the Government of Bolivia US$4.33 million. IDA was able to draw on its international and multi-sector experience in helping to design and introduce a successful model of delivering public health services. The Bank’s long-term engagement in Bolivia and experience in other countries facing similar challenges was instrumental in adopting a bottom-up approach to maternal and child-health services—particularly through public insurance schemes, performance agreements, prioritized investment subprojects, and cost-effective health interventions. Prior analysis identified key economic barriers to access in the health sector: only about 30-35 percent of the population had access to social security or private health insurance, and the rest—mainly the poor and rural inhabitants—traditionally had to pay user fees for health services, even in public facilities. Establishing a public financing scheme for priority health interventions for infants, pregnant women, and women of childbearing age helped overcome this problem and had a spectacular effect on infant and maternal mortality.
Despite progress, Bolivia will need to sustain efforts to improve health outcomes. IDA continues to support these efforts through the second phase of the Health Sector Reform APL (which became effective in February 2002 and closed in June 2008) and its third phase (approved in January 2008).
RSS