INSIDE BARRIO ADENTRO: THE BRV'S PRIMARY HEALTH

C O N F I D E N T I A L SECTION 01 OF 04 CARACAS 002489

SIPDIS

SIPDIS

E.O. 12958: DECL: 07/07/2016
TAGS: PGOV ECON VE
SUBJECT: INSIDE BARRIO ADENTRO: THE BRV'S PRIMARY HEALTH
CARE PROGRAM


Classified By: Economic Counselor Andrew N. Bowen,
Reasons 1.5 (b/d)

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Summary
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1. (SBU) Mision Barrio Adentro ("Inside the Neighborhood")
is a network of BRV-sponsored primary health care modules
largely staffed by Cuban medical personnel. Current
statistics and financial information about this BRV program
are very difficult to obtain. Venezuelan physicians' groups
allege that Cuban doctors practice without Venezuelan
licenses and receive salaries over four times that of local
doctors. Despite instances of malpractice, supply shortages,
mismanagement of funds (at the municipal level) and mediocre
vaccination rates, those who use Barrio Adentro (BA) are
highly satisfied with it. However, only 18 percent of those
polled admitted to having received care. The BRV's growing
focus on BA has diverted resources away from the public
health sector, which has been in a chaotic state of disrepair
for years. Some international organizations have praised
BA's efforts, despite little reliable information about its
efficacy. The program has met the political goal of reaching
and mobilizing marginalized communities, but its public
health value is questionable. End Summary.

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Barrio Adentro 101
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2. (SBU) Mision Barrio Adentro ("Inside the Neighborhood")
was created by President Chavez in December 2003. It is a
government-run network of primary health care modules
(separate from the BRV's public health network) designed to
service marginalized neighborhoods. The program is staffed
mostly by Cuban medical personnel (under the April 2003
Venezuela-Cuba Agreement, trading doctors for oil),and
offers primary care, dental and vaccination services. The
BRV has built a number of small clinics -- recognizable by
their hexagonal brick and blue design -- but "modules" also
include doctors operating out of private homes. The Mission
is present nationwide, but mostly concentrated in Lara state
and the capital.


3. (SBU) Current statistics on Barrio Adentro (BA) are very
difficult to come by. The Mission's website only has
information from 2004, while the Ministry of Health (MSDS)
publishes August 2005 statistics. In the last two years, BA
has expanded to a three-tier system from BA 1 (hexagons and
home clinics) to BA 2 (diagnostics and rehabilitation
centers) and BA 3 (small hospitals). Mision Milagro (Mission
Miracle),a spin-off program that provides free eye surgery
to the poor, was established in 2005. Through this mission,
the BRV flies patients from neighboring countries to Cuba and
Venezuela for care.


4. (C) Dr. Jose Felix Oleta, the Minister of Health from
1997-1999, estimates that in 2004 there were a total of 6,491
BA 1 modules (hexagons and home clinics) operating.
According to MSDS officials in June 2006, there are a total
of 9,000 BA 1 modules nationwide and 4,618 more are under
construction. On August 11, Chavez stated that there were
over 15,000 operational BA 1 modules, 358 BA 2 centers (goal
is 1,200 by end of 2006),and six BA 3 centers (goal is 35 by
end of 2006). MSDS stated that nearly 300 existing hospitals
are set to be converted to BA 3 facilities this year. Chavez
claims that BA 2 and 3 currently reach seven million people,
and according MSDS, the entire BA program has reached over 17
million. (Comment: this number would equate to roughly 65
percent of Venezuela's population. See Para 13). By May
2006, the local press reported that 10,754 Mision Milagro

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patients had received surgical treatment, although MSDS
stated that over 60,000 have been treated.

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Who mans Barrio Adentro?
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5. (SBU) As of January 2006 (according to MSDS),there were
21,745 Cuban medical personnel (14,998 of them "doctors") and
6,283 Venezuelan staff (3,981 nurses and dentists) manning BA

1. The Cuban staff live in the hexagonal modules or in
peoples' homes. According to the Venezuelan Medical
Federation, no Cuban BA physicians are legally licensed to
practice medicine in Venezuela (Ref A). Various reports
allege that the BRV pays the Cuban government up to USD 2,000
to each doctor monthly, but that the employee in Venezuela
receives a much smaller amount, supposedly USD 50 monthly,
with an annual bonus. In contrast, most Venezuelan doctors
in the public health sector earn a base salary of roughly USD
280 per month, only USD 65 over minimum wage.


6. (SBU) Despite the exaggerated service statistics reported
by the BRV, Econoff has yet to see one open clinic (despite
having visited over five BA hexagons during normal business
hours). Opinions from the impoverished neighborhood (Ref B)
suggest that most modules are empty and that Cuban doctors
spend only a short amount of time in Venezuela.
Occasionally, there are reports of defections or doctors
engaging in private practice "on the side," which is not
permitted.

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Financial cost of BA: Unknown
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7. (SBU) Not surprisingly, the budget for BA has never been
released to the public. The only hint about the size of BA's
overall funding came in 2004 from the Minister of Health, who
revealed a USD 3 billion figure. According to Tander
Investments, an economic analysis firm, a quarter of the
BRV's entire 2006 budget is dedicated to social spending (of
which BA would get part). Though BA is managed by the
Ministry of Health, it receives funding from various sources,
including PDVSA (which by May 2005 had allocated USD 91
million to BA),the Ministry of Finance (which allocated USD
837 million for all missions in 2006),and various government
funds. In May 2006, two additional credits were approved by
the National Assembly (NA) for BA and Mision Milagro,
totaling USD 108 million. On Aug 8, the NA approved a
further USD 308 million for the BA Mission. (Note: The
Minister of Finance Merentes announced in July that total
spending for BRV Missions would be USD 6.9 billion in
transfers during 2006. End Note.)


8. (C) Accountability for these funds is murky at best. In
the last year, there has been at least one case of financial
mismanagement at the municipal level. In Lara state, which
in 2004 housed over 87 percent of BA modules, an audit of
unfortunately-named FUMBAL (Foundation for BA Lara) revealed
that nearly USD 20,000 had gone toward the purchase of gold
jewelry. As of July 2006, the BRV had reportedly chartered
2,074 Conviasa flights, some on non-established routes, to
fly in Mision Milagro patients and their families.


9. (SBU) The BRV also provides logistical support to Barrio
Adentro. According to Oleta, in 2004, the military
transported over 2,000 metric tons of medical and dental
equipment. PDVSA provided an inventory control system, two
warehouses, 662 distribution points, and four refrigerated
storage units for BA. SENIAT, the Customs and Tax Agency,
reportedly waives duties on imported medical equipment. In
February in Sucre state, Coast Guard officials told Econoff

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they were taking "Cuban doctors" to Margarita Island free of
charge.

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Real cost of BA: An Ailing Public Health Sector
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10. (SBU) Since BA is essentially a parallel health care
structure, the real cost of the program is the attention and
resources it sucks away from Venezuela's crumbling public
health sector. The MSDS budget for 2006 is 5.1 percent of
the national budget, down from 5.8 percent in 2005 (Note: the
Social Development function of the Health Ministry appears to
have been transfered in 2006 to the new Ministry of Popular
Participation and Social Development. End Note). According
to the World Bank, Venezuela has one of the lowest rates of
public health expenditures as a percentage of GDP in the
hemisphere (in 2002, it ranked below Guyana and Bolivia.)


11. (SBU) The public health care system is highly
fragmented, with six overlapping networks each offering
health services at the national, state, and municipal levels.
Up to 70 percent of the Ministry's budget is eaten away by
salaries or pension payments, and little is left for
infrastructure maintenance, medications, or equipment.
Nonetheless, in the last three months alone, hospital workers
have gone on strike over back pay in Caracas, Apure, Aragua,
Bolivar, Sucre and Vargas states. According to El Universal
(a major local daily),the Caracas municipal government
(where over 400 BA modules were built this year) has a
reported hospital budget deficit of USD 340 million.


12. (SBU) The quality of public health care is dismal. Most
Venezuelans have gotten used to paying for public services
that are supposed to be free of charge, and long waits for
basic care are commonplace. In June, a large Caracas
children's hospital just received its only x-ray machine
after waiting ten years for a replacement. Los Magallanes
Hospital, a large facility in a densely-populated part of the
capital, has only one functioning elevator (which the morgue
also uses),and two adequate operating rooms.

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Is Barrio Adentro cutting it?
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13. (SBU) The quality of Barrio Adentro care is hard to
gauge -- anecdotal evidence suggests that many doctors are
actually either medical students or, more likely, paramedics
trained to diagnose simple ailments and take histories.
Recent comments by one BA worker to Poloff confirmed problems
obtaining a steady supply of medications. In 2004, Provea, a
human rights group, estimated that 11 percent of national
malpractice cases originated in BA. In July, one Chilean
Mision Milagro patient was actually blinded by her surgery,
while a handful of Brazilian patients were flown to Caracas
only to be turned around because they didn't medically
qualify for surgery. According to Oleta, child malnutrition
has doubled since 1998, and yellow fever, dengue, and
tuberculosis are on the rise. BA's vaccination record is
also poor for a primary health network: in 2004, only 161,800
vaccines had been administered nationwide (no info available
for subsequent years). Chavez recently stated that thanks to
Barrio Adentro, there is now 1 doctor per 2,500 Venezuelans
(down from 12,000 in 1999),but this data is not confirmed by
either the WHO or PAHO.


14. (SBU) Though modules are visibly empty and the quality
of care may vary, Datanalysis, a polling firm, reported in
July that 95.4 percent of BA's users were satisfied with the
service. Given that poor Venezuelans typically lacked any
option in their neighborhoods before BA came along, this high

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approval rating is not surprising. Satisfaction aside, only
12.7 percent of those polled said they have used BA 1 and 5.4
percent have used BA 2. (Comment: This percentage starkly
contrasts the statements by MSDS that BA has reached 65
percent of the population.)


15. (SBU) Public perception of BA seems discordant with the
actual number of people BA reaches: 68 percent of those
polled were satisfied with Chavez' management of the health
sector, despite only 18 percent having used BA services.
(Comment: this speaks to the public relations success of the
BRV pitching BA as a highly visible health "solution." End
Comment). Many international organizations, including UNICEF
(which called BA a "model for universal primary health care"
in 2005),have bought into the public image of Barrio Adentro
despite the lack of real information available about the
program.

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Comment
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16. (SBU) Notwithstanding BA's obvious weaknesses -- lack of
financial and statistical transparency, unlicensed
physicians, and dubious quality of care -- it remains popular
among poor Venezuelans because of the inadequacy of existing
public health care. BA must be viewed as a political tool to
increase BRV presence in the barrios, since its medical
success (other than accessing marginalized communities) is
questionable. The highly-visible hexagonal structures,
placed strategically by the freeways (for international
visitors to see),as well as the BRV's public relations push
for the Mission, have many reputable organizations in the
international community endorsing a program whose medical
achievements are unconfirmed. Sadly, the focus of resources
on BA diverts attention from the mainstream public health
sector, which is already on life support. End Comment.
WHITAKER