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The
Lancet, Volume
374, Issue 9688, Page 442, 8 August 2009
BOLIVIA - INCENTIVE VOUCHERS TO
IMPROVE MATERNAL & INFANT HEALTH
The
Bolivian Government is hoping that a financial incentive for pregnant women and
mothers can improve maternal and child health in the country. Anastasia Moloney
reports.
The
Bolivian Government has launched a new wide-ranging initiative in a bid to
reduce high maternal and infant mortality rates in South America's poorest
nation.
The
government is giving out special health vouchers, totalling nearly US$250, to
pregnant women and mothers with children younger than 2 years who have no
access to health-care coverage or other social security benefits.
Roughly
three women die per day in Bolivia from complications during pregnancy or
birth. Haemorrhaging, birth-related infections, complications from unsafe
abortions, and eclampsia account for most of maternal deaths in Bolivia, while
diarrhoea and malnutrition are the common causes of deaths in children younger
than 5 years.
According
to the Bolivian health ministry, 53 children die per 1000 livebirths and 234
women per 10 000 livebirths.
“It's
not possible that we keep losing children and mothers…this is serious. Each
year 318 000 pregnancies are registered, but only 300 000 births take
place in the health system. What happens in the other 18 000 cases?”, said
Bolivian President, Evo Morales, during the launch of the voucher scheme in
late May, as he addressed thousands of women who had congregated in a football
stadium in Santa Cruz to receive their first payment.
During
the first week of the programme's launch, more than 3000 women registered to
receive the government subsidy. Over this year, the voucher scheme is expected
to reach some 510 000 mothers and 260 000 children younger than 2
years in a country of 10 million inhabitants.
The
scheme entitles pregnant women to receive four separate stipends (around $7
each) during the course of a pregnancy. In return, women must attend obligatory
prenatal checkups and give birth in a hospital. Women are then entitled to 12
further payments during the first 2 years of a baby's life providing that they
bring in their children for check-ups and attend postnatal care.
The
Bolivian health ministry hopes that the $25 million initiative, jointly funded
by the government and a World Bank loan, will increase prenatal or postnatal
care coverage across the country. The programme aims to discourage home births,
while encouraging women, especially those living in rural areas, to visit
health clinics and attend regular doctor check-ups. The government also hopes
that women will spend the stipend on food and milk, and in such a way to help
reduce high levels of malnutrition among infants in Bolivia.
The
voucher scheme follows other examples of social programmes in Latin America
where economic incentives are being used to promote changes in social and
cultural behaviour. The trend places the onus on women, rather than on men, to
fulfil specific obligations in return for state benefits. For example, in
Brazil the acclaimed Bolsa Familia initiative pays women stipends on the condition
that they send their children to school.
Bolivia's
leftist president said that the initiative was a “constitutional right of
women”. However, some opposition lawmakers have criticised the latest health
initiative as a populist and vote-seeking measure ahead of the country's
presidential elections in December. They say that the scheme lacks long-term
funding and does not guarantee that women will spend the money on food for
their children.
Some
health officials have drawn attention to the lack of clinics in rural areas and
have questioned whether current health facilities have enough trained staff and
midwives to cope with the expected upsurge in pregnant women attending clinics.
Others point to the problem of birth certificates and identity cards, which is
a requisite for women to receive the government subsidy. Around 12% of children
younger than 10 years do not have birth certificates in Bolivia, according to
UNICEF.
Bolivia
has made progress in reducing infant mortality rates, but it still has a long
way to go before it can meet its UN Millennium Development Goals for child and
maternal health. These call for a two-thirds cut in mortality rates for
children younger than 5 years and a reduction in maternal mortality by
three-quarters from 234 to 98 deaths per 100 000 livebirths by 2015.
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