Every year, 6% of households across Bolivia face catastrophic health expenditures and subsequent impoverishment. In the absence of effective protection mechanisms, underserved groups—particularly indigenous communities and informal labourers—are most vulnerable to high out-of-pocket health expenses. With the largest informal sector in the world, a significant proportion of Bolivia’s workforce lack health insurance coverage. Catastrophic out-of-pocket health spending limits access to health services and derails efforts towards universal health coverage. To address these health inequities and financial barriers, the Bolivian government introduced ambitious health reforms in 2019 through the Single Health System model.

Bolivia is one of few countries globally to implement a universal health coverage model—centering the right to healthcare. The Bolivian government aimed at providing universal and free coverage to 50% of the population—a two-fold increase from previous coverage rates—protecting an estimated five million underserved, uninsured Bolivians. WHO/PAHO’s Country Office in Bolivia (WCO) spearheaded the formulation of Bolivia’s Universal Health Care Policy, facilitating discussions among social organizations representing underserved communities, medical representatives, and various government agencies—to ensure buy-in from multiple stakeholders. From January to March 2019, WCO worked closely with the Ministry of Health (MoH) to develop an implementation plan and build a core working group. WHO/PAHO’s regional team facilitated technical and knowledge sessions to build MoH’s understanding around crucial aspects and implications of the universal healthcare policy, including governance financing, management of health services, and integrated health service networks.

WCO’s efforts towards advancing Bolivia’s Single Health System (SUS) model drove significant outcomes.

Increased health expenditure: As a result of WCO-led deep-dive knowledge sessions on health financing with the MoH, an additional fund of USD 200 million was earmarked for financing the new health policy in the first year of implementation—improving health equipment, supplies, and hiring additional Human Resources. In the last decade (2010-2019), Bolivia tripled public spending on health, escalating public expenditure in primary health care to 37%, and outdoing other countries in the region that average less than 15%. Bolivia is now one of three Latin American countries that have advanced recently close to reaching the goal of allocating 6% of GDP towards public health expenditure. By liaising with multiple stakeholders, WCO ensured that implementing SUS became a key priority for not just the MoH, but also vested donors and other development agencies in the country. WCO’s advocacy efforts channeled resources from Korean Cooperation, World Bank, Inter-American Development Bank (IDB) and Spanish Agency for International Development Cooperation AECID towards advancing SUS. For example, a World Bank project of USD 250 million—originally earmarked to build 10 secondary hospitals—was partially redirected towards strengthening primary health care services to meet a SUS-triggered increase in demand for services across eight integrated health services delivery networks (RISS)in La Paz and El Alto.

Strengthened primary healthcare services: Increased health expenditure enabled improvements in health infrastructure, equipment and equitable distribution of human resources—particularly in primary health centres. WCO conducted an analysis of health worker shortfall, identifying gaps in the availability of physician specialists across the country. WCO subsequently used these findings—estimated at a shortage of around 3000 healthcare specialists—to advocate for funding towards training additional health specialists.Bolivia’s MoH drafted a Family, Community and Intercultural Health policy (SAFCI) that drew from WHO/PAHO’s strategy around primary health care:meeting the majority of people’s health needs through services provided directly in the community where they live. Around 2500 teams of health workers were assigned to 70% of local municipalities—strengthening first-level, primary healthcare services and prioritizing preventive community health. Bolivia is now one of three countries in the region with over 30% of the health workforce engaged in first-level, community health. Reduced out-of-pocket expenditure: Improved services at the primary health level, resulted in prevention and early diagnosis of the main types of chronic non-communicable diseases, and consequently reduced household expenditure on health. The contribution of out-of-pocket expenditure towards tertiary-level hospital budgets dropped dramatically from 65% in 2018 to 19% in 2020.

Bolivia’s health reforms, by way of the Single Health System (SUS) model,thus increased public health expenditure, strengthened primary health services and reduced out-of-pocket expenses for vulnerable communities.

COVID-19 highlighted the necessity and significance of Bolivia’s health model. Despite limitations created by the pandemic and wide-spread social unrest on account of contested presidential election results—public health facilities across Bolivia offered uninterrupted essential health services.Under SUS, funds for Bolivia’s COVID-19 response were available and enabled prompt acquisition of drugs and medical supplies—particularly at the primary healthcare level—in all 339 municipalities of the country. SUS strengthened first-level care with an emphasis on epidemiological surveillance, neighborhood clinics, and health care services for underserved communities.In some municipalities, SUS supported existing health programs (for example: SAFCI and MISALUD), in charge of essential health services. SUS abolished prior affiliation at different levels of healthcare facilities and all Bolivians were guaranteed access to COVID-19 treatment available. Free-of-charge services (even partially) mitigated the enormous economic impact of the pandemicon marginalized and vulnerable groups. Had SUS not been launched a year before the pandemic, Bolivia’s response to COVID-19would have been less prepared. Bolivia’s healthcare model thus holds the promise of a health system strengthened to withstand the impact of future health emergencies.

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Photo caption: Health Team working  on IPC interventions related to COVID-19 control  in Guarani Native Community at Camiri Santa Cruz.

Photo credit: WHO

Disclaimer: This image was taken during a time of no community transmission of COVID-19. Community transmission is defined as the inability to relate confirmed cases through chains of transmission for a large number of cases, or by increasing positive tests through sentinel samples (routine systematic testing of respiratory samples from established laboratories). Preventative measures such as mask wearing and physical distancing should be used to prevent the spread of COVID-19.