Origins
The Barrio Adentro program is an example of Latin American social medicine (LASM), which became prominent in the 1960s and 70s. Amongst others in Latin America, both Salvador Allende in Chile in the early 1970s and Tabaré Vázquez in Uruguay from 2005 have implemented LASM principles. LASM's roots can be traced back to 19th-century European social medicine (particularly the work of social medicine pioneer Rudolf Virchow), which was exported to Latin America in the early twentieth century.
LASM emphasises a collective and holistic approach to healthcare, rather than merely treating the particular symptoms of one individual. Thus the importance of health promotion and disease prevention—informed by the political-economic and social determinants of health—is stressed, over a merely reactive treatment of health problems as they occur. LASM incorporates the concept of primary health care (as defined by the 1978 Alma Ata Declaration), of which the "simplified healthcare" adopted in rural Venezuela in the 1960s and 70s was one form. More recently, in 2006, Barrio Adentro has been described by the Director of the PAHO as "the culmination of 25 years of experience in Latin America and the rest of the world in transforming health systems through the primary health care strategy."
When Hugo Chávez became President in 1999, he sought to implement LASM principles, beginning with their incorporation into the new 1999 Venezuelan Constitution, in articles 83-85 of Title III. These articles enshrine free and high quality healthcare as a human right guaranteed to all Venezuelan citizens. Notably, Article 84 of Title III follows LASM principles in declaring health promotion and disease prevention a priority; it also describes the healthcare system as "decentralised and participative" and declares that the community has "the right and the duty" to be involved in policy decisions regarding the public health system. In addition Article 85 mandates that the government provide adequate funding for the public healthcare system, while Article 84 explicitly proscribes its privatization.
Initial attempts to transform the Ministry of Health to LASM principles, in the 1999–2003 period, met with little success. The Venezuelan Medical Federation was aligned with the Punto Fijo parties, and many of its members in private health care opposed the new emphasis on the public sector. At the same time that the new policies failed to make much ground within the healthcare system, the traditional top-down way in which the policies were developed and carried out prevented a strong connection with the concerns of the poor.
The origins of a different approach for carrying out LASM lay in the Libertador municipality of Caracas, which in 2003 (under a pro-Chávez mayor, Freddy Bernal) set up an Institute for Endogenous Development (IED), broadly intended to improve living conditions through the active participation of the local population. Following a series of discussions between IED and local residents, a proposal was formulated to set up a "Plan Barrio Adentro" using small local clinics to provide free healthcare "inside the neighbourhood" where previously there was none, and to involve residents in the management of the scheme. Bernal then issued a call for doctors, but the Venezuelan Medical Federation put pressure on its members not to apply. Of the 50 Venezuelan doctors who did apply, 30 left on hearing that they would need to live in the barrios; the remaining 20 were specialists and therefore employed in specialist centers and not required to work in the primary health care centers in the barrios. Faced with a lack of willing doctors, Bernal recalled the Cuban doctors who had provided emergency aid following the 1999 mud slides, and discussion with the Cuban Embassy in February 2003 ultimately led to a contingent of 58 Cuban doctors starting the program in April 2003. In the interim, three Cuban physicians spent a month visiting the barrios, examining the homes and clinic spaces offered by the community. By May 2003 another 100 Cuban doctors arrived, and were sent to other parts of Libertador and to other municipalities in and around Caracas. Besides diagnosis and treatment, including the provision of free prescription drugs, the doctors carried out a health census of the barrios, which provided a complete health survey of the Caracas barrios for the first time.
Despite some obstacles (including a refusal by public hospitals to accept referrals for diagnosis and treatment, only gradually and partially overcome during 2003), "Plan Barrio Adentro" became very popular with its constituents. By December 2003, "Plan Barrio Adentro"—having seen over 9m patient consultations and 4m health interventions—was so popular that it was attracting national attention, and President Chávez transformed it into a national program, named "Mission Barrio Adentro" (MBA). It became the first of a series of popular "missions" bypassing existing public institutions.
Read more about this topic: Mission Barrio Adentro
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