Scarce resources, little funding, high costs, limited access
The Centro Medico Humberto Parra is a medical clinic in the small town of Palacios, near Santa Cruz in Bolivia.
By Dr Peregrine Dalziel
A young Australian practises frontline medicine in Bolivia
The Centro Medico Humberto Parra is a medical clinic in the small town of Palacios (pop. 300), near Santa Cruz (pop. 2million) in Bolivia (pop. 13 million). Funded through the NGO ‘The Hamant Foundation’, the clinic provides primary care services and free medications to about 15 poor rural Bolivian communities. It also actively promotes public health and community development initiatives.
The foundation began in July 2001 after a collaboration between two American physicians and a Bolivian endocrinologist. Initially, it was a mobile outreach service going to each community by vehicle (and sometimes on horseback) but, after significant land donations from the Parra family in a jungle zone of Santa Cruz, the clinic buildings were established and the Centro Medico Humberto Parra (CMHP) was born. It is the only free medical clinic in the surrounding 40,000-person rural area. Currently, the clinic attends about 140-200 patients a week providing free medications and assisting with costs of further treatment at tertiary centres.
With time, the clinic was established as a ‘global health’ rotation through the Northwestern Hospital and its attached Loyola University Medical School of Chicago. Resident medical officers, consultants and students can take two-to-four-week accredited (and paid) rotations to the clinic. This has ensured a stable stream of American volunteers.
The clinic functions four days a week for primary care consultation. Visiting Bolivian specialists attend on Saturdays with regular visits by ophthalmologists, physicians and gynaecologists. There is basic equipment with a surprisingly good pathology lab and four consulting rooms.
Previously, the clinic ran a de facto private insurance scheme. In each of the 15 communities, a health worker was trained by the clinic and established as a “health leader”. A family or individual fee of around US$1 per month entitled the user to unlimited access to clinic services. Small funds held by community leaders allow for the payment of any emergency services required out of clinic hours at other hospitals. The patients are brought to the clinic on clinic-funded buses, each community coming at least twice a month. Recently this system has changed to a fee-for service model, where the user pays US0.50 to attend the clinic. This system was instituted to avoid some corruption involved with the collecting of fees.
Perhaps to understand the substantial impact of the activities of an operation such as CMHP, I should explain the Bolivian predicament.
The Bolivian health system - like many public services in developing countries - is beleaguered by a paucity of public funds, discontinuity of care and the inequality of access. Since gaining power, Evo Morales, the first ever indigenous President, has instituted a national health scheme for mothers and children under five. For everyone else, however, nothing is free.
In fact, costs are often in line in absolute terms with costs in developed countries like Australia, sometimes even more expensive. When I first arrived, I was stunned to discover that Augmentin DF cost about $A4.05 per tablet from a Bolivian pharmacy. The price negotiated in Australia under the Pharmaceutical Benefits Scheme is roughly $A1.43 per tablet, the end price for a five-day course to consumers being about $A3.25 for Australian consumers on concession (after subsidy) and about $A40.45 for those in Bolivia in a significantly worse financial situation.
Hospital stays are billed per day. All treatment items prescribed by doctors on the morning round are expected to be purchased by patients’ family members from supply stores outside the hospital. This includes all drugs, dressings, cannulas, catheters, etc. They are then brought back to the hospital and administered by nurses. Where a family cannot purchase the items, the patient goes without, except for some exceptional emergency treatment. Oxygen consumed is billed by the litre.
I recall a man with a cellulitic foot that had become septic after not receiving IV antibiotics for two days because his family had not returned with the medication. He was too ashamed to admit that they could not afford it. For many poor patients, these costs are often met through usury-style loans or by selling things such as their cars - very debilitating if the patient uses the car to earn taxi fares.
In outpatient settings, investigations are ‘prescribed’ and patients must obtain them before returning. Patients may choose to forgo investigations and pathology that are too costly or will delay getting investigations until money is available. The onus is always on patients to obtain the resources for their care.
The clinic sees the standard wide variety of primary care cases, and offers pap smear services. Approximately half the patients are indigenous Kechwa Indians.
As in many tropical fertile countries, obesity in Bolivia is a major issue as poverty directs consumption to low-cost high-carbohydrate items such as rice and deep fried yuca (a tuber similar to sweet potato). This is exacerbated by a cultural belief - common in Latin America - that to be fat is a sign of being well off, or at least ‘not poor’.
So cardiovascular disease and diabetes mete a heavy toll on under-privileged Bolivians. The clinic’s endless source of metformin and continuous supply of cardiovascular drugs ensures that type 2 diabetes monitoring and CV disease constitutes about 50% of the total case load and allows a level of preventive care that simply could not exist for many poorer Bolivians.
Apart from cost, treatment of chronic disease can be further frustrated by idiosyncratic and ignorant beliefs. For instance, many Bolivian people believe they can ‘feel’ their hypertension or hyperglycaemia as a ‘headache’ or ‘agitation’ and will opt to take their medications PRN, especially when the free clinic prescription has run out. I recall one taxi driver who came in feeling ill after taking 30 mg of enalapril for his ‘headache; with a systolic BP of 75, he intimated to me that the pills had seemed to make his headache worse.
Further to this, all medicines are available from pharmacies without prescription and customers are often sold pharmaceuticals for questionable indications. Being sold blood pressure medications for headache is not uncommon.
Chlamydia and gonorrhea are reasonably widespread as usage of condoms and education on STIs is limited. Chagas disease (parisitaemia by trypanoma cruzi protozoan) is prevalent in Bolivia, which poses some interesting challenges. The chronic organomegaly that results causes profound bradycardias and mega-colon-induced constipation. Dengue is endemic in the surrounding areas and there were around 40,000 reported cases of dengue last year in Santa Cruz alone. Abscesses, the occasional lipoma and some interesting skin rashes are also common clinic presentations.
Issues of resource constraint make for interesting scenarios: for instance, the man with one kidney and six months of intermittently-treated pyelonephritis for which he could not afford to stay in hospital for adequate IV antibiotics. His infection was resistant to the ciprofloxacin he had been buying from the pharmacies and he refused to go to hospital because of the cost, despite his high fevers and back pain.
So, late on a Friday, I was trying to coordinate direct IV injections of ceftriaxone via the nursing posts in the district - difficult with a satellite phone and an irate bus full of patients waiting for the last patient to leave the clinic.
Outside the clinic on the days spent in Santa Cruz there is also the possibility to attend ward rounds and teaching sessions at the Hospital Japones or the diabetes clinic run by one of the founders.
Possibilities for non-medical volunteering in the clinic also exist by way of various teaching and health projects. For instance, one of the volunteers began a garden project with the local school, encouraging the planting and consumption of healthy vegetable options. We also did a day trip to an orphanage to explain the importance of hand-washing.
Undertaking volunteer work at the clinic even for just a couple of months was immensely rewarding for me and something which I would encourage others to do. It was interesting to experience attending the Latin American hospital ward rounds and also to work closely with American physicians and nurses. A beginner to intermediate level of Spanish is necessary but there are those in the clinic who can assist with translation if required.
If any readers wish to volunteer, they may contact me at firstname.lastname@example.org or the Hamant Foundation directly.
Published: 02 May 2010