On May 29, 2023, the president of Brazil, Luís
Ignacio Lula da Silva, when inviting his admired friend Nicolás Maduro, highest
authority of the Venezuelan government, to a bilateral meeting between the two
countries in Brasília, hinted, in his public speech welcoming his friend, that
democracy thrives in the neighboring country, and condemned those who consider
Venezuela a dictatorship, defining them as builders of a false narrative. In
this way, it became clear to everyone that Lula considers Venezuela as a
democracy, even been ruled by a government that took control of the legislative
power through authoritarian means and subordinated the judicial power to its
interests and whims. Is this Lula's ideal recipe for democracy?
What happens is that, by maintaining sham
elections, international observers have documented numerous facts that
demonstrate the lack of transparency in the elections in Venezuela since the
beginning of this century. In the last 25 years, there have been more than 15
thousand political arrests of individuals who tried to demonstrate freely or
who were opposition candidates in elections at all levels of government, and
The Human Rights Watch denounced the repression and torture of political
prisoners and proceedings against civilians in military courts.
The subordination of the government and
citizens to the interests of an authoritarian kleptocracy in Venezuela has
generated record impoverishment of its population, with the return of hunger
and previously eradicated endemic diseases. Therefore, it is estimated that by
2024, almost 8 million Venezuelans will have left the country since the
beginning of the Chaves Government, with the majority having immigrated to
other Latin American countries.
But what are the consequences of what Lula considering
“democracy” in Venezuela on that country’s health system and the health of its
population? To talk about this topic, we invited one of the country's greatest
authorities on health policy issues - Dr. Marino J. González R.
Marino Gonzáles is Full Professor of Public
Policy at the Simón Bolívar University (USB) and corresponding member of the
National Academy of Medicine of Venezuela since 2016. He also belongs to the
Academy of Sciences of Latin America (ACAL) since 2020. He is an associate
researcher at the University of La Rioja, from the Health Economics Research
Group in Spain (where he lives) and member of the Advisory Board of the PhD in
Sustainable Development at USB.
His areas of specialization are public
policies, social policies, and health policies. Since 1999 he has directed more
than 50 research and technical assistance projects. He has published 149
specialized works relating to public policy, social policy, health policy and
health economics. To date, he has supervised 23 completed doctoral theses and
17 master's projects in public policy. He was a consultant for the World Health
Organization (WHO), Pan American Health Organization (PAHO), World Bank, IDB,
ECLAC, UNFPA and CAF. He has experience as an international consultant in
Ecuador, Paraguay, Honduras, Dominican Republic, Guatemala, Mexico, and Panama.
He was president of the Venezuela Chapter of the International Society for
Pharmacoeconomics and Outcomes Research (ISPOR) and member of the Board of
Directors of the “Federation for International Cooperation of Health Systems
and Services Research Centers (FICOSER)” between 1990-1994 and between 2002
-2006.
Furthermore, he has a doctorate from the Central University of Venezuela and a specialization in Public Health from the same university and a master’s degree in political science from USB, in addition to a specialization in Public Policy from the University of Colorado in Boulder, United States. He completed his Ph.D. at the Graduate School of Public and International Affairs (GSPIA) at the University of Pittsburgh, United States. With you the words of Dr. Marino Gonzáles.
Health Monitor (MS) – Reports from the
beginning of the last decade show that the Venezuelan government has corroded
the country's health infrastructure, threatening the public health of its
people. For example, between 2009 and 2015, the infant mortality rate increased
from 14.4 to 20.2 per 100 live births. Maternal mortality rates, estimated at
92 per 100,000 live births in 2000, reached, according to PAHO and UNICEF
estimates, 259 per 100,000 live births in 2020. The rate of low-birth-weight
children increased from 8.7 % to 9.7% between 2003 and 2017. But since 2016,
the Venezuelan Ministry of Health has stopped publishing crucial public health
statistics. Given the blackout of statistical data, how can we, even
externally, monitor the public health disaster caused by the Chaves-Maduro
dictatorship in the country? Are there civil society institutions interested in
monitoring the health status of the Venezuelan population?
Marino González (MG) - To understand what happens with
data in Venezuela, the political and governmental context is very important.
Over the past 25 years, Venezuela has suffered a significant deterioration in
democratic capabilities, especially government responsibilities. This
deterioration is manifested in a very noticeable way, but not exclusively in
its impact on the rule of law and the lack of balance of powers, but mainly in
the lack of respect for the processes that guarantee Human Rights. Thus,
Venezuela currently has very low indicators of democratic governance on the
global stage.
In the recent years worsened conditions,
monitoring processes and the quality of public policies assume secondary
importance for government management. Thus, what the country built over decades
in terms of the quality of social measurement systems was mostly lost. This is
why there is no regular, quality information on basic aspects of health
policies. Mortality figures have not been published since 2016, but demographic
data has not been updated since 2012 (almost 12 years). The last weekly
information on notifiable diseases was published at the end of 2016 (seven
years ago).
Facing these immense gaps in information,
initiatives have been generated by universities, civil society organizations,
research centers and public opinion monitoring companies, with the aim of
mitigating, to a certain extent, these gaps in information for policy
evaluation. Obviously, these initiatives are subject to resource constraints,
meaning that they are often uncomplete and irregular, but they play a
fundamental role in a situation in which the public sector has practically
abandoned its constitutional mandate of guaranteeing the best policies for
citizens.
MS – The progressive elimination of sanitary
and epidemiological surveillance processes in Venezuela has increased outbreaks
of communicable diseases in the country to alarming proportions, while at the
same time dismantling vaccination strategies for preventable diseases, such as
measles, diphtheria, and tetanus. In 2016 and 2017, Venezuela had the highest
rate of increase in malaria in the world and tuberculosis rates in 2015 were
the country's highest in 40 years. How is this situation currently? Is there
interest or political will to improve the health of the poorest and most
disadvantaged population? Is a lack of interest in the health of the poorest a
strategy to eliminate the poor population that does not feel represented by the
Venezuelan dictatorship and that is unable to immigrate to other countries?
MG – The government started in 1999, and which continues today, had the
fight against poverty as one of its main messages. This long period of greater
impoverishment that followed in the country is a demonstration that the
government did not have a modern and intelligent strategy to correct
development imbalances. The false premise that it was possible to concentrate
wealth in the State and that, therefore, everything would be resolved, is at
the heart of this monumental failure. In 1999 it was known that countries do
not improve because the State absorbs all political, economic, and social
functions.
This is the reason why Venezuela recorded the
largest increase in the proportion of households in extreme poverty, reaching
75% in measurements from high-quality technical surveys. This increase in
poverty began before the hyperinflation that began in 2017 and increased
further throughout the entire period of hyperinflation (one of the longest
reported in the world). Therefore, it can be said, with complete certainty,
that there was no political will nor technical and institutional capacity to
overcome poverty in the country. The evidence of Venezuela's social and
economic deterioration is the most notable in the last fifty years in the
world. Unfortunately, they are worldwide visible. The migration of more than 7
million Venezuelans out of a total of 30 million is the greatest proof of this
extraordinary disaster in the country's public management over the last quarter
of a century. It's really dramatic.
MS – Venezuela has been using, for a long
time, the strategy of importing family doctors from Cuba, paying the country
with oil. Many claim that the main function of family doctors in Cuba has been,
at least in the past, a surveillance and political propaganda function,
identifying potential people who could threaten the regime and propagating the
government's benefits to have the support of the population out of conviction
or fear. In the case of Venezuela, did doctors imported from Cuba also fulfill
this role? Was the adoption of Cuban family doctors beneficial to the health of
Venezuelans? Did their action cover the entire Venezuelan population or just the
people living in areas identified as supporting the Chavo-Madurista regime?
MG - The arrival of doctors from Cuba began in
2002. That year, when the political crisis had already begun, it was essential
for the Chávez government to regain its popularity, because the management of
the first years did not have much to offer (for example, the medical care
program maternal and child services that served more than 500 thousand children
and pregnant women was eliminated in the first months of its administration).
In this context, the Venezuelan government copied in practice the concept of
the missions that had been implemented in Cuba ten years ago. And one of those
missions was called Barrio Adentro, which included Cuban doctors coming
to Venezuela.
Therefore, the objective of this mission was
not public policy. It was rather a strategy to face the 2004 recall referendum,
which the government won. The services that were developed in this mission had
more advertising effects for the government but had no effects in terms of
health policies. The country's health indicators did not improve due to this
mission. To the point that infant and maternal mortality increased in those
years (there are currently no official figures, but international estimates
indicate that these indicators have worsened significantly in the country).
Many of the Cuban doctors who entered Venezuela joined the millions of
Venezuelans who migrated, either to Colombia and other Andean countries, or to
the United States. At this moment, no one is talking about this mission.
MS – Between 2014 and 2023, around 7.7 million
Venezuelans migrated from the country, which represents the highest immigration
rate from a South American country in history. Among the factors that
contribute to migration are hunger and lack of health care for the population.
For example, between 2017 and 2018, most HIV-infected patients discontinued
therapy due to lack of medication. Many of the HIV patients were able to
migrate to access treatment that was denied to them by the Venezuelan
government. In your point of view, how has the deterioration of the health
system influenced the migration strategies of the Venezuelan population?
MG – They totally influenced it. Since 1999,
there has been a sustained increase in private health financing sources in
Venezuela. Family health expenditure estimated by national health accounts has
become one of the highest in the region. This process coincides with the
deterioration of the country's productive capacity, with the closure of many
companies, and the consequent loss of jobs. In the middle of the last decade,
50% of the population did not have any type of health insurance (neither public
nor private). In three years (2017), right at the beginning of hyperinflation,
this percentage rose to 70%. It is evident that this situation worsened during
the years of hyperinflation, clearly influencing the large wave of migration
that occurred in those years. On the other hand, public opinion surveys have
consistently highlighted the importance that families attribute to health, as a
fundamental problem in their daily lives.
A related aspect is that pension coverage for
the elderly population does not exceed 50% of those who should receive it and,
on the other hand, the value of pensions for this population did not exceed 5
dollars per month for a long time. These pensions are financed with tax
resources, as they do not discriminate based on the work activity carried out.
For many elderly people, with greater restrictions on migration, part of the
survival strategy considers that their children or grandchildren can emigrate
to increase family financing in the country by sending remittances. The costs
of healthcare for this population without any type of financial protection is,
without a doubt, a factor that promotes the migration of their family members.
Migration, in practice, is a demonstration of the immense failures of health
and social security policies experienced in the last 25 years in Venezuela.
MS - Since November 2021, the International
Criminal Court (ICC) has opened an investigation into possible crimes against
humanity in Venezuela, while a United Nations fact-finding mission has found
sufficient reason to believe that crimes against humanity were committed as
part of a state policy of repression against opponents. According to this
investigation, the country's judicial authorities participated in or were
complicit in abuses, serving as a mechanism of repression, including the
failure of millions of people to access adequate medical care and nutrition.
What will be the follow-up to this investigation and what consequences could it
have for the government? Could this research bring elements to reverse the
crisis in the Venezuelan health system that affects the poorest who do not
support the regime?
MG – The evolution of health conditions in Venezuela, especially in the context of the complex humanitarian emergency that has lasted for eight years, has justified multiple investigations in international organizations, both to monitor human rights and their effects on people's lives. It is desirable that all these investigations serve to prevent new situations and compensate for the damage committed. These investigations, due to their own characteristics, have deadlines and processes that must be complied with.
I believe that improving the concrete situation
of citizens, including, of course, health, involves a process of institutional
and political changes that are very complex in Venezuela. The demands to modify
current guidelines are notable and progress is not keeping pace with needs. We
hope that in the coming months we can identify points that will allow us to
improve. The international community and national actors are convinced of the
seriousness of the situation and the consequences for the daily lives of all
Venezuelans, those who live in the country and those who live abroad.
MS – One of Venezuela's biggest problems is
the food crisis, which in addition to being one of the main factors for
migration, affects everyone in the country. In a context of poverty and very
low wages, food prices increased by 315% between September 2022 and September
2023. Many countries have contributed with donations to resolve the
humanitarian crisis which, in addition to hunger issues, involves domestic
violence, violence against women and violence against LGBT minorities. How has
the government faced and/or intends to face these problems?
MG - National organizations that participate in
support tasks within the scope of the complex humanitarian emergency recently
expressed that less than 10% of the population in need is being served.
Although there are resources available to increase this coverage, they
emphasize that multiple obstacles prevent the situation from improving. In
general, there is great dissatisfaction because these difficulties have not
been overcome. The responsibility of government management in this aspect is a
fundamental factor.
MS – Venezuela is currently one of the
countries with the lowest public spending on health (1.7% of GDP and 4.9% of
total public spending). Why is health not a priority in the public budget in
Venezuela?
MG – As in many areas of social policies,
health is affected by this lack of priorities in public management. Short and
medium-term management objectives involve other aspects, including political
supremacy and obtaining resources for activities in the political sphere.
Therefore, the priority for the design and execution of quality health policies
is not the main issue. This would require the implementation of consultation
and agreement processes for which there is no political or technical competence
and, furthermore, are not a priority. The only way to transform this situation
is through a new political phase that focuses sustained efforts on improving
democratic institutions. This is the biggest challenge, in my opinion, that
Venezuelan society faces.
MS – How do you see the health situation in
Venezuela for 2024, including issues of epidemiology, functioning and financing
of the health system?
MG – The entire situation in 2024 is influenced
by the presidential elections, which still do not have a defined date. This
event will affect the political situation and will have social and economic
consequences. The absence of quality policies, for the reasons indicated, is
the predominant factor. Therefore, there can be no modifications to this course
of action without improvements in democratic institutions. In the worst-case
scenario, if there is no progress in the political sphere, what could happen is
that economic restrictions will increase, and the complex humanitarian
emergency will be worsened. I think all the alarms continue to ring in
Venezuela. It is a deep and systemic crisis, with wide repercussions in the
region and, fundamentally, a global crisis in the conditions of Venezuelans. It
must be a situation of utmost concern for everyone, for national leaders and
the international community. It is a very critical year for the future of
Venezuelan society. I have no doubt.
