Sunday, February 18, 2024

The denial of health rights to the poor in Venezuela: An interview with Dr. Marino J. González R.

 

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.

 

 

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