Abstract:
Background: Selective vertical programs have
prevailed over comprehensive primary health care in Latin America. In Bolivia and Ecuador, socialist governments intend to redirect health policy. We outline key features of both countries’ health systems after reform, explore their efforts to rebuild primary health care, identify and explain policy gaps, and offer considerations for improvement. Methods: Qualitative document analysis. Findings: Neoliberal reforms left Bolivia’s and Ecuador’s population in bad health, with limited access to a fragmented health system. Today, both countries focus their policy on household and community-based promotion and prevention. The negative effects on access to care of decentralization, dual employment, vertical programming, and targeting have been not received much attention. The neglect of health care services can be understood in the light of a particular, rigid interpretation of social medicine and social
determinants, international policy pressures, reliance on external funding, and institutional inertia. Current policy choices preserve key elements of selective care and consolidate commodification.
These reforms might not improve health and may worsen poverty. Conclusions: Health care can be considered as a social determinant in its own right. Primary care needs to be founded on an integrated model of family medicine, taking advantage of individual care
as one of the ways to act on social determinants. It deserves a central place on the policy-makers’ priority list in Bolivia and Ecuador as elsewhere.
