Mission Barrio Adentro (English: "Mission Inside the Neighborhood") is a Bolivarian national social welfare program established under current Venezuelan president Hugo Chávez. The program seeks to provide comprehensive publicly-funded health care, dental care, and sports training to poor and marginalized communities in Venezuela. Barrio Adentro features the construction of thousands of iconic two-storey medical clinics—consultorios or doctor’s offices—as well as staffing with resident certified medical professionals. Barrio Adentro constitutes an attempt to deliver a de facto form of universal healthcare, seeking to guarantee access to quality and cradle-to-grave medical attention for all Venezuelan citizens.
The Latin American branch of the World Health Organization and UNICEF both praised the program. According to WHO statistics infant mortality fell from 23 to 20 in males and 19 to 17 in females per 1000 births between 2003 and 2005.   In addition, Russian representatives have visited Venezuelan neighborhoods in order to study Venezuelan public clinics and Russian officials are considering implementing a similar program in Russia.
Of a planned 8500 Barrio Adentro I centers, 2708 had been built by May, 2007, using an investment of around US$126m, with a further 3284 under construction. As of 2006, the staff included 31,439 professionals, technical personnel, and health technicians, of which 15,356 were Cuban doctors and 1,234 Venezuelan doctors.
The Barrio Adentro program was developed against a background of a public health sector crumbling under long-term financial pressure. As part of the neoliberalisation programme of the early 1990s under President Rafael Caldera, a Venezuela struggling with inflation and a low oil price (oil being its primary export) was forced into spending cuts and privatisation in a number of sectors, including healthcare. A 1989 decentralisation law contributed to the trend; from 1993, state governors could request the transfer of public healthcare in their state to their control, and the inability to cope with the new responsibility encouraged cuts and privatisation. Cost recovery became increasingly prevalent through "voluntary" contributions from users. In addition to the problems with the healthcare system, over the course of the decade health problems caused by poverty (infectious and deficiency diseases) increased. By 1999, 67.7% of the Venezuelan population was living in poverty, from 44.4% in 1990.
In 1999, following the election of Hugo Chavez, the Ministry of Health planned to develop a new National Public Health System, with a particular focus on health promotion, disease prevention, community participation, and the strengthening of the primary health care infrastructure. The 2000/1 annual report by PROVEA highlighted a number of positive features of the new approach, including a wider availability of health services through progressive elimination of users’ fees.
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.
"The key aspect of these centers is that they are located within the neighborhood and in the marginalized zones of the large cities," although some facilities were located in higher income areas. "Placement of Barrio Adentro health posts within those neighborhoods that had been most excluded was undertaken at the request of the neighborhood health committees and taking into consideration preexisting health care facilities."
A key part of the national Barrio Adentro scheme, as it was in the original local plan, is the participation of the local community. This takes place through health committees, chosen in an assembly of citizens and typically around 10 people. By 2006, 8951 health committees had been registered (there is one committee for each primary care post). (The total was already 6,241 in 2004. ) A total of 41,639 community health assemblies were held in the first quarter of 2006, with the participation of 1,423,815 people.
The issue of participation goes beyond mere management. As one academic study put it, "the observed role of positive, egalitarian clinical interactions between Cuban physicians and Venezuelan patients and other residents suggests that doctor–patient interactions model power relations between communities and institutions and affect local perceptions and participation." It concluded that developing more positive and egalitarian physician–patient and professional–community relationships "may be one of the easiest, most effective ways" the medical profession can contribute to overcoming health disparities.
Each primary care post covers 250 to 300 families. By 2003, primary medical care coverage was achieved for 70% of the Venezuelan population for whom primary care was previously unavailable, representing over 18m people. By 2007, 3,717 primary care posts had been built and equipped, and a total of 8,633 posts were operational (including those still located in community centers and homes). There were also 4,800 dentists. In 1998 Venezuela had only 1628 staffed primary care posts, and 800 dentists. Between 1998 and 2007 this represents an increase of 530% and 600% respectively.
In addition to the new infrastructure, there are also new outreach programmes. For example, in addition to the drug module for the popular medical dispensaries (which provided free access to 106 essential medicines designed to cover the needs at this level of care), a family drug module was launched in 2005. This programme reaches 40 selected municipalities in 17 states, and every three months delivers drugs and vitamin supplements tailored to the family's needs. Hundreds of thousands of infants, children, and pregnant and elderly women have benefited. Over 150,000 health promoters from local communities were trained in 2004-6 to spread messages relating to ways of improving health.
After the Barrio Adentro's primary care network went nationwide in 2004, moves to expand beyond primary care soon followed. What became known as "Barrio Adentro I" focused on primary health care. "Barrio Adentro II" focused on secondary care, in three main areas: Comprehensive Diagnosis Centers (for more advanced diagnosis), Comprehensive Rehabilitation Centers (for people with disabilities, another social deficit uncovered by Barrio Adentro I—there were only 78 public sector centers in 1998), and Advanced Technology Centers (for more advanced treatment). Plans were made for 600 each of the first two (each serving a population of approximately 40,000 to 50,000) and 35 of the latter (with at least one in each state).
As of 2007, Barrio Adentro II involved 417 Comprehensive Diagnostic Centers (of 600 planned), 576 Comprehensive Rehabilitation Centers (of 600 planned) and 22 Advanced Technology Centers (of 35 planned). Key modern technology is split between CDCs and ATCs (by 2007 CDCs had 13 of the 19 public sector MRI machines, ATCs 15 of the 26 CT scanners). In 1998, there was only one MRI machine and five CT scanners in the public sector.
Barrio Adentro III provides care for those cases which cannot be resolved at the two lower levels—major illnesses, palliative and specialist care. Care is available 24 hours a day. Barrio Adentro IV is responsible for the most complicated and specialized medical and surgical needs. These are national and referral facilities where teaching and research is carried out. On 16 November 2006 the Chavez government introduced this phase of the Barrio Adentro project, with a planned 16 hospitals to be built around the country, especially in poor areas. The Dr Gilberto Rodríguez Ochoa Latin American Children’s Cardiology Hospital, inaugurated in 2007, is the most notable example,, being one of the largest centers of its kind in the world, with 142 hospital beds and 33 intensive care beds.
According to the Ministry of Health, only 50 public health establishments were built in the 1980s and 1990s. Between 2003 and 2007, 4,659 new comprehensive level I and II health care centers were built and equipped. Services in these centers is provided free of charge. In 2004/5 Barrio Adentro provided 150m consultations, four times as many as the conventional outpatient network; 40% of these were home visits.
"In surveys conducted by the National Statistics Institute (INE) in Caracas, 97 percent of the respondents said that they were satisfied or very satisfied with their general medical consultations, and 98 percent said they had little or no difficulty gaining access to health care, while 88.5 percent said that they had had some or considerable difficulty gaining access to health care prior to Barrio Adentro."
Between 1998 and 2007, extreme poverty was reduced from 20.6% to 9.41%, while the infant mortality rate fell from 21.3/1000 registered births to 13/1000.
The Venezuelan Medical Federation, the largest association of medical doctors in Venezuela, has lobbied vigorously against the use of Cuban doctors in Mission Barrio Adentro, and was in a legal dispute with the Chávez administration over the legitimacy of the Cuban doctors' licensure and practice. In 2003 they obtained a court order preventing Cuban doctors from practicing in Venezuela, on the basis that they were not properly licenced according to the Venezuelan system; a compromise was reached enabling them to continue working in Barrio Adentro.
Cuban doctors have continually defected from the Mission since 2004. In August 2006 the United States under George W. Bush created the Cuban Medical Professional Parole program, specifically targeting Cuban medical personnel and encouraging them to defect when they are working in a country outside of Cuba. As of early 2009, of an estimated 40,000 eligible medical personnel worldwide (around half in Venezuela), several hundred have applied under the program. According to a 2007 paper published in The Lancet medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the USA", some via Colombia, where they have sought temporary asylum. In February 2007, at least 38 doctors were requesting asylum in the US embassy in Bogotá after asylum was denied by the Colombian government. Cuban doctors working abroad are reported to be monitored by "minders" and subject to curfew.
Two defected Cuban doctors working in Venezuela have claimed that they were told their job was to keep Chavez in power, by asking patients to vote for Chávez in the 2004 recall referendum. Opposition supporters in Venezuela have called Cuban doctors "Fidel's ambassadors" and refused to go to their clinics.
In July 2007, Douglas León Natera, chairman of The Venezuelan Medical Federation, reported that up to 70% of the modules of Barrio Adentro have been either abandoned or were left unfinished . The claim that some modules have been abandoned has been backed by Venezuelan TV reports and other Venezuelan news agencies, although the state of abandonment and/or unfinished modules has not been independently verified by any other institution. Cuban health professionals in Venezuela in 2007 numbered around 39,000, the highest since the beginning of Barrio Adentro.
In some cases elected opposition officials have tried to impede or close existing Missions. In 2006 Chávez accused the governor of Zulia state of impeding Barrio Adentro there. In Miranda state in February 2009 the governor was reported to have tried to evict a 25-person Barrio Adentro mission to make room for office space.
|Missions of the Bolivarian Revolution|
|— food — housing — medicine —|
|Barrio Adentro · Plan Bolivar
Hábitat · Mercal
|— education —|
Robinson I · Robinson II
|— indigenous rights — land — environment —|
|Guaicaipuro · Identidad
Miranda · Piar
Vuelta al Campo · Vuelvan Caras
|— (Hugo Chávez) — (Venezuela) —|
As the work of the first primary health care Barrio Adentro proceeded, censuses began to reveal "the depth of the social deficits accumulated in these communities." The response was to expand into a number of new areas, creating new missions. Thus under Misión Alimentación, efforts are made to ensure that the vulnerable (children, elderly, etc) receive at least two meals a day. Misión Robinson was created to address illiteracy, which in turn led to Misión Milagro to deal with the revealed deficit of opthalmological care for eye disease.