Bolivia: yearning for progress: the Millennium Development Goals promise poor countries a brighter future through social transformation. Bolivia may be an example for all the Americas: a country in a crisis of confidence, but striving to reach these goals.

Bolivia is today at a historical crossroads. Bolivians from across the social spectrum are clamoring for change. They want a break with business-as-usual in government and public service, which has failed to address the country's political, economic and social problems.

For Bolivia, the global development agenda defined in the Millennium Development Goals serves as a powerful symbol of social inclusion and solidarity. By encouraging shared responsibilities, the goals can be a catalyst for democratic transformation, as well as a platform for commitments to a new model of development based on equity and social justice.

Halfway between the millennium goals' baseline year of 1990 and the target-completion year of 2015, Bolivians are asking whether their country will be able to meet those goals. That they are asking the question is significant in itself. It suggests that a collective consciousness is emerging that could help diminish distrust between social groups and help build new spaces for collaboration on development.

Although the millennium goals have been officially adopted by the Bolivian state, society as a whole is not yet well informed about them, which limits the level of collective commitment to achieving them. In recent years, Bolivians increasingly view national development plans and programs with mistrust, disbelief, frustration and skepticism. Bolivia's poor by now have 20 years' experience in the global economy, and the country has instituted some of the deepest structural reforms in the Americas. Yet it has not been able to achieve sustained economic growth or to overcome its deep social inequities. Efforts to fight poverty have not yielded significant results. Today, marches and protests have become part of everyday life. For the millennium goals to be achieved, words must be replaced by action.

In this complex context, what are the prospects for Bolivia achieving the Millennium Development Goals?

Goal 1: Eradicate extreme poverty and hunger. This will be difficult for Bolivia to achieve by 2015. Doing so would require maintaining annual economic growth of around 5 percent in a country that currently has among the highest levels of poverty and inequality in the region. In Bolivia, the richest 10 percent of the population earns 25 times as much as the poorest 40 percent. The government's own studies show that Bolivia will likely fall some 10 percentage points short of the goal of halving extreme poverty by 2015.

Halving the proportion of the population in extreme hunger will also be difficult. In Bolivia, 26 percent of the poor have incomes lower than the cost of a basic food basket, and rural inhabitants on average consume 28 percent less than the recommended 2,100 minimum daily calories.

Goal 2: Achieve universal primary education. Bolivia can achieve this goal. It could well reach the year 2015 with every boy and girl having the opportunity to complete primary school. Bolivia already has relatively high rates of educational coverage, with 97 percent of children aged 6 to 13 enrolled in private or public school (2001 data). It should be noted that primary education in Bolivia is obligatory and free through eighth grade.

Goal 3: Promote gender equality and empower women. Bolivia has a long and difficult road to travel to achieve greater equity and social justice, particularly in terms of access to training and opportunities for economic and political participation. The official target for this goal is to eliminate gender disparity in primary and secondary education, preferably by 2005, and at all levels by 2015. These are goals Bolivia may be able to meet. Currently rates of school enrollment are not significantly different for boys and girls, with 94 girls enrolled in primary school for every 100 boys, and 80 girls per 100 boys enrolled in secondary school. In the population at large, 7 percent of males are illiterate, compared with 19 percent of females.

Goal 4: Reduce child mortality. Bolivia may be able to meet the target of reducing under-5 mortality by two-thirds by 2015, but doing so will require strong commitment and decisive action. In 1990, child mortality was 116 per 1,000 live births. The results of the country's 2003 National Survey of Demography and Health found the rate had declined to 75 per 1,000. To meet the 2015 target, Bolivia must reach a rate of about 40 per 1,000 live births.

Although the measurement used for the millennium target is child (under-5) mortality, the same survey found that the rate of infant (under-1) mortality was 54 per 1,000 live births, with a higher rate (67 per 1,000) in rural areas and a lower rate (44 per 1,000) in urban areas. Bolivia may be able to reach a national rate of infant mortality of 45 per 1,000 by 2015. However, this rate will not be within reach of the country's rural and indigenous populations unless more effective programs and strategies are developed during the next decade.

Goal 5: Improve maternal health. Recent trends in this area are promising. Figures on maternal mortality are still worrisome, but Bolivia's health policies and programs during the last 15 years have placed priority on reducing maternal deaths. From an alarming 390 deaths per 100,000 live births in 1990, the rate has dropped to 230 per 100,000, according to recent figures. Bolivia's millennium target for 2015 would be 200 per 100,000, a feasible goal if the country keeps this a high priority and if basic obstetric and gynecological care is strengthened, including contraceptive information and services.

Other data related to maternal health are also promising. The proportion of births in which mothers received a doctor's care during pregnancy rose from 49.5 percent in 1994 to 70.2 percent in 2003. The proportion of doctor-attended deliveries rose from 42.7 percent to 55.9 percent during the same period, while institutional deliveries rose from 42.3 percent to 57.1 percent.

All these data demonstrate sustained improvement. However, as with infant and child mortality, there are wide discrepancies between rates among the rural poor and higher-income groups in major cities. More concerted action to address these gaps is needed on the part of the state, civil society, international development agencies and all those who care about the development and well-being of Bolivians.

Goal 6: Combat HIV/AIDS, malaria and other diseases. Official data show 1,286 registered cases of people with HIV. The spread of the epidemic is a latent risk that could be realized unless more concerted, efficient measures are taken. The risk of transmission is currently increasing. Sexually transmitted infections affect 14 of every 1,000 Bolivians of reproductive age. Bolivia lacks the resources it needs to guarantee antiretroviral treatment to people living with HIV/AIDS. It remains to be seen whether the situation will improve in the coming months as the country receives financing for treatment from the Global Fund for AIDS, Tuberculosis and Malaria.

General poverty and lack of basic services, especially in rural and periurban areas, mean that communicable diseases such as tuberculosis, malaria and Chagas' disease are among the many significant public health problems in Bolivia. The high rates of morbidity and mortality due to these diseases reduce the productive potential of Bolivia's human resources and reinforce the vicious cycle of poverty and hunger.

Recent data on these diseases show improving trends, but they will have to be sustained in the coming years if Bolivia is to halt the spread of these diseases and begin to reduce their incidence and prevalence. Many in the country's public health sector believe that the millennium targets associated with these diseases will not be met. Yet the results could be more encouraging if programs were strengthened and if greater attention were focused on primary health care for the country's neediest.

Goal 7: Ensure environmental sustainability. Bolivia is unlikely to reach the targets set for this goal. The country has indeed made progress in incorporating sustainable development principles into its policies and programs in an attempt to reverse the degradation and loss of environmental resources. The proportion of national territory within protected areas has increased from 1 percent in 1990 to 16 percent in recent years, and the trend is still upward. But this is not enough. Bolivia faces a major challenge in strengthening public institutions involved in development and environmental monitoring. The country faces a worrisome list of environmental problems, including increasing soil degradation and erosion, deforestation, loss of biological diversity, environmental pollution, and lack of environmental awareness on the part of the public.

Bolivia has increased water and sanitation coverage in recent years, with 70.3 percent of households having potable water connections and 61.7 percent with basic sanitary services. Bolivia's millennium target for 2015 is 95 percent coverage, however, and this remains a major challenge.

A future for all

What role can the Pan American Health Organization (PAHO) play in helping Bolivia achieve the millennium goals? PAHO can continue its work in helping to strengthen the national health system, but it can also get involved in a new area of action: helping to restore public trust and helping to improve governance and public institutions. From a policy and technical standpoint, PAHO could also take a more explicit position on issues such as structural reform and development models and their impact on health conditions.

Bolivia's social capital and collective aspirations are fundamental resources that can be put to good use in pursuing the Millennium Development Goals. Working with indigenous communities, for example, is crucial for achieving the goals, and this process should be strengthened in the coming years. Also important is technical cooperation in the areas of production and sanitation, with a view to improving social inclusion and quality of life, particularly for the rural poor. PAHO should also promote partnerships, agreements and discussions on health as a public good and a key factor in development.

In Hippocratic medicine, the "crisis" stage of an illness is a decisive moment for a doctor's diagnosis and prescription for treatment. Similarly, Bolivia's current crisis of confidence could be a point of departure for escaping its own malaise. By stimulating imagination, a break with tradition and the search for new solutions, it could fuel efforts to consolidate democracy, improve health and wellbeing, and, in the process, achieve a more just and equitable society.

Jose Antonio Pages is PAHO/ WHO representative in Bolivia.