Lessons from rural Bolivia: the United States must rethink community-based medicine


As I witnessed a team of Bolivian nurses venture on-foot into the rural outskirts of their communities to administer childhood vaccinations, antiparasitic medications, and wound care, I quickly recognized the imperative to extend this approach to community medicine in the United States.

These nurses operate from a primary-health clinic created under the Sistema Único de Salud (SUS) established by the Bolivian government in 2011. SUS assigns 2500 teams of health workers to cover 70% of the population through primary healthcare centers prioritizing community health and outreach. According to the World Health Organization, Bolivia is now one of three countries in the region with over 30% of healthcare workers engaged in community health initiatives.

Despite the clinic’s provision of entirely free services and its walking-distance proximity to most settlements, many children miss crucial vaccinations due to their parents’ inability to take time off from work for clinic visits. Consequently, routine “well-child” check-ups, where vaccinations are typically administered, are infrequent. Similarly, older children and adults often neglect chronic pain, injuries, and health conditions due to work obligations. This underscores the importance of the nurses’ community rounds, laden with backpacks and ice chests filled with medical supplies and vaccines, as they strive to foster health equity not solely within clinic walls, but directly where their neighbors reside.

An Outreach-Based Approach

Partners in Health reports that, in Haiti, 100% of patients with tuberculosis who received daily home visits by community health workers in addition to free care were clinically cured versus 56% cure and 10% death rates in patients who received free care alone. In Lesotho, routine home health visits led to zero maternal deaths despite a 350% increase in deliveries. Acompañantes (accompaniers) have promoted twice the odds of clinical control in diabetes and hypertension sustained beyond 2 years through weekly home visits in Chiapas, Mexico.

The evidence is clear: investing in outreach-based healthcare initiatives through the use of community health workers directly improves health outcomes. By persisting with the notion that medicine is confined within the four walls of a clinic, we fail to adequately serve the most vulnerable members of our communities.

Barriers to Accessing Healthcare in the United States

Studies conducted at various free clinics across different states reveal a common theme: providing free care alone does not resolve health inequities; commitments to work and childcare, as well as lack of access to transportation, can restrict one’s ability to access a clinic, even if the healthcare provided is free of charge.

At a free clinic in Utah, barriers in transportation access, alongside work or caregiving commitments, hindered ability to seek care for uninsured individuals living below 150% of the national poverty level. In Virginia, 57% of respondents cited work or caregiving responsibilities as reasons for missing free clinic appointments. Moreover, a student-run free psychiatry clinic for patients experiencing homelessness in Nebraska found that 62% of participants faced barriers like forgetting appointments, feeling too unwell to go to the clinic, or transportation challenges.

Due to the multitude of social determinants of health that impact patients’ ability to attend an appointment in a brick-and-mortar community health center (a physical, stationary healthcare facility), we cannot continue to rely on providing medical services within traditional clinical settings alone. Instead, we must focus on outreach-based approaches that serve patients wherever they may be located.

What Needs to Happen

Although mobile health and street medicine services have the potential to overcome barriers to healthcare by delivering care directly to underserved populations, these programs remain unreliably funded and insufficiently developed, rendering them unable to adequately meet demand.

In stark contrast to the roughly 14,000 stationary Federally Qualified Health Centers (FQHCs) catering to 30 million patients annually, the presence of an estimated 2,000 mobile health clinics attending to only about 6 million visits per year underscores a critical deficiency in the use of mobile health services. Addressing this significant disparity requires increased investment and advocacy for mobile health initiatives, reframing them not merely as supplementary interventions but as indispensable priorities in ensuring comprehensive healthcare for underserved communities.

Furthermore, community health workers (CHWs) should play a larger role in bridging the gap between healthcare providers and communities. CHWs can assist patients in accessing resources, ensuring medication adherence, and managing health conditions in a way that is culturally and linguistically relevant while forming trusting partnerships with community members that promote continuity of care.

Outreach-based community health strategies have proven to be effective in various settings across the globe. It is imperative that we recognize mobile health and street medicine services as essential components of the American healthcare system and fund them accordingly, ensuring their successful integration within communities through the use of trusted community health workers. By adopting these strategies, we can take larger steps towards enhancing healthcare accessibility and equity for underserved populations in the United States.

About the Author: Sara Habibipour is a Bachelor of Science candidate in Microbiology, Immunology, and Molecular Genetics at the University of California, Los Angeles (UCLA).

Competing Interest: None

Handling Editor: Neha Faruqui

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