The national health insurance plans, the MCHI and the BHI, have been associated with an increase in the use of skilled care, although the level of use among the poorest quintile remains troubling at less than 20 percent in 1998. Obvious steps for improvement include providing readily accessible information to families (especially those most difficult to reach—the indigenous and remote), improving the drug supply, and ensuring timely payment for services rendered. Not so easily remedied would be improving the quality of care provided, which is already perceived by clients and providers as having improved (though competency-based training was not the norm for hospital personnel), reaching the unreached, and addressing the public-private mix. Bolivia's indigenous population constitutes more than half the total population; diversity in languages as well as traditions of health and health care makes this population particularly challenging to reach.

Why did the insurance work to improve coverage with a skilled birth attendant? The answer is, probably by addressing a felt need by a portion of the population to access services. It probably did not act through changing behaviors among families or among providers as efforts to reach out were minimal in the first phase of the insurance plan.

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