Poor people are especially vulnerable to illness, violence, economic crises and natural disasters.

Support for child and maternal health programs is one way the World Bank strives to protect poor and vulnerable groups from illness and recurring poverty. In this work, the Bank is collaborating closely with the World Health Organization and other bilateral donors, including the US Agency for International Development, the UK Department for International Development and the Canadian International Development Agency.

In Bolivia, the World Bank has worked with the government and other partners to strengthen the capacity of local health service providers to reach out to vulnerable groups. They have been helping mothers, particularly in rural and indigenous areas, to protect their children from malnutrition and disease.

In the mid-1990s, Bolivia's infant and maternal death rates were among the highest in Latin America. Much of the wealthiest part of Bolivia's population could afford health care, and lived close to the services they needed. But the poor and indigenous populations were not in the same position. It was difficult to deliver services to the large population of indigenous and rural people living in Bolivia's rugged terrain. Economic problems in the 1980s had also forced cutbacks in health services.

But since the late 1990s, the Bolivian government has made cutting child and maternal mortality rates a central part of its health strategy. The World Bank has been working with the government to help it achieve this goal.

Recognizing that reducing infant mortality takes a sustained effort over a number of years, the Bank initiated a series of short-term loans in 1999, starting with a credit for $25 million to support the government's child and maternal health program. The resources strengthened the government's immunization program, supported a newly-introduced mother and child insurance scheme, and tested new ways to provide health services to mothers and children in isolated areas.

Indigenous people were extensively consulted. They were involved in choosing the agents to provide health care to rural areas, and traditional practices were incorporated into these services.

The project also strengthened the government's efforts to decentralize the delivery of health services. The program was managed at the municipal level and clear targets were established with the federal government, the regions, and the donors to monitor progress. This project met all its national goals. By 2000, trained assistants were attending 50 percent of all births, compared with 35 percent between 1996-1998. Immunization coverage rose to 86 percent from 75 percent over the same period. Treatment of child pneumonia cases rose to 112,154 in 2000 from 66,346 in the 1996-1998 period, while treatment of children's diarrhea cases increased to 450,772 from 292,417.

Nonetheless, in 2001, important gaps remained. About 90 percent of the richest fifth of the population had a skilled practitioner present at births, while only 25 percent of the poorest fifth had access to the same level of treatment.

To help address this problem, the Bank backed a second Bolivian health care project with $35 million in 2001. It supported an extension of health services to remote areas using mobile health teams and community health agents selected by local indigenous organizations. In addition, more health professionals were also made available for rural areas using funds from the joint Bank and International Monetary Fund debt relief program for heavily indebted poor countries.

The package of free services under the maternal and child insurance scheme was also expanded in 2002 to pay for the cost of transporting people between rural facilities and regional hospitals.

Moving forward, there are risks that efforts to improve the access of poor people to child and maternal health care services could be undermined. Rising demands in urban areas for more complex hospital services, which are currently provided for free, account for a growing slice of a limited health budget. Meanwhile, the public health insurance facilities meant to reimburse hospital care costs in rural regions have few financial incentives to do so, making it difficult for rural households to obtain health care.

To manage these risks, local health boards have been established to manage health networks, and the mother and child insurance program that covers transport costs between health facilities. The program is not yet financially independent and the government will need continued outside support to sustain improvements in child health in rural areas.