Public Participation in Health Systems
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Forwarded by Claudio Schuftan <aviva@netnam.vn>
I appreciate the questions regarding public participation in health
systems, particularly are health and health workers the best entry
point for a participatory process. I think these questions beg that
we step back and examine what we mean by health. WHO offers us a
definition that we all know written in 1948, amended in 1998: "Health
is a dynamic state of complete physical, social, mental and spiritual
well-being and not merely the absence of disease." In examining this
definition and building operational models around it, I find it to be
rich in depth and scope. Sadly, if you speak with those at the WHO,
it is hard to find anyone working on well-being and multitudes dedi-
cated to the absence of disease. If we truly accept the WHO defini-
tion then communities primarily preoccupied with poverty issues are
also communities preoccupied with health since poverty is the single
most significant predicator of health status ("it is socio-economic
inequity that has the most profound impact on health status of South
Africans," Health Systems Trust, home page).
If we truly accept the WHO definition then wherever we start is an
entry point to health and a great diversity of professionals, para-
professionals and lay persons become members of a diverse and en-
riched and how we are prepared to do so. Are health workers prepared
to be engaged in a participatory process? Or is all our education de-
signed to fortify us as experts who have the answers? How many commu-
nity health programs have all of us witnessed that are called "par-
ticipatory" which actually means "Here is the program we have de-
signed, now come participate!" These same programs are in the piles
of programmatic failures resulting in remarks such as "those people
don't care" or "you can't sustain a community program" or "we can't
figure out what went wrong!" If we want those trained as health work-
ers to initiate and be active partners in participatory community
processes then we need to provide medical and public health education
that involves teaching students to listen not speak, engage in dia-
logue not monologue, facilitate not teach, serve not lead, be team
players not stars and value the deep intrinsic knowledge of the com-
munity above their own technical expertise.
In summary, we need to prepare health professionals to enter the com-
munity with love as reflected in these words by Jean Vanier: "To love
is not to give of your riches but to reveal to others their riches;
their gifts, their value, and to trust them and their capacity to
grow. So it is important to approach people in their brokenness and
littleness gently, so gently not forcing yourself on them, but ac-
cepting them as they are, with humility and respect."
Continuing from this poem, let us examine what it means "not to force
yourself on them." Often, even with participatory intentions, it is
the health professionals looking upon the community that seek to de-
termine the needs of that community. They make decisions to involve
community members in programs on HIV/AIDS, nutrition, malaria and
other problems that are surely pressing and need attention. However,
to return to the work of Paulo Freire, it is only when people have
strong feelings about an issue that they are willing and capable of
moving beyond apathy to action. Many issues that we as health profes-
sionals deem critical are seen as part of everyday life to those who
face them continually. So, the health professionals chosen point of
entry is often not the communities' point of entry.
Let me site one example: that of Carroll Berhost in Guatemala, a phy-
sician who went to the people and lived among them, facilitating
their own reflective and decision making process. He was thrilled
when they moved to action, dismayed when the first action was to
build a soccer field and further dismayed when the second action was
to put lights on the field. His patience and love, however, bore out
when eventually the community, with a new awareness of their own
power to accomplish, turned to health they did not ask foreign mis-
sionaries to come in to build hospitals and clinics but developed a
comprehensive health promotion and prevention program that has en-
dured long after Dr. Berhorst moved on beyond this earth!
The questions I leave you with are: Can we relinquish our experts
role and become facilitators of the community's vision? Do we trust
the people enough to enter their communities with no agenda such that
they build their own agenda? Do we have the patience to be engaged in
a participatory process that is time consuming and on going? Can we
truly include soccer fields and day care and literacy as part of the
WHO definition of health? Can we redefine our results and find new
ways to assess them? And finally, do we have any other choice in the
face of the multiple failures of the status quo of traditional health
education?
--
Bethann Witcher, Ph.D.
Director of Programs
Global Health Action
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