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The role of social participation in municipal-level health systems: the case of Palencia, Guatemala
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. (Strengthening Primary Health Care)
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Social participation has been recognized as an important public health policy since the declaration of Alma-Ata presented it as one of the pillars of primary health care in 1978. Since then, there have been many adaptations to the original policy recommendations, but participation in health is still seen as a means to make the health system more responsive to local health needs, and as a way to bring the health sector and the community closer together.

Aim: To explore the role that social participation has in a municipal-level health system in Guatemala in order to inform future policies and programs.

Methods: The fieldwork for this study was carried out over eight months and three field visits between early January of 2009 and late March of 2010. During this time, 38 indepth interviews with provincial and district-level health authorities, municipal authorities, community representatives and community health workers were conducted. Using an overall applied ethnographic approach, the main means of data collection were participant observation, in-depth interviews, group discussions and informal conversations. The data was analyzed in two different rounds. In the first one we used documentary analysis, role-ordered matrices and thematic analsis (see papers I-IV) and in the second round, thematic analysis was utilized.

Results: We found four themes that frame what the role of social participation in the municipality of Palencia is. The first theme presents the historical, political and social context that has contributed to shaping the participation policies and practices in Guatemala as a whole. The second theme takes a deeper look at these policies and how they have been received in the municipality of Palencia. The third theme presents data regarding the three situated practices of participation, each occurring at a different level: municipal, community and the individual level. Finally, the last theme presents reflections on what it means to participate to the people that were involved in this study.

Conclusion: In the process of social participation there are two different and complementary kinds of power that depend on the amount and the kind of resources available at each level of the participation structure. Stakeholders that have higher levels of power to formulate policies will have better access to financial, human and material resources while stakeholders that have higher levels of power to implement policies will have resources like community legitimacy, knowledge of local culture, values and mores, as well as a deep understanding of local social processes. The coordination of financial, human and material resources is just as important as the legitimacy that comes from having community leaders involved in more steps of the process. True collaboration can only be obtained through the promotion and creation of meaningful partnerships between institutional stakeholders and community leaders and other stakeholders that are working at the community level. For this to happen, more structured support for the participation process in the form of clear policies, funding and capacity building is needed.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2012. , 71 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1517
Keyword [en]
Social participation, community participation, community heath workers, primary health care, Palencia, Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-59865ISBN: 978-91-7459-470-6 (print)OAI: oai:DiVA.org:umu-59865DiVA: diva2:556967
Public defence
2012-10-19, Bergasalen, Byggnad 27, NUS, Umeå, 09:00 (English)
Opponent
Supervisors
Funder
FAS, Swedish Council for Working Life and Social Research, 2006-1512
Available from: 2012-09-28 Created: 2012-09-26 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Social participation within a context of political violence: implications for the promotion and exercise of the right to health in guatemala
Open this publication in new window or tab >>Social participation within a context of political violence: implications for the promotion and exercise of the right to health in guatemala
2009 (English)In: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 11, no 1, 37-48 p.Article in journal (Refereed) Published
Abstract [en]

Social participation has been understood in many different ways, and there are eventypologies classifying participation by the degree of a population’s control in decisionmaking. Participation can vary from a symbolic act, which does not involve decisionmaking, to processes in which it constitutes the principal tool for redistributing powerwithin a population. This article argues that analyzing social participation from a perspectiveof power relations requires knowledge of the historical, social, and economicprocesses that have characterized the social relations in a specific context. Applyingsuch an analysis to Guatemala reveals asymmetrical power relations characterized bya long history of repression and political violence. The armed conflict during the secondhalf of the 20th century had devastating consequences for a large portion of thepopulation as well as the country’s social leadership. The ongoing violence resulted innegative psychosocial effects among the population, including mistrust toward institutionsand low levels of social and political participation. Although Guatemala madeprogress in creating spaces for social participation in public policy after signing thePeace Accords in 1996, the country still faces after-effects of the conflict. One importanttask for the organizations that work in the field of health and the right to healthis to help regenerate the social fabric and to rebuild trust between the state and itscitizens. Such regeneration involves helping the population gain the skills, knowledge,and information needed in order to participate in and affect formal political processesthat are decided and promoted by various public entities, such as the legislative andexecutive branches, municipal governments, and political parties. This process alsoapplies to other groups that build citizenship through participation, such as neighborhoodorganizations and school and health committees.

Place, publisher, year, edition, pages
Harvard School of Public Health, 2009
Keyword
social participation
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-59846 (URN)
Available from: 2012-09-27 Created: 2012-09-26 Last updated: 2017-12-07Bibliographically approved
2. The process of social participation in primary health care: the case of Palencia, Guatemala
Open this publication in new window or tab >>The process of social participation in primary health care: the case of Palencia, Guatemala
2014 (English)In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 17, no 1, 93-103 p.Article in journal (Refereed) Published
Abstract [en]

Background In 2008, the World Health Organization issued a callback to the principles of primary health care, which renewed interests in social participation in health. In Guatemala, social participation has been the main policy for the decentralization process since the late 1990s and the social development council scheme has been the main means for participation for the country's population since 2002.

Aim The aim of this study was to explore the process of social participation at a municipal-level health commission in the municipality of Palencia, Guatemala.

Methods Analysis of legal and policy documents and in-depth interviews with institutional and community-level stakeholders of the commission.

Results The lack of clear guidelines and regulations means that the stakeholders own motivations, agendas and power resources play an important part in defining the roles of the participants. Institutional stakeholders have the human and financial power to make policies. The community-level stakeholders are token participants with little power resources. Their main role is to identify the needs of their communities and seek help from the authorities. Satisfaction and the perceived benefits that the stakeholders obtain from the process play an important part in maintaining the commission's dynamic, which is unlikely to change unless the stakeholders perceive that the benefit they obtain does not outweigh the effort their role entails.

Conclusion Without more uniformed mechanisms and incentives for municipalities to work towards the national goal of equitable involvement in the development process, the achievements will be fragmented and will depend on the individual stakeholder's good will.

Keyword
Guatemala, health commissions, primary health care, social participation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-48353 (URN)10.1111/j.1369-7625.2011.00731.x (DOI)21902774 (PubMedID)
Available from: 2011-10-18 Created: 2011-10-18 Last updated: 2017-12-08Bibliographically approved
3. 'If no one else stands up, you have to': a story of community participation and water in rural Guatemala
Open this publication in new window or tab >>'If no one else stands up, you have to': a story of community participation and water in rural Guatemala
2011 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, Article nr 6412- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Access to water is a right and a social determinant of health that should be provided by the state. However, when it comes to access to water in rural areas, the current trend is for communities to arrange for the service themselves through locally run projects. This article presents a narrative of a single community's process of participation in implementing and running a water project in the village of El Triunfo, Guatemala.

METHODS: Using an ethnographic approach, we conducted a series of interviews with five village leaders, field visits, and participant observations in different meetings and activities of the community.

FINDINGS: El Triunfo has had a long tradition of community participation, where it has been perceived as an important value. The village has a council of leaders who have worked together in various projects, although water has always been a priority. When it comes to participation, this community has achieved its goals when it collaborated with other stakeholders who provided the expertise and/or the funding needed to carry out a project. At the time of the study, the challenge was to develop a new phase of the water project with the help of other stakeholders and to maintain and sustain the tradition of participation by involving new generations in the process.

DISCUSSION: This narrative focuses on the participation in this village's efforts to implement a water project. We found that community participation has substituted the role of the central and local governments, and that the collaboration between the council and other stakeholders has provided a way for El Triunfo to satisfy some of its demand for water.

CONCLUSION: El Triunfo's case shows that for a participatory scheme to be successful it needs prolonged engagement, continued support, and successful experiences that can help to provide the kind of stable participatory practices that involves community members in a process of empowered decision-making and policy implementation.

Place, publisher, year, edition, pages
Järfälla, Sweden: CoAction Publishing, 2011
Keyword
community participation, community organization, water projects, Guatemala, social development councils
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-48351 (URN)10.3402/gha.v4i0.6412 (DOI)000299012700010 ()21977011 (PubMedID)
Available from: 2011-10-18 Created: 2011-10-18 Last updated: 2017-12-08Bibliographically approved
4. ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala
Open this publication in new window or tab >>‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala
Show others...
2012 (English)In: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 70, 18- p.Article in journal (Refereed) Published
Abstract [en]

Background: In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s healthissues required more than just hospital-based and physician-centered policies. The declaration called for a paradigmchange that would allow governments to provide essential care to their population in a universally acceptablemanner. The figure of the community health worker (CHW) remains a central feature of participation within thePHC approach, and being a CHW is still considered to be an important way of participation within the healthsystem.Methods: This study explores how the values and personal motivation of community health workers influencestheir experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, weused an ethnographic approach and collected data in January-March of 2009 and 2010 by using participantobservation and in-depth interviews.Results: We found that the CHWs in the municipality had a close working relationship with the mobile health teamand with the community, and that their positions allowed them to develop leadership and teamwork skills that mayprove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is akey value in Palencia, but there is a lack of infrastructure and growth opportunities.Conclusion: Attention should be paid to keeping the high levels of commitment and integration within the healthteam as well as keeping up supervision and economic funds for the program.

Place, publisher, year, edition, pages
BioMed Central, 2012
Keyword
Community health workers, Community participation, Guatemala, Primary Health Care, Alma-Ata declaration
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-59860 (URN)10.1186/0778-7367-70-18 (DOI)
Available from: 2012-09-27 Created: 2012-09-26 Last updated: 2017-12-07Bibliographically approved

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Citation style
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