2.1.1. Análisis del Entorno General
2.1.2.3 Investigación de los competidores
In other Asian countries there is limited success reported in attempts to achieve community participation in health care, although success has been claimed in increasing coverage and equity of service delivery at a low cost compared with alternative modes of service organisation. Consistent with Thai studies, research in Nepal revealed that the implementation of community participation in the PHC approach reflected the perspectives and needs of the health bureaucracies involved rather than those of local village interests. Similarly, the work in other South and Southeast Asian countries showed that the concept of community participation was interpreted differently in different bureaucratic settings and adapted to bureaucratic needs, and there was a failure to appreciate and integrate the cultural factors (Justice, 1 986; Stone, 1 986; 1 989).
In African countries, there were some successful cases reported by Bugnicourt ( 1 982) who described some concrete examples of community participation; for instance in the provision of a piped water supply for a squatter settlement in one district in Central Africa, the people decided to break. the costs down by offering to do a large part of the work themselves. People who lived along the loop of the Niger River gave priority in "making books in their own tongue". They used a silk screen technique, as advised by the NGO worker, to produce collections of texts to which everyone contributed, such as proverbs, legends, riddles, history, linguistics, and even traditional medical knowledge, instead of remaining passive and waiting for information from elsewhere.
However, Bugnicourt also identified socio-cultural factors which created barriers to participation which were similar to those identified in Thailand and other Asian
countries. He reported different interpretations of the concept of community participation in different situations to suit local socio-economic structures and related to the local political regime. Government-organised participation reflected a centralised administrative system and desire for standardisation. An hierarchical attitude and bureaucratic tendencies led to a preference for written paper work over direct contact with village people. There was insufficient personal commitment on the part of public servants. Those factors contributed to the officials viewing themselves as specialists and situating themselves in the hierarchical system of
modem
society. The majority of government agents showed little appreciation of the experience and knowledge of the people, and had little ability to examine their behaviour in relation to the majority of the population in the town or country. Moreover, they had serious doubts as to the ability of grass-root groups to understand the situation and to solve the problem. As Bugnicourt concluded: "a certain scorn subsists in regard totraditional
knowledge and the colonial prejudice against thesavages
encountered in the bush still lives on" (Bugnicourt, 1 982, p.72, emphasis original). He concluded that this was a consequence of the education system, the system inculcated to lay the foundation for future people. It was a system of competition, not cooperation, in which those who were gifted, lucky and worked hard kept the results for themselves, and the rest were left behind. It was far from the spirit of solidarity of peer groups (Freyens, Mbakuliyemo&
Martin, 1993; Shoo, 199 1).Nickson ( 199 1 ) reported a successful case in Zaire, where the community was encouraged to identify its own health needs, and to be involved in making decisions to solve the problems. The villagers determined the meaning of health, as perceived by the community. Then a survey was undertaken to measure the extent to which health was present. From the survey, the community decided what their health priorities were, and what strategies would be needed to meet their needs. This example showed how indigenous structures were applied in local initiatives in problem-solving and decision making. Afterwards, a school was built in the village as the chosen strategy to solve the nutrition problem in the village. In Nickson's opinion, a vertical approach tended to be incompatible with community participation, and may even be destructive to the process of group formation and self organisation in development. Community involvement could only become a reality where health authorities were prepared to discuss the ideas and
concepts of the community, and to try to participate and collaborate with the community according to its needs. Since those authorities were key intermediaries between the bodies influencing health policy and the target population, they were the point at which instructions or suggestions were blocked or passed on (Nickson, 1 99 1 ).
Welsch ( 1 986) indicated that the Papua New Guinea health care system had been unable to promote effective community participation and local self-determination. The centralised bureaucracy and the top-down flow of information within the system were the underlying causes of the limitation of communication between levels. There was a general lack of communication from villagers to health workers about how communities defmed and understood their health problems. But equally important, planners never fully understood how rural health workers perceived their own working conditions and the health services they were going to provide. Besides, rural health workers were expected to give health education to villagers, who were assumed to be backward and to lack knowledge about health matters. This encouraged them to feel that they possessed superior health knowledge. There was little interest in the knowledge, beliefs, and ideas that villagers had about illness and its treatment. He concluded:
(T)his pattern is anticipated at each level of the health service. At every level, higher personnel act authoritatively, as if they have some private esoteric health knowledge, and deal with lower ranking staff as passive
acceptors
of this wisdom. Thus, health information and policy decisions flow from more sophisticated centres to what is assumed to be unknowledgeable periphery.(Welsch, 1 986, p. 107, emphasis original)
In Latin America, the Pan America Health Organisation (PAHO) realised that its member countries were encountering serious problems in trying to implement the concept of community participation, particularly within large-scale national health progr
amm
es. Thus the organisation decided to conduct research to answer the questions: why, when, and in what ways community members voluntarily participated, and what sustained this participation over time. The conclusion of the study found there were inherent contradictions between the orientation and structure of most government health systems and conditions necessary for community participation. Most health systems were based on the medical concept of treating patients and curing diseases, which assumed a paternalistic doctor-patient relationship; whereas a participatory system implied apreventive approach, considering environmental and social conditions, group action, and a partner relationship between health personnel and communities. Therefore, the major recommendation from the study was about changes and re-organisation of the bureaucratic system, such as changes in health policy and philosophy, and personnel training systems in order to encourage community participation in that particular national health system. In addition, it was suggested that action research on primary health care be undertaken to help develop a systems approach to community participation (PAHO,
1 984).
U galde also concluded that the promotion of community participation in Latin American countries, in spite of promotion efforts by international agencies, had not succeeded. In contrast to the P AHO report, he viewed the failure of PHC as due to the unrealistic and unimplementable nature of its principle. Community participation, in his view, was not necessary for the success of primary health care. Instead, the failure of primary health care delivery was because of incompetence, corruption, and mismanagement by civil servants; the Cuban situation was raised as an example (Ugalde, 1985).
The examples outlined above demonstrate the difficulties experienced across a range of developing countries in their attempts to implement community participation in CPHC
as
originally conceived by WHO. The conclusion drawn by the P AHO was that the inherent contradictions between the orientation and structure of most government health systems and conditions necessary for community participation could be generalised to most developing countries.Although the notion of participation has been widely accepted by health policy makers and planners success, in its implementation is still very limited (Co hen