Revision sistematica

PARTICIPACION CIUDADANA Y REFORMA DE LA SALUD

Protocolo de Tesis de Maestria en Salud Publica.

Facultad de Salud Publica, Universidad Peruana Cayetano Heredia.

Es común acuerdo que la Participacion comunitaria requiere una evaluación, luego de su generalización en el Peru a partir de los años 1980.

De la misma manera, la literatura coincide en que la reforma sanitaria en latinoamerica ha fracasado, y como uno de sus factores figura la escasa capacidad a nivel local, la falta de financiamiento y no haber desarrollado procesos de descentralización.

En particular desde la experiencia del BID en el desarrollo de sistemas de agua rurales, se reconoce la necesaria participación comunitaria en todo el proceso de los proyectos, pero tambien señala la asistencia técnica y la capacitación.

Menos común y mas actual esta la escasa definición en lo que a Participacion comunitaria se refiere, y coincidiendo con el concepto de Ciudadania y el movimiento por los Derechos Humanos, se promueve la planificación local, el monitoreo social, los jurados ciudadanos como mecanismos técnicos para involucrar a la comunidad en los proyectos sociales.

Mas aun, y con la situación latinoamericana de un crecimiento sustentable se coincide en la educación y la capacitación para la participación, y la contribución a una institucionalidad transparente, responsable, efectiva y por tanto representativa.

Asi pues con el fin de identificar los factores que afectan la Participacion comunitaria con un enfoque de descentralización, y ciudadanía, recogemos las ideas de Atencion Primaria de Salud (1978) y Sistemas Locales de Salud (1982), actualizados con la propuesta de Determinantes Sociales de la Salud (1996).

El esquema básico que hemos elegido es producto de la revisión bibliográfica respecto de la epidemia de peste en la provincia de Ascope, La Libertad, PERU, y la Revision sistematica sobre Capital social y Salud, que presentamos, y basados en el escasa literatura sobre participación comunitaria y descentralización que realizamos en el Taller de Investigacion I, FASPA/UPCH.

Capital social y salud en América Latinay el Caribe: una revisión sistemáticaCristóbal E. Kripper1 y Jaime C. Sapag1

Cada vez es más evidente la importancia de los determinantes sociales para enfrentar los desafíos actuales de la salud y el desarrollo en el mundo. Estos determinantes son las características específicas y las vías por las cuales las condiciones de la sociedad influyen en la salud (1, 2). El tipo y la calidad de las relaciones sociales, la cultura, el barrio de residencia, el trabajo, el nivel socioeconómico, así como la pertenencia étnico-racial y el género, entre otras variables, han sido frecuente objeto de estudio en investigaciones relacionadas con la salud (3). Es una obligación ética desarrollar intervenciones eficaces en el ámbito de la salud desde una perspectiva más amplia que aborde adecuadamente los determinantes sociales y contribuya a la equidad en salud.

En los últimos años se ha descrito la importancia que puede tener el capital social (CS) en el campo de la salud pública, así como en materias tan diversascomo el desarrollo social, la superación de la pobreza (4), la disminución de la criminalidad (5) y el fortalecimiento de la educación (6). No existe una definición única de CS, como tampoco hay una sola clasificación de sus formas o tipos (7–8). Por ejemplo, Bourdieu y Loïc afirman que el CS es el conjunto de recursos reales o potenciales que se vinculan con la posesión de una red duradera de relaciones más o menos institucionalizadas de conocimiento o reconocimientomutuo (9). Sin embargo, Coleman pone el énfasis en los elementos de la estructura social que facilitan ciertas acciones de los actores dentro de dicha estructura (10). Por su parte, para Putnam y colaboradores, el concepto de CS abarca determinados elementos de la organización social —como la confianza, las normas y las redes sociales— que pueden mejorar la eficiencia de la sociedad al facilitar la acción coordinada (11).

Sin embargo, más allá de la variedad de definiciones, hay cierto consenso en considerar que se trata de un recurso intangible y dinámico que existe en el colectivo y abarca elementos como la confianza, la participación y la reciprocidad (7–12).

A Integração Possível Entre o Processo de Descentralização e a Autonomia dos Serviços de Saúde e a Participação do Cidadão— Relato de Experiência.Virginia Gawryszewski *

Este trabalho analisa a experiência de reorganização dos serviços de saúde da Região Emilia-Romana, na Itália, no seu período mais recente, com ênfase nos aspectos da descentralização dos serviços, autonomía local e participação do cidadão. Conclui-se que a descentralização só foi

possível devido às características da autonomia local e da participação do cidadão no processo, e que estes dois últimos fatores devem ser evados em conta no processo de reorganização de serviços atualmente em curso no Brasil.

Apesar das grandes dificuldades para o desenvolvimento da política de programação a nível do Estado italiano, a Região Emilia-Romana, ao adotar este método e seus instrumentos, respaldou-se nas profundas raízes culturais que enfatizaram o papel central das Comunas (menor divisão administrativa do Estado italiano) como principal representante local, e na tradição de participação democrática do operariado urbano e rural.

Como já foi dito anteriormente, a possibilidade que a Região Emilia-Romana teve de desenvolver plenamente sua política de programação no setor saúde ocorreu a partir da promulgação da Lei do Sistema Nacional de Saúde de 1979. Neste novo contexto, a programação passou a ter duas atribuições. A primeira, ser método de governo do novo sistema de saúde. A segunda, ser instrumento para a transformação dosistema pré-existente, no sentido indicado pela Lei.

Todo o arcabouço metodológico que foi desenvuelto perpassou três pilares: autonomia local, descentralização e participação do cidadão. Do ponto de vista da programação propriamente dita, foram quatro as diretrizes fundamentais para a realização do I Plano Regional de Saúde (1980-1983), isto é: a) desenvolver a gestão coordenada dos serviços de saúde; b) promover e desenvolver intervenções específicas na área de prevenção; c) reorganizar e qualificar a rede hospitalar e d) realizar iniciativas no campo da formação profissional (4).

Determinantes sociais e autorrelato de tuberculose nas regiões metropolitanas conforme a Pesquisa Nacional por Amostra de Domicílios, BrasilRejane Sobrino Pinheiro,1 Gisele Pinto de Oliveira,1 Evangelina Xavier Gouveia Oliveira,2 Enirtes Caetano Prates Melo,3 Cláudia Medina Coeli1

e Marilia Sá Carvalho4

O Sistema Único de Saúde (SUS) no Brasil tem como principais pilares a universalização do acesso, a descentralização das ações e a equidade no tratamento (5, 6). A tuberculose é uma doença de notificação compulsória no país e a responsabilidade do setor público vai desde a disponibilização de medicamentos até a assistência, realizada prioritariamente pela rede de atenção básica de serviços de saúde (3, 7, 8). As principais medidas de controle da tuberculose recomendadas pelo Ministério da Saúde aos estados e municípios brasileiros são (3, 9, 10): adoção do esquema de tratamento padronizado mundialmente, com a inclusão do etambutol como quarta droga; priorização do tratamento diretamente observado como estratégia de acompanhamento dos casos; investigação dos contatos; cura com comprovação laboratorial; e adoção de estratégias

diferenciadas para grupos mais vulneráveis, como triagem diagnóstica na porta de entrada para a população carcerária e atenção oferecida no local onde vive a população de rua e nos serviços especializados de Aids.

A determinação socioeconômica da doença, também conhecida, é verificada neste estudo pela associação com renda familiar per capita (12–14, 21). Outros fatores sociais, como escolaridade, densidade intradomiciliar (medida por número de pessoas por dormitório) e raça/cor não mostraram associação estatisticamente significativa no modelo final. A renda é um indicador social importante no estabelecimento das condições de vida do indivíduo. Nas nove regiões metropolitanas do Brasil, ter renda menor do que meio salário mínimo por membro da família foi associado ao relato de tuberculose. A privação e as barreiras de acesso a recursos básicos parecem constituir o fator mais importante para a ocorrência da doença, independentemente da escolaridade.

Há que se considerar, ainda, que a renda é um fator passível de modificação por meio de ações afirmativas provenientes de políticas públicas focalizadas. O país dispõe, atualmente, de políticas públicas específicas para abranger a população não alcançada pelos serviços e ações do Estado. Essas iniciativas foram responsáveis pela redução da pobreza em 58% entre 2003 e 2011 (22). Com a finalidade de superar a situação de extrema pobreza da população em todo o território nacional por meio da integração e articulação de políticas, programas e ações, foi instituído, em 2011, o Plano Brasil sem Miséria, tendo como principais eixos: garantia de renda, acesso a serviços públicos e in-clusão produtiva (23). O Programa Bolsa Família é um programa de transferência direta de renda que reforça o acesso a direitos sociais básicos nas áreas de educação, saúde e assistência social, por meio de condicionalidades, e promove o desenvolvimento familiar com vistas a superar a situação de vulnerabilidade. A inclusão do tratamento de problemas de saúde como a tuberculose nas condi cionalidades poderia ser uma iniciativa governamental para reduzir o impacto da pobreza na saúde da população.

Ter plano de saúde remete a melhores condições de vida, uma vez que o plano de saúde parece não estar entre as prioridades de indivíduos extremamente pobres, que possivelmente enfrentam questões mais básicas de sobrevivência. A associação inversa do autorrelato de tuberculose com a variável “possuir plano de saúde” pode ser explicada pela maior facilidade de acesso aos serviços e às informações (prevenção) sobre a doença por parte dos indivíduos que têm plano de saúde quando comparados aos indivíduos sem plano de saúde.

As taxas de incidência e mortalidade no Brasil vêm apresentando tendência decrescente ao longo dos anos, com redução de 1,4% e 2,9% ao ano, respecti-vamente. O país alcançou, em 2011, uma das metas dos Objetivos de Desenvolvimento do Milênio, de reduzir em 50% a taxa de mortalidade quando comparada aos valores de 1990 (1). No entanto, é necessário estudar de que forma os fatores não programáticos da tuberculose interferem no controle da doença, e de que forma a articulação com outros setores, fora o setor saúde, pode contribuir para acelerar a queda dos indicadores epidemiológicos e o alcance das metas pactuadas. É necessário investimento em outros estudos que avaliem essas variáveis nas esferas local e nacional, pois esse trabalho evidenciou como a situação socioeconômica e o acesso e uso de serviços de saúde influenciam a ocorrência de tuberculose no conjunto das regiões metropolitanas do Brasil.

Processos de exclusão social e iniquidades em saúde: um estudo de caso a partir do Programa Bolsa Família, Brasil Hayda Alves1 e Sarah Escorel2

A abordagem da determinação social do processo saúde-doença envolve desvelar como a estrutura socioeconômica incide na produção de saúde e também analisar a interferência das diferentes políticas de proteção social no enfrentamento desse processo (1). Entender a saúde no sentido amplo e como recurso para a vida digna tem sido um dos fundamentos da Organização Mundial de Saúde (OMS) desde a sua criação. No Brasil, a 8a Conferência Nacional da Saúde, de 1986, estabeleceu uma definição ampliada de saúde, que foi incorporada nas bases legais do Sistema Único de Saúde (SUS). A saúde como campo intersetorial requer a interação entre diferentes políticas públicas para gerar uma gama de efeitos capazes de transformar as expressões da questão social contemporânea, como os processos de exclusão social produtores de iniquidades em saúde (2). Essas iniquidades podem ser alteradas por intervenções vinculadas a políticas universalizantes (3) orientadas ao enfrentamento dos determinantes sociais que resultam em desigualdades em saúde desnecessárias, evitáveis e injustas (4).

A despeito da importância das políticas universalizantes para a proteção social e o combate às iniquidades, verifica-se, a partir de 1990, na América Latina, a expansão de políticas focalizadas, resultantes da enunciação da questão social como pobreza, por influência do receituário neoliberal imposto por agências internacionais, condicionante da renegociação da dívida externa (5). No marco dessas intervenções, foram desenvolvidos, no continente latino-americano, programas de transferência de renda condicionada, como o Programa Bolsa Família (PBF), no Brasil. Criado em 2003, o PBF é o maior programa latino-americano de transferência de renda condicionada. Em 2013, beneficiou mais de 13,7 milhões de famílias com renda mensal per capita até RS 140,00 reais (US$ 70,00), com os objetivos de: promover o acesso à rede de serviços públicos, em especial saúde e educação; estimular a emancipação sustentada das famílias; e promover a intersetorialidade das ações sociais do poder público. A inscrição no PBF ocorre mediante o registro das famílias no Cadastro Único para Programas Sociais do Governo Federal (Cadúnico), operacionalizado pelos municípios e processado no âmbito federal (6, 7).

Entre os principais resultados, destacam-se os efeitos imediatos do PBF relacionados à transferência direta de renda, em particular no aumento do consumo. As narrativas evidenciaram diferentes sentidos adquiridos pelo PBF no enfrentamento de vulnerabilidades econômicas e como apoio à renda de famílias com inserções ocupacionais precárias. O benefício era associado ao “dinheirinho certo” complementar ao trabalho — um trabalho que gerava renda insuficiente para suprir as necessidades básicas das famílias, além de frequentemente ser informal, desprotegido e transitório

Não foram relatados efeitos do PBF relacionados aos programas complementares de inclusão produtiva, considerados como “portas de saída” por meio de capacitação profissional ou ampliação da escolaridade das famílias beneficiárias, porque não haviam sido criados ou não estiveram ao alcance dos entrevistados. Na dimensão social, o PBF atuava promovendo inclusão ao ampliar a participação das famílias na rede de comercio local, possibilitar a aquisição de itens alimentares e de vestuário, material escolar, entre outros, além de viabilizar a compra a crédito de bens duráveis. Dessa forma, fortalecia os laços sociais pela esfera do consumo, de modo a sa-tisfazer algumas necessidades materiais e simbólicas das famílias. Essas necessidades referiam-se à autovalorização do beneficiário como consumidor, como portador de cartão bancário e/ou como alguém que conseguia pagar suas contas em dia — símbolos de autonomia e respeito. Tais repercussões alçavam as mulheres ao papel de protagonistas da própria vida e de suas próprias decisões, e exemplificam como o PBF promove inclusão na dimensão cultural, ao produzir mudanças positivas no status de seus beneficiários.

Entretanto, a política social economicamente orientada que promove a inclusão das famílias no mercado de consumo, sendo, porém desarticulada de outras políticas de proteção social (25) universalizantes e de base constitucional, como seguridade social e educação, compromete, em longo prazo, as possibilidades de o PBF incidir na superação da pobreza geracional e, por conseguinte, promover a inclusão social permanente dessas famílias na cidadania. Ressaltam-se os limites que o incentivo à frequência escolar das crianças e adolescentes encontra na baixa qualidade da escola pública no Brasil.

Os resultados de estudos de caso permitem ainda elaborar recomendações para políticas setoriais e intersetoriais a serem implementadas na localidade pesquisada, visando à inclusão produtiva das famílias e o fortalecimento de políticas de proteção social e de participação a partir da própria institucionalidade do programa (33).

Public participation: more than a method?Annette Boaz1,*, Mary Chambers1, Maria Stuttaford2,3,4

As Whitty and colleagues (1) note, there is scope for increased public participation to influence decision-making and service delivery in healthcare. In a number of countries, the last 20 years have seen an explosion in public participation in health systems governance, health research governance and health promotion. In a recent paper, Evans tracked the evolution of public and patient involvement in research in the UK through an analysis of policy documents (2). Similar to Mockford et al. (3), he found public and patient involvement to be deeply imbedded in research funding structures, but concluded that the drive to involve raced ahead of the establishment of an evidence base for participation.

More recently, researchers have sought to build this evidence base and to establish what might be the optimal approaches to formalised participation (4). Whitty and colleagues provides an interesting comparison between two approaches: discrete choice experiments and citizens juries (1). The authors go on to argue that combining the quantitative (discrete choice experiments) with the more qualitative (citizens juries) can ‘maximise the value of public input to health policy decision-making processes’. Within research and health service delivery, since the first attempts at participation, there have been efforts to achieve ‘genuine’ participation, as envisaged in Arnstein’s (5) now well cited work. However, before those engaged in promoting participation unravelled how to ensure such sharing of power, the concept of participation was appropriated. In so doing, ‘participation’ has all too often come to simply mean consultation. The focus in recent health systems reforms has been on establishing mechanisms of participation, allowing the research enterprise, health services and governance structures to continue largely with ‘business as usual’.

While we continue to grow a body of literature charting the impact of different approaches (to which this papers adds), the literature on public engagement and participation in health has embarked on a somewhat uncritical route. It has been observed that researchers have a tendency to focus on the technical, methodological aspects of practice (6). While this is valuable, we would argue that it sometimes occurs at the expense of a more deep rooted exploration of our practices. Wilsdon et al. (6) argue that researchers often focus on the hardware of participation (the how to, methods, approaches, guidelines etc.) rather than the ‘software’ of values, norms and codes that shape scientific practice. If we are using the terms engagement and participation as proxies for consultation this is less problematic. Difficulties arise where the goal is to develop methods of genuine participation

that can effectively ‘maximise the value of public input to health policy decision-making processes’, share power and valorise all knowledge equally.

Of course, we are not the first to make this observation. For example, Cooke and Kothari’s (7) edited book ‘Participation the new tyranny?’ critiqued the appropriation of participation in ‘development’ and Mosse (8) cautioned against an ‘uncivil’ society. In the public engagement in science literature, there has been considerable debate about the limited value attributed to lay knowledge (9). The challenges of participation are also well documented and there is a wealth experience to be tapped from majority world countries. Our focus in this commentary is on how to embrace formalised participation. Can top-down participation, implemented as part of legislation and wider health system reforms, achieve ‘genuine’ participation?In the past year, we have sought to challenge and exploreDEVELOPING SUSTAINABLE AND REPLICABLE WATER SUPPLY SYSTEMS IN RURAL COMMUNITIES IN BRAZIL Francisco Osny Enéas da Silva(1), Tanya Heikkila (2), Francisco de Assis de Souza Filho (3),

Daniele Costa da Silva (4) .

Various factors may contribute to the difficulty in developing sustainable rural water supply systems. For instance, rural communities are likely

to be less capable of achieving economies of scale in water supply and treatment (State of Ceará, 2009). At the same time, households and

businesses in rural areas may have more limited capacity than wealthier urbanites to raise the capital needed for water infrastructure, or they

may lack the technical expertise needed to operate and maintain water systems. In rural areas that are arid or subject to hydrologic variability,

reliable water supply systems may require more energy intensive infrastructure (e.g. to access and deliver distant surface or groundwater

sources or to allow for multi-season or multi-year storage), which can add to the financial and technical difficulties facing these communities..

Since the 1990s, with increased recognition of the poor performance and periodic failures of water supply development projects around the

world, academics and practitioners have become concerned with understanding the factors that support sustainable rural water supply

systems (e.g. see Serageldin, 1994; Katz & Sara, 1997; Kleemeier, 2000). In general, the endurance of a water supply system, as well as the

system’s ability to adapt to changing consumer needs or preferences for water quality and quantity, are defining features of water system

sustainability (Carter, Tyrell & Howsam, 1999). In this paper, we argue that various interrelated criteria underlie these features of sustainable

water supply systems.

Among the criteria that appear in the literature on sustainable rural water supply systems are social dimensions of project planning and the

communities served by the systems. For example, various scholars recognize that when local communities participate directly in planning their

own water supply systems, these systems are more likely to be sustainable than systems that are imposed by the government or donor

organizations (Katz and Sara, 1998; Carter et al.,1999; Gleitsmann, Kroma & Steenhuis, 2007; Barnes & Ashbolt, 2010). To a large extent this

is because communities engaged in the planning process are more likely to select supply options that they are willing and able to operate and

maintain (Montgomery, Bartram & Elimelech, 2009). This is not to suggest that the process must be entirely community-driven; “polycentric”

approaches that engage the private sector, government actors and communities together can work (Falk, Bock & Kirk, 2009). Successful

community engagement goes beyond mere consultation. At a very basic level, it may even start with the community coming to a

shared understanding of water as a vital resource for a community’s health and growth (Nayar & James, 2010). It can also include dialogue

with the community to explore ideas about infrastructure options, ascertain the community’s preferences for service levels, and clarify the

community’s preferences and responsibilities for financing, operations and maintenance (Katz and Sara, 1998). Since community members

may not quickly or readily agree upon preferred alternatives, successful engagement may also require facilitation and conflict resolution

(Gleitsmann et al., 2007).

Another dimension of the social context that affects sustainable rural water supply systems is the availability of social capital within a rural

community. Social capital can be defined as the set of shared community norms, expectations and patterns of interaction (Ostrom 2000).

Social capital can help a community to develop and deploy their own administrative and financial capital to manage a system. For instance,

research on irrigation systems in rural areas has shown that when infrastructure development does not consider the availability of social

capital in a community, systems are less likely to be sustainable (Lam, 1998; Ostrom, 2000).

Communities may have differing degrees of social capital depending on their prior experience working together on water infrastructure or

other community projects. Social capital is more likely to be present in a community that has established rules and practices for using water or

has organizational bodies capable of making decisions about water management and administration. At the same time, active communication

by local leaders with community members regarding the planning and operations of a water system can help engender the trust that is

essential for social capital building (Montgomery et al., 2009).

In addition to social factors, the technical, administrative, and financial capacities to ensure a system operates effectively over time and at a

reasonable cost are important criteria for sustainable rural water supply systems (Harvey & Reed, 2004). Technical capacity depends on the

availability of equipment for operating the system, people who can be trained to operate equipment, and the quality of construction of the

system (Katz & Sara, 1998). Additionally, sustainable systems are more likely to be found where communities and project operators have

adequate administrative and financial capacity for system operations and maintenance (Montgomery et al., 2009). Technical, administrative

and financial capacities are not independent from the social factors previously discussed. For instance, the presence of social capital, via prior

organizational experience, can make it easier for communities to devise rules for ongoing operations and system administration. At the same

time, community engagement in the planning process can contribute to training and skill building that might be needed for technical capacity.

Still, communities may not always have the technical capacity on their own for extensive system repairs and maintenance (Kleemeier, 2000).

Thus, external technical support needs to be available to help communities maintain and monitor system performance (Gelting & Ortolano,

1998; Lockwood, 2002).

A epidemia de Cólera no Peru como um evento social. As representações das lideranças comunitárias de Villa El Salvador. Lima: 1991. Rio de Janeiro. Fundação Osvaldo Cruz / Escola Nacional de Saúde Pública. Dissertação de Mestrado em Saúde Pública, 1994.

ITURRI, M. Jose

Para começar a responder, tomemos em consideração que a posição do autor sobre participação popular em saúde está, por um lado, próxima

do enfoque que BRONFMAM define como aquele "que privilegia os aspectos políticos e sociais da participação (...) [com dimensões] políticas que

ultrapassam o marco da atenção à saúde, devido a que significa o exercício do poder, e portanto, o fortalecimento da sociedade civil e a

democracia de base" (1994:112). Por outro lado, o autor da tese considera que, como todo aspecto das relações sociais entre grupos e classes,

os processos de intervenção em saúde com participação comunitária são arena de conflito de interesses. Uma arena que não pode ser evitada

pelos grupos populares só pelo fato de apresentar riscos de "cooptação" ou "hegemonia". A hegemonia é "uma praxis e um processo" (CHAUI,

1986:22), não um fato consumado. Esta posição permeou todas as fases da pesquisa.

Precisarei ainda mais "o que estava procurando?". A cólera, indignação, que eu esperava descobrir por meio da análise era uma cólera

"reprimida" que não conseguiria se expressar politicamente, mas existiria e marcaria o discurso; era uma indignação que se explicaria pela

carência de serviços básicos (água, esgoto) e pelas condições de vida; serviços e condições que a epidemia deixava mais em evidência.

A experiência nacional dos últimos anos, o aprofundamento da crise, a fragmentação da sociedade, o papel do terror e da guerra para dissolver

muitos laços sociais me faziam evitar a tese da "polarização social como produto direto da crise" (proposta que "o marxismo vulgar conseguiu

difundir com êxito no Peru e América Latina", e idéia da qual "o Peru dos anos 80 constitui um desmentido" (LOPEZ, 1990:198). Mas, mesmo com

a ressalva de não procurar "polarizações radicais", considerava que ia encontrar um discurso mais reivindicativo. Especificando ainda mais:

esperava que a análise do discurso das lideranças de Villa El Salvador evidenciasse "as reservas da rebeldia e indignação popular".

Mas acontece que o discurso e as representações não são "reservas". Aliás, essa imagem de "reserva" transmite a idéia de um "imobilismo" e

isolamento do discurso das influências da sociedade (assim, persistiria intacto o espírito reivindicativo das décadas de 70 e 80). Essa suposição da

"reserva de rebeldia" contradiz precisamente uma das funções das representações sociais, qual é a de fornecer um meio de se apropriar do

novo. Apropriação na qual o velho se transforma. A imagem da "reserva" também não considera o caráter relacional da construção do sentido

social; como coloca ADRIANZEN "as identidades, assim como as classes e as culturas, à semelhança dos discursos, se desenvolvem sempre em

relação aos outros (...). Neste processo não está permitido o narcisismo" (1990:34; ênfase nossa).

Assim, no seu discurso as lideranças reconhecem e valorizam sua história organizativa, a qual converte-se no principal suporte das suas

resistências à ideologia hegemônica, mas reconhecem as condições reais econômicas, políticas e o "balanço de forças" da sociedade. Nesse

sentido, nossos resultados parecem verificar as colocações de SPINK (1993) sobre a dinâmica do novo e o velho nas representações sociais.

Ao final do ano de 1991 considerava-se em praticamente todos os setores da sociedade peruana que a resposta do Governo frente

à epidemia tinha sido um sucesso, apesar dos danos mencionados e dos seguintes fatos: não ter-se modificado as condições que

determinaram a aparição da doença; a epidemia ter-se transformado numa endemia e o Governo continuar aplicando de maneira

estrita um programa econômico de corte neoliberal que agravou severamente as condições de vida da maior parte da população”

ESTUDIO PILOTO EN EL PROCESO CAUSAL SOCIAL DE LA ENFERMEDAD DIARREICA Y LA DESNUTRICION EN SECTORES POPULARES.CARLOS ALFONSO BARDALEZ DEL AGUILA. TESIS QUE PARA OPTAR EL GRADO DE MAGISTER EN SALUD PUBLICA SOMETE A CONSIDERACION DE LA ESCUELA DE SALUD PUBLICA-DEPARTAMENTO INTERNACIONAL DE CIENCIAS DE LA SALUD PUBLICAALABAMA EN BIRMINGHAM, ESCUELA DE SALUD PUBLICA, ESCUELA DE GRADUADOS.LIMA – PERU 1987.

En resumen, podemos decir que el estado nutricional est  relacionado a variables de car cter estructural de la instancia econ¢mica (condiciones de la vivienda y el saneamiento ambiental), esto est  de acuerdo a las hip¢tesis y al marco conceptual planteados. Lo que no se ha podido determinar son las causas o mecanismos m s directos, a trav‚s de los cuales operan estas variables sociales. Esto demuestra la importancia de la instancia econ¢mica dentro de la determinaci¢n estructural; es lo que Althusser (3) denomin¢ "determinaci¢n en £ltima instancia" por lo econ¢mico. Definitivamente la desnutrici¢n est  causada por la marginaci¢n social, y a su vez, la desnutrici¢n es un mecanismo de marginaci¢n social a largo plazo, ya que limita el desarrollo de las potencialidades f¡sicas, ps¡quicas y sociales de los individuos; adem s interviene en los mecanismos de inserci¢n al aparato productivo al limitar el acceso a determinados empleos. Como dice Behar (9): "Si se reconoce que a toda sociedad le corresponde fundamentalmente garantizar el bienestar de todos sus miembros, incluyendo una nutrici¢n adecuada, la presencia de la malnutrici¢n, cualquiera sea su grado, debe interpretarse como un fracaso de dicha sociedad. Este es el problema que hoy enfrentamos: la estructura misma de la sociedad limita las posibilidades de muchos de sus miembros de satisfacer sus necesidades b sicas, incluida una alimentaci¢n suficiente y apropiada, dado que el poder y la utilizaci¢n de los recursos se concentran en una minor¡a". "Esta situaci¢n tiende a mantener la estructura existente del poder a expensas de las clases necesitadas y, de esta manera, a perpetuar la injusticia social. Considerada desde este punto de vista, la malnutrici¢n no s¢lo es una consecuencia de las graves desigualdades en la sociedad, sino tambi‚n un mecanismo que sirve para mantenerlas".

El trabajo comunitario de salud en Villa El Salvador (Lima/Perú); percepción de las promotoras de salud. CARLOS OTILDO MÁRQUEZ CABEZAS. Tesis de la Universidad Federal de Río de Janeiro para la obtención del grado de Master en Salud Pública.

El abordaje metodológico fue El Método Historia de Vida que busca identificar la percepción de la promotora de salud sobre su trabajo y sus relaciones con la comunidad y las instituciones de salud, en una comunidad peri-urbana denominada Villa El

Salvador, y consiste en solicitar a los sujetos de la investigación que hablen lo que consideren importante en sus vidas al respecto a través de una entrevista abierta. Es un método adecuado para que se oiga el discurso de los desposeídos.

“ La participación social de la promotora se expresa, a través del ejercicio de poder, manifestado primero por estar “arriba”, debido a

la nueva posición social, y por la conquista de las relaciones personales y públicas (relaciones con personas importantes:

profesionales de salud, Alcalde, líderes locales y centrales entre otros) en su comunidad, comienza a capacitarse para realizar sus

funciones, adquiriendo conocimientos e información sobre los servicios de salud de VES (poder técnico). Por tanto, los hechos de

estar “arriba”, de disponer de recursos, de poseer conocimientos e informaciones importantes para su comunidad y de haber

establecido relaciones personales y públicas más visibles en su comunidad determinan que desenvuelva, también ella, la

posibilidad de influenciar y tomar decisiones sobre los programas de salud (poder político). Todo esto también determina que las

promotoras de salud sean reconocidas y consideradas personas importantes, según los espacios conquistados en su comunidad. “

Improving maternal and child healthcare programme using community-participatory interventions in Ebonyi State NigeriaChigozie Jesse Uneke1,*, Chinwendu Daniel Ndukwe2, Abel Abeh Ezeoha3, Henry Chukwuemeka Urochukwu4, Chinonyelum Thecla Ezeonu5

In Nigeria, the government is implementing the Free Maternal and Child Health Care Programme (FMCHCP). The policy is premised on the notion that financial barriers are one of the most important constraints to equitable access

and use of skilled maternal and child healthcare. In Ebonyi State, Southeastern Nigeria the FMCHCP is experiencing implementation challenges including: inadequate human resource for health, inadequate funding, out of stock syndrome, inadequate infrastructure, and poor staff remuneration. Furthermore, there is less emphasis on community involvement in the programme implementation. In this policy brief, we recommend policy options that emphasize the implementation of community-based participatory interventions to strengthen the government’s FMCHCP as follows: Option 1: Training community women on prenatal care, life-saving skills in case of emergency, reproductive health, care of the newborn and family planning. Option 2: Sensitizing the community women towards behavioural change, to understand what quality services that respond to their needs are but also to seek and demand for such. Option 3: Implementation packages that provide technical skills to women of childbearing age as well as mothers’ groups, and traditional birth attendants for better home-based maternal and child healthcare. The effectiveness of this approach has been demonstrated in a number of community-based participatory interventions, building on the idea that if community members take part in decision-making and bring local knowledge, experiences and problems to the fore, they are more likely to own and sustain solutions to improve their communities’ health.

Agente Comunitário de Saúde: elemento nuclear das ações em saúdeSimone de Melo Costa 1 Flávia Ferreira Araújo 2 Laiara Versiani Martins 2 Lívia Lícia Rafael Nobre 3 Fabrícia Magalhães Araújo 1 Carlos Alberto Quintão Rodrigues

O trabalho objetivou identificar as açõesm,desenvolvidas pelo Agente Comunitário de Saúde (ACS) vinculado à Saúde da Família de MontesClaros, MG, Brasil. A pesquisa foi conduzida no âmbito do Programa de Educação pelo Trabalho para a Saúde-PET-Saúde, 2010-2012. Estudoquantitativo e censitário com 241 Agentes. A maioria realiza o cadastro e visita familiar, identifica as famílias de risco e informa à equipe, orientaquanto ao uso dos serviços de saúde, encamina e agenda consultas/exames, realiza educação em saúde e participa de reflexão do trabalho em

equipe. Uma parcela auxilia no ambiente clínico.

Ao associar as atividades com a condição de ter capacitado para a função, somente o encaminhamento para a consulta e a educação em saúde foram associados à qualificação profissional. A maioria dos que realizam a educação em saúde e fazem encaminhamentos se sente preparada para a função. O ACS é o elemento nuclear das ações em saúde, mas as dimensões de atuação exigem investimentos na instumentalização adequada do profissional e na manutenção da qualidade do processo de trabalho executado por ele, em atividades de supervisão e de reflexão em equipe.

Assim,o ACS poderá assumir a corresponsabilidade com a Atenção básica, integrado ao sistema de administração de saúde.

La defensa del derecho de los pueblos indígenas amazónicos a una salud intercultural.

Serie Informes Defensoriales: Informe N° 169

El derecho a la salud de las personas y su adecuada prestación, principalmente a favor de poblaciones más vulnerables como los pueblos indígenas, ha sido,desde el inicio de sus funciones, una de las preocupaciones principales de la Defensoría del Pueblo. Por tal motivo, en diversos documentos defensoriales9 han sido formuladas recomendaciones al Estado y a las instituciones encargadas de su gestión, con la finalidad de garantizar el goce de dicho derecho de modo efectivo y en condiciones de igualdad y calidad.

La Organización Mundial de la Salud (OMS) define la salud como un estado de completo bienestar físico, mental y social, y no solamente la ausencia de enfermedades. Asimismo, en su Constitución, el goce del grado máximo de salud que puede

alcanzarse es reconocido como un derecho fundamental. 10 Así los estados partes declaran la salud como uno de los principios básicos para la felicidad, las relaciones armoniosas y la seguridad de todos los pueblos, más aún, tomando en cuenta que esta permite el ejercicio de otros derechos fundamentales como la educación, el trabajo, entre otros. 11

Dicha definición conlleva una interpretación integral de la salud que tiene correspondencia con las concepciones que los pueblos indígenas tienen de esta, y que incluye aspectos físicos, mentales, emocionales y espirituales; así como las relaciones entre las personas, comunidades, el medio ambiente y la sociedad en general.12

La Constitución Política del Perú reconoce, además, los derechos de las personas a la protección de su salud (artículo 7°) y a su identidad étnica y cultural (artículo 2, inciso 19°).13 Asimismo, establece la obligación del Estado de respetar la identidad cultural de las comunidades campesinas y nativas (artículo 89°). Por su lado, el artículo 25° del Convenio N° 169 de la Organización Internacional de Trabajo (OIT) establece que el Estado tiene la obligación de poner a disposición de los pueblos indígenas servicios de salud adecuados, considerando sus condiciones económicas, geográficas, sociales y culturales, y sus métodos de prevención, prácticas curativas y medicamentos tradicionales. De igual forma, establece que los regímenes de seguridad social deberán extenderse progresivamente alos pueblos interesados sin discriminación alguna, y que los servicios de salud deben organizarse, en la medida de lo posible, a nivel comunitario con cooperación de los pueblos indígenas en cuanto a su planificación y administración. (Artículos 24°, y 25.2 respectivamente)

La participación y la consulta previa a los pueblos indígenas respecto de las medidas administrativas o legislativas que tome el Estado susceptibles de afectarles, constituyen las piedras angulares del Convenio N° 169. Por su lado, la Declaración sobre los Derechos de los Pueblos Indígenas de las Naciones Unidas establece que aquellos tienen derecho a participar activamente en la elaboracióny determinación de los programas de salud, vivienda, y demás programas económicos y sociales que les conciernan (Artículo 23°).El Pacto Internacional de Derechos Económicos, Sociales y Culturales (Pidesc), en su artículo 12°, establece que los Estados parte, con la finalidad de garantizarel disfrute del más alto nivel posible de salud física y mental deben adoptar entre otras medidas: a) La reducción de la mortinatalidad y de la mortalidad infantil, y el sano desarrollo de los niños; b) El mejoramiento en todos sus aspectos de la higiene del trabajo y del medio ambiente; c) La prevención y el tratamiento de las enfermedades epidémicas, endémicas, profesionales y de otra índole, y la lucha contra ellas; y, d) La creación de condiciones que aseguren a todos y todasasistencia y servicios médicos en caso de enfermedad.

En esta misma línea el Comité de Derechos Económicos, Sociales y Culturales de la Organización de las Naciones Unidas, en su Observación General N° 1414 ha establecido que el Estado debe garantizar que el derecho a la salud de los pueblos indígenas sea:

Disponible: previendo un número suficiente de establecimientos, insumos, equipamientos y profesiones de la salud.Accesible: para todos los pueblos indígenas, en términos: geográficos, considerando su condición de lejanía y dispersión poblacional, económicos para que todos y todas estén afiliados a un seguro, y de igualdad para que no sean discriminados por pertenecer a una determinada etnia.Aceptable: en la medida que respete la cultura de cada pueblo indígena a través de programas con pertinencia cultural;

y De calidad: observando que los establecimientos y equipos se encuentren en óptimas condiciones y con personal formado y capacitado para dar un servicio integral con enfoque intercultural. Por tanto, se puede concluir que el adecuado cumplimiento de los elementosdel derecho a la salud permitirá que los ciudadanos y ciudadanas, en especial de las poblaciones más vulnerables, como es el caso de los pueblos indígenas y las minorías étnicas, logren el ejercicio pleno de dicho derecho. Para tal efecto, es necesario que el Estado desarrolle las acciones necesarias que garanticen el estricto cumplimiento de lo dispuesto por el citado Comité en su ObservaciónGeneral N° 14.

Por otro lado, la Primera Conferencia Internacional para la Promoción de la Salud reunida en Ottawa (Canadá), marca un nuevo desafío para la doctrina predominante al establecer que la promoción de la salud debe tomar en cuenta el fomento de la creación de ambientes favorables, el reforzamiento de la acción comunitaria, el desarrollo de aptitudes personales y la reorientación de los serviciossanitarios. Bajo esta nueva concepción de la salud se espera que la población ejerza un mayor control sobre su propia salud, debiendo los Estados proporcionar los medios para que, a lo largo de su vida, la población se prepare para las diferentes etapas de la misma y afronte as enfermedades y lesiones crónicas a través de las escuelas, los hogares, los lugares de trabajo y el ámbito comunitario.15

Asimismo, de acuerdo con la Organización Panamericana de Salud16 el acceso universal a la salud y la cobertura universal de salud implican que todas las personas y las comunidades tengan acceso, sin discriminación alguna, a servicios integrales de salud, adecuados, oportunos, de calidad, determinados a nivel nacional, de acuerdo con las necesidades, así como a medicamentos de calidad, seguros, eficaces y asequibles, a la vez que se asegura que el uso de esos servicios no expone a las usuarias y los usuarios a dificultades financieras, en particular a los grupos en situación de vulnerabilidad. 17

El acceso universal a la salud y la cobertura universal de salud requieren de políticas, planes y programas de salud que sean equitativos y eficientes, y que respeten las necesidades diferenciadas de la población. Al respecto el género, la etnia, la edad y la condición económica y social son determinantes sociales específicos que impactan de forma positiva o

negativa a la inequidad en salud. En el Perú, además del texto constitucional que garantiza la protección del derecho a la salud de todas las personas y establece que el Estado es responsable defacilitar y supervisar el acceso equitativo y libre a los servicios de salud,18 existen otras normas de carácter nacional, como la Ley General de Salud, mediante las cuales el Estado está obligado a implementar diversas acciones a fin de garantizar el referido derecho. En la Ley General de Salud se señala que la responsabilidad del Estado en la provisión de servicios de salud pública es irrenunciable y esun deber intervenir en la provisión de servicios de atención médica con arreglos a principios de equidad.19

Asimismo, se señala que toda persona tiene derecho a recibir en cualquier establecimiento de salud, atención médica quirúrgica de emergencia cuando la necesite y mientras subsista el estado de grave riesgo para su vida o su salud. También menciona que las personas usuarias tienen derecho a exigir que los servicios que se prestan para la atención de salud cumplan con niveles de calidad aceptados en los procedimientos y en las prácticas profesionales.20

Interculturalidad y diálogo intercultural

Todos los grupos humanos son productores de cultura. Esta es un sistema de significados y prácticas, a partir del cual una colectividad interpreta y actúa sobre la realidad.21 Cada cultura tiene una manera o forma particular de hacer, sentir y pensar; de relacionarse (o no) con el resto de la humanidad, con los seres de la naturaleza, con los seres sagrados y con la persona misma

Beyond resistance: A comparative study of utopian renewal in AmazoniaMF Brown - Ethnohistory, 1991 – JSTOR

Abstract:

Recent studies of millenarian movements in tribal societies have tended to interpret them as expressions of resistance to colonial or neocolonial domination. Through a comparison of five case studies of indigenous millenarianism drawn from the history of lowland South America, this essay identifies aspects of utopian renewal that reflect internal political processes and contradictions independent of, and probably predating, native encounters with Europeans. Upon close inspection, the term resistance proves inadequate to the task of illuminating the dialectical processes by which native peoples define themselves in relation to other societies, indigenous and otherwise.

NOS RASTROS DE YAKURUNA: A PARTIDA DE PAWA E A PÓS-SUSTENTABILIDADE ASHANINKALEONARDO LESSIN. Tese para obtenção do título de Doutor em Ciências sociais

UNIVERSIDADE ESTADUAL PAULISTA - UNESPFACULDADE DE FILOSOFIA E CIÊNCIAS, PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS SOCIAIS, CAMPUS DE MARÍLIA

RESUMO

A presente tese é um diálogo com a percepção ameríndia amazônica acerca do desenvolvimento e da sustentabilidade socioambiental. Nossa abordagem tem como referência o aldeamento Ashaninka (Apiwtxa) situado no Brasil, na Terra Indígena Kampa do rio Amônia. Atualmente, este grupo se destaca no cenário ambientalista e indigenista por sua política de implantação de projetos de desenvolvimento sustentável para a Amazônia. Nosso objetivo é analisar o êxito histórico-político da Apiwtxa a partir de sua originalidade perspectiva. Vamos localizar a estruturação ritual da política e da economia desta comunidade no interior particular de seu ambiente sócio-cosmológico tradicional. Propomos o conceito de pós-sustentabilidade com o intuito de identificar omodo pelo qual os Ashaninka produzem sua reciclagem social e econômica. Veremos que, para combater e anular os efeitos do desgaste histórico, o complexo xamânico Ashaninka investe em um constante retorno às origens cosmológicas, agenciandoestratégias de resgate da sustentabilidade mítica primordial que passam pela política de efetuação de alianças e por uma economia culinária produtora de pessoas.

IMPLEMENTATION COMPLETION REPORT (SCL-45360) ON A LOAN IN THE AMOUNT OF US$ 5.0 MILLION TO THEREPUBLIC OF PERU FOR AN INDIGENOUS AND AFRO-PERUVIAN PEOPLES DEVELOPMENT PROJECT

December 8, 2004

Document of The World BankReport No: 30700

Public

The project objective, as defined in the Project Appraisal Report (PAD Project Appraisal Document, Report No: 19867-PE January 5, 2000) was to strengthen indigenous and Afro-Peruvian communities and organizations so that they can design and implement community development sub-projects, better articulate their proposals, and effectively utilize services offered by the State and other sectors within civil society by promoting innovative methods through a "learning by doing" process. The project sought to achieve its objectives through: (a) the strengthening of the organizational, institutional, technical and entrepreneurial capabilities of indigenous and Afro-Peruvian communities and organizations, as well as participating government agencies; (b) the preparation of community development sub-projects based on participatory designs, and organization of technical proposals with the required pre-investment studies; and (c) the implementation of sub-projects with financing from the funding agencies.

The project design and objectives were consistent with the Bank’s strategy developed in the Peru CAS (07/22/97) with an innovative and participatory methodology without precedent at the time of the project outset. The project included five pilot zones in different regions of the country and involved a gender-sensitive methodology to ensure the active participation of indigenous andAfro-Peruvian women's organizations in fostering their own development.

Empowerment through local citizenshipCatherine Dom (Mokoro) on behalf of Irish Aid.

Poor people live their daily lives at the local level where they engage with the state, publicservices, markets and the political system. Their empowerment requires participation andaccountability in local governance and decision making through effective and inclusive local

citizenship. Supporting inclusion requires an understanding of existing power relationships andthe practical obstacles to participation faced by poor people. Public sector decentralisationis an important opportunity for empowerment through increased accountability for publicexpenditure allocations and local delivery of pro-poor policies. Capacity development, for bothcommunities and citizens, must promote leadership and facilitation, communication, advocacyand political skills. Widely available, transparent and substantive information is a critical buteasily achievable first step in capacity development. All development aidmodalities can supportlocal empowerment and donors should co-ordinate to identify and maximise opportunities forempowerment at the local level.

Effective and inclusive citizenship

A citizen is someone with rights, aspirations and responsibilities in relation to other socialand economic actors and to the state. Empowerment through local citizenship of people inpoverty is about changing who has decision-making power and who has a voice at the local level.Effective and inclusive local citizenship means that all people can participate in local decisionmaking processes and hold others to account. In ideal situations, individual citizens shouldbe able to participate. Experience shows that marginalised people gain much from organisingthemselves into groups in order to use their collective bargaining power to greater effect.

Ingredients

ParticipationFor pro-poor growth policies to emerge, poor people need to be informed andempowered to participate in a policy-making process that is accountable to them. Theyneed to have the tools and opportunities to participate in, and influence, the decisions thatare made at local level, and which impact on their daily lives. Promoting the participationof marginalised groups involves changing existing power relations, both the visible and the

invisible ones. Participating in local government budget discussions is not enough if theexisting powers are drafting the budget proposals and setting the agenda for the debate.

AccountabilityParticipation is only effective when the institutions of the state respond. Consultationwithout due recognition of power and politics will lead to voice without influence. Thecritical challenge is for citizens, particularly the excluded and marginalised, to be ableto influence policies and institutions, and for these in turn to become more accountableto them, and act in their best interest. It is not only government institutions that need tobe accountable to the poor. Local politics also involves a multiplicity of local entities(e.g. rural producers’ organisations, market stall owners, wholesale buyers and sellers,semi-state enterprises) operating at the interface between state, market and society in anenvironment characterised by blurred boundaries between the sectors and unclear lines ofresponsibility.

InclusivenessEffective participation and accountability mechanisms require the direct involvement ofpoor and marginalised people. Many factors drive poverty and exclusion. Gender inequality,religion, membership of social or ethnic groups, regions in which they live as well as theirmaterial wellbeing all affect people’s access, status and influence in local politics. Facingexclusion and discrimination, people living in poverty may be too alienated or oppressed toseize new opportunities to act. Women (or men) may not be willing to participate, or workalongside the opposite sex. Designing in inclusiveness in empowerment strategies is crucialand may require different interventions to accommodate all marginalised groups.

Challenges

The local level is sometimes seen as a level at which voice/participation and

accountability are easier to “get right”. Yet there are complex challenges to effective andinclusive local citizenship that donors need to be aware of. For donors, an analysis of thePoverty Reduction and Pro-Poor Growth: The Role of Empowerment – © OECD 2012

Fluid boundaries and informal mechanismsThe boundaries between state, society and market are particularly fluid at the locallevel. For example, in an Ethiopian sub-district 10% of the population sit on the electedlocal council making it perhaps more a community organisation than government. On theother hand the sub-district leader is elected by the community but is directly accountableto the district administrator. In this case it is difficult to say where the boundary betweencommunity and local government lies. Providing support to an entity that appearscommunity-based but is in fact government-controlled, can further entrench patterns ofinformal relationships and loyalties that may be keeping poor people in poverty.

The involvement of local administrations in licensing and regulating agriculturalmarkets (e.g. nominating designated commodity buyers) and the influence of publicexpenditure programmes (e.g. purchases of school furniture or the supply or sale ofagricultural inputs and products) blur the distinction between state and market and can giverise to diverse and contradictory interests and influences.

Power within the community

The power relationships at play in communities are rarely beneficial to people inpoverty. Changing the status quo requires finding ways of avoiding various forms of localelite capture. In many rural contexts, community participation translates in reality intoparticipation of older, land-owning and better-off men; and traditional dispute resolutionmechanisms favour men over women and older people over younger. Local patterns ofpower that may keep people in poverty are particularly difficult to challenge as many are

deeply embedded in the local history and norms – thus strongly internalised and almostinvisible. It takes great sensitivity to tackle these traditional hierarchies in a way thatbecomes acceptable to all members of a community.

Nevertheless, when an acceptable solution is negotiated, it can have a long-lastingpositive effect. Support from customary elites may be crucial in legitimising local propoormobilisation processes, and their support makes the new status quo sustainable(e.g. the Ngorongoro pastoralist land movement was strongly backed by customary mutualrestocking committees).

Even in a very small community “the poor” are not a homogeneous group. They confrontmultiple and varied drivers and manifestations of deprivation and exclusion. There is a needto recognise the diversity of their concerns and interests and of their highly individualisedstrategies of alliance and resistance. This, in turn, requires striking a balance, at timespromoting approaches in which different groups of people in poverty develop alliances to actcollectively in larger numbers; at other times highlighting the necessity of different actionsfor different groups.

The representation of marginalised groups at local level

How poor people are represented within the community, at the local governmentlevel and at higher levels is critical to the extent that they can actively participate in localdecision-making processes. Special measures such as quotas on local elected bodies or incommunity groups can lead to greater representation of marginalised groups. Before sucha measure is suggested, issues of correct targeting and the acceptability of the person(s) forwhom a quota is created need to be considered. The reservation of seats for Dalits in India(in effect for decades) or the many cases of quotas for political representation of womenin local political bodies are examples of successful targeting. Better developed and more

inclusive political parties, denser civil society, higher literacy and education levels, reformsof the electoral system, and support to broad-based cross-party caucuses have all beenproven to have a positive effect on a quota system for the representation of the marginalised(UNIFEM , 2008).

Targeted approaches, focusing organisation and mobilisation efforts on groups thathave a shared profile and strong common interests, can be very effective and may benecessary to foster empowerment of certain vulnerable groups. The Self-Employed WomenAssociation (SEWA ) in India managed to obtain far-reaching empowering policy changesby targeting the poor women working in the informal sector and helping them to form theirown organisations (Box 3.3).

Decentralisation doesn’t always increase accountability

In decentralised countries, the nature of the relationship between central and localauthorities is critical. Successful decentralisation requires a strong but enabling centre,genuinely committed to devolving both decision making powers and commensurateresources. Donors can contribute by supporting the institution of a clear decentralisationframework, which grants sufficient autonomy to local authorities; provides resources thatmatch their mandates; instils effective upward and downward accountability, as well asensuring technical support from central and regional government levels.

The political nature of the link between the central government and local governmentalso matters enormously. Where local and national elites collude, decentralisation is unlikelyto be pro-poor and empowering. Donors can play a role in supporting the empowermentof poor citizens to fight nepotism, and to claim their right to participate in decentralisedlocal decision making. Under the right circumstances, for example where electoral reformand democratisation is making progress, a situation can be created in which more political

capital is to be gained from acting to the benefit of poor people than from colluding orembezzling – a positive politicisation of poverty reduction.

Bridging the gap: citizenship, participation and accountability.Andrea Cornwall and John Gaventa

Andrea Cornwall, Fellow, Institute of Development Studies (IDS), University of Sussex, Brighton BN19RE, UK. E-mail: a.cornwall@ids.ac.uk

John Gaventa, Fellow, Institute of Development Studies (IDS), University of Sussex, Brighton BN19RE, UK. E-mail: j.p.gaventa@ids.ac.uk

Introduction

Around the world, a growing crisis of legitimacy characterises the relationship between citizens and theinstitutions that affect their lives. In both North and South, citizens speak of mounting disillusionment withgovernment, based on concerns about corruption, lack of responsiveness to the needs of the poor and the absence of a sense of connection with elected representatives and bureaucrats (Commonwealth Foundation 1999).

As traditional forms of political representation are being re-examined, direct democratic mechanisms areincreasingly being drawn upon to enable citizens to play a more active part in decisions which affect their lives. In this context, the questions of how citizens – especially the poor – express voice and how institutional responsiveness and accountability can be ensured have become paramount. 

In this article, we explore some of these challenges. Repositioning participation to embrace concerns with

inclusive citizenship and rights, we examine a range of contemporary participatory mechanisms and strategiesthat seek to bridge the gap between citizens and the state.

New contexts, new challenges

In many countries, measures to bring government ‘closer to the people’ through decentralisation and devolution have prompted shifts in approaches to service delivery that have widened spaces for citizen involvement. At the same time, the increasing marketisation of service delivery in many countries has introduced new roles for those who were formerly the ‘beneficiaries’ of government services.

Users have come to be seen as ‘consumers’ or ‘clients’ and civil society organisations have become significant coproducers of what in the past were largely state functions. To some, these new roles are seen as welcome forms of partnership between the state, the market and civil society, while to others they suggest the danger that the state is off-loading its larger social responsibilities to private or non-governmental actors (Cornwall and Gaventa, 2000).

Bridging the gap

In the past, there has been a tendency to respond to the gap that exists between citizens and state institutions in one of two ways. On the one hand, attention has been made to strengthening the processes of participation – that is the ways in which poor people exercise voice through new forms of inclusion, consultation and/ormobilisation designed to inform and to influence larger institutions and policies. On the other hand, growingattention has been paid to how to strengthen the accountability and responsiveness of these institutions andpolicies through changes in institutional design and a focus on the enabling structures for good governance.

Each perspective has often perceived the other as inadequate, with one warning that consultation withoutattention to power and politics will lead to ‘voice without influence’ and the other arguing that reform of political institutions without attention to inclusion and consultation will only reinforce the status quo. Increasingly, however, we are beginning to see the importance of working on both sides of the equation. As

concerns about good governance and state responsiveness grow, questions about the capacity ofcitizens to engage and make demands on the state come to the fore. 

In both South and North, there is growing consensus that the way forward is found in a focus onboth a more active and engaged civil society which can express demands of the citizenry and a more responsive and effective state which can secure the delivery of needed public services. At the heart of the new consensus of strong state and strong civil society are the need to develop both participatory democracy and responsive government as ‘mutually reinforcing and supportive’ (The Commonwealth Foundation, 1999:76, 82).

Re-positioning participation 

Both social participation and political participation have carried with them a distinctive set of methods orapproaches for strengthening or enhancing participation.Traditionally, in the field of political participation, such methods have included voter education, enhancing the awareness of rights and responsibilities of citizens, lobbying and advocacy, often aimed towards developing more informed citizenry who could hold elected representatives more accountable. 

In the social and community spheres, we have seen the development of a number of broader participatory methods for appraisal, planning, monitoring large institutions, training and awareness building. The emphasis here has been on the importance of participation not only to hold others accountable, but also as a self-development process, starting with the articulation of grassroots needs and priorities and moving towards the establishment of selfsustaining local organisations.

Engagement in social and community participation has inevitably brought citizens in closer contact with theinstitutions and processes of governance. Conversely, leaders of projects, programmes and policy researchinitiatives have increasingly sought the voices and versions of poor people themselves.

Where citizens have been able to take up and use the spaces that participatory processes can open up, they have been able to use their agency to demand accountability, transparency and responsiveness from government institutions. An informed, mobilised citizenry is clearly in a better position to do so effectively; the capacities built through popular education on rights and responsibilities also extend beyond taking a more active interest in the ballot box. 

Equally importantly, however, where government agencies have taken an active interest in seeking responsiveness and have not only listened to but acted on citizens’ concerns, otherwise adversarial anddistant relationships have been transformed. Clearly, this also holds the promise of electoral advantage. 

These moves offer new spaces in which the concept of participation can be expanded to one of ‘citizenshipparticipation’, linking participation in the political, community and social spheres (see Figure 1).

New thinking about participation as a right 

The concept of ‘citizenship’ has long been a disputed and value-laden one in democratic theory. New approaches to social citizenship seek to move beyond seeing the state as bestowing rights and demanding responsibilities of its subjects. In doing so, they aim to bridge the gap between citizen and the state by recasting citizenship as practised rather than as given. Placing an emphasis on inclusive participation as the very foundation of democratic practice, these approaches suggest a more active notion of citizenship. 

This recognises the agency of citizens as ‘makers and shapers’ rather than as ‘users and choosers’of interventions or services designed by others (Cornwall and Gaventa 2000). As Lister suggests, ‘the right of participation in decision-making in social, economic, cultural and political life should be included in the nexus of basic human rights… Citizenship as participation can be seen as representing an expression of human agency in the political arena, broadly defined; citizenship as rights enables people to act as agents’ (Lister 1998), (1998:228).

Building on this new thinking about participation, inclusive citizenship, rights and responsibilities, DFID’s recent strategy paper Human Rights for Poor People offers important new directions for participation in development. 

Using the more insistent language of ‘obligation’ rather than the softer term ‘responsiveness’, it enjoinsgovernments to honour commitments to citizens. Casting participation as a human right in itself, it situates the right to participate as basic to the realisation of other human rights: ‘Participation in decision-making is central to enabling people to claim their rights. Effective participation requires that the voices and interests of thepoor are taken into account when decisions are made and that poor people are empowered to hold policy makers accountable’ (DFID 2000).

At the same time, there is a growing recognition that universal conceptions of citizenship rights, met through auniform set of social policies, fail to recognise diversity and difference and may in fact serve to strengthen theexclusion of some while seeking inclusion of others (Ellison 1997). With this has come a renewed emphasis on inclusion and on issues of social justice. In all three spheres of political, social and community participation, greater emphasis is now being placed on the involvement of those with least power and voice, with particular attention being paid to measures to address entrenched gender bias.

New spaces and places for citizenship participation

Such new thinking about citizenship, participation and rights raises the question of how to create newmechanisms, or spaces and places for citizen engagement. It also requires that greater attention is paid to theinterface between citizens and the state, to the intermediaries who play an increasing role in bridging thegap and at processes that can enhance responsibility as well as responsiveness on all sides.

One area of innovation has been to extend the traditional places for citizen engagement from the episodic use of the ballot box. Conventional spaces such as public meetings and committees can be transformed when lentnew powers and responsibilities, as user groups and citizen councils become actively involved in deliberation.Innovative processes taking place in public spaces where the majority of citizens spend their everyday lives involve more than a self-selecting few, opening up spaces for broader engagement. The use of PRA for poverty or wellbeing assessments, for example, offers ways of taking the consultation process to citizens in their own spaces. 

Legislative theatre performances draw together policy makers, service commissioners, providers and managers with community members to engage with the lived realities of everyday life and explore solutions to real-life dilemmas.

Another emerging space for the exercise of citizenship has come with the opening up, and indeed the levering open through citizen action, of formerly closed-off decisionmaking processes. On the one hand, in a number of countries enabling national policy has created a new imperative to consult and involve. In Bolivia and Brazil, for example, participatory municipal planning and budgeting, respectively, have national or state backing. In the UK, central government support for public involvement has led  to a wave of innovation in consultation over a number of high-profile government schemes. 

The adoption of participatory mechanisms for project and programme planning has extended beyond the bounds of discrete initiatives, in some contexts, to on-going processes of citizen involvement in monitoring and evaluation through initiatives, in some contexts, to on-going processes of citizen involvement in monitoring and evaluation through which citizens play a part not only in offering opinions butalso in holding agencies to account 

On the other hand, the increasing use of participatory and deliberative processes have contested and begun to reconfigure the boundaries between ‘expertise’ and ‘experience’ (Gaventa 1993). As citizens are increasingly considered to have opinions that matter and experience that counts, government agencies have involved them more in the kinds of decisions that were once presented as technical, rather than acknowledged as value-laden and political. Nowhere is this more the case than in the opening up of public expenditure budgeting to citizen engagement, as has been the case in several municipalities in Brazil. 

At the local level, a growing emphasis on the co-production and co-management of services has also served to create new spaces for citizen involvement, as the ‘owners’, and to some extent the ‘makers and shapers’, rather than simply ‘users and choosers’ of services.

In other contexts, pressure placed on governments by civil society organisations has forced open spaces through demands for responsiveness and accountability. Perhaps the most notable example of this is the work of MKSS in India, whose public hearings on recorded public expenditure have named and shamed officials and exposed graft to audiences of thousands of citizens(Goetz 1999). 

Numerous other examples exist where NGOs have sought to intermediate between governmentand citizens through the use of participatory mechanisms for enhanced service responsiveness and accountability; for example in the growing move for citizen involvement in local health service management.In areas characterised by uncertainty, the use of mechanisms such as citizens’ juries offers an importantnew dimension: moving beyond eliciting opinions from citizens towards a process in which views are aired and defended, in which contrasting knowledge and versions are weighed up and interrogated, before ‘judgements’ are sought. 

These processes offer a valuable corrective to the tendency found in some participatory processes of simplygathering people’s views, rather than providing opportunities for exploration, analysis and debate.At the same time, citizen involvement in processes where the emphasis has been on mutual learning and newcourses of action has helped mould new forms of consensus, bridging differences of interest and perspectivewithin communities as well as between community members and statutory or non-statutory agencies. This, inturn, has helped create better mutual understanding and with it, the prospects for enhancing relationships thatwere previously characterised by mistrust, suspicion and distance.

Making participation real

Forms of participation run across a spectrum, from tokenism and manipulation to devolved power and citizencontrol. As the uses of invited participation to rubber stamp and provide legitimacy for preconceived

interventions grows, citizens are becoming increasingly sceptical. A recent report by the Commission on Poverty, Participation and Power in the UK for instance warns of ‘phoney’ participation, in which power relations do not shift, and in which rhetoric is not reflected in reality.

In this context, making participation real raises a set of complex challenges. A key challenge is buildingconfidence in the willingness of agencies to hear rather than simply to listen, nod and do what they were going to do in the first place. Where the use of participatory methods for consultation has often been most effective is where institutional willingness to respond is championed by high-level advocates within organisations. Where such ‘champions’ exist and where they can create sufficient momentum within organisations, the processes of invited participation that they help instigate can make a real difference.

New public management strategies emphasise incentives for change from within. One important incentive is to be ‘championed’ as a model for others to follow, as an example of good practice. Equally, recognising and rewarding changes in practice can have significant ripple effects. By creating spaces within bureaucracies in which responsiveness is valued, wider changes become possible.

Yet, as we suggest earlier, such changes are only one part of the story. The best-laid plans for public involvement can falter where citizens express disinterest and where cynical public officials simply go through the motions with no real commitment to change. Citizen monitoring and other forms of citizen action can help force some measure of accountability. To do so effectively, however, requires a level of organisation and persistence that is often beyond many communities who are involved in consultation exercises. Building the preconditions for voice and enabling citizens to actively take up and make use of available spaces for engagement calls for new combinations of older approaches to social, community and political participation.

It is in this that some of the most exciting challenges for a new generation of participatory processes reside: in ways of building more deliberation into consultative processes; in participatory rights assessments that enable people to recognise and articulate their rights; and in moves that turn the tables on processes to gather ‘voices’ to enable poor

people to engage in analysing the policies and institutions that affect their lives, as a starting point for changes that will make a difference.

Citizenship and empowerment: a remedy for citizen participation in health reform

1. Joan Wharf Higgins

+ Author Affiliations

1. Joan Wharf Higgins is an Assistant Professor in the School of Physical Education at the University of Victoria in British Columbia Canada

1. Address for Correspondence: School of Physical Education, PO Box 3015, Victoria BC, Canada V8W 3PI.

AbstractThe article begins by identifying the shared features of participation, empowerment and citizenship by reviewing the literature and grounding the discussion in the case study in health reform in one region of British Columbia. The ethnographic case study followed four health planning groups' efforts to foster community participation in developing local community health plans over an 11 month period. Data were also collected through interviews with participants, and focus groups with non-participants. As the article chronicles, despite the best intentions of the health planning groups, their work more closely resembled a social planning orientation than a community development one. The findings suggest that the concepts of citizenship and empowerment are useful in explaining why some individuals engaged in the work of the health planning groups and others did not. The sense of full citizenship—enjoying the formal status and substantive effects of civil, political and social rights as an equal member of the community—distinguished participants from non-participants. The article concludes with a discussion of the findings from the case study in terms of informing the theory and practice of community development.