PARTICIPACION CIUDADANA Y REFORMA DE LA SALUD II

Revision sistematica

PARTICIPACION CIUDADANA Y REFORMA DE LA SALUD II

Protocolo de Tesis de Maestria en Salud Publica.

Facultad de Salud Publica, Universidad Peruana Cayetano Heredia.

Improving maternal and child healthcare programme using community-participatory interventions in Ebonyi State Nigeria

Chigozie 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 saúde

Simone 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 Montes

Claros, MG, Brasil. A pesquisa foi conduzida no âmbito do Programa de Educação pelo Trabalho para a Saúde-PET-Saúde, 2010-2012. Estudo

quantitativo e censitário com 241 Agentes. A maioria realiza o cadastro e visita familiar, identifica as famílias de risco e informa à equipe, orienta

quanto 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 a

los 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 elaboración

y 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 todas

asistencia 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 elementos

del 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 Observación

General 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 servicios

sanitarios. 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 de

facilitar 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 es

un 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 Amazonia

MF 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 ASHANINKA

LEONARDO LESSIN. Tese para obtenção do título de Doutor em Ciências sociais

UNIVERSIDADE ESTADUAL PAULISTA - UNESP

FACULDADE 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 o

modo 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, agenciando

estratégias 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 THE

REPUBLIC OF PERU FOR AN INDIGENOUS AND AFRO-PERUVIAN PEOPLES DEVELOPMENT PROJECT

December 8, 2004

Document of The World Bank

Report 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 and

Afro-Peruvian women's organizations in fostering their own development.

Empowerment through local citizenship

Catherine Dom (Mokoro) on behalf of Irish Aid.

Poor people live their daily lives at the local level where they engage with the state, public

services, markets and the political system. Their empowerment requires participation and

accountability in local governance and decision making through effective and inclusive local

citizenship. Supporting inclusion requires an understanding of existing power relationships and

the practical obstacles to participation faced by poor people. Public sector decentralisation

is an important opportunity for empowerment through increased accountability for public

expenditure allocations and local delivery of pro-poor policies. Capacity development, for both

communities and citizens, must promote leadership and facilitation, communication, advocacy

and political skills. Widely available, transparent and substantive information is a critical but

easily achievable first step in capacity development. All development aidmodalities can support

local empowerment and donors should co-ordinate to identify and maximise opportunities for

empowerment at the local level.

Effective and inclusive citizenship

A citizen is someone with rights, aspirations and responsibilities in relation to other social

and economic actors and to the state. Empowerment through local citizenship of people in

poverty 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 decision

making processes and hold others to account. In ideal situations, individual citizens should

be able to participate. Experience shows that marginalised people gain much from organising

themselves into groups in order to use their collective bargaining power to greater effect.

Ingredients

Participation

For pro-poor growth policies to emerge, poor people need to be informed and

empowered to participate in a policy-making process that is accountable to them. They

need to have the tools and opportunities to participate in, and influence, the decisions that

are made at local level, and which impact on their daily lives. Promoting the participation

of marginalised groups involves changing existing power relations, both the visible and the

invisible ones. Participating in local government budget discussions is not enough if the

existing powers are drafting the budget proposals and setting the agenda for the debate.

Accountability

Participation is only effective when the institutions of the state respond. Consultation

without due recognition of power and politics will lead to voice without influence. The

critical challenge is for citizens, particularly the excluded and marginalised, to be able

to influence policies and institutions, and for these in turn to become more accountable

to them, and act in their best interest. It is not only government institutions that need to

be 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 an

environment characterised by blurred boundaries between the sectors and unclear lines of

responsibility.

Inclusiveness

Effective participation and accountability mechanisms require the direct involvement of

poor 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 their

material wellbeing all affect people’s access, status and influence in local politics. Facing

exclusion and discrimination, people living in poverty may be too alienated or oppressed to

seize new opportunities to act. Women (or men) may not be willing to participate, or work

alongside the opposite sex. Designing in inclusiveness in empowerment strategies is crucial

and 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 and

inclusive local citizenship that donors need to be aware of. For donors, an analysis of the

Poverty Reduction and Pro-Poor Growth: The Role of Empowerment – © OECD 2012

Fluid boundaries and informal mechanisms

The boundaries between state, society and market are particularly fluid at the local

level. For example, in an Ethiopian sub-district 10% of the population sit on the elected

local council making it perhaps more a community organisation than government. On the

other hand the sub-district leader is elected by the community but is directly accountable

to the district administrator. In this case it is difficult to say where the boundary between

community and local government lies. Providing support to an entity that appears

community-based but is in fact government-controlled, can further entrench patterns of

informal relationships and loyalties that may be keeping poor people in poverty.

The involvement of local administrations in licensing and regulating agricultural

markets (e.g. nominating designated commodity buyers) and the influence of public

expenditure programmes (e.g. purchases of school furniture or the supply or sale of

agricultural inputs and products) blur the distinction between state and market and can give

rise to diverse and contradictory interests and influences.

Power within the community

The power relationships at play in communities are rarely beneficial to people in

poverty. Changing the status quo requires finding ways of avoiding various forms of local

elite capture. In many rural contexts, community participation translates in reality into

participation of older, land-owning and better-off men; and traditional dispute resolution

mechanisms favour men over women and older people over younger. Local patterns of

power 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 almost

invisible. It takes great sensitivity to tackle these traditional hierarchies in a way that

becomes acceptable to all members of a community.

Nevertheless, when an acceptable solution is negotiated, it can have a long-lasting

positive effect. Support from customary elites may be crucial in legitimising local propoor

mobilisation processes, and their support makes the new status quo sustainable

(e.g. the Ngorongoro pastoralist land movement was strongly backed by customary mutual

restocking committees).

Even in a very small community “the poor” are not a homogeneous group. They confront

multiple and varied drivers and manifestations of deprivation and exclusion. There is a need

to recognise the diversity of their concerns and interests and of their highly individualised

strategies of alliance and resistance. This, in turn, requires striking a balance, at times

promoting approaches in which different groups of people in poverty develop alliances to act

collectively in larger numbers; at other times highlighting the necessity of different actions

for different groups.

The representation of marginalised groups at local level

How poor people are represented within the community, at the local government

level and at higher levels is critical to the extent that they can actively participate in local

decision-making processes. Special measures such as quotas on local elected bodies or in

community groups can lead to greater representation of marginalised groups. Before such

a measure is suggested, issues of correct targeting and the acceptability of the person(s) for

whom 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 women

in local political bodies are examples of successful targeting. Better developed and more

inclusive political parties, denser civil society, higher literacy and education levels, reforms

of the electoral system, and support to broad-based cross-party caucuses have all been

proven 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 that

have a shared profile and strong common interests, can be very effective and may be

necessary to foster empowerment of certain vulnerable groups. The Self-Employed Women

Association (SEWA ) in India managed to obtain far-reaching empowering policy changes

by targeting the poor women working in the informal sector and helping them to form their

own organisations (Box 3.3).

Decentralisation doesn’t always increase accountability

In decentralised countries, the nature of the relationship between central and local

authorities is critical. Successful decentralisation requires a strong but enabling centre,

genuinely committed to devolving both decision making powers and commensurate

resources. Donors can contribute by supporting the institution of a clear decentralisation

framework, which grants sufficient autonomy to local authorities; provides resources that

match their mandates; instils effective upward and downward accountability, as well as

ensuring technical support from central and regional government levels.

The political nature of the link between the central government and local government

also matters enormously. Where local and national elites collude, decentralisation is unlikely

to be pro-poor and empowering. Donors can play a role in supporting the empowerment

of poor citizens to fight nepotism, and to claim their right to participate in decentralised

local decision making. Under the right circumstances, for example where electoral reform

and 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 or

embezzling – 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 BN1

9RE, UK. E-mail: a.cornwall@ids.ac.uk

John Gaventa, Fellow, Institute of Development Studies (IDS), University of Sussex, Brighton BN1

9RE, UK. E-mail: j.p.gaventa@ids.ac.uk

Introduction

Around the world, a growing crisis of legitimacy characterises the relationship between citizens and the

institutions that affect their lives. In both North and South, citizens speak of mounting disillusionment with

government, 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 are

increasingly 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 strategies

that 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/or

mobilisation designed to inform and to influence larger institutions and policies. On the other hand, growing

attention has been paid to how to strengthen the accountability and responsiveness of these institutions and

policies 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 without

attention 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 of

citizens 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 on

both 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 or

approaches 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 the

institutions and processes of governance. Conversely, leaders of projects, programmes and policy research

initiatives 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 and

distant 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 ‘citizenship

participation’, 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 enjoins

governments 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 the

poor 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 a

uniform set of social policies, fail to recognise diversity and difference and may in fact serve to strengthen the

exclusion 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 new

mechanisms, or spaces and places for citizen engagement. It also requires that greater attention is paid to the

interface between citizens and the state, to the intermediaries who play an increasing role in bridging the

gap 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 lent

new 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 but

also 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 government

and 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 important

new 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 simply

gathering 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 new

courses of action has helped mould new forms of consensus, bridging differences of interest and perspective

within communities as well as between community members and statutory or non-statutory agencies. This, in

turn, has helped create better mutual understanding and with it, the prospects for enhancing relationships that

were 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 citizen

control. 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 building

confidence 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.

Abstract

The 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.