TECHNICAL
NOTES
Webinar series
Innovative models of
Primary Health Care in
Colombia
4
Fourth webinar
Innovative Experiences in Primary
Health Care in Colombia based on
community participation
Tuesday, July 26, 2022
Document written by Reviewed by
Janet Bonilla Torres Luis Gabriel Bernal Pulido
Oscar Alberto Bernal Acevedo
Manuela Villar Uribe
Fourth webinar
Innovative Experiences in Primary Health Care
in Colombia based on community participation
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Content*
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Key messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Context interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Community participation in strengthening
of the PHC in the department of Cauca . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Intersectorality, multidisciplinary health teams,
and a greater focus on prevention in Cauca . . . . . . . . . . . . . . . . . . . . . . . . . 14
Central interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Experience of community participation in health in Guatemala . . . . . . . . . . . . 16
Interculturality Program of Maternal Care of the-ESE
CXAYU’CE JXUT -Hospitals of Toribío and Jambaló in Cauca . . . . . . . . . . . . . . 23
Community participation at EPSI Anas Wayúu in La Guajira . . . . . . . . . . . . . . . 31
Citizenry participation: from theory to practice.
The experience of the Fundación Rasa – Antioquia . . . . . . . . . . . . . . . . . . . . 36
Panel
Innovative PHC Experiences in Colombia based
on community participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
* This document was translated by Ethical Method Language Solutions
Introduction
The Primary Health Care Performance Initiative -PHCPI, has been working
for several years with different countries around the world in measuring the
performance of Primary Health Care -PHC. In the case of Colombia, PHCPI has
been working with the Ministerio de Salud y Protección Social (Ministry of Health
and Social Protection) on the profile of vital signs of the country in PHC.
In this context, PHCPI is also advancing in the generation of a national
“Comunidad de Práctica”(Community of Practice) that allows knowing and
documenting learning about the innovative models of Primary Health Care
developed in Colombia.
The Innovative Models of Primary Health Care in Colombia webinar series
promotes the discussion around this topic. This document reviews the fourth
webinar in the series, called Innovative Experiences in Primary Health Care in
Colombia based on community participation, held on July 26, 2022.
A special thanks to the speakers of this webinar, who with their experience
and knowledge contributed in a valuable way to this dialogue which we hope will
enrich the reflection and implementation of Primary Health Care in Colombia.
Similarly, thanks to the team of leaders and organizers of the webinars and the
community of practice: Luis Gabriel Bernal, Oscar Bernal, Janet Bonilla, Yulieth
Rodríguez, and Juan Carlos Jiménez.
Manuela Villar Uribe
World Bank Health Specialist
Key messages
Innovative experiences
in Primary Health Care
in Colombia based on
community participation
“With political empowerment, the indigenous communities of Guatemala have
managed to improve the quality of health services and generate relationships of
trust. The experience has allowed support for the construction of active citizenry
in health care and funds have been obtained for human resources of health,
medicines and ambulances”. Lorena Ruano
“We realized that the indigenous population has felt that the State has never
been there for them or has betrayed them many times, likewise, organized civil
society comes and asks for things and then leaves. We started to develop a
platform to report cases of abuse and discrimination based on text messages.
We saw that the process of political empowerment began at the individual level,
trying to increase knowledge of situations of exclusion. Then we moved on to
the construction of collective consciousness to later arrive at the surveillance
of public services with the goal of reaching the political power of the citizenry”.
Lorena Ruano
“In Cauca, the various currents of local thought determine how to care
for health, how to face the challenges posed by the disease, and also how to
manage health care. The care models are adjusted from a community and local
logic. Social and community participation is a permanent force”. Jorge Sotelo
“Social and community participation in PHC, led jointly with the Ministerio de
Salud and health actors, is proposed in the document of the Provision of Health
Services Comprehensive Network, which will be the navigation map to strengthen
the infrastructure of the first levels of care”. Andrés Narváez
“In Cauca, the Sistema Indígena de Salud, Propio e Intercultural (Own
Indigenous and Intercultural Health System) was created. In Cauca there is talk
of respected childbirth. There is a syncretism of care processes in which the
different voices of the territory speak, agree, define forms of communication,
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from the indigenous, the Afro, the mestizo, the peasant, ways to adjust the
processes of health care and health management public”. Jorge Sotelo
“The Interculturalidad en el Cuidado Materno (Interculturality in Maternal
Care) program of the ESE CXAYU’CE JXUT in Toribío and Jambaló in Cauca
reduced maternal mortality in the community to zero and has remained so to
this day”. Beatriz Bohórquez Salinas
“In La Guajira, participation is aimed at developing a management and
administration model centered on the individual and their community. Ruling
T 302 of 2017 of the Constitutional Court establishes that La Guajira is an
unconstitutional state of affairs because there is no guarantee of the right
to health, water, or food security. Part of the challenges is to strengthen the
intersectorality to make an effective intervention of the social determinants”.
Beda Margarita Suárez
“We have our Sistema Indígena de Salud, Propio e Intercultural Intercultural
(Own Indigenous and Intercultural Health System - SISPI). Community
participation is at the center of the system and is guaranteed from the General
Assembly, our highest instance, made up of traditional authorities from the
“Asociación de Cabildos” and the “Asociación Sumuwuja””. Beda Margarita
Suárez
“In order to guarantee access and continuity of care, we have bilingual
shelters, with sentinel teams that are vehicles adjusted to our territory that can
reach both the desert and areas with other vegetation, which carry bilingual
workers and auxiliary nurses, responsible for monitoring cases of public
health pathologies, as well as the transfer of pregnant women so that they
can complete their process in safe conditions at the institutional level”. Beda
Margarita Suárez
“We have a micro-cultural team, responsible for outlining the differential
elements incorporated into our care model, and for determining psychological
and psychosocial factors of our affiliates through a strategic tele-assistance
ally. We have, he says, an induced demand team, with a group of bilingual
educational agents, with mobile units that allow access and continuity of
services within the communities, due to the dispersion of the territory”. Beda
Margarita Suárez
“It is required to go from the concept of Primary Health Care to something
more holistic, more complementary that could be “Acciones Poblacionales
hacia la Salud” (Population Actions towards Health). Towards health in terms of
well-being. To detach the concept of PHC from health interventions”. Gustavo
Campillo
“A first step is to defend the rights so that people do not get sick.
Guaranteeing the protection of the rights of people who are already affected
and that we could have avoided is not an achievement, it is perhaps a failure”.
Gustavo Campillo.
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In the indigenous communities of Cauca and La Guajira in Colombia, the Departmental
and Municipal Development Plans are harmonized with life plans and health worldviews
“We have changed the chip. Before, it the vision of not letting a midwife into the
was western medicine first and then the delivery room, not involving companions,
community. The population had to be adopted not allowing the use of alternative non-
into our health services. Now it is different. pharmacological strategies for pain
management. However, awareness was woven
In our territory, Toribío and Jambaló, we have
little by little, in order to open the mind on both
the Path of self and intercultural health within
sides.
the framework of the Own Indigenous and
Intercultural Health System SISPI, from the life In the Conversations with pregnant women,
plan of the Nasa Project. women of childbearing age, mothers and
midwives, we talked about what a home birth
On this path are the family, the community and
is like, what baths with medicinal plants are
the ancestral experts who are very important
like, in what position women prefer to give
to us. There are health animators who support
birth to feel more comfortable and live that
PHC in the context of the family. Community
experience in a freer, calmer, more respectful
health workers continue. Then, the SISPI team
way. Childbirth ceased to be a traumatic
that is in the community health centers.
experience, to become a beautiful and safe
You have to unlearn a little and keep learning experience.
day by day. For example, the medical staff had
Beatriz Bohórquez Salinas
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Presentation
Innovative Experiences
in Primary Health Care
in Colombia based on
community participation
Departmental and Municipal Development
Plans harmonized with the life plans and
health worldviews of the indigenous
communities of Cauca and La Guajira
The indigenous communities of Colombia and Guatemala were protagonists
of the webinar “Experiencias innovadoras de Atención Primaria en Salud en
Colombia basadas en participación comunitaria” (“Innovative experiences
of Primary Health Care in Colombia based on community participation”).
Beatriz Bohórquez, Manager of the ESE CXAYU’CE JXUT in the department
of Cauca, presented the experience of interculturality in maternal care in
Toribío and Jambaló, and showed how maternal mortality has been reduced
to zero in that region. Beda Suárez, Manager of the health insurer Anas Wayúu
Indigenous EPS (health promotion company), in the department of La Guajira,
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explained the characteristics of community participation in this EPS, the role of
indigenous authorities and assemblies and councils in decision-making. The
Secretary of Health at the Cauca department (Departmental Health Authority of
Cauca), Andrés Narváez, and Jorge Sotelo, public health adviser for the entity,
presented the reorganization of services and intersectoral health actions in
the area. In Toribío and Jambaló, two indigenous communities of the country,
the Departmental and Municipal Development Plans are harmonized with the
life plans and health worldviews of the indigenous communities. International
researcher, Lorena Ruano from the University of Bergen, reviewed the experience
of defenders of the right to health in Guatemala. Gustavo Campillo, president of
the Rasa Foundation from the department of Antioquia, proposes going from
the concept of Primary Health Care to a more holistic one such as Population
Actions towards Health aimed at the well-being in the territories. To detach the
concept of PHC from health interventions.
To finish, the panel mentioned the need to defend and advocate from
Primary Health Care, for the rights of those who are healthy so that they can be
preserved that way.
Further information Watch video in spanish
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Context interventions
Community participation in
strengthening of the PHC in
the department of Cauca
Jorge Sotelo Daza
Consultant in public health management processes, models and health systems
Secretaría de Salud (Health Secretary) of the department of Cauca
PhD candidate in Anthropology, health line, Universidad del Cauca -Popayán.
Master of Public Health, Universidad del Valle Cali. Specialist in Quality Management and Audit in Health Universidad
Cooperativa de Colombia.
Professional Nurse, Universidad del Cauca.
In Cauca, the various currents of local
thought determine how I take care of my
health, how I face the challenges posed by
the disease, and how to manage health care.
Cauca is the most diverse department in Colombia, says Dr. Sotelo, and
therefore full of opportunities from Primary Health Care. Our geography, the
Puracé Volcano and the mountain chain that accompanies us, define the way to
walk the territory from the health point of view.
The department of Cauca is located in the south west of the country. It has a
very important geographical diversity and thermal floors. It is characterized by
the presence of different indigenous ethnic groups, Afro-Colombians, mestizos
and peasants who cultivate the land and provide food to the region and the
country.
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Cauca has about 1,490,000 people. 22% of the population is indigenous
and is distributed in 16 indigenous reservations. 24% of Cauca’s residents
consider themselves Afro, 16% are peasants, and 32% are mestizo. This
ethnic distribution means that there are different currents of local thought that
determine how I take care of my health and how I face the challenges posed by
the disease, explains Dr. Sotelo. These diverse ways of caring for health also
socially and culturally determine the way to manage health care processes. This
poses some challenges to reach the entire population in accordance with local
way of thinking, but also opportunities to manage public health according to
the particularities and essence of the territories. Of course, Sotelo says, there
are also proposed ways to adjust as a health system to the dynamics of PHC.
In Cauca, we take the structure proposed by PHC as a basis and apply it to
the reorganization of services, community participation and sectoral action to
achieve equality in health.
Cauca has some areas that have been distributed for the provision of
services given the enormous distance from some municipalities to Popayán,
the capital of the department. To the south, 350 kilometers away, is Piamonte.
To the west, 600 kilometers from Popayán, is Guapi. There is no highway, you
have to arrive by plane, explains Sotelo. To the north, there is a municipality
112 kilometers away; to the east, there are municipalities 120 kilometers
away; towards the center there is a municipality 207 kilometers away. By this
I mean, Sotelo says, that the geographical distance from Popayán to certain
municipalities poses great management challenges.
If we identify the epidemiological profile in the different territories, it also
becomes different. In the north of Cauca, cardiovascular events are much more
common and in the southern area it is infant mortality due to acute respiratory
infection. This difference must be taken into account.
The document of the Provision of Health Services
Comprehensive Network
Social and community participation in PHC, led jointly with the Ministerio de
Salud and health actors, is proposed in the document of the Provision of Health
Services Comprehensive Network, which will be the navigation map to strengthen
the infrastructure of the first levels of care. That is, from the first contact of
individuals, families, and communities with the Network.
The document, which has a political and economic instance, has been built
with the people, according to the health management itineraries that occur
in each municipality. It is in accordance with the stages of the life course
and according to the needs of the municipalities. Information is generated to
manage the risk in the municipalities according to the particularities and of
course, explains Dr. Sotelo, the financing of this Provision of Health Services
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Comprehensive Network is considered, which includes the individual actions
of the health benefits plan and collective actions of public health plans. The
Cauca Provision of Health Services Comprehensive Network has strong
community participation. It presents us with its needs and limitations in terms of
opportunity, access, quality and continuity of care.
On the other hand, in the administrative process of the department’s
Secretary of health, different elements of public policy converge. Collective
actions are managed taking into account the Plan Decenal de Salud Pública
(Ten-Year National Public Health Plan), we link the National Comprehensive
Health Care Routes that affect the PHC structure. We have an ongoing PHC-
based technical assistance process that calls for community participation.
With them, we do this exercise, the advisor Sotelo Daza says, we strengthen
capacities, at all levels, with the actors of the health system and with the people
in the territory. We link it with public health surveillance, and we exercise the
inspection and surveillance of the actors.
Adjustment of care models from community
and local logic
All these elements are framed in a management model, explains the advisor
Sotelo, who plans to reach all the territories of the department. We have
adjusted the care models from a community and local logic, not only from what
is established by the norm.
We have a quality management process, says Dr. Sotelo, we carry out a
continuous evaluation of level 1 hospitals. In the department’s Secretary of
Health, we have an insurance area that is complemented by public health
management. Each Empresa Social del Estado (State’s Social Company),
each public hospital, render their accounts. We are continually in a process of
capacity development with health personnel at all levels and with those who
manage this matter, explains Dr. Sotelo.
The power of community participation
Management is combined with the strength of social and community
participation in the department of Cauca. We make agreements between
health institutions and the community to see how we reach the territories,
says Dr. Sotelo Daza. There is an exercise in continuous conversation to reach
agreements, to see how attention is raised. This is mobilized through the
collective intervention plans and the consultation tables in the municipalities.
In the departmental development plan, along with other portfolios, limitations
on access, opportunity, and quality are managed, and there is a process
for responding to complaints and claims that also allows for continuous
conversation with community participation.
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With these elements of social and community participation, intersectoral
action and PHC actions, we have continuous conversations with education,
with the person in charge of managing water and basic sanitation, with the
Corporación Regional del Cauca, which does environmental management, with
Indeportes (Sports management entity of the department), with agriculture,
with all gender dynamics, with infrastructure. We have recognized the social
determinants that define these territories. From the analysis of the health
situation, all are permeable to social and community participation.
These strategic elements of PHC that are linked to health policy are related
to the particularities of the territories, the people and the ways of building
alternatives in health care and recovery from illness.
In Cauca, the Sistema Indígena de Salud, Propio e Intercultural (SISPI) was
created, explains Dr. Sotelo. In Cauca there is talk of respected childbirth. There
is a syncretism of care processes in which the different voices of the territory
speak, agree, define forms of communication, from the indigenous, the Afro, the
mestizo, the peasant, ways to adjust the processes of health care and public
health management.
We see PHC as a proposal that generates opportunities to reach the
population. In what sense? In being able to connect and align with the Ten-Year
National Public Health Plan 2022-2031 in the sense that one of the axes is PHC.
From social and community participation in health, there are different
elements that we need to converge to mobilize the aspects that this marvelous
strategy raises for us and thus guarantee the right to health, access and
everything that the values and principles of PHC propose to us, says Sotelo.
See presentation Watch video in Spanish
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Intersectorality,
multidisciplinary health
teams, and a greater focus on
prevention in Cauca
Andrés Narváez
Secretary of Health of Cauca
Dentist. Master in Health Business Administration. Specialist in Hospital Administration and Comprehensive Management
Control and Audit of Health Services. He was Secretary of Health of the Municipality of Caloto and director of the La Niña
María Hospital in the same municipality. He was manager of the Hospital Universitario San José de Popayán, and Manager
of Asmet Salud EPS at the departmental level
In the Secretaría Departamental de Salud del Cauca (Cauca Departmental Health
Secretariat), says Dr. Andrés Narváez, we have fulfilled and advanced on the long
road of improving the performance of the different actors in the health system.
We have led many actions knowing that Primary Health Care is not an end, but
a means to achieve the improvement of the living conditions of our department
that have particularities and all imply a different performance of the actors.
When we worked on the change of the document of the Provision of Health
Services Comprehensive Network, that is approved by the Ministry of Health and
Social Protection of Coombia, it was to seek that the services come closer to the
community through strategies in accordance with the reality of the department.
For example, the document of the Network that we had before, considered the
liquidation of two hospitals, that of Guapi and that of one Empresa Social del
Estado (State’s Social Company) that has three municipalities. Always thinking
about the consumer, explains Dr. Narváez, we told the Ministerio de Salud
(MoH), liquidation is not the way. These institutions must be strengthened. If we
succeed, we will have a better provision of services in the department.
We have acted, says Dr. Narváez, in the structure of the network and we
have ensured that our public managers adopt and interpret the needs of their
municipalities through care models that are consistent with the epidemiological
profile and the needs of each region.
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We work in intersectorality, explains the Departmental Secretary of Health
of Cauca, linking all the actors, being aware and more focused on prevention.
We are acting with the intentions of the new government regarding the
formation of multidisciplinary health teams in different regions. We chose
twenty municipalities of the department. Toribío, here present, was one of
those selected. Multidisciplinary teams are formed to get much closer to the
community.
We know that there are challenges due to geographical dispersion, due to the
high costs of people’s travelling. However, with the resources we have, we can
finance and reach out to multidisciplinary teams and bring care to these distant
sites and seek a characterization of the population. We have pushed meetings
forward with insurers that are responsible for individual care so that together we
can make a much stronger characterization that allows us to focus our efforts
on risk groups, there, in the place where people live.
In the department of Cauca, we work very hard. We have a path that we
have begun to walk and with everyone’s support we are going to improve the
living conditions of our population. We have new care models. One of them,
the care model that we are pleased to show you today, says the Department’s
health secretary, is the one developed by ESE CXAYU’CE JXUT, located in the
indigenous territory of Toribío and Jambaló.
Watch video in spanish
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Central interventions
Experience of community
participation in health in
Guatemala
Lorena Ruano
Researcher and teacher at the Center for International Health at the University of Bergen, Norway.
Coordinator of the research, education, and learning area of the Centro de Estudios para la Equidad y
Gobernanza en los Sistemas de Salud CEGSS (Center of Studies for Equity and Governance in Health
Systems).
Sociologist with a PhD in Public Health from Umeå University, Sweden.
At CEGSS, she leads the Strengthening the Agency and Learning in the Health Systems of the Americas project (SALHSA)
focused on the development of capacities among
academics, civil society, and decision and policy makers of relevant public health organizations in Latin America.
Associate researcher at the Petrie-Flom Center for Health at Harvard Law School. Editor-in-chief of the International Journal
for Equity in Health (IJEqH) since 2008
In Guatemala, with political empowerment,
indigenous communities have managed to
improve the quality of health services and
build trustworthy relationships
In her intervention, pre-recorded for the webinar, the researcher Lorena Ruano
seeks to explain how her institution has supported citizen-led accountability,
how they have used learning cycles to do this more effectively, and how they
support the construction of an active citizenry through these learning cycles.
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Guatemalan Context
We obtained independence in 1821, like the rest of the countries of the
Central American isthmus, says the researcher. From there, we had a history
of totalitarian and right-wing rule, with a brief period of about ten years, from
the October Revolution between 1944 and 1956. During this time the country
enjoyed high levels of social investment in schools, roads, and many things that
helped raise the quality of life of Guatemalans. However, this revolution ended
with a coup led by the USA’s CIA, explains Dr. Lorena. As a result, she says,
we began an internal armed conflict that ended in 1996. During these years,
an estimated 150,000 people were direct victims and generations of leaders
from the 1950s to the 1990s were routinely tortured and killed. Furthermore,
the internal armed conflict, or our war, was characterized by very high levels
of repression and left us with very weak state and social institutions. In 1996
we signed the firm and lasting peace that came with the mandate of equitable
economic and social development for all Guatemalans. This mandate indicates
that the health budget should be increased until reaching 1.44 of GDP by the
year 2000. Today, 22 years later, it is around 2.6% of GDP, one of the lowest in
Latin America.
We have had a legal framework since 2002. These four or five laws allow us
to work directly on the development of the country and focus on the local levels
where all power is decentralized. However, we have very low taxes and very little
ability to collect them from large companies and businesses.
General indicators of pre-pandemic inequality in Guatemala
• 59% of the population lives below the poverty line
• 46% of children under the age of five are chronically malnourished
• One of the highest rates of maternal mortality: 144 per 100.000 live
births according to the government. 290, adjusted data, according to
UNICEF.
• Life expectancy: around 72 years
• 91% of non-indigenous men can read and write.
Indicators compared by ethnicity
In her speech, Dr. Ruano makes a comparison of indicators between the
indigenous and non-indigenous population.
• 79% of the indigenous population lives below the poverty line. Only 35%
of non-indigenous live below that line.
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• 66% of indigenous children under the age of five are chronically
malnourished, compared to 30% of non-indigenous children.
• Maternal mortality of the indigenous population: around 163. 78 from the
non-indigenous population. (Unadjusted data from UNICEF)
• Life expectancy of the indigenous population: 59 years
• Only 35% of indigenous women can read and write in their language, not
in Spanish.
Starting points in the CEGSS
When we wanted to start working with the citizens of Guatemala at the Centro
de Estudios para la Equidad y Gobernanza en los Sistemas de Salud CEGSS,
explains Dr. Ruano, we started from the following aspects:
• Guatemalans do not trust their State as a result of the armed conflict and
social exclusion.
• We use the legal framework to promote participation, generate dialogue,
accountability and contribute to the democratic governance of the health
system.
• We see the need to link academic work and support for the agency of
historically excluded populations in order to enable them to do political
advocacy.
• Today we work in 35 municipalities that have high rates of indigenous
population.
What is our working model?
We focus on participatory research and action, says Dr. Ruano, to:
• Systematize local experience to facilitate collective analysis together
with the indigenous populations we support
• Tie the analysis and reflection of these inequities with action to
understand experiences, perceptions and facts
• Turn excluded communities into researchers and agents of change.
Accountability
Dr. Ruano explains that accountability is the collective effort made by public
officials so that they can give explanations about the quality of the services
they provide and how they use the money. It includes the right and the need to
participate in the development of public policies, and emphasizes the links that
exist between the different types of citizen action.
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Accountability institutionalizes population control over public policy, explains
speaker Lorena Ruano, and is rooted on the use of political costs or reputation
to compel responses from the authorities based on:
• Predefined standards, for example, what the law says or what is defined
by the government
• Information on public actions that have been implemented
• The justification for carrying out those actions
• The imposition of sanctions and rewards as appropriate.
What do we look for with accountability?
Dr. Ruano says, we look for:
• Restricting the power of public officials
• Monitoring the delegation of power from the citizenry to the State. We,
the citizens, give power to the State, but just as easily, we can take it
away.
• There is a lot of opacity in decision making and those who make those
decisions must explain and justify their actions.
Why do we focus on this?
Researcher Ruano explains the following reasons:
• Because the States of low- and middle-income Latin American countries
have become gigantic, complex, and opaque.
• Because they have a lot of discretion when making public policy.
• Because this increase in power in bureaucratic processes has not been
accompanied by a similar process of returning power or increasing the
power of the citizenry.
How did we learn to support the construction of an active
citizenry in health?
Our work has several phases, explains Lorena Ruano.
Phase 1. 2006-2008
We worked in five municipalities and focused on participatory planning. We were
trying to follow the pyramid of evidence in public health by doing quantitative
studies, making an inventory. However, a lot of resources were needed. Many
community leaders abandoned the process, says researcher Ruano. We realized
that it was very easy to dismiss the evidence we were carrying. For example,
we would say that there was a shortage of medicine in a health center and they
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simply did not respond or said, that was when you went, the following day there
were more medicines. So, we said, says Dr. Lorena, this is not working.
Phase 2. 2009-2011
We continued in those five municipalities. We started using mixed methods
using Paulo Freire’s adult education principles, “Education as liberation”.
However, we still invested a lot of resources to produce evidence that the
authorities did not accept. Again, says Dr. Lorena, we returned to the table,
reflected, and concluded that we needed a change. To this was added an
increase in income for a large project and we scaled from five to fifteen
municipalities.
Phase 3. 2012-2013
In this phase, explains Dr. Lorena, we worked with a conceptual framework
for political empowerment. We began working with anthropologists and
ethnographers to identify the ways in which indigenous communities named the
most common instances of abuse and discrimination, and we also worked on a
multidisciplinary model that draws on the use of social sciences.
Within the conceptual framework, we developed the use of tools to identify
abuse and discrimination and began to use community assemblies to foster
trust between them and us and facilitate agency building, explains Dr. Lorena
Ruano. We realized that the indigenous population has felt that the State has
never been there for them or has betrayed them many times, likewise, organized
civil society comes and asks for things and then leaves. We started to develop a
platform to report cases of abuse and discrimination based on text messages.
Thus, we saw that the process of political empowerment began at the individual
level, trying to increase knowledge of situations of exclusion. Then, says the
researcher, we moved on to the construction of collective consciousness and
then to the surveillance of public services with the goal of reaching the political
power of the citizens.
Phase 4. 2014-2015
In this new phase, says Dr. Ruano, we worked with 35 municipalities and we
began to do rapid ethnography. We focused on the collection of audiovisual
evidence. We taught indigenous leaders to use cameras, voice recorders, to
do interviews. We started using human rights approaches, in particular the
right to health. This is how we reached the Defensores Comunitarios por el
Derecho a la Salud (Community Defenders for the Right to Health). These
defenders are recognized by the UN and are trained in the use of the Guatemalan
legal framework of human rights, mainly the right to health, in ethnographic
data collection techniques, and in strategic work with municipal and health
authorities.
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What have we achieved?
As a result of this work, says Dr. Ruano in her presentation, we managed
to improve the quality of services. There are relationships between civil
society, leaders with the Procuraduría de Derechos Humanos (Human
Rights Ombudsman) and with specialized prosecutors. We have developed
relationships based on trust and we have managed to invest more funds for
human resources of health, for medicines, and for ambulances.
How do Community Defenders for the Right to Health work?
In the surveillance cycle, explains Dr. Ruano, the following steps are taken:
1. Collect evidence. Not scientific evidence but information that shows the
situation of the communities. The defenders collect all this information
and contact us at the CEGSS so that we can support them in the
follow-up.
2. Prepare to work with the authorities to which we are going to request
help. We present the evidence to public authorities and ask or demand
solutions. We have noticed, says Dr. Ruano, that when we demand to
be included in a particular space, we are more listened to than in those
where we are freely invited. We use decision trees to help guide the next
steps so that the indigenous population we work with and leaders feel
comfortable.
3. Present evidence and demand solutions. The authorities can react in
different ways when we go to these spaces for participation in health,
says Dr. Ruano. They can accept that the problem exists and plan its
solution, and that can be the ideal solution for us. They may also be nice,
but have no intention of solving the problem. They may deny the problem
or be openly hostile and threaten defenders. For this, the defenders carry
out their strategy and plan, explains the researcher.
4. Adjust the strategy. Depending on the problem identified, the level of
governance where we must influence is defined, says Dr. Ruano. We go to
the Attorney General’s Office and all the Prosecutor’s Offices with which
we work as partners to support the resolution of the problem legally if
we cannot solve it administratively. We have protocols for when there are
threats, says Dr. Ruano.
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5. Follow-up actions. We include activities at the municipal level to inform
the community and we travel to the capital with the leaders to negotiate
with higher level authorities and it is common to work with the Human
Rights Ombudsman.
6. Verify resolution and plan another cycle. As the last step, says Dr.
Lorena, the authorities inform the defenders what has happened. We
verify that the problem was fixed, collect evidence, and close the case.
Watch video in Spanish
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Interculturality Program of
Maternal Care of the-ESE
CXAYU’CE JXUT -Hospitals
of Toribío and Jambaló in
Cauca
Beatriz Bohórquez Salinas
Manager ESE CXAYU’CE JXUT Hospitals of Toribío and Jambaló –
Department of Cauca
Nurse and Public Administrator, with Specialization in Administration in Health and Public Management and Master’s Degree
in Public Health.
Member of the Colombian Association of Public Health.
She was a manager at the Cooperativa Hospitalaria y Empresarial, manager at Harold Eder - Corinto hospital, and manager
of ESE Norte 2.
The Interculturality program in Maternal
Care of the-ESE CXAYU’CE JXUT reduced
maternal mortality in the area to zero
Dr. Beatriz Bohórquez Salinas begins her speech by explaining that the name
of the State’s Social Company CXAYU’CE JXUT that includes the hospitals
of Toribío and Jambaló, in the north of the department of Cauca, is a Nasa
indigenous name that means happy grass that heals or harmonizes. It is a plant
that lives in our region, says Bohórquez.
We are low-complexity or first level hospitals and we have a very beautiful
strategy that we are going to share with you today, says Dr. Beatriz. The strategy
is called Interculturality in Maternal Care. 96% of the population of Toribío and
98% of that of Jambaló are Nasa indigenous people. In our territory we have
the Path of self and intercultural health care within the framework of the Sistema
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Indígena de Salud Propia e Intercultural SISPI (Own Indigenous and Intercultural
Health System), from the life plan of the Nasa Project. On this path, explains Dr.
Bohórquez, are the family, the community and the ancestral experts who are very
important to us. There are health cheerleaders who support PHC in the context
of the family. Community health workers follow this path. Then, the SISPI team
that is in the community health centers.
As a complement to care, we have coordination with western medicine in
the indigenous IPS (healthcare providers), says Dr. Beatriz. In Toribío is the
UNICUSPI - Unidad de Cuidado de la Salud Propia (Intercultural Own Health
Care Unit) and the ESE CXAYU’CE JXUT with complementary services such
as outpatient consultation, dentistry, nursing, pharmaceutical service, health
promotion programs, prevention, and also low-complexity hospitalization,
emergencies, basic care transportation, vaccination, childbirth, and newborn
care.
The intercultural strategy of maternal care
It is a strategy that takes years. I am from the territory, but I came to ESE
CXAYU’CE JXUT two years ago, says Dr. Beatriz. The Maternal Care Intercultural
Strategy arose from the identification of institutional barriers and also due to
the limitations of pregnant women to access health services from western
medicine. There was mistrust and a different worldview. For example, the “cold”
in the care of the pregnant woman. It also arose from analyzing maternal and
perinatal indicators and the need to reduce maternal and perinatal deaths. There
was tension due to the unsafe delivery and fear of attending hospital institutions
on the pregnant women’s part. It was necessary to involve the leaders and also
approach the life plans of the communities from the institutional framework
of the territory. We saw the need for there to be a greater sense of belonging
from the community and also from health workers. We wanted to build trust
with the community so that they could access health services and, furthermore,
articulate ourselves in participatory work. Community participation with
ancestral knowledge has been fundamental in our strategy.
Lines of interculturality in maternal care
Six lines make up this strategy, explains Dr. Beatriz.
1. Training the health personnel on the articulation that we should have
between western medicine and ancestral medicine.
2. Sensitization to all the personnel of the health institution about the
importance of respect for the knowledge of both parties.
3. Conversations and sharing of knowledge with the leaders, midwives, and
ancestral experts of the territory.
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4. Conversations with pregnant women, women of childbearing age,
mothers who are head of the household.
5. Design of an intercultural delivery care manual with a delivery care plan.
6. Adequacy of the infrastructure of maternal services, the delivery room, a
halfway house or maternity home with an intercultural approach.
According to the manager of the ESE, we carried out an exercise of
articulation with the Departmental and Municipal Development Plans and, above
all, with the life plans of the Nasa peoples. In Toribío they are called Nasa Project
Life Plan and in Jambaló, Global Project Life Plan, explains Dr. Beatriz, manager
of ESE CXAYU´CE JXUT. We moved along with those plans. We changed
the chip. Before, it was western medicine first and then the community. The
population had to be adopted to our health services. Now it is different.
As part of the training, we have diplomas in intercultural maternal care, says
Dr. Beatriz, we receive advice from Dr. Susana, who is a doctor, specialist in
midwifery and intercultural maternal care. She is our adviser and she is always
with us.
Induction to new staff
We give new staff a special induction, says Dr. Beatriz. We explain to them that
we abide by western law and also by the law of indigenous peoples. We tell
them about our ritual, our worldview of health. We socialize our own guides for
childbirth and newborn care, adapted to our context and interculturality.
Sensitization to the personnel of the health institution
This has been a difficult challenge. We have spent years, explains Dr. Bohórquez
of ESE CXAYU’CE JXUT. Today I want to recognize the great commitment of the
members and collaborators of our Toribío and Jambaló hospitals. Everything
depends on the will and the love with which new ideas are received. You have
to unlearn a little and keep learning day by day. This awareness was one of
the most difficult steps. For example, the medical staff had the vision of not
allowing a midwife to enter the delivery room, not allowing other companions to
be involved, not allowing the use of alternative non-pharmacological strategies
for pain management. However, the ESE Manager indicates, awareness was
woven little by little, in order to open the minds of both parties. Also, our elders,
our ancestors, said that if the doctors are not going to respect our ritual, it is very
difficult for us to open spaces. Agreements were reached in these meetings. It
began to define how we were going to respect each other, what the limits were.
This was written in our protocols and is documented to build our own delivery
care route, says Dr. Beatriz.
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Conversation with leaders, midwives and ancestral experts
In these spaces, ritual themes were taken into account, the cutting of the
umbilical cord, the experiences of home birth care, the freedom of different
positions to attend the birth, the role of ancestral knowledge in the care of
the birth that is not the institutional one. For us, explains Dr. Bohórquez, the
important thing is to learn among ourselves that this delivery is safe, that we
all work as a team so that this delivery, this mommy, this baby is safe. The
management of medicinal plants, the care of the mother, the newborn, how
to avoid “cultural cold”, food for pregnant women and the benefits of having
companions. All this as part of the Nasa indigenous worldview.
Dr. Beatriz explains that at SISPI they have the Mujer dadora de vida (Life-
Giving Woman) program, which ensures that the birth is attended at home, in
the niche of the Nasa indigenous family, that the birth does not happen far away
from home. If deliveries cannot be attended at home and need to be attended at
the hospital, we as hospitals adapt, says Dr. Bohórquez, so that the mommy and
her family feel at home.
Conversations with pregnant women, women of
childbearing age, mothers, and midwives
Dr. Beatriz explains that in these sessions with women, families, and midwives,
we talk about what a home birth is like, what baths with medicinal plants are like,
what position women prefer to give birth in to feel more comfortable and live
that experience in a freer, calmer, more respectful way. We have been seeing the
evolution of the strategy. Childbirth ceased to be a traumatic experience, says
Dr. Beatriz from ESE CXAYU’CE JXUT, to become a beautiful experience, seeing
how the birth of this new seed is received by all of us, together, with the family.
What this articulation allows is to reduce the maternal and perinatal risk and the
establishment of agreements for a safe delivery.
Health Care Manual for Intercultural Childbirth Care and
Childbirth Plan with an Intercultural Approach
We have, says Dr. Beatriz, manuals for Intercultural Childbirth Care and a Birth
Plan with an intercultural approach. It is a route for childbirth care from the
time the mother is pregnant and is detected by community health workers.
In the antenatal control we have articulated two healthcare providers and the
birth plan. The strategy is being socialized to the pregnant woman and she is
choosing how she would like her delivery to be.
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Adequacy of the infrastructure of the delivery room,
maternal services and halfway house or maternal house
Thanks to the commitment of the Ministerio de Salud (MoH) and the
Government of the Department of Cauca, the municipal administrations, the
International Red Cross, and the ESE’s own resources, says Dr. Beatriz, we have
a delivery room from western medicine that has all the technology to ensure
patient safety and comply with licensing standards.
In addition, continues to explain Dr. Bohórquez, we have our Intercultural
Childbirth Care Room. There are some “chumbes” that hang from the ceiling or
from the wall, as the case may be, so that the mother can have greater freedom
and choose which position she wants to attend to her delivery. In this room,
there is a special decoration that has been done with a cateo, which is a review
of each element that the room has in the hands of our elders from the territory.
They, from their ancestral knowledge, from their feelings, tell us how we should
decorate the delivery room, what color it should be, the figures that the “chumbe”
should contain so that the room is in harmony and in balance with our mother
nature. There are some balls for non-pharmacological pain management and
other strategies such as aromatherapy, music therapy, and massage.
In the infrastructure adjustments, a kitchenette was included in the delivery
room, which has some volcanic stones that help us heat the room and where
the mothers or midwives can prepare the water from medicinal plants. With the
agreements made, we have decided which plants are allowed and which are not.
They have accepted the agreements, says the manager of ESE CXAYU’CE JXUT.
There is also a chair built with the mothers and midwives’ own ideas; they
expressed that this model could greatly facilitate the semi-sitting position.
Everything has been built on the articulation of western knowledge with the
Nasa indigenous ancestral knowledge.
When the birth is in a squatting position, the husband gives strength to
the mommy from behind or from the back. Delivery can be on your knees or
in the all-fours position, or on the floor, or on a mat, or in bed. There are also
deliveries in western medicine ward. The doctor and the midwife together, as a
team, receive the baby. What we always hope with our strategy is that it is not
something traumatic, but a beautiful experience of receiving life.
Other elements of Intercultural Childbirth Care
The strategy includes a differentiated diet that means culturally hot, not hot in
temperature, but there are culturally cold foods that interfere with our worldview.
Also, as we said, Dr. Beatriz claims, there are the baths with medicinal plants,
the cutting of the umbilical cord that is done with scissors or with the reed that
the family brings, which is previously sterilized, according to what the mother,
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the family and the midwife have decided in the birth plan. The accompaniment
of the ancestral is allowed. The midwife can stay with the pregnant woman
throughout her labor, day and night, and for as long as she considers. After
delivery, the placenta is delivered, explains Dr. Bohórquez. It is very important
for the Nasa indigenous culture to carry out a process with the sowing of the
placenta.
For the non-pharmacological management of pain, the husband is given the
plant oils so that he can do the massage. The sister, the midwife, the mother, the
attending physician, and the nurse may be present at the delivery.
We all get involved in each birth, we, the manager, the scientific deputy
manager, the strategy leader who is Diana López, the doctors, the nurses, we all
participate. A birth is something absolutely important to us. It is a fundamental
event in our hospitals.
Intervention and postpartum and puerperium care
The accommodation of the womb is done by the midwife. Breastfeeding is
supported with medicinal plants and education from our western medicine. We
make a kit for each newborn born in our hospital. The kit has the first change,
disposable diapers, and wet wipes, says Dr. Beatriz. We have a bassinet or
hammock, which is a request from mommies and midwives to put babies in
rooming-in. When mommy wants to rest or do another activity, she can have her
baby in the postpartum room.
The maternal house and the tulpa
The maternity home is a temporary home that we have within the hospital
infrastructure, says the manager of ESE CXAYU’CE JXUT. The pregnant woman
can arrive there with her family up to a week or ten days before the probable
date of delivery. It’s like a hotel, they can cook, they have bathrooms and rooms.
They can have a free stay that is not assumed by the health insurer - EPS but
by us to strengthen patient safety and in order to reduce maternal and perinatal
mortality. When labor begins in the active phase, they move to the intercultural
delivery room. There are some pregnant women who prefer to go to the delivery
room of western medicine. Next to the maternal house we built a tulpa, which is
a special space where the ancestor or the eldest is and performs the rituals and
harmonization to give strength to the mother.
Alliance for Telemedicine
This experience of intercultural childbirth has had the support of the Valle de Lili
Foundation. With telemedicine we are constantly trained to reduce obstetric risk.
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It has been very useful for managing emergencies, especially that of obstetric
hemorrhages. Through the tablets, our doctors receive permanent support and
supervision from obstetrician-gynecologists, pediatricians, and neonatologists
from the Foundation. They have supported us infinitely, says Dr. Beatriz. These
alliances have been free. PHC and public health are the most important things
for us, notes Dr. Beatriz.
Strategy instruments
The strategy has several instruments that Dr. Beatriz explains, as follows:
The birth plan: It is like a clinical history of childbirth care in which the family
is educated about the strategy. The birth plan defines how each mom wants
it. She is a guiding guide, it may be that in the end, at the crucial moment of
childbirth, she makes different decisions and these are respected.
The birth certificate: In it, we highlight the joy of the newborn and congratulate
the mommy.
The registry of intercultural births: It is the quantitative record of information
related to the strategy, how many births we attend, what position the mothers
have preferred, number of maternal deaths or perinatal deaths.
Maternal mortality was reduced to zero
The manager of ESE CXAYU’CE JXUT points out that they have increased care
for institutional deliveries. Until 2016, they attended close to 200 deliveries
in hospitals in the area. Today, on average, we are attending between 360 -
365 deliveries a year, says Dr. Beatriz. This has increased the number of safe
deliveries. With the EPS we work so that births are not perceived as an expense
but as a way of caring for the economy due to the cost-benefits they represent.
They are normal deliveries attended in our institution that, on the one hand, will
not reach third-level institutions that may be more expensive, and on the other,
they have a very important moral value for us as a community, because if we did
not have the strategy, a family would have to move from Toribío to Popayán or
Cali, and move away from the territory to have babies elsewhere, and this is very
difficult economically, very difficult from the worldview, and very difficult for our
feelings, says the manager of ESE CXAYU’CE JXUT. I want to tell you, says Dr.
Beatriz, with joy and love, that maternal mortality was reduced to zero and until
today, we have kept it that way, at zero.
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Sharing the experience
We have taken the experience to other spaces and it has been very nice, says
Dr. Beatriz. We have been invited to learn about other proposals. We went to
the Dominican Republic for the ALAMES Congress of Community Medicine.
We were selected as a successful community, participatory and intercultural
healthcare provider - IPS. We were in Australia in 2019. The Ministerio de Salud y
Protección Social recognized it as a successful intercultural experience with an
honorable mention for all the staff of the Toribío and Jambaló hospitals. It has
been, says the manager of ESE CXAYU’CE JXUT, a great motivation to be able to
access these spaces and tell everything we have done in our journey, not only us
as an institution but the life plans of the Nasa territory of Toribío and Jambaló,
the community, the older midwives, and all of us who have built this wonderful
experience.
We have also received visits from hospitals that have wanted to reference
and learn about the experience. They have come from the Susana López de
Valencia de Popayán hospitals, from the Clínica de la Estancia, from the Hospital
de Riosucio Caldas, we are a maternity reference for the departmental health
secretariat. We have received visits from the Universidad Libre, the Universidad
de Santiago de Cali, and French universities. We are very pleased that the
academy is exploring the issue of the adequacy of the territorial context for
Health Care services.
Dr. Beatriz Bohórquez ends her speech by saying: PAY, and explains, PAY is
a Nasa indigenous word that means thank you. The interculturality of maternal
care is our commitment to contribute to the well-being of the mother and her
newborn.
See presentation Watch video in Spanish
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Community participation
at EPSI Anas Wayúu in La
Guajira
Beda Margarita Suarez Aguilar
Wayúu woman of Uriana caste
Manager of the Anas Wayúu Indigenous EPS- Department of La Guajira
Doctor specialized in Health Services Management,
Postgraduate in Medical Auditing, studies in Leadership,
Risk Management, and Intercultural Processes.
Participation is aimed at developing a
management and administration model
centered on the individual and their
community
Dr. Beda begins her presentation with a greeting in Wayúunaiki, the native
language of the Wayúu, and with a tribute to the dance of life, beauty, and joy
typical of their culture. She explains that the dance is related to the closing of
cycles, with the celebration when there is abundance in the crops, when there is
the release of a young Majayut from confinement. The Wayúu woman, she says,
is the multiplier of our clan, and also when any event that puts individual and
collective health at risk is overcome.
The history of the Indigenous Health Insurer - EPSI Anas
Wayúu
Anas Wayúu EPSI, says Dr. Beda, is an Indigenous Health Promoting Company
made up of traditional Wayúu authorities from the association of councils,
traditional authorities, and the Suwuija Association. The first General Assembly
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of Authorities was held in April 2001. In June it received the legal endorsement
of the Ministerio del Interior (Ministry of the Interior) and the same year, the
authorization of the Superintendencia de Salud (Superintendence of Health)
as administrator of the government subsidized regime of health for indigenous
peoples. It is a public entity of a special nature. Its organic and functional
structure is based on its own government structures, represented by its
traditional indigenous authorities. Our management, says Dr. Beda Margarita, is
based on the application of guiding policies of our authorities, such as cultural
cohesion.
The Wayúu indigenous EPSI is only in the department of La Guajira by
mandate of its traditional authorities and out of respect for the dynamics of
the other indigenous peoples settled in our territory. Social participation is
guaranteed in a Wayúu normative context and is in accordance with the social
and organizational reality. We have differential strategies to manage risk, and a
mechanism to guarantee the authorities the social and cultural permanence and
sustainability of the indigenous EPS.
The growth of the institution is carried out according to our operational and
financial response capacity. We are in the territories where it is the will of our
authorities that we have coverage on. We are governed by the same health
legislation that exists in the country and special indigenous regulations, based
on international agreements and treaties.
Our population
We have 223,661 affiliates in seven of the fifteen municipalities of the
department of La Guajira, says the manager of Anas Wayúu. A similar
male-female relationship prevails in our affiliates. 69.83% are of indigenous
background. Of them, 66.31% are in rural areas. 23% of the rural area
corresponds to the deep Guajira, to the dispersed rural area, explains Dr. Beda.
Context
Our entity is in a territory with a high degree of desertification and salinization,
says Dr. Beda Margarita. The Wayúu people are settled in the territory of
Colombia and Venezuela, there is no political-administrative division for us, she
affirms.
On the other hand, the EPSI Manager continues to explain, there are factors
that condition the health of our people: prolonged droughts, the difficulty
in obtaining drinking water, inequitable access to education, the little or no
purchasing power of the communities, food insecurity, high geographical
dispersion, poor quality roads, the fragility of the intersectoral articulation, and
the migratory phenomenon that has brought the appearance of emerging and
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re-emerging diseases in our territory, as well as conflicts between clans for the
return of many people to the territory.
Indigenous System of Own and Intercultural Health
We, says Dr. Suárez, are immersed in the General System of Social Security
in Health SGSSS, but we also have our Own Indigenous and Intercultural
Health System. Community participation is at the center of the system and
is guaranteed by the General Assembly, our highest instance, made up of
traditional authorities from the Association of Cabildos and the Sumuwuja
Association, explains Dr. Beda Margarita. Accountability and analysis of the
different processes of interest for community management are carried out
annually. They, says Dr. Beda, elect the Junta de Control Social (Social Control
Board), made up of authorities; the Consejo Étnico Cultural (Cultural Ethnic
Council), made up of traditional authorities, traditional doctors, leaders in charge
of advising that the differential processes are in accordance with the mandate of
the traditional authorities. The Assembly elects the Board of Directors every two
years, which approves the Risk Management Plan, the budget for the staff, and
elects the manager each year.
Traditional authorities and leaders are also part of user associations. The
institution has an ethnic and cultural coordination, led by a Wayúu doctor. In
her team there are traditional doctors, palabreros, a social worker, and bilingual
guides.
Operational administration and management strategies
Participation, in a macro way, explains the manager of the EPSI Anas Wayúu,
is aimed at developing a management and administration model focused
on the individual and their community, leveraged on indicators that measure
organizational performance, in accordance with the mandate of the traditional
authorities and SGSSS requirements.
The board of directors, says Dr. Beda, formulates, together with the EPSI
monitoring team, the institutional risk matrix that defines the risks to which
we are exposed, quantifies them according to their impact and probability,
and formulates indicators to guarantee the permanence of the institution, in
accordance with the mandate of our traditional authorities.
Operational strategies of cultural integration
The concept of health that the Wayúu have, says Dr. Suárez, implies living in a
territory where there is harmony, where we are not exposed to conflict between
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clans, where drinking water is available, and where it is possible to graze and
cultivate, and, of course, that we are not sick.
We have worked hand in hand with the traditional authorities, continues
explaining Dr. Beda Margarita, in the identification of the health situation from
our own and institutional, from the worldview of our peoples and from western
medicine, the differential strategies to avoid forms of discrimination beyond
language barriers. They have developed culturally appropriate information,
education, and communication actions. We have a media plan, explains the
EPSI manager, defined by our traditional authorities, and in recent years, with the
participation of the palabreros, those in charge of conciliation and guarantors
of the collective health of our communities. This plan seeks to bring relevant
information to the communities in order to strengthen self-care, together with
our customs.
In conjunction with the authorities, several health care routes were built, in
accordance with our population and epidemiological reality: the gender violence
route, the voluntary retirement route, and the dignified death route.
As for the non-allopathic options provided, says Dr. Beda Margarita, there
is differential contracting in which we incorporate health promotion and
maintenance services from the Wayúu indigenous health perspective. Collective
actions are carried out that strengthen protective factors. This has allowed the
social and cultural permanence of our town, affirms Dr. Suárez.
We have held knowledge meetings with midwives, with traditional doctors,
whose intervention is from a spiritual point of view, with palabreros, and with
other traditional health agents who support us and reinforce community
vigilance.
In order to guarantee access and continuity of care, we have bilingual
transit houses with sentinel teams, which are vehicles adjusted to our territory
that can reach both the desert and areas with other vegetation, which carry
bilingual and nursing assistants, responsible for monitoring cases of public
health pathologies, as well as the transfer of pregnant women so that they can
complete their process in safe conditions at the institutional level.
We have, explains Dr. Beda Suárez, a micro-cultural team, responsible for
outlining the differential elements incorporated in our care model, and for
determining psychological and psychosocial factors of our affiliates through
a strategic tele-assistance ally. We have, she says, an induced demand team,
with a group of bilingual educational agents, with mobile units that allow access
and continuity of services within the communities, due to the dispersion of the
territory.
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Challenges
Ruling T 302 of 2017 of the Constitutional Court establishes that La Guajira is
an unconstitutional state of affairs because there is no guarantee of the right
to health, water, or food security. Part of the challenges is to strengthen the
intersectorality and to make an adequate and effective intervention of the social
determinants of health. Other challenges are legal certainty, the problem-solving
capacity of the network within the department, the role of the empowered
citizen, the culture of care and self-care, the health of communities, and
system resources. Everything accompanied by respect for social and cultural
dynamics and our regulatory system. We want to carry out adequate health risk
management, says Dr. Suárez,
Closing her intervention, Dr. Beda says that her EPSI is an institution that over
the course of 21 years has strengthened processes of equity, gender, and all the
people contribute to the health and well-being of the Wayúu people.
See presentation Watch video in Spanish
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Citizenry participation:
from theory to practice.
The experience of the
Fundación Rasa – Antioquia
Gustavo Campillo
President Fundación Rasa. Social Support Network of Antioquia
Business Administrator of the Pontifical Bolivarian University, President of the National Cancer Board
We can move from Primary Health Care to
Population Actions towards Health
Gustavo Campillo begins his intervention by encouraging a reflection on what
Primary Health Care can be. From the perspective of the Fundación RASA, Red
de Apoyo Social de Antioquia (Social Support Network of Antioquia), he says, we
believe that there is a prior legal, institutional legal conception within the health
system. We believe that the definition of PHC, Primary Health Care, could even
be changed for something more holistic, more complementary that could be
Population Actions towards Health. Towards health in terms of well-being, says
Campillo, and, from the perspective of Population Care, separate the concept
of PHC from health interventions. Going one step further back does not mean
going back, explains Dr. Gustavo, but to encompass in a more comprehensive
way the intentionality of the actions of care of incidence on individual and
collective health.
For us, the PHC has nothing to do with contracting models between insurers
and providers of the first level of care. That is only one component and it is part
of the universe that seeks a better well-being for the community.
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PHC has to be seen from individuals as determining subjects
of their own conditions
For us, from the Fundación Rasa, says Campillo, PHC has to be seen, from
individuals, as determining subjects of their own conditions, integrating
autonomy as a fundamental element in the actions that lead to a better or a bad
state of the individuals. It is from there that logical tools are built for self-care
processes that have references from the family environment, as the first social
nucleus, and even in closed communities.
A family, for example, says Gustavo Campillo, can have a conception of
what their health criteria is and, in fact, we see it in the diet of family groups.
Food changes, from one house to another house, or within a neighborhood,
or a town. For the decisions of these actions, it is necessary to have sufficient
enlightenment, education, and information; they are part of what we call
Population Health Actions.
PHC from education
Another factor that affects, explains Campillo, is the educational environment.
From early childhood we have to address elements that allow us better social
interaction, better individual development, better skills, and abilities to care for
the body, the mind, and the environment, that is, the environment that surrounds
us in order to have better living conditions.
PHC from the workplace
Another factor is the work environment that, somehow, we have not articulated
to PHC either. We see it more from promotion and prevention. I believe, says
Campillo, that we have a lot of opportunity to modify actions that allow us to
articulate not only economic or financial resources, but also individual and
collective abilities and human capacities to improve living conditions.
The construction of social network
The proposal is, from those particular views of the individual, the family, the
educational environment, the work environment, to begin to build a social
network, explains Campillo. We have seen two very beautiful experiences of
the importance of the social network, which is not exclusive to an ethnic group
or a race or a culture. The social network is the possibility of interacting in
differences, to develop skills, and improve conditions and quality of life. It is
about having, Campillo explains, a social construction that goes beyond health
intervention and that allows individual and collective care of groups and micro-
groups, and through that community network, gradually expanding the capacity
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for action and the response capacity in better well-being towards localities,
territories, even towards regions, wider territorial expansions which facilitate
respect among our differences and to build collective strategies that can lead to
interventions and impact that get better results.
Individual actions + collective actions
We have, says Campillo, elements in the country’s health system, such as
promotion and prevention actions, in charge of insurance, which are contracted
and directed individually by risk management, which could be added without
including additional costs to these group interventions of the communities, of
the family groups, to have a better result in collective health and a lower cost.
They can also include, explains Campillo, the collective intervention plans,
financed from the territorial entities that are disjointed today from the promotion
and prevention activities. We could, as the health secretary of Cauca has just
shown, articulate promotion and prevention plans for individual actions with
plans for collective interventions focused on specific populations. This could
lead to greater and better results in the preservation of health and, therefore, in
people’s quality of life.
Social determinant factors
Undoubtedly, Gustavo Campillo explains, social determinant factors cannot
be disjointed from population actions in search of an ideal state of health. We
cannot talk about promotion and prevention, collective interventions or Primary
Health Care when there is no drinking water, when there is educational violence,
when there is bullying, or when there is no security. These elements make it
necessary to articulate the processes between individuals and their collectives,
and among the entire response capacity of the State.
We have very generous regulatory frameworks, but they are aimed at benefits
and not at the capacities and abilities of individuals. At Fundación Rasa, says
Campillo, we believe that having other strategies that add to these actions that
have resources from legal life, are necessary and they are showing us, with the
examples we have just seen, that they are absolutely successful.
The insurance that we have does not mean access and access does not
necessarily mean benefits. Access means equity and equity is not only related to
the provision of comprehensive or extra-mural services associated with health
service providers.
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The potential of participation spaces
Regarding the spaces for citizen participation, Campillo explains, we empower
them, we try to make them exist, so that there is real and effective participation.
The spaces for citizen participation in the health system are those that are
directly related to the associations of users of the health service providers or the
EPS, the community participation committees in health, COPACOS; the district,
municipal, and departmental territorial health councils, among others.
But we have not involved other community actors that have an impact on a
better state of health, for example, sports leagues, sport is health. Sports league
leaders should be trained, informed, and empowered to transfer knowledge and
information related to healthy lifestyle habits.
The ancestral knowledge
We have already seen in the experiences of Cauca and La Guajira how ancestral
knowledge is a determining element in individual and collective self-care. This is
fundamental and I believe that the risk managers of both insurers and providers
do not involve these other actors in the response capacity to have Primary
Health Care which, I insist, we should call it differently.
The participation of diverse population groups
Youth organizations, organizations for the elderly, are spaces that we have not
strengthened, and that we could intervene in a positive way so that they join in
the result that we have as a goal in the Colombian health system.
We have to do many things so that the perspective is not only interventionist
from the point of view of care, but also from the inclusion of these population
groups, to have a better approach to local realities and intervene in those
decisions. I insist that the term should not be Primary Health Care, but
Population Actions towards Health.
Watch video in Spanish
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Panel
Innovative PHC Experiences
in Colombia based on
community participation
Jorge Sotelo Daza
Consultant in public health management processes, models and health systems
Secretariat of Health of the Department of Cauca
Beatriz Bohórquez Salinas
Manager ESE CXAYU’CE JXUT- Department of Cauca
Beda Margarita Suarez Aguilar
Wayúu woman of the Uriana caste. EPSI Manager Anas Wayúu- Department of La Guajira
Gustavo Campillo
President of the Fundación Rasa - Department of Antioquia
Moderator: Luis Gabriel Bernal
Member of the PHCPI and World Bank Facilitation Team, Professor at the School of Medicine and
Health Sciences of the Universidad del Rosario in Bogotá..
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Dr. Luis Gabriel Bernal, panel moderator, begins this part of the webinar, referring
to the growing evidence on the benefits of community participation in the
planning, development, and monitoring of Primary Care actions and services.
The panelists answer questions from the audience.
The voice of community participation today is not heard as
it should be
Dr. Jorge Sotelo Daza, from the Secretariat of Health of Cauca, answers the
question about the definition of community participation. He says that social
and community participation is a dynamic that exists in reality, and the health
system must be able to link to that dynamic. In a certain way, he points out,
participation in the health system has been stigmatized in some settings, and
regardless of what the plans, programs and projects say, in the territories the
concept of social and community participation has been considered as an
element that must be included. However, the voice of community participation
today is not heard in the broad framework of what it should be. If we look
at participation as a broad process in the social field of health, where life is
made, it broadens the concept of community participation so as not to make
it instrumental, but to take from that essence, the elements that allow it to
be effectively inserted as a way of assembling ways of caring for health. In
this sense, community participation manages to link the possibilities that this
community force has to achieve the highest possible level of health.
We provide water to communities despite the fact that we
are not an institution with the responsibility of doing so
Dr. Beda Margarita Suárez, from the EPSI Anas Wayúu of La Guajira, answers the
question: How, from an EPS, are actions in defense of the territory and access to
water included? She says that in the work groups led by traditional authorities,
the first thing is to listen to the traditional authorities’ needs, expectations, and
proposals on how they want the intervention to be carried out, respecting our
regulatory system and social and cultural reality. Although, she says, we are an
EPS, we have a strong social and cultural component. We have tank trucks for
water supply. There are many communities that are in scattered rural areas.
A schedule is drawn up so that everyone can, to the extent possible, access
this liquid, which is a determinant that conditions the health of our Wayúu
community. We provide water to communities, even though we are not an
institution with the responsibility to do so. We do it because it is the mandate of
our traditional authorities.
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The Wayúu world is simple
When asked how the impact of community participatory action is measured,
Dr. Beda Margarita of Anas Wayúu says that they use the indicators defined
in Resolution 3280 of the Ministerio de Salud. We have seen the increase in
institutional deliveries in safe conditions and this has strengthened the practices
of midwives within the communities. It has also improved the relationship
between delivery and caesarean section. They have allowed us to rely on
traditional health agents to intervene in deliveries in a very young population.
This has had an important effect and has contributed to the reduction of
morbidity and mortality in the community.
To carry out a population characterization with a differential approach, says
Dr. Beda, the participation of traditional authorities, leaders, educators, young
people, and traditional health agents is important. They all have important
elements so that the result is a model of Comprehensive and Intercultural Care
in dignified and appropriate conditions that respect the social and cultural reality
of the Wayúu people. Dr. Beda complements this by saying that they received
support from the Universidad de Antioquia on issues of methodology and ethics.
We have indicators, she explains, defined with our authorities based on the
motto: the Wayúu world is simple. What we need to know is how the process
is going, if fewer women are dying within the communities, if they are less
complicated, if more children are attending the different programs and plans for
the psychomotor development of minors. We have instruments in Spanish and
in Wayúunaiki. For specific cases, we rely on the Consejo Mayor de Palabreros in
the validation and construction of routes to intervene in the different situations
that are part of the complex reality of health in the Wayúu people.
Effective listening has been strategic in Cauca
To the question about how they have carried out the dialogue of knowledge
with the community for the appropriation of cultural practices of care that
materialize in an adequate use in the health services of the ESE, Dr. Beatriz
Bohórquez from the department of Cauca, answers that it has been built on
effective listening which has been strategic to allow them to make contributions
and feel empowered. The strategy is built by them. When we hear them, we help
to shape it, but it is the citizens who guide the work that is going to be done.
Obviously, explains Dr. Beatriz, there are limits and rules of the game. We tell
them you have to comply with the minimum standards for patient qualification.
What we do with the intercultural approach must be documented, socialized and
it must demonstrate that there is adherence of health personnel and midwives.
For example, there is a plant that we jointly agreed that we are not going to use
in delivery care, it is the brevo. It is a plant that can have a harmful effect at the
time of delivery care. The ancestors accepted it, the midwives also gave in, and
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the health personnel remained calm because there are no unsafe practices.
Everything is in a protocol. When there is evidence, the clinical management
guidelines can be certified and they accept us to enable ourselves with an
intercultural approach.
The value of learning to listen to our elders
Dr. Beatriz Bohórquez talks about the value of learning to listen to the elderly.
They have their skills to guide the path of what to do and what not to do and
what are the precise moments to act. Respect for knowledge is important.
Although the view of the doctor who was trained to provide care with a western
approach is important, we must also respect the midwife who, for many years,
has been attending deliveries with her measures and strategies. It is simply a
very participative sharing of knowledge, explains Dr. Beatriz. Listening and jointly
building all our agreements with a great sense of belonging, that is the key to
success, that all the actors feel involved, respected to maintain the strategy over
time.
The first step is to defend the rights so that people do not
get sick
When asked about the key factors to advocacy in health, Gustavo Campillo says
that although PHC interventions are basic, they are cost-effective, they do not in
themselves mean a reduction or containment of health spending. The first step,
he points out, is not to defend the rights of sick people, but to defend rights so
that people do not get sick. We must prevent sexually transmitted infections,
almost all preventable. Some diseases, such as orphan ones, are not preventable
because they have a genetic origin. We can focus spending, says Campillo, on
fundamental needs and postpone the consumption of system resources for
diseases that are controllable or preventable. When a person is in a disease
condition, he must have a minimum requirement that the State must guarantee.
They are opportunity, early diagnosis, completeness, continuity. A system like
ours, clarifies Campillo, is very divided. What do we gain from doing PHC to
ensure that a person does not get sick, if when they get sick, we do not care for
them adequately and with lower expenses that lead us to consume what we
save in PHC? Gustavo Campillo wonders. A comprehensive view of the system
is required with the involvement of the individual, of their micro-communities,
of their micro-environments, of the local, of the territorial, affirms Campillo.
Guaranteeing the protection of the rights of people who are already affected
and that we could have avoided is not an achievement, it is perhaps a failure,
Gustavo Campillo ends by saying.
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The Consejo Municipal de Medellín approved an agreement
on the vital minimum of connectivity
On the role of social networks in participation in health, Gustavo Campillo
says that virtuality today allows an important penetration to bring information,
education, response capacity from the individual and the collective. However,
he affirms, we have a very large problem of inequity in access to information
technology. I do not know, for example, if there is a health application in the
Wayúu language to give the example of Dr. Beda Margarita. And if we had it,
do we have sufficiently robust connectivity to guarantee the continuity of that
communication?
In Medellín, he says, something very interesting has just happened, the
Municipal Council approved an agreement on the vital minimum of connectivity
to allow access to computer networks, that is to reduce gaps. Nobody will be
able to cut off the Internet. They will have to maintain a basic connectivity as a
vital minimum. But do we have connectivity in all areas? That is the question.
So, networks are very necessary in Primary Health Care to provide tools so that
people can have self-determination that leads to self-care, but we need to close
the communication gaps.
Watch video in Spanish
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