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The famous 1978 Alma Ata international health conference, which elevated primary health care (PHC) to the level of international policy, established the year 2000 as the target year for achieving “Health for All.” As the millennium turned over, the failure to meet the goal received little fanfare in the media. For health development specialists, it was a failure long anticipated. By the 1990s the focus had shifted to neoliberal health reforms that placed emphasis on efficiency and individual responsibility for health and downplayed state involvement in primary care. By then a growing literature attested to failures of large-scale PHC programs based on lay health workers to impact local health problems in poor nations (see Matomora 1989; and Walt, Perera, and Heggenhougen 1989). Although comparative studies verified that well-trained community health workers could expand access to care at low cost, many national programs built in the 1980s had been hobbled by poor training and inadequate support for lay providers (Berman, Gwatkin, and Burger 1987). Many scholars and development planners blamed a lack of “political will” on the part of governments to carry out true reforms in public health (Bender and Pitkin 1987; and Chen 1989). The seeds of the dilemma were tied to the Alma Ata consensus that public health indices reflected not only available health services but also prevailing socioeconomic conditions such as family income, access to potable water, education, and so on (Poteliakoff 1987). PHC’s emphasis on prevention and community education was a corrective for the biomedical model’s myopic curative orientation in health development work, and its effectiveness was to hinge on shock troops of informally trained community-based 171 7 bbbbbbbbbbbbbbbbbbbbbbb The Elusive Goal of Community Participation No, No . . . No, No . . . No basta rezar No, it’s not enough to pray Hay que pasa muchas cosas There is much to be done Para conseguir la paz Before we’ll achieve peace —Verses of song sung by promoters at a monthly retreat of the popular health system providers. These controversial, heavily mythologized lay workers constituted a tactical end run around the shortfall of physicians in rural areas. A key aspect of PHC as initially conceived was “community participation,” to involve citizens in understanding the causes of disease and motivate them to engage in solving common problems. The idea was for recipients of aid to become agents of their own development instead of passive beneficiaries. WHO recommended that projects involve local residents in assessment, definition of problems, setting of priorities, and planning activities (Foster 1982). Health promoters were to be the intermediaries in this outreach work, acting as social change agents—not only educating their neighbors about oral rehydration therapy but also organizing villagers to lobby local authorities for a better water system . Yet by the 1990s, despite two decades of experiments in PHC, community participation remained a rhetorical staple of government health development proposals that often had little reality in practice (Woelk 1992; Wayland and Crowder 2002). The problem was in part political. Alarmed by the potential costs and the implications of hundreds of “social change agents” in rural areas, some governments reacted with skepticism to the Alma Ata plan. Backed by the Rockefeller and Ford foundations and USAID, more conservative health development experts sought to scale back comprehensive PHC to what became known as “selective PHC” (SPHC)—emphasizing a few vertical programs aimed at reducing mortality from a handful of preventable diseases (Unger and Killingsworth 1986). The lay provider under this new SPHC conception had strictly defined duties, often confined to preventive health education. In practice these “mass-produced” village health workers were usually trained in the capital city, were not always native to the towns they served, and often ended up more closely tied to a distant, centralized Ministry of Health than to their village (Gilson et al. 1989; and Matomora 1989). In their landmark endorsement of SPHC, Walsh and Warren argued that comprehensive PHC was idealistic and too costly (1979). Instead of a focus on community participation and equity, SPHC advocates convinced the United Nations to back a few top-down (or vertically designed and controlled) programs targeting a handful of preventable high mortality illnesses (Unger and Killingsworth 1986). So, instead of locally based initiatives, WHO and UNICEF endorsed the well-known “GOBI” programs to reduce child mortality—consisting of growth monitoring, oral rehydration therapy (ORT), breast-feeding promotion , and immunization. International finance institutions aided ministries of health in setting up urban-based training of...

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