Community participation is one of the main axes of health services where the community takes responsibility for its own health. The World Health Organization considers as a cornerstone of the health promotion and disease preventive actions. The population should be involved in activities aimed at improving their health needs, previously identified by them because if their point of view is not taken into account, efforts generated by the health sector to improve their health conditions would result unsuccessful. Participation is an empowerment tool that allows the community a more active role in decision taking to enforce their rights. Achieving more effective prevention of diseases is one of the objectives of participation. No matter the adjective used (social, community..) participation implies to involve and empower citizens because it is essential to identify and approach main health determinants; it is required that a legal support that endorses participation exists; therefore, the General Health Law emphasizes the right of the population to participate in disease prevention. Some groups of community participation in México are Health Committee and Mutual Aid Group (Spanish: Grupo de Ayuda Mutua). Despite it is in all discourses, participation has not been concentrated in social action yet.
Keywords: Community Participation, Primary Health Care, Empowerment
Since the beginning of the Primary Health Care (PHC) in Alma Ata, it was identified that community participation is one of the main axes of health services, that is the reason why in the PHC reform, the World Health Organization (WHO) indicated that people should be placed in the focus, directing attention to the community and promoting their participation1; so there is a legal and regulatory framework at a national and international level, which indicates to use an integral vision to promote self, individual, family and community care.
Community participation is a dynamic space where people reflect and act collectively to improve the living conditions of the community2, where individuals are responsible for their own health, not only they are consulted, but they also take part in decision making; they identify, design, implement and evaluate solutions proposed by themselves to solve their problems3.
The Responsibility is shared because otherwise the generated efforts to promote health would be insufficient; the population must suggest activities aimed at improving their health needs and not only to limit themselves to perform tasks distributed by health personnel4.
WHO recognized community participation as a cornerstone of health promotion and disease prevention, these actions work well when priorities are set and actions are planned through community action in order to achieve better health, being community empowerment the focal point for this process5.
During the lecture in Alma Ata, it was defined the process by which individuals and families assume responsibilities for their own health and welfare and the community to improve the capacity to contribute to their economic and community development6. Also, participation can be defined as a process where members of a community assume different levels of commitment and identify their problems; they formulate and offer solutions to meet the health needs of their community7.
Participation is defined as a process of empowerment, in the sense of access to and control over resources deemed necessary to protect livelihoods, and placing the axis of decisions on local knowledge and power; so people should not only be consulted, but they must intervene in decision-making. Moreover, it is considered as the process that allows the development of the population incorporating the creative capacity of the population, where the population expresses their needs and demands, and defends their interests, struggling for well-defined objectives, so that the community should involve in its own development and take part in decision making8.
WHO said that there are three different ways to participate such as: contribution (community only participates in certain programs through contribution of work, money or materials), organization (this involves creating appropriate structures to facilitate participation), and empowerment (where the power to take effective decisions regarding the services of health care, taking voice, vote and / or control over these programs is developed)9.
In society, there must be an attitude of shared responsibility, so people should be involved closely in the processes that affect their lives, mainly through activities guided at improving the health needs of the population proposed by them and not only by doing tasks distributed by health personnel4.
There is authentic participation if community is active (it intervenes in diagnostic, planning, execution, control and evaluation of health services), conscious (it knows and it is aware of the existing problems) responsible (it compromises), deliberate and free (interventions are voluntary), organized (it has its own organization and does not depend on the health services) and sustained (they are not only specific response actions)10.
We talk about participation when taking into account the point of view of the actors, if they do not recognize that certain issues warrant that they organize and participate, efforts to generate from "outside" are useless and counterproductive8.
The community should create ideas and suggestions, this is essential in all phases of participation (needs assessment, planning, implementation, monitoring and evaluation)11.
It has been proven that in order to make a community program works, it is necessary that the community elaborates its objectives as they have their own needs and they do not always correspond to the ones identified by any health team, also community is part of the interdisciplinary team needed in health care in a community12.
Participants take initiatives and actions that are stimulated by their own thinking where they can exert an effective control, so that they should not accept solutions proposed by health personnel but to innovate to find solutions that agree with them, they must acquire necessary aptitudes to evaluate a situation or problem and solve it; health personnel has the function to explain, advise and provide clear information about the favorable and adverse impact of the solutions proposed by the community10.
Community participation seeks to involve the community in the analysis of their problems, it strengthens the protagonist role of citizens in their health care, it develops health services in a community base, it provides the community with social planning control and performance evaluation of health services, it maximizes multisectoral approach and intersectional coordination10.
Mendez said that participation is an empowerment tool that allows the community a more active and more responsible role in health aspects7. Briceño said that the importance is to involve and empower citizens and communities so that they improve their quality of life and they enforce their rights13.
Health personnel should work for communities to gain dominion and control over their own lives with the purpose of improving their quality of life because people have the ability to direct their lives and the ability to get involved in community life, for many people, it is more valuable and beneficial a mutual assistance to improve their wellness than professional help14.
Participation is not only a mean to avoid or limit damage to health, but also it is an instrument that enables social groups to organize, mobilize and democratize the social groups, and not exclusively about health processes illness care in health services8. It allows people to better understand their own situation and find incentive to solve their common problems15. They can achieve various objectives with participation such as the resource mobilization, the most effective prevention of conditions, habits and adopting healthy lifestyles as well as improving the utilization of health services9.
Direct contact between health professionals and community management strategies allow people to generate profound changes in their lifestyle, also it is essential to raise awareness to their health problems being the protagonists of their own transformation16.
Participation is essential to identify and approach main health determinants that are closely related to socioeconomic, cultural and environmental situations of the population17.
There are favorable and unfavorable positions on participation, some suggest the positive effect on the health of the population which makes it necessary for the success of programs and others they consider it as a way of social and political manipulation. However, the community should take a more active role and more responsibility with the hope that it is empowered7.
The participation of the community in health aspects can be named in several ways, the origin of the meaning comes from social sciences but then it was taken by health sciences. Briceño said that the concept has been developed to reach social participation, however without losing the essence that it is the involvement of the community. He recognizes that to achieve the protection and recovery of health, participation of individuals and communities is needed. Also, he pointed out that regardless of the adjective to deal for participation (passive, active, individual, social collective ...) the importance of itself consist in involving and empowering citizens, communities and organizations in the role that corresponds to them socially to improve their quality of life and to assert their rights13.
Vazquez said that participation used to have a community dimension in its beginning without contemplating the individual dimension; and participation was only considered the sensitization of the population to increase their responsiveness and ability to respond to development programs, without exercising any control over them.
Over the years, it was noted that the community should participate in the formulation, implementation and use of health services, so It should be strengthened local structures that allow citizens to express their views on health services; this involve redistribution of power among groups involved in health decisions, including loss of monopoly on decision-making of health personnel. Therefore, there should be changes in the structure and way of working of institutions18.
He also indicated that in Nicaragua two types of participation were defined: social and community. The social is the increased role of the various social partners in improving health of the population and community volunteers as the provision of services by community. He concludes that the concept is transformed and in reforms of health services various approaches have been taken such as: community participation (as an element of APS), individual and collective participation (providing human, material and financial resources), and social participation (as an element that allows to achieve transparency and accountability of health systems)18.
A fundamental requirement for community participation to exist is the legal framework which supports the right of citizens to participate, although it is not warranty of participation by itself, as it forms a legal support that can favor this participation19. It is the pillar of all model health actions, and despite it is in all discourses, participation has not been concentrated in social action yet20.
Since 1984, with the Health Attention Model to General Population and in 2006 Integrative Model of Health Attention, it was emphasized that health services should preserve health through community participation; the Operating Model of Health Promotion was implemented in 2001 which mentions that citizens must become co-producers of health, and an important part of this model is the community participation21.
In 2006-2012 government, it was elaborated a specific action program ‘Environments and Healthy Communities’ in order to create favorable environments of health through involving people, a challenge of this program is that people are empowered to modify the population health determinants and thus it can provide sustainability to health services22.
The General Health Law stands out the right to health protection through health education where the community can participate in disease prevention23.
The Health Sector Program derivate from the 2013-2018 National Development Plan includes strategies to promote healthy and co-responsible attitudes at a community level and it strengthens actions to promote health through community action and social participation5.
The Integral Attention Model in Health incorporates advances of developed models before in order to homogenize the health sector services focusing on the person and including a component of public participation through integration of social networks; this model was implemented according to the renewal of Primary Health Care. It emphasized the strategy of citizen participation, which is considered a need and right of the population, and a requirement to attest that the provision of services is carried out according to the needs of the population6.
The General Health Law clarifies the obligation to promote the formation of groups to develop programs in health and in Mexico some groups of community participation that can be found in health centers are the health committee and Mutual Aid Group (Spanish: Grupo de Ayuda Mutua)23.
The health committee is the primary form of social integration in health and it is where a group of people from the same community voluntarily (as leaders, teachers, syndics and others) organize themselves with the aim of working on common tasks to improve the level of health of the population, this with the help of health personnel22.
Mutual Aid Group of patients with chronic diseases is the organization of the patients themselves under medical supervision and with the support of health services, they receive necessary, voluntary and regular training with emphasis on non-pharmacological management and self-care health for good control of hypertension and diabetes. They meet once a month and in each session exchanges of experiences are made between members because feedback eases the adoption of behavioral changes required for disease control24.
Health is responsibility of all, community and government; however, health conditions of a population depend on the decisions and actions taken by each individual and service providers, so it should fortify the ability of people to contribute to their own development; the community should be active, conscientious, responsible, organized and empowered, in order to have a real and genuine participation due to the fact that citizens must identify their health needs and propose strategies to improve their quality of life, so participation does not mean distribution of tasks by the health personnel; however, the practitioner should work for the community to gain dominance and control in their lives, as citizens have the ability to direct their lives and get involved in the life of the community providing mutual aid in order to improve their welfare; therefore, mutual aid is more valuable than professional help.
Promoting groups that participate in decisions that affect the health of the population is an obligation pointed by the General Health Law; the effective action of the Health Committee and Mutual Aid Group improve health conditions in a community because healthy lifestyles are promoted.
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[a] ICSA, Department of Medicine, UAEH. a Author for corresponding: libny_abiu@live.com.mx