Local lessons from Latin America

by Professor Geoff Meads, Michiyo Iwami, Research Fellow, Centre for Primary Care, University of Warwick
Tuesday 30th November 1999

During their formative phase many NHS Primary Care Trusts (PCTs) have been eager to define themselves as new kinds of organisations. The terms 'network', 'virtual' and learning' organisations have been used frequently by new PCT chief officers and chairs, often under the facilitating influence of their board's particular management consultant. The most common collective self account, and aspiration however, has been that of 'community organisation'. To really feel that they belong locally, in ways that NHS organisations have rarely experienced in the past, is what most PCTs want. It is therefore little surprise that 150 of them in England alone have nominated public participation as the issue on which they, in conjunction with the NHS Modernisation Agency, are looking to achieve mid-term transformational change.

Throughout Latin America over the past decade local primary care professionals have been opting for exactly the same organisational route. The incorporation of primary care reform into the politics of national regeneration is a distinctive feature of Blairite Britain, but it is also a commonplace component of the rapid shift towards decentralised healthcare systems throughout Central and South America. The pressure that PCTs are under to become established as locally legitimate resource managers rather pales in comparison with the urgency felt by community doctors, nurses and administrators in El Salvador and Columbia for example, as they have sought to avoid a return to central militaristic control through modernisation. For them this means the expeditious establishment of viable local infrastructures that consist of volunteer supported rural health centres and locally insured 'empresas solidarias de salud'. ,

As these examples suggest, in Latin America as in the United Kingdom, the motivation behind becoming a community organisation is both democratic and instrumental. 'Community' sounds good. It is associated with a progressive, liberal and liberating agenda: social capital, public involvement, citizenship and civil rights. But it can also be, at least potentially, a profoundly self interested calculation. The list of associated terms may just as easily read: privatisation, poverty, provider and professional monopolies, and a growing inequity of both local service profiles and health status.

The last is, of course, an especially important message for the 'New NHS'. In drawing up their new Local Health Delivery Plans PCTs should perhaps beware the experience of Bolivia where decentralisation led quickly to excessive diversity, failures of co-ordination across local boundaries and a rapid reversion to central government control. The 1994 Bolivian 'Popular Participation' law was meant to be radical. National taxation funds were transferred to municipal agencies which were required to develop their own versions of local health delivery plans. Easier for community support, a plethora of proposals for the equivalents of healthy living centres and community transport schemes emerged, many to be sustained through local levies and fees. By 1996 the central government, on economic grounds, had been forced to reject almost all of the proposals, reassert its financial control over workforce planning and introduce new regulatory measures to ensure that 'middle England' equivalents in Bolivian community organisations paid sufficient attention to the neglected primary health care needs of mothers and children in poorer neighbourhoods.

Nowadays' Bolivian PCTs' are left simply with the discretion to manage supplies and maintenance functions at municipal level. In many Mexican regions it is a similar story. One recent study of decentralisation describes how 'resource dependency' on the national government has led to primary care professionals and their patients in Oaxaca ending up 'devoid of any power and control over their work'. What began here as an 'organic' community development of elected representatives from several small towns coming together to establish a preventive 'modulo' programme has ended up reliant on Mexico City civil servants for accreditation, training, planning permissions, clinical protocols and salaries (of as little as four dollars per month for lay staff). This co-option is a doomsday scenario that many primary care organisations fear in the UK today, not least in the context of increasingly assertive Assemblies in Cardiff and Edinburgh.

The local lessons from Latin America for PCTs are, however, positive as well as negative. Having helped to pioneer globally the principal and practice of stakeholder pensions, Chile has recently introduced the idea of Common Municipal Funds, whereby local community charges may be utilised for primary health care services in poorer neighbourhoods, augmenting standard government allocations and packages of services in more equitable ways than previous national formulae allowed.

Unlike Argentina, for example, which like the UK has a long tradition of powerful medical professions at state level, Chile has a cultural heritage of community participation, and the importance of nurturing conducive socio-political conditions for health care decentralisation is a lesson that both Venezuela and, to a lesser extent Brazil have heeded. Since 1990 the Venezuelan Fundsalud has ensured that primary health care and community interests have been robustly safeguarded by locating all public health funds and quality assurance regulatory responsibilities with 'watchdog' civil associations. In some regions of Brazil the management of primary and community care organisations comprises a mix of health services, justice systems, non-governmental organisations, educational and public administration representatives. The facilities of the municipal centres at over 2,500 locations now reflect this combination and 'autonomy': integrated care on the grandest scale .

And then there is Peru. In terms of local engagement Peru has beacon site status. As an organisational model for many of those who have visited them, Comites Locales de Administracion de Salud (CLAS) offer a glimpse of what NHS primary care trusts might become. Responsible for all the health care needs in their 1,500 plus localities, CLAS operate as not for profit organisations receiving funding from the Peruvian Ministry of Health (MINSA) on a weighted capitation basis, but with the right to retain income generated through pharmaceutical sales and user charges. Each local committee initially consists of seven members: three community representatives appointed by the 'lead' clinician of the health centre and the clinician him/herself. Each CLAS is responsible for carrying out systematic health needs assessments using the mechanism of regular household health surveys under the terms of rolling three year agreements with MINSA. These ensure professionals administrative support within a framework of centrally determined guidelines and regulations. Accordingly the post 1994 CLAS, with their origins in women's rights, equality and local neighbourhood movements, always operate within the limits of national policy priorities and programmes while being genuinely free to make such operational decisions as the pricing of services and the recruitment of personnel.

The CLAS system still co-exists with a conventional NHS model. For its six million service users it now significantly outsources the latter in terms of levels of access, user satisfaction, preventive health outcomes, special needs services and, of course, community participation. Of course, the CLAS model is not without its difficulties not least in its relationships with regional MINSA authorities, but overall its scorecard is one most PCTs would settle for; and in 2002 Peru also launched its first elected Regional Health Forums.

The Latin America experience suggests that when the UK government declares that 'the NHS will be transformed through better engagement with patients, the public and staff' , this need not just be rhetoric. At present this agenda remains characterised by centrally driven developments - Patient Advocacy and Liaison Services (PALS) and the new Commission for Patient and Public Involvement, for example - but PCTs can take heart that the transferable learning from across the South Atlantic indicates bottom up approaches are better and built to last. Such practical tips as the following are readily applied.

use community representatives and their structures to shape

professional representation, not the other way round
incorporate local health care management within existing viable community cooperative arrangements whenever practicable
select symbolically significant local leaders for primary care organisation 'headship' (from elected mayors to Olympic athletes)
ensure appropriate popular membership, monitoring (and funding) facilities for the organisations' local populations.

'By regularly seeking out and acting on local feedback', through means such as these PCT community organisations may ensure that 'the NHS will create patient responsive services that people perceive to be improving'.

References:

J.V. Spickard, M.P. Jameson (1995). Postwar health care in rural Salvador: healing the wounds of war. In (eds) E.B. Gallagher, J. Subed. Global perspective on health care. New Jersey: Prentice Hall.

S.J. Burki, G.E. Perry, W.R. Dillinger (1999). Beyond the Center: decentralizing the state. New York: World Bank

T. Bosser (1997). Decentralization: a governance option for health policy. Boston: Harvard Institute for International Development.

J. David, L. Zakus (1998). Resources dependency and community participation in primary care and education in Chile, Costa Rica and Venezuela. Washington: Inter-American Development Bank.

E. Zuckerman, E. De Kadt (1997). The public-private mix in social services: health care and education in Chile, Costa Rica and Venezuela. Washington: Inter-American Development Bank.

T. Bosser (1997). Decentralisation: a governance option for health policy. Boston: Harvard Institute for International Development.

M. Iwami, R. Petchy (2002). A CLAS Act? Community-based organizations, health service decentralization and primary care development in Peru. Journal of Public Health Medicine 24(4).

Department of Health (2002) Improvement, expansion and reform: the next three years. Priorities and planning framework 2003-2006. London: DoH.

Professor Geoff Meads writes regularly on international primary care developments for 'Primary Care Reports' (Medicom)