|
|
The Healthy Municipality Experience
Versalles- Valle De Cauca, Colombia
By G.S. Millán
Introduction
To ensure the health and well-being of the population of Versalles,
local development occurs within a health promotion framework and
involves the active participation of community members in determining
priorities for action as well as the appropriate strategies for
addressing the identified needs. This process has resulted in consensus
building and the coordination of work between sectors and non-governmental
entities. Using a methodology that combines analysis, action, and
reflection, diverse sectors work jointly for education, community
participation, equity, and sustainability.
Many individuals and institutions have been involved in the healthy
development of Versalles over the last 11 years. Included among
these are the medical director at the health service provider, various
mayors, the promotion and prevention team of the health department,
and local leaders and community members in both urban and rural
areas. The following local institutions have provided financial
and/or logistical support: San Nicolás Hospital, the Municipal
Administration, the parish, the tourist hotel, Corpoversalles, the
Lions Club, volunteers at San Nicolás Hospital, community
drugstores, the Solidarity Health Company (Empresa Solidaria en
Salud), community adolescent and children committees, the Día
Seniors Center, schools, the fire department, and community action
boards.
Though the health sector has led the Healthy Versalles process,
success would not be possible without the active participation and
commitment of diverse sectors such as education, agriculture, highways,
infrastructure and public services, as well as the local and international
contributions of financial resources, training, and equipment. External
support institutions include the Pan American Health Organization
(PAHO), the Ministry of Health, the Departmental Health Secretariat,
SENA CLEM, FES, Fundación Carvajal, the Consortium of Organizations
for Community Development, SUNA-HISCA, the Colombian Institute of
Family Welfare (ICBF).
Background
In 1989 four crucial events occurred with respect to the process
of community participation and development of Versalles: the enactment
of Ministry of Health Decree 1216, formation of the Primary Care
Team at San Nicolás Hospital, realization of a mental health
workshop, and general consensus on development goals among local
stakeholders. Decree 1216, which regulates Community Participation
Committees (CPCs) for monitoring the delivery of community-level
health services, was the starting point of a new community organizational
strategy in Versalles. Based on newly formed institutional consensus,
implementation of the decree in Versalles was substantially different
from that carried out elsewhere in the country.
Instead of limiting its scope to monitoring activities, the Community
Participation Committee of Versalles started out with two important
philosophical assumptions: first, that the concept of health not
only includes treatment of patients, but also the prevention of
the causes of ill health; and second, that the solutions for most
local problems are in the hands of the community. These two points
were used to create an opportunity for consensus building between
institutions and members of the community, as well as provide a
broader approach to CPC activities.
Simultaneously, San Nicolás Hospital managed to secure resources
for forming a primary care team and preparing a participatory health
survey. As a result, the need for additional services was identified
in the areas of health, the environment, basic sanitation, education,
culture, recreation, nutrition, housing, public services, and the
local production of goods. The survey underlined the seriousness
and the extent of these problems in Versalles and corroborated the
previously defined need for combining efforts and resources.
Another important input regarding community participation was the
Health Department’s presentation of several mental health workshops
to promote values such as tolerance, solidarity, and respect within
the community. Through their methodology and content, the workshops
contributed toward strengthening community participation. In a municipality
that has both high levels of violence and strong communal processes,
the opportunity to reflect on the aforementioned values was important.
Moreover, the use of a participatory methodology, whereby the community
developed or reaffirmed its own knowledge had significant positive
impact. In short, the mental health workshops created an important
opportunity through which the community of Versalles and its institutions
could discuss violence and decide jointly on values for peaceful
coexistence.
The final part of the process stemmed from a strong collective
concern about the problems in Versalles. At the beginning of 1989,
Father Vélez, a parish priest at the time, used his office
to initiate meetings among institutional stakeholders aimed at forging
a different future for Versalles. Initially, the meetings organized
by Father Vélez did not result in a solid working team, but
as the year progressed, together with the aforementioned events,
a group of institutional actors committed to Versalles began to
emerge. These meetings produced three specific results: an expanded
knowledge of activities at each institution, including strengths,
weaknesses, and scope; an analysis regarding possible areas of coordination
and collaboration between sectors; and a mutual vision and commitment
to work for the well-being of Versalles. These actions made it possible
to circumvent personal, institutional, and sectoral jealousies that
are typically present in the development process. In June 1990,
eighteen months after initiating the process, a solid working team
and consensus on what needed to be done were in place.
Difficulties
Lack of mayoral commitment
The lack of commitment on the part of some mayors is gradually waning
as the healthy municipality process begins to show positive impacts
on local quality of life and as the local politicians begin to see
the community as an effective leader in transforming its own reality.
Lack of economic resources
Little by little the community of Versalles is working to overcome
the lack of economic resources to implement development activities.
An effective strategy has been sharing the responsibilities for
projects through formal and informal alliances among business institutions,
the public sector, and the community.
Disparities in Health
An important component of the development of a healthy Versalles
is ensuring that all residents have access to basic health services.
To this end, comprehensive care is provided at every stage of life,
through programs and projects such as maternal and child care, care
for preschool primary school children, adolescents, young adults,
and care for older adults.
Each project is framed within the Municipal Health Plan and its
programs. With respect to basic services, 95% of the population
has access to water supply, sewage, and comprehensive solid waste
management services.
A full 100% of the population has access to health promotion and
disease prevention programs, and 100% of the population has access
to essential drugs. At present, 80% of the low-income population
of Versalles has access to health services through a subsidized
system, while the remaining 20% access services through a contributory
system. Vaccination coverage is 100%.
Project Financing
The project is being financed through strategic alliances between
institutions and sectors, and by the current state revenue allocated
to the municipality for the health, education, agriculture, and
recreation and sports sectors. Moreover, the project is supported
by NGO donations, community contributions in the form of human resources,
and technical support given by organizations such as PAHO.
With regard to the sustainability of the Versalles development
initiatives in terms other than financial, the community has been
encouraging the participation and increased self-esteem of children
and young people, with the goal of instilling a culture of participation.
Accordingly, this prepares the youth to actively participate in
the future development of their community with the goal of achieving
a better quality of life.
Achievements
The most important achievements in the social area include community
organization, institutionalization of intersectoral teamwork, peaceful
coexistence, job creation, greater equity in gender relationships,
and increased quality of life for the population.
The development of community organizations in Versalles grew at
a rapid pace as a result of the CPC process. In 1991 the CPC had
14 groups, but today includes some 85 groups and more than 7,000
individuals. Beyond these figures, however, what is most important
are the qualitative changes occurring in these important groups
during recent years. Another important achievement is the institutionalization
of intersectoral teamwork. At present, teams and intersectoral alliances
are responsible for implementing almost all CPC programs. The community
organization process has managed to promote peaceful coexistence
in Versalles. The number of violent deaths has declined from 28
cases in 1993 to only 5 in 1999, and the level of non-fatal violence
is also lower. Peaceful coexistence was never a specific objective
of the process in Versalles. However, the construction of a viable
social fabric has facilitated a different lifestyle.
“I believe that through this whole
process peace has come to the municipality. And with peace,
it has been possible to coordinate future development. The experience
has been extremely rewarding, because all the leaders took it
very seriously. For me, that’s what I most admired, because
the leaders I worked with—and have always worked with—assumed
responsibility for everything with utter seriousness, and I
believe that the decisions were not decided on the basis of
that particular moment, but on future considerations such as
what’s this about and where are we going with this?…I
think that the experience has a great deal of validity and that’s
the beauty of it—that it has great importance that can
be evaluated in an historical context, producing some highly
positive results…although there are some shortcomings,
but really, the positive aspects are very important.”
Rogelio Giraldo, community leader |
In terms of employment, the CPC went from a volunteer-based
process to an organization that generates employment possibilities
to the point that today, the CPC is the third largest provider of
jobs in the municipality.
Personal growth within the process of community organization
has been remarkable. What is most visible and impressive, taking
into account the local culture, is the change in relationships between
women and men. As a result of organizing, training and strengthening
groups of women, they now have great opportunities for community
leadership. Total death rates, maternal and infant mortality, and
perinatal morbidity have all decreased. Not a single child has been
hospitalized during the last three years with severe malnutrition,
whereas previously there had always been between one and four children
with severe protein malnutrition (kwashiorkor) or marasmus.
“For me this experience has been
relevant because I had not seen any community group working
for the community. Groups worked for their own interests, thinking
only of their individual well-being. Now all we think about
helping our neighbors; we think that working together is the
way to get things done. We also see that other things have arisen
from this perspective that make us think to ourselves, “this
is really worthwhile,” and we have to continue down this
path, because other organizations have come to visit us, we’ve
had more support, we’ve had the freedom to make decisions,
discuss them and request support, we’ve seen that we are
taken into account…that for me has been a big foundation
for community work.”
Nancy Arcila, community leader |
Eighty percent of the population has insurance coverage for health
services, while immunization coverage is 95% and nontraditional
vaccines have been successfully introduced, such as hepatitis, meningococcus
and Haemophilus Influenzae.
The municipal economy has improved through income-generating projects
such as floriculture, family businesses and microenterprises in
agriculture. Accordingly, families have improved their incomes.
We do not have problems of violence associated with common crime,
although we cannot escape our current problems due to unemployment.
However, we are exploring and studying projects that would reduce
these problems in the municipality. Finally the local community
has a system of functional community participation in place to propose
ideas and share opinions and develop strategies.
“I believe that today, power is
not in the hands of any particular person, but in the hands
of all members of the Versalles community….Formerly, power
was in the hands of those who held the belief that a man was
more powerful with a weapon in his hands....Now that’s
not the case. I can sit down and talk with the mayor, the doctor,
with somebody that works at the municipal dump, with a campesino,
with a girl that prepares meals in the home of a given family,
with adolescents, with children, with grandparents. Consequently,
since we all have the power to speak our minds and express what
we want, to share what we feel, I believe that the power is
not in the hands of any one person anymore, but in the hands
of all.”
Ligia Molina, community leader |
For further information, please contact:
Hospital San Nicolás
Calle 9 No. 1-22
Tel 0922213022
Versalles, Valle, Colombia
|
