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1 Qamar Mahmood Senior Program Officer Governance for Equity in Health Systems (GEHS) International Development Research Centre IDRC Ottawa, Canada Postal Address: 150 Kent Street, Ottawa, Canada K1G3H9 Phone no.: Biography: Qamar Mahmood has been a Senior Program Officer with Canada s International Development Research Centre (IDRC) since April Prior to this, he was a Canadian Institutes of Health Research (CIHR) post-doctoral fellow in Public Health Policy at University of Toronto. Dr. Mahmood obtained his PhD in Health and Public Policy from Johns Hopkins University in 2010 and a Masters in Health Policy and Management from Aga Khan University in Dr. Mahmood s primary qualification is in Medicine but he has worked in public health and public policy for most of his career. His career has focused on conducting and managing research in the areas of health equity, health systems and policy, social determinants of health, and political sociology of health among many others. His most recent research interests have been in the area of participatory democracy and health and especially in Latin America. He has worked in Pakistan, South Africa and Canada and coordinated and managed research projects in several countries in Asia, Africa, and Latin America. Carles Muntaner PhD MHS Professor Bloomberg Faculty of Nursing, Dalla Lana School of Public Health & Department of Psychiatry, School of Medicine University of Toronto suite 381, HSB 155 College Street, Toronto, ON M5T 1P8 Canada Grup de Recerca en Desigualtats en Salut (GREDS)/ Employment Conditions Network (EMCONET) Department of Political and Social Sciences Universitat Pompeu Fabra, Barcelona carles.mutaner@utoronto.ca Tel: Carles Muntaner MD, PhD, MHS is Professor of Nursing, Public Health and Psychiatry at the University of Toronto, Canada. He is Adjunct Professor at the Institute for Work and Health, the Keenan Research Center at St Michaels Hospital and the Center for Addictions and Mental Health in Toronto and with the Department of Mental Health, at Johns Hopkins University School of Public Health in Baltimore. As a founding member of the GREDS/EMCONET research group he is also currently appointed at the Universitat Pompeu Fabra, Barcelona. Dr Muntaner has been Principal Investigator on primary data collection grants financed by NIDA, NIMH, NIOSH and CDC in the US and CIHR in Canada. Approximately one hundred and seventy of his three hundred plus publications appear in the Web of Science. He has been first author of studies published in Psychopharmacology, American Journal of Epidemiology, American Journal of Public Health, International Journal of Epidemiology, Annals of Epidemiology, Health and Place and Social Science and Medicine among other journals. He

2 has served as consultant for the PAHO and several governments in Latin America, including Venezuela and Chile. He participated in the "Marmot Review" and is currently part of the review on social determinants and the health divide in the WHO European region. He co-chaired the Employment Conditions Network (EMCONET) of the WHO Commission on Social Determinants of Health. Dr Muntaner's awards include the Wade Hampton Frost Award from the Epidemiology section of the American Public Health Associations for his contributions of social epidemiology. Rosicar del Valle Mata León María Auxiliadora Street, Res. Los Pinos, Piso 9, apto 93, Los Ruices, Caracas, Miranda estate. Postal address Phone Rosicar obtained her Bachelor s in Nutrition and Dietetics from the Central University of Venezuela in She has a Master s degree in Public Health from the Federal University of Bahia, Brazil specializing in Management of Public Health from the Institute of Higher Studies in Public Health Arnoldo Gabaldon. She also has a Master s in Business Management from the Jose Maria Vargas University and is studying for her doctorate in Sciences for the Strategic Development of the Bolivarian University of Venezuela. Rosicar had been Assistant to the Minister of Health for International Relations and Technical Cooperation, Technical Secretary of Environmental Health and Sanitary Control, Food Management Nutritionist at the National Institute of Nutrition, Formation and Training Coordinator, and Citizen Attention Coordinator at the National Socialist Training and Education National Institute of Venezuela. Ramón Ernesto Perdomo María Auxiliadora Street, Res. Los Pinos, Piso 9, apto 93, Los Ruices, Caracas, Miranda estate. Postal address 1071 Phone: ramonernesto_perdomo@hotmail.com Biography: Ramon is an Agronomic engineer from Occidental-Centre Lisandro Alvarado University, Barquisimeto, Lara State where he graduated in He obtained his Master s in Food Nutrition and Health from Bahia Federal University, Brazil. He is studying for doctorate in Sciences for Strategic Development at the Bolivarian University of Venezuela. He is currently Vice Minister Basic Industries. He has worked as President of the Cement National Fabric at the Ministry of Science and Technology, Advisor Autonomous Service of Sanitary Control and also Food Hygienic Director at the Ministry of Health. He has served in indigenous advisory in agricultural matters and was a member of the student movement.

3 Abstract: The Venezuelan health reform Barrio Adentro (BA), initiated in 2003, aims to improve population health and promote popular participation. Access to healthcare has improved but the distinguishing feature of BA is participation by communities. Popular participation has been institutionalized through the formation of health committees and communal councils. We explored the challenges/barriers faced by these community groups in BA. A mixed-methods participatory methodology was used involving thirty-one participants selected through non-random purposive sampling from five Venezuelan states. Results indicate that implementation issues challenge participation. There is political will at the highest level but the opposition political parties, Venezuelan Medical Federation, and the private media oppose the reform. Public participation in state affairs is facilitated if there are popular arenas of participation that promote engagement of organized citizenry with the state and an ongoing interaction between state and civil society in order to radically transform the state Keywords: Venezuela, Health Reform, community councils

4 Title: Popular Participation in Venezuela s Barrio Adentro Health Reform Introduction This article presents findings of a study that was conducted to explore challenges of participation for community groups in the Venezuelan state-initiated health reform Barrio Adentro. The reform aims to improve the health of the population and to promote popular participation. Our main purpose was to identify the barriers to/challenges of participation for community groups involved with Barrio Adentro, a state-initiated health reform to improve health and promote popular participation in health. First, we describe Venezuela s socio-political history and contextualize the country s political experience by comparing it with other countries on the continent. In this section we focus on participatory governance to set the stage for our case study of popular participation in Barrio Adentro which is considered to be a distinguishing feature of recent reform efforts in the country. As a health reform project, Barrio Adentro is unique in that it is taking place in the context of a broader socialist transformation in Venezuela. We then elaborate our methodology which includes the rationale for the study and a brief literature review, the research tools we used to conduct the study, and the results. We end with a discussion of the results and draw conclusions about grassroots social empowerment in Venezuela today. Background State-society dynamics and the polarization of societies in Latin America Decades of economic liberalization policies in Latin America led divisiveness in the societies with a clear distinction between the haves and have nots. This societal polarization, according to Waisman (Waisman 2006) led to gainers and losers of such policies. The former included mainly business interests and other privileged groups. The latter were groups that had been systematically excluded (Oxhorn 2006) such as indigenous people and residents of informal settlements of favelas and barrios. It was the latter group that was later most prominently involved in many social movements such as those against neoliberalism

5 and in other collective forms of struggle to achieve a more inclusive form of citizenship. This marginalized pole became the target of political clientelism both under Latin America s authoritarian regimes and later under the political regimes which came to power and yet continued to show clientelistic tendencies similar to those of their authoritarian predecessors (Avritzer 2002). Oxhorn presents a collectivist perspective on civil society in the context of polarized societies such as those in Latin America, including Venezuela. This collectivist perspective of civil society sees the role of the state in facilitating institutionalization of community organizations to include the poor that have historically been disadvantaged and generally unorganized. In the context of polarized societies and from a collectivist perspective of civil society Oxhorn also rejects the rigid state-society dichotomy. In his view, the role of civil society is defined by its two main aspects: to resist subordination by the state and at the same time demand inclusion into national political structures. This perspective of civil society is radically different from the often accepted notion of civil society in the dominant discourse on democratic governance. That perspective is defined by civil society s roles: monitor the affairs of the state and political society and uphold the idea of civic autonomy. Thus, civil society action is to put external pressure on the state. Oxhorn finds that such a conceptualization of civil society is ideologically liberal, espousing market-based ideals, and individualistic in nature. In fact, such a conceptualization of civil society undercuts the very essence of collectivism. This notion of civil society becomes irrelevant in cultures that are more collectivist in nature such as the indigenous people in many Latin American countries. The emphasis on civic autonomy promotes an excessive state-society dichotomy. Such a dichotomy is in fact detrimental to the cause of the poor especially if the state is on the side of the poor. Political changes in Venezuela during the 1990s The decade of 1990s in Venezuela was marked by the State s implementation of neoliberal policies and a struggle by social movements against these policies (Armada et al. 2009). Political leadership would campaign on an anti-neoliberal agenda to get elected but then implement neoliberal policies while in power. Social mobilization against neo-

6 liberalism resisted such changes. Carlos Andres Perez took office as President in 1989 and implemented a plan, with recommendations from the World Bank and International Monetary Fund, called El Paquete. El Paquete resulted in privatization of public enterprises, reduction of public expenditure, liberalization, and deregulation. It also provided a greater opportunity for foreign oil companies to exploit Venezuelan oil. Popular mobilization grew against these neoliberal policies. Hugo Chavez led this political struggle and attempted a failed coup in 1992 (Alvarado et al. 2008). Rafael Caldera was then elected in 1993 on an anti-neoliberal platform but he also implemented a neoliberal plan - Agenda Venezuela. Chavez won the elections in 1998 and implemented reforms to radically transform the Venezuelan state (Wilpert 2007). Steps taken by Chavez in this direction included naming a cabinet that consisted mostly of those from the Left and none from the traditional political elites. A referendum was then held to get approval for a constituent assembly to write a new constitution. The new Bolivarian constitution was approved in December 1999 (Feo & Siqueira 2004). Since 1998, Chavez s government has implemented a number of radical reforms to transform the state into what is being called 21 st century socialism (Wilpert 2007). Throughout his years in political power Chavez has faced and defeated many attempts to derail this process of transition (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). Venezuela has embarked on a comprehensive and radical transformation of the state. Other states in Latin America are following this path but, limited by their particular political contexts and limited policy maneuverability, their efforts are piecemeal by comparison to those in Venezuela. Political context of the health reforms in Venezuela Changes in the Venezuelan health sector have mirrored what has occurred in the political and ideological spheres. During the 1990s both Perez and Caldera instituted neoliberal changes in the health sector (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). There was fiscal reduction of public health services and health services were decentralized. These poorly financed and managed health services became inefficient

7 when decentralized and handed to regional authorities. This paved the way for greater privatization of health services and institutions. Cost recovery mechanisms were introduced for those health services that remained under public authorities after the widespread privatization effort. By 1997 seventy-three percent of total health expenditure in Venezuela was private. Simultaneous with the political changes during his first years in office, Chavez took the following steps between 1998 and 2002 in the health sector. First, he reversed what were popularly known as Caldera Laws which favored privatization of the health system and implemented a variety of strategies to eliminate barriers to health care (Armada, Muntaner, Chung, Williams-Brennan, & Benach 2009). These included measures such as the implementation of integrated health care, a focus on primary health care centers and on prevention activities that shifted the emphasis away from curative care. However, the most significant change was to transform the understanding of health from that of a commodity to be exchanged in the market to a fundamental right to be provided by the State. Health reforms in Venezuela The transformation of the Venezuelan state has been led by social missions (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). The new constitution was formulated after extensive consultations with various sectors of the society (Muntaner et al. 2006a) and was passed in Until 2002, the government led efforts to reverse the effects of neoliberalization on the health sector. Privatization of health services was halted and barriers to access to care were eliminated. However, popular demand for improved health services required that more needed to be done (Armada, Muntaner, Chung, Williams-Brennan, & Benach 2009). The new Bolivarian constitution required that new and more efficient mechanisms be developed to run parallel to and then replace existing structures. The intent was to avoid undue hurdles within the bureaucracy from those ministries which remained opposed to many of the changes the new President proposed (Muntaner, Salazar, Benach, & Armada 2006a). One such major change to develop alternative redistributive mechanisms to strengthen Venezuelan welfare state was the creation of social missions (Muntaner et al. 2006b). The social missions are social programs created as parallel structures either

8 completely outside the scope of government ministries or in collaboration with them, as a means to increase community participation to meet the new constitutional imperatives more efficiently (Muntaner, Salazar, Rueda, & Armada 2006b). A mission was aimed at concentrating the efforts of different sectors and public organizations in order to rapidly satisfy urgent social needs, increase community participation, get around certain bureaucratic obstacles, and employ the organizational and logistic capabilities of the Armed Forces in the development of civil social actions. (Armada, Muntaner, Chung, Williams-Brennan, & Benach 2009) The missions serve as motors for social change and constitute a social policy which is radically different from focused aid projects (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). Among the social missions, the health mission Barrio Adentro has been the most visible in terms of its achievements (Anon 2006). While missions Barrio Adentro and Mercal are the most prominent and well recognized at the national and international levels, they have also been the target of the political opposition (Maya & Lander 2011). Political opposition to Chavez s regime in fact started from the very beginning when he appointed almost all his cabinet members from the Left and completely sidelined the traditional political elite (Wilpert 2007). In health, for example, in 1999 and 2001 he appointed two past presidents of Latin American Social Medicine (LASM). From the start, they tried to implement a healthcare system based on the principles of LASM. However, they faced stiff opposition from the Venezuelan Medical Federation that had aligned itself with the traditional political parties that had lost power in the 1990s and with the private medical sector that was strongly opposed to Chavez s attempts to reinvent the healthcare system. The President s efforts were based on his progressive political ideology that advocated a strong public health approach for the healthcare system (Briggs & Mantini-Briggs 2009). Participatory democracy While there has been an increase in the budgetary allocation for health, improvements in access to and utilization of health services and improvements in health indicators, the distinguishing feature of Barrio Adentro and other social missions is active community participation. In

9 fact, the intense participation by popular committees is an important aspect of the reform that is leading to a profound change in Venezuela s health institutions (Laurell 2008). Health is seen as part of a general transformation of the state where all social rights are respected. This transformation has involved democratic participation and more broadly a new socio-economic model based on equitable distribution of wealth (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). Through the process of participatory democracy, the locally driven health reform started out primarily in the country s most marginalized and underserved neighborhoods (Muntaner, Salazar, Benach, & Armada 2006a). Article 62 in the constitution relates specifically to participatory democracy. It states that the participation of people in the formation, control and execution of public matters is the means necessary to accomplish the protagonism that will guarantee their complete development, both as individuals and collectively. (Harnecker 2007) Barrio Adentro aims to improve the health of Venezuelans, especially the marginalized, by strengthening community capacity and social organization via participatory democracy (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). This has been achieved mainly through the formation of Health Committees. These committees serve as organizational mechanisms through which barrio residents exercise their participation in primary health care delivery and management (Muntaner, Salazar, Rueda, & Armada 2006b). Health committees are generally made up of 10 people chosen in an assembly of citizens and work with a popular health post (the first level of care) (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008). The mandate of these committees is to assess health problems in the community, prioritize them, and decide on the main actions that the community should take to address them. Supported in each locality by teams consisting of a physician, a social worker, and a nurse, the health committees prepare proposals for health interventions to be considered for funding by the state government ( 2006). There has been a massive increase in the number of health committees with a total of 8,515 committees registered by 2009 (larevolucionvive 2012). Operation of health committees is regulated by the Community Councils Law

10 of 6 April 2006 which was updated in 2009 (Ministra del Poder Popular 2009) and which mandates that health committees work with other committees affiliated with communal councils. Popular participation is established in the 1999 constitution as a mechanism for the state to enforce health as a social right. The articles on health in the Constitution (Articles 83, 84, 85) have the conceptual underpinning of a co-responsibility of the triad state-individual-society in social participation, which enables citizens and individuals to become the main actors in the new society. (Feo & Siqueira 2004) Just as health committees provide mechanisms for popular participation in health, similar popular arenas of participation exist for other social missions as well as public administration at the municipality, district and neighborhood levels. The process, however, is still evolving and Venezuelans are learning by doing. For example, while health committees were established separately from other participatory governance structures in public administration such as the Communal Councils, they are now being considered to act as working committees for the communal councils. Operating at a submunicipal (communidad) level of between 200 to 400 families in urban areas and 20 families in rural areas, the communal councils work with other institutions of participatory democracy, some of which have learned from and built upon the experience of the local participatory budgeting process in Porto Alegre, Brazil (Wilpert 2007). Their activities include but are not limited to gathering and evaluating community projects, working on development plans, and mapping community needs. And, as mentioned before, communal councils integrate the committees of various social missions (Wilpert 2007). They administer the budgets allocated to each community including the budgets of the health committees (2006). Participatory democracy is the fundamental element in the creation of a new health policy (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008) and it forms the common thread weaving various sectors of the society together. Methods Study rationale After a pilot phase in 2003, Barrio Adentro was formally launched at the national level in Since then, several publications highlighting various aspects of the reform have been

11 published. In one of the first articles on Barrio Adentro, Feo and Siqueira (Feo & Siqueira 2004) focused on the constitutional changes that were relevant to health and the initial years of the reform. In 2006, articles by Muntaner et. al (Muntaner, Salazar, Benach, & Armada 2006a;Muntaner, Salazar, Rueda, & Armada 2006b) highlighted the background of the reform and the early years focusing on how the reform process was organized in terms of delivery of services. Later that year, a study was published by the Pan American Health Organization (PAHO) (2006) that detailed various aspects of the reform process such as organization of services, changes in budgetary allocation and distribution of resources, improvement in access to and utilization of health services, and the impact on health outcomes. Additionally, the PAHO report mentioned Barrio Adentro s participatory democracy. An article by Alvarado et. al (Alvarado, Martinez, Vivas-Martinez, Gutierrez, & Metzger Wolfram 2008) was published in 2008 that described Barrio Adentro in detail and the Venezuelan National Public Health System. The article also described the impact of these health policies on the quality of life of the population. Participatory governance can be a top-down initiative or result from bottom-up mobilization (Schonleitner 2006) and is at the interface of state and society. A study by Briggs and Mantini-Briggs (Briggs & Mantini-Briggs 2009) published in 2009 described a mixed-methods case study on Barrio Adentro. The case study used interviews, ethnographic observations and document research, and a household survey to study various aspects of Barrio Adentro. The main conclusion of the study was that Barrio Adentro is mixed or horizontal in nature instead of being a top-down or bottom-up effort. The authors found that decision making in Barrio Adentro resulted from collaboration between professionals and residents in underserved communities and that such reforms could therefore creatively address health inequities. Finally, an article by Armada et. al (Armada, Muntaner, Chung, Williams-Brennan, & Benach 2009) was published in 2009 that reported epidemiological evidence related to access, utilization and impact of Barrio Adentro and survey results from patient satisfaction interviews. The article identified community participation in Barrio Adentro as an area for further research. There is one study

12 related to the participatory democracy aspect of the social transformation process in Venezuela. The study by Harnecker (Harnecker 2007) is about workplace democracy and collective consciousness resulting from workers participation. While the study is not directly relevant to health or Barrio Adentro, there are lessons for participatory democracy in the reform process. The preceding summary of literature shows that while various aspects of Barrio Adentro have received attention, research on its community participation aspect has not been addressed. There is a need to address this area of research as it is one of the highlights of Barrio Adentro. In this context, our study sought to explore the following research question: What are the barriers to/challenges of participation for community groups involved with Barrio Adentro, a state-initiated health reform to improve health and promote popular participation in health? In a review of literature on the challenges of participation at the state-society nexus in participatory governance efforts, Abers (2000) broadly categorized the challenges as relating to implementation, inequality, and co-optation (Figure 1). She used these categories to do a comprehensive analysis of the participatory budgeting experience in Brazil. Since many of the Venezuelan participatory governance institutions learnt from the Brazilian experience (Wilpert 2007), we used Albers categories in this study to analyze the challenges of community participation in Barrio Adentro. Figure 1: The challenges/dilemmas of participation IMPLEMENTATION Political strategy gives control to most organized Political strategy reduces civic autonomy Government control reduces civic autonomy INEQUALITY CO-OPTATION

13 Increased autonomy gives control to most organized Implementation challenges may broadly fall into those related to legal and administrative aspects. The legal basis for implementation of policies promoting popular participation may require constitutional changes and enactment of laws. Administrative challenges may arise if mid- or lowerlevel officials are not willing to relinquish power to citizen groups even if there is political will at the highest political level. Other groups that may have an interest in the status-quo may also create hurdles to the implementation of the policies. Such groups may include powerful business groups and the media. In the case of health, medical associations and pharmaceutical industry may be unwilling to let go of their monopoly power over the health sector. Inequality presents another challenge. Representation in participatory fora may be skewed toward the privileged while the marginalized may be underrepresented. The cost to participate in terms of time and commitment may be much higher for marginalized groups. The cost could be in terms of time or physical/geographic accessibility to popular arenas of participation which may be more for the poor. Also, such groups may lag behind others because of lack of formal education or lack of information and access to information to reach decisions. Lastly, power differentials among groups within deliberative arenas may also pose a challenge that could affect the outcome of such processes. Co-optation presents another dilemma especially in cases of state-led participatory efforts where the state s intention may only be to create a façade of public legitimacy. The poor and marginalized in such cases may be co-opted to gain public legitimacy for policies that actually promote a top-down agenda. It is therefore important to note that participation involves planning and execution of projects and that there is accompanying control and delegation of powers and not simply the implementation of pre-designed programs. When combined in various ways, the three dilemmas present further challenges. For instance, to implement participatory policies with the idea of sustainability if political strategy preferentially provides space to allies it may aggravate the problem of inequality. Or if decision making is left to autonomous organizations then the less organized or unorganized (usually the marginalized)

14 may not be represented adequately, thereby worsening inequality. However, if the state administers control over such organizations to avoid inequality in representation then civic autonomy may be diminished. Process of research We selected concept mapping (Anon 2005;Burke et al. 2005;Kane and Trochim 2007) to study community participation in Barrio Adentro. The study was carried out between June and August Concept mapping is a mixed-methods approach that integrates a structured, facilitated group process with advanced multivariate statistical analyses to enable a diverse group of actors to collaboratively map the outcome domain of a program or initiative ( 2005). Data collection for concept mapping is carried out through a participatory workshop that employs qualitative techniques such as brainstorming, sorting, and ranking of ideas. The study team included the principal investigator, two Venezuelan researchers, and two additional persons (also Venezuelans) who helped out with the workshop. Non-random purposive sampling rather than representative sampling was done in order to have a broad sampling of ideas rather than a representative sample of the population (Kane & Trochim 2007). The study team identified study participants using the following criteria: participant is currently serving either on a health committee or communal council or had served on either or both; participants represent rural, urban, and indigenous areas and states representing varying levels of economic/social development; participants represent areas with varying levels of health services in their neighborhood prior to Barrio Adentro; and participants represent communidads that had varying levels of participation. Thirty-four participants representing five of 24 states in Venezuela (Table 1) were selected and attended the workshop. Data for three participants was not complete and therefore not included in the analysis. Ethical approval for the study was obtained from Johns Hopkins University Institutional Review Board (IRB # ). Participants provided verbal informed consent. Study piloting was done to test various aspects of the workshop such as the appropriate and contextually-specific use of language. Table 1: Classification of Venezuelan states in social territories, 2002

15 (PAHO 2007) Social territory 1 (least developed) Amazonas Delta Amacuro Guarico Social territory 2 Social territory 3 Social territory 4 Social territory 5 (most developed) Yaracuay Lara Nueva Esparta Capital District Sucre Falcon Aragua Miranda Trujillo Monagas Anzoategui Portuguesa Merida Bolivar Barinas Tachira Carabobo Apure Cojedes Zulia Each participant was asked to provide basic demographic/organizational characteristics, the results of which for the thirty-one participants are summarized in Table 2. Table 2: Participant demographic/characteristics Questions Variable Categories 1. Currently are you part of any of the following forms of popular participation? a. Both b. Health Committee c. Communal Council 2. In your community how would you characterize healthcare situation before Barrio Adentro? a. Good b. Bad c. Non-existent 3. Currently how would you characterize healthcare situation in your community? a. Good b. Bad c. No change 4. How would you characterize popular participation in your community? a. High b. Low c. Medium 5. Are health-related decisions taken by the community taken into consideration by the authorities? Frequency Percentage

16 a. High b. Low c. Medium Participants were then asked to brainstorm the barriers/challenges of participation in Barrio Adentro which resulted in 220 short statements or phrases. Brainstorming took about an hour to complete. Statement reduction by the study team took 3 hours and resulted in 100 final statements which were then shared with participants to confirm that all ideas generated during the brainstorm were included. Next, participants were asked to sort similar statements into piles and label each pile based on what they considered to be the common theme of the statements in the pile. Participants were also asked to rank each statement on a scale of 1 (not important) to 3 (very important) according to two criteria, 1) barriers that generated the most difficulties and 2) barriers that needed the most attention. The sorting/piling and ranking activities took about 3 hours to complete. Analysis The workshop was conducted in Spanish. Participant demographic and sort data was entered into the concept systems software ( 2005). Data entry was done in Spanish and later translated to English by the study team. Data was analyzed in three steps. The first step involved analyzing participant demographics using descriptive statistics. The second step involved a graphical analysis of the statements in relation to each other. The graphical representation is in the form of a spread known as the point map with each statement representing a point with the statement number displayed on the graph. The point map uses Multidimensional Scaling MDS technique to aggregate sort data. The key diagnostic test for MDS is called the stress index which measures the degree to which the distances on the map are discrepant from the input sort data. The third step involved using a technique called Hierarchical Cluster Analysis to group individual statements on the point map into clusters of statements that aggregate to reflect similar concepts (Kane & Trochim 2007). Cluster analysis started with twenty clusters. Preliminary analysis by the team narrowed down to a five cluster solution with each cluster containing statements reflecting similar participant ideas. Each cluster label represented a common

17 theme of the statements in that particular cluster. Cluster labeling was carried out using labels displayed as suggested cluster labels by the software that were contributed by the participants during the sorting stage. That and the analysts own understanding of the contents of the map help finalize the most appropriate label for a cluster (Kane & Trochim 2007). Clusters are displayed graphically and overlap point pattern of the point map. Cluster configuration and the overall pattern follow closely the spread of points (statements) on the point map. Cluster size depends on how closely or how far apart the points are on the point map. A compact cluster size depicts close proximity of the points on the point map and reflects greater participant consensus about the interrelationships of the statements in that cluster (Kane & Trochim 2007). Results Participant demographics/characteristics Participants represented the states of Miranda, Bolivar, Lara, Amazonas, and the Capital district (Table 1) which represented different social territories numbered from 1 to 5 based on their economic development status. Table 2 shows that participants represented both health committees and communal councils. The majority of participants described the healthcare situation prior to Barrio Adentro in their communities as either non-existent 45% or bad 39%. Eight-one percent reported the current healthcare situation good. When asked to characterize popular participation in their communities 55% reported medium, 29% high and only 16% low. Lastly, in response to whether healthcare decisions taken by communities were considered by authorities the majority 52% reported medium, 26% low and only 23% high. Clusters/themes Figure 2 shows the point map. The stress value is (recommended range is to 0.365) suggesting a better fit of the point map with the input sort data (Kane & Trochim 2007).

18 Figure 2: Point map with each point representing a statement and shown with statement number Stress value ( ) Figure 3 is a graphical representation of the five clusters that emerged as a result of the analysis. Figure 3: Clusters Contentious political situation Information dissemination; training & education; mutual learning across communities; possible community roles; problems with community participation Relations between Cuban & Venezuelan healthcare providers Problems with general infrastructure Problems with healthcare services

19 Figure 4a summarizes how the most difficult barriers were ranked and Figure 4b summarizes how the barriers needing most attention were ranked. Note that in each figure the height/thickness of the clusters reflects the importance given to that cluster. Figure 4 a: Challenges that generated the most difficulties for popular participation in Barrio Adentro Contentious political situation Information dissemination; Training & education; Mutual learning across communities; Possible community roles; problems with community participation Relations between Cuban & Venezuelan healthcare providers Problems with general infrastructure Problems With healthcare services Figure 4 b: Challenges that deserve attention in order to promote popular participation in Barrio Adentro Contentious political situation Information dissemination; Training & education; Mutual learning across communities; Possible community roles; problems with community participation Relations between Cuban & Venezuelan healthcare providers Problems with general infrastructure Problems with healthcare services

20 Problems with healthcare services Several problems were mentioned that were related to health services such as insufficient number of health facilities and other health resources. It was mentioned that the physical space within most health facilities was limited. Geographical limitation for placing of new health facilities was also a concern, possibly reflecting the space limitation that is typical of the barrios in Venezuela. Problems with general infrastructure Issues related to access to services in general were mentioned. The concern was that poor infrastructure hinders access to services. Infrastructure problems such as in transport, water supply, food supply, and safe garbage disposal had consequences not only for the health sector but across all sectors. The majority of participants reported non-existent or bad healthcare prior to Barrio Adentro indicating that they represented marginalized neighborhoods known as barrios. Problems with community participation, training needs, and inadequacy of information dissemination Participants mentioned that across communities participatory activities were taking place and a process needs to be developed whereby communities could learn from each other. It was emphasized that there needs to be better inclusion of communities in activities such as social audit and decisions on geographic placement of clinics as well as a greater role for health committees in conducting community censuses. The latter was mentioned in relation to improving the knowledge of community members about existing illnesses within their communities. Participants expressed that this knowledge gap hinders their work in conveying health needs information to government ministries. Training needs for health committees in scientific and technical areas was mentioned. Participants also emphasized training for healthcare providers so that they understand the ideological basis of the reform process. The need to promote civic education and awareness for the general public was emphasized. Frequent turn-over of public servants was cited as hampering the continuity of community-generated projects. It was mentioned that continuous motivation for popular participation was a challenge. Possible explanations for this challenge included a general apathy or weakness on part of community, individualism, and competition and internal conflicts among health committees and communal

21 councils. In that regard only a minority 29% reported participation to be high in their neighborhood while the majority 55% considered it to be medium and 16% considered it to be low. When asked whether authorities took into consideration healthcare decisions taken by communities, 52% responded a medium while 23% considered it high. Despite these problems, the participants considered that the successes of the reform process have not been adequately disseminated. Contentious politics Several challenges in the policy arena were identified by the participants. These included a lack of properly defined policies that hindered community participation, a lack of immediate response from state institutions due to bureaucracy within the Ministry, and a need for more dynamic public policies relating to popular participation. Participants cited that particular interests oppose collective interests and personal political promotion and leadership rivalries stifle emerging voices and newcomers. Political resistance from the opposition, a lack of support for reform in opposition controlled states and within governmental levels where opposition is in power, were mentioned as barriers to participation. Consequently, political conflict is such that there is no interest in political integration. Certain sectors have politicized health and private media spreads false and negative news about Barrio Adentro. Relations between Cuban and Venezuelan healthcare providers Rivalry between Cuban and Venezuelan healthcare providers was mentioned as another barrier which has existed since the beginning of Barrio Adentro. Challenges mentioned included a negative attitude of Venezuelan doctors who do not accept the level of expertise of the Cubans as comparable to themselves. This is also reflected in the Venezuelan Medical Federation s negative attitude towards the Cubans. Venezuelan doctors and private clinics do not accept references from the Cubans or share their space with them. There was concern about the living and working conditions as well as the security situation for Cubans. Privatization of healthcare and knowledge of health were also mentioned as barriers to participation and a need was expressed for a radical change in healthcare.

22 Discussion Barrios have historically been areas of deprivation that were not formally recognized neighborhoods and mostly excluded from service provision from the state. While our results mention problems with health services and with general infrastructure, most of the health facilities are placed in these barrios that have been chronically disadvantaged and overcrowded. Thus while mentioning these problems participants were cognizant that this information be put in the context of the reality of barrios. Therefore it was also stated that information about the success of Barrio Adentro had not been disseminated adequately to indicate community members satisfaction with it. In fact, residents of poor neighborhoods reported (Briggs & Mantini-Briggs 2009) that Barrio Adentro is their program and, reflecting their ownership of the reform process, resisted Ministry of Health s efforts to exert limited control over the program. However, it is also reported (Briggs & Mantini-Briggs 2009) that geographic limitations and other issues such as low population density limited MBA [Mission Barrio Adentro s] popular reception and institutional growth. The reform processes going on in various sectors in Venezuela are unique since they are unfolding against the backdrop of social transformation. Maya and Lander (2011) describe this backdrop as not only a transformation of the State but also of the society. The authors indicate that participation is a key educational practice for transforming unequal social relations. Not surprisingly the theme of training and education across various groups was also prominent in our results. Harnecker (2007) also notes the importance of ideological-based education on topics related to the importance of collective consciousness and solidarity in the context of worker cooperatives in Venezuela. She reiterates that for the emergence and development of collective consciousness participatory skills and attitudes are reinforced by participation in other spaces. Thus, workplace democracy and participation in neighborhoods and communities should not be seen in isolation. Participatory experiences in one arena of popular participation reinforce skills in the other.

23 The suggestion that community deliberations and decisions may not be readily taken into consideration in policies and that this may result in apathy on the part of the community fits the claim by Cohen and Fung (2004) that citizen participation suffers if public deliberation and public policy are loosely linked. Such a situation may also reflect that the state or local level authorities may not be confident of the health committees capacities and organizational abilities, as PAHO has reported (2006). While this mismatch needs to be addressed, the displeasure by community groups also reflects how they work closely with the state and yet are able to maintain their autonomy. Armada et. al (2009) report that in 2002 it was pressure from below which led the state to intervene with the social missions initiative. The 2006 PAHO study reports similar findings about community pressures on state to respond to their problems. This pressure from below was not sector-specific and existed even before Chavez came to power; the most prominent example of this is the Mesas Tecnicas del Agua or MTA (Maya and Lander 2011). Community groups also mentioned that the state s lack of expediency was due to bureaucratic procedures at the Ministry of Health. This is despite the fact the Barrio Adentro was initiated as one of the social missions which were specifically established to address the problem of ministerial bureaucracy (Muntaner, Salazar, Rueda, & Armada 2006b). In fact, the missions were established as a temporary policy mechanism to address the urgent needs of the population (Maya and Lander 2011). Participatory councils are generally mandated to address neighborhood issues like the provision of water supply, neighborhood security, health and other services and the monitoring of such services. Being closer to and having their daily lives affected by these problems may give communities rather than state authorities the vantage point to solve those problems. While state authorities may be skeptical of communities capacity to address their neighborhood problems, the reverse may also be true. The context in Venezuela is dynamic and participatory experiences are evolving especially at the local/community level. Our results show that it may well be the case that state policy is not able to keep pace with these changes at the community level. Thus, it may in fact be a case of the state not having

24 this capacity to adequately deal with deliberations at the community level. Abers and Keck (2008) have also reported this question of state capacity about Brazil. Also mentioned was the problem of political difference in some states (controlled possibly by the opposition) and the opposition by certain officials within state administration and bureaucracy. A study by Abers (Abers 2000) about the participatory budgetary councils in Brazil found similar implementation problems. Such problems relate to the fact that although there is commitment to popular participation at the highest political level, this may not be the case for mid- or lower-level officials. Elements within state bureaucracy and administration at the mid- or lower-level, where implementation of such policies actually takes place, may either be not fully aware of the political ideology and the commitment of higher officials to that ideology or that they just oppose such policies. While the Venezuelan State has been promoting its political ideology as socialist transformation of the 21 st century, it faces considerable political resistance. The study participants identified that this political resistance from the opposition is also a hindrance to popular participation especially in garnering support in states led by the opposition. This finding is also reported by the Briggs study (2009) which mentions that the institutional growth of Barrio Adentro is hindered by roadblocks placed by regional governments in some areas. The same study also mentions that health professionals working for Barrio Adentro reported that opposition supporters sometimes blocked ambulances and banged pots and pans, scaring patients. The political conflict in Venezuela needs to be seen in the context of the divisive nature of Venezuelan society. Historically, a small group of elites used the country s oil resources to take control over economic and political. They excluded the majority from benefitting from this resource. In the late 1970s, when Venezuela joined other countries on the continent to implement neoliberal policies social inequalities worsened. Privatization of health services was one example of policies which disproportionately negatively affected the poor. Consequently by the late 1990s class-based health disparities were enormous (Briggs & Mantini-Briggs 2009). In Venezuela popular mobilization against