Health policies and the right to participation
Participation has been recognized as a human right in the Venezuelan Constitution (article 114), in the International Covenant on Civil and Political Rights (article 25) and in the American Convention on Human Rights (article 23).
The right to participation is one of the rights that cuts across all human rights, and particularly economic, social and cultural rights. International agencies such as the United Nations Development Program (UNDP) have begun to recognize the importance of this right by stating:
With regard to the right to health, community participation has been highlighted by various international documents as a core ingredient of health strategies. For instance, the Declaration of Alma-Ata stresses that "people have the right and duty to participate individually and collectively in the planning and implementation of their health care."13 The same Declaration further points out that primary health care "requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate."14
Participation should not be limited to primary health care or to small-scale community projects. On the contrary, the right of the population to participate in various aspects related to health also implies:
This same right to participation in health matters is recognized in articles 5 and 8 of the [Venezuelan] Organic Law on the National Health System (LOSNS) (Ley Orgánica del Sistema Nacional de Salud). The Presidential Commission for State Reform (Copre) (Comisión Presidencial para la Reforma del Estado) proposes three levels of participation in the health sector -- central, intermediate and local -- and suggests that participation should be incorporated into the establishment of priorities, the planning process itself, and the provision of services and evaluation.16
From the above legislation, it is clear that for the development of effective strategies in the health field, participation which is limited to specific stages of decision-making is insufficient. On the contrary, the legislation offers a variety of possibilities for participation including in the planning, evaluation and monitoring phases of health programs. Nevertheless, authorities frequently limit community participation to aspects of project implementation. This fact has been confirmed by the United Nations Special Rapporteur for the Realization of the Economic, Social and Cultural Rights, who indicates that:
The Pan American Health Organization (PAHO) has also confirmed this reality in the health field by stating that:
While it is true that the LOSNS recognizes the importance of community participation in all stages of health policies, it is worth noting that the risk of limited participation exists. Copre underlines that participation "is to be integrated into the process of institutional planning, and is not to be a parallel element, marginal to formal health institutions."19
Participation limited to stages of implementation may lead to the development of "clientele" relationships in which communities feel benefited by being delegated responsibilities of implementation in exchange for expected advantages, such as the use of health centers for community activities. This "clientele" relationship can also have a negative consequence to the extent that communities participating in community health projects can end up renouncing their right to health in a more holistic sense for fear of confrontation with the authorities who "opened the door" for them -- as tiny and irrelevant as that opening may be -- to the co-management of health services.
In this sense, while the population's involvement in hospital boards, administration of public health centers, maternal-infant care programs and other initiatives, constitute legitimate and necessary forms of community participation, they may entail a transfer of responsibilities and/or resources to organized sectors of society which, in turn, may imply that the state is no longer the entity ultimately responsible for the management of such health services. The gaps in the LOSNS on these issues, together with the growing tendency of state agencies to shift their responsibilities to individuals (especially in times of fiscal crisis) may transform participation into a double-edged sword, one that is eventually turned on system beneficiaries.
Finally, it is important to note that the community is to be informed
in order for participation to be effective. To assess the political
will of authorities in this matter, certain factors are to be considered.
Without intending to be exhaustive, the following considerations may
From the above, it may be concluded that the right to participation in health matters is one of the most important areas for ensuring the fulfillment and enforcement of the right to health, and one of the least normatively developed. Developing normative frameworks for participation in health matters and providing the population with effective tools for monitoring official health policies is one of the most urgent challenges in the immediate future for the right to health.
17. United Nations, "Final Report of the Special Secretary of the Human Rights Commission on the Realization of Economic, Social and Cultural Rights" Sub-commission on Prevention of Discrimination and Protection of Minorities. E/CN.4 Sub.2/1992/16, July 3, 1992, paragraph 179.
21. Considering the relatively recent experience of decentralization and transfer of responsibilities in the case of Venezuelan and of the complexities and gaps present in the legislation governing this matter, the topic is not addressed directly in this document, although it will be the object of future research.