Health, Adult education and Democracy

written by M. Teresa Marshall, 1991

To talk about adult education and democracy, one must present examples of concrete problems that illustrate the true nature of this relationship, its contribution, problems and challenges.

Adult education and popular education have accepted the challenge to contribute to the development, strengthening and building of democracy in Latin America. While this would seem to be very ambitious and far reaching assignment, it can be carried out through different educational programs that are now being developed by social organizations. They contribute toward democracy through their orientations, practices, methodology and social and political choices. In this presentation, I will try to illustrate how work in education for health contributes to the development of democracy today.

The challenge of democracy has given new contours to the everyday business of education. Historically the specific contribution of popular education has been found in its work with organizations in civil society, promoting processes of leadership, activism, and participation. At the same time it seeks to promote cultural values based on solidarity, equality and diversity by confronting the day to day problems that affect the quality of life of the most oppressed sectors - values which offer an alternative to the values of the market economy, competition and authoritarianism. In this way, popular education makes a contribution to the democratic process by strengthening social organizations, promoting new values and solving everyday problems.

Viewing the relation of adult education and democracy through an analysis of health practices offers a series of advantages, because health programs face the aforementioned challenges and have components of social participation, of promoting values of equality and solidarity, and collectively looking for appropriate solutions. It is not possible to understand this process outside the context of continuing education activities.

 

Democracy and health: policy orientations

In Latin American countries that have gone through a crisis in the last ten years - a crisis having serious impact on the quality of life of the population, the challenge to democracy is related to its response to these denominated social debts. Yet the larger part of our incomes has been designated to pay the external debt, without paying attention to the great damage that has accumulated in the poorest sectors.

Health is one of the central themes of social policy for democratic governments. It has been one of the principal demands; - and is a major concern today - because the scarcity of healthcare and the deterioration in general health has become intolerable. The relevance of the subject of health for democracy appeals to those of us who work in the field and has made it necessary to formulate an innovative political response to the most urgent problems.

It is clear that today there are different viewpoints and contributions as to how to confront this situation. Those who have a background in the area of adult and popular education, who work in the social and the communitarian area, seek ways to contribute to this process from the viewpoint of health promotion and preventive medicine, with a special accent on strategies for education and social participation.

Today, these areas are very controversial, especially due to the degree that the principal threats to the health of the general public are related to poverty, high risk behavior -AIDS- and environmental conditions. In these three areas, policy necessarily must have an orientation with a social, promotional, and educational character.

Orientations which are key to democratic health policy:

1. A concept of health that is associated with quality of life, that enables us to undertake policies of prevention and promotion in integral and intersectional terms. At the same time, models of development which are able to generate and redistribute the goods and power in society should be considered.
It is no wonder that while development models based on market economy laws, models that accentuate the concentration of wealth and social inequality are being applied, and policies of privatization of health care for the high income sectors are being carried out simultaneously; that at the same time, policies, or better said, charities - of health subsidies for the poorest social sectors are applied. These policies translate into low quality healthcare for the poor, and reflects part of a general strategy of segregating and palliating the poor, that can not hope to repair the damage that has been done in this social group.

2. Health policy should be directed toward reducing inequalities. Serious inequity exists in Latin America - health indicators in rural and poor urban areas are far lower than national averages. Inequality is also reflected in the distribution of resources, as the highest percentage of health spending is concentrated in the high income sector, without the government's having any real powers of redistribution or solidarity. In a democracy, health policy should take inequality into account and act with criteria of positive discrimination, giving priority to assisting high risk social groups.

3.What is needed today is to renew aid to those groups which have been practically abandoned - students, youth, the elderly - while simultaneously, taking a qualitative leap concentrating on the quality of healthcare. In various cases, women in popular health organizations have raised their voices to cry out for more humanized health, with an emphasis on people and the community and not the marketplace.

4. Empowering and channeling the abilities of the social groups that have formed around the need for health care in cities and rural areas represents another clear direction for democratic health policy.

5. Finally, redefining the role of government should be included in this list of priorities, keeping in mind that health is a right of the population and a duty of the government. It is necessary to redefine the role of the government in the perspective of empowering development at the local level, with a permanent incorporation of the organizations of the social fabric. The local dimension in health policy enables us to close the breach between State and civil society, while designing policies starting from local needs and demands.

 

Democracy and health: toward social participation

On many occasions, the concept of democracy is accompanied with the adjective "participative". This phrase lends character to health policy.

The contribution the thinking and practices of popular education has made in this field is of vital importance. Its participative concepts and methodologies have produced a true revolution in traditional thinking about health programs.

a) Participation and knowledge

A unified vision or a single priority to confront health problems has never existed. Different perceptions and analysis are always intertwined. Therefore, the contribution of the community brings new and different elements into play by the definition of their own needs and health problems.

b) Participation and priorities

In participative strategy, it is viable to start work from the needs most felt by the population, and at the same time widen this starting point with technical, social, and educational support, which makes it possible to understand and include the factors that provoke health risks, and to act in more complex ways. For example, work has been done around the problem of nutrition combining activities to diagnose malnutrition, development of organizations to meet nutritional needs - soup kitchens, buying cooperatives - and establishing plans to monitor nutrition with the objective of recuperation and prevention.

c) Participation and action

A strategy of participation is only effective in so far as it is closely tied to specific program goals. Participation in and of itself is a myth, it goes without saying, that participation must be linked to specific actions. Organizing efforts and community based activities cannot bear fruit without the development of skills and technical ability for specific work.

d) Participation and training

Strategies of participation of the population in health policy should be accompanied by a process of training and teaching so that the community is able to work on concrete aspects about community health policy. The needs for learning are sufficiently wide at this level, and include technical aspects of health, but there is a special need to develop leadership, organizing, communication and educational skills, around activities of healthcare.

e) Participation and evaluation

The incorporation of the community in evaluating the framework of health programs, is a key dimension, not only to hear or benefit from their opinions, but also one in which social organizations can become involved.

Different expressions of democracy in health

There are different styles of participation at the community level, and it is not possible to identify any one strategy or model of participation that is applicable to every situation. Not even within the same country. There are no recipes. But it should be very clear that PARTICIPATION and ACTION of and by the people are a central challenge and a key component for a democratic health policy.

Different paths have undertaken the challenge of people's participation and action in a creative way. Among these are:

a) Participation and social policy

There is a consensus about the need to incorporate community participation in the formulation of social policy related to health. The participation of the population in health is connected to the identification of problems, decision making, and carrying out policy. Various experiences have accepted this challenge, and what is needed today is to channel it through the different existing structures and organizations (unions, neighborhood committees, women's groups). In other countries, the promotion of the creation of new organizations to specialize in areas in health, such as the Popular Health Councils and Health Committees, (Bolivia, 1983-85), which worked out, implemented and coordinated fundamental policy priorities.
The participation of the population in the identification of the problems for health policy, (formulation, execution, and evaluation), assured the viability, because it gave the Bolivian programs a permanent connection with reality.
To the degree that health planning entails intersectional policy, different commitments and political will are needed. In such a situation, social mobilization is essential for successful development. And in the moment of implementation of these policies, it is indispensable that the structure of peoples organizations be stable, so that their ability to formulate demands and policy can also be translated into capacity for action, control and evaluation. Again, the example of Bolivia is illustrative. There they achieved ample coverage in vaccination thanks to the sustained action of the popular health committees.

b) Participation and treatment

We are not always in the position to participate or to influence the formulation of public policy. A common case in Latin America, and in many places we find ourselves with precarious and atomized social structures as well. In these situations, often the greatest health demand is for assistance and treatment. It is also possible to implement participative strategies in this context, which will permit the democratization of attention to illness, bring the doctor-patient relationship closer, create channels of communication for learning- teaching apprenticeship in the popular culture. The experience of the Campesino Consultorios in Ecuador, of the Children's Hospital in Panama, and Hospital Without Walls in Costa Rica are examples of a strategy that seeks to provoke participation in different spheres of attention to illness and in actions in defense of health.

c) Participation and social movement

A large part of the efforts - especially those of the non governmental organizations - to develop participative strategies for health have taken the path of strengthening the development of organizations and popular groups who are able to take on leadership in actions for health at the local level. This tendency grew during the 80's - a period of strong economic recession, in which the State reduced health spending and gave priority to decentralization and privatization.
This option sought to strengthen opportunities for participation in civil society, and to reinforce democracy. It works with new demands, - women's health, traditional medicine, ecology - and it creates new forms of struggle in social movements, uniting legal actions addressed to the government, and self-management proposals. In short, it struggles to open a new field of action, anti- bureaucratic, concentrated at the local level, trying out new possibilities, or re- writing old utopias.
It has to do with a strategy that incorporates the demand for health and creates the ability for management at the level of local groups, especially in rural and poor urban areas. It takes into account a series of health needs that have close ties to quality of life and seeks to treat these needs at the community and family level. There is in this a strong local and self-management emphasis; which in goes gathering in its path the need for interlocution, coordination, and collaboration with what the government is doing.

Democracy and health: the contribution of popular education

Popular education and its contribution to building democracy

The relation between education and democracy has a long tradition in Latin America. The last decade, has brought about the challenge of promoting democracy through education, in a perspective able to connect the role of individuals in society and increase the development of their abilities within the framework of liberty, equality, and solidarity.

This relationship is founded in the concept of democracy, that is associated with a growing process whose dynamic is the dialectic among three dimensions: equal opportunity, freedom, and institutions able to channel them. This concept of democracy is a space to build in, to improve, to broaden the agreement about suitable possibilities for development.

Therefore, democracy is both a challenge and a task, whose products are decisions that affect the whole society, even if their starting point has been that small nucleus of civil society, of social movements. It is, therefore, a task which transcends the great public stage, not one exclusively related to accords and debates in the Halls of Government.

It is in this framework that we look for criteria to orient education for democracy. In simple terms, we can identify three principal issues:

a) daily life is the key structure for education for democracy, it should address the problems of the participants.

b) The grass root organizations which unite people who struggle for democratization, constitute a principal focus which is able to take up this challenge.

c) The connection between those who work at the local or private level, and the public policy debate is what guarantees, what assures impact and replicability.

With these issues, we can identify the principal characteristics of the educational process, that aim toward building democratic relations.

First, the contents of education for democracy should be directed to vital and concrete experience that is posed by the groups themselves. Starting with the realities of everyday life and what the group represents this to be, makes it possible to orient education toward this change.

Second, if we want education to produce conscious and committed students, the educative process must teach procedures, and not just transmit information and facts. This means that students must become involved in searching, trying, acting, which promotes creativity and responsibility.

Third, it means developing an educational process that is able to encourage group work and collective action. It is important to learn to discuss, defend different propositions, negotiate, and reach agreement.

Fourth, while the starting point of learning is everyday experience, educational practice should be able to go beyond this concrete level and deal with problems in their totality, with a global perspective that explains and makes it possible to define alternatives to act at the social and political level.

Fifth, the educational process should keep looking for methodology which is congruent to the aforementioned principles, keeping alive the traditions of popular education in participative methodology.

The task of health education in building democracy

It is of interest to present a series of practices and ideas about the daily routine of education in the field of health and their contribution to the task of building democracy.

First, the concept of health education should be analysed in the light of popular education and the democratic challenge.

Traditional educational models are not the answer to today's health problems. In fact, these have proved to be a complete failure. It is not our role to defend this analysis here, but rather to point out the new and original contributions that popular education has to offer. It is a question of an educational method that includes different dimensions: emotional, cognitive, instrumental, and the practical-political. These dimensions are unfolded within the context of social-civic organizations, with the aim of developing their capacity for true social and political activism. In the field of health, it is seen that comprehensive education can bring about true changes in behavior and true social change.

EDUCATION FOR CHANGE, is an educational method whose aim is social and political change, with an interest in amplifying the opportunities for organizing and action in the popular sectors and encouraging their leadership roles. This general aim is manifested in ways that are both familiar and timely, understanding health as a political phenomenon, and seeking opportunities for demands and action. ("I have rights, and now I know how to do it").

TOWARD PERSONAL GROWTH, group endeavor, accompanied by educational work, bring about a process of personal growth and development - becoming conscious of and developing abilities to act. ("I have changed, now I dare to speak out, to ask the doctor, I have the facts"). In this way, personal growth through educational work in health takes on at the same time a therapeutic nature, many situations of emotional conflict are resolved through educational experience.

PROBLEM BASED EDUCATION, the problems which are identified by working with the participants are the basis for planning educational practice - not just problems defined by the educator and technicians. This orientation manifests itself in different ways, such as:

- an emphasis on promotion of health and preventive medicine with the ability to deal not only with specific problems, but also with all the factors associated with it, therefore, assuring prevention;

- a trans-sectional approach, because problems are not just related to "health": AIDS, environmental deterioration, increasing poverty;

- criticizing the dominant system, because the dominant culture does not encourage behavior that promotes health (the culture of alcohol, drugs, unrestricted sex, violence, abuse of power);

- simultaneous action to address several health problems at the same time, because our countries have to solve vaccination coverage, providing infant mother care, and attending to childbirth, adolescent pregnancy, drug addition, and AIDS.

LEARNING AND DOING, not only is it important to want to succeed, but to know how this is to be done - that is to say, choice of methodology. This has been a continuing debate in popular education, one which has sought to give importance to processes and procedures, to methods and techniques. One of the most original aspects is the creation of participative education techniques and of group development. The subject of educational methodology is especially important in health problems, where it has been able to prove that mere knowledge does not bring about changes in practice and conduct.

A RELATION BETWEEN PRACTICE AND KNOWLEDGE, popular education proposes to produce knowledge through analysis of its educational practices, with emphasis on systematization and evaluation processes. This concern is particularly relevant to the field of health, because new areas are being developed and the desire exists to generate new policies about these problems.

In synthesis, it can be shown that popular education and the choice to strengthen the processes to build democracy, has brought about radical change from the methods of traditional education. It is a change not only in content, but fundamental in the aims, methodologies, and the relationship between educators and students.

The present challenge is to develop the ability of popular educators so that they influence the programs that involve different social actors in solving problems.