Health, Adult education and Democracy
written by M. Teresa Marshall, 1991
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.
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.
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.
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
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.
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.
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
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
which are key to democratic health policy:
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
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.
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.
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
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
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
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
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
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
d) Participation and training
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
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
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
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.
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.
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
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
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.
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.
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
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
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
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
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
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.
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").
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.
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.
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.
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.