Challenges of participation in the Venezuelan health reform Barrio Adentro

The Venezuelan health reform Barrio Adentro, initiated in 2003, aimed to improve population health and promote popular participation. The reform has resulted in gains in coverage and utilization and reduction of health inequalities but its discerning feature is participation by communities. Popular participation is achieved through health committees and communal councils. This institutionalization of community organization serves as a mechanism for organized community groups to participate in health decision making. Popular participation in state affairs whether top-down or bottom-up presents certain challenges of participation at the interface of state and society. A study was conducted to explore these challenges from the community's perspective using a mixed-methods participatory methodology called ‘concept mapping'. 31 participants representing health committees and communal councils from five states of Venezuela were selected using non-random purposive sampling. Qualitative techniques such as brainstorming and sorting were used for idea generation. The generated ideas were categorized into clusters/themes using quantitative techniques such as multidimensional scaling and hierarchical cluster analysis using the concept mapping software. The results indicate that the political will for the reform is there at the highest political level. However, the opposition political parties, the medical federation, and private media oppose the reform. Public participation in state affairs is facilitated if there are popular arenas of participation which serve to increase the surface area of the state to promote engagement of organized citizenry with the state. This, in turn, leads to ongoing interaction between state and civil society in order to radically transform the state.