title: The role of social participation in municipal-level health systems: the case of Palencia, Guatemala.
abstract: BACKGROUND
  Social participation has been recognized as an important public health policy since the declaration of Alma-Ata presented it as one of the pillars of primary health care in 1978. Since then, there have been many adaptations to the original policy but participation in health is still seen as a means to make the health system more responsive to local health needs and as a way to bring the health sector and the community closer together.
  
  
  OBJECTIVE
  To explore the role that social participation has in a municipal-level health system in Guatemala in order to inform future policies and programs.
  
  
  METHODS
  Documentary analysis was used to study the context of participation in Guatemala. To do this, written records and accounts of Guatemalan history during the 20th century were reviewed. The fieldwork was carried out over 8 months and three field visits were conducted between early January of 2009 and late March of 2010. A total of 38 in-depth interviews with regional health authorities, district health authorities, community representatives, and community health workers (CHWs) were conducted. Data were analyzed using thematic analysis.
  
  
  RESULTS
  Guatemala's armed civil struggle was framed in the cold war and the fight against communism. Locally, the war was fed by the growing social, political, and ethnic inequalities that existed in the country. The process of reconstructing the country's social fabric started with the signing of the peace agreements of 1996, and continued with the passing of the 2002 legal framework designed to promote decentralization through social participation. Today, Guatemala is a post-war society that is trying to foster participation in a context full of challenges for the population and for the institutions that promote it. In the municipality of Palencia, there are three different spaces for participation in health: the municipal-level health commission, in community-level social development councils, and in the CHW program. Each of these spaces has participants with specific roles and processes.
  
  
  CONCLUSIONS
  True participation and collaboration among can only be attained through the promotion and creation of meaningful partnerships between institutional stakeholders and community leaders, as well as with other stakeholders working at the community level. For this to happen, more structured support for the participation process in the form of clear policies, funding and capacity building is needed.
authors.affiliation: Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden; alruano@gmail.com.
authors.forename: Ana Lorena
authors.initials: AL
authors.lastname: Ruano
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration; D006166:Guatemala; D006291:Health Policy; D006801:Humans; D058992:Social Participation; D019037:Urban Health Services / Q000458:organization & administration*
keywords: alma ata; community health workers; community participation; guatemala; palencia; primary health care; social participation
references.citation: Med J Aust. 2003 Jan 6;178(1):17-20
references.pmid: 12492384
references.citation: Health Policy. 2005 Jul;73(1):92-103
references.pmid: 15911060
references.citation: Gac Sanit. 2002 Jan-Feb;16(1):30-8
references.pmid: 11841753
references.citation: Int J Health Serv. 2002;32(4):709-32
references.pmid: 12456122
references.citation: BMJ. 2008 Mar 8;336(7643):536-8
references.pmid: 18325964
references.citation: Rev Panam Salud Publica. 2005 Mar;17(3):210-20
references.pmid: 15826402
references.citation: Health Expect. 2009 Sep;12(3):226-36
references.pmid: 19754687
references.citation: Cad Saude Publica. 1994 Jan-Mar;10(1):111-22
references.pmid: 15094924
references.citation: Soc Sci Med. 1988;26(9):931-40
references.pmid: 3388072
references.citation: Am J Public Health. 2003 Jan;93(1):44-8
references.pmid: 12511382
references.citation: Image J Nurs Sch. 1996 Fall;28(3):221-6
references.pmid: 8854543
references.citation: J Adv Nurs. 2003 Feb;41(3):306-13
references.pmid: 12581118
references.citation: Health Policy Plan. 2001 Dec;16 Suppl 2:52-60
references.pmid: 11772990
references.citation: Soc Sci Med. 1998 Dec;47(11):1749-62
references.pmid: 9877345
references.citation: Subst Use Misuse. 1997 Jul;32(9):1155-73
references.pmid: 9261916
references.citation: Cad Saude Publica. 2002 Jul-Aug;18(4):905-25
references.pmid: 12118301