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Introduction
In many developing countries, strengthening the partici-
pation of health care users in decision-making has been an
important component of the health sector reform.1–3 Increas-
ing user involvement is thought by international and national
policymakers to contribute to improved efficiency, equity and
quality of health care delivery.2,4,5 In Colombia and other
Latin American countries where such reforms have been
especially prominent, changes have been undertaken as part
of wider transformations in democratic processes and politi-
cal economies.2,6
There is a large body of literature concerned with partici-
pation in health which can be roughly classified into two
opposing perspectives: participation as a means, and partici-
pation as an end in itself – also referred to as the technologi-
cal or target-oriented, and the critical or empowerment
approaches. In the former approach, people may not be
expected to participate in identifying problems or designing a
development programme, but are expected to serve the ends
of professionals or authorities in charge of such programmes.
The latter approach, conversely, emphasizes participation as
a process in which confidence and solidarity among people
are built up. This is defined as a social process by which indi-
viduals and groups seek to identify their needs and make
decisions in order to establish mechanisms to meet them.
Neither of these perspectives explicitly recognizes that the
degree and form of people’s participation depends signifi-
cantly on the political and economic system in which it takes
place.
During the 1980s, under pressure from social movements7–9
and the recommendations of national and international agen-
cies,10,11 the Colombian government introduced changes in
the health sector. These included policies intended to
accelerate decentralization, improve management capacity
within the sector and increase community participation. The
latter initiative advocated the need to empower communities
in order to enable individuals to have greater control over
decision-making through the implementation of primary
health care strategy, the development of Local Health Dis-
tricts and health promotion approaches.12–14 In practice, it
resulted in what Ugalde15 defines as ‘symbolic participation’,
whereby community involvement was largely confined to col-
laboration with the existing system and hence ‘the legitimisa-
tion of low quality care for the poor’. Despite this limited
initial scope, diverse legal mechanisms for user participation
have been enacted since 1975, aimed at regulating and
strengthening historical forms of participation (Decrees 35016
of 1975; 121617 of 1989; and 141618 of 1990). The former par-
ticipatory experiences took place in the context of a highly
centralized state and a vertically integrated health system
with multiple providers, and a large, centralized Ministry of
Health.6
In the second half of the 1980s, participation in Colombia
came to be seen as one of the main ingredients in moderniz-
ing the state, which required a new relationship between the
state and society.19,20 It was thought that the government
should help the users of public services to have a stronger
voice in investment, planning and service delivery, as well as
ensure the accountability of local officials.
A combination of external and internal factors brought about
the political momentum to formulate Law 100 of 1993, which
HEALTH POLICY AND PLANNING; 16(Suppl 2): 52–60 © Oxford University Press 2001
Strengthening user participation through health sector reform
in Colombia: a study of institutional change and social
representation
M MOSQUERA,1,2 Y ZAPATA,1K LEE,2C ARANGO3AND A VARELA4
1Escuela de Salud Publica, Universidad del Valle, Cali, Colombia, 2Health Policy Unit, London School of Hygiene
and Tropical Medicine, London, UK, 3Community Psychology Research Group, Escuela de Psicologia, Universidad
del Valle and 4Escuela de Salud Publica, Maestria en Epidemiologia, Universidad del Valle, Cali, Colombia
The challenge of achieving community participation as a component of health sector reform is especially
great in low- and middle-income countries where there is limited experience of community participation in
social policy making. This paper concentrates on the social representations of different actors at different
levels of the health care system in Colombia that may hinder or enable effective implementation of the par-
ticipatory policy. The study took place in Cali, Colombia and focused on two institutional mechanisms created
by the state to channel citizen participation into the health sector, i.e. user associations and customer service
offices. This is a case study with multiple sources of evidence using a combination of quantitative and quali-
tative social science methods. The analysis of respondents’ representations revealed a range of practical con-
cerns and considerable degree of scepticism among public and private sector institutions, consumer groups
and individual citizens about user participation. Although participation in Colombia has been introduced on
political, managerial and ethical grounds, this study has found that health care users do not yet have a
meaningful seat around the table of decision-making bodies.
07mosquera (ds) 9/11/01 11:31 am Page 52
marked a profound change in the entire health system by
attempting to materialize the goals embodied in the 1991 new
Constitution,21 i.e. universality, solidarity, quality, efficiency
and participation. The social security reform, with a national
health insurance programme, attempts to ensure universal
access to a basic health care package with public financ-
ing.22–24
In 1993, Colombia became one of the first middle–low income
countries to adopt a managed competition strategy to reform
its health care system.25,26 The reform process has taken on
most of the features of the current agenda on health sector
reform that is disseminated internationally.27–38
The new system separates and differentiates its functions into
regulation (modulation), financing, articulation and pro-
vision of services. The health reform introduces structured
competition using market forces as the means of achieving
public sector goals and generating an appropriate environ-
ment for private sector participation. The health reform
creates two types of affiliation. The contributory regime is
intended for those who are able to pay and who are either
employed in the formal sector (for whom two-thirds of the
contribution will be paid by their employers), or are self-
employed and earn at least the equivalent of double the
minimum wage (and pay 12% of their income). The subsi-
dized regime is for those who are deemed unable to pay; it is
financed mainly by the general national budget and receives
1% from the contributory regime.
The health care system, which was originally structured to
subsidize supply, was reorganized to subsidize demand,
enabling health care users to move from one provider to
another. By introducing greater choice and competition
among public and private insurance companies and pro-
viders, the reform attempts to improve quality and efficiency.
In this context, the views of consumers on service provision
and their choices are believed to be of crucial importance for
the optimum functioning of the health system as a market-
place. As one policymaker summarized, ‘users are now the
engine and quality regulators of this sector’.
The assumption behind the reform was that strengthening a
variety of democratic measures in the health system in
Colombia would balance bureaucratic, professional and
administrative controls as well as reduce the abuse of power,
inefficiency and corruption, and improve the quality of public
service delivery.39–41 Local fiscal choice provides theoretical
foundation for the above policies. Local governments raise
most of their revenues on their own from local taxpayers.
Public sector decision-making then has to deal with the reali-
ties of budget constraints. This places special importance on
local institutions whose function, among others, is to collect
citizens’ expressions of service demands and hold local
government responsible for satisfying them. In theory this
model works when multiple and independent channels of
expression are present.
Participation in Colombia is thus conceived within a new
political, economic and legislative framework, in which citi-
zens are entitled to influence issues of public interest through
the exercise of rights and duties in the process of health ser-
vices and programme management. Colombian health care
reforms provide the opportunity for people to participate
individually or collectively as citizens and consumers (i.e.
they can exercise ‘voice’ and ‘exit’ options). Both forms of
participation are put into practice by means of setting up an
institutional framework characterized by an open system and
welfare rights. According to the legislation, users can now
participate either collectively, through user associations,
oversight committees, community health committees, and
elected community representatives in local administrative
boards, or individually, through customer service offices.42
The study focuses on two institutional mechanisms created by
the state to channel citizen participation into the health
sector, i.e. user associations and customer service offices.
According to the legislation, the customer service office is a
complaint mechanism, which, in theory, should contribute to
and enable the decision-making process among providers,
insurers and users, building up adequate means for protecting
and promoting user rights and health care quality improve-
ments. Likewise, user associations are intended to represent
user interests through monitoring health service quality and
mediating between insurers/providers and users when user
entitlements have been undermined. By law, these mechan-
isms should be in place in both insurer and provider organiz-
ations regardless of their legal status (private or public).
This paper concentrates on the social representations of
different actors (policymakers, civil servants, user associ-
ations and users) that may hinder or enable effective
implementation of participatory policy. The concept of social
representation is used here to refer not simply to systems of
knowledge and belief that are held by different members of
society, but also to systems that are socially constructed and
communicated.43–45 The analysis considers that the position
of different actors in the policy arena, the relevance they
attach to the issue under study, and their interests, may hinder
or enable policy implementation.30,46
The study was conducted in a health district with 280 000
inhabitants in Cali, Colombia, a city of 2 million people. This
site was selected for various reasons. First, it has a variety of
private and public insurance companies and health care pro-
viders at all levels of health care delivery. Secondly, it has a
high rate of coverage from contributory and subsidized affili-
ation. And thirdly, its population is representative of differ-
ent socioeconomic strata.
Methodology
This case study, with multiple sources of evidence,47,48 uses
a combination of quantitative and qualitative social science
methods. It is concerned with social representations that
reflect the interactions among the different actors and insti-
tutions at various levels of the health system in Colombia. A
selected set of informants was chosen from the different
bodies operating at different levels of territorial adminis-
tration, such as the Ministry of Health at central level and
the health secretariats at departmental (state) and munici-
pal levels. A group of selected insurance and provider
Strengthening user participation in Colombia 53
07mosquera (ds) 9/11/01 11:31 am Page 53
54 M Mosquera et al.
organizations, which work within the limits of a health dis-
trict in Cali, were selected along with the population living
in this administrative area. The techniques employed are
shown in Table 1.
Qualitative methods
Group discussions
All groups were users who represented low socioeconomic
strata based on classification by the Municipal Planning
Department in Cali. They were recruited from various neigh-
bourhoods within the study area. Each group was divided into
three sub-groups according to age (18–30, 31–50 and over 51
years) with a balance in sex distribution within each group.
Users were defined as participants who had used one health
facility at least in the 6 months prior to the group discussion.
Semi-structured interviews
Semi-structured interviews were conducted to explore the
social representations. Selection of informants at different
levels of the health system was purposive and included poli-
cymakers, government officials, managers from both public
and private insurance companies, and health services pro-
viders, as well as consumer group representatives from the
study area.
Quantitative methods
A structured questionnaire, designed on the basis of prelimi-
nary qualitative analysis, was applied between August and
September 1998. A probabilistic multi-stage stratified sample
was designed, the sample frame including six strata from
different socioeconomic levels as classified by the Cali
Municipal Planning Department. To make the strata more
manageable, they were divided into three levels: low level,
which included strata 1 and 2; middle level, which included
strata 3 and 4; and high level, which included strata 5 and 6.
The sample size of 661 subjects was estimated through Epi-
Info software (version 6.0) and adjusted to account for non-
response and non-participation. The number of subjects to be
interviewed per stratum was estimated through random
selection of households according to the percentage of popu-
lation belonging to each stratum.
The data, collected by an interviewer-administered question-
naire, consist of socioeconomic information, perceptions
about participation in the health care system, and knowledge
about how the system works. Some specific questions were
reformulated after a pilot study.
The interface between health care user and health care insti-
tution was evaluated according to both individual and collec-
tive participation in health care. Individual participation was
measured by what subjects believed they could do as indi-
viduals to improve health care, i.e. complain. Collective par-
ticipation was measured by their willingness to participate in
an association to improve health care, i.e. participation medi-
ated by groups or associations.
The data were double entered into a computerized database
using Epi-Info software (version 6.0) and analyzed using
STATA software (version 6.0).
Results
Institutional actors
The researchers had difficulty making appointments for inter-
views with institutional actors. In most cases, managers or
directors did not attend the appointments, which caused
delays in the process and prevented access to other insti-
tutional stakeholders.
The study found similarities as well as conflicting views
among government officials and managers over the potential
of the new policies and legislation to enhance participation.
Analysis of respondents’ perceptions revealed a range of
practical concerns, which can be summarized as follows.
At the Ministry of Health (central level), there was great
enthusiasm about the benefits of the new participatory
mechanisms. Most informants agreed that services based on
negotiation with the user are more effective and efficient than
those which are not. Participatory mechanisms, they argued,
allow policymakers, implementers and managers to identify
consumer needs. At the same time, they anticipated stum-
bling blocks to effective involvement of the user in health care
decision-making and health system monitoring, mentioning
that embedded bureaucratic and professional cultures would
Table 1. Techniques employed in data collection
Techniques Actors Number
Group discussions Health care users from both contributory and subsidized regimes, 9
and the non-affiliated.
Semi-structured interviews 5 policymakers from the Ministry of Health; 3 key informants 34
from departmental level and 3 from municipal level; 9 informants
from health care providers and 8 from insurance organizations
from public and private companies; and 6 consumer group representatives.
Structured questionnaire Individual adults (over 18 years old) who had used health care in 661
the previous 6 months.
07mosquera (ds) 9/11/01 11:31 am Page 54
delay effective user involvement. Policymakers felt that
modifying this entrenched belief might hinder true partner-
ship between provider and user.
At department level, there was concern about the role of the
user in monitoring the system. This type of input from society
at large was perceived as a duplication of effort that had
already been expended in setting up existing quality control
mechanisms. At this level of the health system, leaders
showed scepticism with regard to the ability of user capacity
to influence decision-making. Given the gap in knowledge
between professionals and lay people, they found it difficult
to conceive that a user should have a say in technical matters.
Therefore, according to these views, participation is limited
to complaining or resolving specific grievances rather than
influencing policy content or organizational change. As one
informant put it “You can participate, he/she can participate,
they can participate, but it is I who decides”.
At municipal level, and despite enthusiasm towards user
involvement in health care decision-making, respondents felt
there was a lack of specific resources for promotion and
development of participation in health. They also pointed out
that the type of contracting carried out between insurance
bodies and providers conditioned and limited the scope of
participation. Participation was thus tied to predetermined
procedures, i.e. user influence could not go beyond what is
legally stipulated. Another issue to emerge was that the state
and its agencies have neither the capacity to enforce legis-
lation on participation nor the political willingness to do so.
Private insurance companies and private health care pro-
viders have limited information about participatory mechan-
isms. Neither sees the benefit of involving people in
decision-making or as quality controllers. However, the
private sector sees benefits in customer service offices. This is
an individual participatory mechanism used to monitor the
quality of health care provision – users’ complaints are gener-
ally taken into account when a contract with a provider is
revised.
Health insurers and care providers in the public sector con-
sidered that there were not enough financial resources to cover
the operating costs of participatory mechanisms nor a specific
item in the general budget to support their functioning. In con-
trast, the customer service offices in the private sector were
seen as usually adequately funded to fulfil their role.
Private sector institutions, however, demonstrated a lack of
trust and commitment in setting up user associations. They
also expressed concern about the ‘politicization’ of these
groups and their interference with management decisions. In
contrast, public sector informants were more inclined to
implement participatory mechanisms – because of legislative
imperative rather than a belief in the potential to improve
quality.
Respondents at almost all levels argued that a lack of a ‘par-
ticipatory culture’ is one factor that may affect the sense of
ownership by a user of newly created participatory mechan-
isms. ‘Indolence’ and fear of retaliation from the provider, in
terms of refusing to provide services, were highlighted as
factors that deter people from participating.
User associations
Of the institutional sample, only three health providers,
exclusively public, had set up user associations. These
included a primary level hospital with three user associations:
one group a self-created community organization and the
other two organized by the institution and based on affiliation
criteria, i.e. contributory and subsidized, and also including
uninsured people. In addition, there were two public health
centres each with two associations. The first centre belonged
to the public health services network under the jurisdiction of
municipal government; this mainly served uninsured people
and users with subsidized insurance. The second centre was
part of the former Institute of Social Security, which, both
before and after the health reform, exclusively served people
with contributory insurance.
In regard to health insurers, only two had user associations.
One was a co-operative and the other belonged to the munici-
pal government. For both of them, their affiliates were chiefly
people with subsidized entitlements.
User associations, as consumer groups, face stumbling blocks
in getting involved in quality control. Representatives of
these associations felt that they could not play their role ade-
quately because they lacked clear communication channels
with the community they represented, and their election
tended to be politicized (in the sense that political parties and
other community groups influence the voting process, in
which there is usually low participation).
With respect to issues of representation, in neither the policy
nor the legislation are there details about the meaning of
‘democratically elected representatives’. Furthermore, the
legislation does not address issues concerning proportional
representation. The study shows that the majority of those
who attended the electoral meeting were entitled to elect rep-
resentatives. In all cases, the election processes were carried
out and legitimized by a minimal fraction of the total users or
affiliates.
The user association representatives felt that they had limited
knowledge of existing participatory mechanisms and of the
health system itself, and therefore could not have an impact
on decision-making. The asymmetry of information between
consumer representatives on the one hand, and managers,
civil servants and health personnel on the other, was men-
tioned as a key factor. Lack of willingness on the institutional
side to interact constructively with the representatives was
also referred to as an important issue. This institutional atti-
tude is manifested by not allocating resources for partici-
pation. There is thus a shortage of resources for consumer
groups to exercise their functions properly.
Users
Recruitment for group discussions proved to be difficult.
First, the high level of criminal activity in the selected
Strengthening user participation in Colombia 55
07mosquera (ds) 9/11/01 11:31 am Page 55
neighbourhoods hindered access to people’s homes; second,
the incentives for attending meetings were not of interest to
the participants. Therefore, some sessions were cancelled
because of low attendance or an imbalance in sex distri-
bution of participants. Men were the hardest to persuade.
In general, participants in the focus group discussions had
limited knowledge of the new institutional participatory
mechanisms, and of the entitlements available under the com-
pulsory basic health care package. Most participants with
social security coverage, either with subsidized or contribu-
tory affiliation, recalled having attended talks on topics
related to health care entitlements and participatory mechan-
isms after the participation issue had been introduced.
However, none could actually remember what their health
care entitlements were or what information they had been
given about participatory mechanisms.
When asked if they knew of any form of participation to
improve the quality of health service, informants enrolled in
either affiliation or without social security coverage high-
lighted collective action as the best way to exert pressure on
health care personnel. All groups expressed commitment to
such values as mutual support, solidarity, working together
and helping each other. They considered that protesting and
complaining could achieve improvements in public health
care. Those enrolled in the subsidized system and those
without social security recognized the above actions as a
moral right, given that they perceive health care as a govern-
ment responsibility.
When participants were asked afterwards for their opinion on
why people did not participate, those covered under the con-
tributory affiliation argued that lack of interest and apathy
prevented people from participating. Those with subsidized
affiliation, as well as those without insurance, of all ages
stated that resignation and fear of expression were the main
reasons why people did not get involved in any participation
activity affecting health care. One respondent stated that
“People are resigned to receiving any old thing and do
nothing to look for alternatives to improve things”. Another
stated that “People are used to being treated badly and to
being abused and do nothing about it”. Fear of expressing
their views on health care performance was also mentioned:
“In Colombia people fear to speak out”. They are afraid that
health care personnel will retaliate by providing low quality
health care or by refusing to attend them personally.
A few respondents stated that politicization of community
groups and lack of leadership discourages participation.
Another factor mentioned, particularly by those without
social security, was distrust of both public institutions and
democratic mechanisms. Some thought that decision-makers
and health care personnel, particularly in the public sector,
might not take participation seriously.
Factors associated with willingness to participate
Of the 661 people interviewed, 62% were women and 38%
were men, with an age range of 18–89 years and an average
age of 42 years (median 40). Of the respondents, 13% had no
formal education, 36% had primary education only, 26% had
high school education, 8% had technical degrees and the
remaining 15% had bachelors degrees or had started post-
graduate studies. Forty-two percent belonged to a low socio-
economic level, 21% to a middle level and 36% to a high level.
Regarding participation in the General Health Social
Security System, 57% were covered by the contributory
system, 14% by the subsidized system and 30% were not
covered by insurance; 51% used public health care, 45% used
private health care and the rest could not recall the type of
health care they had used during the previous 6 months.
Survey participation was higher in the low and middle socio-
economic levels than in the high socioeconomic level. In the
former it was easier to establish direct contact with the inter-
viewee and almost all people contacted agreed to participate.
People in the higher socioeconomic levels seldom answered
the door themselves, and we often needed to use personal
contacts to convince people to participate.
Of the respondents, 50% stated that they could do something
to improve health care quality, 37% believed that there was
nothing they could do and the remaining 13% did not know
or simply did not answer the question. Regarding collective
participation, 65% expressed an interest in participating in a
user association to improve the health care system, 31% were
not interested and 4% did not know or did not answer the
question.
This survey shows the factors associated with the barriers to,
and opportunities for, user participation in the health care
system. These factors include: level of information about the
new social security system, including the new institutional
participatory mechanisms; willingness to participate and per-
ceived ability to affect health care decision-making; belief in
the capacity to move from one provider to another; and a
sense of ownership by the user of the new health system
(Table 2).
Individuals that expressed interest in participation were more
likely to hold the following beliefs: that they knew the law;
that they could choose where to get health care; that they
were part of the system; and that they could influence
decisions within the system (p < 0.05). The beliefs that were
significantly associated with interest in collective partici-
pation were that ‘they felt part of the system’ and that they
believed they could influence it (Table 3).
Discussion
The concept of participation or user involvement has been
meaningfully transformed over the last three decades accord-
ing to changes in the global political economy.5,20,49 Previ-
ously associated with community development approaches,
user participation is now considered against a background of
more market-oriented reforms.50–55 Users are increasingly
being treated as consumers who make demands and have
needs that the health services must strive to meet.56,57 There
is, however, considerable controversy over whether or not
consumers are able to make informed judgements about
56 M Mosquera et al.
07mosquera (ds) 9/11/01 11:31 am Page 56
Strengthening user participation in Colombia 57
complex technical issues, whether consumers are willing to
spend time at meetings and to challenge authorities, and
whether the mechanisms in place are appropriate to channel
society’s preferences.58,59
State and social sector reforms in Colombia, it is said, have
been largely influenced by neoliberal conceptions of the
public as consumer.60 There is, however, also evidence for
the communitarian values associated with participatory
democracy.6,11,41 Thus, conflicting principles underlie partici-
pation in Colombia – the study found a disjunction between
efforts to strengthen participation and belief in the potential
of participation to improve the quality of health services.
Overall, the data have shown that health care users do not
yet have a meaningful seat around the table of decision-
making bodies. Their involvement remains limited to
expressing dissatisfaction through complaint channels, but
they are not sufficiently able to influence decisions taken at
an earlier point in time. There are five main reasons for this.
First, despite the unprecedented burst of institutional inno-
vation regarding participatory policies and legislation in
Colombia, this study has found that, so far, institutional
stakeholders are not entirely convinced of the need for par-
ticipatory mechanisms, nor that such mechanisms can con-
tribute beneficially to the working of the health system. These
ambiguous feelings by policymakers and health care man-
agers, towards the feasibility and potential contribution of the
user in technical or managerial matters, affect resource allo-
cation to participatory mechanisms.
Secondly, there is uneven implementation of participatory
mechanisms between the public and private sectors, despite
the law making it compulsory for both insurer and provider
Table 2. Distribution of responses regarding health sector reform and participatory mechanisms
Social representationsan/Nb%
Knowledge of the new health care system 123 / 659 18.66
Knowledge of the new participatory mechanisms 59 / 653 9.04
Knowledge of some form of collective participation 61 / 657 9.28
Knowledge of what a user association is 55 / 659 8.35
Knowledge about a person or group that represents user interest 83 / 659 12.59
Knowledge of the existence of custom service offices 334 / 635 52.60
Utilization of this office 57 / 392 14.54
Perceived ability to choose where to get services 486 / 657 73.97
Feelings of being part of the system 489 / 652 75.00
Perceived ability to influence decisions within the system 332 / 659 50.38
aThese include beliefs, knowledge and feelings.
bThe denominator includes only those who answer the question (people who did not answer the question were not included).
Table 3. Relationship between respondents’ beliefs regarding the user’s role in the system and interest in individual and collective partici-
pation
Knowledge and beliefs % endorsing statementa
regarding the user’s –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
role in the systembAll respondents Of those answering yes to:
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Individual participationcCollective participatione
–––––––––––––––––––––––––– –––––––––––––––––––––––––––––––
n/Nd% p n/N % p
“I know the law” 9 42/318 13 0.014 39/420 9 0.883
“I can choose where to get services” 73 246/319 77 0.000 311/424 73 0.162
“I am part of the system” 75 257/317 81 0.000 330/418 79 0.022
“I can influence decisions within
the system” 50 198/322 61 0.000 258/425 78 0.000
aOut of the people interviewed, those who answered these questions.
bThese beliefs are the users’ social representations concerning the health care system.
cIn individual participation, individual actions are channelled through customer service offices.
dDenominators vary according to who is endorsing the statement; those who stated they did not know the answer.
eIn collective participation, actions are channelled through user associations or community groups.
07mosquera (ds) 9/11/01 11:31 am Page 57
organizations to implement such a system regardless of their
legal status (private or public). The study found that there is
neither institutional capacity nor willingness to enforce the
regulation, and that the existence of a legally created partici-
patory mechanism does not guarantee user participation in
decision-making. Kadt61 and Rodriguez et al.62 point out that
some institutional initiatives create tensions between com-
munity and government agendas; communities are forced to
adjust to the structural, cognitive and political limits of the
prevailing institutional norms.
Thirdly, there is a lack of a feeling of empowerment among
health-care user associations. Our findings coincide with
issues pointed out by authors such as Oakley,63 Mosquera,64,65
Rifkin66 and Standing,67 i.e. the persistence of long-standing
impediments to user involvement in health services decision-
making, and political asymmetry, since the gap in technical
competence between user and health worker is too wide to
negotiate services. Macdonald68 and Saint Lamont69 argued
that it would be naïve to imagine that the mere adoption of
the concept of participation would remove the obstacles
inherent in bureaucratic culture and professional paradigm.
The dilemma lies in whether or not it is possible to reconcile
the operational logic of technical knowledge with community
values and ways of working. The ideal of participation is that
those affected by decisions must be involved in making them,
thus ensuring that any decisions made are acceptable to those
affected by them.
A 1994 World Bank70 report suggests that, given the techni-
cal nature of the health field and the tendency of local elites
to capture the participatory mechanism, user input alone
cannot be counted on to guide decision-makers in allocating
resources in a more efficient and equitable manner. The
report points out that experiences in the past have shown that
populations often demand inefficient, curative-intensive
health care.
There is a strong feeling among users, policymakers and
health care managers that community representatives and
user associations are highly politicized and lack leadership.
Community leaders do not necessarily act in the best interest
of the community; they are as likely to represent factional
groups or to be bound to powerful interests through which
they can capitalize benefits for themselves.60,64,65,67,71,72
Fourthly, the people interviewed felt able to affect health care
decision-making collectively (through community groups) or
individually. Nevertheless, the study shows a lack of actual
knowledge among health care users of the new health care
system, health entitlements and user associations. This would
suggest that, with better communication and information
strategies, the user’s perceived ability might be translated into
active participation. Apart from knowledge and perceived
ability to affect changes, attitudes, beliefs and values under-
pin the effective operation of participatory mechanisms.
Apathy, resignation and fear of retaliation, politicization of
community leaders and distrust of both public institutions
and democratic mechanisms were mentioned in the group
discussions as impediments to people’s involvement. Issues
concerning political culture are not easy to change among
institutional actors and citizens in spite of transformations in
the political framework.
The survey also indicated that people know more about cus-
tomer service offices than about other types of participatory
mechanism. More emphasis has been put on this mechanism,
particularly in the private sector, given its perceived import-
ance for developing marketing strategy, but people have
hardly used these offices. This suggests inconsistency between
the feeling of being able to affect changes, knowledge and
actual participation.
The new participatory policies and legislation are apparently
seen, by national policymakers, as a step towards greater
democracy for Colombia, at least in terms of formally recog-
nized goals and principles; they reflect high-level consensus at
the Ministry of Health that achievement of good governance
is central to the reform agenda. The challenge that remains is
how to actually implement these goals and principles into
workable institutional mechanisms and realise their potential
benefits. The Ministry of Health has made important progress
in promoting greater participation, but this has not yet
reached the key institutional and social actors.
The global economic reforms and significant advances toward
democracy made by many countries have tended to result in
an overly optimistic and sometimes euphoric view of com-
munity involvement. This study has shown that participation
is not a matter of policies and legislation; it is a complex
process involving belief, customs, ways of life and power
relations.
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Acknowledgements
This investigation received financial support from the UNDP/World
Bank/WHO Special Programme for Research and Training in Tropi-
cal Diseases (TDR). We would like to thank a number of people in
Colombia who made this study possible. In particular, we wish to
acknowledge the invaluable support given to us by Celia Almeida,
Norman Hearst and those who helped us throughout the process of
writing this paper.
Biographies
Mario Mosquera, BA, MEd, PhD candidate, is a consultant and lec-
turer in health promotion and research methodologies at the Public
Health School, University of El Valle, Colombia. For the past 11
years he has worked in Latin America and South Africa on a variety
of research and intervention projects in health promotion. He is cur-
rently a leading researcher in an EC-funded comparative study of
barriers to, and opportunities for, user involvement in health care
quality control in Colombia and Brazil. His interest is in recent
health sector reform initiatives, which seek to strengthen the capac-
ity of users of health services to participate in, and influence the
nature and quality of, health services.
Yolanda Zapata, BA, MSc, is a lecturer in health services manage-
ment at Javeriana University and the Public Health School of El
Valle University, Colombia, and a freelance consultant in public
health. She was director of communication and information at the
Departmental Health Secretariat of Valle del Cauca (regional
administrative level of MoH), Colombia, for 15 years, and has been
actively involved in health sector reform policy development and
implementation. Her areas of interest include regulation of the
private/public mix of health financing and service provision, and
health care related participatory institutional mechanisms. She is
currently a leading researcher in an EC-funded comparative study of
barriers to, and opportunities for, user involvement in health care
quality control in Colombia and Brazil.
Kelley Lee, BA, MPA, MA, DPhil, is a senior lecturer in global
health policy at London School of Hygiene and Tropical Medicine
and honorary lecturer in the Division of International Health, Yale
University. In recent years, she has written extensively on UN health
activities and reform and has contributed to two major WHO studies.
Her current research focuses on the impact of globalization on
health, including a review of UK public health measures concerned
with transborder health risks and a global analysis of the political
economy of tobacco control policies in low- and middle-income
countries. She is chairperson of the WHO External Advisory Group
on Globalization and Health.
Carlos Arango, BA, MA, PhD, is a lecturer in social and organiz-
ational psychology at the School of Psychology, University of El
Valle, Cali, Colombia. He has been a member of the Popular Edu-
cation Group at the University of El Valle for 22 years. His main
research areas have revolved around participatory processes at com-
munity level within the framework of participatory action research,
including participatory behavioural studies. He is currently the
general coordinator of the Community Psychology Research Group.
At present, he is leading a study on the construction of participatory
and peaceful co-existence in a neighbourhood in Cali.
Alejandro Varela, MD, MSc, is a lecturer in health services epidemi-
ology at Javeriana University, and invited lecturer at the University
of El Valle, Colombia. His current research interest is the impact of
participation on health sector reform, including establishing the
extent to which user knowledge about the new health system may
affect proper health services utilization. He is also a member of the
Epidemiological Research Centre at the University of El Valle and
executive secretary of the Southwest Chapter of the Colombian Epi-
demiological Association. He is currently conducting comparative
research on hospital attention models, looking at quality, efficiency,
and cost control as the main variables.
Correspondence: Mario Mosquera, Grupo de Investigación en Psi-
cología Comunitaria, Escuela de Psicología, Universidad del Valle,
sede Melendez, Cali, Colombia. Email: mmosquera@mail.com
07mosquera (ds) 9/11/01 11:31 am Page 60
