Néstor Mendieta, a doctor by training, has created schools to train leaders of community-based health care organizations. The schools assist local community health programs to gain access to the newly privatized health maintenance organization funds in Colombia and to develop sustainable health care programs within their communities.
The New Idea
With the recent passage of laws to privatize health care in Colombia, Néstor Mendieta is teaching local health care centers how to survive and benefit from this change. By providing training to link these centers with health maintenance organizations (HMOs) and insurance carriers, Néstor supports the capacity of existing organizations. Because everyone must have social and health insurance, Néstor is looking to assist people using the subsidized, and therefore usually of lower quality, insurance plan. Local health care centers learn the rules and regulations of HMOs and how to provide care under a privatized system. In each school, community health leaders learn to train others to develop and implement community health promotion and prevention projects. A local health committee is formed, which then works to develop its own projects and plans to improve health at the local level. Analyses consider local norms, traditional knowledge, and sociocultural differences, instead of being based solely on technology imported from abroad or from the cities. The communities and local health care centers then join together in a national network which identifies best practices and shares them with other communities. For example, in this network, the locale with the best policy for fighting infant diarrhea shares its experience with another community which boasts the most successful plan to reduce teen pregnancies. The combination of integrated health experiences, including ways to fight disease, improve infant nutrition, educate communities on sexual and gender issues, and ensure food security, yields an effective strategy for confronting health care issues.
Over the past decades, inequities and poverty have persisted throughout Colombia as in the rest of Latin America. According to the United Nations Children Fund (UNICEF), in 1992 nearly fourteen million Colombians were living below the poverty line. In 1991, according to the same study, 78 percent of children under five years of age in the capital city of Bogotá lived in homes suffering from some sort of poverty. These numbers, due to economic adjustment, have not improved in the last few years, but have probably worsened. There exist today approximately eighteen million Colombians living in poverty. Doctors continue to receive traditional training, based on technology brought from outside countries and not taking into account distinct cultural, economic, and social realities. Training is standardized across the country, in what Néstor refers to as "massive and anonymous training," and does not prepare doctors for medical practice beyond the university teaching hospital setting. Recent laws have earmarked increased resources to public health policies, but have brought difficulties for local health care centers. Law 100 requires all people to have health insurance and social security coverage and hospitals or health centers to direct fees to an administrator affiliated with the social security system. This law has affected many communities with small health centers because of the further requirement to register with the administrator of an insurance company as a condition for their license to operate. As health systems across Latin America become privatized, local health centers find themselves in difficult situations when they do not know how to negotiate with the insurance companies, and when they are required to upgrade their facilities but lack the resources to do so.
At Néstor's schools, health care leaders arrive as local representatives, elected by their communities. They join other health care leaders to learn strategies for promoting healthy lives and for stimulating preventative health care measures in their communities. These "community agents" work alongside, and complement the work of, medical doctors. The schools also serve as information and training centers where the health care leaders are trained as promoters who can develop community capacity to manage and motivate local health care initiatives. After their training they form community health committees, in which community members design their own health projects. These committees work together to form their own health care plans and projects for the future, based on the specific needs of each community. Each school maintains an information center which receives updated information from government institutions, nongovernmental organizations, and the community groups. This information is a service offered to community members to promote knowledge of and assistance for health promotion. The school also hosts events such as meetings and workshops where community representatives exchange ideas regarding health policies, community organization, and health care management. Local centers also learn the regulations of HMOs and how to continue functioning in a privatized health system. They learn how to partner with HMOs, thereby supporting the capacity of existing organizations. By improving institutionalization and the ability to respond to these challenges, local centers' autonomy, management capacity, and social representation are reinforced. The disintegration of these local groups would represent an enormous loss for health promotion processes and for the life quality of more than half of Colombians who are part of marginalized communities. In contrast, their strengthening as institutions of service and community health promotion can convert them into poles of development for their communities. Néstor has developed this model with nineteen community groups in Bogotá and has identified 25 additional groups. He has made additional contacts with twelve different communities in Bollaca, Popoyan, Cauca, Bucaramanga, Cali, Barranquilla, and various indigenous communities. The next step is to bring all these groups together in a national network of best-practice experiences. Each community shares its experiences and results of their health experiments and policies. Supporting this national network are the National Council of Colombia, Equity for Women, and the country's President. Contacts include at least 30 institutions with experience in different aspects of health promotion, all of which participate in the formation of local health groups. As health care privatization continues to spread throughout Latin America, Néstor's model has great potential application. Néstor has received funding from the World Council of Churches as well as the German nongovernmental organization, Misereor. He has been invited to France to demonstrate his model and is part of the French Association for Latin America. He works with many displaced persons from Guatemala and Chile, as well as many marginalized communities within Colombia.
Disillusioned by the staid and inhuman quality of his medical school training, Néstor found that he acquired the best training outside of the formal medical school curriculum, in his first year of required field service in the rural region of Tumaco, where he lived from 1987 to 1988. In Tumaco, he had the opportunity to structure a program for Primary Health Care Attention and Family Health for Rural Communities. The Agrarian Bank, which had no prior experience in these areas and contracted Néstor for the project, allowed him the opportunity to develop a health program according to his philosophy. The project was not based on traditional medical structures but gave Néstor the freedom for experimentation to develop his initiative. After only six months he had an established program for medical consultations, prevention, health education, and formation of community health groups in four rural zones of the municipality. When Néstor returned to live in the country's capital in 1989 he began to work with the Colegio Claretiano de Bosa, a local high school, to develop a program for Community Medicine within the context of a secondary school. For the next three years he structured a complete curriculum in the school's health program. In 1992, after realizing that his ideas needed the support of a team working toward similar objectives, Néstor joined the Fergusson Group. With this nongovernmental organization he tested his proposal in the Alfonso López community in Usme. There he began his process of educational self-management in health. In one year he achieved the consolidation of a local health committee and, by the third year, the creation of the Corporation for the Development of Alfonso López Community, which continues to function to this day. The success of the Alfonso López experiment led Néstor to expand his project to more local communities of Colombia, which he has been dedicated to ever since.