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Apropriação e participação comunitária

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O conteúdo em Portugês estará disponível em breve.

Health systems can be transformed to deliver better health in ways that people value: equitably, people-centred and with the knowledge that health authorities administer public health functions to secure the well-being of all communities. These reforms demand new forms of leadership for health. The public sector needs to have a strong role in leading and steering public health care reforms and this function should be exercised through collaborative models of policy dialogue with multiple stakeholders, because this is what people expect and because it is the most effective.

A more effective public sector stewardship of the health sector is justified on the grounds of greater efficiency and equity. This crucial stewardship role should not be misinterpreted as a mandate for centralized planning and complete administrative control of the health sector. While some types of health challenges, for example public health emergencies or disease eradication, may require authoritative command and control management, effective stewardship increasingly relies on “mediation” to address current and future complex health challenges.

The interests of public authorities, the health sector and the public are closely intertwined. Health systems are too complex: the domains of the modern state and civil society are interconnected, with constantly shifting boundaries. Effective mediation in health must replace overly simplistic management models of the past and embrace new mechanisms for multi-stakeholder policy dialogue to work out the strategic orientations for primary health care reforms.

Community ownership and participation[1]

At the core of policy dialogue is the participation of the key stakeholders. Health authorities and ministries of health, which have a primary role, have to bring together:

  • the decision-making power of the political authorities
  • the rationality of the scientific community
  • the commitment of the professionals
  • the values and resources of civil society.

This is a process that requires time and effort. It would be an illusion to expect primary health care policy formation to be wholly consensual, as there are too many conflicting interests.

However, experience shows that the legitimacy of policy choices depends less on total consensus than on procedural fairness and transparency. Without a structured, participatory policy dialogue, policy choices are vulnerable to appropriation by interest groups, changes in political personnel or donor fickleness. Without a social consensus, it is also much more difficult to engage effectively with stakeholders whose interests diverge from the options taken by primary health care reforms, including vested interests such as those of the tobacco or alcohol industries, where effective primary health care reform constitutes a direct threat.

Esta seção do perfil do sistema de saúde está estruturado da seguinte forma:


Analytical summary

O conteúdo em Portugês estará disponível em breve.

In Botswana, structures for community participation at the district level include chieftaincy, village development committees and village health committees. Other community structures that act as the voice of the communities are community home-based care committees. The village development committees' function is to identify and prioritize village needs as well as to liaise between the villagers and the politicians and local authorities. The village health committees focus on matters directly related to health.

Chieftaincies dialogue through open community fora (dikgotla) where community members may make development decisions and have the chiefs pass them on to the local authorities. Through these fora, politicians, including the President and his cabinet ministers, public officers and development partners may dialogue with community members. Concerns, needs and feedback on Government’s programmes can be discussed and civil servants may disseminate the Government’s policy. Thus, through a web of institutions and personnel, health concerns are communicated between the health decision-making bodies and the citizens.

The Government media such as radio, television and newspaper are heavily charged with sensitizing and educating communities on health matters. Although personalized health service may be difficult in urban public facilities where client–provider ratios are often unrealistic, in peripheral facilities where the ratios are realistic and where client education on prevailing health problems and determinants of health is a daily norm, meaningful and personalized client–provider interaction is possible.

There is a commendable effort on the part of the Government to provide quality and people-centred care. Between 2009 and 2010, the Ministry of Health commissioned a project in six selected health facilities with the aim of improving health facilities’ readiness to meet the expectations of patients, health care providers and the communities through institution of remedial measures to address identified challenges.

The intervention resulted in facilities improving their range of quality scores from the lowest of 36% and the highest of 42% to the lowest of 41% and the highest of 81%. The introduction of youth-friendly adolescent sexual health and reproductive services, and the wide involvement of young people in the planning and implementation of the adolescent sexual and reproductive health strategy also provide evidence of the Government’s commitment to people-centred care.

Civil society organizations are organized into a structure Botswana Council of Non-Governmental Organisations (BOCONGO) for coordination and easy communication with the Government. The private sector also has an association Confederation of Commerce, Industry and Manpower (BOCCIM) that communicates regularly with the Government. Challenges in community participation include lack of resources for civil society organizations that should play the role of watchdogs for good governance and the welfare of the communities. Civil society organizations depend largely on donor and Government funding. Their capacity should strengthen to allow them to become the voice of the community. Another challenge is thinning out communities’ representation as dialogue moves to higher decision-making echelons.

Participation as an individual, User and provider interactions

Local community mobilization

Civil society Involvement

Endnotes: sources, methods, abbreviations, etc.


  1. Systems thinking for health systems strengthening (pdf 1.54Mb). Geneva, World Health Organization, 2009