Lessons from local engagement in Latin American health systems

Abstract

Objectives  To examine the management of recent policies for stronger patient and public involvement in Latin American health systems, identifying common features and describing local practice examples of relevance to the UK.

Context  Participation is a core principle of many contemporary policies for health system reform. In Latin America, as in the UK, it is frequently associated with innovations in primary care services and their organizational developments. This shared interest in alternative models of local engagement offers new opportunities for collaborative research and policy development.

Design  Commissioned by UK policy makers, a 4‐year research programme was designed to promote exchanges with international counterparts focusing on how modern reform policies are being implemented. The selected countries possessed comparable principles and timeframes for their reforms. A series of individual country case studies were undertaken. Data were drawn from literature and documentary reviews; semi‐structured interviews with national policy makers and expert advisers; and with management representatives at local exemplar sites. The aggregate data were subjected to thematic analysis applying a model for sustainable development.

Results  Six common factors were identified in Latin American policies for stronger patient and public involvement. From these the most significant transferable learning for the UK relates to the position and status of professions and non‐governmental agencies. Illustrative case exemplars were located in each of the eight countries studied.

Introduction and objective

Participation in the development of local health systems is much more than just an ethical issue. Several recent cross‐country surveys and individual state studies ¹ , ² , ³ , ⁴ , ⁵ , ⁶ have indicated that globally policy makers now often regard enhancing patient and public involvement in decisions about the use of health and health‐care resources as desirable on grounds of both cost and clinical effectiveness. The benefits of this involvement in both the process and content of such decision‐making are perceived as essentially functional. They concentrate on the potential for positive compliance with a restricted range of priorities for public health and health‐care provision. These restrictions arise from limited levels of resources. Since the advent of market‐oriented health systems in the early 1990s the pursuit of this compliance has accompanied the use by policy makers of a growing number of research evidence‐based protocols to constrain the options for clinical intervention. Prior to this time Participation was viewed more from an ideological perspective as a universal right to promulgate, and specifically as one of the three ‘Pillars’ of post‐1978 global policies for primary health‐care development. ⁷

The World Health Organization has drawn on both the present pragmatic and previously more philosophical imperatives for enhanced patient and public involvement in specifically identifying community empowerment, decentralization and the policy processes required for their enactment as major priorities for international research. ⁸ Whilst in practice these have applied mostly to developing countries, in Western states too, such as the UK, there has been a growing desire to discover ways in which the political responsibilities for difficult decisions can be more successfully shared. ⁹ , ¹⁰ The desire to avoid the popular discontent these decisions can engender has strengthened as the financial pressures on publicly funded health services have grown. Evidence of an ‘educative impulse’ ¹¹ amongst patients and the public for the more informed involvement that might pave the way to lower expectations has, however, continued to remain sparse, at least in the states of Europe and North America. ¹² , ¹³

One consequence has been a novel willingness amongst some of the latter to learn from developing countries located in parts of the world where national health systems are at relatively immature stages of development, but where Participation is a pivotal feature of this development. Especially in Latin America these systems are often characterized from their inception by forms of organizational development that many ‘modernizing’ policy makers in Europe and North America are now seeking to implement. Creating the capacity to identify which particular factors and which of their combinations contribute to the strengthening of both patients’ and public assumptions of responsibility for health and health‐care decision‐making is a powerful current impulse for research internationally into processes of health policy implementation. Our study objective has been to identify such factors through an examination of some of these processes in Latin America. Here, they are regularly seen as part of the sort of sustainable cultural change now being sought in the UK.

Context

In 2000, this change was set out in the UK government’s new 10‐year strategy for the National Health Service (NHS). ¹⁴ This laid the foundations for what subsequently became the policy of a ‘Patient‐centred NHS’. It envisages that patients themselves will, through a new diversity of providers, be enabled to exercise informed choice as both a right and a responsibility across all stages of health‐care, from referral and diagnosis to treatment, discharge and review. ¹⁵ However, back in 2002 those policy makers at the UK Department of Health who articulated this vision were also concerned about what they perceived to be a series of relationship deficits in the NHS. They feared that these could obstruct progress being made in practice towards reaching the goals of a ‘Patient‐centred NHS’. Accordingly, with financial support from the Health Foundation, those with ‘lead’ central responsibilities for new NHS primary care trusts commissioned an international research programme with the aim of ‘transferable learning’. There were five designated subjects for this study: health and social service combinations; collaborations with non‐statutory agencies; cross‐sectoral public health initiatives; curricula developments in interprofessional learning and education and finally in respect of Participation, alternative models of what was then termed ‘local engagement’. At this time in 2002 it was hoped to draw on the experience of up to 10 countries over the course of an academic year. Each of the five policy subjects was regarded as an area of comparative weakness for the UK, in which there were lessons to be gleaned from other nation states from both their more advanced practices and the policy implementation processes these had required.

Design

Over the subsequent 2003–06 period we explored the subject of local engagement specifically in relation to Latin America through a series of eight individual country case studies. Fieldwork was undertaken in Bolivia, Brazil, Chile, Colombia, Costa Rica, Mexico, Peru and Venezuela.

The country selection was originally derived from criteria defined in 2002–03 through three rounds of open interviews with representatives of the principal commissioners and clients of the research. The criteria have since been reviewed annually and revised through a similar process of interviews with these officials and, where applicable, their successors. In 2002–03, as reported in detail elsewhere, ¹⁶ the first round of interviews sought to define those elements of ‘modernizing’ health reform policies which taken together could be regarded as an appropriate framework for the selection of the countries to be examined. In summary terms, local resource management, independent regulation and corporate governance, cross‐sectoral partnerships and public health stewardship were defined as these elements. A post‐1997 timeframe was also agreed upon. Only democracies with broadly comparable central controls of complex health policy decision‐making processes were considered.

Other rounds of interviews were with the four programme managers and professional advisers in the Department of Health then accountable for the development and delivery of NHS primary and care trusts, and with four local board members of these organizations in London. The NHS Plan in 2000 and its subsequent guidance had determined that the principal responsibility for commissioning would in the future be with NHS primary care trusts. ¹⁷ The interviews led to patient and public involvement being identified as one of those significant areas of relationship deficit, in terms of effective policy implementation, that merited international research. A workshop for all interviewees was held which validated the emergent research questions. This added the further priority for research of multiple forms of financing.

As a result of the process outlined above the initial research question from UK policy makers in relation to local engagement was in general and quasi‐political terms. The revised research questions of 2004 and 2005 became more specific and less politicized in response to the twice yearly feedback of the on‐going research findings. Individual country case studies and comparisons were also regularly reported in the relevant professional press. ¹⁸ The three research questions are included in the outline of the study schedule set out in Table 1.

Table 1.

 Outline study schedule

Reviewable Research Question	Country case studies	Local exemplar sites	Principal patient group/ public representatives
Phase 1: 2003/2004
How should modern complex primary care organisations increase capacity with parity between stakeholders in the community?	Brazil	Jardina Franixcata, Community Health Centre, Londrina	‘Brave Women’s’ movement members
	Chile	Centro de Salud Familia, San Joaquin, Santiago	Welfare benefits unions
	Peru	Max Salud, Clinic, Chiclayo	Domestic abuse support groups
Phase 2: 2004/2005
How can collaboration with non‐governmental organisations fulfil a dual purpose of extending primary care services and public participation?	Colombia	Santiago de Cale University, Family Health Training Programme, Medallin	Displaced and refugee families
	Costa Rica	Ebais de Guadalupe (Clinic), San José	Senior citizens and native Indians
	Mexico	IMSS Opportunidades Sedesol Programme, Puebla	Unemployed adults in rural areas
Phase 3: 2005/2006
Which factors promote the implementation of health policies for strengthening patient and public involvement in decisions about their health‐care and public health?	Bolivia	Ancoraimes Centro de Salud, near Titikaka	Indigenous neighbourhood groups
	Venezuela	Libertador Consultarios opulares, Caracas	Unemployed and low‐income co‐operatives

In total the research programme involved fieldwork in 24 nation states, of which a third are in Central and South America. The country selection drew on a project database of relevant findings from over 350 reports, peer‐reviewed articles and other publications. Many of these emanate from the World Health Organization, the UK Department for International Development and the Regional Observatories on Health Systems in Transition. The research team drew on this database to draft country overviews which were updated after the fieldwork. In each selected country semi‐structured interviews were conducted with the national policy directors for decentralization, primary care development and partnerships; and with local management representatives of those local health service organizations nominated by policy makers nationally as best representing the model for each country’s ‘modernizing’ reforms. Interviews employed a standard topic guide and were double noted. Local documentation was collected during visits and supplementary interviews were undertaken with expert commentators for each national health system in situ. Participants were asked to confirm the accuracy of our data capture by responding to the updated written country overviews.

For the individual country case studies the six prioritized UK policy subjects (see above), including local engagement, were used to categorize both the accumulated documentation and the captured fieldwork interview data. Key emergent themes and their relationships to each other were then identified. A three‐dimensional analytical framework for cultural change and sustainability was used to help identify the themes.

This framework distinguishes between what have been termed ‘pre‐disposing’, ‘precipitating’ and ‘enabling’ influences. ¹⁹ Originating in Canada its past application to policies in the UK criminal justice and social services sectors contributed to its credibility with the research commissioners and clients. Pre‐disposing influences are those structural and social factors which, in the case of patient and public participation, support a sustainable cultural change. Financial and educational regimes, income distribution, civic virtue and cohesion are examples of some of the categories from which such influences might be derived. Precipitating influences are much more short term. These are the particular issues which can trigger the change process. However, they only become effective in terms of helping to deliver sustainability if they stimulate an array of stakeholders that coalesce around, for instance, a crisis or a new cause, as a powerful coalition in which individual interests are subsumed. The final enabling influences are those which create the environment that allows such issues to be positively defined so that the required structural and social forces can function effectively. This environment includes the interplay between the media in all its guises, a plethora of institutional actions and subcultures plus, for local engagement specifically, the role of municipal level authorities.

Applying this analytical framework individual themes were identified in relation to patient and public involvement in health‐care decision‐making. Those occurring across a majority of states were highlighted and then categorized. As a result six common factors for sustainable change were defined. These factors spanned the three dimensions of sustainable cultural change and in their relationships to one another seem to offer some insight into why some combinations are more effective than others in achieving the ‘modernization’ of national health systems.

Results

The six common factors identified as key contributors to effective policies for sustainable cultural change in relation to local engagement in contemporary health systems were as follows:

• 1the inclusion of locally elected community representatives in governance arrangements at first tier levels of decision‐making;
• 2revenue raising responsibilities for health and health‐care at local community levels that make an essential contribution to core service funding and provision;
• 3a commitment to improving health and health‐care as part of a wider Development agenda which addresses in particular issues of inequality;
• 4the presence of a range of non‐governmental health‐care agencies which offer both diversity as individual service options and together a collective movement for community health improvement;
• 5the principal allegiance of the primary care organization with the local community rather than with any particular profession or form of health‐care practice and
• 6the inclusion of locally legitimized alternative and complimentary health services within strategies for health systems development.

Our analysis was rooted in an essentially contextual view of the determinants of health policy and its implementation. This views ‘sense of place’ as overwhelmingly important. ²⁰ Successful policies are those that fit with the increasingly complex, tiered and interactive processes that characterize ‘deliberative democracies’ in those countries seeking to pursue a more participative ‘modernization’ agenda. ²¹ Such nation states move beyond simple ballot box mechanisms, and the ways in which health systems operate can be an important indicator of a country’s capacity to extend its democratic culture.

The six factors we have identified divide evenly between the three different types of influence for sustainable cultural change. Table 2 sets out this classification and refers to an example from one of the countries studied which illustrates the impact on local engagement particularly well. These are described individually in more detail in the paragraphs that follow. Whilst no country in Latin America would claim to have fully comprehensive policies for local engagement in their health systems, and still less equivalent operational plans for their implementation, Table 2 does clearly indicate the extent of patient and public participation in this global region. Moreover, if the classification is viewed as a single ‘ideal type’, ²² then it may be recognized, by policy makers elsewhere in the world, as a thorough and robust management strategy for achieving sustainable cultural change in a subject area that has been stubbornly resistant to the interventions of reformers in the past. ²³

Table 2.

 Local engagement in Latin American health systems

Factor	Type of influence	Exemplars
Inclusion of locally elected community representatives in governance arrangements at first tier levels of decision‐making	Pre‐disposing	Peru: Community Health Committees, Comunidades Locales de Administración de Salud (CLAS)
Revenue raising responsibilities for health‐ care at local community levels that make an essential contribution to core funding	Pre‐disposing	Chile: Zonal Mayors elected with municipal taxation powers hypothecated to model multiprofessional health centres
Commitment to improving health and health‐ care as part of a wider Development agenda which addresses in particular issues of inequality	Precipitating	Venezuela: Mision Barrio Adentro (National Health Crusade) programme to address Health and Poverty via 10 000 new Consultorios Populares (Clinics)
Presence of a range of non‐governmental agencies which offer both diversity as individual service options and together a collective movement for community health improvement	Precipitating	Colombia: Service programme delivery through mix of private health co‐operatives (ESS), state social enterprises, collective health insurance companies and health promotion enterprises
Principal allegiance of the primary care organization with the local community rather than any particular profession or form of health‐care practice	Enabling	Costa Rica: Social Action Development programme with local Health Technicians and Cantons
Inclusion of locally legitimized alternative and complimentary health services within strategies for health systems development	Enabling	Bolivia: Local network elected Health Boards (DILOS) of community and state representatives which sanction national health insurance programmes (SUMI)

Taking the common factors in turn we found that the inclusion of locally elected representatives in governance arrangements at first tier levels of decision‐making is an influential factor contributing to cultural change in the majority of the countries where we undertook fieldwork. The new Popular Health Councils feeding into the people’s regional and national health assemblies in Brazil, and the Bolivian Local Health Boards which give equal shares to community and state representatives, are two illustrations of the structural developments that seek to build on the social constituents and relationships peculiar to individual countries. These both merit further investigation for their transferable learning. In relation to this first ‘pre‐disposing’ influence, however, the outstanding exemplars are the community health committees of Peru: Los Comunidades Locales de Administración de Salud (CLAS).

By 2003 when we carried out our fieldwork there were around 780 CLAS in Peru responsible for managing over 2000 service outlets across the country. The standard community health committee comprises six lay representatives and a clinical director. Their powers extend to setting the levels of prescription charges in line with local socio‐economic conditions, as well as specifying principal local public health and health‐care priorities. The lay members assume individual leadership responsibilities for each of these, and garner the support of large numbers of community volunteers for the different interventions and promotional or fundraising campaigns that ensue. In Chiclayo at the MaxSalud clinics we found that such campaigns were characterized by the wearing of brightly coloured t‐shirts with logos that highlighted family planning facilities and the risks of domestic violence. Half the lay members are elected directly by the local community and half by local community organizations, to encourage the widest ownership of health issues. Evaluations indicate that CLAS have been successful so far not just in terms of numerical popular participation, but also in respect of extended levels of health coverage and efficiency. ²⁴ The national government role is to provide the frameworks for regional CLAS registration and monitoring, as well as those for clinical quality and effectiveness, and the necessary logistics of information technology, capital and human resources. The lay committee members themselves are part of a national civil society movement and send up to 3000 delegates from the majority of Peru’s 24 Departments to the co‐management conferences of ForoSalud. This is a country in which Society has its own structures alongside those of the State which can be exploited for the purposes of patient and public involvement.

The second ‘pre‐disposing’ influence is integral to the effective performance of CLAS, as it is elsewhere, for example, in the local premium paying supplements for the IMSS Oportunidades programme that has rolled out primary health‐care to Mexico’s most remote areas since 1998. The exemplar is in Chile, South America’s most economically dynamic country, where we found the most effective revenue raising responsibilities for health and health‐care at local community levels. These make an essential contribution to core service funding. The mechanism is the new Zonal Mayor elected by the whole community on 4‐year fixed terms with a mandate for local health improvement. The outcome in the South Metropolitan Zone of Santiago, for example, has been an 85% turn out at the polling booths and a doubling of funding for local primary health‐care services, principally through means tested local taxation, plus some co‐payments for services. At the Centro de Salud Familia San Joaquin the results were certainly tangible with no fewer than nine different health professionals providing direct and open access, including psychologists and nutritionists, as well as family doctors, occupational and physical therapists, community nurses, dispensers, dentists and social workers. In 2003, this was the model for Chile’s 568 health centres and their delivery of a nationally defined ‘Family Health Plan’. The central government backed up its policy of ‘Municipal Reinforcement’ with its own funding policies. These included weighted variations in local needs related allocations from the National Health Fund (FONASA) to Zones of as much as 40%. In Chile, the renewed sense of civic virtue and association in the post‐Pinochet period provide the ‘pre‐disposing’ influences for cultural change in relation to local engagement, and are expressed through the new financial and political structures for the health system.

The first factor we identified as commonly contributing a ‘precipitating’ influence towards local engagement is a commitment to improving health and health‐care as part of a wider Development agenda which addresses in particular issues of inequality. This is visibly expressed in the multipurpose new community centres of Brazil where across 5600 municipalities Local Health Councils may oversee facilities that range, under one roof, from vaccination clinics to youth and dance clubs and older people’s day care and occupational therapy. In Peru, again the holistic philosophy of the communitarian academics who supply much of the leadership for the ForoSalud movement is that of comprehensive Development. Unequivocally, however, it is in Venezuela that this approach has precipitated the most far reaching changes, as local engagement in health and health‐care has been presidentially prescribed to be the political response to crisis conditions in both. The consequence is a revolutionary change.

On the outskirts of Caracas, accordingly, we interviewed at the Libertador Consultorio Popular in 2005 one of the 10 000 general medical practitioners who, we were told, had been imported from Cuba over the previous 2 years to provide the professional health‐care contribution in a Mercal (co‐operative) cross‐sectoral approach to community development. This has witnessed the number of registered co‐operatives increase to over 55 000 from less than a thousand in 2000. At Libertador the newly formed managing Social Council includes Health Forums each responsible for the well‐being of 250 household family units. Mostly local women they meet every 8 days, have their own ‘Health Houses’ and ensure not just compliance with, for example, child health surveillance protocols, but also sufficient supplies of adequate drugs and dietary supplements at the local Mercal store. This is located adjacent to the clinic, which is itself in one of the most Spartan sites in a rundown neighbourhood. Representatives from the Social Council attend one of the Citizenship Assemblies organized at State level at which the presence of the President himself would be no surprise. Either he or his Ministers have opened many of the new local clinics. All have been built with government funds and the lower socio‐economic classes have had overwhelmingly first priority. The urgent issues of Development are driven by an unequivocally modern Socialist set of beliefs and political power.

Choice is a topical issue in contemporary health‐care politics, especially in the UK. Its counterpart is the presence of a range of non‐governmental agencies which offer real diversity as service options. Together, in such countries as Bolivia where they constitute the majority of frontline health‐care resources and reflect the rich cultural range, they represent the second type of ‘precipitating’ influence for sustainable change in respect of local engagement. Moreover, these agencies may too collectively comprise a movement for community health improvement.

This was certainly the intention in our Colombian case exemplar of Medellin where the city’s main university has pioneered cross‐sectoral educational programmes in support of the national primary care‐oriented Compulsory Health Plan (POS). Although Colombian general medical practitioners are scarce the POS has sought to supply a nationwide framework of community base Family Health improvement for the 1076 municipios. Since the Decentralisation Laws 10 and 60 of 1990 and 1993 the municipal councils have held the main management responsibility for health systems development. Diversification via innovative, often overlapping but extended collaborations with all of the different strands of the Third Sector has been their approach. The result of this novel stakeholder style of community health development has been remarkable. In 2003, when the Health Ministry was subsumed into the Department for Social Protection we were advised that only 4% of national social security funds went on health provision, yet nationally health‐care expenditure had risen to over 10% of GDP.

At Medellin the municipal entrepreneurialism was reflected in sponsorships stretching from McMaster University to the Kellogg Foundation and the World Bank to Canning House (UK). There were private clinics and Empresas Solidarias de Salud (health‐care co‐operatives), with the latter often being the creation of poorer neighbourhoods. In contrast two‐thirds of the Entidades Promotoras de Salud (health promotion enterprises) were commercial companies, notwithstanding their public duties under the terms of a compulsory employees’ contributory insurance scheme covering 21 million Colombians. This in turn at Medellin was augmented by a multimunicipality regional health insurance programme with its own corporate providers. And, finally there are public health centres and small community hospitals, with support from specialist and tertiary units that come under the jurisdiction of the country’s 32 Departmental Governors. Here, in Colombia, urgent issues relating to the lack of a credible central political authority and the potential for multiple forms of external investment helped to precipitate health system reforms in which a new diversity of providers are seen to have served as effective proxies for public and patient participation.

In Colombia, many of the new investors seem to have had mixed motives. In Costa Rica, we found the same is true in terms of, for example, multinational corporation trials of new technologies and mission‐based agencies’ forays for religious converts in indigenous areas on the back of offers of new medical facilities. But, unlike Colombia, Costa Rica has enjoyed long‐term peace and stability and is the best exemplar of where primary care organizations possess a principal allegiance with the local community rather than with any particular profession or form of health‐care practice. This is the first of our ‘enabling’ influences of participation. It was evident in all of the eight countries of our Latin American research programme, although not always in our other European and Asian case studies. In the UK, for instance, the principal allegiance historically has been with the individual general practice.

In Costa Rica, the local practices are all part of the ‘Healthy Cantons’ national network with its annual prizes and strong expectations of Seniors involvement. At the Guadalupe Ebais (clinic) as elsewhere a 75% norm applies to the local origins of the staff, both professional and non‐professional. For the latter there are well‐established career development ladders, formalized in the regional curricula at the University of San Jose’s local campus outposts, which enable, for instance a Chirripo health technician undertaking regular household health needs assessments after just 6 weeks training to progress, over time, to full professional nursing or even doctor status. This ‘Social Action Development’ is integral to the university’s agreement with the Health Ministry’s national Social Security agency (CCSS), and is reflected in the tolerance of the latter for local herbal treatments and indigenous remedies in its fee scales and terms.

This appreciation of different cultures is even more apparent in Bolivia, with its 36 different indigenous ethnic groups. In La Paz, our interviews included one with three members of the Department of Traditional Medicine. This is actually located within the main Ministry of Health building; although with subsidies from a Canadian donor. The systematic inclusion of locally legitimized alternative and complimentary health services within strategies for health systems development was the least expected of the six common factors defined by our research. It enables participative processes extend to minorities, and disadvantaged groups in particular, with whom engagement would otherwise not take place.

The La Paz government passed legislation in 1994–95 entitled the Laws of Popular Participation and Administrative Decentralisation which transferred all health‐care assets to 327 municipalities. Subsequently, it has been at this community level of around 10 000 that, for example, the post‐1996 National Maternal and Child Health and Basic Health Insurance programmes have been delivered. The latter includes 92 culturally tailored benefits but without specifying precise modes of clinical practice and intervention. It is what Bolivians term a ‘Health with Identity’ programme. Local healers called Callawayas or Yatiri are often regarded by local communities as equivalents to Western family doctors in both rural areas and such large massive new urban conurbations as El Alto. Health policy itself nationally has been largely formulated through the PROCOSI Council, which includes no fewer than 36 non‐governmental organizations each with a different philosophy and model of health‐care intervention. Many of these like Pro‐Mujer (Women’s Health) and Socios del Desarollo (Development Alliance) are local partnerships with benevolent international donors. At the Ancoraimes Health Centre on the shores of Lake Titikaka we witnessed how such a partnership, for example, has led to adjacent buildings for the mainstream team of community nurses, a dentist and two doctors; and for the Traditional Medicine Practice. The latter was funded and built through voluntary contributions from a United States Methodist Church. Both are part of the SUMI (National Health Insurance). Both come under the mediating auspices of the DILOS or Local Health Board. Both perform similar functions including deliveries at childbirth. However, unregulated Traditional Medicine may be it is seen to raise awareness of health issues often by being present in the local markets, networks and settlements; and it is this awareness that the SEDES (regional health service) looks to build upon in its public health initiatives and hospital services. Fundamentally responsibility for health and health‐care in Bolivia belongs to the community and its customs. The State role is, at best, that of a safety net.

Discussion

The six international case exemplars above illustrate the range and richness of Latin American developments for potential transferable learning in respect of developments in public and patient participation. Overall, they point to the important growing contribution of non‐governmental organizations in health and health‐care and associated changes in the role and perception of frontline health professionals. Above all they indicate that influences at all levels of health systems development are operating in favour of more substantial local engagement, although the influence of the different formative policy factors we have identified varies according to context.

With its focus on the comparative management of health policy it was beyond the scope of our research to evaluate in any detail or depth the actual practice of patient and public involvement. However, for policy makers in search of effective implementation, our findings do seem to suggest the need for a multidimensional approach to local engagement which pays more attention to environmental ‘enabling’ influences than is currently the case in the UK, and is not over reliant on either particular structures or issues.

There is an unexpected level of commonality between contemporary Latin American and UK developments. The policies of the latter for national regeneration via modernized public services are, at times, remarkably similar to those in countries also seeking to generate new social capital after periods of military and civil unrest, which have often followed periods of dictatorship. In both settings health systems reform is seen as a vital component of government and, in particular, of securing national political authority, when globalizing forces could point to alternative supranational sources of governance becoming effective within the foreseeable future.

As a consequence local engagement in this reform can become a vital element of State survival. Our study indicates it cannot be achieved through a reliance on the previously prevalent vertical models of institutional or incremental policy implementation. ²⁵ Interestingly none of the six ‘Influences’ identified in our research rely on the national level for either the effective formulation or implementation of Participation policies. The management responsibilities for the ‘pre‐disposing’ influences are local. The energies of ‘precipitating’ influences are harnessed at intermediate tier levels (such as the Prefecture or Region). Most surprising of all, the source of ‘enabling’ influences for local engagement seems as likely to be international as domestic with, for example, Costa Rica drawing via its adroit usage of the Internet and telemedicine on a world of ideas for its Healthy Cantons, and Bolivia heavily dependent on overseas aid charities and foreign academics.

Other recent research, again especially in Latin America, has also pointed to the redundancy of conventional health policy development models. Attempts, for example, to extend patient and public participation in parts of two of the countries we studied, Mexico and Colombia, have relatively swiftly culminated in major policy reversals as national government has felt compelled to re‐assume control from local agencies to avoid complete breakdowns in popular health service delivery. Such studies have led to theoretical developments in relation to the concepts of resource dependency and regulatory capture, ²⁶ , ²⁷ which together have diminished confidence in the principles and practice of decentralization. In our own case exemplars it was apparent that challenging issues regarding empowerment and exploitation were likely to become more pronounced in the future as local communities, and especially unpaid women volunteers, were co‐opted into official state structures for service delivery and control.

Nevertheless, in terms of conceptualizing the models of policy development required for Decentralisation, the present study goes some way towards redressing the balance. While, of course, no country can just adopt another’s, adaptation to particular contexts is a positive practical proposition. Table 3 lists some of the specific UK recent initiatives that have been influenced by the lessons from Latin America, with details of the mechanisms used in this research programme to facilitate ‘transferable learning’. Our experience has been that the case for this international exchange is strengthened when that which might be adapted is seen as an amalgam of approaches across leading practice sites in several countries of a single global region; and where these approaches have been identified through a sound methodology with a validated analytical framework for sustainable cultural change.

Table 3.

 Transferable learning examples

Policy UK initiative	Contributory Latin American country policy sources	Mechanism for transferable learning
Lay Health Trainers attached to NHS primary care trusts and public health directorates 28	Peru, Costa Rica, Mexico, Venezuela	Pre‐white Paper seminars leadership, Department of Health Strategy Unit, 2004–05
Alternative lay management models for NHS primary care and foundation trusts 29	Colombia, Venezuela, Peru, Chile	Series of articles in ‘Primary Care Report’ and allied conference presentations, 2003–06 ( for example 33 )
Independent sector ownership and management of General Medical Services providers 30	Brazil, Costa Rica, Bolivia, Mexico	Cabinet Office/Office for Public Services Reform briefings, 2004–05
New Integrated Care models for NHS community hospitals 31	Peru, Chile, Venezuela, Costa Rica	Inclusion of local case exemplars on Department of Health websites, 2005–06
Community Development Foundation Degrees in Health and Social Care Higher Education 32	Costa Rica, Brazil, Colombia, Chile	Short course and seminar module design, 2004–06

Conclusion

UK policy makers have been historically ambivalent about the efficacy of local engagement. ³⁴ As we have noted, the rhetoric of patient and public involvement has far outstripped the practice. It has always in the past been intellectually straightforward as well as politically expedient to point to the failure of other countries to match the performance of our NHS with their decentralized alternatives. This study may make such assertions more contestable in the future.

Conflicts of interest

None.