PRÁCTICA FAMILIAR RURAL│Vol.1│No.3│Noviembre 2016

Cómo citar este árticulo

Troya, C. Emerging problems in rural practice. Práctica Familiar Rural. 2016 noviembre; 1(3).




Emerging problems in rural practice

[a] Carlos Troya Altamirano

a. Hospital Hesburg


"In the era of globalization of diseases
and of attention to chronic diseases,
achieving universal coverage is relatively
simple in principle but becomes difficult in practice."

Maria Inez Padula Anderson
Family and Community Medicine

At present, the idea of ​​discussing health policies would seem unnecessary and even impertinent. It would seem that international and regional institutions have established a single discourse on access to health services. In Latin America, exclusion and inequality have fallen off the public’s agenda because, as Mario Testa(1) would say, we have become entangled in words. "Is it true that the Alma Ata proclamation has been fulfilled? Or this illusion is only the product of the absence of social movements in the political discourse on health?"

In the absence of social movements, Latin America has presented a "wave" of "progressive" governments, which creates a curtain that hides a "concrete" reality; this reality is the inequity in access to health services. The expectation of the last decade was that the regional "progressive wave" would provide the changes that had been dreamed so many years ago. We cannot deny the many reformist transformations that have benefitted the most impoverished sectors. We can cite successes, such as investing in human resources training, the technological modernization of health care facilities, or the development and fulfillment of certain goals to reduce maternal and infant mortality. Despite this effort, access to health continues to be limited. How do we explain that contradiction?

The possible explanations of this contradiction are two sides of the same coin. The first side is a mistaken political orientation. The second side is its epistemological counterpart. The changes in health policy in the region and in the world have been able to shake out the rug of public health, but we have kept the trash under the rug. In spite of the modernization of equipment and infrastructure or the number of graduates in family medicine that a country has, the main investment in health continues to be at the top of the pyramid. Enormous amounts of resources are directed to third-level hospitals where only 10% of the demand goes for services, while the base of the pyramid continues to deal with few resources, many patients, complex problems, and the problems of the past.

This political side of the issue must be made explicit because politics has to do with the exercise of power, be it economic, communicational or ideological; the power is in the hands of the countries that make up “late capitalism.” The periphery, where Ecuador appears, can only claim a few crumbs. Health policies continue to be developed by large corporations, governmental or non-governmental, and the peripheral countries continue to apply "vertical programs" or "service packages." Policy has turned its attention to what is controllable and "neutral."  We receive instructions instead of making our own policy.

This orientation has profound epistemological implications since what is controllable and neutral obeys positivist science and therefore, in the medical field, policies for "diseases" are developed  instead of for societies, communities, or individuals. The development of a policy program might affect the economy, and therefore healthcare expenses. But where are the people in this Procrustean bed? Where are the sick? Where are the human faces?

A permanent longing, even more visible from Alma Ata, has been Universal Health Insurance. But how is health assured if we think about diseases instead of people? Part of the challenge facing family medicine in urban and rural areas is to stage these contradictions in the midst of this ambiguous scenario. It is important to recognize that the intimacy of the patient-doctor relationship makes this experience a trench to make the human faces visible that the positivist reasoning, in its political and scientific forms, needs to hide to achieve "neutrality" and "efficiency."

Universities and scientific groups should encourage these reflections in order to awaken greater commitment by health professionals in the medium and short term. The discussions demand that we be pragmatic and reflective, realistic, and at the same time, human. The unavoidable discussion, which is generally left at the end of political agendas, revolves around financing. But what have we learned from health systems based on the state as the only responsible entity for financing? What are the advantages and disadvantages of health systems in the hands of private health companies? Are there conditions for mixed models? In what way does a mixed model fail to protect the most vulnerable sectors?

Rural areas need not discuss whether there is vulnerability in their context. The modern and western model of development has shaped the countryside’s dependence on the city.  The model has created marginality, where the city is the champion of progress, and “rurality” is destined to follow it as a shadow.

The discussion of health policies requires actors from the micro and the macro, public health professionals and clinicians, as some of the invited actors.  The true core is in the subjects, who are currently absent. In an age governed by the laws of the market, returning with a new lens to "old problems" is not returning to the past. It is recovering humanity because like any human process, the history of medicine is also history. But this is a story with human faces, and although physicians' faces appear to define the needs of communities, those faces cannot replace the historical subjects.

(1) Mario Testa, an Argentine doctor who spent several years in Venezuela working on the health sector’s planning and power structure, criticizes normative and strategic planning in his most renowned book STRATEGIC THINKING AND PROGRAMMING LOGIC.