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Grass roots, herbs, promoters and preventions: a reevaluation of contemporary international health care planning. The Bolivian case.
Social Science and Medicine. 1983; 17(17):1281-9.In evaluating a United States Agency for International Development (USAID) project in Bolivia, the author argues that the program unwittingly contributed to the situation that created Bolivia's political problems. A 5-year pilot project which covered 39 villages and colonies in the Montero district in the state of Santa Cruz began in 1975 and was completed in 1980. In 1980 the project was "deobligated" when all but essential economic aid to Bolivia was halted following a political coup. The pilot project was based on 1) community participation through health care; 2) a referral system from health post of the promotor to the center with an auxiliary nurse midwife, to secondary and tertiary care in hospitals by physicians; 3) an emphasis on preventive medicine; and 4) the use of traditional medicine along with other therapy by the promotor. Although these concepts sound appropriate, they are in fact derived from contemporary thought in advanced industrial societies. The assumptions about social reality that are inherent in these plans actually misconstrue Bolivian society. The unintended consequences of the project actually diminish rural health care. A difference between the Western health planner's conception and the Bolivian conception--of community, of effective referral systems, of preventive and indigenous medicines--can have the effect of producing a health care program that has little resemblance to what was originally intended. The Bolivian elite actually manipulated the USAID health care programs through hegemony in the villages. The Jeffersonian concept of community is not applicable in Bolivia where resources are only exchanged through personal contacts. In villages of multiple class or ethnic groups or both or in villages with close ties or histories of ties with larger, more cosmopolitan groups, multiple different interests exist. These work against each other to prevent the very cooperation envisioned by the health care programs. The author suggests that developed countries should consider native ideologies, native social relations, and indigenous medicine more sensitively in design.