The success of the Program's due to the transformation of the way health services are delivered to the communities. Attention is directed to the root cause of those processes that correlate directly to health problems. Its reach extends over a broad spectrum of common daily situations, going beyond the traditional medical emphasis.Health is conceptualized as a multifactorial process, which has as a final outcome a specific pathology. In determining and preventing the conditions thatlead to a particular disease, it is possible to break its cycle in the initial stages, where the economic cost is much smaller and with an overall higher social benefit. For this to be accomplished, it is necessary that the health team be intimately integrated with the target communities understand that there's a commitment to resolve their problems, which in turn motivates them to participate in more active manner. To this is added the integration of the actions carried out by various institutions and organizations that have ashared responsibility for solving the problem, all of which permits a better utilisation of available institutional resources for the benefit of the sound development of the communities involved.
Examples of these actions can be observed in two neighborhoods located in the northern part of the city,which contain a high percentage of American Indian population (Wuayuá). Thefirst of these is San Antoniode los Ca±os that was established in 1972. At the beginning of our work, thiscommunity did not have any public services (electricity, water, sewage,adequate roads), spatial ordering and in spite of being located within the perimeter of the city, it presented characteristics one might expect to find ina rural area. This situation creates a large number of health problems, due to the absence of minimal subsistence conditions. As a consequence of this situation, and due to the characteristics of the area, the inhabitants were encouraged to establish contacts with the National Agrarian Institute (I.A.N.)to request a planimetric survey (road and lot map) of the community.
By the end of 1994 theI.A.N. execute the map of the community and in 1.995 work was initiated for theinstallation of electrical service with the direct participation of ElectricalCompany of Venezuela (ENELVEN). At present it has extended electrical service to approximately 40% of the families of the neighbourhood. Currently the population is being educated and prepared on ways of processing the water, by means of the utilisation of sodium hypochlorite, in order to obtain drinking water. Up until now the only available water had been untreated. This learning-process is being accomplished with the co-operation of various organizational take part in training and citizen formation, one being the MunicipalTraining and Citizen Education Institute (IMCEC) and another the Centre at the Service of Popular Action (CESAP - NGO). This has clearly demonstrated the possibility of consolidating different institutional efforts that participate actively in the development of the communities
In the second case, the neighbourhood Jesus of Nazareth, a community established in 1.982, along theperiphery atop an old, saturated garbage landfill. A short time after the landfill was closed the area was occupied by squatters and the community founded. The health problems in this community are as a result of very serious characteristics. This is not only as a direct result of the landfill itself,but also because the community did not understand the gravity of the problem and continued to indiscriminately throw garbage all over the neighbourhood. In1.994 the main street of the neighbourhood was cleaned in four differentopportunities due to the fact that the neighbours insisted in continuing toobstruct the public way with garbage. As a result of this situation, the community presented high rates of skin and skin related diseases, in addition to frequent enteritis outbreaks. These problems were given the traditionalattention by the public health facilities, but nothing was done to resolve theconditions, which were originating the diseases. For this reason the recurrence of these maladies was of a permanent nature and serious due to its magnitude.
After the arrival of the Mobile Unit in September 1.993 to these communities, the process of increasing community awareness and of inducing inter-institutional participation was initiated.Measures were taken in order to integrate the efforts towards common-objectives, joining actions and assuming shared responsibilities to take on and control the problem, one that seriously affects about 15.000 persons. During the year 1.995 activities aimed at increasing awareness have been undertaken,in addition to accomplishing the following direct actions with organizations:
o Heathland Social Welfare Ministry (Sanitary Engineering, Malarial and RuralEndemics):
o Sessionof elimination of vermin and fumigation, with its respective orientation.
o HealthPromoters Workshop for training members of the community and the provision ofmedicines for the anti parasitic treatment for the families that inhabit the banks of the garbage landfill.
o Municipal Sanitation Institute:
o Partialre-establishment of the trash collection system.
o Reopening of the principal access route to the community that borders the garbagelandfill, along with the collaboration of the Municipal Engineering Department.
o Municipal Engineering Department:
o Topographical measurement study.
o Preparationof the road and lot map of the Cujicito landfill.
o Placementof notices forbidding the dumping of garbage.
o Preparation of a preliminary design project aimed at recovering the garbage landfill.
o Centre atthe Service of the Popular Action.
o Workshop on Citizen Participation.
o University of Zulia. Postgraduate School of Environmental Engineering.
o Visit to the landfill by a team of experts on solid wastes with the objective of preparing proposals for the better utilization of the land that occupies the garbage dump, as well as the gases which emanate from it.
A thorough evaluation was performed and the necessary studies undertaken to determine the viability of a development project, one which at present is awaiting the construction blueprints for a recreational park and the planting of trees along the length and breath of the landfill. It is expected that its execution will permit alessening of the harmful effects that the present situation effects on the health of the population that presently inhabits the area. Besides the cleaning and embellishing of an area that was lacking in adequate environmental conditions for any human presence, the project will also encourage sports and recreational activities, which will contribute in reducing criminal activitiesin the area. From the working meetings with this community, there emerged two legally constituted neighbourhood associations as acting representatives of-their communities. The end of 1994 attained a commitment by all theorganisations that participated in the project, and as a result an educationalprevention process was initiated.
Positive results have been obtained with respect to the behaviour of the community, so much so that fromNovember 1994 the principal avenue is free of garbage as a result of communityinitiative. Programmed garbage collection on the part of the MunicipalSanitation Institute has been obtained, and a planning process for the repairof the banks and crust of the landfill has been initiated. There is now astanding objective of recovering the four hectares that the landfill occupies,which will benefit the surrounding population of about twenty thousand (20,000)people. Latin American societies, and very notably Venezuelan society, haveundergone transformations as a result of macroeconomic, political and socialfactors which are causing serious problems to the middle income groups, andvery particularly to those groups of very limited resources. The impact of thissituation severely limits the ability to subsist of the poor neighbourhoods ofthe cities, where we find malnutrition problems affecting nearly 30% of theinfantile population with the trend due to increase in the immediate future.Some actions have been taken to provide the necessary information to promoteadequate nourishment, so as to encourage the utilisation of the naturalresources produced in the region, which would provide an important quantity ofnutrients at lower cost. With the advice of the NourishmentSchool of the University of Zulia,the creation of a nutritional recovery unit is being promoted. The primaryemphasis is an educational approach, one which would be undertaken directly inthe target communities. In this way, it is hoped that a greater impact in thenutritional recovery of children and expecting mothers can be achieved, sincethey would be to control all the factors which are involved in the process.
The resources for thisproject were requested of FUNDASALUD (Health Foundation ascribed to misgoverning of the State of Zulia),and at this time an answer is awaited on the budgetary availability to begin the implementation of this nutritional recovery unit. Breast feeding has been promoted in continuous fashion as a means to prevent malnutrition and childhooddiseases, as well as giving orientation as to the indications for the recognition of warning signs that could put in danger the life of children five years old or younger, such as diarrhoeic conditions. This has been achieved by educating the population on the benefits of the renationalisation of Oral RehydrationTherapy (TRO). As a result of these policies, there has been a promotion for the installation of Community Oral Rehydration Units (UROC), which allow the communities to have this service twenty-four hours a day, having a positive-impact in the decrease of negative complications as a result of infantrymen. By the end of 1995, we will have a total of five Community Oral Rehydration Units in operation.
At the beginning of ouractivities it was observed that over 50% of children five years old or less inthe two communities studied had not received any form of immunisation.Therefore, they were found to be in high epidemiological risk. This situationresulted in the active participation on the part of the Paradise Clinic(private hospital), the Department of Epidemiology of the Health Ministry, andthe Saint Ines Archdiocesan Ambulatory, in the execution of an intensevaccination campaign. At the present time, about 80% of these children havebegun a vaccination schedule, many of which have received all the necessary injections. Around the end of 1.994 a group of students of the School of Psychologyof the University Rafael Urdaneta concluded an independent study on the scope of the intervention of the PROGRAM in the neighbourhood Jesus of Nazaret. Oneof its recommendations was to include within the services paleontological attention and a respiratory therapy unit, this last one due to the high rate of infant mortality as consequence of the acute respiratoryinfections and recurrent asthmatic conditions. In the month of October 1.995,each Mobile Unit was equipped with a respiratory therapy unit, and conversations initiated with those responsible for the Acute Respiratory Infection Program (IRA), of the Health Ministry, to include the Mobile Units intheir community attention programs beginning in the month of November.
In the area of prenatal care, and particularly with adolescents, educational processes are promoted for the prevention of precocious pregnancies. And in the detected cases, follow-upsare performed since they are considered to be of high risk. Given thepredominantly Indian population of the attended communities, there are at present a high number of home deliveries attended by midwifes, who do not havethe necessary minimal preparation, with the observable result of a high rate of neonatal sickness and mortality. As a result, they have been prepared andsupplied of the minimum material requirements so as to assist in the deliveries-under more adequate hygienic conditions, motivated in great part to theexpecting mothers' refusal to go to public health centres, due either to economic or cultural motives. The odontological services were initiated in the-third trimester of 1995 under the preventive educational modality. It hasencouraged the participation of the private company (Colgate-Palmolive) in the way of organising campaigns in the application of fluoride to the infant population and education on oral hygiene techniques. The Odontological Unit isequipped to give integral preventive attention as well as curative, taking into account that it is the only service of its kind operating in the area.Currently in its final stage before signing, a co-operation agreement is beingprepared with the Archdiocese of Maracaibo for the installation of a clinicallaboratory in the Saint Ines Archdiocesan Ambulatory, located in the ParishIdelfonso Vßsquez, that will directly benefit a approximate population of20.000 persons. This will be the first laboratory of its kind in the parish,which has an overall population of approximately 90,000 people.
As example of better-practice, the Mobile Clinics Program undertakes in a systematic way the accomplishment of its established goals. This is a result of the offering of accessible solutions to short, medium and long-term health problems that affecturban communities living in extreme poverty, improving their quality of live in the process. It is promoted in integral form, encouraging inter-institutionalparticipation, within an all-encompassing process, and working towards commongoals. It is achieved by means of the direct action, a favourable response to a decision making process where the target community is the principal actor inthe solution of its problems. All of which occurs within a preventiveeducational scheme as part of the medical attention process.
A new Municipal Government structure, with the novel figure of the Mayor, which began functioning in 1.989 in Venezuela, hasresulted in a general reorganisation of the departments of this important localinstitution. This has permitted the design of a set of policies and strategiesdirectly linked with the mission, vision and objectives of the MunicipalGovernment, all of which allows for the application of solutions to the needsof the inhabitants of Maracaibo.Within this reform framework, the decentralisation of the health sector towardsthe municipalities is included as one of the local government. Even though itis not under its direct responsibility, it is of its incumbency, and as suchencourages the undertaking of immediate actions toward this important sphere ofthe general welfare of the community. The Mobile Clinics Program of theMayoralty of Maracaibo emerges from the need of improving the environmental,social, cultural and economic conditions of the inhabitants of the low-incomeneighbourhoods of the municipality, through the provision of primary healthservices. With its creation, the Mayoralty of Maracaibo is inserted into theNational State Reform Project and of society in general, in addition toparticipating actively, as is established in the Law of Municipal Government aslaid out in its article 37; which determined that the Mayoralties will cooperatewith all existing institutions of the health sector to improve the quality oflife of the population. In order to accomplish the objectives of the Program,the use of specialized vehicles is required, vehicles designed especially toundertake educational-health assistance functions as well as support vehiclesthat permit the supply of the former. The Assistance Mobile Unit is a bus type vehicle accommodated with a thoroughly equipped medical doctor or odontologicaloffice (according to the type of unit), that contains the working materialrequired to give educational as well as curative attention when required. It also is equipped with a programmed data base designed to process theinformation generated by the Program. Each medical Assistance Mobil Unit is outfitted with the following personnel: Doctor, Nurse, Social Worker,Nutritionist and Paramedic. In the case of the odontological Assistance MobilUnit, they rely on the same number and type of personnel, except for anodontologist in substitution for the medical doctor. This equipment, with theaccompanying certified multidisciplinary personnel, resolves problems in acomprehensive and specialized fashion, one which permits a better understandingof the variables present in the ongoing social processes.
The Mobile Clinics Program represents a strategy change within health care model in the city of Maracaibo. The systemproposes the taking of concrete actions with respect to the particular problemsof each community, through a multifaceted approach that begins with thehealth process and encompasses the total spectrum of situations, which are thesource of common pathologies. Due to the mobility of the equipment, which have access to those communities that even though they are located within the city limits embody characteristics of outlying rural areas (the absence of basic public services), thus offering coverage to a high percentage of the population whose overall social and economic situation prevents them from having easy access to public health services. It is this particular segment of the overall population-of the city, which is at greater risk of presenting endemic pathologies, which can evolve into general epidemics. A clear example of this danger was the recent Dengue and Venezuelan Equine Encephalitis epidemic, where this population was an important factor for the appearance of these pathologies in the city, as a direct result of the own migrant processes of the Wayuá ethnic group, which accounted for approximately 80% of the reported cases in theMunicipality of Maracaibo.
In the province of sanitation management, special attention is given to the importance ofhumanising the actions of the health teams, both in the area of investigation and the search for answers to specific problems. Doing so facilitates those-processes that permit the different communities to learn to solve their ownproblems while simultaneously integrating themselves to different participatinginstitutions, be they public, private, non government organisations (NGOs), religious and of any other nature, that promote the attainment of needed solutions. In-this way, the inhabitants of these communities learn to know what the processesthat determine the health situation are, and to initiate actions with the participation of the relevant institutions to bring about desired solutions.
This program provideswidespread coverage to those cities that as a result of their rapid growth suffer from restrictions in their ability to service areas at health risk in of themselves and to the rest of the city.
Coverage: 150,000 people
Number of people assisted with educational measures: 90,587
Number of people benefited by direct action and education concerning sanitation in the Cujicito landfill:5,121
Number of people benefited by direct action by the cadastral survey of the San Antonio de los Ca±os neighbourhood: 2,678
Total medical attention(includes medical, odontologic and nutritional cases): 36,724