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Community participation as a strategy in health aims to increase the role of citizens in health decision-making which are contextualised within the institutions of democracy. Electoral representation as the dominant model of democracy globally is based on the elite theory of democracy that sees political decision-making a prerogative of political elites. Such political elitism is counter to the idea of democratic participation. Neoliberalism together with elitism in political sphere have worsened social inequities by undermining working class interests. Latin America has seen adverse consequences of these social inequities. In response, social movements representing collective struggles of organised citizens arose in the region. This paper explores the theoretical underpinnings of democratic participation in contemporary Latin American context at the nexus of emerging social movement activism and policy responses. The paper will use empirical examples to highlight how such democratic practices at the societal level evolved while demanding political inclusion. These societal democratic practices in Latin America are redefining democracy, which continues to be seen in the political sphere only. Health reforms promoting participatory democracy in several Latin American countries have demonstrated that establishing institutions and mechanisms of democratic participation facilitate collective participation by the organised citizenry in state affairs.

Universal access to healthcare has assumed renewed importance in global health discourse, along with a focus on strengthening health systems. These developments are taking place in the backdrop of concerted efforts to advocate moving away from vertical, disease-based approaches to tackling health problems. While this approach to addressing public health problems is a step in the right direction, there is still insufficient emphasis on understanding the socio-political context of health systems. Reforms to strengthen health systems and achieve universal access to healthcare should be cognizant of the importance of the socio-political context, especially state-society relations. That context determines the nature and trajectory of reforms promoting universality or any pro-equity change. Brazil and Venezuela in recent years have made progress in developing healthcare systems that aim to achieve universal access. These achievements are noteworthy given that, historically, both countries had a long tradition of healthcare systems which were highly privatized and geared towards access to healthcare for a small segment of the population while the majority was excluded. These achievements are also remarkable since they took place in an era of neoliberalism when many states, even those with universally-based healthcare systems, were moving in the opposite direction. We analyze the socio-political context in each of these countries and look specifically at how the changing state-society relations resulted in health being constitutionally recognized as a social right. We describe the challenges that each faced in developing and implementing healthcare systems embracing universality. Our contention is that achieving the principle of universality in healthcare systems is less of a technical matter and more a political project. It involves opposition from the socially conservative elements in the society. Navigation to achieve this goal requires a political strategy that involves various actors within the state, the political society and civil society.

The Venezuelan health reform Barrio Adentro (BA), initiated in 2003, aims to improve population health and promote popular participation. Access to healthcare has improved but the distinguishing feature of BA is participation by communities. Popular participation has been institutionalized through the formation of health committees and communal councils. We explored the challenges/barriers faced by these community groups in BA. A mixed-methods participatory methodology was used involving 31 participants selected through non-random purposive sampling from five Venezuelan states. Results indicate that implementation issues challenge participation. There is political will at the highest level but the opposition political parties, Venezuelan Medical Federation, and the private media oppose the reform. Public participation in state affairs is facilitated if there are popular arenas of participation that promote engagement of organized citizenry with the state and an ongoing interaction between state and civil society in order to radically transform the state. [ABSTRACT FROM AUTHOR]

Introduction: Participatory governance is about state and society jointly responsible for political decisions and services. The origins and trajectory of participatory governance initiatives are determined by the socio-political context and specifically the nature of state-society relations. Participation by communities in health interventions has been promoted globally as a strategy to involve citizens in health decision-making but with little success. Such participatory governance in health should be seen not as a strategy alone but as a political project in which organized communities challenge the status-quo in health. Methods: This paper deals with the wider socio-political context of participatory governance initiatives. It uses comparative politics literature to analyze socio-political context in Brazil and Venezuela, historically spanning half century prior to 2015, to assess whether it was conducive to participatory governance. The focus of this paper's analysis particularly is on the socio-political changes that were taking place in Brazil and Venezuela in the decades of the 1980s and 1990s. Those decades formed the bedrock on which the two countries experienced democratization and a socialist transformation that has lasted well into the first decade of the twenty-first century. The situation in the health sector is also described for the two countries showing a parallel trajectory to the wider political context and that reflected the political ideology. For this assessment, we use a contemporary framework called the 'socialist compass' which links dynamics of power relations in various ways among three domains of power, namely, state power, economic power, and social power. Socialist compass can be used to assess whether such reforms are moving towards or against social empowerment. Conclusion: Our analysis reveals that both Brazil and Venezuela were moving in the direction of social empowerment until at least the year 2015, just before the political turmoil started engulfing the left-leaning regimes in both the countries. [ABSTRACT FROM AUTHOR]