Integrated local health systems in Central America.

This paper describes a few Central American experiences related to the development of integrated, participatory health care systems. Theory and analytic method center on the tensions inherent in the dichotomies of professional/popular, center/periphery and biomedical/traditional. Using a framework rooted in the World Health Organization's 1978 call for 'health for all' based on community-oriented primary care, this paper concludes that the underlying conditions necessary for truly integrated local health systems have not yet developed. Except for the cases of Costa Rica during 1978-1982 and Nicaragua during 1979-1990, the political will to create and support such systems has not existed. Perhaps more importantly, the cultural milieu in which Central Americans interact with their society fosters an individualistic, commercial, and paternalistic citizen/society relationship rather than the cooperative, community-oriented and democratic spirit needed for successful development of integrated local health systems. Nevertheless, there are a number of positive examples from which we can learn, and a growing tradition of citizen participation which may lead toward appropriate, sustainable, and truly integrated local health systems.