Strengthening Community Health Capabilities: A Case Study of One Volunteer Run Social Solidarity Clinic

Kolokytha, Efthymia; Kalisperati, Maria; Katsanou, Maria; Mylonas, Nikolaos; Triliva, Sofia (2014). 'Strengthening Community Health Capabilities: A Case Study of One Volunteer Run Social Solidarity Clinic' Paper presented at the annual conference of the HDCA, 2-5 September 2014, Athens, Greece.

      The global financial recession that many countries have encountered during the past several years has brought to the forefront human rights issues especially for people facing social and economic exclusion and living without access to basic health care.   Access to health care is a basic human right and one of the major human capabilities (Nussbaum, 2006).  Nevertheless, people in Greece have been affronted with severe austerity measures, a burgeoning 'healthconomic crisis' (Williams & Maruthappu, 2013), constant change and turmoil regarding basic social and health services and 'denialism' (Kentikelenis, Karanikolos, Reeves, McKee, & Stickler, 2014) regarding rights, inequities, and capabilities.  Various changes have been launched in the health  care sector, including a downsizing of health care personnel, a reduction in the number of public hospitals and in hospital beds as well as shortages in drug supplies (Kalafati, 2012) and public health has been impacted greatly (Kondilis, Giannakopoulos, Gavana, Ierodiakonou, Waitzkin, & Benos, 2013).  Moreover, the cuts in public health spending, cost shifting to patients and the exponential rise in the number of uninsured people have led to the deterioration in public health and what has been described as a 'Greek tragedy' (Bonovas & Nikolopoulos, 2012; Kentikelenis, Karanikolos, Papanicolas, Basu, McKee, & Stuckler, 2011).

      These crises have mobilized political action by health care professionals culminating in the development of volunteer run solidarity schemes.  Community clinics have mushroomed in cities and prefectures all over the country providing primary health care to uninsured populations. The first volunteer run Social Solidarity Clinic (SSC) was established in Rethymno, Crete, six years ago, and the primary focus of the services rendered at that time was the health care of undocumented immigrants. The advent of austerity measures brought changes and Greek uninsured service users have dramatically increased. This type of medical care and praxis has brought to the forefront issues regarding social justice in health care, re-thinking of the epistemological underpinnings of systems of care, and how volunteer capacities and resources can best put to use in bolstering services and social capital.  

       In order to explore the solidarity agenda and the social justice and health care philosophies of all involved in the Rethymno SSC we conducted a three phase study:  1) participatory observation and volunteering at the center; 2) quantitative demographic data analysis, and 3) interviews and analyses of the policy charter that all SSCs abide by.   More specifically, the study aimed to clarify how volunteers and users of the services conceptualize and talk about the solidarity schemes.  Six individual semi-structured interviews were conducted after the recruitment of three health care volunteers, two service users and the city council member responsible for public health in the municipality of Rethymno. The interviews were transcribed verbatim and analyzed by using thematic analysis (Braun & Clarke, 2006). Outcomes revealed that all the interviewees consider health as a universal human right that needs to be protected taking into consideration that it is in unprecedented peril due to the austerity regime. Moreover, and contrary to expectations,  they emphatically stated that the services that are being provided by such health facilities are not and should not be the final solution to health care crisis and that the clinics need to be rendered null in that medical services should be provided by the welfare state.  Along these same lines, volunteers explained that they aim to subvert the current socio-political situation and try to promote medical practice in a more holistic way, considering medical problems as a result of social, physical and environmental factors. Furthermore, they mentioned that they aspire to engage in health promotion and prevention initiatives.

         Additionally, quantitative analyses revealed that although the fundamental reason for establishing SSC was the estimation of the problem of undocumented immigrants' health care and to raise awareness of such inequalities and disparities, it seems that their highest priority at this juncture is to promote uninsured people's health (both Greek nationals and immigrants) within the community and how to best meet the needs of the rising numbers of service users.  According to SSC' s yearly statistics, the clinic  a) eliminates disparities in health provision; b) enhances general health; c) detects community's health needs; and d) provides a framework for the assessment of health care crisis' consequences. Thus, the overall clinic's contribution is in line with health related functionings (Venkatapuram, 2012).

        Despite the fact that Rethymno's SSC plays an important role in community health functioning, some serious problems were identified through the research process. More specifically, the service users' misconception of the scheme's voluntary character, unwillingness to actively participate and contribute in the center's management, insufficient knowledge base regarding health issues, and finally, their non-politicization  point to power differentials and imbalances that need to be rectified if equity and social justice are to prevail. The findings are discussed by putting forth a proposal as to how they and the challenges outlined can be confronted by applying a Community-Based Participatory Research (CBPR) paradigm. CBPR 'brings the best and latest technology for design and measurement to the major issues impacting community health' (Israel, Eng, Schulz, & Parker, 2005, p. xiii). Such an approach will place emphasis on community resources, volunteer capacities, and the expansion of health capabilities far beyond physical health into the realm of social and political capital. In conclusion and keeping in line with the outcomes, a theoretical inquiry regarding the utility of CBPR in developing community health capabilities will be outlined.



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