Health Sociology Review

ISSN: 1446-1242 (Print) 1839-3551 (Online) Journal homepage: http://www.tandfonline.com/loi/rhsr20

Facilitating Indigenous women’s community

participation in healthcare: A critical review from
the social capital theory

Lila Aizenberg

To cite this article: Lila Aizenberg (2014) Facilitating Indigenous women’s community
participation in healthcare: A critical review from the social capital theory, Health Sociology
Review, 23:2, 91-101, DOI: 10.1080/14461242.2014.11081964

To link to this article: http://dx.doi.org/10.1080/14461242.2014.11081964

Published online: 04 Feb 2015.

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 Copyright © eContent Management Pty Ltd. Health Sociology Review (2014) 23(2): 91–101.

Facilitating Indigenous women’s community participation in healthcare:

A critical review from the social capital theory

Lila Aizenberg
Postdoctoral Fellow, CIECS–CONICET–National University of Córdoba, Córdoba, Argentina

Abstract:  This article examines how Indigenous women who receive intercultural healthcare programs manage to
develop cooperation networks, get involved in community affairs and improve their reproductive healthcare. It concen-
trates on the case of the Bolivian intercultural health program ‘EXTENSA’ and analyzes how this program is successful
at activating greater community participation in health prevention and improving the reproductive healthcare of the
Indigenous women who live in the Department of Beni, Bolivia. Through an ethnographic analysis, it argues that com-
munity participation and healthy behaviors are the result of tapping into bonding social capital and fostering women’s
empowerment. The analysis shows that the program gives women community leaders and women networks members (who
predate EXTENSA) access to different types of resources, allowing women to transform their community assets into sources
Downloaded by [La Trobe University] at 06:40 25 January 2016

of collective empowerment.

Keywords: intercultural healthcare, community participation, social capital, sociology, gender, Bolivia

H istorically, the model of ‘modern-­western’

healthcare has been characterized by its
excessive emphasis on the psycho-physical aspects
of the healthcare process (Menéndez, 2005).
However, since the end of the 1980s, academia and
policy makers have moved away from an inter-
pretation of healthcare based on merely physical
elements to provide more room for social aspects,
based on the belief that social determinants have a
major impact on people’s health and on healthcare
inequalities (Marmot, 2005). Since then,‘commu-
nity participation’ has been identified as the key
to primary health care and has been expected to
bring about the following benefits for the people:
better use of existing health services and increased
sustainability of new services by being involved in
decisions about the development of the services;
and change in their poor health behaviors after
being involved in exploring the consequences of
these behaviors (Rifkin, 1990, p. 11). From this
perspective, healthcare no longer depends exclu-
sively on the actions of healthcare agents or pro-
gram providers, but on the beneficiaries as well
(Heritage & Dooris, 2009; Morgan, 2001; Rifkin,
1996; Smithies & Webster, 1998; World Health
Organisation, 1986).
The concern regarding active commu-
nity participation in health programing was
embraced by the intercultural healthcare approach
when it emerged in the 1990s as a response to
the specific challenge of reaching Indigenous
populations in Latin America (Deruyttere, 1997;
Griffiths, 2005). Intercultural healthcare has been
defined as an approach in health that aims to
reduce the gap between Indigenous and west-
ern health systems, on the basis of mutual respect
and equal recognition of these knowledge sys-
tems (Torri, 2012, p. 31). In this sense, the inter-
cultural healthcare approach to public policies
has been seen as a way to guarantee Indigenous
peoples’ right to health according to their own
customs and traditions (O’Neill, Bartlett, &
Mignone, 2006). The intercultural approach has
been considered a key strategy to improve the
health of the Indigenous peoples. But this has
especially been recognized as a unique opportu-
nity for women, who are recognized as the most
vulnerable group of the Indigenous population
because of poor sexual and reproductive health
indicators and gender inequality (Bant & Girard,
2008; Camacho, Castro, & Kaufman, 2006; Pan
American Health Organisation, 2009).
Interest in Indigenous health has been related
to local politics and to a global demand of major
development organizations. Since mid-1990s,
development organizations have added the pro-
tection of Indigenous peoples’ rights to their
operational guidelines, allocating specific funds to
the development of Indigenous populations, and
financing actions from a standpoint of cultural

Volume 23, Issue 2, August 2014 HSR 91

 HSR Lila Aizenberg
adaptation (Hall & Patrinos, 2006). Interest in
the needs of the Indigenous communities com-
ing from development organizations was not
just happenstance. Neoliberal health reforms
common in low and middle-income countries
worldwide beginning in the 1980s-showed poor
health outcomes in the majority of cases and,
in particular, a large gap in indicators between
the Indigenous and non-Indigenous popula-
tion (Hall & Patrinos, 2006). For example, in
order to improve Indigenous health outcomes,
in 1994, the Inter-American Development Bank
created an Operational Policy on Indigenous
Peoples (OP-765), which mandates the Bank to
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mainstream Indigenous peoples specificity into
its programs and to support ‘development with
identity’ initiatives. With regard to health proj-
ects, the policy requires the Bank to support the
articulation of public health services, taking into
account Indigenous knowledge, practices and
values, and also the preservation and strengthen-
ing of traditional Indigenous systems of health
and healing (O’Neill et al., 2006, p. 1). At the
end of the 1990s, Latin American governments1
had made significant efforts to create special-
ized institutions that manage intercultural health
policy, especially when promoting the inclu-
sion and participation of Indigenous people in
their design, as a way to guarantee Indigenous
peoples’ right to health according to their own
culture (Torri, 2012). The intercultural health
approach mainly aimed at improving Indigenous
reproductive health and gender equity, including
women’s participation in preventive behaviors
and community activities regarding healthcare
(Bradby & Murphy-Lawless, 2005; Campos &
Citarella, 2004; Cline, 2010).
In Latin America, the Indigenous peoples have
historically been identified as one of the most
Several Latin American governments (Argentina, Bolivia,
1
Brazil, Colombia, Costa Rica, Ecuador, Guatemala,
Honduras, México, Nicaragua, Perú and Venezuela) started
to incorporate the intercultural approach to health into
national documents. At the country level, progress has
been made in different ways: constitutional recognition,
creation of agencies or offices on intercultural health, and
implementation of intercultural health models.
92 HSR Volume 23, Issue 2, August 2014
vulnerable groups health-wise (Hall & Patrinos,
2006; Montenegro & Stephens, 2006; Stephens,
Porter, Nettleton, & Willis, 2006). Studies of
Indigenous health in the region noted major
inequalities in health outcomes for Indigenous
peoples compared with non-Indigenous pop-
ulations, including higher rates of maternal
mortality and women’s morbidity than their non-­
Indigenous counterparts (Casas, Dachs, & Bambas,
2001; Ewig, 2006, 2010; Nigenda, Moa-Flores,
Aldama-López, & Orozco Núñez, 2001; PAHO,
1998; Paqueo & Gonzalez, 2003; Plant, 1998;
Psacharopoulos & Patrinos, 1994). It is, however,
15 years ago that Indigenous health needs started
to be considered a priority in national health poli-
cies such as has been the case in Bolivia. Bolivia is
a country with the greatest number of Indigenous
inhabitants in all of Latin America, which
accounts for over half of the country’s total of
60% (PAHO, 2009). Despite improvements in key
health indicators over the last 20 years, Bolivia still
shows the second worst health indicators in Latin
America. Life expectancy at birth is only 65 years
(INE, 2001) and maternal mortality remains the
highest in the region after Haiti (PAHO, 2009).
Estimates indicate that in 2003, maternal mortal-
ity was set at 203 per 100,000 live births (PAHO,
2009). Within Bolivia, maternal mortality varies
regionally and rates are approximately 50% higher
in Indigenous groups than in non-Indigenous
ones (Silva & Batista, 2010). Studies have shown
that Indigenous women’s poor health outcomes
are linked to complex phenomena related to:
(a) a lack of cultural understanding between the
practitioners of the modern health services and
the users of traditional services; (b) economic/
geographical barriers that limit or prevent access
to health services; (c) gender discrimination suf-
fered by Indigenous women; and (d) restricted res-
olutive capacity of health units in the Indigenous
communities (Bradby & Murphy-Lawless, 2005;
Meentzen, 2001; Ollé Goig, 2000; Otis & Brett,
2008; O’Rourke, Howard-Grabman, & Seoane,
1998; Pooley, Ramírez, & de Hilari, 2008; The
World Bank, 2004).
Recent changes in the Bolivian government
have resulted in a state discourse centered on
interculturality that advocates Indigenous rights.
© eContent Management Pty Ltd
 Facilitating Indigenous women’s community participation in healthcare
As a result of this discourse, the implementa-
tion of new policies and programs within the
healthcare system has been carried out to help
to improve both health outcomes and access to
quality care for Bolivia’s Indigenous popula-
tions (Andolina, Laurie, & Radcliffe, 2009). The
Indigenous population’s recognition, visibil-
ity and needs have become a turning point in
how health policies operate: instead of includ-
ing Indigenous populations in universal health
programs, new healthcare policies have started to
be designed specifically focused on reaching this
population group from an intercultural perspec-
tive. In 2003, in order to improve Indigenous
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health outcomes, the Bolivian Government
launched an intercultural health program
called EXTENSA (National Programme for
the Expansion of Coverage of Health Care),
designed to provide direct basic health services
to Indigenous women and children in remote
areas of the country (Pooley et al., 2008).
EXTENSA is formed by multidisciplinary
mobile health teams, who mainly provide the
Universal Mother and Child Health Insurance
(SUMI, by its Spanish acronym),2 in rural com-
munities, which are visited every 2 months.
The program is an example of the development
strategy under the World Bank OP-410, imple-
mented by the Bolivian government to improve
the health of Indigenous communities. It arose
in Bolivia in response to demand by interna-
tional organizations to start the Bolivian Poverty
Reduction Strategy (EBRP, by its Spanish acro-
nym),3 which includes among its objectives the
Identity-based Development Strategy and the
Millennium Development Goals (MDGs). From
2
SUMI is the principal maternal-child health insurance
in Bolivia. It provides free care for children age five and
under and for women during pregnancy and six months
following delivery.
3
The Bolivian Poverty Reduction Strategy (EBRP) was
a part of the Initiative of the Highly Indebted Poor
Countries to alleviate external debt. As a part of this
Initiative, international loan organizations forced the
countries to fix priority health indicators and to meet
MDGs. EBRP includes, among its main objectives,
identity-based development and reduction of inequalities
and existing barriers in ethnic discrimination.
© eContent Management Pty Ltd Volume 23, Issue 2, August 2014
HSR
an intercultural point of view, the community’s
health promoters, healers and traditional mid
midwifes are incorporated into the program and
receive a health kit and training on maternal-
child health prevention so that they can attend
health emergencies and deliveries and foster the
community’s healthy behaviors.
Even though community participation was
thought by intercultural advocates as a cru-
cial element to horizontally bridge the cultural
divide between traditional and biomedical medi-
cine, authors interested in analyzing how inter-
cultural health programs work have pointed out
that in practice it meant a way of inculcating
cultural values regarding health that were more
in line with modern medicine (Lorenzetti, 2011;
Menéndez, 2006; Radcliffe & Laurie, 2006;
Ramírez Hita, 2006, 2009). In this sense, several
authors have drawn attention to how modern
medicine has fostered Indigenous community
participation in health affairs by training health
promoters and local leaders in order to transmit
these values to the community. As Ramírez Hita
(2006) pointed out, training is one of the main
activities of international organizations interested
in implementing intercultural health programs in
Bolivia. ‘These institutions (international organi-
zations) work on the supposition that by training
representatives from the traditional medical sys-
tem (traditional healers, midwives), these repre-
sentatives can then serve as mediators within the
community and help to transform it’ (Ramírez
Hita, 2006, p. 405). In other words, training is
based on the belief that certain behaviors of
Indigenous peoples such as promoting health
care must be modified in order to meet modern
medicine views to optimize their practices with
the aim of obtaining improvements in the popu-
lation’s health.
This article examines how Indigenous women
who receive the intercultural healthcare program
‘EXTENSA’ manage to develop cooperation
networks, get involved in community affairs and
improve their sexual and reproductive healthcare,
in the Department of Beni, Bolivian Amazon.
The analysis shows that the program gives access
to community leaders and network mem-
bers (who predate EXTENSA), by providing
HSR 93
 HSR Lila Aizenberg
them with new opportunities so that they can
­transform their community assets into sources of
collective empowerment. The article reinterprets
the mechanisms that allow programs to increase
the community’s involvement in health: from
an approach based on what programs offer – in
terms of bridging Indigenous medicine and bio
medicine cultural gaps – toward another view
on how programs help women understand their
community assets and utilize them to increase the
community’s health promoting behaviors.
The strategy of bonding social capital
as a source of community participation
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and empowerment
Since the 1990s, an important number of social
scientists have sought answers to explain social
mobility among the poor. In particular, their
interest has focused on analyzing how people
can reduce the effects of poverty and develop
mechanisms to improve their social conditions.
From the field of development, a great num-
ber of authors have started paying attention to
the role that social capital can play in this pro-
cess. These studies have pointed out that social
networks based on trust, reciprocity and coop-
eration are key elements in diminishing poverty
and in increasing the wellbeing and possibili-
ties for economic and social improvement of
the population (Coleman, 1990; Portes, 1998;
Putnam, 1993). Social capital emphasizes the
potential that the poor have to escape poverty
and improve their behaviors through their own
community assets in conjunction with the sup-
port provided by development programs. In par-
ticular, ‘bonding social capital’ found at the level
of community assets – such as informal networks
and community leaders – has been emphasized
as a key asset in promoting collective actions to
resolve common problems (Saegert, Thompson,
& Warren, 2001; Woolcock & Narayan, 2000).
Authors interested in analyzing the formation
of bonding social capital have pointed out that
community bond is not seen as a new one formed
where there had been none in the past. Instead, it
is seen as an existing bond, albeit a weak one which
predates the arrival of development programs but
needs them to grow stronger. As the literature
94 HSR Volume 23, Issue 2, August 2014
explains, communities possess important infor-
mal networks that provide mutual support and
­designate community roles which are constructed
as community assets. However, when communi-
ties suffer from poverty, they lack connections at
a higher level and thus have fewer opportunities
to use their assets as channels for improving the
quality of their lives (Bebbington, 1999; Durston,
1999a, 2000; Durston & Duhart, 2003; Fox, 1996).
Development programs can serve as intermediar-
ies for strengthening these assets, thus increasing
the opportunities of community members. As a
result, they can help the assets to become true
vehicles for collective action which can then be
used by the people who possess them to improve
community wellbeing (Bebbington & Perreault,
1999). In summary, the synergy between policy
providers and users is seen as the result of a com-
plementary strategy that combines the promo-
tion of community assets with the mobilization
of new capitals.4
Authors interested in understanding the factors
that allow external programs to enhance bonding
social capital have placed emphasis on the notion of
empowerment.The vision of empowerment empha-
sizes the role that the poor have as active subjects
in the development of their community while
highlighting the importance of intra-community
assets in this process (Durston, 2000; Durston &
Duhart, 2003). The main criterion of the con-
cept is to transform socially excluded sectors into
political actors. Empowerment means ‘changing
the power relations in favor of those who had
little power over their own lives in the past […].
It is the process of taking control’ (Gita Sen, 2000
quoted by Durston & Duhart, 2003). Durston
(2000) points out that empowerment is not a lofty
entity that grants power to others. It is the antith-
esis of paternalism, the essence of self-management,
the capabilities of a person or social group to build
4
Fox (1996) highlights the key role of the interventions
of international entities in the possibility of increasing
the alternatives for excluded groups to gain access to
resources by offering political support, financing and
contacts that allow these groups to move upward and
consolidate this position with as actors at the national
and international level.
© eContent Management Pty Ltd
 Facilitating Indigenous women’s community participation in healthcare
on their existing strengths. From this perspective,
the development of poor communities would
depend on how development programs promote
empowerment strategies that allow actors to
assume an active and critical position in their own
development.
The concept of empowerment perme-
ates the literature on bonding social capi-
tal applied to the field of healthcare (Green,
Poland, & Rootman, 2000; Hawe & Shiell,
2000; Heritage & Dooris, 2009; Kawachi &
Sapag, 2007). Wallerstein (1992) points out that
empowerment is a strategy that allows people
to develop their capabilities in order to join
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forces to achieve better results in terms of their
health (Wallerstein, 1992, p. 198). The social
capital debate and the promotion of healthcare
also take a political economy viewpoint when
describing the health of poor populations. In
this case, authors associate the obstacles that
the poor face in terms of healthcare with
fewer opportunities (i.e., material and social
opportunities as well as those related to politi-
cal power), while emphasizing the community
networks as key assets to improve health behav-
iors. The literature then suggests that the suc-
cess of policies that promote healthcare depend
on the degree to which external health pro-
grams are capable of strengthening community
assets (informal networks focused on health-
care), by mobilizing new capitals (human and
financial) and opening new spaces for commu-
nity participation (Uphoff, 2000; Uquillas &
Van Nieuwkoop, 2003).
The notions of bonding social capi-
tal and empowerment are highly useful for
understanding how EXTENSA is success-
ful at increasing community participation
and improving health. The article argues that
EXTENSA raises community participation
and increases the health of the women in the
Department of Beni by drawing on existing
community assets (health care promoters and
informal networks) that women possess to
foster bonding social capital. In addition, the
increase of community participation is part of
a process of collective empowerment, which
is enabled because the program provides
© eContent Management Pty Ltd Volume 23, Issue 2, August 2014
HSR
those who possess these assets with new tools
(financial, educational and political tools) that
allow them to strengthen their assets and to be
legitimized by the population. When the com-
munity sees its collective assets as a source of
opportunity for improving their living condi-
tions, they can benefit from them, get involved
in community affairs and work to improve the
quality of their lives.
This article is divided into three parts.The first
part presents the methodological aspects of this
study. The second part presents the main results
and explores the success of the intercultural
healthcare program, EXTENSA, in increasing
Indigenous women’s participation in healthcare.
This section is divided into two sub-sections.
First, the case of those communities that possess
community leaders is analyzed. Second, the case
of those communities that have informal com-
munity networks is examined. The third part, in
the conclusion, summarizes the outcomes of the
field work. Based on social capital and empow-
erment theoretical approaches, the article sug-
gests a new interpretation of how intercultural
healthcare programs are successful at activating
greater community participation in health pre-
vention and thus, improving the reproductive
healthcare of Indigenous women.
Methodological aspects
An ethnographic research was conducted in five
Indigenous communities in the Department
of Beni, Bolivian Amazon, which received the
program EXTENSA. The study is part of the
author’s doctoral dissertation project which
aimed at analyzing the case of intercultural
health programs in Latin America. The Beni
Department was chosen because of the lim-
ited information about the Amazon side of
Bolivia and its poor indicators of reproductive
and maternal healthcare. Within Bolivia, the
Beni Department is one of the most vulner-
able ones. The high level of geographical isola-
tion of the rural communities and the lack of
road infrastructure, lead the people to face great
barriers to access primary healthcare services.
Statistically speaking, only 6 out of 10 child-
births take place at health institutions and are
HSR 95
 HSR Lila Aizenberg
attended by skilled staff (Instituto Nacional de
Estadísticas y Censos, 2004). Two of the greatest
difficulties faced by the Indigenous communi-
ties of Beni Department are their geographi-
cal isolation and dispersion. In Beni, as in other
Departments in the country, the healthcare cen-
ters are located in urban and semi-urban areas.To
reach these areas, the communities must travel
long roads and, in some cases, cross large rivers.
Geographic isolation is not the only obstacle for
Indigenous women to receive healthcare ser-
vices. Low quality of service in public healthcare
services, together with gender, race and social
class barriers, affect the relationship between the
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Indigenous women and the healthcare person-
nel, generating a negative impact on women’s
access to healthcare services (Ramírez Hita,
2009). More in particular, Indigenous women
are excluded from access to birth control as well
as from information on reproductive rights by
factors that are both exogenous and endog-
enous to the health care system. Exogenous
factors include: Female illiteracy, poverty, geo-
graphic barriers, gender inequality and historic
discrimination against the Indigenous people.
Endogenous factors include: systemic inad-
equacies such as the inability to solve health
problems, limited coverage, frequent changes in
health care providers and different cultural per-
ceptions of the quality of care (Silva & Batista,
2010; UDAPE & PAHO, 2009).
The first contact with EXTENSA was made
in the city of La Paz, where the main offices of
the program are located. Two interviews with
executive staff of the project were conducted in
order to introduce the research and get access
to the program’s information. The majority
of the data were collected in five Indigenous
communities that received the EXTENSA
program located in three municipalities of the
Department of Beni. The information about
the municipalities and communities that were
receiving the program was provided by executive
staff of EXTENSA in the city of La Paz. For the
final selection of the municipalities, health and
poverty criteria, and the rural and Indigenous
nature of the population based on local statisti-
cal reports (INE, 2004), were taken into account.
96 HSR Volume 23, Issue 2, August 2014
The selected municipalities were Exaltación, San
Andrés and San Javier. The selection of commu-
nities (Elena, Nueva Flor, Salsipuedes, Universal,
Palermo) that were receiving the EXTENSA
program within these municipalities was not
predetermined but, instead, was done through
the ‘snowball sampling’ technique. Final access
to the communities was provided through con-
tact with the Central de Pueblos Indígenas del Beni
(Confederation of Indigenous Peoples of Beni,
CPIB). CPIB members acted as key informants
during the whole study and were also interpret-
ers when necessary.
The data collection used in each commu-
nity included: (a) in-depth interviews with
women healthcare promoters and women
(N = 15); (b focus groups with Indigenous
women (N = 5); (c) semi-structured individual
interviews with the health care professional in
charge of the municipality’s health care center
(N = 9); and (d) direct observation in communi-
ties. All the names of the communities and cer-
tain features have been changed to ensure the
anonymity of communities and the interviewees.
Field work was carried out between 2006
and 2007. Ethics approval was obtained from
the Bolivian National Ministry of Health and
Sports and informed consent was requested
from all women prior to their participation.
All interviews were recorded and transcribed.
The data reduction, processing and analysis of
the interviews were performed by the author
of this paper as the principal researcher. Analysis
was done concurrently with analysis of the
field notes, reflexive diary, interviews and focus
groups transcriptions. English translation was
made by a professional translator and validated
by key informants.
Discussion
Tapping into bonding-based social capital
with pre-existing leaders
When I arrived in the Nueva Flor community,
in the municipality of San Andrés, the first per-
son I interviewed was the healthcare promoter,
Ángela. She was a reference point in terms of
health and was deeply involved in encouraging
the population to improve their quality of life.
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 Facilitating Indigenous women’s community participation in healthcare
Ángela’s legitimacy was based on the fact that
she was a channel for assistance for the locals.
EXTENSA had provided her with a health
kit and had trained her in preventing illnesses.
Thanks to the health kit and the training, Ángela
had become an intermediary between the pro-
gram and the community. Above all, she had
become a key source in people’s daily survival:
People went to see her to receive medicine from
the health kit, which Ángela channeled using
the knowledge she had incorporated from the
training talks. The resources and knowledge that
Ángela had obtained from the program allowed
her to take advantage of her leading position and
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gave her a high level of legitimacy in the popula-
tion. As Ángela explained:
I take advantage of the meetings that the programs
hold here so afterwards I go from house to house talk-
ing with mothers and let them know what they can
do to help their children so the community is happy
because they receive a better care and they are less wor-
ried […]
The story of Ángela shows how EXTENSA
allows healthcare promoters to increase their
power in the community and to have a positive
effect on the community’s healthcare. In this case,
the program is successful because it incorporates
existing leaders such as the healthcare promoter
while strengthening their role. One key aspect of
this intervention is related to promoting mecha-
nisms of empowerment. Thanks to her role as
a community leader and as a healthcare pro-
moter, Ángela was able to take advantage of the
resources offered by EXTENSA, transforming
her role into an effective channel for improv-
ing the health of the population and their living
conditions.
The case of María, the healthcare promoter in
the Salsipuedes community in the municipality
of San Javier, provides further evidence of the
importance of focusing on empowering exist-
ing leaders when attempting to understand how
EXTENSA transforms them into vehicles for
collective mobilization. María was a leader of the
CPIB in the mid-1990s. Two years before, María
had been chosen by the community to be the
healthcare promoter. Thanks to her leading role
© eContent Management Pty Ltd Volume 23, Issue 2, August 2014
HSR
in the CPIB, María was deeply acquainted with
the situation of Indigenous women’s access to
public healthcare services. During the interview,
she explained how hard it was for the commu-
nity to get decent treatment from the healthcare
center doctor:
They (health providers) have to be more patience,
because our people know very little about health. Our
people do not have the training and they need the
support of the professionals. You need their support,
you need them to come to you and explain things to
you, for them to treat you as a patient but decently.
In the same way, we treat other humbly and work to
cooperate with them, that’s the same way they should
treat us.
EXTENSA arrived in the community and
provided María with training on promoting
health. María utilized this information and shared
it during meetings that she organized with the
community. The following comment from a
community member shows that the community
had fostered preventative behaviors in relation to
the environment and personal hygiene:
We all share the work: maintaining our homes and
animals, disposing of trash, treating the water. Things
have gotten better. It was not like this in the past but
now people are trying to protect the environment so
that it is healthier. Now we pay more attention to
washing our hands and washing diapers as well. Things
are changing because people have grown accustomed
to taking care of themselves.
Tapping into bonding-based social capital
with pre-existing networks
Bolivian communities have significant informal
community networks, which predate the arrival
of EXTENSA and were formed with the objec-
tives of providing mutual support and channel-
ing community programs. This was the case for
the Palermo community in the municipality
of Exaltación. Here, the women had formed a
‘Mothers’ Club’ several years earlier. A talk with
one of the leaders of the Mothers’ Club showed
that before EXTENSA’s arrival, the organiza-
tion had already been playing an active role in
helping expectant mothers take care of them-
selves and ensure their deliveries were as safe as
possible. As one member of the Mothers’ Club
HSR 97
 HSR Lila Aizenberg
explained: ‘We are very united here. We help one
another; someone is always there to see if a pregnant
woman needs something and there were even many
times that we found the way to take pregnant women
to the hospital.’
The case of the Mothers’ Club in Palermo
revealed that the program’s success was based on
community empowerment, which resulted from
strengthening the existing community assets
possessed by women. EXTENSA acknowledged
the role of the Mothers’ Club and opened new
channels for participation so that these women
could attend workshops on the use of contracep-
tion methods. In addition, these workshops pro-
Downloaded by [La Trobe University] at 06:40 25 January 2016
vided information on SUMI and on its benefit
for women. The focus group with members of
the Women’s Club revealed that the educational
spaces created by EXTENSA allowed women to
take advantage of the network and to use it for
the benefit of their health. In particular, the case
of the Mothers’ Club showed how the educa-
tional spaces created by the program became an
opportunity for members to use the community
network to defend women’s healthcare rights. In
this regard, mechanisms of empowerment were
visible in this process. As a woman said:
He (the doctor) informed us about SUMI (telling us)
that we could go to the healthcare center. He told us
that as women, we had the right to a delivery covered
by SUMI so we are all going to demand this when the
doctor from the health post comes […] We are aware
that we need to make this demand of the healthcare
center, because SUMI provides care for children but
does not provide care for the women.
On the other hand, the opportunity of
learning more about their healthcare rights led
women to become active in searching for solu-
tions to reproductive healthcare. For example,
one woman mentioned that all of the club’s
members had participated in the talks that the
program gave on preventing pregnancy and that
later, they had asked the program to return to do
Pap smears and deliver contraception:
Once, EXTENSA came and called the members of the
Mothers’ Club together. They gave us talks on (contra-
ception) methods to avoid getting pregnant. They also
explained the Pap smear […] So we all participated in
98 HSR Volume 23, Issue 2, August 2014
these talks and then asked them to come back to do
the Pap smears and bring us the contraception.
The analysis of the stories of the Palermo com-
munity reveals how the program gets women to
start using their community assets to their own
benefit because it constructs mechanisms for
collective empowerment. In this respect, women
start using their own community network – the
Mothers’ Club – to defend their rights as citi-
zens, to obtain healthcare resources and infor-
mation, and to help other women care for their
reproductive health.
Conclusion
This article analyzes how the EXTENSA pro-
gram succeeded in encouraging community
participation and improving health. The analy-
sis focuses on the explanations provided by the
social capital theory and the empowerment
approach and uses these concepts to analyze how
EXTENSA promotes participation and health-
care. The paper shows how the women who are
EXTENSA beneficiaries see their informal net-
works as effective channels for improving their
health and for getting the population involved in
caring for the community’s wellbeing. This anal-
ysis demonstrates that networks become a useful
tool to improve health because the women feel
that the program allows them to turn these net-
works into effective vehicles for improving their
living conditions. In particular, it shows how
this process results from empowerment, which
takes shape when the existing community net-
works are deepened.
The article highlights that pre-existing
networks of Indigenous women together with
­
external resources provide the main vehicle for
Indigenous’ community participation in health-
care (Bebbington, 1999; Bebbington & Perreault,
1999; Durston, 1999b, 2000; Durston & Duhart,
2003; Fox, 1996).Women’s pre-existing social net-
works are strengthened by the program’s resources
and by the opportunities it offers. As the literature
on intercultural healthcare has argued (Camacho
et al., 2006; Campos & Citarella, 2004; Deruyttere,
1997; O’Neill et al., 2006) Indigenous women are
isolated from the sphere of modern medicine.
However, the analysis showed that Indigenous
© eContent Management Pty Ltd
 Facilitating Indigenous women’s community participation in healthcare
women are part of a broad pre-existing network
of social relations that operates within their com-
munities (Meentzen, 2001; O’Rourke et al., 1998).
Nevertheless, Indigenous women face different
obstacles when they attempt to mobilize. As the
weakness of Indigenous’ community assets can be
explained by a lack of opportunities, they can be
strengthened if the local context changes. Thus,
the strengthening of community’s assets depends,
to a great extent, on how programs can enable
access to material and educational resources, and
open new spaces for participation. In this regard,
it is important to understand that communities’
culture before the arrival of programs is not an
Downloaded by [La Trobe University] at 06:40 25 January 2016
‘obstacle’ to participation or to community health.
Rather, the article argues that the existing culture
and the assets within can be a source of empow-
erment for women. The article shows how the
communities’ past, the knowledge of their needs
and the interest in improving the quality of life of
their members are key elements that allow com-
munity leaders to take advantage of the opportu-
nities which the program provides and transform
their assets into vehicles for collective mobiliza-
tion. The mechanisms of empowerment are fun-
damental to understanding how the program
manages to transform community assets into
bonding social capital (Uphoff, 2000; Uquillas &
Van Nieuwkoop, 2003; Wallerstein, 1992). When
those who possess these assets can obtain tools to
improve the quality of life of the population, they
increase their ability to impact the community
and to interest people in improving their living
conditions. In a context such as the Department
of Beni, Bolivia, which is characterized by sig-
nificant healthcare barriers, these tools becomes
sources of collective mobilization because women
use their assets in the hope of overcoming such
barriers. For this reason, the mechanisms that
allow the intercultural health programs to increase
community participation should focus on how
women interpret intra-community ties, construct
bonding social capital networks, and utilize them
to impact the community’s wellbeing.
Acknowledgement
I thank Leslie Gates for supporting and advising
me during my whole doctoral process.
© eContent Management Pty Ltd Volume 23, Issue 2, August 2014
HSR
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Received 30 January 2012 Accepted 25 November 2013

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