A Discussion with Juan Silva, Eye Care Regional Advisor for Latin America and the Caribbean, WHO-PAHO

With: Juan Silva Berkley Center Profile

January 21, 2009

Background: This discussion between Juan Silva, Katherine Marshall, and Thomas Bohnett took place January 21, 2009 as part of preparation for a January 30 consultation in Antigua, Guatemala on faith-inspired organizations and development in Latin America. In this interview, Silva discussed his work for the Pan American Health Organization in building relationships with the Catholic Church to improve access to health care for poorly served populations and integrate religious organizations into large health systems. He describes the problems Latin American governments have had in delivering health care to the populations that most need it, and suggests the work of faith-inspired health organizations as a key tool in filling those gaps.

Can you tell me a bit about your own professional path? How did you come to work with PAHO and with issues of bridging faith and health?

I am an ophthalmologist by training. I joined PAHO seven years ago as a regional advisor, initially to work on my area of specialization, eye care programs.

It was my job to do situational analyses and program design for eye care at the national level in different countries in the region. After a time, I decided to move towards public health, and thus have progressively been more and more engaged in PAHO's work in this area, though I still work on eye care programs. I pursued an academic degree in the field, an MPH from Johns Hopkins University. A central theme in my work and study has been the link between communications and health, and health promotion and education.

Can you sketch what PAHO is and does, for those unfamiliar with its work?

PAHO is the regional office of the WHO for the region of the Americas, and as such it is an intergovernmental organization. In Latin America, as elsewhere in the world, PAHO/WHO works mostly with governments, focusing above all on service delivery. We also work with other organizations that provide services related to health, because we know that governments by themselves are not capable enough to deal with all health needs of a population. Our primary purpose is to strengthen the capability of health systems to meet effectively the health needs of the public.

What more specifically is PAHO's work to link to religious organizations?

My first involvement with religious health providers came in 2007, when I was asked to become the focal point between PAHO and CELAM (Consejo Episcopal Latinoamericano), the regional Catholic organization based in Bogota. The main focus of the partnership, and also what I see as the most important thing to focus on in terms of integrating religious organizations into larger health systems, is to strengthen their capacity to do what they are best at, which is primary health care delivery, communication of health-related messages, and ministering to the chronically ill. Other areas which are important are work with the disabled (where the Church is very active) and with vulnerable groups such as older people. The experience of the Church in these areas as well as serving rural community and working with children and adolescents is valuable and we are working to capture it and explore the policy implications. Three months ago in Colombia, we held a joint session with CELAM on approaches to prevention of HIV/AIDS by the strengthening families program.

We are focusing particularly on how the governments and the Church might work better together. This will vary from country to country, and in some countries the relationships between the government and the Church are not easy. So on the one hand we have the clear potential for working cooperatively, and on the other a somewhat uncertain path on how to do so.

The CELAM partnership has existed for just over one year, so we don't yet have a comprehensive analysis of its impact or lessons learned. We started with Colombia, mostly because I am located here. Once we have a bit more experience and background with this type of partnership, we will increase our involvement, but for now we are largely in a learning mode.

Have issues which produce controversies in some settings presented difficulties in your engagement with CELAM (for example differences in WHO and Church approaches to reproductive health)?

No, mainly because we have made concerted efforts to ensure that they do not. We are not trying to mediate between the Church (and so far our experience is only with the Catholic Church) and the government on controversial issues such as reproductive health or abortion, nor are we addressing differences in policy or philosophy. What we are trying to do, instead, is to identify issues where there is common ground already and the possibility for cooperation. We are trying to identify common denominators.

Among these, the concern with access to basic health services is the priority, and what the Catholic Church brings is its heavy emphasis on the community, through its many community based organizations, and on participation. By this means they have the potential to help create a far more supportive environment for better health practices and more effective care. The links between public policy in health and what the Churches are doing and can do are not well developed but there is great potential.

There has been no real resistance within PAHO to this idea of partnerships with religious organizations. In fact, the idea for the partnership came from PAHO's director. Of course, PAHO is home to many public health practitioners that are not used to working with the church. So from some people there may be a little bit of skepticism and wariness, but on the whole the organization has supported this.

Governments are often, but not always, a different story. You can find strong resistance there to the idea of working with religious organizations. Much of our work in this area has been convincing governments to work with religious organizations. One main reason for that is that you simply have different policies about health issues. Also, and not insignificantly, in Latin America most national governments are on the left now, and getting them to work with churches is not easy. The process of getting them to incorporate religious organizations into their work needs a lot of patience.

What do we know about religious health providers in Latin America? Do you have a working estimate of what share of health care services are provided by faith organizations?

No, we do not. It is in practice very difficult to know the precise share of health services provided by religious organizations at either the national or regional level. Also, the nature of the services provided is somewhat unclear. We know some things that they do, but we don't have a complete or comprehensive picture of all of the services they provide. Those are two important questions---certainly ones that we will need to address if we are going to increase their involvement with health services in the future.

There are also questions about what other churches, especially the Protestant and Pentecostal, are contributing. Almost all of my experience with religious organizations is with the Catholic Church and so I am unfamiliar with this. Certainly there is a huge potential for them to become involved and they are growing very fast in many parts of the region. However, they are organized very differently from the Catholic Church, which is well established. The new churches generally organize themselves in a far more decentralized manner, so the approach would need to be quite different from our current partnership with CELAM.

What are some of the priority problems facing governments in the region in terms of health?

That is a difficult question, in part because the problems and challenges vary so dramatically across the region. In some countries, you have health systems that are similar to the U.S., with strong participation by the private sector. In those systems, which are in places like the Colombia, Dominican Republic, and Chile, you have one set of issues. In other countries that are more state-oriented, you have a different set of problems. In general, one of the weaknesses that stretches across the region is primary health care. In fact, though, that's one of the reasons why we're interested in religious institutions---we think that they can be equipped to fill the gap, at least partially.

In Latin America there is tremendous variation in the ability of different populations to access services. The rural poor are the population that is least served. If we identify organizations, such as religious organizations, that can help increase coverage, then that is something we need to focus on.

Another category altogether, because of poverty levels, is Haiti. Haiti is a very difficult place to work for a variety of reasons. I have been working there for a number of years, and it's only recently that we've had success in our programs.

What are some of the strengths that you have observed in religiously-motivated health organizations?

One of their greatest strengths is that they are community based. They are present in the rural areas, and they have a connection to the populations most in need of and least able to afford health care. Churches often have special programs for youth. Also, in Colombia, the church has a program for internally displaced populations, where we support them in many technical areas, including water, sanitation, and housing. They are drawn to work with those displaced populations and, more generally, the poorest of the poor---that is a real strength that they have.

Have you worked with indigenous communities?

I do have some experience with this, especially with indigenous communities in the limits between Colombia and Brazil in the Amazon basin. One of the most obvious challenges in this area is simply reaching indigenous populations, which are usually located in remote areas that are difficult to reach with supplies. The other main challenge is that you have totally different ways of seeing the world, and of understanding health. Indigenous communities have their own value systems, their own notions of healing. We teach them to do many different things, but in many cases they will continue to do as they have always done. We need to be, above all, respectful of their traditions, while also offering what help we are able to in terms of trainings and supplies.

How does PAHO work with the Pastoral de Crianca? That seems like a strong model of cooperation between government and the Church with a long-tested record of delivery and focus on both faith and professionalism.

Yes, the program created and run by Dr. Arns is remarkable. It began in Brazil and is strongest there; in Brazil, PAHO is not directly involved. It is also operating in different countries, though often with different models. Dr. Arns is a remarkable advocate and authority on children and infant issues.

An experience of the Pastoral that has broader relevance is its very tight links with government. That is a model that we want to encourage elsewhere. The model that they have developed has real potential in attaining a fundamental objective, which is improving both access to and quality of basic health services.

What is your hope and expectation from the consultation in Antigua?

One of my main hopes is to benefit from a more academic view of what contributions can be made by religious organizations. I want to learn what has been done and what others are doing, to get a view of how our programs compare. I think that what we are doing in Bogota is susceptible to improvement, and I think this will be an opportunity to learn about how the program could be improved. That's my main interest.

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