Background

The city of Maracaibo, the second largest in Venezuela, has a population of approximately one million four hundred thousand people. Its rapid growth has overwhelmed the health service facilities, negatively affecting especially those citizens with low incomes. This has resulted in the available resources being earmarked to curative activities, relegating almost completely existing medical assistance preventive programs. 

The Mobile Clinics Program, conceived as a primary health service facilitator, utilizes Mobile Units to promote changes in medical attention by means of educational and preventive processes. The target populations which are to receive this new service are those living in outlying communities with few or no basic public services, much less medical facilities. 

Narrative

The success of the Program is due to the transformation of the way health services are delivered to the communities. Attention is directed to the root cause of those processes that correlate directly to health problems. Its reach extends over a broad spectrum of common daily situations, going beyond the traditional medical emphasis. Health is conceptualized as a multifactorial process which has as a final outcome a specific pathology. In determining and preventing the conditions that lead to a particular disease, it is possible to break its cycle in the initial stages, where the economic cost is much smaller and with an overall higher social benefit. For this to be accomplished, it is necessary that the health team be intimately integrated with the target communities understand that there is a commitment to resolve their problems, which in turn motivates them to participate in more active manner. To this is added the integration of the actions carried out by various institutions and organizations that have a shared responsibility for solving the problem. All of which permits a better utilization of available institutional resources for the benefit of the sound development of the communities involved. 

Examples of these actions can be observed in two neighborhoods located in the northern part of the city, neighborhoods which contain a high percentage of American Indian population (Wuayu·). The first of these is San Antonio de los CaÒos which was established in 1.972. At the beginning of our work, this community did not have any public services (electricity, water, sewage, adequate roads), spatial ordering. and in spite of being located within the perimeter of the city, it presented characteristics one might expect to find in a rural area. This situation creates a large number of health problems, due to the absence of minimal subsistence conditions. As a consequence of this situation, and due to the characteristics of the area, the inhabitants were encouraged to establish contacts with the National Agrarian Institute (I.A.N.) to request a planimetric survey (road and lot map) of the community. 

By the end of 1.994 the I.A.N. execute the map of the community and in 1.995 work was initiated for the installation of electrical service with the direct participation of Electrical Company of Venezuela (ENELVEN). At present it has extended electrical service to approximately 40% of the families of the neighborhood. Currently the population is being educated and prepared on ways of processing the water, by means of the utilization of sodium hypochlorite, in order to obtain drinking water. Up until now the only available water had been untreated. This learning process is being accomplished with the cooperation of various organizations that take part in training and citizen formation, one being the Municipal Training and Citizen Education Institute (IMCEC) and another the Center at the Service of Popular Action (CESAP - NGO). This has clearly demonstrated the possibility of consolidating different institutional efforts that participate actively in the development of the communities. 

In the second case, the neighborhood Jesus of Nazaret, a community established on 1.982, along the periphery atop the an old, saturated garbage landfill. A short time after the landfill was closed the area was occupied by squatters and the community founded. The health problems in this community are as a result of very serious characteristics. This is not only as a direct result of the landfill itself, but also because the community did not understand the gravity of the problem and continued to indiscriminately throw garbage all over the neighborhood. In 1.994 the main street of the neighborhood was cleaned in four different opportunities due to the fact that the neighbors insisted in continuing to obstruct the public way with garbage. As a result of this situation, the community presented high rates of skin and skin related diseases, in addition to frequent enteritis outbreaks. These problems were given the traditional attention by the public health facilities, but nothing was done to resolve the conditions which were originating the diseases. For this reason the recurrence of these maladies was of a permanent nature and serious due to its magnitude. 

After the arrival of the Mobile Unit in September 1.993 to these communities, the process of increasing community awareness and of inducing inter-institutional participation was initiated. Measures were taken in order to integrate the efforts towards common objectives, joining actions and assuming shared responsibilities to take on and control the problem, one that seriously affects about 15.000 persons. During the year 1.995 activities aimed at increasing awareness have been undertaken, in addition to accomplishing the following direct actions with other organizations: 

Health and Social Welfare Ministry (Sanitary Engineering, Malarial and Rural Endemics): 

• Session of elimination of vermin and fumigation, with its respective orientation.
• Health Promoters Workshop for training members of the community and the provision of medicines for the antiparasitic treatment for the families that inhabit the banks of the garbage landfill.

Municipal Sanitation Institute: 

• Partial re-establishment of the trash collection system.
• Reopening of the principal access route to the community that borders the garbage landfill, along with the collaboration of the Municipal Engineering Department.

Municipal Engineering Department: 

• Topographical measurement study.
• Preparation of the road and lot map of the Cujicito landfill.
• Placement of notices forbidding the dumping of garbage.
• Preparation of a preliminary design project aimed at recovering the garbage landfill.

Center at the Service of the Popular Action. 

• Workshop on Citizen Participation.

University of Zulia. Postgraduate School of Environmental Engineering. 

• Visit to the landfill by a team of experts on solid wastes with the objective of preparing proposals for the better utilization of the land that occupies the garbage dump, as well as the gases which emanate from it.

An thorough evaluation was performed and the necessary studies undertaken to determine the viability of a development project, one which at present is awaiting the construction blueprints for a recreational park and the planting of trees along the length and breath of the landfill. It is expected that its execution will permit a lessening of the harmful effects that the present situation effects on the health of the population that presently inhabits the area. Besides the cleaning and embellishing of an area that was lacking in adequate environmental conditions for any human presence, the project will also encourage sports and recreational activities, which will contribute in reducing criminal activities in the area. From the working meetings with this community, there emerged two legally constituted neighborhood associations as acting representatives of their communities. By the end of 1994 a commitment by all the organizations that participated in the project was attained, and as a result an educational prevention process was initiated. 

Positive results have been obtained with respect to the behavior of the community, so much so that from November 1994 the principal avenue is free of garbage as a result of community initiative. Programmed garbage collection on the part of the Municipal Sanitation Institute has been obtained, and a planning process for the repair of the banks and crust of the landfill has been initiated. There is now a standing objective of recovering the four hectares that the landfill occupies, which will benefit the surrounding population of about twenty thousand (20,000) people. Latin American societies, and very notably Venezuelan society, have undergone transformations as a result of macroeconomic, political and social factors which are causing serious problems to the middle income groups, and very particularly to those groups of very limited resources. The impact of this situation severely limits the ability to subsist of the poor neighborhoods of the cities, where we find malnutrition problems affecting nearly 30% of the infantile population with the trend due to increase in the immediate future. Some actions have been taken to provide the necessary information to promote an adequate nourishment, so as to encourage the utilization of the natural resources produced in the region, which would provide an important quantity of nutrients at lower cost. With the advice of the Nourishment School of the University of Zulia, the creation of a nutritional recovery unit is being promoted. The primary emphasis is an educational approach, one which would be undertaken directly in the target communities. In this way, it is hoped that a greater impact in the nutritional recovery of children and expecting mothers can be achieved, since the would be to control all the factors which are involved in the process. 

The resources for this project were requested of FUNDASALUD (Health Foundation ascribed to the Governership of the State of Zulia), and at this time an answer is awaited on the budgetary availability to begin the implementation of this nutritional recovery unit. Breast feeding has been promoted in continuous fashion as a means to prevent malnutrition and childhood diseases, as well as giving orientation as to the indications for the recognition of warning signs that could put in danger the life of children five years old or younger, such as diarrhetic conditions. This has been achieved by educating the population on the benefits of the utilization of Oral Rehidration Therapy (TRO). As a result of these policies, there has been a promotion for the installation of Community Oral Rehidration Units (UROC), which allow the communities to have this service twenty-four hours a day, having a positive impact in the decrease of negative complications as a result of infant diarrhea. By the end of 1995, we will have a total of five Community Oral Rehidration Units in operation. 

At the beginning of our activities it was observed that over 50% of children five years old or less in the two communities studied had not received any form of immunization. Therefore, they were found to be in high epidemiological risk. This situation resulted in the active participation on the part of the Paradise Clinic (private hospital), the Department of Epidemiology of the Health Ministry, and the Saint Ines Archdiocesan Ambulatory, in the execution of an intense vaccination campaign. At the present time, about 80% of these children have begun a vaccination schedule, many of which have received all the necessary injections. Around the end of 1.994 a group of students of the School of Psychology of the University Rafael Urdaneta concluded an independent study on the scope of the intervention of the PROGRAM in the neighborhood Jesus of Nazaret. One of its recommendations was to include within the services provided odontological attention and a respiratory therapy unit, this last one due to the high rate of infant mortality as consequence of the acute respiratory infections and recurrent asthmatic conditions. In the month of October 1.995, each Mobile Unit is equipped with a respiratory therapy unit, and conversations initiated with those responsible for the Acute Respiratory Infection Program (IRA), of the Health Ministry, to include the Mobile Units in their community attention programs beginning in the month of November. 

In the area of prenatal care, and particularly with adolescents, educational processes are promoted for the prevention of precocious pregnancies. And in the detected cases, follow-ups are performed since they are considered to be of high risk. Given the predominantly Indian population of the attended communities, there are at present a high number of home deliveries attended by midwifes, who do not have the necessary minimal preparation, with the observable result of a high rate of neonatal sickness and mortality. As a result, they have been prepared and supplied of the minimum material requirements so as to assist in the deliveries under more adequate hygienical conditions, motivated in great part to the expecting mothers refusal to go to public health centers, due either to economic or cultural motives. The odontological services were initiated in the third trimester of 1995 under the preventive educational modality. It has encouraged the participation of the private company (Colgate-Palmolive) in the way of organizing campaigns in the application of fluoride to the infant population and education on oral hygiene techniques. The Odontological Unit is equipped to give integral preventive attention as well as curative, taking into account that it is the only service of its kind operating in the area. Currently in its final stage before signing, a cooperation agreement is being prepared with the Archdiocese of Maracaibo for the installation of a clinical laboratory in the Saint Ines Archdiocesan Ambulatory, located in the Parish Idelfonso Vasquez, that will directly benefit a approximate population of 20.000 persons. This will be the first laboratory of its kind in the parish, which has an overall population of approximately 90,000 people. 

As example of better practice, the Mobile Clinics Program undertakes in a systematic way the accomplishment of its established goals. This is a result of the offering of accessible solutions to short, medium and long term health problems that affect urban communities living in extreme poverty, improving their quality of live in the process. It is promoted in integral form, encouraging inter-institutional participation, within all encompassing process, and working towards common goals. It is achieved by means of the direct action, a favorable response to a decision making process where the target community is the principal actor in the solution of its problems. All of which occurs within a preventive educational scheme as part of the medical attention process. 

Impact

• Coverage: 150,000 people
• Number of people assisted with educational measures: 90,587
• Number of people benefited by direct action and education concerning sanitation in the Cujicito landfill: 5,121
• Number of people benefited by direct action by the cadastral survey of the San Antonio de los CaÒos neighborhood: 2,678
• Total medical attention (includes medical, odontologic and nutritional cases): 36,724

Sustainability

A new Municipal Government structure, with the novel figure of the Mayor, which began functioning in 1.989 in Venezuela has resulted in a general reorganization of the departments of this important local institution. This has permitted the design of a set of policies and strategies directly linked with the mission, vision and objectives of the Municipal Government, all of which allows for the application of solutions to the needs of the inhabitants of Maracaibo. Within this reform framework, the decentralization of the health sector towards the municipalities is included as one of the local government. Even though it is not under its direct responsibility, it is of its incumbency, and as such encourages the undertaking of immediate actions toward this important sphere of the general welfare of the community. The Mobile Clinics Program of the Mayoralty of Maracaibo emerges from the need of improving the environmental, social, cultural and economic conditions of the inhabitants of the low income neighborhoods of the municipality, through the provision of primary health services. With its creation, the Mayoralty of Maracaibo is inserted into the National State Reform Project and of society in general, in addition to participating actively, as is established in the Law of Municipal Government as laid out in its article 37; which determined that the Mayoralties will cooperate with all existing institutions of the health sector to improve the quality of life of the population. In order to accomplish the objectives of the Program, the use of specialized vehicles is required, vehicles designed especially to undertake educational-health assistance functions as well as support vehicles that permit the supply of the former. The Assistance Mobile Unit is a bus type vehicle accommodated with a thoroughly equipped medical doctor or odontological office (according to the type of unit), that contains the working material required to give educational as well as curative attention when required. It also is equipped with a programmed data base designed to process the information generated by the Program. Each medical Assistance Mobil Unit is outfitted with the following personnel: Doctor, Nurse, Social Worker, Nutritionist and Paramedic. In the case of the odontological Assistance Mobil Unit, they rely on the same number and type of personnel, except for an odontologist in substitution for the medical doctor. This equipment, with the accompanying certified multidisciplinary personnel, resolves problems in a comprehensive and specialized fashion, one which permits a better understanding of the variables present in the ongoing social processes. 
The Mobile Clinics Program represents a strategy change within health care model in the city of Maracaibo. The system proposes the taking of concrete actions with respect to the particular problems of each community, through an multifactorial approach that begins with the health process and encompasses the total spectrum of situations which are the source of common pathologies. Due to the mobility of the equipment, which have access to those communities that even though they are located within the city limits embody characteristics of outlying rural areas (the absence of basic public services), thus offering coverage to a high percentage of the population whose overall social and economic situation prevents them from having easy access to public health services. It is this particular segment of the overall population of the city which is at greater risk of presenting endemic pathologies, which can evolve into general epidemics. A clear example of this danger was the recent Dengue and Venezuelan Equine Encephalitis epidemic, where this population was an important factor for the appearance of these pathologies in the city, as a direct result of the own migrant processes of the Wayu· ethnic group, which accounted for approximately 80% of the reported cases in the Municipality of Maracaibo. 
In the province of sanitation management, special attention is given to the importance of humanizing the actions of the health teams, both in the area of investigation and the search for answers to specific problems. Doing so facilitates those processes that permit the different communities to learn to solve their own problems while simultaneously integrating themselves to different participating institutions, be they public, private, non government organizations (NGOs), religious and of any other nature, that promote the attainment of needed solutions. In this way, the inhabitants of these communities learn to know what the processes that determine the health situation are, and to initiate actions with the participation of the relevant institutions to bring about desired solutions. 
This program provides widespread coverage to those cities that as a result of their rapid growth, suffer from restrictions in their ability to service areas at health risk in of themselves and to the rest of the city. 

Contact

Mobile Clinics Program 
Calle 77 entre Av. 13 y 13A Edif.Yeppas 
Maracaibo 
Zulia 
Venezuela 
4002 
58 61 978 983

Sponsor

Mayoralty of Maracaibo 
Mayorality of Maracaibo 
Calle 95 frente a la plaza BolÌvar 
Maracaibo 
Zulia 
Venezuela 
4001 
58 61 232 479

Partners

University of Zulia 
Otton, Fernandez H. 
Apartado postal 1156 
Maracaibo 
Zulia 
Venezuela 
4001 
58 61 410 895 / 58 16 616 907 

Center at the Service of Popular Action (CESAP) (NGO) 
Fernando Chumaceiro Ch. (Mayor) 
Calle 95 frente a la plaza BolÌvar 
Maracaibo 
Zulia 
Venezuela 
4001 
58 61 229 944 

Archdiocese of Maracaibo (Catholic Church)