Doctors under the knife

With Bill Clinton's new reforms only a month away, the health-care system is on the operating table--and the doctors are under the knife. Americans have a love-hate relationship with physicians: they like the care that doctors provide but hold them to blame for the nation's health-care mess. NEWSWEEK looks at how the culture of medicine may change, assesses doctors' fears--and examines the brave new world of HMOs.     

Participatory development: an approach sensitive to class and gender

This article begins by presenting development experience gained in the Indonesian province of Irian Jaya as a means of highlighting the centrality of popular participation to the development process. Important lessons from the ongoing development work in Irian Jaya were that it is not sufficient to consult beneficiaries and then act on their behalf or to engage in a development process unless the participants understand the project's conceptual orientation and language and have the tools to assess their needs and options for constructive change effectively. Also, developers must supply participants with information about the larger economic and political context in which they are operating. The article continues with an exploration of the ways in which a focus on class and gender raises participatory development to a new level. Constraints on transformative participation are then defined as 1) the political conditions and power structures existing in the country and community, 2) administrative opposition, 3) sociocultural impediments, and 4) limitations imposed by daily life. While it may be impossible to avoid the effects of such constraints, development agents can help villagers anticipate their impact and support efforts to cope with them. Participatory development challenges the status quo by enhancing economic equity and social equality and, if effective, will engender opposition, especially when a large amount of funding is at stake. Opposition can take many forms, including ridicule or resistance and can get personal. The demand to produce quick results also creates restraints on development agents. It is concluded that the development agent must engage key sectors of the local population in the development process and nurture this participation. Development agents should act as facilitators rather than independent initiators telling people what is best for them. Development agents must become very familiar with the community to earn the trust that is needed to guide people toward self-analysis and priority-setting.