Participatory Communication for Social Change: Which are the obstacles that the Democratic instituti

As stated in the third Programme for the Union`s action in the field of health (2014-2020), the general objectives according to which the EU policies should concentrate on while cooperating with the Member States are involving health promotion, diseases prevention and fostering supportive environments for healthy lifestyles; prevention of serious cross-border health threats which could endanger the health of the EU citizens; contribution to the development of innovative, efficient and sustainable health systems and provision of access to better and safer healthcare for the Europeans. The objectives stated in the third Programme are also supported by the World Health Organization (WHO) which affirms that in order to improve the health of the population in Europe and reduce the inequalities in healthcare standards which exist among the Member States, it is crucial for both institutions and organizations not simply to focus their attention to physical health but also to encourage the EU countries to recognize health improvements as a high priority in their national initiatives.

However, despite the progressive and highly ethical intentions of the EU and WHO, certain Member States are not able to maintain and further develop the ratified objectives due to limited institutional and organizational efficacy in their dialogue with professionals and related agencies. The growing number of socio-economical, health and environmental challenges nowadays created a strong necessity of new collective efforts and innovative strategies for managing with the existing and preventing further global and national obstacles. Namely this demand has made the participatory communication for social change one of the main interactive models which aim to create a multidimensional discourse on numerous subjects such as healthcare and among various stakeholders including local and supranational institutions. Still, this collective aim remains a great challenge for many welfare states.

This article attempts to define the present obstacles which restrain the democratic institutions in their progress and cumulative development within the EU zone. Through the implementation of the Participatory Communication for Social Change Theory and the Dependista perspective (Servaes et al. 1996) the paper aims to study the administrative organization in European states with low and middle incomes as regards their limited functionality and not enough sufficient level of effectiveness in their participation in universal and transnational organizations such as EU and WHO. In addition, the work will attempt to measure the level of institutional functionality and effectiveness within the EU zone concerning the healthcare sector. It is known that in spite of its significance in the scientific realm the healthcare field remains underestimated by the governments in many states. The case on the Republic of Bulgaria is included in the text with the intention to represent the stages of institutional development and the overall organizational matter of managing with the process of national democratization in the healthcare realm.

The Participatory Communication for Social Change

The Participatory Communication for Social Change represents an interactive model which intends to create a dialogue and to encourage an action in certain community, nation or state with the purpose to assure better welfare and health conditions for all stakeholders. As a theory, the participatory communication was created in the 1970s with the growing amount of scholars and public activists in Latin America (Beltrán 1974, Bordenave 1976, Rogers and Shoemaker 1981) and their strong willingness for civil and healthcare national improvements and achievement of stable and long-lasting results in their discourse with the local institutions.

The participatory communication, as a practical model, has the potential to straighten the connection between various universal institutions such as the European Union (EU), the United Nations (UN), the World Health Organization (WHO) and the North Atlantic Treaty Organization (NATO) in their transnational collective goals concerning the economic, humanitarian, public, health and innovation realms. These practices are most often achieved through the establishment of open forums, conferences and workshops but these activities do not appear to be enough sufficient as regards the huge amount of countries which face serious obstacles to become truly participative, in the common democratic sense, due to numerous socio-political and economic issues, e.g. emergence of wars, fall of dictatorships, affliction from rare diseases and increasing negative impacts as result of the climate changes.

Surely, the participatory communication for social change represents a shape of communication which is far more demanding than the common verbal and non-verbal technics since the involved set of priorities concerns specific internal components, divers external factors and stakeholders from different national and international backgrounds, e.g. governmental agencies, academics, scientists, social organizations, institutional representatives and marketing professionals, but it should be remembered that no form of communication has been completely realized without the strong willingness for collective action and consensus regarding the recognized goals and objectives.

Why the Healthcare Study has an Essential Impact on the Institutional and Academic Fields?

Despite the fact that the most common form of health research is the clinical trial in which the patients voluntarily take part in surveys with the purpose to examine the efficacy and safety of new medical interventions, the contemporary health analysis is concentrated on the increase of the information volume regarding the health technological development, improvement of patients` privacy and establishment of better social medical care. The healthcare study contributes also for handling with numerous national and global concerns related to disease trends and risk factors, public health interventions, patterns of care and healthcare expenses. In broad terms, the healthcare analysis offers various approaches and complementary insights of data sets concerning the efficacy and positive effects of medical interventions over humanity, i.e. the regular measurement of outcomes from clinical experience for comparing and improving are constantly updating the level of impact of drugs, vaccines, medical devices and diagnostics over the patients. Certain account of these results have led to advanced scientific discoveries in specific medical branches such as breast cancer (the implementation of the HER-02 oncogene protein as a predictor of both overall survival and time to relapse in patients with breast cancer), birth defects (the use of folic acid during pregnancy as a preventive neutral tube against birth defects) and patients` safety (the reduce of medical errors in healthcare establishments by developing patient reported outcome measures research methods and generic health and assessment questionnaires as common clinical practices for improving the general quality of life) while others have eased the development of new therapies and have facilitated the process of healthcare and public health development, in general.

By choosing the topic of healthcare as a case study in this paper, I believe that researchers, medical experts and policy-makers will obtain transparent information for the institutional capability in states with low and middle incomes from the EU zone as regards their efforts of managing with major national and transnational obstacles in the healthcare sector such as rural health, public medical treatment and patient safety.

The choice of Republic of Bulgaria as a case study

The Republic of Bulgaria is situated in the eastern part of the Balkan Peninsula, in south-eastern Europe. The establishment of a new constitution in July 1991 has initiated the process of democratization and transition from highly centralized to decentralized governmental structure in the state. Although Bulgaria has a long-standing presence in the international healthcare affairs, the demographic development of the country has been characterized by population decline, a low crude birth rate, a low fertility rate, a high mortality rate and an ageing population since the last 20 years. The country has been defined as a health system in transition by the European Observatory on Health Systems and Policies since the beginning of a stabilizing political process and an economic uphold in 2000.

Bulgaria is accepted in the EU zone in 2007. Presently, the state still lags behind the EU averages in most mortality and morbidity indicators. The national health system is financially unstable and most of the healthcare establishments, especially hospitals are struggling with serious underfunding. According to the statistics for 2009, health workers were estimated on 4, 9 % of the overall workforce. In comparison to the other EU Member States, the respective account of physicians and dentists is particularly high but the relative number of nurses continues to be below the EU15, EU12 and EU27 averages. Bulgaria is also striving with constant internal structural reforms which lead to growing professional mobility.

Obstacles which Restrain the Participatory Communication for Social Change at Times of Global Development

There are two leading obstacles which overwhelm the participatory communication field nowadays: first, both citizens and institutions need truly long period for adaption towards the participatory decision-making models which have been developed as part of the contemporary international dialogue and second, the communication as type of universal form of collective expression is at stage of request for improvement in numerous states. Generally, the emergence of these issues can be explained with the long-standing historical background of the democratic welfare state, its role of protagonist and impose of vertical, unilateral and authoritarian technics of communication in order to achieve better control over society, i.e. before the globalization progress and ICT revolution the governmental, clerk and educational institutions have been performing their authority mainly through top-down and hierarchical forms of communication with the nation.

Currently, this classical democratic matter of continuing imposing hierarchical form of authority is frequently leading to lack of cooperation or consensus first, between institutions and citizens on regular basis as regards socio-economic subjects and second, among institutions at international level while attempting to achieve positive results in their participatory dialogue concerning global topics such as equalization of standards in health and environmental realms. In some cases, the administrative refuse of collaboration caused by top-down decision-making practices could also lead to contradictions with other related agencies including ministries, academic and public research centres and non-governmental organizations. The passive reception of messages expressed from the elite groups and bureaucratic authorities towards the nation is a common sign of poor participatory communication which aims impose particular ideological convictions rather than to work in favour the progress of the whole nation state.

The Dependista Perspective or How the Elitist` Societies impose their National Priorities?

Although numerous theoretical concepts devoted to the state of dependency became apparent within the academic sphere, the most common dependency description related to the methodology system emphasizes the holism premise and the external factors which have a constant impact on it, e.g. socio-political and economic affairs, emergence of regional contradictions, polarization content between development and underdevelopment processes and role of subjective factors in history.

The communication aspect within the sense of the dependency perspective is associated with the ’media’ field or the ‘cultural imperialism’ stance. As regards the second association, the dependistas academics have distinguished themselves from the modernization scholars who seize the nation-state as a basic reference framework to their research, by concentrating their analytical standpoint on the domination relationships which exists among countries and regions as a predominant factor for driving the international affairs. Thus, they claim that the domination of the periphery by the centre is demonstrated through a combination of power factors, e.g. military, police and political structures, which also seriously affect the internal relations within the state. Widely, the development of sustainable and effective global rhetoric is highly depending on the conditions of internal stability and good communication practices among states. The existence of dependency between centre and periphery nations and the rising number of socio-economic inequalities between rich and poor classes motivate the dominant attitude expressed by the elitist and top-centred ruling groups at local level to be manifested at universal level through the demonstration of sceptical and reserved political position towards the collective participatory activities or inability to realize the set of mutual institutional objectives.

The Question of Sovereignty and Economic Inequality within the EU zone

The EU does not appear to be as politically sustainable and financially profitable union as many policy-makers expected it would be. Presently, numerous Member States support rather controversial standpoints as regards the external and internal policy principles within the EU zone, i.e. the far-right discourse based on immigration hostility, anti-Semitic, xenophobic and nationalistic attitudes has gained significant electoral support in many EU countries since the last decade. Most of the democratic governments approve the general European request for expansion of free and balanced flow of goods, persons, services and capital between and among states, but not within the boundaries of their nations. This paradox can be particularly explained as an institutional attempt to prioritized each nation`s sovereignty from the centralized administrative approach of the EU.

Initially, the classical concept of sovereignty refers to the state of national independence, cultural and identical self-determination which are officially represented by traditional power authorities, e.g. president, national assembly, parliament, military and police agencies, etc., and which do not necessarily share the intention of participation in an “external sovereignty” model, i.e. the condition in which each state is acting as a recognized entity at the international scene, without being submitted to any foreign power. This specific shape of democratic obstructiveness may be caused by various reasons including geographical expansion, economic impoverishment, political superiority and even certain trends in the general scientific progress. However, in the case of EU, the community`s supranational goal regarding the equalization of social policy, health and consumer standards among Member States has not been achieved yet due to the growing gap between rich and poor European citizens, their amount of households` incomes and inability to distrust in the democratic welfare functioning and institutional practices. The appearance of these obstacle as well as the existence of different forms of national governmental models within the EU zone have created a real burdensome challenge concerning the participatory communication between administrative agencies and common progress in all branches, including the health and innovation sectors.

The General Condition and Structural Functioning of Healthcare sector in the EU

According to the World Bank statistics, the healthcare sector in Europe is striving to establish efficient and equal standards for all Member States. This intention is particularly motivated by a prognosis concerning the public expenditure on healthcare in the EU which predicts that the current amount of 8% of GDP in 2000 will increase to 14 % in 2030. The future considerations associated with the healthcare sector within the EU zone are demanding the creation of relevant strategy for managing the imbalances in national budgets which will inevitably appear as a consequence of the rapidly ageing population in the continent. It is known that the universal healthcare system in Europe is financially sustained by the citizens at large and on the principle of solidarity which also hides potential risks of medical expenditure in the near future.

With the intention to determine the actual legislative capacity and extent of institutional authority towards the healthcare field, the scope for EU action in this policy sector is set in Article 168 of the Treaty on the Functioning of the European Union. As stated in the Article, a prime essence for all European health institutions and universal EU policies is the value of human health, its protection and presence as an overriding priority in all related activities. In this sense, the EU`s general health policy assists that the national policies in each Member State have to ensure that every citizen who is living within the EU zone has access to quality healthcare.

On its regular basis, the EU health policy focuses on the disease prevention, promotion of healthier lifestyles, patients` and citizens` protection from serious cross-border threats to health, improvement the access to healthcare, institutional support towards the dynamic health systems and new technologies and provision of high quality and efficacy medicinal products and devices for patients` use. On functional level, the EU health policy is realizing its working objectives through the establishment of various international projects and activities including: creation of multiannual strategic programmes similar to the third Programme for the Union`s action in the field of health (2014-2020); collaboration on global level with a series of worldwide agencies such as World Health Organization (WHO) and The United Nations Children's Fund (UNICEF); establishment of institutions which are cooperating with all Member States on governmental level so to improve the citizens` living and labor conditions by ensuring a high level of human health and consumer protection in the EU, e.g. Employment, Social Policy, Health and Consumer Affairs Council configuration (EPSCO Council) and organization of common EU initiatives such as helping to reduce tobacco smoking, fighting obesity, reducing the harm caused by alcohol, etc.

The case on Healthcare in the Republic of Bulgaria

Although the Republic of Bulgaria is a state which has equal rights and responsibilities as the other EU Member States, its` national democratic apparatus as well as health system are seriously affected by the process of transition from highly centralized to decentralized governmental structure which officially has taken place since July 1991. Geographically, the country is situated in south-east Europe, in the eastern part of the Balkan Peninsula. To the north Bulgaria is bounded by Romania. To the west the country has a common border with Serbia and Macedonia. Greece and Turkey are the state`s sought neighbours and the Black Sea represents the Republic`s natural eastern boundary.

The Healthcare reform in Bulgaria has been realized on three basic stages. The first stage (1989-1996) has been devoted to the abolishment of the national health system`s centralization through the establishment of a decentralized healthcare administration and the beginning of a project of establishment new health insurance system. The second stage (1997-2001) has been concentrated on the introduction of the health insurance system through the adoption of landmark laws concerning the health insurance, the healthcare establishments and the professional organizations of physicians and dentists. During the third stage (2002-present), the legislative character of the reform has been conducted through the adoption of additional laws, regulations and amendments to the already existing regulatory acts with the intention of a complete restructuring of the medical field. This third stage continues to be ongoing as prime governmental strategy for improvement the healthcare sector despite the strong social and professional dissent.Furthermore, the third stage of the reform`s implementation has caused crucial public and expert discontent by several other reasons including financial imbalanced overall condition of the healthcare system, highly limited funding of healthcare establishments, especially the hospitals, serious maladjustments in the organization of primary healthcare, regional unequal distribution of general practitioners and lack of funding for primary and specialized medical practices. Basically, these obstacles have led to reduce of the average length of stay in the healthcare establishments and drastic increase of the migration rates concerning nurses and medical specialists, i.e. according to the EU, 15, EU 12 and EU27 averages during the first nine months of 2010, more than 340 physicians and 500 nurses left the country.

The quite sceptical overview of the Bulgarian healthcare system is supported by highly fragmented administrative representation. Currently, the healthcare institutional organization in the Republic is based on hierarchical principle represented by Ministry of Health which operates its duties through the presence of health minister, three deputy ministers, one head of the political cabinet, one parliamentary secretary, one general secretary, one general national health inspector and nine directions. The Ministry is in charge of the national health policy pursuance and overall functioning of the nation health system including sixteen national health institutes, research centres and medical commissions in 28 districts and 265 municipalities in the state. The Ministry is also responsible for the development of medical science, collecting and maintaining data regarding the health status of the population and the national health accounts and for planning and ensuring human resources for the health system. The governmental agency collaborates with all other ministries concerning the public health.Other key players in the healthcare system are the National Health Insurance Fund and the voluntary health insurance funds which are responsible for the insured individuals, the healthcare providers and the third-party payers. Through the realization of healthcare reform in Bulgaria, the health financing has been divided under the response to both public and private medical and health establishments. This means that all healthcare providers are autonomous self-governing organizations and all primary medical, dental and pharmaceutical care, most of the specialized outpatient care and some hospitals are hold by the private sector, while the state owns all university hospitals and national centres, specialized hospitals at national level, centres for emergency medical care, psychiatric hospitals, centres for transfusion haematology and dialysis, as well as 51% of the capital of regional hospitals.

The Stubling Blocks in the EU Healthcare

As practical model, the participatory communication has the potential to improve the dialogue which exists among democratic institutions during the process of succeeding in their transnational collective goals since it represents a shape of communication which is far more advanced than the common verbal and non-verbal technics utilized by the common people.

At the same time, the case on the Republic of Bulgaria confirmed disturbing results concerning the condition of healthcare sector in the state as well as institutional ability to manage with the obstacles which have emerged during the national stage of democratization. The need of long-term political strategy for holding the young people and professional experts in the healthcare field and establishment of more efficient coordination and cooperation between the national institutions in order to demonstrate a better representation at the international level are just part of the many issues which the county needs to take care of before to become truly effective participant in the collective transnational discourse.

Moreover, this case indicates the still existing institutional dependency on classical elitarian and top-down governmental models in numerous democratic states which attempt to impose their authority in order to achieve better control over society instead of being adequate and supportive contributors to the communication processes which occur within the EU zone. In this sense, the proposed analysis proves that the level of institutional functionality and effectiveness in the EU countries with low and middle incomes is not enough sufficient as regards the present worldwide requirements for development of innovative, efficient and sustainable models of collaboration among states and regions.

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