Florence Levy with indigenous traditional birth attendant
In the North Atlantic Autonomous Region of Nicaragua, the social determinants of health approach is not new to the indigenous people who live there. Their holistic and interconnected view of the world means they understand health at a community level, relating it with the access to land, to employment, to water and to leisure time. Florence Levy, from Health Unlimited talks about this perspective and the work she is doing to influence the Government to stop inappropriate vertical interventions.
I have been working with Health Unlimited UK in Nicaragua since 2004. I myself am Nicaraguan from the North Atlantic Autonomous Region, (RAAN) where indigenous and ethnic communities have preserved their languages and practices. I trained as a medical doctor but no longer practice as a clinician. After two years social service, I decided to go into public health to reach larger populations.
It is interesting to think about the social determinants of health approach because, where I come from, this is the way that indigenous people see health anyway. If you do not own your land, if you do not have water, if you do not have adequate housing, if you do not have spare food, if you do not have opportunities to socialise (for instance at baseball games), you cannot expect your health to be good. For many people, a social determinants of health approach stays at a very conceptual level. The comprehensiveness of the approach is very easy to put on paper, but when people try to put it into practice, it does not happen. We have been saying all along, why do people want to separate health from who we are and how we see things?
The Ministry of Health has a very vertical approach to working with indigenous people in their service delivery system. They look at individuals first, then families and lastly communities. As for us, the indigenous people, it is the other way around. You have to address the community first. If the community is not in equilibrium, you look into the families, see how they are functioning and whether their basic needs are being met. The individual is still important of course, but not alone, rather as a member of a family and community. The impact of the health programmes implemented by the Ministry of Health is limited, as their approaches do not look at the indigenous people’s perspective.
Indigenous people have a holistic view of the world. Everything is interconnected and linked. This has been really difficult to get across when we work with different health interventions, either for prevention, promotion, or direct service provision. This is the reason why we are working hard to establish a health system model which addresses the indigenous people’s real needs.
The development of this system is a process in itself. In the RAAN, Health Unlimited is making a direct contribution by introducing a model for safe motherhood which is appropriate to the indigenous populations. We work to tell the Government what the indigenous communities want and need in order to stay healthy. This is a steep learning curve for health officials who see health as all about providing medicines and medical attention.
We had been to the people, we had asked them how they wanted to be attended, we documented this, and then we prepared guidelines for antenatal care and birth attendance, guidelines for traditional birth attendants (TBAs), and health committees. We are not saying that what the Ministry of Health is doing is wrong, we want to complement their services. We need to include indigenous people’s perception of the world, and make the links between traditional practices and western care.
Previously the Ministry of Health would come and tell indigenous mothers to plan their delivery in advance. They came with a model brought from another part of the world, and told mothers to plan whether they want to go to a hospital or have a traditional birth attendant (TBA), or a trained medical professional if they can afford it. They train community people, especially TBAs to do this. When we saw all this we thought it wasn’t a bad idea but we saw the flaw in their plan. We did a rapid appraisal and asked the indigenous people: who is responsible in the community for avoiding maternal deaths? Everyone placed the husband first, followed by the girls’ parents. They were quite clear about the power that exists. The Government’s model of intervention did not take the husband into account and this is what was required.
I like the social determinants of health approach because it gives health professionals the opportunity to work with others. We are not going to solve health problems in the community by ourselves. Health is important, but if we do not link it with other determinants we will fail. When we go into a community and work with a sick population we should try to make sure that we work with the Government in order to cover different areas. If one ministry is working on health, we need to make sure others are working on education, on land, on migration, on food security. All of these have a direct impact on the health of the people.
Looking at the social determinants of health is a good opportunity to change the way we are addressing health. Health is not a service that the Government provides, or does not provide. Health is a right. Indigenous people understand this in terms of land, and so they now understand this about health too. You cannot achieve anything unless you have land, and good health.
Florence Levy is Country Manager at Health Unlimited UK, working in Nicaragua
Contact: huniccmf@cablenet.com.ni
Website: www.healthunlimited.org
Filed under: social determinants of health
