Rural indigenous citizens in Guatemala are not able to access health care services on an equal footing with wealthier urban populations. Despite a national constitution which allows for public participation in health care decisions, indigenous people face barriers to doing so. Walter Flores, Ismael Gomez, and David Zakus explain how, through an action research project, citizens have become empowered to monitor public health policy and resource allocation effectively.
Guatemala is a country of contrasts. It is a middle-income country with a strong agro-export sector and is among the top five world exporters of coffee and sugar. Yet is has some of the worst health and social indicators in the Latin American region. Guatemala’s indigenous population experiences high avoidable infant, child and maternal mortality and extreme poverty.
These contrasts are explained by two historical factors. Firstly, the economic model concentrates most income in a small percentage of the population with little investment in public services and human development. Secondly, indigenous people, particularly those living in rural areas, are systematically excluded. In addition, the country experienced a 36 year civil war (1960-1996) characterised by dictatorial governments, brutal repression and gross violations of human rights, especially of the indigenous populations, who continue to this day to suffer from structural inequities.
Since the beginning of the democratic era in 1989 and more after the signing of the peace accords in 1996, the country has been implementing social reforms. However, it is still the better-off populations and those in large urban areas who benefit the most. Advantages for rural populations (about 60 per cent of the total population) are still very limited.
Participation in theory
The country has implemented some progressive laws that recognise the right to health and promote the participation of citizens in the development, implementation and evaluation of public policy. Although this legal framework is a major step forward, the effective participation of citizens, particularly those affected by inequity and social exclusion, is very limited. Barriers include distance, transport costs and travel time, having less formal education and speaking languages other than the official language of mainstream business (Spanish). These barriers prevent indigenous citizens from actively engaging in the deliberation of public policy and influencing the allocation of public funding towards services that can benefit them.
One of the most acute problems to advancing the right to health and improving equity is the imbalance of power. Private provision of basic health services (including by NGOs), although needed in many rural areas, does not address this power imbalance. It also probably eases the responsibility of the Guatemalan State to fulfill and guarantee the provision of health services (as required by the constitution).
Changing power relations
A civil society coalition (community based organisations, local health care workers and researchers), with the financial support of the International Development Research Center (IDRC) in Canada, designed and implemented a participatory action research project to change power relations at the municipal level. The main idea was that empowered rural citizens could affect the power balance in public decision-making and lead to pro-equity public policy and resource allocation.
Our project started in 2007. Since then, we have been working in six rural municipalities, with a majority of indigenous people with poor health and social indicators. From the very beginning, we partnered with community based organisations.
Baseline study
In phase one, we carried-out a baseline study that involved in-depth analysis of local conditions. This included collecting key indicators about equity in accessing health services and of resource allocation. We also applied rapid ethnographic techniques (social mapping, document analysis, participant observation and in-depth interviews to key social actors) to analyse and understand power relations and social determinants of health. We were also interested in the perceptions of key social actors of the barriers to participation in public policy, dialogue and debate: community leaders, local health authorities and representatives from municipal government.
Capacity building
Based on the findings of the baseline study, we designed and implemented a capacity building process. This included training workshops in which community representatives and some local authorities acquired knowledge and skills around the legal framework for health and social participation in Guatemala, participatory planning, monitoring and evaluation, advocacy and negotiation strategies. These workshops, based on popular education and adult learning techniques, resulted in an action plan for each of the six municipalities. Common problems to all the plans were identified and discussed. From this analysis, the most common problem was: ‘Families seeking health care services frequently do not receive them due to lack of drugs, equipment and other medical supplies or absence of medical personnel’. Phase three involved designing, field testing and implementing a participatory system to monitor whether public polices and resources at the municipal level were addressing and resolving the access to health care problems.
For monitoring the activities we developed two instruments: a) health care facility surveys to assess availability of essential drugs, medical equipment/supplies and availability of human resources; and b) a questionnaire for families who had faced a health care problem, had gone to a public health care facility but did not receive adequate care. The purpose of adding family interviews was to demonstrate that the inability of public health care facilities to solve the basic health care needs of families has a negative impact on their survival. They had to use scarce resources to pay for medicines, transport to a central hospital, and also endure working days lost to illness. Community leaders were trained to apply the instruments and to carry out the analysis of collected data.
Community leaders demand right to health
Community leaders then presented the analysis to local health and municipal government authorities. They accompanied the presentation with specific demands to improve the situation. Although the process is still in its early stages, there have already been achievements. Municipal governments have increased their funding to buy petrol for the local ambulance during emergency transport (families were paying before). Two sub-contracted providers for immunisation and other basic health services had their contracts terminated due to corruption (revealed by the monitoring work of communities). The working hours of health facilities have been extended, and complaints by indigenous families that they had received disrespectful treatment by medical doctors have been taken seriously.
The Monitoring group signing the report
The above achievements have resulted in a tremendous boost in the self-confidence and motivation of community leaders. “I feel this is an awakening for all of us; we know now that it is possible to demand our right to health and we have seen that change is possible,” One leader stated, during a recent project evaluation.
Another female community leader said: “Through the training and monitoring system we are now capable of discussing with the doctors and municipal authorities the problems with medicines and personnel in the health centre and health posts. Before that, we had to accept that services were almost never there and we thought nothing could be done about it.”
After three years of implementation, the project is concluding and a follow-up project is currently being planned in which we will monitor and evaluate whether the empowerment process is leading to improved equity of access and a pro-equity allocation of resources. In addition, community leaders from these six municipalities will be the facilitators to transfer skills and knowledge to new municipalities that have learned about our work and would like to replicate the process.
Lessons
We believe that this partnership of rural citizens, health care workers and researchers demonstrates two important lessons:
1) Through a participatory action research approach, citizens affected by inequity in health can become research partners and actively participate in the monitoring of public policies;
2) Demanding actions from local governments, parliament and the executive branch is a valid and reasonable intervention to promote health care equity.
Walter Flores and Ismael Gomez, Centro de Estudios para la Equidad y Gobernanza en Sistemas de Salud (Center for the Study of Equity and Governance in Health Systems). Guatemala City, Guatemala.
David Zakus, International Development Research Center, Ottawa, Canada.
For more information, contact Dr. Flores at wflores@cegss.org.gt or visit http://www.cegss.org.gt/
Filed under: Public engagement in health research Tagged: | community engagement, health research, indigenous communities, public engagement
