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Community Vigilance for better health care services in the Highlands of Guatemala
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Abhijit Das
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Background
It was to be our third day on the road, and the first two days hadn‘t gone well to say the least. It was 6 am in the morning and we were all gathered in the courtyard of Hotel Don Gabriel in the city of Uspantan in the Guatemalan highland province of Quiche. It was cold and there was no morning cup of coffee or tea to warm us up when we set off with the headlights of our two Toyota Hiace vans piercing the mist. After a short ride of twenty minutes or so we suddenly left the tarmac road behind and started descending on a wet slushy mud track. I had remarked just the last evening to my friend and host Walter Flores how I found the hill roads of Guatemala to be in excellent condition in contrast to the hill roads in the Kumaon Himalayas in India where I am a regular visitor. I immediately remarked to Walter that I would like to take back the compliment I had paid earlier. Walter smiled and said welcome to the ‗cloud forests‘ of Guatemala. These moist, inaccessible, forested areas were home to the indigenous Mayan people where Government services were skeletal and inadequate to say the least. We bumped along the wet, winding and mostly potholed road for the next couple of hours before we came to the broad valley and market town of La Parroquia where we were supposed to meet with the members of the Citizen‘s Council of Zona Reina and learn how they were negotiating with the Municipal Government and the Ministry of Health to get better health services for themselves. |
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I was part of a twenty member group that had come to Guatemala to learn about the social accountability work around health that was being done by Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud or CEGSS in the remote municipalities in the highlands of Guatemala. Over seven days we travelled across four locations meeting with members of citizen‘s councils, municipal authorities as well as health providers to learn of how members of the citizen‘s councils had started becoming more active and articulate to demand their health rights from the local authorities. The Mayan people are the original inhabitants of Guatemala, but today the communities we visited were among the most marginalised in the country. Though free health care is a constitutional right of citizens of Guatemala, the situation on the ground was very different. Most of the group that had come to see the social accountability work were from Eastern Europe (from Macedonia and Bulgaria) and they were taken aback by the lack of health care facilities; however they were also very impressed with the degree of social mobilisation among the rural Mayan communities and their collective struggle to obtain better health care services for the community.
We traveled across four locations meeting with members of citizen’s councils, municipal authorities as well as health providers to learn of how members of the citizen’s councils had started becoming more active and articulate to demand their health rights from the local authorities.
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The Ministry of Public Health and Social Welfare (MSPAS) is the main provider of health services in Guatemala and this is done through mobile paramedic teams that visit communities once a month, a network of health posts staffed by paramedics, primary health care clinics with doctors and hospitals. First level care is mainly targeted towards maternal and child health and emergency care. The health problem that was mentioned to us most frequently was the lack of emergency transport for women requiring emergency obstetric care services. We were told that most births took place at home under the supervision of TBAs (Traditional Birth Attendants), however, in cases of emergency there were hardly any ambulance facilities available to transport women to the hospitals where emergency obstetric care facilities were available. In Zona Reina and Nebaj (province of Quiche) and in Ixchiguan (province of San Marcos) the main struggle of the Citizen‘s Council was to obtain regular ambulance services and they had been successful in doing so. The members of the citizen‘s councils also conducted regular facility surveys at the hospitals through which they identified gaps in supplies and medicines and then pushed for adequate stocking and supplies.
The Citizen‘s Councils of Health were the key citizen‘s group with whom CEGSS worked to strengthen the work of social accountability around health. These councils are mandated by law and work as platforms that encourage citizen participation in governance. The membership of the citizen‘s council comprises of leaders from different villages and they are expected to function as watchdogs over the work of the municipality and the MSPAS, however in the case of health, the division of roles and responsibilities is not always very clear since the municipality is expected to contribute with resources to local social services and at the same time the MSPAS is responsible for maintaining the network of public health services. But in Tectitan (province of Huehuetenango) we found that the citizen‘s council had been successful in working with the Municipality to add more beds and equipment at the local hospital and in Ixchiguan to improve the hygiene in the local market place. In Tectitan the citizen‘s council had also started a programme to address malnutrition with the Municipality providing inputs for vegetable gardening. At Nebaj we learnt that the Citizen‘s Council had raised the issue of disrespectful treatment with the authorities at the municipal hospital. The Hospital Director had no hesitation in concurring that the issue of treating the local Ixil Maya respectfully was being discussed regularly during staff meetings and citizen‘s council noted that there had been an improvement over the last few months.
Dr Walter Flores, Director CEGSS explained that their approach to social accountability was based on the legal commitments of the Government of Guatemala to its citizens. They believed that it was possible to work together with local communities to collectively analyse and reflect upon their current situation of health needs and existing gaps to develop a critical consciousness on health eq u ity an d r igh ts . Th is consciousness of rights then becomes the basis for examining the existing health policies and provisions and for collective demands for reform and change. Dr Ismael Gomez, Field Director of CEGSS explained that they had four steps in their approach. First they approached communities to assess the status of their mobilisation. They conducted a rapid assessment of existing community council and their leadership. If they found that leadership was committed, legitimate and representative, they moved into their second step which comprised of capacity building of the members of the citizen‘s council. In those cases that community councils have limited capacities for mobilisation or representation, CEGSS would support an initial community organisation strengthening through supporting community assemblies that would expand the number of community leaders in the council and its representation.
The capacity building process extended over six to nine months and comprised of a once-a-month interactive session discussing issues like legal and policy framework, participatory planning, monitoring of public policy, tools and methods and so on. Capacity building is based on popular education and other critical pedagogy approaches. In the third step the citizen‘s councils actually engaged in a process of vigilance through in-depth data collection at the family level and by conducting health facility surveys. In the fourth and final step the citizen‘s councils engaged in a process of strategic advocacy using different tools like media advocacy, lobbying and negotiation, public demonstrations and so on. CEGSS was currently working with citizen‘s councils in 15 municipalities in the more remote regions of the country, and we met with four of these groups.
Guatemala we learnt is still recovering from a 36 year long civil war which ended in 1996. The indigenous Mayan population had to face the brunt of this war because of their demands for land reform and fair wages and nearly 200,000 were killed during this period. This prolonged period of violence and repression has led to continued sense of insecurity and a shrinking of space for community or public participation among the Mayas. Today even though half the country‘s population is of Mayan origin, less than 10% of the deputies of Congress are from this group. Within this overall atmosphere of insecurity where the situation of the indigenous Mayan people continues to remain precarious, t h e m o b i l i z a t i o n a n d empowerment of local Mayan leadership that has been fostered by CEGSS is impressive. They have been able to create pockets of community leadership where local Mayan women and men are able to negotiate with public authorities for improved public services. However, the overall state of health services available to the communities living in the remote highlands continues to be very poor and one hopes that the continued vigilance and pressure from these increasingly articulate communities will be able to change the situation in the near future.
The Citizen‘s Councils of Health were the key citizen‘s group with whom CEGSS worked to strengthen the work of social accountability around health. These councils are mandated by law and work as platforms that encourage citizen participation in governance. The membership of the citizen‘s council comprises of leaders from different villages and they are expected to function as watchdogs over the work of the municipality and the MSPAS, however in the case of health, the division of roles and responsibilities is not always very clear since the municipality is expected to contribute with resources to local social services and at the same time the MSPAS is responsible for maintaining the network of public health services. But in Tectitan (province of Huehuetenango) we found that the citizen‘s council had been successful in working with the Municipality to add more beds and equipment at the local hospital and in Ixchiguan to improve the hygiene in the local market place. In Tectitan the citizen‘s council had also started a programme to address malnutrition with the Municipality providing inputs for vegetable gardening. At Nebaj we learnt that the Citizen‘s Council had raised the issue of disrespectful treatment with the authorities at the municipal hospital. The Hospital Director had no hesitation in concurring that the issue of treating the local Ixil Maya respectfully was being discussed regularly during staff meetings and citizen‘s council noted that there had been an improvement over the last few months.
Dr Walter Flores, Director CEGSS explained that their approach to social accountability was based on the legal commitments of the Government of Guatemala to its citizens. They believed that it was possible to work together with local communities to collectively analyse and reflect upon their current situation of health needs and existing gaps to develop a critical consciousness on health eq u ity an d r igh ts . Th is consciousness of rights then becomes the basis for examining the existing health policies and provisions and for collective demands for reform and change. Dr Ismael Gomez, Field Director of CEGSS explained that they had four steps in their approach. First they approached communities to assess the status of their mobilisation. They conducted a rapid assessment of existing community council and their leadership. If they found that leadership was committed, legitimate and representative, they moved into their second step which comprised of capacity building of the members of the citizen‘s council. In those cases that community councils have limited capacities for mobilisation or representation, CEGSS would support an initial community organisation strengthening through supporting community assemblies that would expand the number of community leaders in the council and its representation.
The capacity building process extended over six to nine months and comprised of a once-a-month interactive session discussing issues like legal and policy framework, participatory planning, monitoring of public policy, tools and methods and so on. Capacity building is based on popular education and other critical pedagogy approaches. In the third step the citizen‘s councils actually engaged in a process of vigilance through in-depth data collection at the family level and by conducting health facility surveys. In the fourth and final step the citizen‘s councils engaged in a process of strategic advocacy using different tools like media advocacy, lobbying and negotiation, public demonstrations and so on. CEGSS was currently working with citizen‘s councils in 15 municipalities in the more remote regions of the country, and we met with four of these groups.
Guatemala we learnt is still recovering from a 36 year long civil war which ended in 1996. The indigenous Mayan population had to face the brunt of this war because of their demands for land reform and fair wages and nearly 200,000 were killed during this period. This prolonged period of violence and repression has led to continued sense of insecurity and a shrinking of space for community or public participation among the Mayas. Today even though half the country‘s population is of Mayan origin, less than 10% of the deputies of Congress are from this group. Within this overall atmosphere of insecurity where the situation of the indigenous Mayan people continues to remain precarious, t h e m o b i l i z a t i o n a n d empowerment of local Mayan leadership that has been fostered by CEGSS is impressive. They have been able to create pockets of community leadership where local Mayan women and men are able to negotiate with public authorities for improved public services. However, the overall state of health services available to the communities living in the remote highlands continues to be very poor and one hopes that the continued vigilance and pressure from these increasingly articulate communities will be able to change the situation in the near future.
This prolonged period of violence and repression has led to continued sense of insecurity and a shrinking of space for community or public participation among the Mayas. Within this overall atmosphere of insecurity where the situation of the indigenous Mayan people continues to remain precarious the mobilization and empowerment of local Mayan leadership that has been fostered by CEGSS is impressive.
They believed that it was possible to work together with local communities to collectively analyses and reflect upon their current situation of health needs and existing gaps to develop a critical consciousness on health equity and rights. This consciousness of rights then becomes the basis for examining the existing health policies and provisions and for collective demands for reform and change.
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ABOUT AUTHORS
Abhijit Das is a Steering Committee Member of COPASAH and also Director, Centre for Health and Social Justice, India. To know more about the work of Centre for Health and Social Justice, please CLICK HERE
Abhijit Das is a Steering Committee Member of COPASAH and also Director, Centre for Health and Social Justice, India. To know more about the work of Centre for Health and Social Justice, please CLICK HERE
