Indigenous peoples suffer from poorer health and social outcomes than non-indigenous populations. Forty years after the Alma Ata declaration, renewed and scaled up efforts to ensure that indigenous peoples are not left behind are needed if Universal Health Coverage (UHC) is to be achieved by 2030. Recent work by IDS and partners in Latin America and South Asia has shown how indigenous peoples and other ethnic minorities face political as well as practical barriers to engaging with health systems. A better understanding of indigenous peoples’ own health aspirations and of existing innovative efforts to overcome these barriers is essential.
Discussing indigenous health at the Fifth Global Symposium on Health Systems Research (HSR2018). Toby Phillips Photography
These issues were at the heart of the session entitled ‘Overcoming recognition, participation and accountability barriers to UHC for indigenous peoples: lessons from Guatemala, Brazil and India’ held at the HSR2018 in Liverpool earlier this month. They also informed a compelling article in La Nación written by Health Systems Global (HSG) award winning media fellow Irene Rodríguez.
Three case studies were presented in the session:
• Pauline Oosterhoff (IDS) talked about recognition and invisibility of indigenous and minority women’s health rights and priorities in Asia, based on her work in Vietnam and India
• Maximiliano Correa Menezes Tukano (FOIRN) and Alex Shankland (IDS) shared lessons from the Unequal Voices project on engaging with local health system management in Brazil
• Benilda Batzín presented the work by REDC Salud (La Red de Defensores Comunitarios por el Derecho a la Salud) on citizen-led accountability in Guatemala
Indigenous peoples fight for the right to health
Walter Flores from the Centre for Research on Equity and Governance in Health Systems (CEGSS) introduced the session by pointing out that there are more than 370 million indigenous people spread across the world, who are frequently oppressed, excluded, marginalised and displaced from their ancestral territories. They share certain commonalities across their range of diverse beliefs, including on the fundamental interconnectedness of health and wellbeing with the environment, land, community and society, which current thinking on health systems would benefit from as policymakers seek ways of working beyond the health sector.
All of the case studies presented in the session demonstrated the great strides indigenous groups have made through mobilising to fight for their right to health in the face of substantial structural and systemic barriers.
In Guatemala, for example, the Network of Community Defenders for the Right to Health (REDC Salud) has led activities around advocacy and capacity building of indigenous peoples to better monitor policies and services, and demand accountability from authorities, as well as health rights literacy campaigns. These efforts have led to 35 municipalities establishing active channels of engagement with citizens to discuss problems and implement solutions. In 28 of these municipalities the government has allocated financial resources to improve services, and the number of complaints about discrimination against indigenous people has also fallen in these 28 municipalities.
In many countries, diverse communities of indigenous peoples have been able to work across languages and cultures to mobilise collectively and continue to challenge the dominant understanding what ‘a community’ is or what a ‘community health system’ should look like. Pauline Oosterhoff cautioned, however, that her research in India has shown that indigenous women may face not only discrimination from mainstream health systems but also barriers to exercising voice within traditional governance institutions.
The experiences shared showed the inherently political nature of indigenous exclusion from existing health systems, and as a result these are issues that cannot be resolved through technical health sector work alone.
Lessons from Brazil: FOIRN’s experience
The case of Brazil is an example of how large a gap there can be between the way indigenous citizens’ rights are framed in national law and the practice at the local level, and where politics can create substantial barriers to access and complicate health outcomes.
Since the mid-1990s, Brazil has transformed health policy to try to ensure that the poorest people and places are covered by basic services. Despite this, the country’s indigenous peoples continue to lag behind the population as a whole in terms of improved health outcomes.
The Federation of Indigenous Organisations of the Rio Negro region(FOIRN) has successfully engaged with the government health system to secure accessible, appropriate and culturally acceptable care, and is one of the areas of focus of IDS research with partners in Brazil under the ESRC-DFID funded Unequal Voices project on the politics of accountability for equity in health systems.
FOIRN went from being one of the leading indigenous organisations in a social movement campaign for differentiated health care for indigenous peoples launched in 1993 to taking over responsibility for delivering services in the Rio Negro region under contract to Ministry of Health in 2004-2006. Despite initial rapid progress in developing and implementing an innovative service delivery model co-managed by indigenous leaders and non-indigenous health professionals, the Brazilian government subsequently re-centralised control over decision-making. Despite significantly increased budgets the quality of services declined, as indigenous leaders were sidelined.
In the HSR2018 session, Maximiliano Correa Menezes Tukano explained how he was selected in 2016 by FOIRN as the first indigenous Technical Advisor appointed to the Upper Rio Negro Special Indigenous Health District (Distrito Sanitário Especial Indígena do Alto Rio Negro). However, he was dismissed a year later after FOIRN protested about the poor quality of the District managers’ response to a severe malaria outbreak. According to Tukano, the appointee who replaced him was recommended by municipal politicians connected to Brazil’s ascendant right-wing national political networks. These politicians also took over control of the District Indigenous Health Council (CONDISI), a participatory space for service oversight that FOIRN had originally helped to establish.
Continued commitment required to ensure health services meet needs of indigenous peoples
The shared narrative that emerged across all of the case studies presented in the session was one where indigenous peoples adapt and mobilise in the face of persistent exclusion and marginalisation, while their health needs continue to go unmet. It is clear, from both the HSR2018 session and research undertaken by IDS and its partners, that a more integrated and culturally sensitive approach that recognises the structural barriers indigenous people face in claiming their right to health is required. One that acknowledges the value of indigenous health practices on an equal basis to ‘Western’ medicine, and that cuts across private and public sectors as well as civil society.