Rural public health systems and accountability politics: insights from grassroots health rights defenders in Guatemala

ABSTRACT

As the pandemic reveals how multiple intersecting inequalities affect public health, the work of rural activists defending their communities' rights to health, land, and gender, ethnic and environmental justice demonstrate how intersectional analysis can be put into practice. In the interviews that follow, Guatemalan Maya Tz'utujil activists Paulina Culum and Benilda Batzin describe how ‘health rights defenders’ seek justice for rural indigenous communities – work that the pandemic makes more critical than ever. Their strategies and insights have implications for addressing rural health rights around the world.

KEYWORDS:

• Health rights
• defender
• Guatemala
• community health worker
• accountability
• COVID-19

Acknowledgements

The authors wish to thank Walter Flores, Jun Borras, Marta Schaaf, Abhijit Das and three anonymous reviewers for their feedback on this manuscript. Thanks also to Louisa Reynolds for her translation and Jihane El Khoury Roederer for her design.

Disclosure statement

No potential conflict of interest was reported by the author(s).

A Note about this Manuscript

The body of this article was developed to produce an Accountability Note published with photos, in English and Spanish, by the Accountability Research Center (https://accountabilityresearch.org/publication/defending-the-right-to-health-in-guatemala-reflections-of-two-indigenous-women-on-the-frontlines/.) Julia Fischer-Mackey conducted open-ended interviews in Spanish with Benilda Batzin and Paulina Culum to understand their life experiences and current work. Julia reviewed the translated transcripts to identify themes, which she used to select excerpts. She then she wrote framing questions and an introduction. Additional academic and organizational materials were provided by CEGSS to explain particular issues. The preface was written by Jonathan Fox specifically for the Grassroots Voices section. The updates about the COVID-19-related activities were provided by Benilda and Paulina.

Support for the Accountability Research Center comes from the Ford Foundation, the William and Flora Hewlett Foundation, the John D. and Catherine T. MacArthur Foundation, and Open Society Foundations.

Center for the Study of Equity and Governance in Health Systems (Centro de Estudios para Equidad y Gobernanza en los Sistemas de Salud, CEGSS) is a civil society organization that implements applied research, capacity-building and strategic advocacy around access to health affecting indigenous and other marginalized populations. During its 10 years of existence, CEGSS has successfully evolved from an initial focus on academic research to an action research approach that engages with grassroots organizations, policy-makers and academia. The organization also evolved from a conventional public health team (medical doctors and PhDs) to an interdisciplinary team that includes political sciences, anthropology, social work, medicine, law, psychology, education, journalism and computer science. The CEGSS team is made up of 14 staff members, more than half of whom are women and/or indigenous. https://cegss.org.gt/en/

Network of Community Defenders of the Right to Health (Red de Defensores y Defensoras Comunitarios por el Derecho a la Salud, REDC-Salud) is a network of 140 volunteer health defenders who were chosen by their communities to defend the human right to health. The defenders, organized in 2008, are active in 30 municipalities in 5 departments of Guatemala, and they meet annually to share learning, coordinate and strategize. REDC-Salud members engage in capacity building in human rights and the country’s legal frameworks for citizen participation, monitoring techniques, and negotiation and advocacy skills, and provide supportive accompaniment to community members seeking health services. https://vigilanciaysalud.org/

The Accountability Research Center (ARC) is an action-research incubator based in the School of International Service at American University. ARC partners with civil society organizations and policy reformers in the global South to improve research and practice in the field of transparency, participation and accountability. www.accountabilityresearch.org

Notes

1 According to an online search of the entire collection of past issues of JPS, the term ‘health’ appears only once as a keyword and twice in a title.

2 For example, there is a large, specialized public health literature on community health workers (often rural). A recent comprehensive review of that research found significant gaps in areas where other disciplines could contribute: ‘on the rights and needs of CHWs, … on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance’ (Scott et al. 2018).

3 For a study of how grassroots rural movements in Mexico’s state of Guerrero applied the discourse of transparency and accountability to their longstanding justice struggles, see Fox, Jiménez, and Haight (2009).

4 Now that the term ‘frontline’ has been widely applied to health workers who risk their lives in order to carry out their mission, the term’s military association recalls previous episodes in history when health workers have faced direct military threats – as in the case of Nicaragua in the 1980s, when civilian health workers in rural areas were targeted for assassination by the US government-backed Contra rebels. Their goal was to deprive the rural population of access to health services (Garfield, Freidman, and Verlund 1987, 615).

5 Contrast two emblematic studies. Banerjee et al detail an Indian case of nurses’ resistance to a field experiment that attempted to impose top-down surveillance mechanisms without addressing the nurses’ motivations (2008). In contrast, Tendler and Freedheim’s institutional political economy analysis identified how in a Brazilian public health program: ‘The state created an unusual sense of “calling” among the program’s workers, a sense of prestige in the communities where they worked, and an informed citizenry that both monitored the workers and trusted them’ (1994, 1771).

6 For a recent review of the literature on ‘informal payments,’ see Schaaf and Topp (2019). On anti-corruption issues in health systems more generally, see Vian (2020). Accountability frames can also address systemic injustices that are independent of corruption, such as anti-rural bias in public resource allocation or lack of interpreting services for access to health services in vernacular languages. In contrast, the development industry’s approach to accountability emphasizes rural health worker ‘performance’ in terms of fulfilling tasks, usually without addressing whether or not governments respect their labor rights, provide training and equipment, or actually pay their salaries. For example, in the predominantly rural, Afrodescendant Colombian province of Chocó, the government owed health workers vast sums of back pay well before the Covid-19 crisis. https://www.elespectador.com/noticias/nacional/personal-del-hospital-de-tado-choco-denuncia-falta-de-pagos-y-deterioro-de-la-infraestructura-articulo-913702

7 On state-society interfaces, see Long (2001) and Hevia and Isunza Vera (2010).

8 Scott, George, and Ved (2019) review the vast literature and find a need for more ‘critical comparative research … [to] … feed back into programme reforms … , particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.’

9 For example, India’s National Rural Health Mission supports the Community-Based Monitoring and Planning program in rural Maharashtra. See the work of Support for Advocacy and Training to Health Initiatives (SATHI) at http://sathicehat.org/. Like CEGSS, they have produced an extensive body of reflective action-research and evaluation. See Khanna (2013); Marathe et al. (2020); Shukla, Scott, and Kakde (2011); Shukla and Saha (2014); and Shukla, Saha, and Jadhav (2015).

10 Drawing from these diverse experiences with using accountability discourse to claim health rights, from both the state and society, the international global South-led Community of Practitioners on Accountability and Social Action in Health (COPASAH) promotes mutual learning and exchanges of experiences. See position papers and grounded case studies at https://www.copasah.net/.

11 The term ‘collective identity’ registers (only) 46 times in the entire online collection of the Journal of Peasant Studies, which suggests that more direct engagement with the political sociology literature on social movements would be productive. See, for example, Van Doorn, Prins, and Welchen (2013).

12 This paragraph draws on Fox (2020). For CEGSS approaches to power analysis, see Flores (2019), Flores and Ruano (2015) and Hernández et al. (2019).

13 See Fox and Aceron (2016) and Fox (2016). For an innovative application of this multi-level analytical framework to an agrarian reform campaign in the Philippine province of Bondoc, see Isaac, Carranza, and Aceron (2017). Aceron extends this approach in a comprehensive comparison of six multi-level advocacy campaigns (2018).

14 For a comparative analysis that distinguishes between different terms of engagement with municipal health authorities in Guatemala, see Hernández et al. (2019). Another social accountability initiative in Peru sustained a partnership between grassroots indigenous women health rights defenders, a national health rights CSO coalition and the Puno regional office of the national human rights Ombuds agency – also affiliated with the COPASAH network (Frisancho and Vásquez 2015; Samuel 2016). This official legitimacy for watchdog work bolstered the standing and room for maneuver for independent oversight.

15 This line of work is especially timely insofar as privatization has undermined investment in preventative public health. ‘Compromised health systems’ clearly produced vulnerability to previous pandemics (Wilkinson and Leach 2015).

16 For example, frontline health workers may not show up for work, or they may charge patients ‘informal payments,’ but the underlying causes may be systemic (such as non-payment of wages, or the extraction of bribes by managers) rather than purely the result of individual failings (as is often assumed by social science field experiments – e.g., Banerjee, Glennerster, and Duflo 2008). See Schaaf and Topp (2019).

17 Thanks to Walter Flores for sharing this observation.

18 For example, see the STEPS Centre’s interdisciplinary work on epidemics and pandemics (https://steps-centre.org/covid-19-coronavirus-resources-research-epidemics-pandemics/).

19 ‘Guatemala’s legal framework created the Urban and Rural Development Council System (CDUR) in the year 2002 as a source of resources for social spending … The CDUR system has five tiers. The lowest tier includes the Community Development Councils (COCODE), which are based on community assemblies. Then, there’s the municipal level and the Municipal Development Councils (COMUDE), which includes COCODE representatives, municipal government representatives, as well as representatives from other government bodies (such as the ministries of Health and Education) and non-governmental development organizations in the municipality (the municipal development council is different from the local government’s municipal council). The COMUDE is led by the mayor. The next tier includes the Departmental Development Councils (CODEDE), which includes departmental authorities appointed by the Executive (ministries and secretariats), municipal authorities (the mayors of the municipalities in each department), the departmental governor. The most important of the five levels in terms of ascertaining social investment priorities is the municipal level, which is where the COCODE submits requests for infrastructure and social services. At this level, the COCODE and the municipal authorities discuss and agree on a final list that is submitted to the departmental tier in order to allocate the resources that will be distributed among the municipalities. The Development Council Act and its implementation is far from perfect and has many limitations, including the representatives’ legitimacy, representation quotas within the councils and the process followed to allocate resources in order to meet different sectors’ priorities.’ From Flores and Sánchez (2010).

Additional information

Notes on contributors

Julia Fischer-Mackey

Julia Fischer-Mackey is a Scholar-in-Residence with the Accountability Research Center. She has conducted development program-related research and evaluation in several countries, including in Guatemala. She is interested in questions of power, knoweldge and evidence, and has experience in the thematic areas including health, gender, and environmental justice. She received her PhD from the School of International Service at American University. Email: [email protected]

Benilda Batzin

Benilda Batzin holds a bachelor’s in Social Work and has worked on various community and environmental issues. She serves as a liaison between CEGSS staff and the health defenders, providing accompaniment and capacity building, coordinating strategy to achieve health rights for indigenous populations in the department of Sololá and throughout Guatemala. She was elected to become the new Executive Director of CEGSS, by her colleagues, and she continues to advise health defenders in Sololá. Email: [email protected]

Paulina Culum

Paulina Culum is an indigenous community leader from San Pablo la Laguna, Guatemala who began participating in civic actions when she was 13 years old. Paulina was a founding member of the organization Women Weaving a Good Life, which works on women’s rights, access to land, defense of territory, and food sovereignty. She is part of the Peasant and Indigenous Women’s Association and the Network of Community Defenders of the Right to Health. Email: [email protected]

Jonathan Fox

Jonathan Fox is Professor of Development Studies and founder and director of the Accountability Research Center at the School of International Service, American University. He studies the relationships between accountability, transparency and citizen participation. Email: [email protected]