Conflicting Health Interventions: Participation in Health in Rural Nicaragua

Abstract

Nicaragua has a long history of health activism and government policies aimed at achieving various models of participation in health. Drawing on ethnographic research in rural Nicaragua, this article situates contemporary participation within this larger historical and political context and critically explores how participation in health is understood and practised. Contemporary health interventions focus on compliance in their endeavour to improve maternal health. This focus, I argue, creates a productive tension between health seekers’ and health workers’ understanding of themselves as citizens and the government’s attempt at achieving public health aims. My empirical focus is on the brigadistas (community health workers), women and expectant mothers. I describe how brigadistas work as interlocutors between the government and the people. In this relation, women and brigadistas express expectations of and dissatisfaction with the healthcare services offered. Drawing upon an extensive literature on participation, I suggest that within this particular relational space a new political space may appear where demands for improved healthcare services can be articulated and recognized.

Keywords:

• Nicaragua
• participation
• health system
• maternal health
• community health workers

Acknowledgements

My sincere thanks to the many people in Nicaragua who shared their views and experiences with me, and to Sidsel Roalkvam and Katerini Storeng for reviewing drafts and providing valuable and constructive advice. This study was supported by the Centre for Development and the Environment (SUM), University of Oslo, as part of my Ph.D. thesis.

Notes on contributor

Birgit Kvernflaten is a Ph.D. candidate at the Centre for Development and the Environment (SUM), at the University of Oslo, Norway. Her research has focused on reproductive health and maternal health in Guatemala and Nicaragua, exploring local perspectives in the context of policies and interventions. Her current Ph.D. research concerns maternal health among rural women in Nicaragua, in particular the policies and practices in relation to maternal healthcare, and how maternal health interventions encounter local socio-cultural realities.

Notes

1 Cabildos Abiertos are legacies from colonial times, revitalized during the revolution to consult upon and give legitimacy to draft the new constitution in the 1980s. Today they are to function as open municipal assemblies arranged by local governments to inform, consult upon and include people in decision-making.

2 Although the majority will define themselves as Sandinistas, there are differences as to whether people are convinced danielistas supporting Daniel Ortega, positive to FSLN (if not Ortega), or more resigned rather identifying themselves with the revolutionary Sandinismo. Yet all have probably voted for Ortega.

3 The ‘liberals’ are fractured into several parties today all of which claim general adherence to the traditions of the historical liberal movement in Nicaragua (Wilm, 2011, p. 4). Local residents generally defined it as being in opposition to FSLN.

4 The proportion of deliveries assisted by a skilled birth attendant (SBA) has become the main performance indicator for measuring progress on MDG 5. During fieldwork, about 30–50 per cent of women in the study area gave birth at home.

5 This plan includes number of antenatal check-ups, who attends the birth and where, danger signs in pregnancy and birth, the importance of saving money for the birth and arrange transport option to the hospital in emergencies. The vast majority of women did not have such written plan, partly due to lack of copies to be distributed.