HISTORY, A DETERMINANT OF HEALTH: A FOCUS ON INDIGENOUS GUATEMALA

Hi everybody, welcome to a new month!

When we last met, we took a walk through Guatemala’s history and gained some insight into the prevailing historical events that led to the initial marginalization of her Indigenous people. We learned that indigenous Guatemala (most of whom are Mayan) began facing marginalization and oppression after the nation was colonized by Spain. We learned how the growing influence of American interests furthered this oppression, triggered their displacement, and resulted in decades of violence and revolution. We also learned that after almost 36 years of civil and political unrest, the Guatemalan government formed the National Reconciliation Commission (CNR) to begin a transition towards peace and stability. Under this commission, several plans were made to address the nation’s social and structural issues, its poor and marginalized populations, and its need for a revised health care system.

So, if plans were made to address all these issues, how did Guatemala’s current healthcare system come to be? And why have Indigenous Guatemalans repeatedly gotten the short end of the stick?

The evolution of Guatemala’s health care system began with its government. During the previous years of conflict, “the Guatemalan government was largely removed from health care provision,” especially in the areas where indigenous Guatemalans made up most of the population. The system was left to govern itself.

During this time, Guatemala’s health care system was composed of four main levels:

1. Specialized hospitals at the National level
2. Department hospitals at the Regional level
3. Health centers at the Municipal level
4. Health promoters at the Community level.

After the accords, the government remodeled this system and introduced the Comprehensive Health Care (CHC) system. The goal of this system was to transfer “the role of the State in administering health care to private entities.” At this point, the Guatemalan government lacked the resources needed to fully operate the health care system, and their history with indigenous Guatemala made it difficult for them to form connections and build positive relations. They hoped that the CHC system would change this and address the outstanding issues.

"The private sector and privatization in health care refers to the involvement of non-government entities in health care delivery. It generally includes for-profit businesses, charitable and non-profit organizations. It can involve the delivery of health care services through private for-profit or non-profit hospitals and clinics and the financing of services through individual out-of-pocket payments and private health insurance."
An Overview of Public and Private Participation

In 1997, under the Ministry of Health and Social Assistance and the operation of the CHC system, the population was divided into multiple regions. Each region had approximately 10,000 people and would be served by an assigned non-governmental organization (NGO). To ensure that the NGOs did not have full power over the system, a “mixed-contract” was introduced in which the NGOs would be hired by a governmental health provider team and be contracted as health service administrators and financial managers.

By 2002, 88 NGOs had entered contracts with the government to provide care to over 3 million Guatemalans (in 2002, the overall population was about 12.15 million). It was estimated that the amount of Guatemalans with no access to care had decreased from 46% to 9%. On the surface, this new system seemed to be working, however, the quality of the care being provided and the indigenous populations that were still unaccounted for were not being taken into consideration.

Funds were often insufficient and governmental health providers were not always able to fully pay the NGOs, resulting in the suspension of multiple health services. It was also found that many of the NGOs that had been hired, had little to no experience in healthcare and were further contributing to the issue of low-quality care. In addition to this, the government’s minimal involvement and failure to test the effectiveness of this new system resulted in the poorest Guatemalans (again, most of whom were indigenous) receiving “extremely limited services“, thus further alienating indigenous Guatemala from the system.

Today, Guatemala’s healthcare system has evolved from the CHC system and is now split into three separate divisions: the public, private non-profit, and private for-profit sectors. The public sector is accountable for about 88% of Guatemalans and is responsible for providing free care through hospitals, health facilities, and health centers. Due to chronic underfunding and shortages of drugs and equipment, this sector tends to only treat severe health issues, and “not mundane ailments”. The private sector, both for-profit and non-profit, covers about 12% of the population and operates through private clinics and hospitals. This sector tends to provide better quality care, but services often require upfront payments.

Despite the multiple reforms to Guatemala’s health care system, the indigenous population remains at risk for poorer health outcomes. Seeing as most indigenous Guatemalans reside in rural areas, they tend to experience greater inequality in access to education, employment, sewage systems, clean water, electricity, humane working conditions, and adequate infrastructure. All these factors contribute to the population’s lack of access to modern health care services. Even when access is granted, the quality of care is often reduced due to limited transportation and language barriers.

The majority of health care services are situated in the nation’s capital, Guatemala City, “making them geographically unreachable” for much of indigenous Guatemala. For them to make the trips to the capital from their rural homes, they would need to “take time off work, pay money out of pocket for transportation and travel many hours to the capital.” For families already struggling to make ends meet and afford “basic daily amenities such as food and clean water”, such a journey is unattainable.

Over 30% of Guatemalans cannot speak Spanish and most public health care providers cannot speak any of the Mayan languages. This makes it hard for doctors and other health professionals to “understand the needs and complaints of the indigenous communities they are serving.” In turn, the language barriers make it hard for these communities to trust their health care providers and results in them relying on traditional healers, who can communicate and relate with them.

For Guatemala, where an estimated 40 percent of the population is indigenous, access to quality care and resources remains a persistent challenge. From environmental to socioeconomic factors, many confounding variables have made access to health care highly difficult for Indigenous Guatemalans. However, this is not an unsolvable issue. Many groups and communities, both local and international, are taking action in various ways. Through advocacy, community-centered care, and political movements, the health of indigenous Guatemala is being addressed and barriers are being eliminated.

In the next part of our series, we are going to learn about how a “community-led national alliance of Indigenous women’s organizations in Guatemala is working to improve the delivery of health care for Indigenous women through collaboration with other community-based organizations, government, and international partners” (Velasquez et al., 2018).

Together we can make an impact on the health of the nations and the generations to come.

The mission of WHEF is to increase accessibility to medications and supplies for healthcare facilities in Guatemala and Grenada. If you are interested in hearing more about the work we are doing, or in connecting with us, you can visit our website, check out our instagram or facebook, or sign up to receive our newletters. If you would like to support us in our work, please donate here.

The mission of WHEF is to increase accessibility to medications and supplies for healthcare facilities in Guatemala and Grenada. If you are interested in hearing more about the work we are doing, or in connecting with us, you can visit our website, check out our instagram or facebook, or sign up to receive our newletters. If you would like to support us in our work, please donate here.