Defending the right of Amazonian indigenous peoples to intercultural health.

Pedro Enrique Quiñones Figueroa MD, MPH

A brief from his Thesis for Masters degree “ Community participation as critical node for decentralizarion as a social process in Peru”.

Framework of the Project on TB to be presented for opinion to the National Institute of Health, Direction of Indigenous peoples affairs, MOH - PERU .

To be presented for funding to CONAMUSA – MOH PERU, THE  GLOBAL FUND.

HUMAN RIGHTS AND HEALTH INSTITUTE

Defending the right of Amazonian indigenous peoples to intercultural health.

The right to health of people and their adequate provision, particularly for vulnerable populations such as indigenous peoples has been, from the beginning of their functions, one of the main concerns of the Ombudsman. Therefore, various documents made recommendations to the State and the institutions responsible for their management, in order to ensure the enjoyment of those rights effectively and equal quality.

Definition of health  entails  a comprehensive interpretation that has correspondence with the conceptions that indigenous peoples have , and that includes physical, mental, emotional and spiritual aspects; and the relationships between people, communities, environment and society in general.

The Political Constitution of Peru also recognizes the rights of individuals to protect their health (article 7) and their ethnic and cultural identity (Article 2, paragraph 19 °) .13 It also establishes the State's obligation to respect the cultural identity of the peasant and indigenous communities (Article 89). On the other hand, Article 25 of the Convention No. 169 of the International Labor Organization (ILO) provides that the State has an obligation to make available to indigenous peoples adequate health services, considering their social economic, geographic, and cultural, and methods of preventive care, healing practices and medicines. Similarly, states that social security schemes shall be extended progressively to these peoples without discrimination, and health services must be organized, as far as possible, at Community level cooperation of indigenous peoples in their planning and administration. (Articles 24 °, and 25.2 respectively)

The Committee on Economic, Social and Cultural Rights of the United Nations, in its General Comment No. 1414 has established that the State must ensure that the right to health of indigenous peoples is:

Available: providing a sufficient number of facilities, supplies, equipment and health professions.

Accessible: for all indigenous peoples in terms geographic, considering his condition remoteness and population dispersion, affordable for all and all are affiliated to safety, and equal to not be discriminated against for belonging to a particular ethnic group.

Acceptable: to the extent that respects the culture of the indigenous people through culturally relevant programs;

and Superior: observing that facilities and equipment are in good condition and with trained and skilled to provide a comprehensive service approach to intercultural staff.

On the other hand, the First International Conference on Health Promotion held in Ottawa (Canada), marks a new challenge to the prevailing doctrine to establish that health promotion should consider encouraging the creation of favorable environments, strengthening community action, developing personal skills and reorienting health services health. Under this new concept of health population is expected to exert greater control over their own health, states must provide the means for that, throughout his life, people prepare for the different stages of it and face as chronic diseases and injuries through schools, homes, workplaces and community level.

Universal access to health and universal health coverage require policies, plans and health programs that are equitable and efficient, and which satisfy the different needs of the population. Regard to gender, ethnicity, age and economic and social status are specific social determinants that impact positively or negatively on health inequity form. In Peru, the Constitution also guarantees the protection of the right to health of all people and provides that the State is responsible for facilitate and monitor equal and free access to health services .

Multiculturalism and intercultural dialogue

All human groups are producers of culture. This is a system of meanings and practices, from which a community interprets and acts on. Every culture has a particular manner or way of doing, feeling and thinking; to interact (or not) with the rest of humanity, with the beings of nature, with the holy beings and the person himself

Recent studies of millenarian movements in tribal societies have tended to interpret them as expressions of resistance to colonial or neocolonial domination. Through a comparison of five case studies of indigenous millenarianism drawn from the history of lowland South America, we need to identify aspects of utopian renewal that reflect internal political processes and contradictions independent of, and probably predating, native encounters with Europeans. Upon close inspection, the term resistance proves inadequate to the task of illuminating the dialectical processes by which native peoples define themselves in relation to other societies, indigenous and otherwise.

W e need to establish a dialogue with the Amazon Amerindian perception of development and environmental sustainability. Our approach is a reference to  the Ashaninka village (Apiwtxa) , and the Indigenous Land  (Kampa). Today, this group stands out in the environmental and indigenous scenario for its implementation policy of sustainable development projects for the Amazon. Let's find the ritual structure of politics and economy of this community in particular within their traditional social and cosmological environment.

It is proposed  the concept of post-sustaining in order to identify the way in which the Ashaninka produce their social and economic recycling. We will see that, to combat and reverse the effects of historical wear the shamanic complex Ashaninka invests in a constant return to cosmological origins, touting rescue strategies of the primordial mythical sustainability passing by effecting political alliances and a food-producing economy of people.

The project objective

Strengthen indigenous communities and organizations so that they can design and implement community development sub-projects, better articulate their proposals, and effectively utilize services offered by the State and other sectors within civil society by promoting innovative methods through a "learning by doing" process. The project sought to achieve its objectives through: (a) the strengthening of the organizational, institutional, technical and entrepreneurial capabilities of indigenous and Afro-Peruvian communities and organizations, as well as participating government agencies; (b) the preparation of community development sub-projects based on participatory designs, and organization of technical proposals with the required pre-investment studies; and (c) the implementation of sub-projects with financing from the funding agencies.

Vision:  

Empowerment through local citizenship

Poor people live their daily lives at the local level where they engage with the state, public services, markets and the political system. Their empowerment requires participation and accountability in local governance and decision making through effective and inclusive local citizenship.

Supporting inclusion requires an understanding of existing power relationships and the practical obstacles to participation faced by poor people. Public sector decentralization is an important opportunity for empowerment through increased accountability for public expenditure allocations and local delivery of pro-poor policies.

Capacity development, for both communities and citizens, must promote leadership and facilitation, communication, advocacy and political skills.  

Widely available, transparent and substantive information is a critical but

easily achievable first step in capacity development. All development aid modalities can support local empowerment and donors should co-ordinate to identify and maximise opportunities for empowerment at the local level.

 Effective and inclusive citizenship

A citizen is someone with rights, aspirations and responsibilities in relation to other social and economic actors and to the state. Empowerment through local citizenship of people in poverty is about changing who has decision-making power and who has a voice at the local level.

Effective and inclusive local citizenship means that all people can participate in local decision making processes and hold others to account. In ideal situations, individual citizens should be able to participate. Experience shows that marginalised people gain much from organizing themselves into groups in order to use their collective bargaining power to greater effect.

Ingredients

Participation

For pro-poor growth policies to emerge, poor people need to be informed and

empowered to participate in a policy-making process that is accountable to them. They need to have the tools and opportunities to participate in, and influence, the decisions that are made at local level, and which impact on their daily lives. Promoting the participation of marginalised groups involves changing existing power relations, both the visible and the invisible ones. Participating in local government budget discussions is not enough if the

existing powers are drafting the budget proposals and setting the agenda for the debate.

Accountability

Participation is only effective when the institutions of the state respond. Consultation without due recognition of power and politics will lead to voice without influence. The critical challenge is for citizens, particularly the excluded and marginalised, to be able to influence policies and institutions, and for these in turn to become more accountable to them, and act in their best interest. It is not only government institutions that need to be accountable to the poor. Local politics also involves a multiplicity of local entities (e.g. rural producers’ organisations, market stall owners, wholesale buyers and sellers,

semi-state enterprises) operating at the interface between state, market and society in an environment characterised by blurred boundaries between the sectors and unclear lines of responsibility.

Inclusiveness

Effective participation and accountability mechanisms require the direct involvement of poor and marginalised people. Many factors drive poverty and exclusion. Gender inequality, religion, membership of social or ethnic groups, regions in which they live as well as their material wellbeing all affect people’s access, status and influence in local politics. Facing exclusion and discrimination, people living in poverty may be too alienated or oppressed to

seize new opportunities to act. Women (or men) may not be willing to participate, or work alongside the opposite sex. Designing in inclusiveness in empowerment strategies is crucial and may require different interventions to accommodate all marginalised groups.

Participation and Rights .

As traditional forms of political representation are being re-examined, direct democratic mechanisms are increasingly being drawn upon to enable citizens to play a more active part in decisions which affect their lives. In this context, the questions of how citizens – especially the poor – express voice and how institutional responsiveness and accountability can be ensured have become paramount. 

In many countries, measures to bring government ‘closer to the people’ through decentralisation and devolution have prompted shifts in approaches to service delivery that have widened spaces for citizen involvement. At the same time, the increasing marketisation of service delivery in many countries has introduced new roles for those who were formerly the ‘beneficiaries’ of government services.

In the past, there has been a tendency to respond to the gap that exists between citizens and state institutions in one of two ways. On the one hand, attention has been made to strengthening the processes of participation – that is the ways in which poor people exercise voice through new forms of inclusion, consultation and/or mobilisation designed to inform and to influence larger institutions and policies. On the other hand, growing attention has been paid to how to strengthen the accountability and responsiveness of these institutions and policies through changes in institutional design and a focus on the enabling structures for good governance.

Each perspective has often perceived the other as inadequate, with one warning that consultation without attention to power and politics will lead to ‘voice without influence’ and the other arguing that reform of political institutions without attention to inclusion and consultation will only reinforce the status quo. Increasingly, however, we are beginning to see the importance of working on both sides of the equation.

Re-positioning participation 

Both social participation and political participation have carried with them a distinctive set of methods or approaches for strengthening or enhancing participation.Traditionally, in the field of political participation, such methods have included voter education, enhancing the awareness of rights and responsibilities of citizens, lobbying and advocacy, often aimed towards developing more informed citizenry who could hold elected representatives more accountable. 

In the social and community spheres, we have seen the development of a number of broader participatory methods for appraisal, planning, monitoring large institutions, training and awareness building. The emphasis here has been on the importance of participation not only to hold others accountable, but also as a self-development process, starting with the articulation of grassroots needs and priorities and moving towards the establishment of selfsustaining local organisations.

Equally importantly, however, where government agencies have taken an active interest in seeking responsiveness and have not only listened to but acted on citizens’ concerns, otherwise adversarial and distant relationships have been transformed. Clearly, this also holds the promise of electoral advantage. 

New thinking about participation as a right 

The concept of ‘citizenship’ has long been a disputed and value-laden one in democratic theory. New approaches to social citizenship seek to move beyond seeing the state as bestowing rights and demanding responsibilities of its subjects. In doing so, they aim to bridge the gap between citizen and the state by recasting citizenship as practised rather than as given. Placing an emphasis on inclusive participation as the very foundation of democratic practice, these approaches suggest a more active notion of citizenship. 

…  ‘the right of participation in decision-making in social, economic, cultural and political life should be included in the nexus of basic human rights… Citizenship as participation can be seen as representing an expression of human agency in the political arena, broadly defined; citizenship as rights enables people to act as agents’.