Health and Autonomy: the Case of Chiapas
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Translated from Spanish Health and Autonomy: the case of Chiapas A case study commissioned by the Health Systems Knowledge Network J.H. Cuevas March 2007 Translated from Spanish Background to the Health Systems Knowledge Network The Health Systems Knowledge Network was appointed by the WHO Commission on the Social Determinants of Health from September 2005 to March 2007. It was made up of 14 policy-makers, academics and members of civil society from all around the world, each with his or her own area of expertise. The network engaged with other components of the Commission (see http://www.who.int/social_determinants/map/en) and also commissioned a number of systematic reviews and case studies (see www.wits.ac.za/chp/). The Centre for Health Policy led the consortium appointed as the organisational hub of the network. The other consortium partners were EQUINET, a Southern and Eastern African network devoted to promoting health equity (www.equinetafrica.org), and the Health Policy Unit of the London School of Hygiene in the United Kingdom (www.lshtm.ac.uk/hpu). The Commission itself is a global strategic mechanism to improve equity in health and health care through action on the social of determinants of health at global, regional and country level. Translated from Spanish Acknowledgments This paper was reviewed by at least one reviewer from within the Health Systems Knowledge Network and one external reviewer. Thanks are due to these reviewers for their advice on additional sources of information, different analytical perspectives and assistance in clarifying key messages. This work was carried out with the aid of a grant from the International Development Research Centre, Ottawa, Canada, and undertaken as work for the Health Systems Knowledge Network established as part of the WHO Commission on the Social Determinants of Health. The views presented in this paper are those of the authors and do not necessarily represent the decisions, policy or views of IRDC, WHO, Commissioners, the Health Systems Knowledge Network or the reviewers. Translated from Spanish Health and Autonomy: the case of Chiapas General framework- • The health system in México. • Mexico's indigenous peoples • Chiapas, background information • Health services structure in Chiapas. The Zapatista Autonomous Health Care System • Historical background. • The EZLN Autonomy Project. • Health policy . • Structure of the SSAZ (Autonomous Zapatista Health Service). • Interaction with the national health system • Outcome indicators. General framework- Health system in Mexico During the 1940s and 1950s, against the background of the period that followed the revolution of 1910, the Ministry of Health and the Mexican Social Security Institute were set up in response to the social demand for care for the thousands of peasants who took part in the revolutionary struggle against the chiefs and landowners who owned practically the whole territory. However, it was not until 1984 that the Mexican health system was set up, on the basis of the right to health, and the assumption by the state of the responsibility to grant and supervise that right, on the basis of Article 4 of the 1917 Constitution. It has a vertical structure, with three levels of care: the primary level, comprising general practitioners, nurses and health technicians; the secondary level, with highly specialized hospitals and institutes. In providing care, a distinction is made between the working population and the population at large. Care for the former is provided inter alia by the Instituto de Seguridad y Servicio Social para los Trabajadores del Estado (ISSSTE )[The Social Security and Service 1 Translated from Spanish Institute for State Employees] and Mexican Petroleum (PEMEX) to which workers contribute directly. The remainder of the population, most of whom are peasants and indigenous people directly depend on the network of services provided by the Secretary for Health (SSA). Over the years, the relatively affluent part of the population has come to meet its needs by using private medicine. Mexico's indigenous peoples These make up more than one tenth of the population of Mexico and number 12 million in all. They live on (and own) one fifth of the national territory and make the greatest contribution to the nation's wealth1; examples of this are five of the country's major hydroelectric dams which are located in and draw their water from indigenous territories. In addition, 67% of the indigenous population are engaged in agriculture, while only 22% of the rest of the non-indigenous population work in this sector.2 Chiapas.- This State has a population of 3 920 8923 and is currently on one of the lowest rungs of the ladder so far as the health structure is concerned. It possesses great petroleum wealth, accounting for 21% of national petroleum production (Mexico is the fifth producer of petroleum in the world), at the same time Chiapas generates 55% of the national electricity output, plus that which is exported to Central America, produces 47% of the nation's gas, and is a producer of timber and agricultural produce. However, it is the state with the highest poverty and marginalization figures, particularly in those administrative areas with the highest indigenous populations. Approximately 30% of the total population are from the following ethnic groups: Tojolabales, Mames, Tzotziles, Tzeltales, Lacandones, Zoques and Choles, all of them of Maya stock, all of them with their own language, culture and religion, this native population is mainly concentrated in two regions: Altos and Selva. Structure of the health services in Chiapas 1 CDI National Commission for the Development of the indigenous peoples. cdi.gob.mx 2 Idem 3 Population census. National institute of Statistics, Geography and Informatics (INEGI) 2000. 2 Translated from Spanish The health infrastructure consists of 1,147 primary-level medical units and 38 second-level hospitals. There is a total of 1443 surgeries (i.e. roughly one per 2716 population.),and 2229 hospital beds (equivalent to one bed per 1759 population, far from the global indicator). In this case, in the same way as for the distribution of doctors, approximately 45% of units are concentrated in regions such as the centre and the coast4. One important indicator, given the degree of dispersal of the population, is the proportion of communities per local authority and primary medical unit; for example, the municipal authority of Palenque has within its boundaries 679 centres with a population of less than 5000 pop. and has 265 medical units; Ocosingo6 has 883 localities with a population of less than 5000 and 36 medical units, i.e. 25 localities per unit; where the population's conditions of access and mobility govern actual coverage, so that many localities remain virtually without any health services. The Zapatista Autonomous Health Care System (SSAZ) Historical background Health care has existed since the times of the ancient Maya peoples. Around the year 300 A.D., they had attained a significant level of development, expressed in the construction of ceremonial sites, the development of a form of writing based on hieroglyphics, development of medicine, mathematics, astronomy, the plastic arts, and a series of agricultural innovations. Between 600 and 900 A.D. these civilizations reached their greatest splendour in the Mayan world. Internal problems began, there was a population explosion, conflicts broke out between nobles and the military, and there were internal revolutions, all of which gave rise to a period of decline and to major migrations 4 Chiapas statistical yearbook 2005, health. data up to December 2004. www.finanzaschiapas.gob.mx. 5 Data from the Chiapas health institute, health jurisdictions, 2000. 6 Ocosingo is one of the country's largest municipal areas and, together with Palenque, is the largest in the North and Selva regions of the State of Chiapas. 3 Translated from Spanish towards Yucatan. By the year 1200 AD, collapse was inevitable and the cities were abandoned.7 This exodus left small indigenous populations which established themselves in other parts of Chiapas. It is these groups that survived and each passing generation reproduced a series of health care practices, through such personages as the curandero [healer] , hierbero [herb gatherer], pulsador [pulse taker], Ilol [physician], partera [midwife]. In more recent times, during the nineteen-fifties and nineteen-seventies, the indigenous population of Chiapas was still enduring the most unjust conditions, even though major changes had taken place in the post-revolutionary period, in relation to land tenure, in the case of Chiapas this had not occurred; the Indians were bonded serfs, trapped in a work cycle designed to keep them indebted for life, without many options and finding refuge in the Selva Lacandona jungle of Eastern Chiapas, thus occupying that area. During the nineteen-seventies and nineteen-eighties, there was a series of campaigns and protests, involving peasant organizations, cooperatives, associations, etcetera, which achieved great strength in calling for attention to the problems of the peasantry, particularly indigenous groups, notably land, trade, education and health.8 Against this background various social actors (the Catholic Church, NGOs, the universities, INI9) intervened in different areas, in which, where health is concerned, allopathic medicine was introduced, accompanied by methodologies aimed at transfer of knowledge so that the community could practise auto- medication.