Socio-cultural adaptations and public health techniques in the indigenous health perspective.

What was the problem to be investigated?

The baseline of the sociocultural and technical adaptations of the health programs for the indigenous peoples of Antioquia, Cauca, Nariño and Vaupés is not very encouraging. Nevertheless, it allows us to see the situation and make adjustments. For the research, key actors from territorial health directorates, EPS, IPS and indigenous organizations were interviewed, and it was found that the lack of adjustments, with the exception of what happens in indigenous institutions, is quite generalized. The current regulations that guide the socio-cultural adaptation of services and programs for these peoples are not being complied with and their fundamental rights are being affected. Binding guidelines with clear methodologies for their implementation and technical assistance and follow-up processes are required.

Indigenous population in Colombia

Colombia's indigenous population accounts for 3.43% of the total (1,392,623 people), distributed in 27 of the country's 32 departments. Colombia has 87 recognized indigenous peoples (102, according to ONIC) who speak 64 different languages and a diversity of dialects grouped into 13 linguistic families.

The State has signed international agreements aimed at eliminating racial discrimination, incorporating health as a right, strengthening prior consultation, and creating more inclusive and adequate health models available to indigenous populations. In 1991, the Colombian Constitution recognized the multiethnic and multicultural reality of the nation, granting indigenous peoples the right to govern themselves according to their ways of life and cultural systems, in coordination with the different sectors. Health legislation establishes mechanisms to guarantee that they enjoy the right to health framed in their cultural perspective and needs. Recently, the Intercultural Indigenous Health System (SISPI) was defined as a mechanism to guarantee the access of these peoples to the fundamental right to integral health.

However, indigenous peoples in Colombia have higher mortality and morbidity rates than their non-indigenous counterparts and have less access to health services, evidencing an imbalance between current legislation and its application. The sociocultural and technical adequacy in the provision of health services offered by the actors of the General Social Security Health System (SGSSS) to ethnic groups is fundamental in the resolution of their health needs and expectations according to their uses and customs.

What did we do?

We did a baseline survey of the socio-cultural and technical adaptation of public health programs for indigenous peoples in the departments of Antioquia, Cauca, Nariño and Vaupés.

What did we find?

Between 2011 and 2012, Sinergias built a general framework of the situation of sociocultural and technical adequacy of public health programs in Vaupés, Nariño, Cauca and Antioquia based on a literature review and individual or group interviews with institutional and social actors linked to public health programs and the issue of sociocultural adequacy, using an instrument designed by the Ministry of Health and Social Protection (MSPS). The instrument, with closed and open questions, had six thematic axes: human talent, prior consultation and agreement, programs and services, service provision, planning and insurance. In addition, we inquired about the progress made in each of the ten priority lines in public health.

In each department, we interviewed the departmental and 2 municipal territorial health directorates (DTS), 2 health service provider institutions (IPS) or state social enterprises (ESE), 2 subsidized health promotion companies (EPS-S) or indigenous (EPS-I) and at least one indigenous organization.

We built a framework proposal to contribute to the structuring of the sociocultural adaptation process, based on three dimensions: political, conceptual and operational.

With the exception of specific experiences, we found that departmental and municipal STDs are unaware of basic instruments such as prior consultation with the indigenous population, consider knowledge about the health of these populations to be mere curiosity and/or attach little importance to “cultural barriers”.

The ESE, responsible for the execution of public health actions, present similar dynamics but conceive “cultural barriers” as obstacles to be solved through “education”.

The IPS-Is showed variations when recruiting indigenous human talent, including “traditional physicians” and were similar in their acceptance of the sociocultural adaptation of services.

As for EPSs, differences were evident. Those of indigenous origin are more sensitive than others in the subsidized regime, with the former showing more adequate processes in the departments of origin.

Social and community organizations, especially in Cauca, recognize general guidelines on where to direct efforts, which include respecting prior consultation and agreement, as well as linking “own resources”, traditional medicine, among others, to health actions.

Multiple barriers were found (individual, socio-cultural and economic factors), institutional (organization of health services, administrative and management processes, supply of services, human talent) and structural (national and sectoral legislation and regulations, information systems, participation of other sectors) for the implementation of these processes.

Recommendations

Many indigenous communities, especially in dispersed rural areas, lack access to health services, affecting their fundamental rights. The current regulations that guide the sociocultural adaptation of services and programs are not being complied with.

In general, the four departments visited lack appropriate knowledge about the sociocultural adequacy of health services for the indigenous population, which contributes to the execution of certain contingent, asystematic and targeted actions to certain settlements and communities in response to specific needs.

The country has the obligation and the challenge of articulating and operationalizing health rights and for this it is essential to ensure that the key institutions of the SGSSS and the indigenous organizations themselves have the tools to facilitate the development of processes of adaptation of health services, programs and models.

In this sense, our framework proposal for the structuring of the sociocultural adequacy process based on the political, conceptual and operational dimensions is very useful in articulation with the developments proposed by the MSPS.