Melbourne School of Population and Global Health - Theses
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ItemModels of Indigenous community-controlled health care in Chile( 2019)For Indigenous peoples, community-controlled health services are a key means by which communities exert control in the planning, development and delivery of primary health care services and represent an avenue to ensure that health policy and services reflect Indigenous values and an understanding of their health needs. Sustainable implementation of community-controlled health services is strongly dependent on the existence of supportive policy, as well as a health system that is open, flexible and able to respond to external input. However, assessments of participatory health initiatives frequently examine the features of the initiative or program with minimal consideration of how the wider policy environment affects participatory processes. The current study examines the influence of local and distant factors on the effectiveness of Indigenous community-controlled health centres as participatory mechanisms, including interactions between international and domestic legislation and policy. Additionally, the research explored the applicability of lessons learned from countries’ experiences in Indigenous community participation in health to other international contexts. Case studies were undertaken with two Mapuche community-controlled health centres in Chile in order to gain perspective on the day-to-day workings and decision-making processes of the health centres. Interviews were also conducted with Ministry of Health personnel to provide a comprehensive picture of Indigenous health policy and stakeholders’ perspectives. Evidence from international experiences was then used to contextualise the Chilean findings and provide some guidance for strengthening Indigenous community participation in health both in Chile and internationally. Mapuche health administrators cited the existence of a wider system that was extremely resistant to external influence and ‘blind’ to Mapuche health as a key barrier to their work. As a result, Mapuche health centres were highly restricted in terms of their capacity to respond to local priorities and needs, even as staff considered the centres as potential vehicles for increased Mapuche political power within the health system. One of the primary aims of Indigenous community control, increased autonomy and self-determination, was thereby curtailed. Overall, the evidence indicates that international legislation alone carries little weight in facilitating consultation or engagement with Indigenous communities; however, these instruments can provide guidance to countries for the alignment of domestic policy with established principles. Such alignment both enables countries to adopt international agreements and subsequently facilitates implementation of the relevant principles and obligations. The research makes the case for approaches to Indigenous health policy that are undertaken with an eye towards building cohesion between legislation and policy across all levels to support engagement with Indigenous peoples. In conjunction with stronger political representation, incorporating the principles of reciprocal accountability into contractual agreements between the State and Indigenous health centres could support a shift towards relationships that are more equitable, provide greater stability for Indigenous health centres and facilitate increased latitude to respond to their communities’ needs appropriately. Analysis of Indigenous health policy, programs and services that takes a holistic perspective of the international, national and community-level factors impacting implementation would support decision-making in this area.