The Limits of Trust: The Millennium Development Goals, Maternal Health, and Health Policy in Mexico 9780773552500

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the limits of trust

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M c G ill - Q ue e n’s St ud i e s i n Ge n d e r, S e xual i t y, a n d Soc i a l J ust i c e i n t h e Glo bal S o u t h Series editors: Marc Epprecht, Rebecca Tiessen, and Habiba Zaman The twentieth century was a time of intense political, economic, social, and cultural change in the Global South. Continents were colonized, then decolonized. Millions of people relocated to cities, sought employment in new kinds of jobs, and experienced the effects of technological innovations and globalization. These changes have also reshaped the way that the people of Asia, Africa, and Latin America understand and experience gender and sexuality. In turn, gender roles and sexual ideologies have shaped political and economic changes. The McGill-Queen’s Studies in Gender, Sexuality, and Social Justice in the Global South series traces the changing conceptions of gender, sex, and sexuality in the developing world as well as the effects that these changes have had on politics, society, and social justice. Combining studies from a historical perspective with works focused on contemporary issues of social justice, this series welcomes publications from a variety of academic ­disciplines and backgrounds. At the heart of the series is a desire to raise awareness of forgotten histories and a range of topics including the intersections of gender, sexuality, and social justice in decolonization movements, sex work and questions about autonomy and agency, how gender constructs are shaped by economic, cultural, and religious conditions, and societies’ responses to violence, activism, health, youth cultures, and global change. This series will also illuminate LGB TQ issues and transgender politics in different cultural contexts and the ways in which gender roles and sexual hierarchies are produced, reinforced, and challenged at the state and local level. 1 Obligations and Omissions Canada’s Ambiguous Actions on Gender Equality Edited by Rebecca Tiessen and Stephen Baranyi 2 Resilience and Contagion Invoking Human Rights in African HI V Advocacy Kristi Heather Kenyon 3 The Limits of Trust The Millennium Development Goals, Maternal Health, and Health Policy in Mexico Lisa Nicole Mills

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The Limits of Trust The Millennium Development Goals, Maternal Health, and Health Policy in Mexico

lisa nicole mills

McGill-­­Queen’s University Press Montreal & Kingston • London • Chicago

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©  McGill-­­Queen’s University Press 2017 ISB N ISB N ISB N ISB N

978-0-7735-5108-4 (cloth) 978-0-7735-5109-1 (paper) 978-0-7735-5250-0 (eP DF ) 978-0-7735-5251-7 (eP UB)

Legal deposit fourth quarter 2017 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada.

We acknowledge the support of the Canada Council for the Arts, which last year invested $153 million to bring the arts to Canadians throughout the country. Nous remercions le Conseil des arts du Canada de son soutien. L’an dernier, le Conseil a investi 153 millions de dollars pour mettre de l’art dans la vie des Canadiennes et des Canadiens de tout le pays.

Library and Archives Canada Cataloguing in Publication Mills, Lisa Nicole, 1967–, author The limits of trust: the Millennium Development Goals, maternal health, and health policy in Mexico / Lisa Nicole Mills. (McGill-Queen’s studies in gender, sexuality, and social justice in the Global South; 3) Includes bibliographical references and index. Issued in print and electronic formats. ISB N 978-0-7735-5108-4 (cloth). – IS BN 978-0-7735-5109-1 (paper). – ISB N 978-0-7735-5250-0 (eP DF ). – IS BN 978-0-7735-5251-7 (eP U B ) 1. Maternal health services – Mexico.  2. Pregnant women – Services for – Mexico.  3. Pregnant women – Health and hygiene – Mexico.  4. Pregnancy – Complications – Mexico – Prevention.  5. Mothers – Mortality – Mexico – Prevention.  6. Millennium Development Goals.  7. Medical policy – Mexico.  I. Title.  II. Series: McGill-Queen’s studies in gender, sexuality, and social justice in the Global South; 3 RG963.M6M 55 2017   362.198200972   C2017-905619-0  C 2017-905620-4 This book was typeset by Marquis Interscript in 10.5/13 Sabon.

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A la memoria de Nellys Palomo Sánchez (1957–2009) Mujer luchadora y tejedora de puentes; to my dear friends, Jill and Lorena; and to the many men and women in Mexico who work tirelessly to prevent maternal mortality.

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Contents

Tables and Figures  ix Acknowledgments xi Abbreviations xv Introduction 3 1  Mexico and the Implementation of the Maternal Health Millennium Development Goal  33 2  Maternal Health and Health Sector Reform in Mexico  54 3  Guerrero: The Limits of the Local  90 4  Chiapas: The Challenges of NG O Collaboration  118 5  Oaxaca: The Impact of Doctors’ Mobilization  143 Conclusion 160 Notes 171 References 189 Index 219

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Tables and Figures

ta b l e s

2.1 Public spending on health according to social security status, 2000–12 (in 2012 US dollars)  69 2.2 State solidarity contributions to Seguro Popular revenues: “liquid” contributions and “credited” contributions by state, 2006–11 (in thousands of Mexican pesos)  75 2.3 Beds per thousand according to social security status, ­nationally and in selected states  77 2.4 Doctors and nurses in contact with patients per thousand according to insurance coverage, nationally and in selected states 79 2.5 Maternal deaths and maternal mortality ratio (M M R) in Mexico, 2002–12  85 2.6 Maternal deaths according to institutional affiliation, 2012 85 2.7 Location of death: distribution by percentage of maternal deaths according to place of death, 2012  85 2.8 Maternal mortality ratio (MMR) by state and nationally, 2010 86 figures

2.1 The Mexican health care system, 2010–11  56 2.2 Programs whose financing is deducted from the federal ­solidarity contribution (asf ) 74

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Acknowledgments

This book could not have been written without the generosity, ­hospitality, and support of many individuals and organizations in Mexico, Canada, and Australia. There are a number of individuals I have not named; I am no less grateful for their help. I first wish to thank the health professionals, N G O staff, policymakers and administrators, researchers, midwives, and parteras interviewed for this study, particularly those from CI E S AS , Coordinadora Guerrerense de Mujeres Indígenas, E CO S U R, Fundar, Health Jurisdiction 2 in Chiapas, Health Jurisdiction 6 in Guerrero, I M S S Oportunidades, I SE C H , K’inal Antzetik, Luna Maya Casa de Partos, the MacArthur Foundation, the SSO , and Ucizoni. Staff from ­Fundar and C IE SA S spoke to me on multiple occasions; I am grateful for their willingness to share their knowledge with me. The ­MacArthur Foundation was also very open to assisting me with the project. It  was thanks to Nellys Palomo Sánchez and the staff of K’inal ­Antzetik that I first travelled to Oaxaca and Guerrero; I am very grateful for the opportunity to observe their work, and to the parteras, parteros, and health promoters who graciously allowed me to be present at workshops and training sessions. Representatives from the Coordinadora Guerrerense de Mujeres Indígenas took me to villages in the Costa Chica, which enabled me to gain some understanding of the difficulties of getting transport to medical care, and of the need for services in the region. Similarly, I spent some time with doctors in the Los Altos region in Chiapas, and gained insight into the conditions under which they laboured. Ucizoni staff gave generously of their time, spending several days taking me to health clinics in the Istmo region; as did the health care workers from the

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xii Acknowledgments

Movement for Dignifed Health Care. Jonathan Kirsch from Doctors for Global Health took me to meet with doctors and administrators in Altamirano, Chiapas. In Chiapas, I stayed with Bela Wood for four months; I am grateful for her friendship, kindness, and great good humour … and for taking care of me when I was sick. Bela’s home was a haven of inspiring conversation about Mexico and Chiapas, from which I learned much, especially from Richard Stahler-Sholk and Vicki Lindsay. I’m also very thankful for the kindness and care of Manuela Gómez Méndez and Teresa Santíz Gómez. Thanks to Hepzibah Muñoz-Martínez and her family, with whom I stayed in San Luis Potosí, I was able to meet with researchers at the university there to discuss the project. I am grateful for Rawi Hage’s support in the early years of the research for this book; his daily phone calls to Mexico were an important source of sustenance. Reginaldo Gómez, Victor Meza, and Veronica Lares worked ­diligently to transcribe the Spanish-language interviews. Rebecca Bartlett of Carleton University Library Research Services produced the book’s map of Mexico. The fieldwork between 2004 and 2006 was made possible by a SSHR C 4A grant and a Carleton University / S S H RC G R6. Much of the first draft of this book was written while I was a visiting fellow at the University of Sydney’s Centre for Rural Health (U C R H) in Lismore, NSW, which provided a welcoming and supportive environment in which to work on the manuscript. I am particularly grateful to Lesley Barclay, Jo Longman, Margaret Rolfe, Judy Singer, and Shawn Wilson for their friendship and interest in my work. I am grateful to the staff at McGill-Queen’s University Press, especially Kyla Madden, who has been consistently encouraging; and to Scott Howard and Kathleen Fraser, for their careful work on the manuscript. The book has been greatly improved because of the careful reading and detailed responses of two anonymous reviewers. I deeply appreciate their work. Doris Buss also read early versions of the manuscript and made helpful suggestions, particularly on chapter 1. Rianne Mahon commented on an article in Social Politics on which chapter 1 is based, and her reading group on the politics of scale was an important forum for sparking ideas and discussion about the

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Acknowledgments xiii

project. Eloy Rivas Sánchez provided very helpful comments on an  early draft of chapter 2. Carleton University’s Gender Equality Measurement group also provided me with an opportunity to present my research and receive helpful feedback. I owe particular thanks to Katie Isbester, who always championed the project; kept in touch with me throughout the research; and urged me to keep going when I was discouraged. She also read and provided helpful comments on early drafts. While the advice of my colleagues and friends has been greatly appreciated, any errors or omissions in the book are my own. I appreciate the support and encouragement of my colleagues at Carleton University, especially Christina Gabriel, Laura Macdonald, Diana Majury, Pauline Rankin, Cristina Rojas, and Jennifer Stewart. I also wish to thank my family, Lorrie, Ros, and Shelley Mills, and Nicolás García Mills, for their love and support. Ros Mills generously gave me a home in which to write the final drafts of the book in 2015–16. Thank you to all my friends for their love, encouragement, and interest in the project, over many years, particularly Doris Buss and Jo Hodgson; Trish Flindall; Nancy Greenway; Donna James; Catherine and Peggy Lathwell; Justin Paulson; Rebecca Schein; Karin Schlapbach; Priscilla and Greg Smith; Susan Spronk; and Jill Wigle and Lorena Zárate. Thanks to Jo Estes and Cath Walker for laughter and good times in Oaxaca. I am especially grateful to Deborah Clipperton for helping me to start the project, and to Ilana Laps and Virginia Simonds for helping me finish it. Thank you all so much.

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Abbreviations

A C A SA C ACG A FA SPE

A IDEM A PPO A PV A SE A SF C A U SES

C B M C C ESC - DDS

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Asesoría, Capacitación y Asistencia en Salud A.C. (Advice, Training, and Assistance in Health) Asosiación Cívica Guerrerense (Guerrero Civic Association) Acuerdos para el Fortalecimiento de las Acciones de Salud Pública en los Estados (Agreements for the Strengthening of Public Health in the States) Análisis Inmediato de las Defunciones Maternas (Immediate Analysis of Maternal Deaths) Asamblea Popular de los Pueblos de Oaxaca (Popular Assembly of the Peoples of Oaxaca) Arranque Parejo en la Vida (An Equal Start in Life) Aportación Solidaria Estatal (state solidarity contribution) Aportación Solidaria Federal (federal solidarity contribution) Catálogo Universal de Servicios Esenciales en Salud (Universal Catalogue of Essential Health Services) Cuadro Básico de Medicamentos (basic set of medicines) Centro de Capacitación en Ecología y Salud para Campesinos y Defensoría del Derecho a la Salud (Training Centre in Ecology and Health for Peasants and Defendor of the Right to Health)

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xvi Abbreviations

C DI

C F C G MI C IESA S

C IMA C

C ISC C N DH C N EG SR

C N PSS

C OC EI

C OC OPA C ON A ME D C ON A PO Coneval

C OPLA M A R

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Comisión Nacional para el Desarrollo de los Pueblos Indígenas (National Commission for the Development of Indigenous Peoples); previously known as the National Indigenous Institute, I N I Cuota Familiar (family contribution) Coordinadora Guerrerense de Mujeres Indígenas (Guerrero Indigenous Women’s Organization) Centro de Investigaciones y Estudios Superiores en Antropología Social (Centre for Research and Advanced Study in Social Anthropology) Comunicación e Información de la Mujer (N G O that publishes news about the status of women from a gender and human rights perspective) Centro de Investigaciones en Salud de Comitán (Comitán Centre for Research in Health) Comisión Nacional de los Derechos Humanos (National Human Rights Commission) Centro Nacional de Equidad de Género y Salud Reproductiva (National Centre for Gender Equity and Reproductive Health) Comisión Nacional de Protección Social en Salud (National Commission for Social Protection in Health) Coalición Obrero Campesino Estudantil del Istmo (Coalition of Workers, Peasants and Students of the Istmo) Comisión de Concordancia y Pacificación (the Commission for Harmony and Pacification) Comisión Nacional de Arbitraje Médico (National Commission of Medical Arbitration) Consejo Nacional de Población (National Population Council) Consejo Nacional de Evaluación de la Política de Desarrollo Social (National Council for the Evalaution of Social Development Policy) Coordinación General Del Plan Nacional de Zonas Deprimidas y Grupos Marginados (National Program for Depressed Areas and Marginalized Groups)

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Abbreviations xvii

C PMSR C S C SG DF DG E DIF EC OSU R EmOC EN SA N UT EZ LN FA FOMU N

FA IS FA SSA FC S FOC A FPG C

FPP Frayba

FU N SA L UD

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Comité Promotor Por Una Maternidad sin Riesgos (Safe Motherhood Committee) Cuota Social (social contribution) Consejo de Salubridad General (Public Health Council) Distrito Federal (Federal District) Dirección General de Epidemiología (General Directorate of Epidemiology) Desarrollo Integral de la Familia (Integrated Family Development) El Colegio de la Frontera Sur (College of the Southern Border) emergency obstetric care Encuesta Nacional de Salud y Nutrición (National Health and Nutrition Survey) Ejercito Zapatista de Liberación Nacional (Zapatista Army of National Liberation) Fondo de Aportaciones para el Fortalecimiento de los Municipios y el D.F. (Fund for the Strengthening of Municipalities and the Federal District) Fondo de Aportaciones para la Infraestructura (Fund for Social Infrastructure) Fondo de Aportaciones para los Servicios de Salud (Fund for Allocations for Health Services) Fondo de Comunidades Saludables (Healthy Communities Fund) Formación y Capacitación A.C. (Formation and Training Group) Fondo de Protección Contra Gastos Catastróficos (Fund for Protection Against Catastrophic Expenses) Fondo de Previsión Presupuestal (Fund for Budgetary Preparedness) Centro de Derechos Humanos Fray Bartolomé de Las Casas (Human Rights Centre, Fray Bartolomé de las Casas) Fundación Mexicana para la Salud (Mexican Foundation for Health)

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xviii Abbreviations

G A TT G IR E

IA DB IB R D IFI IMSS IN EG I IN I IN SP IPPF ISI ISSSTE

MA IS MDG s MMR N A FTA OEC D OMM PA C PA N Pemex Posadas AME

PR D PR I

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General Agreement on Tariffs and Trade Grupo de Información en Reproducción Elegida (Group for Information on Reproductive Choice) Inter-American Development Bank International Bank for Reconstruction and Development international financial institution Instituto Mexicano del Seguro Social (Mexican Social Security Institute) Instituto Nacional de Estadística y Geografía Instituto Nacional Indigenista (National Indigenous Institute) Instituto Nacional de Salud Pública (National Institute of Public Health) International Planned Parenthood Federation import substitution industrialization Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (Institute of Security and Social Services for Government Workers) Modelo de Atención Integral a la Salud (Integrated Health Care Model) Millennium Development Goals maternal mortality ratio North American Free Trade Agreement Organisation for Economic Co-operation and Development Observatorio de Mortalidad Materna en México (Observatory of Maternal Mortality) Programa de Ampliación de Cobertura (Program to Extend Coverage) Partido Acción Nacional (National Action Party) Petróleos Mexicanos (Mexican Petroleum) Posada para la Atención de la Mujer Embarazada (Guest House for the Care of Pregnant Women) Partido de la Revolución Democrática (Party of the Democratic Revolution) Partido Revolucionario Institucional (Institutional Revolutionary Party)

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Abbreviations xix

Prodh

Prog r e sa

Pron aso l PT PV EM R EPSS

Sedena Sedeso l SEG OB Semar SHC P SIC A LIDA D SMN G SN TE

SN TSS

SPSS SSA SSF SSO

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(Centro de) Derechos Humanos Miguel Agustín Pro Juárez (Miguel Agustín Pro Juárez Human Rights Centre) Programa de Educación, Salud y Alimentación (Education, Health and Nutrition Program); renamed Oportunidades in 2001 Programa Nacional de Solidaridad (National Solidarity Program) Partido de Trabajo (Workers’ Party) Partido Verde Ecologista de México (Mexican Green Ecologist Party) Regimenes Estatales de Protección Social en Salud (State Regimens for Social Protection in Health) Secretaría de la Defensa Nacional (Ministry of Defence) Secretaría de Desarrollo Social (Ministry of Social Development) Secretaría de Gobernación (Secretary of the Interior) Secretaría de Marina (Ministry of the Navy) Secretaría de Hacienda y Crédito Público (Ministry of Finance and Public Debt) Sistema Integral de Calidad en Salud (Comprehensive System of Quality in Health) Seguro Médico para una Nueva Generación (Medical Insurance for a New Generation) Sindicato Nacional de Trabajadores de Educación (National Union of Education Workers) Sindicato Nacional de Trabajadores del Sector Salud (National Union of Health Sector Employees) Sistema de Protección Social en Salud (System for Social Protection in Health) Secretaría de Salud (Ministry of Health) Seguro de Salud para la Familia (Family Health Insurance) Secretaría de Salud de Oaxaca (Oaxaca Ministry of Health)

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xx Abbreviations

SWA P TLC A N

UAA Ucizoni

U MR U N A M U N DP U N FPA U N IC EF U N R ISD WHO

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sector-wide approach Tratado de Libre Comercio de América del Norte (North American Free Trade Agreement, or NA F T A ) Unidades de Atención Ambulatoria (ambulatory care units) Unión de Comunidades Indígenas de la Zona Norte del Istmo (Union of Indigenous Communities of the Northern Zone of the Istmo) unidades medicales rurales (rural medical units) Universidad Nacional Autónoma de México (National Autonomous University of Mexico) United Nations Development Program United Nations Population Fund United Nations Children’s Fund United Nations Research Institute on Social Development World Health Organization

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Map by Rebecca Bartlett. The map was created using Q G I S 2.18.8 and the following datasets: Populated Places (1:10 million), Admin 0 – Countries (1:50 million).

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the limits of trust

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Introduction

There was a woman who died in childbirth in Los Altos [the central highlands of Chiapas]. She had attended all of her prenatal consultations, and lived ten minutes from a health clinic. Her husband attended the consultations with her. She gave birth at home attended by the partera (traditional midwife).1 The baby was born prematurely, and the woman suffered from uterine atony [in which the uterus does not contract normally after the ­delivery of the baby and placenta, usually leading to postpartum haemorrhage]. So, she haemorrhaged. Because her home had a dirt floor, the blood disappeared into the floor and the extent of the bleeding wasn’t ­noticed immediately. The family called the doctor, who arrived in 10 minutes, but the woman was already dying. On the death certificate, the doctor certified the cause of death as gastrointestinal cancer. The other researchers and I heard about this because one of the health promoters2 told us that a woman had died. And we asked her, was she young? And when she said yes, we went to talk to the family to determine whether this was a maternal death. Her husband told us the whole story, and we asked for the death certificate, which had the doctor’s signature on it, and we took a photograph of it. We went to the clinic to talk to the doctor, explaining that we wanted to understand what had happened. There was no oxytocin in the clinic. There was no ergometrine [drugs which may be used to control postpartum haemorrhage]. We asked if we could see the woman’s file, but there was no trace of her. And the doctor almost cried, and said when a woman dies they point you out, you’re stigmatized, because you’re the doctor that killed a woman! You were the one who was there when the woman died. There’s a lot of pressure on primary care doctors. … It’s unforgiveable that the clinic didn’t have oxytocin. It costs 10 pesos [about US$1]; not to have it is a crime. (Interview, C IESA S-1 2008b)

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4

The Limits of Trust

I heard this story from a researcher who was investigating maternal mortality in the state of Chiapas, Mexico. The event described occurred in 2008. It encapsulates a number of problems with maternal health in the state. Although it seemed that everyone in the health sector, from Ministry of Health bureaucrats to doctors in local clinics, was aware of the problem of maternal mortality and the importance of combatting it, if the health care system3 itself does not have sufficient resources or qualified staff to address the issue, there is a risk that maternal deaths will be covered up rather than prevented. This case also indicates a lack of trust inside of the health care system: the doctor, who may not have been able to do anything to prevent this particular woman’s death, was sufficiently afraid of his colleagues’ reaction to disguise the cause of death and destroy the evidence of his consultations with her (although there was no risk of legal sanction). By covering up the cause of death, the doctor undermined not only the validity and legitimacy of the health system’s records, but the possibility for individuals to place trust in the competence and honesty of the doctors, and ultimately in the system itself. The fifth Millennium Development Goal – M D G -5 – aimed by 2015 to reduce the maternal mortality ratio4 (M M R ) by 75 per cent from 1990 levels (Hogan et al. 2010, 1609). Since then, the international community and developing country governments have accorded more attention to this issue (Victora et al. 2016; Waage et al. 2010). During the interviews with doctors and Ministry of Health officials in Mexico about improving maternal health, everyone I spoke to mentioned the M D G s as a motivating factor. When the M D G s were announced in 2000, approximately half a million women worldwide died each year from complications associated with pregnancy and childbirth;5 the most recent survey suggests that this number has fallen to approximately 303,000 each year (W H O 2015, ix). The most common causes of death are haemorrage, sepsis, unsafe induced abortion, hypertensive disorders of pregnancy, and obstructed labour (Maine et al. 1997, 4). Although women both in the Global North and South may experience these complications, in  the Global North women are much more likely to have them resolved promptly and effectively by the health care system (Freedman et al. 2004). Mexico was one of the 189 countries that committed to the M D G s, and it is also one that did not reach M D G -5 by 2015. In 1990,

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Introduction 5

Mexico had an MMR of 90 per 100,000 live births; in 2013, this number had fallen to 31.7 per 100,000 live births (S S A 2015a, 2). Mexico is an O E C D nation, and although its M M R is much lower than countries in Sub-Saharan Africa and south Asia, the chance of a woman dying from a pregnancy-related complication is still five times higher than that of countries in the Global North (Norandi 2010, 41). National statistics also mask deeper problems in different regions of  the country.6 The southwest region encompassing the states of Chiapas, Oaxaca, and Guerrero has the highest M M R in Mexico.7 It is also the region with the largest number of Indigenous peoples8 and the highest levels of poverty and marginalization (Freyermuth Enciso 2012).9 Both the Mexican government and Mexican non-governmental organizations (NGOs)10 have implemented a number of strategies to reduce maternal death since the MDG s.11 During the administration of President Vicente Fox (2000–06), whose election brought an end to seventy years’ rule by the Institutional Revolutionary Party (P RI ), the minister of health established a new policy to address maternal and infant health. Arranque Parejo en la Vida (AP V – An Equal Start in Life),12 established in 2001, established local-level projects to build linkages between communities, parteras (traditional midwives), and the health care system in rural areas. The effort to link remote villages to the system through networks of parteras and health promoters was not new; programs to do this have been implemented since the 1970s. What was different this time, however, was that federal and state governments began to collaborate with N G O s to form these connections, and the connections were intended not just to promote family planning programs, but to facilitate the use and monitoring of the health care system. The Equal Start program also required that all maternal deaths, whether in the public or private health care system, be immediately reported to the federal Ministry of Health (G T R 2014, 7). This ministry established a group (A I DE M – Immediate Analysis of Maternal Death) to identify where problems in the health care system resulting in a maternal death occurred. The minister of health, Julio Frenk, introduced a health insurance scheme entitled Seguro Popular (Popular Insurance), for those who did not have health coverage with the existing social security institutes (roughly half the population). Seguro Popular was intended to democratize the health care system and expand access to care for the most marginalized (S S A

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6

The Limits of Trust

2001), thereby providing access to heath care during pregnancy and birth for those previously denied it. Feminist N G O s in Mexico have also developed programs focusing on improving maternal health. A number of organizations in southwest Mexico have received funding from the Chicago-based MacArthur Foundation – which began prioritizing maternal health program funding in 2000 in response to the M D G s – to undertake research, advocacy, and community-building work in maternal health. The Mexican government’s stated commitment to the M D G s, and the availability of funding for maternal health projects, has provided N G O s with the discursive and material resources to advocate for better maternal health care. Both N G O s and the Mexican government have implemented strategies that depend for their effectiveness on building or strengthening trust in communities, and between communities and the health care system. In this study, I ask: How has MD G-5 been implemented in Mexico? How has its implementation been experienced by those individuals and groups working to reduce maternal mortality, especially in poor regions where mortality is high? In implementing policies and strategies to improve maternal health, what obstacles have been encountered, and what factors have facilitated improvements in maternal health? I have focused on the states of Guerrero, Chiapas, and Oaxaca, because these were the states in which, at the time of my research, NGOs and governments were collaborating to implement maternal health programs.13 These were also the states with the highest MMR s in Mexico, which was one of the reasons why maternal health advocacy organizations had developed there, particularly in Chiapas and Oaxaca, in the 1980s and 1990s. After the announcement of the MDGs in 2000, the US-based MacArthur Foundation focused its project financing on maternal health, and, in Mexico, on these three states. This meant that organizations in the region had funding to strengthen and expand their maternal health work. Both N G Os and governments in the region were engaged in building trust networks linking the communities they serviced to the health care system. In analyzing the data from interviews with N G O s, government officials, and health care workers, I examine the degree to which mechanisms that facilitate trust in the health care system were strengthened or developed through the implementation of N G O and federal government strategies. I argue that, although building trust at the local level is critical, especially in regions where there are cultural, linguistic, and geographic

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Introduction 7

barriers to the use of health care services, trust cannot be established locally unless the health care system itself warrants generalized trust – that is, unless the system has the technical and institutional capacity to ensure quality of care. In each of the three states, there were problems with the supply of infrastructure, medical provisions, and skilled personnel. The desire to avoid maternal death, in a context in which providers may not have the skills or resources to deal with obstetric emergencies, results in a system with little trust between health care workers and the agencies that they interact with. While the technical and institutional dimensions of health care are important here, the interpersonal dimensions of care are also critical. Women need care that is respectful of their rights and dignity, over and above being technically competent. While the introduction of Seguro Popular has expanded the accessibility of the public health care system14 for the uninsured population – who, in the 1980s and 1990s, had to pay user fees to access it – the availability and quality of maternal health care services is much lower in the public health care system, which undermines both maternal health outcomes and trust in public health care. Women who have health insurance coverage through Seguro Popular, rather than one of the social security institutes, are much more likely to die during pregnancy or childbirth. The legacy of the neoliberal15 policies of the 1980s and 1990s, insufficient investment, and the nature of federal-state fiscal arrangements has limited the potential for a positive transformation of the health care system for the poor. This study contributes to several bodies of literature. First, I contribute to the literature on M D G -5, by exploring how the implementation of this goal at the local level depends on the existence of a health care system that ameliorates inequality rather than reproduces it. In the Mexican case, although the introduction of Seguro Popular has improved health care access, ongoing issues with the technical and cultural competency of care must be addressed in order for the system to generate trust among health care workers and users. I also consider how the introduction of regimes to measure progress toward reaching M D G -5 have affected maternal health policy and practice on the ground. Second, I contribute to the literature on trust, health care, and welfare regimes. The literature on trust argues that systems which provide universal benefits and promote goals of social solidarity are more likely to generate trust than segmented and targeted systems. My research supports this argument, but also emphasizes that generating trust requires the

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The Limits of Trust

provision of care that is respectful of differences in gender and culture, as well as accessible regardless of class. It contributes to this literature by examining how broader, macro-level inequalities are experienced at the local level. Policies and strategies to address poor health outcomes that result from poverty, inequality, and discrimination run up against the ways in which these forms of inequality are reproduced in the health care system, undermining the possibility for successful policy implementation. Finally, I hope to provide insights about the role of N G O s in development. In the context of the developing world’s debt crises of the 1980s and 1990s, the international financial institutions (I F I s) promoted N G O s as an alternative source of welfare provision. A number of authors have criticized N G O s for participating in this agenda and thereby furthering the I F I s’ neoliberal policy prescriptions. Recently, however, some feminist authors have come to the defence of N G O s, arguing that at least they are more connected with anti-neoliberal social movements than the State.16 I argue that in the cases I examine, feminist N G O s have been important advocates for poor and Indigenous women’s right to appropriate care in pregnancy and childbirth, and that this advocacy is necessary given the failings of the health care system, particularly in poorer states. While N G O s’ long-term relationships with the communities where they work means that they are likely to be trusted by their members, N G O s nevertheless cannot compensate for State failures to provide adequate care, and the organizations themselves recognize this. In the reminder of the introduction, I will provide an overview of MDG -5 and its origins in the feminist movement for reproductive rights in the 1990s; outline the concepts of trust and health care that will guide my analysis; and briefly review the relevant literature on N G Os and the State. I will also provide an introduction to the N G O s discussed in the book, and the donor organization for the majority of them, the MacArthur Foundation. Finally, I will provide an overview of the book chapters. the context: the origins of mdg-5

The inclusion of maternal health among the M D G s was both a triumph and a failure for the international women’s health movement, which had campaigned for women’s reproductive rights from the 1970s. On the one hand, the inclusion of the maternal health goal

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Introduction 9

meant that one aspect of women’s reproductive health was recognized, and governments were obligated to improve it. On the other hand, MD G-5 was considerably narrower than the goal of reproductive health and rights for which women’s health advocates had been fighting for at least two decades – and which had been codified in the Programme of Action at the International Conference on Population and Development in Cairo (Cairo Conference) in 1994 and the Platform for Action of the Fourth World Conference on Women in Beijing (Beijing Conference) in 1995. The women’s health movement of the 1970s and 1980s was influenced by the concerns of NGOs and social movements from both the global North and South. While Northern advocates emphasized women’s right to reproductive autonomy and access to contraception, those from the South underscored the need to be free from coercive population policies which imposed (sometimes inappropriate) contraceptive methods. Women’s groups in the South also began to address the issue of maternal mortality and morbidity in the developing world, where, until the late 2000s, approximately half a million women a year died in pregnancy and childbirth (Petchesky 2003, 3–4). In Mexico, activists and researchers began working on maternal health in Chiapas in 1985 (Interview, ACAS AC-1 2004).17 In 1987, the Women’s Global Network for Reproductive Rights and the Latin American and Caribbean Women’s Health Network decided to launch the Campaign for the Prevention of Maternal Morbidity and Mortality at the first International Day of Action for Women’s Health in 1988 (L A C WH N 2011). The same year, U N agencies began collaborating on the maternal health issue: the World Health Organization (WH O) and a number of other agencies18 sponsored the Safe Motherhood conference in Nairobi, Kenya, which led to the creation of the Safe Motherhood Initiative and Inter-agency Group (Starrs 2006, 1130).19 The director-general of the W H O , Halfdan Mahler, argued that the problem of maternal mortality and morbidity had only recently been brought to light because countries with high rates of maternal death often had not registered the deaths, let alone their causes; however, since 1974, community-level surveys in ten countries had uncovered the extent of the problem. Mahler also declared that the situation was a consequence of women’s powerlessness. Maternal mortality “has been a neglected tragedy; and it has been neglected because those who suffer it are neglected people, with the least power and influence over how national resources shall

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The Limits of Trust

be spent; they are the poor, the rural peasants, and, above all, women” (Mahler 1987, 668). In the wake of the international conference, María Carmen Elú established a Safe Motherhood ­ Committee (C P MSR ) at the national level in Mexico. A conference on maternal health took place in Chiapas in 1998, leading to the formation of a state-level Safe Motherhood Committee (Interview, A C A SA C -1 2004). The two strands of feminist thought and advocacy, on maternal health specifically and reproductive health more broadly, were united at the 1994 Cairo Conference (Petchesky 2003, 35; Roseman 2009, 94). Cairo brought about a paradigm shift in which the concept of population control was replaced with that reproductive rights: states agreed that having the capacity to exercise control over one’s fertility without coercion, to enjoy a safe sex life, and to have access to health care services allowing a safe and healthy pregnancy and delivery constituted a human right which they had an obligation to fulfill.20 Paragraphs addressing the right to choose freely and responsibly whether to have children, how many to have, and over what period of time were accompanied by articles outlining the problem of maternal mortality in the developing world. Paragraph 8.19 notes that approximately half a million women per year die during pregnancy or childbirth; that these women live predominantly in the developing world; and that there is a huge gap between the risk incurred in developed and developing countries for childbearing women (I C P D 1994). The Cairo and Beijing conferences also framed the issues of reproductive rights, health, and population as deeply connected with gender inequality. Women’s inability to control their own fertility, or to get access to adequate reproductive and maternal health care, was understood as a fundamental part of the curtailment of women’s autonomy and well-being in general. Furthermore, gender equality was understood to be not only essential for addressing the problem of maternal mortality and morbidity and the failure to fulfill reproductive rights, but also as necessary for development. Principle 4 stated: “Advancing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women’s ability to control their own fertility, are cornerstones of population and development-related programmes. The human rights of women and the girl child are an inalienable, integral and indivisible part of universal human rights” (IC PD 1994).

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Introduction 11

While the conferences brought about a dramatic shift in population policy, feminist advocates failed to achieve their aims on abortion rights, which were not recognized in the Cairo or Beijing documents.21 Although the documents had not gone nearly as far on  questions of abortion and sexual rights as many feminist and Southern advocates would like, a backlash against the recognition of reproductive rights was underway even before the Beijing conference (Petchesky 2003, 51). This backlash meant that the reproductive health goal was dropped from the M D G s. The omission was partially rectified in 2007, when, as a result of a campaign launched by the International Planned Parenthood Federation, and the recommendation of task forces commissioned by the Millennium Project,22 a target of universal access to reproductive health services was incorporated into MDG-5 (as Target 5b) (W H O 2011b, 4; Bernstein and Edouard 2007, 187). In the Mexican case, the existence of the M D G s meant that there has been an explicit focus on maternal health rather than reproductive health more generally.23 Maternal health N G O s, however, have continued to emphasize sexual and reproductive rights in their work, which differentiates the approach they take to working with parteras and health promoters from the approach of state governments in the region, who have focused on family planning as a means of demographic control rather than as the fulfillment of human rights (C NDH 2002; G I RE 2015). t r u s t a n d h e a lt h c a r e

As I will explain further in chapter 1, maternal health – particularly the provision of care in an obstetric emergency, such as haemorrage or eclampsia – depends on the existence of a well-functioning health care system. This functioning is a product of, and reinforced by, mechanisms which increase trust (Gilson 2003). The importance of trust was something that emerged from interviews with N G O s, doctors, public officials, and researchers working on maternal health. The sentence “the women don’t have confidence in the system” (las mujeres no tienen confianza en el sistema) came up repeatedly. In analyzing the interviews, I have drawn on concepts of trust and its importance to the health care system from Gilson (2003), Freedman et al. (2004), and Birungi (1998), as well as ideas about trust developed by Tilly (2005, 2007), Giddens (1990), Levi (1998), and Cohen (1999). I have conceptualized the linkages between pregnant women and the health care system via parteras and health promoters as trust

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The Limits of Trust

networks. According to Tilly (2005, 4), a trust network connects a number of people through similar ties; enables individuals connected by these ties to call on each other for assistance; and places them, along with the group as a whole, at risk with respect to the intentional or unintentional mistakes and failures of its members. The element of risk is critical to trust, which exists in the context of a relationship in which “at least one party places valued enterprises at risk to the errors, failures, or malfeasance of another party” (Tilly 2007, 94). In the case of maternal health, the valued enterprise is the birthing woman’s own life and health. In trusting the partera – or, in the case of projects connecting her to the health care system, the system itself – with her care during pregnancy, abortion, or childbirth, a woman puts her life at risk to the errors or negligence of others. While their lives are the most significant thing risked, women may also risk their bodily integrity, dignity, and right to treatment free from abuse and discrimination. For Tilly, democracy depends on the partial integration of trust networks with the State. Complete integration occurs in the case of totalitarian governments, under which social networks are completely dominated by the State and lack the option of withdrawing their consent from public programs; complete autonomy from public politics, however, means that groups are unable to influence policy and may be subject to nongovernmental forms of domination (Tilly 2007, 88). The integration of networks of parteras, volunteer health promoters, and families with government health services as part of maternal health policy implementation can be seen as an example of partial integration, particularly when NGOs act as intermediaries between the State and community trust networks. There are two forms of trust that are most relevant to my study: generalized trust, or trust in institutions; and interpersonal trust,24 or trust between individuals (Gilson 2003, 1457 and 1459). Generalized trust is the “belief in the legitimacy of institutionalized norms, acceptance of the universalistic principles of reciprocity and societywide social solidarity, and confidence that these will orient the action of both powerful elites and average citizens” (Cohen 1999, 220). Society-wide trust in an institution, therefore, depends on a belief that the institution operates to meet the needs of its citizens and that these needs are met without discrimination on the basis of gender, ethnicity, race, religion, or class – what Tilly (2007) would call “categorical inequalities.” In a capitalist society, Tilly

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Introduction 13

suggests, categorical inequalities are unavoidable; however, generalized trust emerges when democratic politics demands that public politics, and decision-making about public policy, is insulated from these categorical inequalities (2007, 96). That is, although inequalities continue to exist, politics is democratic to the extent that it does not reflect and reproduce these inequalities, but challenges and ameliorates them.25 Interpersonal trust “involves not only the experience of the other’s reliability, but also the moral obligation of the trusted person to honour the trust bestowed upon her” (Cohen 1999, 221). In the case of health care institutions, there is a reciprocal relationship between interpersonal trust and generalized trust. Our belief that the health care system has our welfare at heart leads us to trust in individual health care providers; a positive experience with these providers will, in turn, reinforce our trust in the institution (Gilson 2003, 1458). The patient / provider relationship is shaped by institutions within the health system (which may also encourage or discourage generalized trust). Three institutions are key, according to Gilson: professional and ethical codes and licensing systems; funding arrangements; and the organizational environment, particularly the network of relationships between providers and other actors in the system (1459). Licensing systems and ethical codes foster trust in  the competence, honesty, and conscientiousness of health care providers. Institutions’ capacity to instill trust through the licensing, monitoring, and disciplining of actors depends upon the possibility of questioning adherence to the values on which the institution is based. Trust, therefore, is only meaningful if it can be withdrawn; it is precluded by compulsion or dependency. In this sense distrust, as well as trust, is necessary for the flourishing of democracy, which depends on “contingent consent” – order that is based on the willingness of the governed to adhere to rules, but only within limits determined by the governed themselves (Tilly 2007, 94; Levi 1998). Funding arrangements may influence trust at two levels. On one level, patients’ trust in providers is fostered if they know that the providers’ decisions about their treatment have not been influenced by financial considerations, but have been made in accordance with the best interests of the patient (Gilson 2003, 1459). At another level, financing mechanisms “may also demonstrate norms or values, such as solidarity, fairness and procedural justice … that promote trust in the system within which providers are located” (1459). A

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The Limits of Trust

universally accessible health care system may therefore inspire more trust than a targeted one; a system which provides services according to need, rather than the ability to pay, will be more respected than one in which these priorities are reversed. Universalism also enhances citizens’ trust in the legitimacy of the State. Whereas targeted and means-tested programs entail a level of bureaucratic intrusion that stigmatizes the recipients and undermines their sense of autonomy, the principle of equal treatment expands individuals’ autonomy and may expand their perception that opportunities are equally available to them. Targeting, however, reinforces existing class and racial divisions in society, thereby reducing the possibilities for generalized, as opposed to in-group, trust. For Rothstein and Uslaner (2005, 44), although universal social programs create the possibility for greater equality of outcomes and opportunities, it is equality of outcomes which is at the start of the causal chain; universal programs are more likely to exist in more equal societies. Or, as Lindert (2004, 15) observes, “history reveals a ‘Robin Hood paradox’ in which redistribution from rich to poor is least present when and where it is most needed.” Universal social programs are more likely to have long-term redistributive effects because of their political consequences. Political support for welfare benefits depends upon the formation of a cross-class coalition between the working class (or the poor) and the middle class. Targeted policies, on the other hand, create conflicts between the extremely poor, who receive benefits, and the moderately poor, who contribute to those benefits through the taxation system but do not receive them (Korpi and Palme 1998, 672). Directing welfare payments and services toward the most marginalized in the interests of efficiency therefore undermines the possibility for cross-class coalitions, and so undermines the possibility for longterm support for the welfare state. The size of the budget available for redistribution is not fixed, but is instead an outcome of the degree of support for the welfare state. “The greater the degree of low-income targeting, the smaller the redistributive budget” (663). Targeting also limits the pooling of risks and resources. In the case of health care, universal programming enables the sharing of risk across socioeconomic groups, whereas targeted programs separate people with lower socioeconomic status, higher risk profiles, and lower levels of resources from higher socioeconomic status groups who have both more resources and less need for them (671).

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Introduction 15

Finally, there are two sets of networks that influence the development of patient / provider trust: the network of relationships between government departments and agencies that support the health care system, and a network spanning private and public providers. The networks in which the system is embedded also may help to build a  foundation for interpersonal trust. These include the network between public health systems and other public institutions, and within the public and private segments of the health care sector and their funding bodies. As Gilson (2003, 1460) notes: “The way the networks function determines not only whether individual providers have the range of resources necessary to provide care, such as drugs, equipment and access to referral services, but also the way they provide care, the range of services they offer and people they seek to serve.” m e x i c o ’ s h e a lt h r e f o r m a n d l at i n a m e r i c a n s o c i a l p o l i c y

Since the 1980s, Mexico has been through a series of health sector reforms, which have had an impact on the system’s degree of universality and hence its capacity for generating trust. The most recent reform – the introduction of Seguro Popular, providing basic health care coverage to the uninsured segment of the population – has been layered over the existing structure of welfare provision, which is bifurcated. Mexico, like other Latin American countries, has high levels of poverty and inequality and low levels of social protection (Filgueira 2005, 9; Huber and Stephens 2010, 159). In the absence of a social policy system strong enough to warrant the title of “welfare state,” Filgueira (2005, 10) identifies three forms of “social state”:26 stratified universalistic, in which everyone has access to basic services, but only a segment of the population can count on more extensive and / or better quality welfare provision; dual regimes, in which some groups and / or regions have access to health care and other social protections while others are excluded; and exclusionary regimes, in which the majority of the population do not have any social benefits. In this typology, Mexico was best classified as a “dual regime” until the 1990s, after which it could be classified as a hybrid between a dual regime and an “egalitarian exclusionary basic protection state” (10). The dual regime, in the Mexican case, accompanied an import substitution industrialization (I SI ) development model. The latter

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The Limits of Trust

facilitated economic growth, the development of a formal labour market, and urbanization. The social policy regime that evolved in tandem provided social security coverage to workers in the formal sector, gradually extending these protections to more of the population over time as this sector expanded in the post–World War II era. While some regions and groups were integrated into a corporatist27 system that provided them with protections and benefits in return for their political support, others were excluded from formal markets and their associated forms of protection and relied on connections to local elites for security (Filgueira 2005, 25). The corporatist model limits risk-pooling by excluding those who are unemployed or outside of the formal labour market, and reinforces the distinctions between groups (Korpi and Palme 1998, 671). Those who benefit from corporatist institutions contribute to their maintenance and are therefore concerned about any diminution of benefits that may occur if the institutes’ services were made available to noncontributing members. The corporatist model, therefore, “highlights socio-economic distinctions among different categories of citizens and creates divergent interests among these categories” (682). Latin American corporatism was gendered, in that it was male-dominated trade unions who benefitted more from entitlement systems, whereas women were more likely to work in low-paid, unorganized, and informal sectors of the workforce (Molyneux 2007, 6). Women’s entitlements were also dependent on their class, social, and spatial location, as well as their relationship to a male breadwinner (4). In the Mexican case, the social security system provides health care, along with other social services, to the 48 per cent of the population employed in the formal sector and their dependents (I M S S 2014, 7). The largest social security system is the Mexican Social Security Institute (I MSS), which covers private-sector workers; there is also the Security and Social Services Institute for State Employees (ISSSTE) for public sector staff, as well as institutes for those employed by the State oil company (Pemex), or by the military. A slightly greater proportion of men have I M S S social security coverage: 50 per cent of men are affiliated with this institute, compared to 47.7 per cent of women. However, more women – 10.4 per cent of the female population – are affiliated with I S S S T E compared to 9.4 per cent of men (I NE GI 2013, 83).28 A higher number of women than men have Seguro Popular coverage: 37.1 per cent of women compared to 35.1 per cent of men (83). Women who are not

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Introduction 17

working outside the home are less likely to have any form of health and welfare coverage – 45 per cent of these women lacked social benefits, and 59.9 per cent of those with benefits were covered by Seguro Popular, rather than one of the social security institutes (85). Uninsured workers in the informal sector and their families, who make up approximately 52 per cent of the population, are covered by the public health care system. Until the 1980s, the federal Ministry of Health was responsible for administering the latter system. In the 1970s, services for the rural poor were expanded under the I M S S Social Solidarity Program,29 which was financed by I M S S general revenues and in-kind contributions from communities where services were provided (Dion 2010, 107–8). In the wake of the 1982 debt crisis, Mexico’s I S I model was largely replaced by a neoliberal economic model, in which trade was liberalized, subsidies to agricultural production removed, Stateowned enterprises privatized, and land redistribution programs ended (Teichman 1996, 3–6). The dual regime in social policy was not dismantled, but the protections offered to workers in the formal sector were significantly weakened over the period from the mid1980s to the present – while, from the late 1990s onward, basic welfare and health care benefits were extended to the other half of the population. The Mexican federal government privatized the pension systems of the two major social security institutes, the I M S S (for workers in the private sector) and the Institute for Social Security and Services for State Workers (i.e., the I S S S T E , for workers in the public sector), and it facilitated the subcontracting of their services to the private sector. This constituted “the abandonment of a movement begun in the 1970s to universalize and expand access to social insurance benefits” (Dion 2010, 192). As a result of the debt crisis and associated neoliberal restructuring, the class power of workers in the formal sector declined, and the number of workers in the informal sector expanded (192–3). The federal government’s role in the provision of health care to the uninsured was dramatically cut. As part of the structural adjustment / debt repayment programs implemented in the 1980s, per capita health care spending fell by 50 per cent in the social security sector, and 60 per cent in the public health sector (Laurell 2001, 299). The federal government also decentralized health care services in an effort to reduce spending. The Ministry of Health devolved responsibility for public health care service provisions to fourteen of Mexico’s thirty-two states,

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The Limits of Trust

and, in these states, allowed I MSS-Solidaridad services to be merged with state health services, to the detriment of the former. As part of the decentralization agreements, states were permitted to keep the revenues from cost-recovery programs; as a result, they introduced or increased user fees (Birn 1999). The late 1990s brought about another shift in social policy in Latin America, with efforts to provide basic social services to the expanding population in the informal sector. The main features of the new social policy, or second-wave neoliberalism,30 were targeted services; conditional cash transfers; decentralized administration and decision-making; greater reliance on private providers, whether non-profit or for-profit; and a shift from financing of supply to demand (Filgueira 2005, 38). The conditional cash transfer (CCT ) program, Progresa – later renamed Oportunidades (Opportunities) – exemplifies the shift in social policy. It has three characteristics which distinguish it from earlier social programs: it is targeted to the poorest members of the population; it creates demand for health and education services, rather than their supply; and its distribution was intended to be more transparent and accountable than its predecessor under the Salinas administration, Pronasol (Dion 2010, 203). Seguro Popular was designed according to similar principles. Exemptions from insurance premiums were to be granted only to the poorest two income deciles; rather than building new health care facilities, the population was affiliated with Seguro Popular in areas which already had clinics and hospitals, to facilitate demand rather than supply; and the formula for calculating benefits was based on cost-effectiveness principles. This shift in social policy in Mexico – from a dual regime to one that expands basic social protections to uninsured, informal sector workers while weakening those benefitting the formal sector – has provided some benefits to a population historically excluded from the Mexican social settlement. Nevertheless, there have been a number of elements in the design and implementation of the program which made it difficult for it to achieve its goal of universal coverage by 2010. First, the program is an insurance program, rather than a health care program (Lakin 2010, 315). By financing many of the costs involved in providing care to newly insured people, the federal government has facilitated an expansion in services and an increase in the number of personnel and the availability of medications. However, because the emphasis has been on financing demand rather than supply, infrastructure

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Introduction 19

development has been neglected. This meant that regions without infrastructure, particularly rural and Indigenous areas, affiliated people to the program more slowly. In these marginalized areas, there were fewer hospitals and clinics to provide the services guaranteed by the scheme. Two other issues of concern regarding Seguro Popular relate to its financing structure. In the original program design, both the states and the federal government had to contribute to its financing. However, states were able to avoid paying their contributions by crediting past infrastructure spending toward their share of the bill. States’ infrastructure spending has been low; only a fraction of the federal government’s separate fund for infrastructure has actually been spent by the states. Program financing also depends on voluntary affiliation by families, with the exception of the lowest two income deciles, who are exempt from paying the premium. Because it relies on individual contributions, it cannot be said to foster social citizenship. In practice, however, nearly all Seguro Popular affiliates are exempt from payment (Lakin 2010, 334). The overrepresentation of payment-exempt families may suggest that, at least, the extremely poor are being enrolled in the program. However, Scott (2006, 149) argues that the program has both mistargeted exemptions and misreported the number of extremely poor families covered by the program, compared to the statistics reported by a nationally representative survey. While Progresa / Oportunidades programs have alleviated extreme poverty, and Seguro Popular has provided health care services to those previously deprived of them, such programs are “very distant from the kind of redistributive compromise necessary to reduce poverty and inequality over the long term” (Teichman 2008, 447). The literature on trust would suggest that it is such a redistributive compromise that is necessary to create generalized trust. In this study, I will consider how the implementation of programs such as Seguro Popular has limited the fostering of trust because the extent and quality of services still differs dramatically from those provided to  the social security sector. In 2010, a United Nations Research Institute on Social Development (UN RI S D ) report noted that “the lack of an integrated and universal approach to social service provision” is constraining progress in social welfare across the developing world (U NR I SD 2010, 166). Universal policies are necessary for long-term improvements in social welfare, which cannot be achieved without state intervention and wealth redistribution (161). The

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The Limits of Trust

literature on trust and health care institutions would suggest that policies that promote universal health care provision increase the legitimacy of the system in the eyes of the population. While Seguro Popular claims to be a universal system, it has not achieved universal coverage, nor does the quality of care in this system approach that provided by the social security institutes. The layering of a new set of institutions and organizations over existing ones also tends to produce disjointed and fragmented structures and undermine existing institutions (Streeck and Thelen 2005, 22). This has implications for gender relations as well as for generalized trust. The original institutions – in the Mexican case, the social security institutions, and the I MSS-Solidaridad system introduced in the 1970s to provide services to the uninsured – may suffer from institutional drift, in which the supports necessary for successful functioning are not maintained (31). In my study, this is clearest in the case of Oaxaca, where I MSS-Solidaridad has provided health care services to the rural poor since the 1970s. It has more recently been eclipsed by Seguro Popular, and its infrastructure has not been maintained in spite of expanding demand for its services. The I M S S Solidaridad system depended partly for its support on payment in kind from the community; this community labour was gendered, with women taking on the burden of cleaning. The addition of conditionality associated with the introduction of CCT schemes has meant that the burden on women has increased: they are expected to comply with conditionality requirements for both the I M S S Solidaridad and the C C T programs. f u rt h e r d i m e n s i o n s o f t r u s t i n h e a lt h c a r e

In the case of health care, interpersonal trust is founded not only on health care providers’ technical competence, but also on their capacity or willingness to honour the trust bestowed upon them by respecting the patients’ dignity; ensuring that medical care respects patients’ right to privacy, confidentiality, and informed consent; and refraining from verbally or physically abusing patients. However, in Mexico and elsewhere around the world, women’s trust in their health care providers is undermined by obstetric violence, which the Mexican women’s health coalition has defined as “a form of institutional violence against women which includes any act of omission or commission by health care personnel which damages, harms, or

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Introduction 21

denigrates women during birth, and / or dehumanizing or discriminatory treatment, and / or treatment which violates their right to bodily integrity, reproductive health, and informed consent” (López Uribe 2014). The rights which are most frequently violated in Mexico are the right to non-discriminatory treatment, especially with regard to sexual and reproductive health; the right to be informed about the risks and consequences of medical intervention, and to give (or withdraw) consent based on that information; and the right to decide on the number and spacing of their children (López Uribe 2014; Valdez Santiago 2013). Instances of physical and verbal abuse are not uncommon. A 2013 study of two hospitals in the state of Morelos found that 29 per cent of women reported some form of abuse in hospital (Valdez Santiago 2013, 6). The researchers, who surveyed all obstetric patients and then interviewed those reporting abuse, found that 19 per cent experienced verbal abuse and 8 per cent experienced physical abuse, including being hit on the legs, pushed, pinched, and subjected to painful pressure on the uterus.31 The authors conclude that abusing female patients was considered normal in health institutions (6);32 a study by Castro (2014) found that, at least in public hospitals, obstetric violence was common and a product of “medical authoritarianism” instilled through professional and gender hierarchies at all stages of medical education. Authoritarian practices were also more likely to be found in public hospitals where women do not pay for their care (197). In my interviews with representatives from non-governmental organizations (N G O s) and researchers, all of them reported that one of the reasons why women did not attend medical facilities to give birth was because they had heard about, or experienced, mistreatment there. Although obstetric violence is an issue for non-Indigenous as well as Indigenous women, the latter are more likely to experience it (Camacho Servín 2014, 4), and the forms it takes mean that it is also an issue of cultural recognition or cultural justice. Indigenous Mexican women experience not only an absence of emergency obstetric care, but forms of cultural injustice which make them less likely to seek it in the first place. Forms of cultural injustice include cultural domination, in which individuals of one culture are subject to the practice and forms of communication of the dominant culture; non-recognition, in which one’s own practices, language, and ways of communicating are rendered invisible in the dominant

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The Limits of Trust

culture; and disrespect, in which one is subject to stereotyping and demeaning behaviour (Fraser 1995, 70). In the case of Indigenous women and maternal health care, cultural injustice is experienced when their forms of prenatal and childbirth care are forbidden in health care systems; when there is nobody available to translate between their languages and Spanish; and when they are physically or verbally abused by health care providers. In the states of Chiapas, Oaxaca, and Guerrero, especially in rural areas, women have an alternative to medical care: the partera or traditional midwife. Although parteras are rarely, if ever, able to resolve obstetric emergencies, in the case of uncomplicated births they are able to offer care which is respectful, supportive, and reproduces a set of cultural practices which give birth meaning. In the Costa Chica region of Guerrero, for example, a team of parteras attend the woman, so that she is never left alone. Birth is understood as a warm process, which needs to be supported by a warm environment: warm food, warm drinks, and a herbal steam bath (temazcal) are prepared for this purpose. The woman’s family members fulfill a variety of roles during labour, such as cutting wood for the temazcal (generally done by men in the family), cooking soups and teas, and providing emotional and physical support. During labour, women stand or squat rather than lying down (Interview, CG M I -1 2004; Interview, C SG 2004). None of these practices are accommodated within medical facilities, however. There, women may not be accompanied by their family members or by parteras; they are forced to give birth lying down; and they are washed with cold water and deprived of food or drink. With the partera, women in rural communities in Mexico (particularly in the south) may have access to care from women and men whom they trust, who speak their language, and from whom they experience support and comfort. The partera or partero also performs a role in reproducing a set of cultural practices around birth. Under these circumstances, most women will choose to give birth at home with a partera rather than in a medical facility. The Mexican government, as well as NGO s, has established strategies to transport women from home to medical facilities in case of obstetric emergency, and these strategies depend on the trust relations established between the parteras and birthing women, and between the partera and the health care system (with an N G O as intermediary in some cases). Transporting women is not only a matter of obtaining

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Introduction 23

transport, however (and even this requirement might not be met). The partera has to identify the need for care, find a means of transport, and, in some instances, convince the woman’s family members to allow her to be transported. These tasks become all the more difficult if the woman fears the health care system, or if the partera fears that doctors and nurses will denigrate either the woman or herself when they arrive at the hospital or clinic. The N G O s building or strengthening trust networks with parteras in the three states examined are engaged in a politics of recognition, arising from “social patterns of representation, interpretation, and communication” (Fraser 1995, 70). They want to render visible the cultural injustices experienced by Indigenous women and parteras in the health care system, and to validate the skills and knowledge of parteras. Some of the N G O s working on maternal health have come out of the Indigenous rights movement, and are active in the movement for Indigenous women’s rights. Hernández Castillo (2003) has emphasized the role of Indigenous women, who are calling on Mexico to recognize their communities’ rights to autonomy within a multicultural State, while simultaneously challenging practices within those communities that oppress women and undermine gender equality. K’inal Antzetik, which works in all three states, and the Committee for Indigenous Women, in Guerrero, are particularly concerned with Indigenous women’s lack of access to health care, and their treatment when they do receive it. These N G O s are cognizant of oppressive gender practices in their communities; they are also aware of discriminatory treatment in the health care system. Rather than disconnecting from the system, however, they are engaging with it, and also monitoring the attention that Indigenous women receive. n g o s a n d t h e s tat e

In my study, I focus on the work of maternal health N G O s in Guerrero, Chiapas, and Oaxaca, who are engaging in maternal health advocacy and / or the building of trust networks between the system and remote communities. The development literature has identified a number of adverse consequences of the greater reliance on N G O s in the provision of social welfare. First, it has been argued that N G O s are both an effect and a driver of neoliberalism. N G O s have been accorded a greater role in policy implementation,

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The Limits of Trust

traditionally the province of the nation-state, only because the State itself has been rolled back under the pressures of structural adjustment and neoliberalism. By participating in this process, N G O s have facilitated State rollback and the privatization of formerly public services (Bernal and Grewal 2014; Alvarez 1992; Kamat 2004). Second, NGOs’ assumption of State power is particularly problematic because, unlike governments or even bureaucracies, N G O s have few if any mechanisms to ensure that they are accountable to their constituents (Kamat 2004, 156). Third, the promotion of grassroots action by both the political left and right, which privileges N G O s, risks romanticizing and essentializing “the local,” overlooking the way in which specific sites are, in fact, shaped by broader social and political forces, and may be equally riven by asymmetries of power and resources (Mohan and Stokke 2000, 249). Further lines of criticism have been expressed in the feminist literature. NGOs, it has been argued, have been depoliticized, and / or co-opted, by the donor agencies or governments from whom they receive funding. NGOs have participated in a process whereby social problems are redefined as “technical” problems which can be solved through actions carried out by non-government actors at specific sites, rather than through broader social and political transformation (Fisher 1997). Feminist NGO s have also been criticized for the abandonment of collective, social movement politics, and replacing it with officially sanctioned organizations which are disconnected from their base (Alvarez 1992, 2009; Hodžic´ 2014). Recently, however, development and feminist scholarship have taken a more nuanced approach towards the role of N G O s. Kamat (2004, 156) argues that the state / N G O relationship should be understood not as “a struggle between the state and civil society,” but as a part of a global process that “involves an overall restructuring of public good and private interest.” Contrary to what one might expect, NGO s can play a role in defending the public good from States and international organizations, which have allowed the sphere of public decision-making to be colonized by private interests. N G O s, therefore, may threaten rather than facilitate a neoliberal agenda (167). Molyneux (2008, 788) observes that in Latin America, N G O s engaged in social welfare work were not replacing a previously engaged State, but were providing services that were not, and perhaps had never been, provided. Alvarez (2009) argues that the purported disjuncture between feminist N G O s and social

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Introduction 25

movements has never been as clear-cut as the literature would have it. Many feminist organizations, she argues, remained connected to their constituencies; many have conducted research work that has been vital to the women’s movement; and many have educated not only feminist but other civil society groups about the findings of their research. Alvarez points out that feminist N G O s have reflected on their position in global neoliberalism and are pursuing new strategies, such as engagement with the World Social Forum (W S F ) rather than the UN (2009, 171–7). Tracing the genealogy of the critique of NGO s as de-politicizing, Hodžic´ (2014) claims that the criticism rests on an idealization of women’s movements that fails to accurately represent movement histories, including the conflicts and inequalities that existed within them. My argument in this book aligns more closely with the recent reappraisal of the role and function of N G O s. While the neoliberal embrace of the NGO has opened up access to governments, communities, and donor funding for maternal health N G O s in Mexico, other factors have also played a role in opening space for N G O s, and the organizations themselves have been fierce critics of neoliberalism, lobbying for increased intervention by the State to address maternal mortality. Although the Fox administration’s maternal health program, An Equal Start in Life, identified N G O s and communities as solutions to the problem, N G O s were still not playing a service provider role here, but a role as mediators between the State health care system and communities in need. While participating in actions to build trust networks in communities and link them to the health care system, NGO s have never ceased to publicize the shortcomings of public service provision. In this, it could be argued, they have fulfilled the role assigned to them by the “New Right” (Mohan and Stokke 2000): that of monitoring the actions of an inefficient state. Unlike the New Right, however, maternal health advocates in Mexico have lobbied for more State, not less, and with a greater oversight role for the federal government. While their knowledge of conditions at the local level has enabled some organizations to challenge government reports of the health care system, they have not relied only on local knowledge, but have engaged with research, and demanded changes, at the national level. Another approach to understanding the N G O -State relationship assesses it in terms of the degree of complementarity between the two parties, in terms of their skills, resources, and goals (Ullah et

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The Limits of Trust

al. 2006; Coston 1998; Gómez-Jauregui 2008; Rico and GómezJauregui 2011). In the cases I examine, some degree of complementarity has been achieved. While using this frame is helpful for understanding the nature of the relationship between government and non-governmental organizations, I argue that how the relationship may affect, and be affected by, the trustworthiness of the health care system should also be considered – because this is ultimately what will strengthen the system and generate the possibility of improved outcomes. n g o s a n d t h e m a c a rt h u r f o u n d at i o n

The N G Os in Chiapas and Guerrero who are the focus of my study were financed by the MacArthur Foundation. Before the announcement of the MDGs, the foundation had been financing organizations working to implement the Cairo program of action. From 2000 on, as a result of the MD Gs and the foundation’s own restructuring, the MacArthur Foundation decided to focus on two areas: maternal mortality, and young people’s reproductive and sexual health and rights (Interview, MA 2004). The organization focused on three countries – India, Nigeria, and Mexico. In Mexico, between 2002 and 2008 the MacArthur Foundation invested US$5 million in Mexico to support maternal health N G O s (Gay and Billings 2009, 1). It concentrated on the three states with the highest maternal mortality ratios: Guerrero, Oaxaca, and Chiapas. The organizations funded by the MacArthur Foundation formed a loose maternal health advocacy coalition (Layton et al. 2007, 28).33 At the core of the group was Fundar, an NGO dedicated to the analysis of Mexican federal budgets, which has played the leading role in coordinating maternal health research, lobbying for increased spending, and, since 2006, establishing an expanded coalition of women’s health organizations. In 2002, the foundation began financing Fundar to work on maternal health issues. From 2003 to 2006 it aimed to strengthen maternal health programs and ensure that the issue of maternal health was included in congressional budget debates (Layton et al. 2007, 27). Because the Fundar staff initially did not have expertise on maternal health issues, they identified partners in Chiapas, Guerrero, and Oaxaca with this knowledge, as well as other N G O s in Mexico City with experience in sexual and reproductive health. Their major partners were K’inal Antzetik, the National Safe

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Introduction 27

Motherhood Committee (C P MSR ), and several academic researchers in Guerrero, Oaxaca, and Chiapas.34 The Group for Information on Reproductive Choice (GI R E ) also collaborated with the group on occasion, as did another pro-choice group, Catholics for the Right to Decide, and Ipas, a reproductive rights N G O headquartered in North Carolina which operates in Mexico and many other countries (Gay and Billings 2009, 8). methods

I have focused on the states of Chiapas, Oaxaca, and Guerrero, which were the states with the highest M M Rs in the country, and the area in which NGOs have established projects to combat mortality at the local level. This has enabled me to investigate the interaction between NGOs and the State, as represented by local health services and officials within the state Ministry of Health’s regional administration (jurisdicción), in the implementation of maternal health policy. In the state of Oaxaca, my research took a different bent. As in the other two states, I researched maternal health N G O s; however, when I learned about the health care workers’ strike in the Isthmus region of the state, I spent time in the region interviewing the participants, and the chapter on Oaxaca focuses on this event and its outcomes. This chapter also explores the interaction between an N G O and the State, but in this instance the State employees were taking action against their employer. This case gave me an insight into the challenges faced by health care workers providing services in the public system, and illuminated a different kind of collaboration between State employees and an NGO . In exploring one or two local projects in each state, I have used a multiple case study method (Stake 2006) which is employed to explore something – in this case, maternal health policy – with many cases, elements, and actors. In this research design, “the single case is of interest because it belongs to a particular collection of cases. The individual cases share a common characteristic or condition” (4). The individual cases are interesting for what they reveal about the whole – in this instance, the challenge of improving maternal health outcomes in a region in which the risk of death is higher than elsewhere in the country. An alternative method would have been to compare the effectiveness of implementation in one of more of these states with the

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The Limits of Trust

effectiveness in a state with better maternal health outcomes. However, it is not easy to compare implementation or outcomes in Chiapas, Guerrero, or Oaxaca with implementation or outcomes in other states, because the demographic and socioeconomic factors are different: the southwest has the highest levels of poverty and marginalization, and the largest number of Indigenous citizens; states with low maternal mortality ratios have the opposite characteristics. Another approach might have been to compare Chiapas, which, between 2000 and 2006, had a state government that was more committed to maternal health and N G O collaboration than the other two states; however, my conclusion has been that Chiapas’s efforts were nevertheless undermined by the weakness of the health care system generally. This book is based on fieldwork done in July and August 2004; in July 2005 and 2006; from December 2007 to August 2008; and in June 2010. During those periods, I visited health clinics, attended training sessions for traditional midwives, and interviewed seventy people, including N G O representatives, government officials, doctors, midwives, and researchers. While I interviewed individuals from government, N G O s, and academia, in each state, I had difficulty obtaining interviews with some levels of government officials. In 2006, I was able to get interviews with federal government representatives, but after that year I could not. In 2010, I was unable to interview government officials in Chiapas. I was not able to obtain interviews at the state government level in Guerrero at any time; nor was I able to interview staff with the state offices of Seguro Popular (R E P S S ). I can only speculate about the reasons for the lack of access. In Guerrero, public officials’ failure to answer phone calls or emails may have reflected a general lack of capacity in the Ministry of Health, or a lack of concern about maternal health. N G O s spoke of similar difficulties in trying to communicate with the ministry. In Chiapas, the contrast between relative openness before 2006 and less afterwards may reflect a degree of disruption in the Ministry of Health: between 2006 and 2008, there were three different health ministers. It may also be indicative of a lesser degree of commitment to maternal health than that expressed by the minister who served from 2001 to 2006. In Oaxaca, state government officials were willing to be interviewed, but only if they were assured that I had no connections with the People’s Popular Assembly of Oaxaca

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Introduction 29

(A P P O ), which occupied the city for six months in 2006. After Felipe Calderón’s election to the presidency in 2006, requests for interviews with officials in the federal Ministry of Health were directed through a communications office, which did not respond to my correspondence. This has meant that a far greater proportion of the interviews has been conducted with representatives from N G O s and research institutes than with government. However, I have tried to round out the perspectives by speaking with local-level government officials and doctors, examining government documents and maternal mortality statistics, and reviewing academic evaluations of the programs and policies. I referred to statistics from the DirectorateGeneral of Health Information (D G I S ) and from the Observatory for Maternal Mortality (O MM) for maternal mortality statistics and figures on personnel ratios, funding, and infrastructure; to studies from the National Institute of Public Health (I N S P ) for information on the state of infrastructure and supplies of medication; to academic reports commissioned by the National Population Council (C ON A P O ) for information about progress on the M D G s; and to reports from the National Commission for Human Rights (CN D H ), as well as academic studies, regarding the abuse of women seeking obstetric care in public health institutions. I have also examined the federal Ministry of Health’s yearly reports on the performance of Seguro Popular in order to understand the design and implementation of the system, and reports by the Council for the Evaluation of Social Development Policies, Coneval, for qualitative and quantitative information on the occurrence of maternal death in the health care system. With the exception of the Observatory for Maternal Mortality,35 which is a hybrid organization, all of these organizations are public. o r g a n i z at i o n o f t h e b o o k

The book is organized as follows. Chapter 1 examines the impact of MDG -5 on the measurement and monitoring of maternal health in Mexico, and how this influenced the generation of trust within the public health care system. I argue that the more rigorous reporting systems introduced partly as a result of Mexico’s commitment to the MDG s reinforced a shift from an approach to maternal health that was based around the concept of obstetric risk, to one based on the

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The Limits of Trust

availability of emergency obstetric care (EmO C). The latter requires a well-functioning health system, so policy-makers became more concerned with health system performance as part of this shift. The availability of statistics and qualitative information about the management of maternal death also strengthened N G O s’ claims about the failures of the system. However, when workers lack the resources to resolve obstetric emergencies, monitoring systems may lead them to fear the condemnation of their colleagues in the event of a maternal death, causing them to act in ways which undermine trust in the system, such as avoiding delivering babies or concealing records when a maternal death has occurred. Chapter 2 examines national health care reform in Mexico from 1982 to the present, to determine how the reform has affected mechanisms which enhance trust. While Mexico’s health care system was and continues to be divided between the social security institutes for the insured and the public system for the uninsured, from the 1980s onwards it was transformed by structural adjustment programs and associated neoliberal reform policies. The most recent reform, Seguro Popular, has improved the accessibility of health care for the poor and uninsured. However, although improvements have occurred, the system has not achieved universal coverage, nor has there been a dramatic improvement in the quality of care which would be necessary to resolve the maternal health problem. Neither the technical nor institutional dimensions of care necessary to build trust in the system are present. Chapter 3 examines maternal health in the state of Guerrero, which had the worst maternal mortality figures in the country. Guerrero was one of the fourteen states in which public health care systems were decentralized in the 1980s. As a result, there was an increasing disparity between the services available to people living in urban and rural areas. I examine a project in the Costa Chica region that attempts to bridge the cultural divide between Indigenous Mixteca and Amuzgo communities, on the one hand, and the health care system on the other. The house for Indigenous women’s health (Casa de la Salud de las Mujeres Indígenas) was established by a federal department, the National Commission for the Development of Indigenous Peoples (CDI), to act as an intermediary between women and the health care system. Although the service was intended to advocate for the rights of Indigenous women, its ability to affect change in the local medical system was limited because it lacked the capacity to

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Introduction 31

enforce any of the accords reached with medical facilities in the region. Thus, NGOs’ efforts to connect trust networks to the health care system were undermined by the failure of local health care facilities to respect the agreements reached with them. The elimination of user fees only occurred after Seguro Popular had reached a greater proportion of the population, but even then, poor individuals were excluded because they lacked the necessary identity documents. Chapter 4 considers state and local policy initiatives in Chiapas. For a short time around 2005–06, Chiapas was regarded by maternal health advocates as a success story. The democratic transition in Chiapas occurred at the same time as the national one, and the new Health minister was committed to improving maternal health. Two new maternal health programs were established in the state of Chiapas, and a coalition of NGOs implemented a pilot project in the municipality of Tenejapa in the central highlands of the state. However, there is still insufficient infrastructure in Chiapas, and the state has not resolved problems with its medical supply distribution system. In the case of the Tenejapa project, collaboration between government and NGOs did not occur, because of a lack of trust between the two institutions, as well as among the various NGOs themselves. Chapter 5 discusses the impact of activism in the state of Oaxaca on changes in the health care system – changes which have the potential to strengthen the technical capacity and social networks necessary to generate trust. Unlike Guerrero, Oaxaca’s health care system was not decentralized until the 1990s; hence, Oaxaca did not lose the I MSS-Solidaridad services administered by the federal government. However, in the new millennium, I M S S -Solidaridad services suffered from some of the problems that beset the rest of the health care system. What makes Oaxaca unique is that, in the Istmo region, health care workers went on strike to demand more medical staff, equipment, and resources, and were partially successful in achieving their demands. However, the Istmo region may have been more successful in its efforts because of its history of successful mobilization; and the agreements to strengthen networks between different health care systems, such as I M S S -Oportunidades and the Oaxacan Ministry of Health, were not always complied with. I conclude that the building and strengthening of trust networks at the local level, by NGOs in collaboration with parteras and health promoters, can strengthen mechanisms to increase trust. They can do this by facilitating the monitoring of human rights abuses in the

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The Limits of Trust

health care system; combatting cultural injustice by educating rural women about their human rights in the health care system and reporting on the abuse of these rights; and approaching their relationships with the community through the paradigm of sexual and reproductive rights, rather than population control. N G O projects have also potentially increased trust by strengthening the cultural and technical competency of health care providers. I submit that in a context where people’s trust in health care systems, and the State generally, is low, NGOs may play a role in strengthening linkages between the health care system and communities by strengthening the capacity of parteras and promoters in those communities to negotiate with families and medical professionals, thereby providing a bridge between rural villages and the system. N G O s have been concerned with combatting the power dynamics within families and communities, as well as within the health care system, and developing parteras’ ability to negotiate with family members as well as medical professionals may enable them to build linkages between the system and birthing women and their families. Nevertheless, trust networks at the local level are not sufficient in themselves. In order to save women’s lives, and to generate trust, the health care system must provide emergency obstetric care that is technically competent, respectful of women’s human rights, and does not reproduce cultural injustice. There are three key mechanisms for facilitating generalized trust in the health care system: financing arrangements, licensing regimes, and the networks comprising the organizational environment. The introduction of Seguro Popular, and programs to strengthen the quality of care in the public health care system, have brought about changes which can increase the fairness of the financing arrangements, the appropriateness of the licensing regimes, and the capacity for collaboration across different health care systems. Nevertheless, the system still reproduces inequalities between the insured and uninsured, cannot ensure qualified care in well-resourced health care facilities in rural and poor urban areas, and presents barriers to collaboration across networks.

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1 Mexico and the Implementation of the Maternal Health Millennium ­Development Goal introduction

Mexico had implemented policies and programs to improve maternal health before the declaration of the M D G s.1 However, it was after the declaration of the MDGs that Mexico announced a national maternal and infant health program, Arranque Parejo en la Vida (An Equal Start in Life – A P V ); and it was largely in order to determine whether Mexico was complying with the maternal health M D G that the federal government instituted a new regime for reporting maternal death as part of this program. The effects of reporting and measuring maternal mortality have had paradoxical effects on the generation of trust. Mechanisms for ensuring the technical competence of health care providers are critical for creating trust (Gilson 2003). Insofar as the measurement of maternal mortality has facilitated the identification of problems within the health care system, providing maternal health advocates with an evidence base on which to demand improvements, measurement has the potential to increase the trustworthiness of the system. Measurement has a “knowledge effect,” rendering visible problems that might otherwise escape the attention of policy-makers (Merry 2011, S84). Statistics produced through this new regime have revealed the extent to which a woman’s risk of dying is dependent on her geographic location, ethnicity, and class (i.e., whether she has health coverage with one of the social security institutions) – highlighting the way in which categorical inequality has been reproduced by health care policies. The analysis of the data has also influenced, and been influenced by, a shift within the Ministry of Health: from a

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The Limits of Trust

risk approach to maternal health, to an emergency obstetric care (EmOC ) approach. Because the effectiveness of emergency obstetric care is dependent on a well-functioning health care system, this shift has meant that the ministry has become more concerned with the system’s performance. Measurement also has “governance effects,” in that it enables governing authorities (governments, organizations, corporations) to avoid directly monitoring individuals, resulting instead in individuals monitoring themselves in order to meet the desired numerical standard (Merry 2011, S85). Thus, rather than a physician being directly monitored by a higher authority, the existence of statistics on the number of maternal deaths occurring under her care may result in changing her behaviour to meet the statistical requirement. While this may seem to be a desirable effect, in a context where health care workers may not have the skills or resources to provide sufficiently good care, measurement may also undermine trust in the network of relations between the health care worker and other actors and agencies of government. It may also result in doctors “gaming” the system by failing to register maternal deaths (as the story which opened this book indicates). This chapter is organized as follows. In the first section, I provide a brief overview of the importance of quantitative measurement to MDG-5. In the second section, I explore how, in the context of post2000 democratic transition in Mexico, the Fox administration committed to the MDGs. In the third section, I outline the measurement system introduced as part of the Equal Start in Life program from 2004 onwards. The evidence of problems in the resolution of obstetric emergencies in the health care system reinforced Mexico’s paradigm shift from an obstetric risk model to an emergency obstetric care model, and the next iteration of Equal Start (from 2007 to 2012) demonstrated the latter, as I outline in the fourth section. In the fifth section, I detail the requirements of the new regime, and indicate the role of NGOs in publicizing new knowledge about the causes of maternal death. In the final section, I present some evidence that the monitoring system has made doctors in rural areas frightened of the consequences of reporting a maternal death, thereby undermining their trust in the networks in which they are embedded and creating the risk that deaths will go unreported. My analysis draws on concepts from Sally Engle Merry’s work on measurement and global governance (2011; Davis et al. 2012; Merry and Coutin 2014).

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Mexico and the Maternal Health MDG

35

m d g - 5 : t h e m at e r n a l h e a lt h m i l l e n n i u m development goal

The Millennium Development Goals were influenced by two trends in development thought: human development and results-based management (R B M). In the human development paradigm, improving individuals’ health and well-being is both a goal of development and a means for its achievement. Rather than delaying efforts to improve human welfare until a certain level of economic growth has been achieved, the human development paradigm contends that improving people’s health, education, and welfare in the present will contribute to growth, whereas growth in the future may not ensure well-being (Hulme 2010; see also Sen 1999). Results-based management focuses on policy outcomes rather than processes, and involves measurement as a means of ensuring that the desired outcomes are being met. In the case of the MDGs, the influence of RBM can be seen in three ways. First, the MD Gs set out a series of goals and targets to be achieved, as well as indicators for measuring progress. Second, the targets were specified in order to become achievable; the goal of eliminating extreme poverty was replaced with that of halving it in order to improve the likelihood of achieving the outcome. Third, the M D G s left aside goals that are less amenable to quantification (Hulme 2010, 21), such as reproductive health. The existence of the goals, therefore, has encouraged quantification in countries that want to meet them. In the case of Mexico, the M D G s led to a greater emphasis on measuring and monitoring development outcomes to determine the degree of progress being made toward the goals (Lozano et al. 2011). mexico and the mdgs

The MDGs were announced in the same year Vicente Fox was elected president of Mexico, an event that ended seventy years of one-party rule and which has been seen as the culmination of the country’s democratic transition (Preston and Dillon 2004). Beth Simmons (2009) has argued that international treaty obligations2 are more likely to be met when domestic institutions are in transition because of those obligations’ effect on national politics. In stable democracies, human rights commitments may be superfluous; in stable autocracies, human rights commitments may be needed but are impossible

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The Limits of Trust

to achieve. It is in the shift from one to another that the motive and the means for achieving human rights goals are likely to align (16). Simmons also attests that States are most willing to commit to international obligations when they accept the content of the agreement and believe that they can comply (64). In Mexico’s case, the new administration believed that the MDG s prescribed obligations that they were willing and able to meet. President Fox stated, “we are working with complete resolve to achieve the M D G s. We have policies and programs oriented towards the fulfillment of each of them. Our chances of reaching them are excellent” (Fox Quesada 2005, 3). Fox noted the “two realities” of Mexico, in which some parts of the country have high levels of wealth and human development, while other regions are subject to extreme poverty and marginalization. The numbers gathered to report on the M D G s, he noted, indicated not just slight differences between groups according to location, gender, or ethnicity, but rather large gaps. Reporting on progress towards the MDG s was, therefore, part of a national conversation about long-term development, democratic consolidation, and citizen participation, involving multiple levels of government, academia, and N G Os (3–4). In addition to reporting to the U N in 2005, 2006, and 2011 on Mexico’s progress toward the M D G s, the federal government also asked the national Council on Population (CO N AP O ) to conduct a series of studies on Mexico’s progress and the best way to reach the goals (Zúñiga Herrera 2005, 9–10). This resulted in a detailed volume of statistics and analysis on Mexico’s position with regard to each of the goals. t h e m d g s , a n e q u a l s ta rt i n l i f e , and measurement

An Equal Start in Life was a means of complying with the maternal and infant health goals of the MDGs (Knaul 2013, 220; S S A 2008, 7). An Equal Start in Life was launched in seven states in 2001, and thereafter in the rest of the country. In 2003, the Ministry of Health established the National Centre for Gender Equity and Reproductive Health (CNE GSR ) in order to administer Equal Start and the existing programs on family planning and reproductive health (GómezJauregui 2008, 83). The program aimed to decrease maternal mortality, especially in the regions with the highest maternal mortality ratio (M MR ), and to provide universal health care coverage with

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37

equal access to a high quality of care (S S A 2002, 33). In its first years of operation, Equal Start focused on creating, or strengthening, the social networks between communities and the health care system, and within the system itself. Equal Start facilitated the organization of clinics and health centres into networks (redes) connected to a single, “anchor” hospital (Hospital Sí Mujer). These clinics, in turn, were connected to networks of smaller health facilities, and the doctors, parteras, and health promoters who attended women in remote and rural communities where these facilities were located. In order to enable the transport of women to better-equipped clinics (and, if necessary, hospitals), social networks, NGOs, and municipalities were seen as critical to the functioning of Equal Start. In this design, municipalities would play a role in providing transport; that is, vehicles owned by the municipal government were to be made available for transporting women in need. The municipalities would also be responsible for building hostels (Posadas A M E ) near the anchor hospital, where women with high-risk pregnancies could stay in the days before giving birth. In its dependence on multiple actors at lower levels of government and the non-government sector, Equal Start reflected trends in results-based and new public management, in which policy outcomes are to be achieved through the actions of private actors. Indeed, Health Minister Frenk emphasized the role of non-government actors in his claim that Equal Start was “a social movement” (Notimex 2006). One of the most striking things about the Equal Start in Life program, however, is that it is based on the assumption that levels of obstetric risk can be determined during pregnancy, and that women who have been identified as being at high risk of obstetric complications, due to factors such as maternal age, parity (number of previous births), and past caesarean sections or miscarriages, can be referred to an appropriate medical facility. While emergency obstetric care is mentioned in the Equal Start guidelines, the risk model is what underpins the program. This model implies a particular set of responsibilities for health care providers. Primary care physicians providing prenatal care need to be able to identify high-risk patients and refer them to secondary-care hospitals for treatment. It is unlikely that they will have to either recognize or manage an obstetric emergency. Because high-risk patients will already have been referred for care, hospitals are also less likely to have to resolve emergencies.

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However, since the late 1990s, the maternal health paradigm has shifted. Most maternal health advocates have argued that in order to reduce the prevalence of maternal death worldwide, governments must expand access to emergency obstetric care (Maine et al. 1997; Maine and Rosenfield 2001; Yamin and Boulanger 2013; Coneval 2012b). This does not mean that other factors are unimportant in preventing maternal mortality. Prenatal care, adequate nutrition, access to transport to a medical facility, and the identification of women at high risk of pregnancy complications are all necessary to reduce the incidence of maternal death – but they are not sufficient (Fortney 2001, 95). If these factors are addressed, but EmOC is unavailable or inaccessible to women suffering from complications, many will still die (95). Although it is possible to identify some women at high risk for obstetric complications in advance of their giving birth, not all of these women will experience complications. Women who are at low risk may experience complications; and because more individuals fall in the low risk than the high risk category, a greater number of women may face life-threatening disorders in spite of a low risk assessment (Maine and Rosenfield, 2001, 100).3 The main advocates of E mO C , Deborah Maine and her colleagues at Columbia University’s Mailman School of Public Health, have argued that access to EmOC is obstructed by three delays: the delay in deciding to seek care, in reaching a treatment facility, and in receiving adequate treatment at the facility (Maine et al. 1997, 11). The first delay may arise if the birthing woman, and those present at the birth, cannot recognize the signs of pregnancy complications; if the women does not have the status or autonomy to demand that she be taken to a medical facility (in opposition to her family’s wishes); if the woman does not know that services are available; or if access to the services depends on the ability to pay. The second delay may arise if transportation to a health care facility is not available, or if the family does not have the resources to pay for it, or if the roads to the facility are flooded, damaged, or poorly maintained. The third delay relates to the quality of the medical care itself. Many women who have overcome the first and second delays die in hospital because medical practitioners do not have the equipment, medication, infrastructure, or (in some cases) the skills to save them. In practice, the delays are mutually reinforcing. Women, or their families, who fear that they will not receive adequate care within the health care system may delay the decision to seek care (11).

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In Mexico, the E mOC paradigm, and the “three delays” model, did not replace the obstetric risk paradigm until 2009, upon the release of the Integrated Strategy to Accelerate the Reduction in Maternal Mortality (Estrategia Integral para Acelerar la Reducción de la Mortalidad Materna en México). However, the EmO C paradigm featured more predominantly in the next iteration of the Equal Start program under the administration of President Felipe Calderón (2006–12). From 2004 on, reports drawing on the data generated by the new measurement regime identified the health care system’s inability to resolve obstetric emergencies as a problem, and emphasized the functioning of systems rather than social networks. the effects of measuring and monitoring

The use of indicators4 has a knowledge effect (Merry 2011, S 84). Indicators produce clear and simple forms of knowledge that are legible across cultures and contexts. An indicator allows countries, organizations, or individuals to be ranked in spite of their differences. The maternal mortality ratio, for example, allows the state of Guerrero to be compared with Nuevo Leon, and Mexico with Canada or Sierra Leone. Because of the apparent objectivity of numbers, judgments based on them seem apolitical and value-free. They also appear to be transparent in ways that other forms of information do not (S 84). Measurement has the effect of bringing social problems to light that would otherwise not come to the attention of policy-makers. By measuring their frequency, social justice advocates can expose the extent of human rights violations, or inequality of income and opportunity, or health care system failures. Simultaneously, however, measurement systems render invisible what is not measured (Merry and Coutin 2014, 1–2). The measurement requirements of the Equal Start in Life program, along with the associated recording and analysis of qualitative information, influenced and reinforced Mexico’s shift from an obstetric risk model to an E mO C model. While the federal government had generated statistics since the 1980s to guide health policy and evaluate the health care system (Jauregui et al. 2010, 7), the level of informationgathering increased dramatically in the post-M D G era. The director of the General Directorate for Health Information (D G I S ), Rafael Lozano, noted that the M D G s had had an “extraordinary” effect on the production of information (Lozano et al. 2011). He also stressed

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the importance of accurately registering maternal death in order to evaluate Mexico’s progress towards the M D G s (Lozano Ascencio 2008, 2). In 2004, the Council for Public Health (CS G )5 decreed that all health institutions, whether public or private, must comply with the “substantive and strategic” components of Equal Start, and must report a maternal death within twenty-four hours of its occurrence (C SG 2004). The C SG is the most authoritative health authority in Mexico, and its jurisdiction extends to all health institutions, not just those under the regulation of the Ministry of Health (Interview, SSA -1 2006). Before 2004, although the reporting of maternal deaths was obligatory, it was rare for a report to come in promptly. After the publication of the C SG declaration, the time it took to report a maternal death gradually decreased from forty-five days in 2005 to eighteen days in June 2006 (Interview, S S A-2 2006). Because Mexico’s public health care system had been decentralized in the 1980s and 1990s, and states had varying degrees of commitment to maternal health, this form of monitoring was a means of ensuring that states became concerned about the issue, and of enabling the federal government to act on problems within a given state (Interview, S S A -1 2006). The importance of the issue, and of the notification of maternal death, was reinforced by federal Ministry of Health officials, who present the statistics on notification at meetings of the National Health Council,6 attended by each state’s minister of Health (Interview, SSA -2 2006). Under this decree, the health facility where the death took place and / or the health region responsible has to notify the federal Ministry of Health of the death, and then undertake an investigation and analysis of its causes. The study of the causes of death should include the clinical file; the death certificate; the protocol and results of an autopsy if one is conducted; and a document explaining the treatment that the patient had been given, the time lapses which may have occurred between the patient’s seeking and receiving treatment, the preventability of the death, and recommendations for its prevention (SSA 2012a, 12, 23). This documentation is also forwarded to the local Maternal Mortality Committee (16). Local and / or statelevel health officials have a month in which to investigate, revise, and analyze the files (Interview, SSA -2 2006). In order to establish the accuracy of the existing maternal mortality statistics, in 2002 the DG IS also revised the files of reported deaths in nine states to

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determine whether they represented maternal deaths that had previously been classified in another category. Since 2003, the D G I S has continued to revise files in which it appears that a maternal death has been misclassified, and adjust the mortality figures accordingly (SSA 2012a, 11, 24–5). The Ministry of Health also formed a national-level committee for the Immediate Analysis of Maternal Death (AI D E M ), which examines 200 of the roughly 1,000 maternal deaths that occur in Mexico each year. A I D E M teams, comprising analysts from the National Institute of Public Health, investigate the circumstances surrounding a death, particularly in areas where more than one maternal death had been reported. Their analysis has been guided by a critical links (eslabones críticos) methodology, in which the researchers examine the existence and effectiveness of preventive health programs; health centres at the first level of attention (i.e., centres that provide primary health care); the process of referral to the second level of attention; the effectiveness and quality of care provided by the hospital during and after the birth and in their follow-up with the mother and baby (Núñez Urquiza 2004, 5). From 2010 onwards, immediate notification occurred through an online platform (G T R 2014, 7). The strategy for addressing maternal mortality in highly marginalized municipalities was intensified in 2012, with the Task Force for the Reduction of Maternal Mortality working with joint federal-state supervision teams examining hospitals with higher rates of maternal death (8). By 2014, 30 per cent of states had telephone alert systems to connect clinics to obstetric teams at state and federal levels. It has been argued that this has contributed to a reduction of maternal death in Chiapas and Guerrero (9). In the case of reporting maternal deaths, numerical data has been accompanied by qualitative information about the causes of death. While gathering quantitative data has been crucial, the investigations that were also required under the Equal Start in Life program have enabled third-party investigative teams to assess and interpret the data, which has ultimately resulted in a shift in understanding about the causes of maternal mortality. The change in perspective cannot be attributed just to the existence of numbers and other data, however. It must also be attributed to the existence of an alternative paradigm, the emergency obstetric care paradigm, for understanding the causes of death. In the Mexican case, the focus on the provision

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of emergency care has entailed a shift of responsibility away from traditional midwives (parteras) and women’s refusal or failure to engage with the health care system, and towards the system itself. In a study commissioned by the National Population Council (C ON A PO )7 in order to assist the federal government in meeting the MDG s, the architects of the new regime for measuring maternal death argued that maternal mortality was an issue not only because of its effects on individual families, but because it was an indication of social inequality, and the poor coverage, functioning, and quality of health care services (Lozanco Ascencio et al. 2005, 167). Given that the maternal mortality figures indicated that a majority of deaths occurred in hospitals, the authors concluded that there must be deficiencies in the capacity of the system to resolve obstetric complications and provide good quality of care. They reported that 81  per cent of deaths had occurred in medical facilities, and that documentation showed poor management of pregnancy and birth complications, including the failure to use medication for the treatment of pre-eclampsia and eclampsia due to a lack of supplies (182). Data from the state maternal mortality committees showed that up to 30 per cent of women who had died in rural areas had gone to two or more health facilities before their deaths (183). The renewed Equal Start in Life program for 2007–12 announced a shift away from the risk focus that previously guided the program, toward a focus on the capacity to resolve obstetric emergencies, as well as toward the strengthening of networks to connect communities in remote areas with clinics and hospitals (SSA 2008, 21). The program report noted that data gathered by AIDEM had allowed the Ministry of Health to conclude that the major factors in maternal mortality were problems with the quality of care and the incapacity to resolve obstetric emergencies (SSA 2008, 21). A great number of deaths had occurred in secondary-level care facilities, particularly in “community” or “integrated” hospitals run by state Ministries of Health, which had fewer resources than general hospitals. The study noted World Bank and World Health Organization recommendations concerning the need to improve access to EmOC in order to reduce maternal mortality (27). The director of the centre responsible for maternal health, Dr Patricia Uribe Zúñiga, stated in 2010 that “we have a serious problem with the quality of attention in various Ministry of Health hospitals and our women are dying in the hospitals” (Ruíz 2010). Uribe Zúñiga identified the problem not as one of

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primary care providers’ failure to identify women at risk, but secondary level providers’ capacity to provide quality care. Her approach to the problem was influenced by the existence of the MDGs. She noted the need for a national strategy to accelerate the reduction of maternal mortality, “given that it is one of the MDGs, and we are not decreasing mortality at the rate we wish” (Carrera 2009). The measurement system introduced in 2004, and the accompanying case documentation,8 also made it possible for maternal health and feminist groups to expose problems in the public health care system. Fundar, which had requested data from the Ministry of Health using the Freedom of Information Act, found that of the deaths which that had occurred in hospitals in 2005, 86 per cent had occurred in the public health care system. The women who died either had no health coverage, or were covered by Seguro Popular (Díaz Echeverría 2006, 20, table 5).9 Organizations such as the C PMSR and Observatorio de Mortalidad Materna have continued to publicize the fact that the majority of maternal deaths occur in hospital, and that more than half of the women who die are affiliated with Seguro Popular (Goche 2013). Since 2008, Mexico’s Safe Motherhood Committee has held yearly technical consultations, in which academic researchers, N G O s, and officials from the state and federal governments are brought together to hear reports on the most recent evidence. The first technical meeting for the promotion of maternal health in Chiapas, Guerrero, and Oaxaca was held in Oaxaca in February 2008.10 The meeting was organized by the national Committee for Safe Motherhood and its state counterpart, and financed by the MacArthur Foundation. It brought together representatives from the federal and state Ministries of Health, officials from the Mexican branches of the United Nations Development Program (UND P ) and Population Fund (U N F P A), maternal health experts, and NGO s. Senior bureaucrats from the C N EG SR , as well as academics and N G O s, presented research on the causes of maternal death, the strategies for combatting it, and the role of the health care system in contributing to the problem. The meetings have been repeated each year since then. All of these consultations have focused on the states with the highest M M R, Chiapas, Guerrero, and Oaxaca. The state of Veracruz was added in 2011 (C PMSR 2014). The technical meetings not only provided a forum for sharing information about maternal mortality, but resulted in federal and

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state government commitments to address it. The Safe Motherhood Committee had campaigned for free access to medical care during pregnancy and childbirth since at least 2004 (CP M S R 2004). At the meeting, state and federal governments also agreed on the importance of universal access to free obstetric care, regardless of their ability to pay or their affiliation with a social security institute. The three states examined in this book agreed to guarantee pregnant women’s access to emergency obstetric care.11 Through SubSecretariat of Health Promotion Mauricio Hernández Avila, the federal government agreed to develop mechanisms within existing programs for the uninsured, such as Seguro Popular and Medical Insurance for a New Generation (SM N G ), to make sure that pregnant women had medical coverage from the beginning of pregnancy instead of only after giving birth (CP S M R 2008b). Medical Insurance for a New Generation had been announced soon after Felipe Calderón became president. Under this program, all babies born on or after the president’s inauguration on 1 December 2006 would be automatically enrolled in the Seguro Popular program, along with their families. Maternal health advocates were immediately concerned that the program prioritized the baby’s access to care over the mother’s, as well as violated the principle of universal health coverage (Interview, K A -1 2008). Roughly three months after the technical meeting, President Calderón announced the introduction of the program Embarazo Saludable (Healthy Pregnancy) as a mechanism to provide Seguro Popular coverage to all uninsured pregnant women and their families. In 2009, the federal government announced that it would provide access to care regardless of institutional affiliation, by entering into an agreement with the major social security institutions, I M S S and ISSSTE. The Interinstitutional Agreement for Attention in Obstetric Emergencies enabled women in need of emergency obstetric care to receive attention at any of the social security institutes or state Ministry of Health facilities (SSA, I MS S, and I S S S T E 2009). Prior to this agreement, women who were not affiliated with a social security institute would not have had access to its services, although an institute hospital or clinic may have been closer than a Ministry of Health facility, and transport to a closer (and better-equipped) facility may have saved the woman’s life. The agreements made at the technical meeting also committed state governments to improving the availability of medications to treat obstetric emergencies; ensuring the accurate measurement of

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maternal death; allowing use of Seguro Popular funds to pay for the services of obstetric nurses and professional midwives (the latter had not been part of the Mexican health care system since the 1960s); and incorporating maternal health N G O s into the state and jurisdictional level maternal mortality committees. The specific commitments varied slightly according to each state’s circumstances. Chiapas and Guerrero agreed to distribute kits containing medication for eclampsia and pre-eclampsia (in a cherrycoloured box or caja guinda) and for obstetric haemorrhage (in a pink box or caja rosa) (C P MSR 2008b), measures which had already been implemented in Oaxaca. All states agreed to improve the supply and distribution of blood for transfusion by consulting with the National Centre for Blood Transfusion (CP M S R 2008b). While all states were legally compelled to report maternal death to the federal Ministry of Health, NGO s, particularly in Chiapas, knew of cases in which deaths had not been registered; the state agreed to provide training in maternal mortality reporting to its medical staff, and, in municipalities with low human development indices and / or high MMR s, to investigate cases in which women of reproductive age had died in case the deaths had been misregistered (CP M S R 2008b). In 2010, the agreements addressed very specific issues of concern, and raised new issues with regard to ensuring access not only to emergency obstetric care, but humane care during childbirth (parto humanizado). In Chiapas, the participants agreed to develop a proposal to guarantee funding for transportation to medical care in twenty-eight priority municipalities; to consider the establishment of a professional midwifery school; and to promote courses for medical staff in the handling of obstetric emergencies (CP M S R 2010a). The accord with Guerrero’s Ministry of Health obligated the Ministry to continue working with NGOs; to ensure their representation on maternal mortality committees at the state and jurisdictional level; and to work with the federal Ministry of Health and N G O s to resolve problems with Ometepec’s regional hospital, which had long been on N G Os’ radar as an institution where disrespectful, negligent, and abusive treatment of birthing women had been permitted to continue (C PMSR 2010b). Rehabilitating Traditional Midwifery (Partería) The quantitative and qualitative data about deaths in public health care facilities reinforced NGO s’ earlier conclusions about problems

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in the health care system, and motivated a desire to rehabilitate the  reputation of parteras, who had been – and to some extent, continue to be – blamed for maternal mortality. Some N G O s, and some representatives from the Comission for the Development of Indigenous People (C D I ), wished to shift responsibility back to the health sector. In Oaxaca, the desire to rehabilitate traditional midwifery arose during discussions at the first national Safe Motherhood Committee in 1995, where health sector officials attributed the state’s high maternal mortality to the incompetence of parteras. According to an official from the C D I : “It was clear that in Oaxaca maternal mortality was high. But in this period, the health sector always said that it was high because the parteras are stupid, they’re ignorant, because they haven’t studied” (Interview, C D I 2008). In conjunction with U N I C E F , Ignacio Bernal, a doctor from the National Indigenous Institute (I N I – Instituto Nacional Indigenista, now known as C D I ), conducted a study on traditional midwifery. He and his colleagues found that traditional midwives were not responsible for maternal mortality. We realized that … women were dying in the health sector and accidentally we became defenders of midwifery, and we said [to the health sector], you are making unfair accusations. In fact, the parteras are doing things that you should be doing to improve the quality of care and reduce maternal mortality … We were defending parteras because there was a model of health care that was more humane, more in keeping with Indigenous culture. And we were recognizing that maternal mortality is multifactorial, but one important factor is poor quality of care … so the discourse changed. Now we have better information systems, now we realize that [the health care system] is culpable, and now we recognize that we have a debt, that we have an historical debt with the parteras, because they have done what we haven’t done; that’s what we’ve been proclaiming for almost twenty years. (Interview, C DI 2008) The study, therefore, was not only about maternal mortality, but about relieving parteras of culpability for maternal death, thereby opening a way of recognizing their skills and contribution to Mexican culture. As a representative from the Rosario Castellanos Centre argued, intercultural awareness is about recognizing the

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significance of Indigenous knowledge: it “has to go hand in hand with really respecting the ancestral knowledge of the original cultures. Thanks to this knowledge, the peoples of the region have survived, without the Ministry of Health” (Interview, RCC-2 2008). There is some evidence that state health officials’ minds have been changed by the evidence on maternal death within the health care system. An official with the Ministry of Health in Chiapas reported that as a result of participating in the annual technical consultations, he is more aware of problems within the system: Death during childbirth isn’t just happening in the home, it’s happening in the hospitals; the frequency is high, more than half the women are dying in the hospital. Parteras are transporting women who die while being transported, or die at the hospital because their complication is too advanced when they arrive. But this nevertheless obliges us to consider the other component: it’s very likely that the medical care isn’t high quality, that there’s medical negligence. And this requires that we implement other strategies so that we have highly trained people to attend births. (Interview, I SE C H 2008) While still emphasizing the role of the partera and the failure to get access to the health system on time as causes of maternal death, the official has acknowledged that quality of care is also at issue, with a corresponding need for the ministry to respond. While the measurement and related documentation of maternal mortality has allowed research groups such as the National Council for the Evaluation of Social Development Policies, Coneval, to identify problems within the health care system, the local-level monitoring of maternal mortality has at times failed to identify systemic problems, and has continued to blame parteras. In the event of a maternal death, state Ministry of Health officials report it to the federal Directorate General of Epidemiology, and also begin an investigation of the death with the health district in which it occurred. The investigation includes a confidential questionnaire, the “critical links” document, and a discussion with the ­relevant Maternal Mortality Committee (Comité de Mortalidad Materna), which writes a report with recommendations. By 2010, 91 per cent of the hospitals in the four largest states in the country had such committees (Coneval 2012b, 32). However, the quality

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of the committees that assess and advise on maternal deaths is highly variable: The records and minutes that emanate from the maternal mortality committees has a heterogeneous quality – the committees often make general observations, there is little homogeneity in the professionals who fill out the records and in the methodology that is applied to analyze the cases and, above all, to make recommendations and improve performance. (Coneval 2012b, 20) The investigations often conclude by finding the primary care provider, the partera, or the woman herself responsible for the death. Over time, the analyses became more perfunctory, with the opinions of only one or two people prevailing (Roldán 2009, 144). So, while the reporting of maternal mortality and the analysis of centrally collected data have permitted a shift in emphasis concerning the causes of maternal death, and in the assignment of responsibility from the partera to the responsibility of the health care system, local investigations have not necessarily been as carefully conducted, and so they have continued to find parteras responsible and have not driven local-level changes in the system. This is not to idealize parteras or overestimate their capabilities. Nevertheless, a system which places responsibility for maternal death on the partera is unlikely to encourage her to trust that system, and may deter her from using it. An activist with a Chiapas community-organizing group called F OC A (Training and Capacity Building) reported: “Sometimes, parteras take the women [to the hospital or clinic] because they’re afraid. Because as always, the health sector blames them. And sometimes they’re afraid to take them, or they take them to the hospital and leave them there. If the woman dies, the medical staff will blame the partera. They don’t analyze the situation, the level of poverty” (Interview, F O CA-2 2008). the “governance effects” o f m e a s u r i n g m at e r n a l m o rta l i t y

Since the introduction of the measuring system, the question of responsibility for maternal death has also become an issue for doctors who deliver care to women during pregnancy and childbirth. The blame that was (and to some extent continues to be) directed at

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parteras has been redirected towards other health care workers. As Merry (2011) notes, metrics allow governments to step back from direct monitoring: “there is a shift of responsibility that masks the underlying power dynamics: the indicator itself does the work of critique, and the governed person seeks to conform to the terms of the government” (S88). Rather than being monitored directly by an authority, individuals whose performance is being measured modify their own behaviour in order to meet the required standard (S 85). The shift in responsibility may “undermine autonomy, a sense of trust, and a willingness to co-operate with certain kinds of populations” (S 90). The governance effect, therefore, may motivate resistance as well as responsibility. In Mexico, the reporting of maternal mortality to the federal Ministry of Health, and the creation of local and national committees to investigate the causes of death, have redirected attention to the actions of doctors and other health care workers. While this monitoring has allowed for deeper analysis of the causes of morbidity and mortality, its governance effects mean that some physicians and other health care workers will feel blamed in cases of maternal death, and may resist responsibility by avoiding delivering babies or by changing the records of death. In my interviews with health sector officials, doctors, and N G O s, claims about responsibility frequently surfaced in the discussion of maternal mortality. An I MSS-Oportunidades official discussed how the process of reviewing and analyzing cases of maternal death led to the assumption of responsibility by the attending physician: When there’s a maternal death, everything changes … everything changes, because none of us wants to have a maternal death … When a doctor has a case, he has to present himself to a local committee, he feels responsible for what has happened. If the analysis shows that the doctor made a mistake or didn’t act in a timely manner, or the patient wasn’t assessed properly and was sent home and unfortunately died, then, first there’s training, he’s sent to obstetrics at the hospital. Secondly, well, he assumes the ethical and professional responsibility and then says, this no ­longer has to happen to me. (Interview, I M S S -o 2008) This quote suggests that, rather than being disciplined, a doctor would receive the appropriate training – which, given that he or she

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may not have had such training previously, could potentially be a helpful response. However, the ethical and professional responsibility is perceived as pertaining to the individual rather than to the health care system, or the medical profession. In cases of maternal death, it is the individual who is confronted with the situation, and who will assume – or avoid – responsibility for it. But what is overlooked in this focus on an individual’s culpability is how a series of systemic factors such as poor training, insufficient supplies, and inadequate emergency transport may result in a failure to act appropriately. The quote above also suggests that a doctor found responsible for a maternal death will receive training and support to improve his or her skills. Doctors I spoke to in the I M S S -Oportunidades health clinics in Oaxaca, however, feared that their counterparts at the hospital would blame them in the case of maternal death. The lack of resources at the clinics means that doctors feel that they are unable to resolve obstetric emergencies but fear referring patients to the regional hospital, both because they doubt the hospital’s capacity to provide adequate treatment, and because they dread the opprobrium of their colleagues at the hospital if the patients they refer die upon arrival. A doctor who had witnessed two maternal deaths said that “when we arrive at the hospital, they totally blame us, they crucify us. They say: you were there and you saw what happened … The truth is that we’re afraid to attend a birth … Because we know that if a patient dies with us, we’ll be a laughingstock, and we’ll be questioned from all sides and we’ll have to carry the blame. So, there’s a certain fear of attending a birth, and the community notices it … The government is applying pressure, but for me it’s irrational that we wouldn’t have maternal deaths when we’re under psychological pressure and we don’t have the appropriate equipment, besides” (Interview, I MSS-MR 3 2008). There is some evidence that this has led to an under- or misreporting of maternal death. The report from Chiapas that opens this book highlights an ill-equipped physician’s destruction of patient records in the wake of a woman’s death in childbirth. An N G O representative in Oaxaca also reported that the doctors were frightened of experiencing a maternal death, and, particularly in the context of an increase in the number of deaths in 2007 in the I M S S -Oportunidades system, this led to under-reporting of maternal mortality.

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This year there’s been a rebound in maternal death. This rebound has been in the institutions, and I M S S -Oportunidades has had a striking increase. I have good relationships with people in the health sector, in I MSS-Oportunidades, and they tell me that the central authorities are terrifying them … But what I’m telling you is that we have doctors who are unaware, we have doctors who are terrified, and we have to raise their awareness. Because with this increase in maternal deaths, if they apply sanctions in areas where there’s been more deaths, if they find culpability for the sake of appearances, what then? So the doctors are terrified. And what happens? Sub-registration. There are deaths that are recorded under other categories. (Interview, RCC-2 2008) While the Directorate General for Health Information investigates and corrects cases of misclassified maternal deaths (S S A 2012a, 11, 24–5), more accurate statistics are produced but the problems with the organizational environment remain. If primary care physicians fear the professional consequences of a maternal death, yet also feel that the system does not provide them with the resources to prevent it, trust in the networks which comprise the system is undermined. In my discussions with health sector officials and doctors, they frequently stated that medical personnel were unfairly maligned in cases of maternal death, and they tried to shift responsibility to other parties: the woman’s culture, her family, even the woman herself. Interviewees often suggested that it was the woman’s failure to deliver at a clinic or hospital that led to her death, and that her use of a medical facility had been prevented by her husband, mother-inlaw, or a culture in which her life was not worth the cost of the trip to hospital. An official from I MSS-Oportunidades, for example, told me, “The grave problem we have in Oaxaca is our population; our population still doesn’t understand the value of life, neither for the woman nor the child” (Interview, I M S S -O 2008). This is not to deny that gender inequalities and family dynamics have harmed women’s decision-making autonomy and prevented them from accessing emergency obstetric care when needed. Kolodin et al. (2015) report that the degree of women’s decision-making autonomy about when to seek care varies widely among communities; in some, husbands and / or mothers-in-law have the final say about whether to obtain medical assistance in childbirth. In my fieldwork, both doctors and N G Os cited instances where family members had prevented, or tried

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to prevent, women from being transported to medical care. However, when those within the system blame the communities or families it allows officials and doctors to avoid examining the problems of the health system itself. Delays in seeking care may also be intertwined with families’ perceptions of the system (Maine et al. 1997, 11); in the Mexican case, we do not know whether or how the two reinforce each other, and whether the refusal to transport a birthing woman to medical care is an expression of gender-based violence or of fear of the system itself, based on past experiences of racism or discrimination. Given that hospitals, particularly in marginalized regions, may not have the capacity to resolve obstetric emergencies, people’s lack of trust is not necessarily unwarranted. conclusion

One of the ways in which M D G -5 influenced maternal health policy in Mexico has been through its emphasis on quantitative measures of progress. In 2004, Mexico introduced a more rigorous system for the reporting of maternal mortality, which mandated that deaths from complications of pregnancy and childbirth be declared to federal authorities. Local systems for the investigation of maternal deaths had existed in hospitals since the early 1980s, but in the post-M D G era they were supplemented with a national-level committee, A I D E M . The evidence that emerged from the new measurement regime had several knowledge effects. First, it showed that the majority of deaths were occurring in public health care facilities, and not at home under the care of parteras. Second, this evidence reinforced the shift of paradigms underlying maternal health policy from an obstetric risk model to an EmOC model. While a well-functioning health care system is important in both models, it becomes even more important in the E mOC model. If it is the management of obstetric complications, rather than the identification of risk, which becomes critical, then more attention needs to be given to the system’s capacity to resolve complications. Third, the data presented at technical meetings organized by maternal health NGO s informed public health officials about problems inside the system, and reinforced N G O s’ earlier conclusions about the relative responsibility of medical practitioners rather than parteras.

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Mexico and the Maternal Health MDG

53

The exposure of failures within the system, and the attention to the causes of maternal mortality, has the potential to increase trust in the system by ensuring that practitioners behave ethically and responsibly, which would increase generalized and interpersonal trust. However, in a context in which individuals may not have the appropriate training or medical supplies to manage an obstetric emergency, a punitive response may undermine their trust in the networks that comprise their organizational environment. If blame is placed on individuals rather than the structures in which they work, the trustworthiness of the system will be undermined rather than enhanced.

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2 Maternal Health and Health ­Sector ­Reform in Mexico

introduction

Although a woman’s health in pregnancy and childbirth is influenced by numerous factors, her chances of surviving obstetric complications are greatly affected by the existence of a well-functioning health care system. Mexico’s health care system is a fragmented one. Individuals who work in the formal sector have, along with their families, access to health care, among other social services; they are rights-holders (derechohabientes) within one of several social security institutes. Those in the informal sector, who are referred to as the uninsured, do not have access to social security benefits, but they do receive varying degrees of care through services provided by the state Ministries of Health, and federal government programs such as IMSS-Oportunidades.1 Although the most recent health care reform, the introduction of Seguro Popular, has extended health care access to much of the Mexican population and has thereby increased the potential for trust in the system, there are dramatic differences in the quality of care covered by Seguro Popular (which I will refer to as public health care). As discussed in the introduction to this book, trust between the patient and health care provider is shaped by the nature of the health care system itself (Gilson 2003; Freedman et al. 2004). Funding systems that promote norms such as solidarity and fairness, resource allocation mechanisms such as risk-pooling, and service provision based on need rather than ability to pay, all increase the possibilities for trust (Gilson 2003, 159–60). Corporatist social security models, which segment risk pools along socioeconomic lines, foster

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Maternal Health and Health ­Sector ­Reform in Mexico 55

divergence between different socioeconomic groups and undermine the potential for cross-class solidarity (Korpi and Palme 1998, 671). In Mexico, while the corporatist welfare system established in the post–World War II period gradually expanded to cover an increasing number of people, it segmented the population into those with the right to social security and those without. The Seguro Popular system introduced in 2003 has been “layered” over the social security system (Dion 2010, 210). It has three elements that enhance trust in the system: it has expanded access to services based on need, rather than ability to pay; it has reduced the disparities in financing between the social security and the public health care system; and, specifically in relation to maternal health, it has provided pregnancy and childbirth services (including emergency obstetric care) free of charge to extremely poor women who had to pay user fees before the program’s introduction. Nevertheless, the system still retains elements limiting the provision of good quality maternal health care services and the building of trust. The existence of two systems still means that risk-pooling and cross-class solidarity is limited. While resource allocation between the two systems in more balanced than before 2003, it still favours the social security system. The range of services offered under the Seguro Popular program, while more comprehensive than what was available in the 1980s and 1990s, is much more limited than the range on offer for those with social security coverage. The state of infrastructure, the availability of skilled personnel, and the supply of medications are all compromised in the public system. The result is that the quality of care is lower, and women are more likely to die in pregnancy and childbirth if they are covered by Seguro Popular than if they have access to the social security system. overview of the social security system

The social security system was created as part of the corporatist regime consolidated by the Institutional Revolutionary Party (P RI ) in the post–World War II period. While the P RI was not monolithic, and encompassed a range of ideological strains, access to decisionmaking power and influence was unequal; groups with a greater capacity to bargain and mobilize were granted access to public goods in exchange for their support. Under the corporatist system, organized groups – in this instance, workers in the formal sector

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11% of total

1% of total

51% of total

58,293,160 10% of total

10,887,507

46% of total

51,823,314

State health services (funded by Seguro Popular funding, other federal funding, and state contributions)

Seguro Popular Tripartite (federal government, state government, individual); in practice, federally funded

Uninsured (Workers in the informal sector)

IMSSOportunidades (managed by IMSS; funded by federal government)

Public

2% of total

2,049,024

Private

Total Population: 114,706,614

Private insurers and private health care providers

Employer

Individual

Private

Figure 2.1  The Mexican health care system, 2010–11 Diagram adapted from Coneval 2012a, 59; figures from I M S S 2012, 2, for 2011–12. Percentages rounded up to next percentage point. According to the I MS S document, the total number of affiliates may exceed the population total because individuals have enrolled in more than one insurance system (2).

12,206,730

Institute for Private Sector Employees

Institute for Government Employees

1,114,346

Population:

(Navy)

Semar

(Ministry of Defence);

Sedena

IMSS

ISSSTE

Tripartite (employer, employee, federal government)

Social Security (Workers in the formal sector)

(Mexican Petroleum);

Pemex

Health Care Providers

Source of Funding:

System:

Sector:

(Regulatory body)

Ministry of Health (Secretaría de Salud – SSA)



Maternal Health and Health ­Sector ­Reform in Mexico 57

– received access to goods and services such as social security benefits, in exchange for their support for the ruling party (González Rossetti 2004, 2). Corporatism created a degree of political stability and, in the period following World War II, strong rates of economic growth: between 1940 and 1968, the yearly growth rate averaged 6 per cent (Padilla 2008, 9). This growth, however, was unevenly distributed across income groups. In 1950, the poorest half of the population received 19 per cent of national income; by 1975, this share had dropped to 13 per cent, while the top fifth of the population controlled 62 per cent of the income pie. Thus, “underdevelopment manifested itself not only through the continued existence of poverty, but through the deterioration of living standards for a significant portion of the population, especially in the countryside” (9). Income inequality was reflected in, and reinforced by, social security coverage. While about 60 per cent of the population in the highest income quintile have coverage, this is true for only 12 per cent in the lowest income quintile (O E C D 2005, 66). In 1943 the federal government created the largest of the social security institutes, the Mexican Institute of Social Security (I M S S ), which provides social security coverage to formally employed workers in the private sector. Public sector workers are covered by the Institute for Security and Social Services for State Employees (ISSSTE ), established in 1960; military staff are covered by the defence department’s institute, Sedena, while navy staff are covered by Semar; and workers with the State-owned petroleum company, Pemex, are covered by its institute. These organizations provide not only health care, but old-age pensions, maternity leave, sick leave, and child care services to their members. These benefits accrue to the rights-holder and his or her family (O E CD 2005, 32).2 Each of the social security institutes owns its own facilities and employs its own salaried staff (19). I MSS is financed through contributions from employees, employers, and the federal government; the other institutes are financed by employee and employer contributions, but the employer in this case is usually the federal government (34). The existence of several separate social security systems is inefficient: resources may be overextended in a hospital in one system, for example, while in a nearby hospital in another system, there may be an oversupply of beds or other equipment (89–90).

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In the 1950s and 1960s, the government of López Mateos (1958– 64) expanded the social security system in response to uprisings by peasant movements and industrial action by trade unions, including those representing teachers and railway, telegraph, and petroleum workers (Dion 2010, 89–93, 100–2). Agricultural workers, members of ejidos (communal landholdings) and credit associations, as well as some peasant proprietors, were incorporated into I M S S (BrachetMárquez 2010, 187–8). In 1960, the government established the social security institute for government workers, I S S S T E (Dion 2010, 188). Although the government expanded social security membership over time, coverage never exceeded 56 per cent of the population, peaking in 1990 (Laurell 2001, 299).3 The economic crisis of the 1980s and 1990s, and the rise of the neoliberal policy paradigm, shifted the federal government’s policy toward the I MSS and weakened, but did not eliminate, the institution. After the 1982 debt crisis and the implementation of structural adjustment policies (which will be discussed further in the next section), per capita social security spending fell by half. From 1987 to 1995, spending increased again, funded by a rise in employees’ I M S S contributions; but it fell once more with the peso crisis of 1994–95. Because employee contributions are calculated as a percentage of income, wage restriction in the structural adjustment period resulted in lower revenue for the I MSS; the federal government also decreased its contributions to the institute (Laurell 2001, 299). These cuts were implemented “at the expense of the maintenance of equipment and installations, work materials, and drugs, leading to a deterioration in the quality of care and working conditions” (301). The governments of Carlos Salinas (1988–94) and Ernesto Zedillo (1994–2000) wanted to implement five reforms4 to the I M S S system; the opposition of the I MSS union meant that only two of these changes were ultimately approved by the Mexican Congress in 1995. While the labour movement was able to stop the privatization of health care services5 under the Zedillo administration, it was unable to prevent the privatization of the pension system, which it had successfully stymied during the Salinas sexenio (Dion 2010, 134, 136). The 1995 legislation replaced defined benefit pensions with a system of individual accounts, managed by private financial institutions (Dion 2010, 135; O E C D 2005, 95).6 A similar privatized pension system was implemented at I S S S T E in 2007 (O E CD 2007, 49, box  2.1).7 Changes were also made to the financing of I M S S

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Maternal Health and Health ­Sector ­Reform in Mexico 59

health care services. Before the I MS S reform, pension funds had cross-subsidized the provision of health care (González Rossetti 2004, 77). After the reform, the financing of health care services was separated from the financing for illness or disability benefits, and health care contributions were gradually transformed into a fixedrate contribution for all workers. The contribution scheme was also modified, so that employees and employers contributed less, and the federal government increased its share to compensate for the reduction (Dion 2010, 137). t h e m i n i s t r y o f h e a lt h ( s s a ) a n d i m s s - o p o rt u n i d a d e s s e r v i c e s

In 1943, the administration of Ávila Camacho (1940–46) merged the Ministry of Public Health and the Ministry of Welfare to form the Ministry of Health and Welfare (S S A ) (Birn 2006, 247) – now known simply as the Ministry of Health.8 This organization was the counterpart of the I M S S for the uninsured population: it set public policy and provided health services to the uninsured through clinics and hospitals throughout the country. These health facilities were owned and managed by the Ministry of Health and financed via general tax revenues; their staff received a salary (O E C D 2005, 19). However, the government has provided fewer resources to Ministry of Health services than to Social Security on a per capita basis, and these services, like those of the I M S S and the other social security institutes, were unevenly distributed geographically, with hospitals and clinics concentrated in urban areas (O E C D 2016). In the late 1970s, the P R I implemented a significant policy shift to ameliorate the health conditions of the rural poor. In response to rural land invasions and the development of peasant movements, in 1973 the administration of López Portillo (1976–82) created the IMSS Social Solidarity program. Its goal was to provide non-­ contributory health care services to the rural poor through a network of health centres and hospitals that were managed by I M S S , but funded by the federal government9 and in-kind contributions from the communities receiving services (Dion 2010, 107–9). The program was renamed several times, becoming I M S S -Coplamar10 in 1979; IMSS-Solidaridad in 1989; I M S S -Oportunidades in 2002; and IMS S-Prospera in 2014 (I MSS 2017).

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The principles underlying I MSS-Solidaridad were based on those enunciated at the 1978 International Conference on Primary Health Care at Alma Ata, which produced the first international declaration on primary health care and the goal “Health for All by the Year 2000” (Litsios 2002). In 1983, I MS S -Solidaridad adapted these principles into the Integrated Health Care Model (M AI S ), in which attention was directed to “the individual, family, and community,” and community participation was regarded as central to the model’s success (Escandón Romero and Silva Batalla 2001, 42). Each community where an I MSS-Solidaridad clinic operated had a health committee of three to six members elected by an assembly, which acted as a liaison between the clinic and the community. The organization also established networks of voluntary rural health promoters (promotoras voluntarias rurales), the majority of whom were women, who were trained to visit homes, identify health problems, and promote healthy practices, particularly regarding sexual and reproductive health, contraception, and vaccination. There were 32,000 rural health assistants, elected by community assemblies, who received three months of training and then volunteered in villages with fewer than 500 people to carry out simple medical procedures, refer more complex ones, and promote health education (Cabral Soto et al. 2001, 36–7). Like the Ministry of Health, I M S S Solidaridad also trained parteras.11 This training involved lecturestyle instruction in the physiology of pregnancy and birth, the importance of hygienic delivery (ensuring that materials were clean and sterilized), and the identification of risk factors which, if present, meant that the partera should refer the pregnant woman to the nearest health clinic. A number of authors have concluded that training parteras is ineffective at reducing maternal mortality (Gloyd et al. 2001; Sibley et al. 2007; Wilson et al. 2011).12 Others have observed that, because parteras are more likely to learn through apprenticeship than verbal instruction, and because their model for understanding health and human physiology is so different from the biomedical model,13 training programs run by medical practitioners are unlikely to change the behaviour of trainees; in some cases, they might replace effective existing practices (such as using freshly cut bamboo to sever the umbilical cord) with poorly understood biomedical ones (using scissors cleaned with boiling water, but then dropped on the ground) (Jordan 1983, 1989). The greatest contribution of training programs may be in changing how the parteras talk

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Maternal Health and Health ­Sector ­Reform in Mexico 61

about and legitimate their work, rather than changing their approach to birth itself (Jordan 1989, 928; Pigg 1997). From 1977 onwards, parteras were also trained to promote family planning methods; I MSS-Solidaridad directors reported that “the strongest connection between parteras and the health care system occurred through their family planning activities” (Alarcón Navarro 2001, 25). While the I MSS-Solidaridad and the Ministry of Health systems embraced parteras as a means of encouraging contraceptive use among rural and Indigenous women, the paradigm operating was one of population control rather than sexual and reproductive rights. The latter paradigm did not drive maternal health programming until at least the 1990s, and even as recently as 2002, the National Human Rights Commission reported incidents where Indigenous people’s reproductive rights had been violated by both Ministry of Health and I MSS services. Indigenous women’s reproductive rights had been violated when they were threatened with the withdrawal of social benefits if they did not agree to the insertion of an IU D, and Indigenous men’s rights were also compromised when they were offered material inducements to agree to vasectomies (C N DH 2002, 1). By 2001, I MSS-Solidaridad served more than 11 million people and had built more than 3,500 clinics14 and sixty-nine rural hospitals, the bulk of which had been constructed in the early 1980s (Cabral Soto et al. 2001, 37; Homedes and Ugalde 2006, 53). The greatest period of service expansion was in 1979–81, when thirty secondary care hospitals and 2,715 primary care clinics were built. After another expansion in the late 1980s and early 1990s, there was very little growth in infrastructure or service provision, until the program was reintroduced to the states of Guerrero and Mexico in 2009 (IMSS 2014, 174). As I will discuss in chapter 5, few of the clinic buildings themselves were designed to accommodate the number of people who now use them, and nor were they designed to handle the extremely hot or cold weather in the regions where they are located. The I MSS-Solidaridad clinics functioned with one general practitioner and a bilingual auxiliary worker who could translate the local Indigenous language (Cabral Soto et al. 2001, 32). Nevertheless, in the 1970s I MSS-Solidaridad provided an unprecedented level of service to the uninsured population; as Gómez Dantes has noted, this service “benefited considerably from the overall standards of the regular I MSS regime” (n.d., 8). As I will discuss in the

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next chapter, in Guerrero, the loss of I M S S -Solidaridad services in the 1980s because of policies of structural adjustment and decentralization exacerbated an already bad situation. structural adjustment and neoliberalism: t h e f i r s t wav e

In 1982, Mexico defaulted on its foreign debt, setting off the Third World debt crisis of the 1980s. The United States responded by bringing in the International Monetary Fund (I M F ) and World Bank to manage the crisis. These organizations provided loans to Mexico and other developing countries on the condition that they restructure their economies to allow greater freedom for market forces and facilitate debt repayment by directing production towards export, rather than domestic, markets. Structural adjustment loans incorporated the following conditions, among others: trade liberalization; the privatization of state enterprises; fiscal austerity; the promotion of foreign investment and export industries; and the removal of state subsidies (Ewig 2010, 66). In this period, which Ewig has labelled “first-wave neoliberalism,” the international financial institutions (IFIs) and developing country governments focused on restoring countries’ financial credibility, and did not initially address the impact of structural adjustment programs on poverty, inequality, or the health of the population. Social programs were therefore not developed in this period; instead, they were eliminated or had their budgets cut. Per person public expenditure on health care for the uninsured fell by 60 per cent between 1982 and 1987. While funding recovered over time, it still fell below pre-crisis levels in the year 2000 (Laurell 2007, 516). Along with budget cuts in the health sector, the government of Miguel de la Madrid (1982–88) partially decentralized the Ministry of Health system for the uninsured, transferring the responsibility for health care service delivery to fourteen of Mexico’s thirty-two states. In the fourteen selected states, I M S S -Solidaridad services were merged with Ministry of Health services, and their management was taken over by the state government (O E CD 2005, 46), although it was “generally acknowledged that I M S S -Solidaridad provided better services than did the Ministry and at lower cost” (Laurell 2001, 299). I MSS-Solidaridad staff were given the choice of staying in the I MSS system, rather than joining the state government

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Maternal Health and Health ­Sector ­Reform in Mexico 63

health services. Roughly 7 per cent of personnel chose that option, leaving the new state systems understaffed (Homedes and Ugalde 2006, 60–1). Decentralization also meant that states were able to keep user fees charged to the population; previously they needed to remit those fees to the federal government. Thus, states had a greater incentive to charge such fees, and came to see them as an increasingly important source of revenue in the context of budget cuts (Homedes and Ugalde 2006, 63). As a result of decentralization, the inequality of services among states increased. While states such as Aguascalientes spent 20 per cent of their budgets on health care, others, such as Oaxaca and Chiapas, directed no more than 5 per cent of their resources to health (O E C D 2005, 46). Following protests about the impact of health care decentralization, and opposition from the I M S S health care workers’ union, decentralization was temporarily halted until the mid-1990s (Birn 1999, 93). When it resumed, I M S S -Solidaridad services were exempt, remaining under the control of I M S S . In 1988, Carlos Salinas de Gortari (1988–94) took office after elections that were widely regarded as fraudulent (Thompson 2004). With his support weakening among the population and in the corporatist sectors on which the P R I had traditionally depended, Salinas introduced the National Solidarity Program (Pronasol). With Pronasol, the federal government provided funds to groups who requested money for infrastructure projects in health, education, the provision of clean water, or agriculture. In order to receive funds, communities had to contribute to the projects’ development with their own labour (Encisco L. 2011, 3). The program was run out of the president’s office and bypassed the corporatist groups, “superseding negotiation with national workers’, peasant, and popular organizations, and establishing a direct relation between the president and small local groups” (Laurell 1999, 147). Salinas’s successor, Ernesto Zedillo (1994–2000), replaced Pronasol with a conditional cash transfer (C C T ) program, Progresa, which was renamed Oportunidades and expanded by the Fox administration (2000–06). s e c o n d - wav e n e o l i b e r a l i s m

In the 1990s, neoliberalism in Mexico was deepened further. The Salinas government amended the constitution to permit the sale of communal (ejido) land in 1992; the country became a signatory to

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The Limits of Trust

the North American Free Trade Agreement (N AF T A), which entered into force on 1 January 1994. These policies were followed by an even more profound economic crash, the peso crisis of 1994/1995. In the face of capital flight and a dramatic devaluation of the peso, the US and I MF orchestrated a US$42 billion bailout and further structural adjustment measures (Laurell 1999, 147). In 1995, Mexico’s GDP shrank by approximately 7 per cent. An additional 16 million people fell into extreme poverty, or pobreza alimentaria, in which people do not have sufficient resources to obtain a basic basket of food supplies (Coneval 2009, 18). In this period, the I F I s were shifting to a form of structural adjustment that emphasized the creation of social safety nets and antipoverty policies. There were three influences here. The first was the dissemination of research findings about the negative impacts of structural adjustment. In the report Adjustment with a Human Face, U N IC EF pointed out the negative consequences of adjustment policies for child poverty, health, and nutrition (Walton and Ragin 1990). The second influence was the strengthening of social movements in the Global South and North. In numerous adjusting countries, people rioted against austerity measures; in the US, the UK, and other countries of the Global North, movements such as Fifty Years is Enough and the Jubilee movement called for debt forgiveness and the lifting of loan conditions (Brown and Fox 2000). The third influence on the I F I s was human capital theory, which argued that economic growth depended on the quality – and ultimately the health and education levels – of the population (Ewig 2010, 67). Without abandoning the macroeconomic principles guiding adjustment policies, in Latin America the World Bank and Inter-American Development Bank (I A DB ) began lending to support investment in health, education, and anti-poverty programming. These programs were based on the neoliberal principles of “targeting, decentralization, and cost-efficiency” (Laurell 1999, 147), but they can nevertheless be seen as examples of “second wave” neoliberalism (Ewig 2010) insofar as they re-emphasize social policy, the protection of the most vulnerable from extreme poverty, and the allowing of a greater role for the state in creating social safety nets. In Mexico, the major anti-poverty intervention was the C C T program, Progresa, which was introduced in 1997 to replace Salinas’s Pronasol. It was later expanded and renamed “Oportunidades” under the Fox administration.15

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Progresa / Oportunidades Progresa / Oportunidades is a means-tested conditional cash transfer program in which the female head of household receives a cash payment to support the household’s food purchases, as well as an amount to support each child’s education (at the secondary school level, the amount is larger for girls than for boys, in order to promote girls’ education). The program also provides nutritional supplements for breastfeeding and pregnant women, for children under the age of two, and for those under the age of five if needed. In exchange for financial support, women have to send their children to school; attend talks (pláticas) on hygiene, health, and family planning; attend five antenatal checkups if they are pregnant; and ensure that they, and their children, attend monthly medical consultations. Progresa / Oportunidades was designed to reduce intergenerational, rather than currently existing, poverty; by investing in children’s health and education (and thus their human capital), the designers of the intervention intended that the children of beneficiaries would have the means to escape poverty which had been denied their parents (González de la Rocha 2007). By 2007, approximately 5 million households, or 25 million people, received Oportunidades. Under the Zedillo administration, the program focused on rural poverty, but beginning in 2001 the Fox administration expanded it to include urban as well as rural families, and to pay for children to attend school until the pre-university level (preparatoria) – up from the third year of secondary school (González de la Rocha 2007). Second-Wave Neoliberalism and Health Care Reform When it comes to health care reform in the Global South, Cristina Ewig argues that there have been three periods in second-wave neoliberalism, each one leading to a greater level of state responsibility in health care. During the first period in the late 1980s and early 1990s, policy-makers targeted both populations and the health care packages they received, the contents of which were determined according to cost-effectiveness calculations. Governments used means testing to identify who could receive a limited service package free of charge; user fees continued to be applied to those

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The Limits of Trust

who were, in this scheme, able to afford health care, and / or to the interventions not covered by the package. Some countries introduced community-level insurance or health care financing schemes (Ewig 2010, 72). The I F I s encouraged private sector service delivery and competition between the public and private sectors, which necessitated a “purchaser-provider split” wherein health care funding might be directed towards the private or the public sector (Laurell 2007, 517). The I F I s also promoted health care decentralization, in the belief that services managed at a lower level of government would be more responsive to patient needs, and more efficient, than those which were centrally managed (Ewig 2010, 72). In the second period, from the mid- to late 1990s, the I F I s promoted sector-wide approaches to health (SWA P s), which involved partnerships among State, N G O, and international actors, and the strengthening of health care systems (72). In the third period, which arose at the beginning of the new millennium, the State became more engaged in health care provision, as a result of increasing I F I acceptance of a greater role for the State or because of domestic political shifts (particularly in the case of Latin American countries that had elected leftist governments) (72–3). In Mexico, the first period of second-wave neoliberalism corresponds with the Zedillo administration’s introduction of a targeted health care package, the Program to Extend Coverage (P AC), and reintroduction of the decentralization that had stalled in the late 1980s. The federal government borrowed from the World Bank to finance the P A C , which comprised a basic package of thirteen health interventions (Gómez-Dantés 2012, 4),16 for 8.1 million people, or roughly 16 per cent of the uninsured population. In order to deliver these services, the P A C also deployed mobile units to transport doctors and nurses to remote villages once a month. In the 1990s, the OEC D reported that “17 million persons lived in rural villages with no health-care unit” (O E C D 2005, 64); the use of mobile units under the PA C would do little to compensate for that reality. While the PA C provided some health care, the package was minimal, particularly when compared to the services offered by I M S S -Solidaridad. Mobile units could, in theory, provide antenatal care and referrals, but they would not be able to delivery emergency obstetric care. While the P A C did cover care during pregnancy and childbirth, during my fieldwork in Guerrero I found that women in the poorest municipalities were still being charged user fees to give birth in clinics and hospitals.

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The reintroduction of decentralization was part of a broader strategy implemented by Zedillo to devolve power and resources to states and municipalities under the New Federalism initiative. In health care, decentralization was intended to increase the accountability of state officials for health care provision, speed up decision-making, and encourage states to direct resources toward the specific health problems in their territory (Homedes and Ugalde 2006, 69). To this end, the federal government transferred its control over personnel, material, and finances to the states, and provided them with new resources. It established a new budget line, Item 33 (Ramo 33), through which the Fund for Basic Health Services (F AS S A) was created to direct funds to the states for health care (Falleti 2010, 225).17 The amount of F A SSA funds for each state was calculated according to the existing level of infrastructure and personnel, the operating and investment expenses, and the salaries of the medical staff. These three components of F A SSA meant that the fund reinforced existing health inequities among states, because states with a greater supply of infrastructure and human resources received a greater share of federal funding. The fourth component of F AS S A was based on a redistributive formula which tried to promote equity in service provision among the states, calculated according to the number of uninsured people in the state; however, this was only a small component of FA SSA , and was not sufficient to bring about major change. In a later report, the SSA stated that “if we continue using this formula to distribute resources, it will take decades before the differences among states will disappear” (SSA 2001, 125). the system for social protection i n   h e a lt h  /  s e g u r o p o p u l a r

The Mexican government’s introduction of the System for Social Protection in Health (SP SS),18 or Seguro Popular, is part of the third period of neoliberal health reform (Ewig 2010, 73). When Mexican Minister of Health Julio Frenk introduced the Seguro Popular in 2003,19 he wished to increase Mexico’s low level of health spending; reduce the out-of-pocket spending that impoverishes poor families; redistribute the allocation of resources between those in the social security system and those outside it; and improve investment in health infrastructure (Frenk et al. 2006, 1526). Ewig notes that reforms such as Seguro Popular “might not be considered neoliberal at all, given that they incorporate greater numbers of the poor into

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social policy systems,” but “like the reforms that preceded them, these insurance programs still mimicked markets by separating financing and delivery elements of health coverage, as well as offering narrowly defined packages of health care services selected on a cost-efficiency basis” (2010, 73). The system was envisaged as an insurance system, in which “all individuals [would] have access to affordable health-care insurance, particularly those who are poor”; in exchange, they would be entitled to a package of health care interventions free at the point of service (OECD 2005, 108). As such, Seguro Popular maintained the neoliberal principles of prepayment, the targeting of a package of services selected on a cost-efficiency basis, and the purchaser-­provider split. However, it has departed from earlier versions of neoliberalism in several ways. It has encompassed a far greater number of people (at least 40 million);20 the package of services is larger than that offered under the PAC in the 1990s;21 and, in practice, the system has operated as a tax-financed system rather than an insurance system, because very few affiliates have been charged a premium. The administration’s five-year plan for the health sector was ­subtitled “The Democratization of Health in Mexico: Towards a Universal Health System,” and it linked the development of a health insurance program to the democratic transition Mexico began in the year 2000. Human capital theory provided a rationale for action: the report noted that, along with education, health was essential for strengthening human capital, without which Mexico could not develop. It also acknowledged that health was both a determinant and a result of development; that good health was a consequence not only of health policies, but actions across a range of sectors; and that improving Mexico’s health would fortify its social fabric (S S A 2001, 17). This funding asymmetry between the social security and public health systems has been significantly reduced since the introduction of Seguro Popular. In 2004, the year that Seguro Popular was rolled out, roughly 66 per cent of public health care funding went to the social security system; by 2012, this figure had fallen to 52 per cent (Coneval 2013a, 40) (see table 2.1). Nevertheless, less than half the Mexican population receives more than half of the federal resources, and the social security system also receives funding via individual and employer contributions. While Seguro Popular funding is also tripartite in theory, in practice the other parties contributing to the

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Table 2.1  Public spending on health according to social security status, 2000–12 (in 2012 US dollars) Year

2000

2006

2011

2012

Currency (millions)

USD*

USD

USD

US D

Total spending

19,306.49 25,700.70 34,998.66 35,074.66

Uninsured population

6,620.00 1,0397.55 1,5917.22 16,737.59

Ministry of Health (SSA)

5,087.10

8,200.61 12,540.98

1,172.73

Ramo 12 “Salud”

1,808.95

4,143.86

7,850.70

8,624.45

Ramo 33 “FASSA” (federal transfers to the states)

3,278.13

4,056.75

4,690.27

4,708.27

525.75

513.83

617.40

3,686.41 12,231.98

6,712.14

†

IMSS-Oportunidades Insured population IMSS

999.94 11,891.30

‡

Public sector social security institutes (ISSSTE, Pemex, Sedena, Marina) Spending on uninsured population as a percentage of total spending

646 5,417.08

889.99

889.99

2,686.47

340.68

5,282.15

4,527.09

34.29

35.25

45.49

47.72

* US dollar exchange rate of 0.076 from Canadian Forex, Foreign Exchange Services, at http:// www.canadianforex.ca/forex-tools/historical-rate-tools/yearly-average-rates. †

Ramo 12 includes spending on programs such as the Program for Quality Medical Care; the Program for Healthy Communities; the Program for Mobile Medical Units (SFP 2015).

‡

Includes subsidies for Family Insurance (Seguro de Salud para la Familia), the voluntary IMSS insurance program that may be purchased by individuals not affiliated with the social security system.

Source: Adapted from Coneval 2013a.

program – the states and individuals – contribute far less than what was intended in the original program design. The Design of the System for Social Protection in Health (Seguro Popular) The System for Social Protection in Health (S P S S ) has five main components (SSA 2014, 3–4). Seguro Popular, the main pillar of the system, provides insurance coverage for 285 medical interventions in hospitals and clinics, including emergency and non-emergency obstetric care.22 The Fund for Protection against Catastrophic Health Costs (F P GC ) provides coverage for fifty-nine further interventions with high costs, such as treatment for cervical cancer and HIV /A ID S. Medical Insurance for the Twenty-First Century (formerly known as Medical Insurance for a New Generation) covers

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children under five for medical treatments not covered under Seguro Popular or F P GC . The health component of Oportunidades provides beneficiaries of the conditional cash transfer program with a guaranteed health package, plus nutrition supplements for infants and pregnant women. Finally, the Fund for Budgetary Preparedness (FPP) consists of a contingency fund and a reserve for infrastructure investments.23 These programs and funds are, in theory, financed from three sources: the federal government, the state government, and families enrolled in the program. In practice, as I will explain further below, financing is more complicated and fewer funds are directed to the program than one might expect, given the parties’ stated obligations. The federal government provides two contributions. The first contribution, the social quota (C S), is provided to each individual affiliated with the program. Until 2010, it was calculated at 3.92 per cent of the daily minimum wage in the Federal District, added over a year and adjusted quarterly for inflation; in 2013, this amounted to Mex$911, or approximately US$70 per affiliate (S S A 2014, 92; my currency calculations).24 The second contribution, the federal solidarity contribution (A SF ), is one-and-a-half times the social quota; in 2013, this was Mex$1,367, or approximately US$105 (S S A 2014, 92; my currency calculations). However, as I will discuss below, once the cost of other similar health programs has been deducted from this contribution, fewer resources are made available (S S A 2014, 93). State governments are the second source of funding; they provide a solidarity contribution (A SE ) which is equivalent to half the federal social quota for each individual enrolled. In 2013, this was Mex$455, or approximately US$35 (SS A 2014, 92; my currency calculations). States, however, are able to count past spending on health-related infrastructure toward their solidarity contributions, so the actual cash amount contributed is lower. The third source of funding is the insurance premium, the family quota (CF ), paid by individuals or families affiliated with the program. People in the lowest two income deciles have always been exempt from this premium; since 2010, those in the third- and fourth-lowest income deciles have also been exempt (Laurell 2013, 91), as have those in the lowest seven income deciles if the family includes a woman who is pregnant or gives birth at the time of affiliation to the program (SSA 2014, 94). In June 2015, 99.8 per cent of affiliates belonged to the lowest four income deciles, and therefore did not pay; only 0.2  per cent of affiliates contributed to the scheme (S S A 2015b,

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13–14). For those few who do pay, the premium ranges from Mex$2,075 (roughly US$160 per annum) for families in the fifth income decile, to Mex$11,378 (roughly US$876 per annum) for families in the top income decile (SS A 2014, 94; my exchange rate calculations). As I will discuss below, all three sources have generated fewer resources than intended in the program design. The funds are managed by the National Commission for Social Protection in Health (C NP SS), which transfers funds to each state’s Regime for Social Protection in Health (RE P S S ), which is in turn overseen by the state’s Ministry of Health (Bonilla-Chacín and Aguilera 2013, 11). The states then use the funds to finance services provided by their health ministries, according to the health care package – so in the case of Seguro Popular, each state’s Ministry of Health must supply 285 medical treatments free of charge to Seguro Popular affiliates. The federal Ministry of Health aimed to incorporate 14.3 per cent of the uninsured population into the S P S S  / Seguro Popular system each year until total coverage had been reached (Bravo y Rincón 2006, 22). The Ministry of Finance had insisted on an affiliation rate no greater than 14.3 per cent because of fears of the impact on the federal budget (Lakin 2010, 325). According to the National Commission for Social Protection in Health (CN P S S ), the goal of complete coverage was reached in 2011, with the affiliation of 49  million people (Cruz Martínez 2010, 32). In 2013, the CN P S S reported that more than 55 million people were covered by Seguro Popular (SSA 2014, 6). The National Survey of Employment and Social Security (E NE SS) produced a figure of 41 million, however (IN EG I 2014, 19, table 2.1). The survey reported that, in a population of roughly 118,500,000, approximately 77 per cent had some form of health care coverage, whether in the form of social security, Seguro Popular, or other public or private institutions; this still left more than 26 million people, or 23 per cent of the population, without coverage (I NE GI 2014, 19, table 2.1).25 While it is impossible to determine the reason for the discrepancy between the Ministry of Health figures and those reported by the National Institute for Statistics and Geography (I NE GI ), Laurell (2013, 53) has pointed out that the state and federal Ministries of Health have an interest in inflating affiliation data. Affiliation rates have also varied by state, and program incorporation has proceeded more slowly in states with larger numbers of Indigenous people (Bravo and Rincón 2006, 61–2): Guerrero’s

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affiliation rate was the lowest (66). States began their Seguro Popular affiliation drives in urban areas, which were better equipped with the health care infrastructure needed to provide services to new members (81); this has meant, however, that people in remote, poor, and / or Indigenous municipalities, without existing infrastructure, have been affiliated last, thus compounding their disadvantage.26 This strategy has also been employed in the Oportunidades program. Women did not receive Oportunidades if they lived in villages so poor that they did not have a school or medical centre to enable women’s compliance with the conditions of the program (de la Rocha 2007). When President Felipe Calderón (2006–12) was inaugurated, he introduced an additional program to increase Seguro Popular affiliation. Medical Insurance for a New Generation (S M N G ) applied to  all babies born on or after the president’s inauguration on 1 December 2006, and gave children insurance coverage for a series of infant illnesses as well as the interventions covered by Seguro Popular (C NP SS 2011, 4). Feminist NG O s pointed out the injustice of a program that provided a child with health insurance while not protecting his or her mother during pregnancy and childbirth (Interview, K A -1 2008); two years later, Calderón’s government introduced a strategy to increase Seguro Popular affiliation among pregnant women, called Healthy Pregnancy (Embarazo Saludable). l i m i tat i o n s o f t h e s y s t e m

Financing The federal government is responsible for most Seguro Popular funding, and it has increased funding to the system by 11.5 per cent annually in real terms (Joint Learning Network 2013), resulting in an additional US$5 billion between 2004 and 2013 (S S A 2014). As discussed above, Seguro Popular has three main sources of funding – a social quota and solidarity contribution from the federal government, a solidarity contribution from each state government, and insurance premiums from individuals and families in higher income deciles – in each case, the amount of revenue is nonetheless lower than originally intended. Furthermore, in 2010, the federal government made changes to the formula for calculating the Social Quota (the contribution for

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each affiliated family). Until December 2010, the quota was calculated per family; after that date, it was calculated per individual. However, when the amount was calculated for each affiliated family, it was on the assumption that the average family contained 2.9 individuals; when it was calculated for each individual, it still used the number of affiliated families as its reference point, but assumed that the average family contained 2.79 individuals rather than 2.9, with a resulting reduction in funding (Laurell 2013, 85). The total annual funding decreased by 13,448.4 million pesos, or roughly US$1.75 billion (Laurell 2013, 87; my currency calculation). As a result, the federal and state government solidarity contribution also diminished because it is based on the number of individuals enrolled (87). The other federal government transfer, the federal solidarity contribution (A SF ), is 1.5 times the social quota. However, the program regulations permit funds from several other health care programs (such as the fund to improve the quality of health services, the health component of Oportunidades, and salary provisions) to be deducted from the A SF (SSA 2014, 93); this means that the AS F has little impact on funds transferred to the states (Laurell 2013, 90). While it may be argued that these funds are instead provided through other programs (see Chacín and Aguilera 2013, 6), given past underinvestment in health care, and low public expenditure as a proportion of G DP,27 both streams of funding are needed. A reduced amount in the federal solidarity fund means a lower contribution from the states (whose contribution is set at half the amount of the AS F for each state), and a lower contribution for infrastructure spending (set as a percentage of federal Seguro Popular funding, including the federal solidarity contribution). The state solidarity contribution is also limited. The contribution “was opposed by most state governments from the beginning” (Lakin 2010, 325). The federal government decided to allow states to count infrastructure investments that they had made in the five years before entering the program toward part or all of their contributions (327). In Ministry of Health documents, states’ contributions to Seguro Popular are categorized as “liquid” (liquida) if funds have actually been rendered, or as “credited” (acreditable) if no funds have been contributed; but past funds have been counted in place of current expenditure. However, such past expenditure has not necessarily been put toward services for the uninsured population. Instead, it has been for specialty hospitals where Seguro Popular

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The Fund for Basic Health Services for Individuals (FASSA – P) National Health Programs Medical Insurance for the Next Generation (SMNG) Salary Provisions Support to Strengthen Health Services Quality The health component of Oportunidades Figure 2.2  Programs whose financing is deducted from the federal solidarity ­contribution (ASF) Source: Secretaría de Salud. 2014. 93, Figura 7.1

affiliates are entitled to only a very limited number of treatments. Lakin notes that, in Oaxaca and Chiapas, states have credited investments in specialty hospitals in major cities, which provide few services to Seguro Popular beneficiaries. In addition, it is not clear that state contributions to Seguro Popular are coming from state revenues rather than federal transfers (Lakin 2010, 327–9). Although the Ministry of Health aimed to have all states making “liquid” contributions by 2010, on average only 28 per cent of state funds were “liquid” in that year (C NP SS 2012a, 49). The 2013 Seguro Popular report indicates that states are still allowed to credit past contributions, but the report does not break down the total amount for each state, nor the distribution between “liquid” and “credited” amounts (SSA 2014, 94). Individuals and families have not contributed significantly to Seguro Popular either: only 0.2 per cent of affiliates pay a premium for joining the scheme (SSA 2015b, 13–14). While this has meant that the system is virtually tax-financed, thereby increasing people’s access to a package of health care services, that result has been by default rather than design; it also means that unless federal government payments increase to compensate for the loss of revenue, the system will be underfunded. In 2005, the O E CD reported that, “if, for example, 20% of the currently uninsured population do not insure with Seguro Popular, the additional resources for the uninsured at the end of the transition period [2012] will be lower by 30%” (2005, 121). Currently, far fewer than 20 per cent of the target population have become paying members of the scheme.

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Table 2.2  State solidarity contributions to Seguro Popular revenues: “liquid” contributions and “credited” contributions by state, 2006–11 (in thousands of Mexican pesos)

State Aguascalientes Baja California Baja California Sur Campeche Chiapas Chihuahua Coahuila Colima Federal District (DF) Durango Guanajuato Guerrero Hidalgo Jalisco México Michoacán Morelos Nayarit Nuevo León Oaxaca Puebla Querétaro Quintana Roo San Luis Potosí Sinaloa Sonora Tabasco Tamaulipas Tlaxcala Veracruz Yucatán

Current (“liquid”) contributions as State solidarity contribution Credited contribution percentage of total state contributions (“liquid”) (for past spending) 1,077, 487.9 245,814.0 1,182,000

9,149.6 114,381.1 177,689.9 1,492,158.5 357,319.7 3,701,596.5 968,653.5 389,481.5 1,380.5 682,808.7 687,930.3 209,601.3 149,436.3 400,667.3

508,292.0 2,974,842.0 66,906.2

993,657.4 753,741.8 86,662.7 869,010.1 3,916,225.5 2,078,113.0 1,040,718.4 693,603.0 4,304,913.7 776,601.2 5,254,424.7 1,169,017.9 2,010,174.8 3,743,665.4 4,427,093.4 1,603,121.8 1,165,067.0 1,113,729.9 1,567,612.4 3,148,352.3 3,301,536.7 972,314.7 610,946.4 1,977,884.8 1,900,796.1 1,566,546.6 3,753,310.9 2,663,732.7 659,610.1 3,443,566.8 1,377,138.1

0 58 73 0 23 0 0 1 0 12 3 56 15 0 45 37 25 1 0 21 20 17 19 16 0 0 0 0 43 46 4

Source: Adapted from CNPSS 2012a, 73–4.

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Health Care System Functioning: Infrastructure The increased funding for the public health care system via Seguro Popular funds has resulted in infrastructure improvements. Nevertheless, my observations during fieldwork, and a number of internal and external evaluations, indicate that Mexico’s health care infrastructure is deficient – particularly for the uninsured or Seguro Popular affiliates. This not only affected the capacity to deliver good health care, including maternal care, but it may also undermine trust in the system. In its analysis of 11,854 complaints about the health care system received between 2000 and 2009, the National Commission on Human Rights reported: “The lack of hospital infrastructure and material resources … presents an obstacle to the effective guarantee of the protection of the right to health. In many instances the complaints make reference to the insufficient number of beds; of medications; of hospital infrastructure, above all in rural zones; of medical equipment that is indispensable to care for the sick or perform necessary surgical interventions” (CN D H 2009). In 2010, the Ministry of Health also stated: “Mexico’s public health institutions do not have sufficient resources to attend to the needs of the population for whom they are responsible” (S S A 2010, 18). This, the authors continued, was a problem of absolute scarcity as well as maldistribution of resources, and, in the case of hospital infrastructure, “is reflected in the low availability of beds, surgeons, specialized equipment, doctors, and nurses in the states with the fewest resources which paradoxically are those with the greatest need” (18). No public health care institution – whether affiliated with social security or the Ministry of Health – has enough hospital beds (S S A 2010, 18). The number of doctors and nurses per thousand people is lower in the public health care system than in the social security system, as is the number of hospital beds. The problem is more severe in the Ministry of Health system than in the social security system, however, particularly when regional differences are taken into account. The Ministry of Health system has 0.6 beds per 1,000 population, whereas I MSS and I SSST E each have 0.8 beds. Chiapas and Oaxaca have fewer than 0.4 beds; Guerrero has slightly more than this number (SSA 2012c). Health care centres28 lack the basic infrastructure for the delivery of health care services. A 2007 survey conducted for the Oportunidades program found that 30 per cent of facilities did not have

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Table 2.3  Beds per thousand according to social security status, nationally and in selected states State National Federal District Chiapas Guerrero Oaxaca

Total

Uninsured

Insured (via social security coverage)

0.8 1.8 0.4 0.6 0.6

0.7 1.7 0.4 0.4 0.5

0.9 1.9 0.8 1.0 0.8

Source: SSA 2012c.

running water; 12 per cent lacked bathrooms for the doctors and nurses working in them; and 19 per cent lacked bathrooms for patients. While “nearly all – 98% – had electricity, a high percentage had frequent interruptions in supply” (I N S P 2011, 16). A “significant number” of facilities lacked telephone or radio service, let alone internet (16). Although 1,010 new medical units have been built since the introduction of Seguro Popular, and 450 have been renovated (Cruz Martínez 2010, 32), this is still fewer than the units built in one year under the I MSS-Solidaridad program. Under Seguro Popular, the SSA has introduced an accreditation system for clinics offering services to affiliates. By 2009, roughly half (49.6 per cent) of the Ministry of Health clinics were accredited; but, again, the rate of accreditation varied among states, with only 18.5  per cent of centres in Chiapas and 20.5 per cent of those in Guerrero qualifying (surprisingly, at 52.6 per cent, Oaxaca slightly exceeded the national average) (I NSP 2011, 16). The transfer of infrastructure spending in the federal budget has been unclear. The Budgetary Reserve Fund (F P P ) is the source of infrastructure funding: via this fund, 2 per cent of Seguro Popular revenues go towards infrastructure investments in poor communities, with an additional 1 per cent of funds held as a reserve to cover unforeseen demand for services and to support interstate service provision (SSA 2014, 113). If, in any particular year, this fund is not used for infrastructure, the money reverts back to the Budgetary Reserve Fund. Between 2004 and 2009, however, only 25 per cent of the money in the infrastructure fund was transferred to the states (Interview, Fundar-2 2010; see also Laurell 2010). A representative from Fundar noted that “if [infrastructure spending] was the

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objective of this fund, then that objective hasn’t been complied with. The explanation for this has been nonexistent. The annual and semiannual reports of the Commission for Social Protection in Health don’t explain why” (Interview, Fundar-2 2010). Another reason why infrastructure funds may not have been spent is because state government infrastructure plans must conform to an Infrastructure Master Plan (Plan Maestro de Infraestructura) before funds are authorized (C NP SS 2012b, 51). It is possible that some states have not had the capacity or will to create infrastructure proposals that conform to the Master Plan, and hence have not received funding (Interview, Fundar-2 2010). The staff at Fundar pointed out that funding for hospital renovations had been authorized under a different section of the federal budget. They were nevertheless concerned about the lack of explanation for why the infrastructure fund was not being used, and also concerned that, given the past lack of investment, infrastructure spending was not sufficient to compensate for accumulated deficits in the system. At the National Budget Convention (Convención Nacional Hacendaria), Fundar argued, unsuccessfully, for a large, short-term investment of funds to address the infrastructure deficit, rather than providing a small amount of funding each year (Interview, Fundar-2, 2010). The Auditor General of the Federation (which audits the accounts of programs and organizations using federal funds) has also raised questions regarding the F P G C funds (Méndez 2007). According to a recent C N P S S report, 77 per cent of the Budgetary Preparedness Fund was spent on infrastructure between 2007 and 2012, a considerable improvement on previous years (2012a, 51). This nevertheless left roughly US$180 million unspent. Personnel Mexico suffers from a shortage of medical staff, who are poorly paid and frequently not appropriately trained to serve the needs of the population. Doctors and nurses in both the social security and the Ministry of Health sectors are paid salaries, whereas private sector practitioners are paid on a fee-for-service basis (OECD 2005, 56). Wages are lower in the Ministry of Health than in the social security system, potentially undermining performance. The OECD observed that “low wages may reduce incentives for professionals to remain in the health-care sector and may also lead to absenteeism, low staff

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Table 2.4  Doctors and nurses in contact with patients per thousand according to insurance coverage, nationally and in selected states State National Federal District Chiapas Guerrero Oaxaca

Total

Uninsured

Insured (via social security institutions)

4.0

3.9

4.2

8.3 3.0 3.5 3.8

7.7 2.8 3.0 3.7

8.8 4.2 4.9 3.9

Source: SSA 2012b.

morale, and the involvement of health professionals in second jobs (in either the public or the private sector, or even outside the health sector) … Nurses’ hourly wages appear to be particularly low, representing approximately one-third less than the average wage” (2005, 56). In 2009, there were 0.6 doctors and 0.5 nurses in contact with patients per 1,000 people in the Ministry of Health system: the World Health Organization (WH O) recommends 1 per 1,000 people (IN SP 2011, 16). The number of doctors and nurses in contact with patients (as opposed to doing administrative or management tasks) also varies according to social security status and location, with the uninsured having less access to medical professionals, particularly in Chiapas, Guerrero, and Oaxaca. This figure includes recent medical school graduates, known as pasantes, who are completing their compulsory year of social service. The administration of Lázaro Cárdenas (1934–40) instigated the social service system in 1936 to provide medical services in rural areas; now, however, the system limits the number of positions available for permanent employees. The head of Mexico’s largest medical school, at the National Autonomous University of Mexico (U N AM ), has stated: “Eleven thousand pasantes in the rural area provide primary care for this unprotected population, saving the health sector from contracting 11,000 general practitioners to meet this objective. In this way, paradoxically, the pasante misses out the following year on the opportunity to be contracted by the national health care system” (Graue-Wiechers 2011, 522). The pasantes are poorly paid, earning Mex$1,100 a month (US$88) (S E G O B 2011). Roughly 40 per cent of the health care

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centres in rural areas are operated solely by pasantes (I N S P 2011, 36).29 The National Human Rights Commission (C N D H ) noted that the right to medical care has been compromised by the failure to supervise pasantes and medical residents. The organization stated that the most serious problems that confront the institutions charged with the provision of health services is the relative lack of doctors, specialists and nurses necessary to meet the demand; the lack of training to develop efficient diagnoses and offer treatment appropriate for the illnesses; and the insufficient supervision of residents or pasantes by health care personnel … It is clear that there are various aberrations in the delivery of medical care, such as treatment that does not respect the dignity of the person and, in some cases, discriminatory conduct that affects the welfare of the patients; the lack of attention in emergency facilities; irregular attention; the mistreatment of patients; negligent surgical interventions; inadequate delivery of medical service, and deficient maternal-infant care during pregnancy and childbirth. (C N DH 2009) As a part of the Seguro Popular reform, the Ministry of Health implemented a commendable change in the field of medical education: in order to be hired by state, federal, or social security health institutions, medical staff must have graduated from an accredited medical or nursing school. In 2000, only twenty-three of seventyeight medical schools were accredited, and only five of 300 nursing schools (OECD 2005, 58). The greater incentive for accreditation is a step in the right direction. Nevertheless, Graue-Wiechers (2011, 521) acknowledges that there is “some truth” to the claim that Mexican medical schools are “not training general practitioners with the competencies, knowledge, and skills that the country requires.” Given the levels of violence and conflict in many parts of the country that are embroiled in the drug war, the pasantes themselves face threats to their security. In the last six years, “three pasantes have been murdered, two kidnapped, one attacked with an ice pick, at least two taken by armed commandos to treat a wounded person, one raped and beaten, and 62 threatened” (Martínez and Alatorre, 2012). A survey carried out by the UNAM Faculty of Medicine found that 60 per cent of their pasantes in the 2009–12 cycle had been sent

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to clinics without a phone service, 19 per cent had been robbed, 1.5 per cent had been kidnapped, 37 per cent felt insecure in their location, and 23 per cent had thought about resigning because of the level of insecurity (Martínez and Alatorre 2012). Medications In my fieldwork, I found that doctors, researchers, and N G O s frequently mentioned the lack of medicines, including medicines needed to treat obstetric emergencies. It is not clear why there are problems with the supply and distribution of medications. The O E CD commented that the system for supplying and distributing medicines and medical materials “does not appear well-governed or well-managed.” The organization recognized, however, that the difficulties may be as much a consequence of past austerity as current mismanagement: “low efficiency in provision may reflect the effects of the severity of past budget constraints on supplies of materials and pharmaceutical drugs, rather than simply a management or programming problem” (2005, 135). A Ministry of Health report classified hospital supplies as “good,” but noted variation across states and between the social security and Ministry of Health systems. Hospitals in Chiapas had less than 40 per cent of the necessary supplies at hand; the Hospital General de San Cristóbal de las Casas had less than 20 per cent of the medicines listed in the basic set of medicines (CBM ). In its study, the Ministry of Health also found hospitals “without glucose solution or penicillin” (SSA 2010, 33). Although particular states and cities lacked adequate supplies, hospitals in general were better equipped than clinics and health care centres. On average, the National Institute of Public Health (IN SP) found that clinics had 85 of the 264 medications listed in the basic set of medications (2011, 31). A study by Granados-Cosme et al. (2011, S460) found that problems existed in states where the supply and distribution of pharmaceutical and other supplies were managed by the state Ministry of Health, but also where those functions had been outsourced to the private sector. The participants interviewed in the study cited differing reasons for problems with supply. Some respondents stated that, under the Seguro Popular system, their budget for medical supplies was lower than it had been when they obtained user fees from patients. Others argued that the

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resources were sufficient but ill-timed: their delivery in the last quarter of the year meant that clinics were scrambling to obtain supplies until the disbursement arrived. In both systems, respondents complained that they did not receive the medications they needed, while receiving those they did not (S465). As with other medical resources, wealthier states pay more than poorer ones to make medications available to their populations: in  the most extreme example, Chihuahua spends 276 times what Hidalgo spends on pharmaceuticals per family (Mex$408 versus $1.48, or US$32 versus $0.11) (Murayama-Rendón 2011, 502). States were also not spending the money allotted to them under Seguro Popular for medicines: in 2009, states spent Mex$786.3 million (approximately US$61,690,000), which represented only 15 per cent of the amount that should have been dedicated to pharmaceutical supplies (498). Of the funds spent, on average, state Ministries of Health paid almost one-third more than necessary for medicines, because they are purchasing them at higher than the list price; only 47.2 per cent of the key medications were acquired at the recommended prices. Measures to Improve Quality of Care Two programs are specifically intended to address the quality of care in the medical system. In 1996, the Zedillo administration established the National Commission for Medical Arbitration (CONAMED), which aimed to resolve conflicts between health care providers and patients through conciliation and arbitration procedures (OECD 2005, 58). However, CONAMED lacks regulatory bite; it “cannot compel health care organizations to submit to investigation when they have been denounced for medical error or negligence,” nor can it ensure that they comply with the organization’s recommendations (Cruz Martínez 2011, 42). For its part, the Fox administration launched the National Crusade for Quality in Health Services (Cruzada Nacional por la Calidad de los Servicios de Salud), which aimed to create a culture conducive to quality improvement in the health care system (SSA 2007, 12). One important mechanism for inducing such a culture was the accreditation system introduced under the legislation that created the SPSS, which mandated that units supplying service to affiliates of the system must be accredited (19). The National Crusade for Quality in Health Services was

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replaced by the succeeding administration with the Comprehensive System of Quality in Health (SICALIDAD). In its justification for updating the previous program, the Ministry of Health commented that the new program intended to bring a more integrated and unified approach to quality improvement. SICALIDAD would improve “the technical quality of care and patient safety; users’ perceptions of the quality of care; and quality in the management of health services” (24). It would maintain accreditation processes established under the previous administration and would develop new means of monitoring and evaluating the system, including the use of NGOs to monitor health care services; the analysis of health care practitioners’ experiences in trying to deliver quality of care; and the introduction of specific actions to prevent violations of safety, such as measures to prevent hospital-acquired infections. Regarding maternal and perinatal mortality, SICALIDAD advocated the inclusion of quality indicators in the state-federal government agreements through which the SPSS is managed. It also recommended the inclusion of criteria specifically related to maternal health in accreditation processes (33). An evaluation by Durán Arenas (2010), however, found that hospitals’ implementation of quality improvement plans was highly uneven depending on the hospital and the strategy. The author noted the need for infrastructure improvement: most health care units’ infrastructure was in enough disrepair that it did not warrant accreditation. He also pointed out that a number of managers had done as little as possible to satisfy the accreditation standards, without committing to organizational change: “one big problem with accreditation is that the Ministry of Health hospitals do the minimum amount necessary to comply with the requirements, and they do not maintain these levels of quality [after accreditation has been achieved]” (108). The S I C A L I D A D document does not address the largest obstacles to quality of care – the problems with infrastructure, the large proportion of care delivered by pasantes in Seguro Popular and I M S S -Oportunidades facilities, and the difficulties with the supply and distribution of medications. Another evaluation in 2015 found that the implementation of S I CAL I D AD varied widely across Mexico, and that some states – Guerrero, Campeche, Michoacán, and Yucatán – had not implemented elements of the program. The evaluation noted that only 27 per cent of health care facilities had been accredited under the program, and none had been accredited in Guerrero or Yucatán (Rivera-Buendía et al. 2015).

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The Limits of Trust m at e r n a l h e a lt h

The maternal mortality ratio (MMR ) has declined in Mexico since the turn of the millennium (see table 2.5). However, deaths are more likely to occur if the woman has no form of insurance coverage, or is covered by Seguro Popular or I MS S -Oportunidades rather than one of the social security institutes. In 2012, almost 70 per cent of deaths were of women without social security coverage; by contrast, women in social security services represented roughly 15 per cent of the deaths (See table 2.6). Almost half of the deaths occurred in federal or state health care facilities; another 13 per cent occurred in private clinics or hospitals, compared to 15 per cent in social security services (see table 2.7). The MMR also varies by state. In 2012, the state of Sonora, in Mexico’s north, had an M M R of 27.7, whereas Oaxaca’s was more than three times as high, at 88.8 (see table 2.8). One of the reasons why women who lack social security coverage are more likely to die than women who have it is that the public health care system is less capable of dealing with obstetric emergencies; it lacks sufficiently trained personnel, equipment, and medications to do so. Mexico’s National Council for the Evaluation of Social Development Policy (Coneval) stated that “the clinical management of a good part of the cases [of maternal death] analyzed revealed deficient capacity, not only regarding basic medical education at the primary care level, but training in the medical specialties” (2012b, 20). Frequent contact between the patient and her medical providers in the antenatal period did not guarantee that she would be referred appropriately to a higher level of attention (e.g., to a hospital rather than a clinic, or to an obstetrician rather than a general practitioner), nor that obstetric complications would be adequately managed (19). The hospitals that were open around the clock, and which did have the human and material resources to resolve complications, were filled to capacity. The result was that women were discharged in spite of having been diagnosed as high-risk patients, or having come to the facility with symptoms of obstetric complications (71). The failure to resolve pregnancy and childbirth emergencies, especially at the primary care level, meant that women were transferred multiple times, delaying their receipt of adequate attention (95). Coneval found problems with the coordination of and communication between the first and second levels of attention, and the nodes in the networks of attention; women arrived at the

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Table 2.5  Maternal deaths and maternal mortality ratio (M M R ) in Mexico, 2002–12 Year

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Number of deaths

1,308 1,313 1,239 1,242 1,166 1,097 1,119 1,207 992 971 960 861 872 712

Maternal mortality ratio (MMR) 59.9

62.8

60.9

61.8

58.8

55.8

57.2

62.2 51.5 50.7 50.5 38.2 38.9 31.7

Source: O M M 2012, 10, 13; OMM 2014a, 68; and SSA 2015a, 2.

Table 2.6  Maternal deaths according to institutional affiliation, 2012 Institution or type of affiliation

Percentage of total deaths

None Seguro Popular (including IMSS-Oportunidades) IMSS, ISS STE, Pemex, Sedena, and Semar Other Not specified Total

14.7 55 20.4 1.3 8.6 100

Source: OMM 2014a 46.

Table 2.7  Location of death: distribution by percentage of maternal deaths according to place of death, 2012

Location

Social In transit Private State or federal health security or other Other/not services (includes health clinics and IMSS -Oportunidades) services hospitals Home locations specified

Percentage of deaths

47

14.9

13.2

6.9

0.3

17.7

Source: OMM 2014a, 56.

secondary level facilities without having been referred by a primary care provider, and / or without being accompanied during the transfer between facilities (19). These problems correspond not only “to the low level of abilities and competencies of the health care service providers, but the impossibility of the system functioning as a network of services. In recent years, there has been an important investment in the formation of service networks … an evaluation of this project is needed to identify the causes of its limited scope” (161).

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Table 2.8  Maternal mortality ratio (MMR) by state and nationally, 2010 State

MMR

Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas Chihuahua Federal District (DF) Durango Guanajuato Guerrero Hidalgo Jalisco México Michoacán Morelos Nayarit Nuevo León Oaxaca Puebla Querétaro Quintana Roo San Luis Potosí Sinaloa Sonora Tabasco Tamaulipas Tlaxcala Veracruz Yucatan Zacatecas National

44.6 42.5 41 55.3 51.6 0 73.2 66.4 58.8 52.6 43.1 85.5 65.6 38 45.5 68 35.3 48.1 18.8 88.7 52.5 40.1 48.7 47 40.5 27.7 36.9 45.9 63.8 61.3 35.7 47.4 51.5

Source: OMM 2012, 48.

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The second major reason why Seguro Popular has not adequately reduced maternal mortality is because women in extreme poverty lack the means to pay for transportation to a hospital, and for family members to come along and stay nearby. Women who live in remote rural communities may not be able to afford transport to clinics for antenatal checkups, or cover out-of-pocket expenses such as payment for laboratory tests (70–1). The Coneval authors report that “to be a beneficiary of Seguro Popular or I M S S -Oportunidades isn’t sufficient to guarantee the opportune transfer and treatment and the limitation of economic barriers to treatment. The out-of-pocket expenses that are borne by the pregnant woman or her family frequently impede her decision-making” (66). The General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies (caeo) In an effort to overcome the fragmentation of the health care system and its negative effects on maternal health, in 2009 the major Mexican health care institutions (the I M S S , the I S S S T E , and the Ministry of Health) signed a collaborative agreement ensuring that, in the event of an obstetric emergency, a woman could receive care free of charge at any of the participating institutions, regardless of whether she was affiliated with that institution (O M M 2014b, 1). While the existence of this agreement indicates some level of commitment to improving maternal health in spite of health care segmentation, the very need for it is evidence of the problem of unevenly distributed resources. The Maternal Mortality Observatory (O M M ) has also found that co-operation between the three institutions is “limited or non-existent”; that there were problems with the availability of services even in facilities reportedly capable of managing obstetric emergencies; and that the services were not entirely free of charge (O M M 2014b, 1). Even in hospitals or clinics that were purportedly able to provide emergency obstetric care, the researchers found that resources – such as medical specialists, laboratory services, or transport to other health care facilities – were not available around the clock every day of the year. Even in the Federal District, women still had to pay costs which could be prohibitive, such as for medications, laboratory tests, or ambulance transfer. In four of the five states studied, the O M M documented

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cases in which women were sent to two or more facilities in search of emergency obstetric care (A E O ) (4). conclusion

Mexico has a highly unequal society. The literature on trust would suggest that this level of inequality undermines trust in public institutions, including those providing health care, whereas greater equality in the provision of health care could combat the presence of general mistrust and help to generate a more trusting society (Gilson 2003; Freedman et al. 2004). The Mexican health care system, however, has historically and recently tended to reinforce these inequalities. For example, while the social security systems provided comprehensive care to roughly half the population, these systems excluded the other half and took the larger share of public resources. A divided system does not support the norms of fairness and solidarity which, Gilson argues, facilitate trust (2003, 1459). The neoliberal and structural adjustment period of the 1980s and early 1990s exacerbated these inequalities. Wealthier states have a greater capacity to offer health services than poorer ones, and the decentralization of service provision reinforced this inequity. The trend was only minimally addressed later in the 1990s, during the second wave of neoliberalism, with federal funding for the states in the form of F A SSA , and the P A C , which provided thirteen treatments free of charge at the point of service. States had an incentive to charge user fees for remaining services, which was recognized as having a regressive impact (see for example Ridde and Morestin 2011). The P A C did not improve access to emergency obstetric care, however; nor, given its limited and targeted focus, could it strengthen the health care system. The most recent health care reform, Seguro Popular, is an improvement on the neoliberalism of the 1980s and the 1990s. The system has offered an expanded range of services to a large proportion of the previously uninsured population. Since the introduction of the program, maternal health services (including care during obstetric emergencies) have been available free of charge at the point of service. The expansion of services on the basis of need, and the fact that the system is, practically speaking, non-contributory, are factors that may enhance trust and support the building of improved maternal health services.

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There are limitations to these improvements, however. While the program is effectively non-contributory, meaning that health care treatment for affiliates is free at the point of service, the dearth of individual contributions means that the funding upon which the program was designed has not been forthcoming. Government budgets have not compensated for this; in fact, federal and state governments have also contributed less than originally intended. While the asymmetry in federal government funding between the public and social security systems has narrowed, there are still problems with the infrastructure, equipment, and supply of qualified personnel who provide services to women affiliated with Seguro Popular compared to those in social security institutes – particularly in rural areas of Mexico, the southern states, and poor urban areas. This has negative results for maternal health. Programs to address quality of care could help, but recent studies indicate that these programs are also heterogeneous in their implementation, with Guerrero, a poor performer in maternal health, also failing to implement elements of quality of care programming. It should also be noted that funds for improving health care quality under the S I CAL I D AD program are deducted from the amount of the federal government’s Seguro Popular solidarity contribution to the states, meaning that funding to improve the quality of care for the uninsured population comes at the expense of the money to care for them. As the O E CD has noted, “Mexico’s public investment in its health system, rising from 2.4% to 3.2% of GD P between 2003 and 2013, has failed to translate into better health and health system performance to the extent that one would have wished. A programme of continued, extensive reform is needed. Mexico needs an equitable, efficient, sustainable and high quality system of health care. This will not be delivered by its current fragmented health care structure, with different levels of care for different groups, provided at different prices with different outcomes” (2016, 13).

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3 Guerrero: The Limits of the Local

introduction

Guerrero is the second-poorest state in Mexico (after Chiapas).1 Until 2013, it had the highest maternal mortality ratio (M M R) of any state; in 2012, this meant that fifty-six women died, resulting in an MMR of 93.1 per 100,000 live births (O M M 2014c, 22). Although marginalization is widespread – the relatively wealthy city of Acapulco, for example, still has half of its population living in poverty – there are pockets where deprivation is highly concentrated: in the state’s four poorest municipalities, more than 90 per cent of the inhabitants are poor (Coneval 2013b, 34). Guerrero’s history has been marked by conflict. Socialist and social justice groups seeking change through the electoral system have been consistently repressed, and so turned to guerrilla activity. Since the 1980s, the repression of social movements has intersected in complex ways with the war against drugs. Large swaths of territory have become contested ground for drug traffickers, the police and military apparatus, and local communities. In rural and Indigenous areas, the distrust of the State includes distrust of the health care system. Women continue to be cared for by parteras, and to avoid clinics and hospitals where discriminatory treatment and obstetric violence occur. There are other barriers to health care access: economic barriers, because of the cost of health care and transportation to it from remote villages; cultural barriers, because few health care providers speak Indigenous languages or are inclined to accommodate traditional birthing practices; and barriers associated with women’s lack of autonomy within the family.

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Through the Arranque Parejo en la Vida (An Equal Start in Life) strategy, the federal government and N G O s have tried to overcome these barriers by strengthening trust networks between parteras, community health promoters, and the health care system. The federal government’s Equal Start strategy and Casas de la Mujer Indigena (Houses for Indigenous Women) arranged for obstetric care to be provided to the extremely impoverished women of the area at a reduced cost. However, hospitals and clinics continued to charge women for obstetric services, and N G O s were powerless to change the practice; NGOs are unable to effect improvements in the health care system in the absence of broader, systemic change. It has only been since the extension of Seguro Popular to a large proportion of the population that care has become free at the point of service, and even in 2012 the program still did not cover everyone who needed it. Thus, although Seguro Popular increased access to health care, there are women who remain without coverage; and problems with the quality of care, as well as discrimination towards poor and Indigenous women, continue to undermine the trustworthiness of the system. The chapter proceeds as follows. In the next section, I will provide an overview of the context in which maternal health policies are being implemented, followed by a discussion of the 1980s decentralization. I will then examine a case of interaction between the State and N G O s in the Ometepec area of the Costa Chica region, and discuss the impact of Seguro Popular and the ongoing limitations of the health care system in spite of its implementation. guerrero: the context

According to Tilly (2007, 75), democratization doesn’t depend on the elimination of inequality, but it does require the insulation of public policies from it. Insulation is aided by, among other processes, an equalization of “assets and/or well-being” among unequal groups. According to these criteria, Guerrero’s democratization process is deeply flawed, in spite of the election of a party other than the Institutional Revolutionary Party (P RI – Partido Institucional Revolucionario) for the first time in 2005, when a candidate from the Party of the Democratic Revolution (P RD ) was elected governor. There has been little equalization of well-being. Guerrero had 3,388,768 people in 2010 (I NE GI n.d.). In 2012, 69.7 per cent of

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the state’s people lived in poverty; approximately 50 per cent of this number in extreme poverty (Coneval 2012c). A third of the impoverished population lived in the five poorest municipalities of the Costa Chica and La Montaña, in the southern part of the state near the Oaxacan border (Coneval 2012c). Development processes have resulted in the displacement and dispossession of the state’s poorest people, with the result that many Indigenous people have migrated to the US or northern Mexico in order to support their families. Of the 3.6 per cent of the population who had migrated (I N E G I n.d.). a quarter had gone to the US; most of the remainder went to other Mexican states, mainly Sinaloa, to work as agricultural day labourers. Guerrero’s rate of migration is slightly higher than the national average (3.3 per cent), as well as that of Oaxaca (3.1 per cent) and Chiapas (2.1 per cent) (I NE GI n.d.).2 Guerrero has roughly half a million Indigenous people, or 15 per cent of its population. Nationally, Indigenous people are slightly more likely than the nonIndigenous to migrate; while 6.6 per cent of the population speaks an Indigenous language, this is true for 8 per cent of Mexican migrants to the US (Rodríguez Abreu, 2014). Guerrero has been riven by arbitrary coercive power and the existence of autonomous power centres. Since at least the 1920s, the state has been gripped by cycles of citizen mobilization, followed by repression, then organization for self-defense (Illades 2014). Under the governance of the P R I in the post–World War II period, Guerrero’s economic development resulted in the enrichment of political and economic elites (who were often one and the same), and the displacement of the peasantry. In the 1950s and 1960s, federal and state government officials promoted the expansion of largescale export agriculture and tourism as the sources of economic development; they were often investors in, as well as promoters of, these projects (Blacker 2009, 187). In the 1960s, four companies dominated the state’s timber and mining industries (Watt 2010). The building of dams and other infrastructure to facilitate tourism and agriculture projects resulted in the dislocation of the peasantry, an increased concentration of land ownership, and environmental degradation (Blacker 2009, 197). Organizations of teachers, workers, and peasants mobilized against the government to demand the conservation of the state’s forests, an end to government repression, recognition of the right to unionize, and the provision of public services, particularly education

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(Blacker 2009, 191). The Guerrero Civic Association (ACG ) coordinated state-wide protests by these groups, and ultimately demanded the resignation of the governor, Raul Caballero Aburto, who had repressed labour unions and individuals in order to further the interests of his family’s firms. The federal senate removed Caballero Aburto, but protestors’ other demands were not met, nor did the repression let up (189–93). In 1960, the military fired on peaceful protestors in the state capital of Chilpancingo, killing seven; in 1962, there were further attacks on protestors in Iguala, the Costa Chica, and the Costa Grande (195), and in 1967, in Atoyac (199). During this period, two leaders of the Civic Association, Genaro Vásquez Rojas and Lucio Cabañas, abandoned hope for peaceful change and formed small guerrilla movements in the mountains. The state and federal governments pursued the two leaders as part of Mexico’s “Dirty War” against left-wing and guerrilla groups in the 1970s, which was fought more vigorously in Guerrero than in any other state (183). President Luis Echeverría deployed 24,000 soldiers in Guerrero; between 1968 and 1981, 529 people were “disappeared” (Bricker 2011). The military detained and killed not only members of the guerrilla movement, but those associated with them and with other social movements: “If an individual were suspected of radical activities, he or she was seized, tortured, disappeared, or murdered. No independent campesino [peasant], worker, or student organizations remained overtly active. The populace was subject to military incursions and to the tactic known as ‘tierra arrasada,’ a ‘razed earth’ practice that left entire communities bereft of shelter and crops” (Blacker 2009, 201). In 1995, at Aguas Blancas, 400 police killed seventeen and wounded twenty-one members of the peasant organization Peasants from the Mountains of the South (O CS S – Campesina de la Sierra del Sur), which had previously expelled police who were responsible for forced disappearances. The state’s governor, Figueroa Alcocer, was forced to resign after the Supreme Court found him culpable for the murders (Illades 2014). The Dirty War has since morphed into the drug war. Guerrero is a major transit region for the drug trade, and one of the world’s largest producers of opium paste (Illades 2014). The US-sponsored anti-­ narcotics strategy, which replicates American anti-terrorism strategy in the Middle East, involves eliminating “high value targets,” the leaders of the drug cartels. However, this has meant that large cartels

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have disintegrated into smaller units, increasing the violence as multiple groups struggle for control over territory (Neuman 2015). Until 2007, the dominant cartel in the state was the Beltrán Leyva group. When one of its leaders, Arturo, was executed in 2009, the cartel’s fragmentation led to multiple, smaller-scale conflicts in communities throughout the state (Illades 2014; Neuman 2015). We do not know how many military personnel are deployed in Guerrero, but since President Calderón authorized anti-narcotics operations in the state in 2007, the murder rate has tripled. The Committee of Families of the Kidnapped, Disappeared, and Murdered “has counted 299 disappearances over the past six years” (Bricker, 2011). Counter-narcotics operations have occurred alongside, and, some would argue, as a pretext for attacks against activist groups. In a report released in 2010, the Bar Human Rights Committee of England and Wales reported that “human rights violations committed by the military within … Guerrero since the 1980s included rapes, murders, forced disappearances, arbitrary detention, and harassment” (BHRC 2010, 23–4). In response to gang violence and State brutality and intimidation, by 2014 community police forces had been established by fortyseven of eighty-one town councils (ayuntamientos) (Illades 2014). A recent, shocking act of violence has mobilized families of the disappeared and drawn international attention. In September 2014, forty-three students from a rural teachers’ college (rural normal) in  the village of Ayotzinapa were forcibly disappeared. A further six  people, including three students, were killed. The federal ­attorney-general, Jesus Murillo-Karam, announced in January 2015 that he could present the “historical truth” about what had occurred (Goldman 2015). According to his account of events, the murder and disappearance of the students was triggered by the actions of Iguala’s mayor, José Luis Abarca, and his wife, whose brother was a member of the Guerreros Unidos (United Warriors) drug gang. When a hundred students entered Iguala on buses commandeered3 to travel to Mexico City for the commemoration of the massacre of students at Tlatelolco in 1968, the mayor, fearing that a political event organized by his wife would be disrupted, ordered the municipal police to detain the students “by any means.” The police fired on them, killing three students and three others, and then abducted fortythree more, handing them over to the Guerreros Unidos. The gang then took them to the nearby town of Cocula, where they shot the students, burned their bodies in the municipal dump, and threw the

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remains into the San Juan River in garbage bags. Having thoroughly investigated the incident, the attorney-general said that there was no need to question either the Mexican army or the federal police (both of which have bases in Iguala). However, other, reputable organizations have questioned this version of events, particularly the exculpation of the federal police and military. The Argentine Anthropological Forensic Team (E A AF ), which had been brought in to investigate the crime but was excluded from examining the evidence at certain critical points, released a sixteen-page report which criticized the attorney-general’s inquiry into the events at Cocula/ San Juan River (Goldman 2015). The Mexican National Human Rights Committee listed thirty-two failures of the investigation – such as failure to question witnesses and examine critical evidence – which meant that the case could not be solved (AP 2015). A group of five legal and human rights experts appointed by the InterAmerican Commission for Human Rights corroborated reports that the federal police had been monitoring students and must have known that they were under attack in Iguala. Recent efforts to look for the students’ bodies have found numerous graves filled with unknown victims – none of whom were the students. According to an internal report from the US Northern Command, the discovery of these graves led to “alarming questions about the widespread nature of cartel violence in the region and the level of government complicity” (Goldman 2015). In October 2014, facing public criticism for his handling of the case, the governor of Guerrero, Ángel Aguirre Rivera from the P RD , stepped down, as did Minister of Health Lázaro Mazón Alonso (A P 2014). The minister, who had been the mayor of Iguala in the mid-1990s and early 2000s, resigned because of questions about his relationship with José Luis Abarca, the mayor in 2014. Mazón Alonso nevertheless denied having any influence over the P RD ’s choice of Abarca as the party’s candidate for leadership of the city (El Informador, 2014). The health care system has also, on occasion, been complicit in the military’s abuse of human rights because of medical workers’ fear of reprisal. In 2002, soldiers raped and tortured two women from a Me’phaá community, Valentina Rosendo Cantú and Inés Fernández Ortega. The Bar Human Rights Committee reported that “following the attack, Valentina went to the nearest health centre, where she was refused help. The health centre was worried about

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repercussions from the military. Valentina went to the general hospital in Ayutla where they noticed her stomach injury but did not make any further examination. It was not until August, 2002, six months after the attack, that Valentina received proper medical care” (B H R C 2010, 26). t h e h e a lt h c a r e s y s t e m i n t h e 1 9 8 0 s : d e c e n t r a l i z at i o n

While Chiapas, Oaxaca, and Guerrero all have poorly functioning public health care systems, the situation in Guerrero is somewhat worse because of the loss of I M S S -Solidaridad services to the uninsured – a result of decentralization in the 1980s. In 1984, President Miguel de la Madrid decreed that the public health care system for the uninsured population would be devolved to thirteen of Mexico’s states, including Guerrero (Homedes and Ugalde 2006, 55). Decentralization ultimately resulted in greater inequality of health services provision among the state’s regions, the charging of user fees to extremely poor people, and the deterioration of services. In this period, per capita health care spending on the uninsured fell by 60  per cent (Birn 1999, 82); for Guerrero, the combination of reduced spending and decentralization was disastrous. Under the decentralization plan, I M S S -Solidaridad services (later called IMSS-Oportunidades)4 were merged with Ministry of Health (SSA ) services and administered by the state government. I M S S Solidaridad was run by the largest social security institute, I M S S , and funded by the federal government; its services were of higher quality and its staff better paid than in the S S A. Soon after the decentralization, the number of health care workers serving the uninsured fell by 10 per cent (Birn 1999, 90). Although pay differentials had been addressed, I MSS-Solidaridad workers did not want to be subject to SS A working conditions, and opted for employment in the social security system instead (Gershberg and Jacobs 1998, 30). Although all states endured greatly reduced health budgets, the decentralization in Guerrero meant that the poor suffered a disproportionate loss of health care services, compared to their compatriots in Oaxaca, where services remained under federal control. According to González-Block et al. (1989, 310): “Decentralization thus implied [a] 180 degree change in the policy of service distribution, from a pattern of equity to one of inequity. It is remarkable

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that, in spite of the economic crisis, the state as a whole received more services, yet all of the increments went to benefit the most important cities of the state. Approximately 8% of the population – those in the lower two [income] strata – suffered a significant drop in services; these people were mainly Indians and peasants living in the small and dispersed settlements with a regional or subsistence economy.” This occurred because Guerrero made further decentralization agreements with the majority of the state’s municipalities, which allowed the relatively wealthy municipality of Acapulco to claim additional resources, while the poorer regions, including those left out of the decentralization agreements, declined even further. “The economically important municipality of Acapulco enjoyed direct financial agreements and support from the federation, bypassing any state-level negotiations. Thus, while the poor municipalities became truly decentralized financially, the rich ones became, in fact, further centralized” (González-Block et al. 1989, 309).5 Under decentralization, an increase in the application of user fees further limited access to health care. Before the decentralization decree, the federal government required user fees to be deposited with the Federal Welfare Agency (Beneficiencia Federal), which gave states no incentive to impose such charges (Homedes and Ugalde 2006, 63). After service downloading, states could keep any fees collected, and this, combined with federal budget cuts, gave states an incentive to implement them. In the thirteen decentralized states, user fees more than doubled as a proportion of spending on the uninsured, from an average of 4 per cent in 1985–6 to 9.3 per cent in 1994–5 (Birn 1999, 33). In Guerrero’s Costa Chica region, user fees supplemented the meagre income of the social services students (pasantes) who staff the majority of the state’s rural health centres (Interview, O J 6 2008). User fees for obstetric services represented a huge proportion of poor people’s income. In 2008, the minimum wage in rural areas of the state was Mex$49.50 (approximately US$4.45) per day (I NE GI 2010b, 31). A normal birth in a hospital cost between Mex$1,800 and $2,000 (approximately US$162 to $180); a caesarean section, between Mex$3,000 and $3,500 (approximately US$270 to $315) (Interview, CG M I -1 2008). Thus, medical care for a normal birth would cost more than a month’s wages for a poor resident of Guerrero; a caesarean section, more than two months’ wages. Apart from the strain that these costs place on severely impoverished households, the impact of this cost – and

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the difficulty of raising the cash – may mean that poor families delay the decision to seek medical care until it is too late to avoid mortality or morbidity. By the late 1980s it was apparent that health care services and infrastructure, particularly in Guerrero, had deteriorated instead of improved in the decentralization period (Birn 1998, 30). The I M S S union opposed any further decentralization of I M S S -Solidaridad services, and were supported by the communities they served, whose members occupied clinics (Interview, H R 2008). Health care system decentralization was therefore halted until the inauguration of the Zedillo administration in the mid-1990s, and, when it was re-­ initiated, I MSS-Solidaridad was kept under federal control. In 2009, I MSS-Oportunidades was finally re-established in Guerrero, in the wake of the 2008 financial crisis and its impact on the extremely impoverished people of the state. I M S S -Oportunidades invested Mex$246 million (approximately US$18.2 million) each year to build a rural hospital and twenty-seven clinics (Diario 21 2009). i m p r o v i n g a c c e s s t o h e a lt h c a r e s e r v i c e s : a r r a n q u e pa r e j o e n l a v i d a , l a c a s a d e l a m u j e r indígena, and the role of ngos

Casa de Salud de la Mujer Indígena “Manos Unidos” (The “Joined Hands” House of Indigenous Women’s Health): Ometepec, Costa Chica Two main NGOs have been involved in maternal health programming in the Costa Chica region: K’inal Antzetik and the Guerrero Co-ordinating Group for Indigenous Women (Co-ordinadora Guerrerense de Mujeres Indígenas). Both groups emerged from the broader Indigenous people’s movement for self-determination. K’inal Antzetik, which means “Land of Women” in the Mayan Tzeltal language, was founded in 1991 by feminists and activists from the teachers’ and Indigenous rights movements in Chiapas. Initially working to assist Indigenous women establish co-operatives for the sale of handcrafts, K’inal developed workshops on sexual and reproductive rights, and became an advocate for Indigenous women’s health (Interview, K A -1 2008; Layton et al. 2007, 27). In

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Guerrero, Oaxaca, and Chiapas, K’inal Antzetik has conducted workshops with Indigenous women and men on sexual rights and health; co-operated with officials from health districts in the three states to build trust networks between communities, parteras, and the health care system; and used those networks to monitor the system. K’inal has collaborated with academic researchers to explore Indigenous women’s experience of sexuality, pregnancy, and childbirth, and shared the findings with state and federal officials. It has used both the Cairo and Beijing frameworks, as well as the Millennium Development Goals, to inform its analysis of Indigenous women’s circumstances and to structure its interactions with rural communities. The other organization, the Coordinating Committee for the Indigenous Women of Guerrero, also arose in the 1990s from the Indigenous people’s movement for self-determination – particularly the intercontinental campaign known as 500 Years of Indigenous, Black, and Popular Resistance, which grew out of a forum held by Ucizoni, an Indigenous peoples’ organization, in Oaxaca (Sánchez Nestor and Ochoa 2009; see also chapter 5). Before the 1990s, Indigenous people had been more likely to participate in peasant organizations and identify as peasants rather than Indigenous ­people. As avenues for peasant mobilization closed, and a greater international consciousness of Indigenous identity and concomitant possibilities for mobilization developed, organizations in Mexico began to advocate for autonomy and the recognition of cultural as well as economic rights (Sánchez Nestor and Ochoa 2009; Jung 2008). In 1997, the “500 Years” national campaign formed a national Indigenous women’s chapter; one year later, the Guerrero chapter of this organization was formed, which became the Coordinating Committee for the Indigneous Women of Guerrero in 2004 (Sánchez Nestor and Ochoa 2009). These NGO s collaborated with a project funded by the Commission for the Development of Indigenous People (CD I ), the Casa de Salud. The Ometepec Casa de Salud is one of eighteen such casas in fifteen states designed to build a bridge between Indigenous women and the health care system (C I MA C 2011). Although the casas are a federal government project, they are also an example of the indirect impact of the MacArthur Foundation on maternal health programming: it was MacArthur grantees who conceived the idea of a place where Indigenous women’s health could be promoted, and many of the

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women associated with the program have been MacArthur grantees. Paloma Bonfil Sánchez, from the C D I , promoted the idea both in the C DI and in the federal Ministry of Health. The casas were intended to provide a place where women could, at the time of birth, meet with a partera or health promoter who was Indigenous and bilingual, and who would accompany her to the hospital, act as a translator, and observe any instances of mistreatment by hospital staff. The casas also served as a location where parteras, health promoters, and Indigenous women could meet and participate in workshops on domestic violence and sexual and reproductive health and rights (led by N G Os such as K’inal Antzetik), and where parteras could be trained (by the state Ministry of Health). The workshops I attended at the casa in Ometepec consisted of training for parteras, conducted by Ministry of Health nurses in both Mixteca and Amuzgo, the major Indigenous languages of the region; and sessions on sexual and reproductive health and rights, conducted by facilitators from K’inal Antzetik. When I visited the casa in July 2004, some of the promoters and parteras staffing it slept there overnight, in order to be available twenty-four hours a day to any woman who needed them. (This could not be said of the health centres in the region.) The casa was not exclusively an N G O project, and, because responsibility for financing shifted from one government department to another, its dependence on government funding meant interruptions in its operation. Initially, the CDI and the United Nations’ Development Program (UNDP) funded the pilot project; the UNDP funding terminated after the pilot. The CDI then took over financing, but later transferred that responsibility to the federal Ministry of Health (SSA) (Interview, KA-1 2008). In 2005–06, eight months passed in which the casa did not receive funding; under these conditions, workshops and other activities ceased, and some of the very dedicated staff who had worked there in 2004 left for other jobs (Interview, CIESAS-1 2006). One researcher raised concerns that the casa reflected a devolution of the state’s responsibility towards nongovernment actors: “The casa is intended to provide women with access to health care services. Like a bridge. But this should be the responsibility of the State, to adapt its services [to make them more accessible]. There should be a translator at the hospital. But that’s really expensive, and so we have this type of project that is very local and very small, and also very expensive” (Interview, CIESAS-1 2006).

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This is an instance where parteras, health promoters, and NGOs have taken up responsibilities which should fall under the remit of  the State. In order to provide service to Indigenous (and non-­ Indigenous) populations, public health care services should have translators available; they should be connected to their users via serviceable roads and ambulances; and they should deliver care competently and respectfully. However, in Guerrero, with the possible exception of areas served by IMSS-Solidaridad services in the late 1970s and early 1980s, this has never been the case. The State, in Guerrero and elsewhere in rural Mexico, has always relied on largely voluntary, female labour to ensure that births are attended and, when necessary, women are connected with transportation. The differences in the current period are that there is a liaison role between NGOs, public health care services, and the community; that there are some State resources available to support women’s physical and emotional labour; and that there is the possibility of holding the State to account for its treatment of women in the health care system. Until and even after the complete roll-out of Seguro Popular, women in the region were charged user fees to deliver babies in a medical facility. Under an agreement between the Casa de Salud, the Guerrero Co-ordinating Group for Indigenous Women, the Guerrero Ministry of Health, and the director of the Ometepec hospital, the latter hospital was to charge women half the normal user fee for obstetric services if they were accompanied by staff from the Casa de Salud. This accord, even though it related to only a 50 per cent reduction in fees, was not respected by the hospital after an initial period (Interview, C SG 2004). A researcher reported: “It’s a constant fight to have the agreements respected” (CI E S AS -1 2005). Even when the government of Guerrero, along with those of Chiapas and Oaxaca, agreed in 2008 to exempt women from user fees for obstetric services, the exemption was still not applied uniformly. An N G O representative observed that the exemption “has allowed women to go to [hospitals and clinics] without fear that they will be charged”; but she nevertheless reported that “if the women don’t know about the agreement, they still have to pay” (Interview, CG M I -1 2008). In spite of this, NGO representatives thought that the casa had raised consciousness among women of maternal health as a state responsibility, and maternal mortality as an avoidable rather than inevitable part of life:

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I would say that the Casa de Salud has had an impact on the community, in the sense of raising awareness among women about their health. So that women don’t see just that a woman died in their community, but that there’s a problem with maternal mortality, and they see the death in their community as part of that larger problem. The Casa de Salud has created an awareness that maternal mortality should not be seen as something natural, because if it’s “natural,” then the state has no responsibility … At the same time, the Casa de Salud has made visible those who are responsible for preventing maternal mortality. (Interview, C GMI -2 2004) The NGOs working at the casa tried to address both the cultural norms that contributed to maternal mortality, and the State’s failure to provide adequate services: a lacuna that remained invisible while the concept of maternal death as a “natural” outcome prevailed. They were therefore providing a basis for which trust networks could be linked to the State. If the latter has no responsibility for the provision of services because maternal mortality is unexceptional, then individuals and families are unlikely to seek medical care or the other connections to the State which will make such access possible. Transportation and Accommodation The Fox administration’s Ministry of Health recognized that lack of access to transportation and accommodation was compromising women’s access to obstetric care. The Equal Start program aimed to provide transport by facilitating community networks connecting pregnant women to vehicle owners, and / or encouraging the purchase of ambulances or other vehicles by the municipal council. In addition, such purchases required municipal provision of gas, payments to drivers, and maintenance of the vehicle. Guesthouses for pregnant women to stay at prior to birth (Posadas AM E ) were also to be paid for using municipal funds. However, given the varied capacity and political will among municipal governments to use these municipal resources to improve maternal health, some municipalities have been left without well-functioning transport arrangements or accommodation systems. The transport problem in some areas of Guerrero is extreme: there are villages that do not have roads. In 2004, a member of the

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Co-ordinating Committee for Indigenous Women in Guerrero took me from village to village in the municipalities of Xochistlahuaca and Malineltepec in the Costa Chica region. The scattered communities had populations from a few hundred to a thousand people. None of the communities we visited had running water; some lacked electricity. Without roads, we travelled on horseback. In other locations, roads become impassable in the wet season. Sometimes there are roads, but no one owns a car; in other cases, there are cars, but the pregnant woman cannot afford the rates charged by the owners. According to one researcher, in the villages, “those who own the trucks (camionetas) are caciques [political bosses], and those who use them, pay. In one proposal [to improve transportation access], the doctors have to know who has a car; but it’s the owner who has a right to decide ‘yes’ or ‘no.’ It costs 800 pesos [approximately US$64] for two hours” (Interview, C I E S AS -1 2005). Access to transport, like access to health care services themselves, was restricted according to ability to pay rather than being a service equally available to all. One’s ability to pay for transport could only be overcome through connections to the politically powerful; thus, in the instances where trust networks compensated for economic inequality, they reinforced political inequality. From the 1980s onward, municipal governments, which had been dependent on the discretion of state governors for funding, gradually became more autonomous – both fiscally and politically. The most dramatic changes occurred in 1997, when the federal government created a series of funds under Ramo 33 (Item 33) of the budget, two of which provided funding directly to municipalities for infrastructure: the Fund for Social Infrastructure (F A I S );6 and the Fund for the Strengthening of Municipalities and the Federal District (F A F O M U N ). In 1999, municipalities were “recognized as another level of government” (Faletti 2010, 226, 228). This did not necessarily mean that they were equipped to manage large flows of funds, however. As Merilee Grindle notes, “the vast majority of municipalities in the country at the time … did not have the basic administrative infrastructure to respond to the new challenges of decentralization” (2007, 40). In Guerrero, the resources directed to accommodation and transport for pregnant women depended on municipal capacities and political will. As such, they were vulnerable to changes in municipal government which, in Mexico, occur every three years (Selee 2012,

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102). Because the municipal government in Ometepec had not covered the costs of transport for pregnant women, the Costa Chica health district authorities were paying for it, from funds associated with the Oportunidades and Seguro Popular programs, not Equal Start funds (Interview, O J 6 2008). The Guerrero Committee for Indigenous Women reported having a positive relationship with the health district authorities, describing it as “a respectful relationship, a relationship that has allowed us to progress because women have some support” in the form of money for transport. The committee also noted the importance of a commitment to maternal health on the part of some officials within the health district. While I was waiting to speak to the head of the health jurisdiction, I noticed that one of the parteras had been speaking to him. He explained that “the partera is very concerned about her patients, she came to request help with payment for gasoline [to transport them] … Here we cover the costs, all the costs, of food, medicines, transport, laboratory tests, with the intention that the woman doesn’t experience complications, that she doesn’t die, because of the tremendous social cost if a woman dies” (Interview, O J 6 2008). This example demonstrates the importance of funding from the state and, ultimately, the federal government, in the absence of a municipal commitment to maternal health. The Ometepec health district, however, did not have sufficient funds to pay for a Posada A ME , with the result that one did not exist in Ometepec – although one was operating in the neighbouring municipality of San Luis Acatlán, where it was reported that the municipal president was more committed to the reduction of maternal mortality. However, the hospital in San Luis Acatlán was a basic community hospital, unable to perform caesarean sections, whereas the Ometepec hospital was a general hospital, and received referrals from San Luis. It would have made more sense, therefore, to have the Posada A ME operating in Ometepec. A health district official noted that “the Posadas A ME depend on the commitment of the municipal authority. In San Luis, the authorities are conscious [of the maternal health issue], and the municipality pays two people who take care of the food and the cleaning. The guesthouse is there, but women have to come to Ometepec for a caesarean … Ayutla has a municipal government that’s aware of the problem, but in Copala, there isn’t a hundred per cent commitment” (Interview, O J 6 2008).

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Furthermore, some municipalities misdirected resources from Ramo 33 funding: “unfortunately, we’ve seen, for example in [a town in the region], a bull ring built with funding from Ramo 33” (Interview, OJ 6 2008). The Equal Start program assumed that municipal governments would willingly support services that facilitated women’s access to hospitals; these examples from Guerrero demonstrate that in the areas of greatest need, that may not always be the case. Monitoring the Health Care System While building trust networks between parteras, community health promoters, and the health care system, N G O s have also used those networks to monitor the system for instances of discrimination and mistreatment of Indigenous women.7 Poor and Indigenous women may be rejected from health care facilities, or experience verbal or physical abuse within them. Apart from the gender, class, and racial discrimination occurring when women are rejected or abused within the system, the knowledge that such discrimination exists may influence the decision to seek care, potentially causing life-threatening delays during an obstetric emergency. According to the Guerrero Co-ordinating Group: the insensitivity that some doctors and nurses, not all, but some, display, affects us, because women say, “I’m not going to the hospital because they will yell at me or tell me that my clothes or my body are dirty,” because yes, there have been people who’ve been told, first, go bathe, and then you can come here, otherwise, you can’t be here … Women have said, if a rich person arrives, they are attended quickly, but when [the medical staff] see how I’m dressed, that I speak the [Indigenous] language and that I’m poor, they say “Wait, I’ll see you when I can.” There have been cases of women giving birth in the waiting room or the bathroom. It’s these things that generate distrust. (Interview, CG M I -3 2008) This account helps to explain some of Indigenous women’s resistance to attending public health care facilities – whereas medical professionals tended to perceive women’s reluctance as stemming only from their lack of autonomy within the family and community.

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Instead, this interview indicates that women’s experience of discriminatory treatment because of their class and Indigenous status is what accounts for their distrust of the system. Another representative from the organization pointed out Indigenous people’s simple desire to be treated as human beings: “The health sector needs to implement a course in intercultural awareness (interculturalidad) so that the doctors understand Indigenous women, that we’re not rats to be experimented upon. They think that we don’t think and don’t feel … Today we have the opportunity to be inside the hospitals and this is a topic that we’ve discussed in forums, in workshops, in meetings. That Indigenous people also demand respect, also demand dignified treatment. Not special treatment; rather, that we are treated like the human beings that we are” (Interview, C G M I -1 2008). The failures to respect Indigenous women’s basic right to dignified treatment in the health care system undermine the possibilities for interpersonal and generalized trust. It is not clear, even to NGOs themselves, whether the presence of parteras or health promoters have led health care practitioners to change their behaviour dramatically, but the NGOs believe that monitoring may have mitigated the worst abuses. In 2008, a representative from K’inal Antzetik stated: The mistreatment is a constant. What’s changed is that the women have a greater capacity to denounce it. We are part of the civil society watchdog [aval ciudadano] that is a space for N G O s to denounce this kind of situation. We’ve been teaching our ­participants how to make a report when there’s a question of violation of human rights, of discrimination. Women [in the Indigenous communities where K’inal Antzetik works] are always saying that they’re mistreated, that there are no medications, that they’re not being attended to … this is constant. For example, in the hospital in Ometepec, there’ve been many deaths due to medical negligence. But we say that [people] now think twice before committing the barbarities that they used to. (Interview, K A -1 2008) While the worst “barbarities” of the system may have diminished because of NGO monitoring, sanctions have not been applied in cases of medical negligence. While I believe that formal and informal sanctions may undermine trust in situations where health care

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providers have not had the resources to provide proper care, the failure to sanction negligence is a violation of one of the principles for fostering trust – the existence of ethical and professional codes and means of enforcing them. K’inal Antzetik, in collaboration with the Guerrero Network of Human Rights Organizations (Red Guerrerense Organismos Civiles de Derechos Humanos), brought legal action against the Ometepec hospital in a particularly egregious case resulting in the death of a woman, Marina Garcia Santiago. Doña Marina, from the municipality of San Luis Acatlán, was transported to the hospital in Ometepec in May 2005 when the hospital in San Luis was not able to attend to her. After three days in Ometepec, her baby had died; a surgeon performed a caesarean section, leaving a wad of medical gauze in her abdomen (Berrío Palomo 2011). Two months later, with Doña Marina suffering from fever and abdominal pain, her husband, Apolonio Dircio Solano, took her to the hospital in Acapulco, where doctors detected the foreign body and operated to remove it. After the operation, Doña Marina had difficulty breathing, but the hospital did not have a mechanical ventilator, and told Señor Apolonio that one could only be acquired for Mex$700 (roughly US$55) an hour. Because this was beyond Don Apolonio’s means, he had to operate the ventilator himself by hand. Doña Marina died. A social worker informed him that an autopsy would not be performed – it was too expensive. Don Apolonio took the case to the state commission for medical arbitration, which ruled that the medical personnel at the Ometepec hospital had been negligent, and that the hospitals in both San Luis Acatlán and Acapulco had failed to comply with their responsibilities as health institutions. However, any action against the doctors responsible in Ometepec was overruled by the Ometepec Judicial District’s judge, who, in 2009, denied the public prosecutor’s order of apprehension on the grounds that it was never conclusively determined that the gauze left in Doña Marina’s abdomen had been the cause of death (Gómez Quintana 2009). Thus, public accountability mechanisms, which might not only have provided some measure of justice in this particular case, but also enhance trust in the system, failed to facilitate confidence in health care services. N G Os have continued holding the system accountable for human rights violations by building networks between the health care system and Indigenous villages. In 2007, K’inal Antzetik reached an agreement with the Guerrero Ministry of Women’s Affairs (Secretaría

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de Mujer, which was created by the N G O s government elected in 2006), to pay thirty-three parteras and health promoters Mex$400 (approximately US$30) a month for their work in their communities. This work included determining the number of pregnant women, identifying those with high-risk pregnancies, assessing the progress of the pregnancy, and transferring high-risk women, or those with difficulties during childbirth, to the health care system. In 2007, the parteras and promotoras attended 401 pregnant women, ninetythree of whom had high-risk pregnancies; none died (Interview, K A -2 2008). Thus, they played an important role in the census of pregnant women (censo de las embarazadas) that the health districts were carrying out in the Costa Chica and La Montaña regions. In 2007, K’inal and the Guerrero Committee were working with thirty-three promotoras/parteras; in 2008, the number had increased to fifty-five (Interview, C GMI -1 2008). When transferring women, the proper functioning of these networks depends on the skills and capacities of the parteras and health promoters. Women’s transport depends not only on overcoming financial barriers, but being attended to by a partera with the skills to negotiate with potential transport providers and the public health care system. A representative from K’inal Antzetik pointed out that transferring a woman from her home and community to a hospital is not just a matter obtaining a vehicle, but of exercising a number of skills: In Guerrero, parteras transfer women frequently; in Chiapas, that’s not the case, and so we concluded that transporting [canalizar] isn’t easy. To transport someone implies, one, the ability to recognize an obstetric risk or complication. That’s the first thing. Two, the capacity to convince the woman and her family members [that she should be transported to the hospital]. Three, to get a vehicle. Four, to be able to negotiate with the health sector. And this implies a series of stresses, and abilities that are not easy to activate. This implies security, self-confidence, the ability to make demands. It’s good if you are an excellent detector of obstetric risk, if you’re a partera who knows that she shouldn’t attend a particular birth, that’s a start; but if you don’t know how to deal with the staff at the Ometepec hospital, then maybe you won’t move the señora, maybe you’ll stay where you are. (Interview, K A -2 2008)

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The need for parteras to exercise these skills, however, is an indication of the shortcomings of the public health care system. The need to negotiate for transport would not arise if there were an ambulance service; and the partera might not fear transporting her patient to a clinic or hospital if the system were more receptive to parteras and birthing women in the first place. Nevertheless, an administrator in the Costa Chica health district thought that the co-operation between N G O s and the health sector had been very successful. “We surveyed 100 per cent of the pregnant women, we worked in a team, with all our colleagues (compañeros) in the health centres, in the hospitals, in private clinics, with all of them we worked in a team, and we achieved this success. At the beginning [in 2005] we had twenty-two, twenty-three maternal deaths a year; in 2006 there was a very good reduction, we had thirteen deaths in the Costa Chica region. And in 2007 we ended with eleven maternal deaths, this was an important reduction. But the coordination is key, we have NGOs who are very involved” (Interview, OJ6 2008). In all three states, NGOs’ efforts at documenting maternal death and discriminatory health practices were intended, among other things, to emphasize the responsibility of the health sector – and ultimately the state – for poor obstetric care. But in Guerrero, on top of decrying discriminatory treatment in the health sector, N G O s also  identified and tried to combat gender discrimination within Indigenous communities. Some of the concern with sexism in Indigenous communities arose from the personal experience of female leaders, including being refused positions of responsibility within Indigenous organizations (Interview, CG M I -3 2008). K’inal and the Guerrero Committee’s workshops on sexual and reproductive rights inform women of their entitlement to dignified treatment in the health sector; but they also challenge cultural beliefs that limit women’s access to care. “Cultural issues continue to be a problem, such as the fact that a woman isn’t able to make the decision about where, when, and how she wants to have access to health services … Physical violence [towards women] has resulted in premature births and miscarriages, and endangered the woman’s life. The working day also [threatens women’s health]. In all of the workshops that we’ve done, there have been women who were almost at the point of death and who lost their baby because they were working in the fields and they slipped or fell” (Interview, N G O s-2 2004).

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In this quote, the interviewee identifies lack of autonomy and domestic violence as threats to women’s lives. However, she also notes that the material circumstances in which women labour have also affected their health. (This was the only interview in which working conditions were identified as a factor in maternal death.) Cultural practices and ideologies around sexuality were also identified as playing a role in women’s decisions not to seek obstetric care, and particularly the reluctance to be examined by a male doctor. “The reality is that women resist going to the health services. Why? Because they don’t have confidence in the doctors, and there’s a culture regarding sexuality that doesn’t allow the doctors to touch you. If [the doctor] is a man it’s very complicated; in some cases a woman isn’t permitted to attend the clinic if the doctor is a man. Nor do we want the doctor to look at us, for example. There’s a lot of shame among women” (Interview, CG M I -3 2008). For N GO s, gender discrimination within the family intersected with, and was compounded by, the lack of functioning health care services. The delay caused when women’s lives are not valued is compounded by the delay caused by dysfunctional clinics: “When a woman is pregnant and her family doesn’t value her sufficiently – we’re always leaving our health until later, we’ll see what happens – when we see that things are really bad, when there’s no other option but to go to the health centre – these are the famous delays – you arrive at the centre, there’s no doctor, there’s no medications, you know you have to go somewhere else. While you’re trying to find transport to get to a hospital, time is passing and women die” (Interview, C GMI -2 2004). The N G O representatives, and parteras themselves, also emphasized the positive respects in which their culture values birth and the birthing woman. The women wanted to maintain the elements of their culture which nourished and supported women, while working to eliminate those elements that oppressed them: they did not see a conflict between their identity as Indigenous people and their identity as feminist women who claimed their autonomy in relation to men. One birthing practice that was particularly valued was the temazcal, in which, during the birth and for forty days afterward,8 the labouring woman rests in a herbal steam bath, a bit like a sauna. The temazcal is one of several birth practices in which the birthing woman is kept warm, because birthing is, in the Indigenous cosmology of the region, considered to be a warm process. As the following

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quote shows, it is also a social process in which a labouring woman would not normally be left alone: Women in Indigenous communities, during or after the moment of birth, take warm things, because this helps to accelerate the birth, and to make them feel better. After the birth they have a bath of temazcal. It’s part of life here, but in the hospitals, no. In the hospital, they bathe you with water that’s cold, that’s freezing. These are the things that people don’t like … and they’re left alone in the public health services, because there aren’t enough personnel, because they don’t have time, because that’s how they work. In contrast, if they deliver with the partera, the partera doesn’t work alone, she has a big team … Each partera has her helpers to make the teas [which usually include herbal teas to aid in the birth process], to prepare the temazcal baths. So when a woman is in labour, they talk to her, they inspire her, they give her courage, they give her affection, and her husband is there. In the hospitals, the husband isn’t permitted, nor is the partera … At home, they’re not yelled at. At home, the birth also proceeds more easily and quickly … After the birth, the partera keeps watch, and continues bathing her, for the forty-day period … Another thing is that the doctors don’t wish to deliver a baby normally, because it takes too much time; they perform caesareans when they’re not necessary. And women resist this too. (Interview, C GMI -3 2008) The Autonomous University of Guerrero undertook a study of the integration of Indigenous cultural practices in hospitals and clinics with the Amuzgo people in the municipality of Xochistlahuaca. While there was some evidence of improved behaviour on the part of medical staff towards the Indigenous women in their care, there was also evidence of practices that I venture to say would be, at the very least, unpleasant for most women, but abhorrent to Amuzgo women given their understanding of birth. Of the ten women being attended in hospital, seven were asked their opinion about how they wanted the birth to proceed; six were permitted to choose the position in which they were to give birth (for example, sitting or squatting rather than lying down); and three were given the placenta after the birth. However, three out of ten were not permitted to keep their amulet during the birth; and six were bathed with cold water afterward (CIET 2011).

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As in other states, the introduction of Seguro Popular in Guerrero has meant an injection of much-needed funding into the health care system; as a result, some of the state’s marginalized people now have access to health care that they did not have during the structural adjustment period, the 1990s, or even in the post–World War II period. However, citizens in the most marginalized municipalities of the Costa Chica and La Montaña were enrolled in the program more slowly, and the number of women who die without any form of health coverage indicates that there are still some women without Seguro Popular. Nor do those in these regions who are affiliated with the program have access to good quality health care, because of the inadequate numbers of personnel and inadequate supply of medicines and other equipment. The amelioration of inequalities across geographical regions and between Indigenous and nonIndigenous people has therefore been hindered by these limitations in the program. Affiliation Rates In Guerrero as in the rest of Mexico, Seguro Popular first enrolled urban, rather than rural, residents because existing infrastructure in the cities meant that the services affiliates were entitled to could be provided more readily. Affiliation therefore proceeded first in the ­cities of Acapulco, Chilpancingo, and Iguala (Interview, CI E S AS -1 2008a). The consequence was that the lack of access to health services in the state’s rural areas was not addressed. Low affiliation rates in marginalized regions have also been brought about by practical obstacles, and by the program’s principle of financing the demand for, rather than supply of, health services. One barrier is geographic: unless they have been affiliated during a community enrolment drive, individuals can only enrol at a hospital, not a clinic; for people living in remote villages, obtaining transport to a hospital is a challenge in itself. In order to enrol, the state also requires that the individual present an identity card (CU RP – Clave Única de Registro de Población) which many Indigenous women do  not have; furthermore, the registry office charges Mex$1800 (approximately US$140) to provide the card to an adult woman, an  enormous sum for someone living in extreme poverty.9 Other

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identity documents, such as a birth certificate, are required to obtain the identity card; but a birth certificate also requires time and money to acquire (Interview, C G M I -1 2008). As a result, it has been easier, according to N G O s, for women to gain access to the program through the Medical Insurance for a New Generation program (SMN G ) (Interview, C GMI -3 2008). In that program, any child born after the inauguration of President Felipe Calderón on 1 December 2006 is entitled to Seguro Popular, as is her family. Incapacity of the Health Care System The Guerrero health care system lacks trained personnel, medical supplies, and adequate infrastructure. Of the roughly 900 medical units10 in the state (Meléndez Navarro 2005, 54), 400 were not functioning in 2011, and the rest lack medications (Guerrero 2011b). The director of the state branch of the health workers’ union stated that deficiencies in medical supplies had been detected in 780 health centres (Guerrero 2011b). An official in the Costa Chica health district acknowledged the lack of resources: “Some of our health centres are without equipment, without material, without supplies for attending a birth. We’re glad that [births] are covered under Seguro Popular … but it’s not as we would wish; we wish that resources were flowing more rapidly. It’s a very slow process that will take years, and there’s already demand … Our hospitals are in such poor condition, they don’t have the equipment, the infrastructure” (Interview, O J 6 2008). The problem of an insufficient supply of medications is exacerbated by the fact that the state pays higher prices than necessary. Guerrero was the worst offender of twenty-four states that paid more than the reference price for medications; that purchased drugs not included in Seguro Popular’s catalogue, CAU S E S (Catálogo Universal de Servicios de Salud); that proceeded with tendering processes without sufficient checks; and that bought patented drugs without authorization. Murayama-Rendón (2011) argues that “the existing model of purchasing and supplying medicines needs to be profoundly re-thought in order to ensure adequate, timely and equitable access” (503). Perhaps as a consequence of increased focus on maternal health, in a study of fifteen basic community hospitals and ten general hospitals in 2008 and 2009, Meléndez Navarro (2010) found that, in

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the previous two years, there had been a substantial improvement in  the availability of medications to treat obstetric emergencies. Nevertheless, the lack of a full complement of staff remained a problem in the basic community hospitals. Contract staff worked under precarious employment conditions, performing activities that went beyond their job descriptions. None of the hospitals distributed information about the availability of free medical care during pregnancy and birth; nor did many staff know about the Healthy Pregnancy (Embarazo Saludable) program, under which pregnant women can enrol in Seguro Popular. Some hospitals continued charging user fees for obstetric care; all hospitals charged patients for meals. Although personnel in all of the hospitals studied had received some training in the management of obstetric emergencies, only three hospitals thought that the training had been sufficient (Meléndez Navarro 2010). The state has had great difficulty finding medical personnel to work in impoverished areas: in December 2010, the Ministry of Health held a call to contract 600 general practitioners, 200 specialists, and 300 nurses, but it received only six applications because of the persistence of low-intensity warfare and the lack of social services (Guerrero 2011a). Deteriorating infrastructure and poor working conditions have driven even the pasantes from the Costa Chica region. A health district official reported: “We have a tremendous lag in our region. Pasantes who come from other states resign because of the situation, because of the condition of our health centres. It’s very, very bad. They resign and go to other places … after fifteen days or a week at the health centre and they go … They tell their school about the conditions and the school helps them to resign” (Interview, OJ6 2008). Low affiliation rates in rural areas have contributed to this problem. Federal transfers depend on the number of people affiliated, so a low number of affiliates means a lower amount of funds transferred. The state government has not made its full contribution to Seguro Popular funds either. Between 2006–11, the state contributed only 56 per cent of the funds required to Seguro Popular, or roughly US$117.3 million, rather than US$209.3 million (see CN P S S 2012a, 73–4, and chapter 2). Nor has the state managed federal transfers well. When the federal auditor general examined Guerrero’s Seguro Popular finances, it found that strategies and mechanisms of control “were not sufficient

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to guarantee compliance with the guidelines and transparency in the fund’s operation” (A SF 2011, 2). The auditor general also concluded that the state’s Ministry of Finance and Administration was not transferring Seguro Popular funds to the state Ministry of Health sufficiently promptly. conclusion

In Guerrero, which has the highest M M R of any Mexican state, a number of policy shifts have undermined the trustworthiness of the health care system. In the 1970s, the creation of I M S S -Solidaridad compensated somewhat for the effects of Mexico’s “dual regime” in social services, or the schism between those with social security benefits and those without. The 1980s health system decentralization, however, resulted in the end of I MS S -Solidaridad services for the poor and uninsured, thereby undermining the nascent possibilities for solidarity and universal service provision in the state. The inequity of the system was further exacerbated by the greater application of user fees. If, as Gilson (2003) suggests, interpersonal trust is also affected by the degree to which treatment is influenced by financial considerations, user fees may have eroded this form of confidence too. Pasantes (social service students), who provided most of the medical care to the poor citizens of the state, depended on these charges to supplement their incomes. It was only with federal intervention in the form of Seguro Popular that more women gained access to health care, and goals of social solidarity have informed the system. Individuals and families affiliated with the national insurance program are exempt from user fees. However, despite universal coverage being declared in Mexico in 2010, there is evidence that not all women are covered by the Seguro Popular program. In Guerrero in 2012, 12.5 per cent of the women who died in pregnancy, childbirth, or the postpartum period had no health insurance coverage. One reason for this may be the difficulty of poor people living in remote villages to obtain a CURP identity card, or the money and other documents necessary to obtain one. But it should also be noted that even with Seguro Popular coverage, women are receiving a lower quality of care than those in the social security system. Seguro Popular affiliates were more likely to die than women who had social security coverage – 60.7 per cent of maternal deaths were among Seguro Popular–affiliated women (O M M 2014a, 22).

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For the extremely poor women living in the rural regions of the state, access to health care depends not only on the ability to obtain medical care free at the point of service, but the ability to access transport to that service. The Fox administration’s Equal Start strategy was intended to connect women with the health care system by allocating the responsibility for transport and accommodation to municipalities and trust networks. The Costa Chica and Montaña regions of the state demonstrate the limits of this strategy. As Mohan and Stokke (2000) note, asymmetries of power are just as present in small communities as in larger ones, if not more so. Trust networks in local areas may reinforce the categorical inequalities experienced by those who are excluded from them. Women without money to pay for transport could not rely on trust networks to get them to hospital if those networks were associated with a political or religious group to which they did not belong. Under these circumstances, N GO s depended upon the assistance of the State, in the form of the local health jurisdiction and its access to Seguro Popular or Oportunidades funds, to get women to hospital. Although N G O s could combat neither women’s extreme poverty nor the biases of local trust networks, they were able to liaise between women and the regional health jurisdiction, build trust networks that were linked to that jurisdiction rather than to caciques, and develop parteras’ capacity to negotiate with family members and the health care system. They also worked to overcome cultural norms around pregnancy and childbirth that normalized maternal mortality and reduced the State’s responsibility for the provision of life-saving care. In acting as intermediaries between women and the State, N G O s have contributed to what Tilly (2007) would call the partial integration of trust networks. However, their integration has not had as much of an impact on State actions as I, or the N G O s, would like to see; nor has it had the impact that Tilly believes to be necessary for democratic practice. In Tilly’s terms, the networks may not be far enough along the continuum that starts with disconnection from the State, and ends with State domination (neither of which is desirable). Greater, though still partial, integration would only be likely, and meaningful, if State actors became more responsive to the women’s demands for both redistributive policies and the recognition of their right to dignified care in pregnancy and childbirth.

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In the absence of such responsiveness, N G O s’ support for parteras as intermediaries is both necessary and limited, because the organizations encourage women to place their trust in an institution which in many cases has yet to earn it. Parteras’ creation and maintenance of networks requires a high level of skill and commitment from women who are themselves impoverished and marginalized in nonIndigenous society – and perhaps even their own communities. In order to reduce maternal mortality, the State depends on their loyalty to their communities and their belief in the State’s commitment to care for women’s health; but this commitment must be fulfilled in order for that trust to be created and maintained, and there is much that continues to undermine it.

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4 Chiapas: The Challenges of NGO Collaboration

introduction

Chiapas was the first of the three states examined in this book to elect a non-P R I governor.1 Pablo Salazar Mendiguchia, who ruled from 2000 to 2006, led the Alliance for Chiapas, a coalition of eight opposition parties (Mattiace 2003, 149). After education, investing in health was the government’s highest priority (Gobierno de Chiapas, 2001). The new government introduced its own maternal and child health program, Vida Mejor (A Better Life), which, along with funds from Seguro Popular, led to infrastructure improvements, more medical personnel, and the greater availability of medical supplies. The government was also more open than previous administrations to consulting with maternal health N G O s, and it funded infrastructure for transporting women to hospitals and clinics (ambulances and radio communication systems). In this chapter, I will examine a maternal health project in Tenejapa, a municipality in Los Altos (the Central Highlands).2 This project can be seen as attempting what Tilly (2007, 88) has called “the partial integration of trust networks into public politics,” whereby the state government has tried to reduce maternal mortality, and increase the use of the health care system, by integrating parteras and community health promoters with the health care system. As in other parts of Mexico, such efforts at integration are not new. In the case of Tenejapa, the attempt occurred via an agreement between the health jurisdiction and four NGOs, who were concerned not only with connecting women to the health care system but with reducing discriminatory practices within the system, affirming the knowledge

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of parteras, and questioning the assumptions about Indigenous culture as a cause of maternal death. Coston (1998, 358) constructs a continuum of relationship types between government and N G O s based on “the government’s resistance or acceptance of institutional pluralism, the relative balance of power in the relationship, and the degree of formality and – by extension – the level of government linkage.” The continuum ranges from government repression of N G Os, at one end, to co-operation and complementarity at the other (361). In Coston’s terms, the relationship between the N G O s and the government of Chiapas in the Tenejapa case could be classified as one of complementarity: it is based on comparative advantages; in principle, each sector contributes to the other; and the two sectors’ technical, financial, and / or geographic areas of specialization complement each other (362). The relationship also had elements of collaboration, in that the government accepted the N G O s’ role, and the organizations operated with a high degree of autonomy from the government. However, resource and information sharing were limited, as was joint action (362). In this case, there was the potential for mutual benefit, in that the two sectors had demarcated areas of activity: the State provided health care services, and the N G O s’ role was to strengthen the community’s capacity to gain access to those services. The state, at least to some degree, accepted the role of the N G Os, and granted them operating autonomy. However, there were difficulties in both the N G O sector and the state sector that undermined the potential for complementarity and collaboration. The collaborative relationship between the N G O s was donor-driven, and there was some tension between different visions of maternal health. Although the state government increased both its rhetorical and material commitments to maternal health, the infrastructure and resources necessary for resolving obstetric emergencies were still lacking. Thus, the potential for the creation and maintenance of trust networks linked to State agencies was inhibited by relations between the NGO s themselves and between the N G O s and the State, as well as by the trustworthiness of State health services. The chapter proceeds as follows. I will outline the context in Chiapas, a state that, like the other two, is characterized by inequality and conflict between Indigenous people and the state. Next, I will provide an overview of some of the events motivating the Salazar Mendiguchía administration’s commitment to improving health care in Chiapas. I will then highlight the Los Altos region where N G O s

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collaborated with the state government, exploring how collaboration proceeded, what the obstacles to it were, and the limitations of the health care system in the state. c h i a pa s : t h e c o n t e x t

According to Margaret Levi (1998, 85), “A trustworthy government is one that has procedures for making and implementing policy that meet prevailing standards of fairness, and it is a government that is capable of credible commitments.” States can signal fairness by coercing those who do not comply with State laws; applying universal criteria in policy-making, implementation, and the staffing of bureaucracies; establishing impartial institutions to arbitrate disputes and protect minority interests; and encouraging citizen participation in the policy-making process (90–2). The state government of Chiapas has often violated these standards, resulting in high levels of distrust and, after the 1994 Zapatista rebellion, the creation of autonomous communities which have actively rejected engagement with the State. Chiapas is the poorest state in Mexico. Its people are not only materially impoverished, but socially marginalized; the state is riven by inequalities of class, gender, Indigenous status, and political affiliation. More than a fifth of the adult population is illiterate; a similar number live in houses without adequate drainage or sanitation; a quarter do not have running water (Sánchez et al. 2008, 287). It is also one of the most ethnically diverse states in the country. There are twelve Indigenous peoples in Chiapas: Tzeltal, Tzotzil, Chol, Zoque, Tojolabal, Kanjobal, Mam, Chuj, Mochó, Cachinquel, Lacandón, and Jacalteco (El Estado / Agencia 2016). Indigenous peoples are much more likely to be impoverished, lack access to essential services, and be in poor health. The state has a history of exploiting Indigenous peoples’ land and labour. This exploitation by both capital and the state and federal governments – as well as Indigenous peoples’ resistance to it – has fragmented communities at an accelerating rate since the outbreak of armed rebellion in 1994. The relationships between the state and its Indigenous and peasant citizens have been characterized by repression and violence. Where ties have developed, they have been clientelistic3 rather than based on relations of trust.

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History Within twenty years of the Spanish conquest of the region in the sixteenth century, the population of Chiapas had declined by 80 per cent – a result of military attack, the spread of European diseases, enslavement, and deportation. In the colonial period, Chiapas was a part of Spain’s Central American colony; it joined Mexico after the war of independence in 1821 (Gobierno de Chiapas 2001). In the late nineteenth century, Chiapas became integrated into global markets through the development of tropical agriculture. The government sold approximately a third of the state’s land, mainly to foreign investors, for the development of tropical plantations. However, further state action was required to coerce Indigenous people to work on the plantations. Although much land had been expropriated, Indigenous people were still able to feed themselves on their ejidos (collective property); to force them to become plantation labourers, the government not only privatized more property, but used debt as a mechanism to drive them to plantation work (Rus et al. 2001, 9). Chiapanecan workers laboured under forms of debt servitude up to and after the Mexican Revolution, which was fiercely resisted by members of the state’s landed elite (Benjamín 1996, 148). The land reforms that were finally instituted from the 1930s onwards did not increase the power of labour in relation to capital, but “served to provide the state with a large pool of agricultural workers tied to their communities but forced by economic necessity into poorly compensated migrant labour” (216). While Indigenous communities were sites of resistance to the depredations of plantation work, they were also subject to clientelist patterns of rule by caciques, or party bosses, affiliated with the P R I (211). Local systems of rule also had a religious dimension (Rus et al. 2001, 10). In the 1970s, the material basis for clientelistic rule began to break down, and Indigenous resistance became more widespread, overt, and organized. Commodity prices fell, or stagnated; the cost of agricultural inputs increased; the availability of credit declined; and land was expropriated for petroleum exploration or dam building (Washbrook 2007, 10; Rus et al. 2001, 11). The population also grew dramatically, more than doubling in thirty years (Favre 2002, 32). The mobilization of Indigenous populations developed in this period. In 1974, the bishop of San Cristóbal de las Casas, Samuel

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Ruíz, sponsored the First Indian Congress, which brought together leaders of more than 300 communities (Benjamín 1996, 235). The congress also had an impact on the diocese of San Cristóbal, which thereafter identified with the poor and began the process of training Indigenous people to carry out ecclesial ministry in their own communities (Andraos 2000, 96–8). Liberation theology was not the only challenge to traditional forms of Catholicism; evangelical Protestant sects had also established missions in Chiapas. Sarah Washbrook emphasizes the political dimensions of changing religious affiliations: “after 1970, conversion also constituted a political strategy; by rejecting the traditional civil-­ religious Indigenous authorities, who had often become incorporated into the party-state apparatus (above all in the central highlands), converts were expressing their oppositions to state corporatism and caciquismo” (2007, 12). The first expulsion of Protestants from traditional Catholic communities took place in San Juan Chamula in Los Altos in 1974 (Rivera Farfán et al. 2005). By 1997, there were over 30,000 displaced people in Chiapas (Washbrook 2007, 12). In the 1980s, internal conflict and displacement were compounded by an influx of 200,000 refugees fleeing from the military government of Guatemala (Benjamín 1996, 245). With fewer jobs and a greater number of people looking for work, Chiapanecan labourers went further afield to search for an income, elsewhere in Mexico and to the US. At the national level, the 1980s was the decade in which Mexico, along with many other developing countries, shifted from an import substitution industrialization (I S I ) to a neoliberal development model, in the wake of the 1982 debt crisis. In addition to implementing structural adjustment programs, Mexico joined the General Agreement on Tariffs and Trade (G AT T ) in 1986, and, in the early 1990s, entered NA F T A with the US and Canada. While negotiating the agreement, Mexico also ended its constitutional commitment to land reform by amending Article 27 of the constitution, which had guaranteed peasants’ right to land, and required the state to fulfill this right by redistributing the property of large landed estates (Kingsolver 2001, 65). The day NAFTA entered into force, the Zapatista Army of National Liberation (EZLN) launched a military uprising, briefly taking over seven towns – including Chiapas’s second largest city, San Cristóbal de las Casas – before retreating from Mexican army attacks. By choosing 1 January 1994 as the day to launch their rebellion, the

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Zapatistas linked their struggle for Indigenous peoples’ rights to selfdetermination to worldwide struggles against neoliberal globalization. Soon after the rebellion, the Mexican government entered into negotiations with the Zapatistas, which resulted in a set of agreements, the San Andres Accords, which guaranteed Indigenous rights (Sánchez 2003, 98). In late 1996, however, President Zedillo suspended dialogue with the EZLN. The legislative agenda based on the San Andres Accords and developed by a commission ­comprising Congressional representatives of four political parties (COCOPA)4 was not presented to Congress (Washbrook 2007, 5). The Zapatistas established autonomous communities with parallel health clinics, justice systems, and schools. Many Zapatista supporters began refusing government services (Brentlinger et al. 2005, 1002). Paramilitary activity, frequently supported by the PRI, grew; in 1997, a paramilitary group with the name Peace and Justice (Paz y Justicia) murdered forty-seven Zapatista sympathizers in a church in the village of Acteal, Los Altos (González F. 2004, 8). In 2000, Vicente Fox was elected president of Mexico. Initially, it seemed that the change would bring about a resolution of the Zapatista conflict. During the election campaign, President Fox had declared that he could resolve the conflict “in fifteen minutes.” After the election, the Zapatistas and their supporters marched from Chiapas to Mexico City, passing through ten states, to address the Mexican House of Representatives (Cámara de Diputados (González F. 2004, 8). Unlike his predecessor, President Fox did send the C OC OPA legislation to Congress, but it was only passed subject to amendments which were unacceptable to the Zapatistas, and to the commission that had originally drafted it (Washbrook 2007, 5). Since the outbreak of the conflict, the fragmentation of communities has increased further. Historically, the people in Chiapas have lived in small villages of fewer than 2,500 inhabitants; the number of such villages has increased from 16,422 in 1990 to 19,453 in 2000, and, by 2003, 22,000 (Sánchez et al. 2008, 11). This is an indication of the level of social division. Although there has not been another massacre like the one that occurred at Acteal in 1997, lowintensity conflict has persisted in the region, aggravated by the presence of the federal army and paramilitary groups (12). Indigenous communities have resisted infrastructure projects, such as highway construction and expansion, in which the federal government has appropriated their land; in one instance in Los Altos, a paramilitary

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group kidnapped and assaulted several men opposed to a new highway (Frayba 2010, 14). The state and federal governments have pursued infrastructure developments, such as highway building, as part of Project Mesoamerica (Proyecto Mesoamérica – formerly known as Plan Puebla-Panamá), which is intended to increase economic growth by integrating the southern states of Mexico with the nations of Central America, plus Colombia and the Dominican Republic, via highway, energy, and information technology development (Cepal 2009, 1). As has historically been the case, such development projects have infringed on the rights and collective property of Indigenous peoples (Frayba 2010, 36). The war on drugs has also reinforced the militarization of Chiapas. Under the Merida Initiative (Iniciativa Mérida), the United States has contributed $1.3 billion to combat drug trafficking. According to the human rights organization Frayba (Centre for Human Rights, Fray Bartólome de las Casas), the initiative “has resulted in the militarization of civilian life across the country, an increase in violence, and, de facto, in the normalization of a state of siege” (Frayba 2010, 67). Groups such as Human Rights Watch and Amnesty International have criticized military abuses of human rights, and domestic groups have argued that the drug war provides a pretext for the criminalization of social protest (67). The ongoing conflict has had a negative impact on health in general and maternal health in particular. Brentlinger et al. (2005, 1004) studied the impact of the conflict on obstetrical outcomes, comparing communities aligned with the government, those in opposition to it, and divided communities whose loyalty was split between two political and / or religious groups, each of whom had their own governance structures. According to the latter definition, twenty-three communities were divided (1005). The researchers randomly selected six villages of each political type in three of the regions most affected by the Zapatista / government conflict (1003). They found that health outcomes were worse in divided communities, and that people experienced discrimination from health service providers based on their political and / or religious affiliation; that health workers had experienced harassment and extortion at road blocks when trying to transport patients out of their villages; and that some workers could not transport women with obstetric complications at night because travel was considered unsafe. During the study period, there were eight maternal deaths, resulting in a maternal mortality ratio of

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542 / 100,000 adjusted for sampling (1007) – a figure more than eight times the MMR reported for Chiapas. c h i a pa s s i n c e t h e d e m o c r at i c t r a n s i t i o n

In August 2000, Pablo Salazar Mendiguchía defeated the PRI candidate in gubernatorial elections (Martínez Garcia 2001). His government eliminated the State Commission on Re-municipalization (Comisión Estatal de Remunicipalización) which had created new municipal structures in order to undermine Zapatista support.5 The government also announced seven priority areas – education, health, infrastructure, administration of justice, protection of natural resources, economic growth, and improvement in the quality of life (Martínez Garcia 2001). In health, the government wished to “improve the quality and coverage of health services, according to the principles of equality and inclusion, guaranteeing the coordination of the social security and public health institutions, strengthening hospital infrastructure … and ensuring the supply of medicines in all health centres” (Government of Chiapas 2001). The new government’s task was made more difficult by the condition of the health infrastructure it inherited: it had been left with “devastated public clinics with no medications” (Martínez Garcia 2001). Like Oaxaca and unlike Guerrero, Chiapas escaped the decentralization of public health care in the 1980s, and as a result still retained its IMSS -Solidaridad services. It did go through the 1990s decentralization, however, which meant that the state government had more autonomy to decide on the configuration and implementation of programs, and even which ones to apply. This included choosing how public health workers could operate in their communities, the intensity of such work, and how a gender perspective would be applied to its programs and actions (Nazar Beutelspacher et al. 2007). The government introduced a program called Vida Mejor (A Better Life)6 to improve the health of women and children, through coordinated actions in health, education, housing, water, and nutrition (Meneses Navarro 2007, 23). In 2003 the program was implemented in three municipalities (including Comitán, which will be discussed below). It involved linking communities with the health care system by improving transportation and communication networks, installing radio communication systems in over 100 locations in 2005, and making available a US$500 revolving fund to

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cover fuel costs incurred while transporting a labouring woman to a medical facility (23). Under Vida Mejor,7 there were some efforts to strengthen the health system: thirty-one additional doctors were hired in 2005, as well as over 100 technicians (23). However, these improvements could have only a small impact, given the enormous needs of the state. While the Vida Mejor program addressed both maternal and infant health, the program was created after a dramatic increase in the number of infant deaths at the general hospital in Comitán (Freyermuth n.d.).8 Twenty-five babies died in December 2002 (Dominguéz F. 2003). On 4 January 2003, the Chiapas Ministry of Health reported the deaths to its federal counterpart (Frenk Mora 2003); national and local newspapers carried the story. Comitán, which has approximately 83,000 inhabitants (121,000 in the greater municipal area), is one of nine municipalities covered by health jurisdiction 3. Eight of these municipalities are classified as highly or very highly marginalized. The hospital also drew patients from twentyfive other municipalities, and from Guatemala and El Salvador. At the time of the babies’ deaths, 90 per cent of the population in the region was without health coverage (Frenk Mora 2003). The federal Minister of Health, Julio Frenk, initially blamed the deaths on the lack of prenatal care in remote communities, and the Christmas closure of private clinics in the area (Magally 2003).9 Later, however, when addressing the Senate on the issue, he acknowledged that the poor condition of the public health system may have played a role. In his Senate testimony, although Frenk repeated his claims about the lack of prenatal care and closure of private clinics, he also acknowledged that poverty and lack of access to medical care had contributed to the loss of life: “Behind this sudden increase in neonatal mortality, lies the limited access to prenatal care, linked to poverty and marginalisation, the lack of skilled care during pregnancy and for newborns, and, of course, the lack of financial protection for low-income families as a result of insufficient public investment in health” (Frenk Mora 2003).10 Frenk did not address any specific failings of the hospital or health care system, and his reference to a lack of skilled prenatal care may have been directed more toward the role of parteras than to medical personnel.11 The state Human Rights Commission, however, concluded that the deaths were due to medical negligence (La Crónica de Hoy 2003).

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Both the governor of Chiapas, Pablo Salazar, and Julio Frenk argued that problems associated with decentralization had contributed to the tragedy. They differed on the responsibilities of the two levels of government, however. Salazar decried the federal government’s transfer of deteriorating infrastructure to the states, which had occurred under decentralization (“they transferred old hospitals, old beds, old iron bars”); and he pointed to its failure to invest in infrastructure since coming to power (Segundo 2003). In his Senate testimony, Frenk also noted the need for more federal intervention, but in the form of regulatory oversight rather than infrastructure investment: “In a health system that’s completely decentralized … the federal Ministry of Health must strengthen its capacity for oversight, supervision, and advice” (Frenk Mora 2003). After the event, a team of specialists from Mexico City analyzed both the hospital and the health region. The federal Ministry of Health arranged for 300 health workers, including parteras, to be trained (Frenk Mora 2003). Health clinics in all of the region’s municipalities received more resources, there was an increase in the number of health workers employed, and almost all of the clinics were open twenty-four hours a day, seven days a week. Some health centres were expanded, with funds for construction coming from the municipalities, and funds for staff coming from the state Ministry of Health. The introduction of Seguro Popular had an important impact, increasing the accessibility of health services in the region. Affiliated women were able to give birth free of charge; prior to the implementation of this program, they had to pay a user fee of approximately US$60, according to a midwife at one Posada AM E (Interview, C J 3-2 2006). The Relationship with ngos The change of government brought with it an increased acceptance of “institutional pluralism” (Coston 1998, 361) – that is, a willingness to work with, and recognize the autonomy of, N G O s. The governor instructed the Ministry of Health to work more closely with civil society organizations, which was a new development in the history of Chiapas (Interview, SC C J 2-1 2004). Public health officials believed that the health sector benefitted greatly from co-operation with N G Os. Before the new approach to external collaboration, the

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Ministry of Health did not really understand what N G O S did or how they were doing it; joint agreements provided a window into their activities. It also facilitated information sharing, particularly in the case of research organizations, such as E CO S U R (El Colegio de la Frontera Sur – College of the Southern Border), and organizations undertaking research in their geographic area. The ministry benefitted in two respects. First, it gained access to findings from internationally recognized publications of which they may not previously have been aware; and second, it learned from N G O s’ on-the-ground experience in particular locations. The interaction with these organizations undermined the ministry’s denial of the health problems in the state: “now we recognize the existence of trachoma, of maternal death … now the government says yes, we are the state that has the greatest number of deaths from disease X” (Interview, S CCJ 2-1 2004). In some instances, the interaction between the state government and NGOs also resulted in greater co-operation between levels of government. The municipality of San Juan Cancuc (in Los Altos) was working with an international N G O on a project to eliminate trachoma. In order for this to be effective, the state government needed to build a road for the population to get access to health care services; the Ministry of Health therefore worked with the Ministry of Communication and Transport and the Ministry of Public Works to ensure that a road would be built in time to implement the project. This was the first time that the Ministry of Health and the municipality had collaborated on a municipal development project with health implications (Interview, SC CJ 2-1 2004). Agreements with NGO s also allowed the state to ensure that the organizations complied with national and state guidelines, with regard to both constitutional guarantees and state and local regulations (such as building codes). However, in some instances, N G O s’ specialization and resulting capacity in a particular area meant that the government did not enter into an agreement because it could not match the level of service offered by the N G O , or meet the potentially increased demand for it. For example, the ministry would not enter into an agreement with the sexual and reproductive health services N G O Marie Stopes International if that agreement entailed the distribution of contraceptive patches, because the ministry did not supply them (Interview, SC C J 2-1 2004). In this instance, therefore, a  partnership with the potential to expand women’s reproductive

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health options was not entered into because of the limitations in the state’s capacity. t h e r e d s o c i a l i n t e n e j a pa

The Context: Los Altos In Chiapas, there are ten health districts (jurisdicciones), each of which covers an area of ten or more municipalities (Nazar Beutelspacher et al. 2007). The Los Altos region, District 2, covers 18 municipalities and approximately 730,000 people in the state’s central highlands (Freyermuth Enciso et al. 2006, 62). There are more municipalities in this region that are categorized as extremely poor than there are in any other area of the state. With the exception of the city of San Cristóbal de las Casas, the eighteen municipalities encompassed by District 2 are classified as having high or very high levels of marginalization (Meneses Navarro 2007, 20). Los Altos is also the region in Mexico with the highest number of Indigenous speakers: a third of the state’s Indigenous population lives there (Freyermuth Enciso 2008, 138). Most of this population speaks one of two Mayan languages, Tzotzil or Tzeltal. Female Indigenous language speakers tend to be monolingual and illiterate. Many of the villages have fewer than 1,000 people, and some are distant from municipal centres where health clinics are located (Interview, S C C J 2-1 2004). Although the number of births in medical facilities has increased in Chiapas (from 43 per cent of births in 2006 to 78 per cent in 2012) in some municipalities in Los Altos more than half the babies are born at home (Kolodin 2015, 54–5). As in other locations studied by Kolodin et al. (2015, 46), the majority of parteras in Chiapas are over the age of forty and monolingual in an Indigenous language. Poverty and marginalization have been intertwined with intracommunal conflict: since the 1970s, more than 35,000 people have been expelled from their villages in political-religious strife (Sánchez et al. 2008, 10). Los Altos was the centre of the Zapatista movement, and many communities refuse to recognize the State’s legitimacy or use State services. The state Ministry of Health was forced to coordinate with Médecins sans Frontières (France), who were providing medical assistance to Zapatista families, in order to combat an

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outbreak of whooping cough among children in the village of San Juan Cancuc (Interview, SC C J 2-4 2008). Conflict has occurred not only between the Zapatistas and the state government, but between PR I and PR D supporters, as well as between Catholics and evangelical Protestants. In 2004, villages in the municipality of Tenejapa were occupied for two weeks by the Zapatistas, followed by the P RI . In both cases, it was more difficult for people to get out of the village if they needed medical care, or for medical personnel to enter the village to provide it (Interview, L MC P 2004). The region has two hospitals, both in San Cristóbal: the state Ministry of Health hospital, which has thirty maternity beds (Interview, L MC P 2004), and the I M S S -Oportunidades hospital, which does not have staff available to attend obstetric emergencies at all times of the day or the year (Freyermuth n.d., 3). Eight of these municipalities do not have Ministry of Health clinics (26). In 2004, the principal causes of death were obstetric haemorrage, accounting for 70 per cent of deaths, followed by puerperal infection and hypertensive disorders (Meneses Navarro 2007, 20). Located in Los Altos, the municipality of Tenejapa comprises fifty communities, thirty-one of which have fewer than 500 people; in 2000, it had a population of approximately 30,600 (Freyermuth et al. 2004, 7). There are roughly 900 births each year (Interview, LMCP 2004). The MMR was very high: between 1997 and 2001, it was 110 maternal deaths to 100,000 live births. There were three deaths in the first two months of 2004 (Freyermuth et al. 2004, 8). The Ministry of Health operates nine medical facilities; IMSS-Oportunidades operates a further five (Freyermuth Enciso et al. 2006, 62). The Project The Red Social social network was a three-year project that ran from 2005–08 in Tenejapa, about 27 km from San Cristóbal in Los Altos.12 It was established when the MacArthur Foundation, which was funding several NGO s working on maternal health in the region, decided to bring the NGO s together to address different aspects of the problem in a particular municipality, in conjunction with the state health sector (Interview, MA 2004). Although, as noted above, the state government was open to working with N G O s in a way it had not been in the past, the Ministry of Health was initially reluctant to engage with them, because of “a long and complex history in

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Chiapas that if there’s an intervention, it’s better if it comes from the outside. Because of course the locals don’t have the capacity. It’s like the First World coming to rescue the Third World” (Interview, EC OSU R 2008). After telephone discussions, the ministry met with representatives from the MacArthur Foundation and the N G O s and asked them which area they wanted to be responsible for. However, the N G O s had neither the capacity nor the desire to provide maternal health services (Interview, E C O SU R 2008). Because the NGOs were already working in Tenejapa, which also had a high MMR , it was decided that this community would be the site for the Red Social. The Red Social project was to create a social network with the aim of raising awareness of maternal mortality in the community, and educating people about danger signs of obstetric complications; training parteras to recognize signs of obstetric complications and transport people to medical care; training health workers in handling obstetric emergencies; and developing their capacity to communicate with their patients across cultural and linguistic barriers. The MacArthur Foundation wanted to collaborate with the state government in the development and implementation of the Red Social; however, as we will see below, participants disagreed about the extent to which collaboration took place. The Red Social had the potential for complementarity, in that the state was constructing a social network to connect the general hospital to local communities via ambulances and radio communication systems. The hospital also improved its services: it installed a blood bank, ensured that someone was available to answer urgent calls and alert local health committees about obstetric emergencies, and hired better-qualified people at the first point of contact between the patient and the hospital. However, complementarity was compromised because of problems with the municipal responsibility for transport. Although there were some improvements at the hospital, neither those changes nor changes at the primary level of care were sufficient to address maternal mortality. The four NGOs determined that each would be responsible for a particular aspect of the project. Marie Stopes International provided emergency obstetrics training; the group for Advice, Assistance, and Training in Health (A C A SA C ) developed community education programs on maternal mortality, using radio broadcasts as well as faceto-face communication;13 the Comitán Centre for Health Research (C ISC ) trained health care providers in patient care and its social

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and cultural dimensions;14 and Luna Maya Birth Centre, which opened in 2004, trained parteras and health promoters in Tenejapa.15 The four organizations themselves did not form a network, however. According to one participant, the degree of trust and reciprocity among the NGOs themselves was limited, because they had not come together on their own initiative, but on the initiative of the funder (Interview, E C OSUR 2008). The project organizers wanted to ensure that parteras, health promoters, and people in the community could recognize obstetric emergencies and, having identified the problem, could transport women from the community to the local clinic or general hospital in San Cristóbal. Two of the interviewees thought that the efforts to increase knowledge and awareness had been successful in the municipality: “I think that the Red Social has been very successful because there’s been penetration of the local population, the Tzeltal population, and this has permitted referrals [to medical services]. There has been maternal mortality in Tenejapa, I think there have been deaths in the last two or three years, but there has been a significant reduction” (Interview, CPMSR 2008). There were two health promoters who worked face to face with people in the community. A maternal health researcher commended their efforts: “They did a fantastic job. They put maternal health on the agenda of the municipality. Everyone in the community knows them now, they know all of the communities and the communities know them. They are synonymous with maternal health in the community” (Interview, CIESAS-2 2008). The transportation itself was provided and organized by the state government in conjunction with the municipal authorities. The state Ministry of Health supplied ambulances to the municipalities; the municipalities were responsible for providing gas and drivers. In the Tenejapa case, however, the Ministry of Health took back possession of the ambulances, which were then kept at the local health centre, because municipal officials had used the vehicles for other purposes, such as carrying wood (Interview, SC C J 2-4 2008). The municipality had also agreed that it would reimburse half the costs of transporting a woman by taxi. However, this meant that the family was still responsible for the transport cost upfront, which, in some cases, was beyond the family’s capacity to pay. Taxi drivers were charging Mex$600–$800 (approximately US $50–$65). By making families responsible for some transport costs, the likelihood of a pregnant woman getting transported could be undermined – particularly if

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she has little financial autonomy, her family members regard the cost as too great, or the funds cannot be raised (Interview, L M CP 2010). Although the municipality had pledged to split taxi fares with the family, in practice it was difficult for people to get reimbursed. Taxis in Los Altos do not provide receipts, and, when a family requests reimbursement from the municipal accounting office, they may be told that there are no longer any funds for that purpose (Interview, LMC P 2010). Not only were there administrative problems with financing transport at the local level, but the commitment to maternal health was vulnerable to political change. Local government elections are held every three years, and the new administration may not be committed to reducing maternal mortality; such a regression occurred in Tenejapa after the 2008 elections (Interview, CI E S AS -2 2008). Therefore, staff from the health jurisdiction had to repeat the work of convincing municipal authorities to support maternal health programs and to dedicate part of their budget to emergency transport costs (Interview, L MC P 2010; Interview, S CCJ 2-6 2008). In the case of communication networks, the MacArthur Foundation provided the hardware (two-way radio systems) and the health jurisdiction established networks to use it. The jurisdiction trained municipal health committees to create communication networks to help transport women out of the community in case of an emergency. The committees needed to know where in the community the telephones or radios were located, the phone number of the hospital, and the name of the person they needed to contact at the hospital (Interview, SC C J 2-1 2004). The hospital ensured that a social worker was available at the reception desk to identify emergencies and improve patient care. Before this change, “a woman in labour would arrive at the reception and be told – by someone with no medical knowledge – that she should go for a walk because she wasn’t about to give birth yet. That doesn’t happen anymore. All the pregnant women are a priority now” (Interview, S CCJ 2-1 2004). Midwifery Training The state and federal Ministries of Health in Mexico have conducted midwifery training since the 1970s. Such training has generally been conducted by doctors or nurses, in Spanish rather than an Indigenous language (Indigenous language speakers or translators have

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only recently gotten involved), and it has been criticized both by anthropologists for its devaluation of midwives’ practices (Pigg 1997; Jordan 1989, 1992), and by public health specialists for its ineffectiveness (Starrs 2006). The training conducted as part of the Tenejapa project differed from that implemented by the health ministries because it was conducted by a professional midwife who was committed to facilitating and encouraging home birth where possible (Interview, L MC P 2010). The midwifery training involved fifty-five parteras and eighteen health promoters (Interview, L MC P 2005a). In the first year of the Red Social program, the training focused on assessing risks and identifying and managing emergencies. In the second year, discussion and learning focused on the issue of violence against women, which was “what the parteras wanted to talk about.” In the final year, twelve of the original group of parteras, who had been more active in the group and attended a lot of births, studied primary care. They were taught, among other things, how to do a physical, perform a Pap test, and check for diabetes. The educator was unsure of how much the parteras learned from the training, because of the difference between the Mayan understanding and a Western approach to medicine and childbirth. “The visions of the Western and the Indigenous world are so different,” she said. “The way that [Indigenous people] meet and greet each other and hold a meeting and decide there’s a problem and what to do about it is so different from the way we do it, and nobody’s bothered to check out how that works. Especially people who work with Zapatista communities have really great intentions, but the pace is so slow” (Interview, L MC P 2005a). Five years later, she was still concerned about knowledge translation between the Mayan and Western approaches to medicine: “Every midwife will tell you that she wants more education … but the Mayan cosmovision is so different, I’m always concerned about ‘Is this making things clear?’ I’m not sure what happens on the ground afterwards. It’s difficult to know how they apply what they learn in midwifery training. And what the world wants them to know about is risk, but what they’re concerned about is normal birth” (Interview, L MCP 2010). Still, what did emerge from working together for over three years was a sense of unity among the midwives, whose relationship had previously been characterized by mistrust and competitiveness. The midwifery educator understood the mistrust to be a consequence of

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“the brunt of poverty” as well as a lack of midwifery regulation, which, combined with a punitive response to maternal death, means that midwives will try to protect themselves and blame others if a death has occurred in the community (Interview, L M CP 2010). The midwives did not often work together, but the training project provided them with an opportunity to learn together, with an instructor who believed that the midwives’ knowledge and skills were valuable and worth preserving. Through working together, the group developed a sense of unity, and a belief (reinforced by their educator) that parteras are “the keepers of normal birth in the community”; that is, that most births will occur without complications and can best be managed by midwives at home (Interview, L M CP 2010). Some deaths may have been averted by midwives’ interventions in cases of social isolation and / or violence. Women who birth at home without assistance are at higher risk. There was one case in which a partera checked in on an unassisted birth in which the placenta had not been delivered, and she was able to get the woman medical attention and thereby avoid a haemorrhage. The midwifery training also involved developing strategies in the event that the birthing woman’s family refused to have her transported. Because the local health promoters were male and therefore had more authority in the community, when the midwife and health promoter worked together they often successfully convinced the family to authorize transportation (Interview, L MC P 2010). The focus on keeping birth in the community, however, conflicted with the message from ACAS AC, which emphasized the potential for complications at any time. Thus, the N G Os “didn’t have a common message as a group; we weren’t able to come to a consensus about what the message would be” (Interview, LMC P 2010). This meant that collaboration between the health jurisdiction and N G Os was more circumscribed than the N G O s would have liked. According to the midwifery educator, “we needed a friend at the hospital – we needed someone with whom we could make alliances. The Ministry of Health wasn’t interested in alliances, nor was the health workers’ union” (Interview, L M CP 2010). Interculturalidad (Intercultural Communication) As part of the Tenejapa project, CISC developed a course for Los Altos health workers that aimed, ultimately, to decrease discriminatory

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behaviour towards poor, marginalized, and Indigenous people using the health care system. The approach developed in this course was distinctive because the educators rejected the label “intercultural,” and tried instead to encourage health care system employees to reflect on their own position within the system. The goal was to think about and develop empathy with their patients by starting from an understanding of their own experiences of having been discriminated against, on the basis of race, class, gender, sexual orientation, or other categories. The educators’ reason for rejecting the concept of “intercultural” communication (interculturalidad) was that they believed that it reinforced, rather than challenged, a hegemonic discourse of Indigenous inferiority: It’s like the emperor’s new clothes for talking about Indigenous people, but keeping them in the same situation. Now everything is intercultural … you have to incorporate an intercultural dimension into everything, but there hasn’t been an effort, or at least not a considerable effort, to determine what this means. There are intercultural universities … and their programs include ecology, land conservation, eco-tourism … it’s for training tourism workers! I worry about what is lost … [When Indigenous concepts and ideas] enter hegemonic discourse they lose their capacity to change reality, and become a means to legitimate the hegemonic culture. (Interview, E C O S U R 2008) Instead, what the C I SC educators tried to do was encourage the course participants to think about what it meant to be a health worker in a multicultural environment, beginning with their own understanding of their role in the system and the influences on their position and behaviour. This entailed talking about what the workers found difficult or challenging in their work; the relationship they had with their superiors in the system hierarchy; gender relations; and experiences of abuse within the system. They also discussed the workers’ experiences of discrimination and exclusion. Because in Ministry of Health training courses, “one isn’t used to talking about oneself in terms of one’s identity and how it’s produced,” this experience was “very emotional” (Interview, E CO S U R 2008). In the second year of the project, Luna Maya was involved with the health worker training, and the midwifery educator spoke of a

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similar experience with the students. In this case, the health workers spoke not about their experiences of discrimination per se, but about the frustrations of working within the health care system: “The doctors said things such as: if I do a Pap smear, the cytology results won’t come back … I don’t have any drugs to treat [post-partum] haemorrhage … the last time I referred a woman to the hospital, I was berated for sending someone with a normal birth” (Interview, LMC P 2010). In the second part of the C I SC course, in which the students reflected on their experience of Indigenous people, their characterizations either denigrated or idealized them. No matter how much, or for how many years they had been working with Indigenous people, they thought in stereotypes: Indigenous people are poor, dirty, ignorant; or they knew very ­little about Indigenous people and then the stereotype was that they weave beautifully, they attract the tourists, they are one of the treasures of Chiapas. And so, it’s almost as if, in [providing health services] to Indigenous people, it’s because “I’m giving you something because you’re ignorant, incapable.” Rather than that each of us has rights and that one of these rights is the right to health and, as a health worker, I contribute to guaranteeing that right. (Interview, E C O SUR 2008). In order to try to challenge these stereotypes, the course participants discussed Indigenous concepts of health and illness in the context of the Mayan cosmovision. They also talked about different forms of inequality, including gender and race / ethnicity, and how these are reproduced; and they explored different ways to interact with clients in the health care system that demonstrated recognition and respect (E C OSUR n.d.). It was noted by the C I SC and midwifery instructors that the majority of the health workers who took the course were perhaps the least likely to need it: nurses and social workers rather than doctors and medical specialists. When doctors did attend, they were more likely to be women than men (Interview, E CO S U R 2008). The Tenejapa project tried to address the social dimensions of the maternal health problem, and to address them in such a way that it was not only Indigenous people who were seen as the problem and the obstacle to change. This approach was not fully embraced by the

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state health ministry or the local health jurisdiction, nor did the N G Os themselves cohere in their understanding of the problem or strategies to address it. p r o b l e m s i n t h e h e a lt h c a r e s y s t e m

Between 2003 and 2007, Chiapas experienced a steady decline in the number of maternal deaths, from 106 to 78 per 100,000 live births; however, the number increased to 92 in 2008. The number dropped in 2009, but early figures indicated that the 2010 figure would again be higher than the previous year. In 2009, 70 per cent of deaths occurred in the hospital, 13 per cent occurred while on the way to medical care, and 17 per cent occurred at home (Gómez Montes 2010). Throughout this period in Chiapas there were two issues that could only be resolved at the state level in coordination with its federal counterpart: the inability to distribute medical supplies effectively to hospitals and clinics across the state, and the lack of fully qualified doctors and obstetrician-gynecologists. While there was some evidence of improvement in the supply of medicines in Los Altos in 2006–07, problems nevertheless persisted, and were still cited as problems in 2009. In 2004, Freyermuth and Meneses Navarro studied ten clinics in Los Altos that had just been classified as “Clínicas Si Mujer” – that is, these clinics had the capacity to manage obstetric emergencies. In spite of this classification, the researchers found that few of the clinics had the human or material resources to manage obstetric emergencies. Half of the clinics had deteriorating infrastructure: paint peeling off the walls, problems with drainage, and, in some cases, problems with the water supply (30). Although all of the clinics had a doctor and a nurse, none had medical staff available at all times of  the day or year. None of the clinics employed a gynaecologist-­ obstetrician, and none had a blood bank for cases of postpartum haemorrhage (35). Three of the facilities did not have the equipment necessary to manage a birth in the clinic. Only two had oxygen tanks and masks – but in neither case were these functioning (33). In the majority of cases, the clinics had neither the medications to manage an obstetric emergency, nor staff with sufficient knowledge and experience to employ such resources if they were available. Only two of the clinics had oxytocin available at the time of the researchers’ visit; only three had the drugs necessary for the treatment of

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eclampsia (34). Half of the doctors interviewed did not know how to treat a case of postpartum haemorrhage, and fewer than half had the skills to manage complications such as pre-eclampsia, eclampsia, or retained placenta (41–2). Infrastructure and the availability of trained personnel, medications, and equipment improved during the life of the Red Social. Nevertheless, problems with supplies, particularly those required to attend obstetric emergencies, remained. Over time, the introduction of Seguro Popular increased the resources available in the health care sector. Before the program’s introduction, Chiapas had only one doctor per 2,500–3,300 people; after, the figure changed to one per 2,000 people (Meneses Navarro 2007, 29). In Los Altos, the number of doctors and nurses increased by roughly 50 per cent; social workers and nutritionists were also hired in this jurisdiction (29). Although infrastructure improved, it was still inadequate. In 2008, Argüello (2010) examined the conditions of Ministry of Health clinics and hospitals in Chiapas.16 She and fellow researchers at CI E S AS developed an indicator measuring the availability of health care, which monitored the availability of appropriately qualified staff, the supply of necessary medications, and whether the facility was open around the clock. None of the health care facilities examined fulfilled these criteria. The researchers also considered the accessibility of the facilities – an indicator that measured the availability of bilingual health promoters, transport, radio communication, and the dissemination of information about programs (Argüello 2010). The AI DE M program, which examines cases of maternal death in order to find the “critical links” (eslabones críticos) that led to death in a given instance, has found significant problems with the management of obstetric complications in Chiapas. In approximately 18 per cent of cases, the group attributed the cause of death to mismanagement of complications; in approximately 20 per cent of cases, to a failure to refer the patient to the next level of care or to an untimely referral; and in approximately 9 per cent of cases, to a failure to identify risk factors. Luna Gordillo (2009) concluded that the principal cause of death was related to the quality of care received. In the case of maternal death caused by eclampsia, AI D E M found that in 70 per cent of cases, the patient had symptoms that were not recognized; and in 83 per cent of cases, the women had sought attention but been turned away from a health facility (Luna Gordillo 2009). The personnel themselves lacked job security and benefits associated

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with permanent or long-term employment, and rotated in and out of jobs frequently. They were hired on short-term contracts, sometimes for as little as a single month, which did not provide them with benefits such as health care, social security coverage, or vacation pay (Interview, C I E SA S-2 2008). conclusion

Like Guerrero and Oaxaca, Chiapas is a site of struggle. Lack of trust in the State is such that Zapatista communities have disengaged from it, refusing government services, including health care. Nevertheless, apart from the Zapatista communities, the state government has connected trust networks comprising parteras, health promoters, and pregnant women to the health care system. The partial integration of these trust networks with the State was facilitated by a degree of complementarity between the state government and N G O s. However, while complementarity existed along some dimensions, it was missing from others – not only in the relation between the State and non-State actors, but also among the N G O s themselves. A number of elements contributed to complementarity between the state and NGOs in the case of the Red Social in Tenejapa. The state government was more committed to maternal health than its predecessors; it had a higher degree of acceptance of institutional pluralism; and, unlike the other two states in this study, it contributed to the functioning of networks by providing ambulances and radio communication systems. When I interviewed federal officials in 2006, they were adamant that the most progress in improving maternal health had been made in Chiapas, and urged me to visit Comitán. The state government elected in 2000 had directed more resources to health care, and its provision of ambulances meant that the social networks linking communities and urban hospitals functioned better in Chiapas than in other states lacking this investment. The government’s commitment to health in general, and maternal health in particular, led to an increase in access to the system and a promotion of social solidarity. But although the government improved health care infrastructure, increased the number of personnel, and financed new equipment, many of the health care facilities in Los Altos did not meet the standards for adequately attending to obstetric emergencies. The

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conditions in which health care workers laboured also undermined the potential for the development of trust in the system; not only did pasantes and other workers lack the skills in many cases, but their own employment was precarious and they lacked social security protections. The partnership with NGOs complied with two principles that have been identified as necessary for success in health care: first, that government is responsible for the health care of its citizens; and second, that the role of NGOs is to build the capacity of individuals, communities, and government, and to support community action (Ullah et al. 2006, 153). However, the third principle – that the involvement of NGOs should be based on mutual strengths, philosophies, and objectives – was only partially complied with. While both the government and NGOs wanted to reduce maternal mortality, and were somewhat open to NGOs’ approaches to this problem, neither the organizations themselves, nor the organizations and the government, shared a philosophy for addressing this. They agreed on the necessity of emergency obstetric care, but not on the importance of supporting parteras’ practices of delivering babies at home in the community (in the case of normal births), and not about challenging those practices in hospitals which reinforced patterns of marginalization and deterred women from seeking institutional care. The state government in both Los Altos and Tenejapa has adopted the practice of training of personnel with the aim of transforming disrespectful and discriminatory behaviour towards patients. However, attendance at this training was itself gendered, with women and people lower in the hospital’s occupational hierarchy more likely to attend. This case study also highlights the challenges that may arise when N G Os act as intermediaries between trust networks and the State. The issue is not only one of complementarity between the State and N G Os, but among NGOs themselves, and the extent to which their respective goals, strengths, and philosophies are compatible. The N G Os had not previously worked together; the impetus to do so came from their common relationship with the donor rather than with each other. They did not form a trust network, and there was a lack of reciprocity among the organizations. Consequently, while organizations have continued publicizing the issue of maternal health, training health care workers, and connecting village networks to health care centres, they have done so separately, rather than as part of an NGO Red Social. Internationally funded N G O s

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wishing to enter into mutually beneficial relationships with the State must also contend with the asymmetries of power that ensue when an external agency wishes to provide a solution, or part of a solution, to an internal problem. Although the Salazar Mendiguchia administration was much more open to N G O engagement, it was nevertheless initially concerned about what this entailed. Officials wanted to retain control over NGO s – justifiably, in some cases – in order to maintain their jurisdiction and avoid the proliferation of activities which duplicated or undermined policy goals.

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5 Oaxaca: The Impact of Doctors’ Mobilization

introduction

Like Chiapas and Guerrero, Oaxaca has a high maternal mortality ratio in comparison with the Mexican average. In addition, like those states, it is a poor state with a large Indigenous population and history of authoritarian rule by the P RI – in fact, it was the last state in Mexico to elect a non-P R I government, in 2010. Two institutions provide services for Oaxaca’s citizens who are not covered by the social security system (roughly half of the population).1 The first is IMSS-Oportunidades (formerly I MSS -Solidaridad), which is funded by the federal government and run by the I M S S . The second is the Oaxacan Ministry of Health (SSO), which receives Seguro Popular funding but is administered by the state government. Because Oaxaca was not incorporated in the first wave of decentralization in  the 1980s, it was able to keep its I M S S -Solidaridad services.2 However, after surviving the budget cuts of the 1980s and 1990s, IMSS-Oportunidades has suffered from institutional drift: the institution has not expanded to cope with the growing population requiring its services, nor has its infrastructure transformed to address the maternal deaths that were not on the political agenda in the 1970s. In this chapter, I will focus on a mobilization by doctors and other health personnel in the Istmo region, in the southeast of Oaxaca. While I went to Oaxaca to examine maternal health initiatives, in this chapter I have explored only the case of industrial action taken by health care workers in the Istmo region because of the light it sheds on the problems besetting the public health care system, and the kind of action that might improve its trustworthiness. These

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IMSS-Oportunidades employees formed an alliance with a major Indigenous peoples’ organization, the Union of the Indigenous Peoples of the North of the Istmo (Ucizoni), and with people in the communities they served. They then went on strike to demand improved infrastructure, a reliable and adequate supply of medicines and equipment, and adequate staffing of the regional hospital. They also demanded improvements to the functioning of the networks that linked them to the hospital, and to other systems’ services in the region, such as Oaxaca’s Ministry of Health hospitals. The lack of resources threatened not only physicians’ abilities to do their jobs, but the degree of trust generated by the networks in which they were embedded. In the case of an obstetric emergency, the hospital’s lack of skilled personnel or supplies meant that patients could be transferred elsewhere, eroding their trust that the system was acting in their best interests. In the case of a maternal death in a rural area, the physician would be subject to his or her colleagues’ derision, undermining relationships between the physician and other actors in the network. The health care workers were more likely to take action – and were partially successful in realizing their demands – because they were permanent employees rather than contract workers or students fulfilling their social service obligations. They also took action in a region with a history of successful mobilization for the rights of Indigenous communities, and they were making their demands of a federal rather than state-level institution. Their actions were successful insofar as the workers obtained improved infrastructure and replenished medical supplies. They also reached formal agreements to strengthen networks between primary care doctors and hospitals, as well as across different sectors of the system. The latter, however, were not working as well as hoped for two years after the strike, and human resources issues continue to be a concern. oaxaca: the context

In Oaxaca, as in Chiapas and Guerrero, the relationship between the State and society has been characterized by violence and repression, rather than by the “broad, equal, binding and protective relations between citizens and states that constitute democracy” (Tilly 2007, 96). Before the P R I lost power at the state level in 2010, democratic regimes existed only in the Istmo region after 1981, which was the

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year that the Coalition of Workers, Peasants, and Students of the Isthmus (C OC E I )3 won municipal office in the city of Juchitán (Rubin 1997, 161). Oaxaca has a population of approximately 3.5 million. It is one of the most rural, and Indigenous, states in Mexico. In 2005, 53 per cent of the population lived in rural areas; 36 per cent spoke one of fifteen Indigenous languages (Durazo Hermann 2010, 89). Oaxaca is territorially, economically, and politically fragmented: it is composed of 570 municipalities (89), many of which are located in mountainous terrain. Although the federal public sector began investing in Oaxaca, particularly in the oil industry, in the 1950s, wealth-­ generating industrial development tended to be confined to particular locations in the state and was not well connected to the rest of the economy (91). The population is poor: more than a quarter of the people have no income at all, and a further 19 per cent receive only minimum wage (Castañeda Pérez 2005, 80). Until 2010, when a non-P R I government was elected for the first time in the state’s history, the Oaxacan government was identified as an example of “subnational authoritarianism” (Durazo Hermann 2010; Gibson 2005). Gibson (2005, 107) argues that national democratization has often been accompanied by provincial authoritarianism; when central governments relax their control over their state counterparts, the states no longer have a higher authority to whom they must answer, leading to an even greater deployment of authoritarian practices at the subnational level. In Oaxaca, authoritarianism intensified in the wake of the national democratic transition. Oaxaca is highly dependent on federal government transfers: more than 90 per cent of its revenues come from the federation. Some of these funds were earmarked and monitored by federal delegates; after Fox’s election, however, Oaxacan governor José Murat Casab (1998–2004) replaced these staff with his own employees (117). Murat chose Ulises Ruiz Ortiz as the P RI candidate to succeed him in the 2004 elections. A coalition of the P AN , P RD , and Democratic Convergence (Convergencia Democrática), headed by Oaxaca City Mayor Gabino Cué Monteagudo, opposed Ruiz, but it was ultimately defeated, probably with the help of electoral fraud (101). Ruiz, who ruled from 2004 to 2010, attempted to consolidate power, on one hand by investing in infrastructure, and on the other by repressing social organizations that opposed the government (Durazo Hermann 2010, 102).

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The most violent acts of repression occurred during the Oaxacan uprising of 2006. The rebellion began when striking teachers, from Section 22 of the teachers’ union (the National Union of Education Workers – SNT E ), occupied the central plaza (zocalo) of Oaxaca City in May. On 14 June, Ruiz ordered police to break up the encampments and attack the demonstrators with tear gas and batons. In response, social organizations joined the teachers, staging a march of more than 100,000 people demanding the governor’s resignation. A few days later, Section 22 and a collection of social movement organizations formed the People’s Popular Assembly of Oaxaca (AP P O). A P P O ejected the state government from the city, set up barricades, and governed the city for five months (Roman and Arregui 2007). On 29 October, 4,000 federal police arrived to break up the protest, backed by military forces outside the city (Grillo 2006, 4515). The police launched their final assault on the city at the end of November, after which “a state of siege was imposed … hundreds were arrested, disappeared, tortured” (Roman and Velasco Arregui 2007, 248). Governor Ruiz remained in power: the federal P AN ’s dependence on support from the P R I ensured that the federal government would not force him to step down. In the midst of the rebellion, the P AN had won the federal election by a mere 0.5 per cent of the vote (Olvera 2010, 90). To assume the presidency the P AN needed the PR I’s support, which it obtained when the Senate’s fact-finding mission refrained from calling for federal intervention to end the Oaxaca conflict (Durazo Hermann 2010, 103). When federal police did finally intervene, it was to back up Ruiz, who was able to hold onto power for a further four years until the 2004 opposition leader, Gabino Cué, broke the P R I stranglehold in Oaxaca in 2008. The conflict in Oaxaca made it even more difficult for women to access necessary obstetric health care, and created tensions between NGOs who had aligned themselves with APPO, and NGOs that continued working with the state government in various capacities (Interview, RCC-2 2008). There was also conflict between social movements in the Istmo region, where COCEI supported the state government, but Ucizoni supported APPO. A well-functioning health care system may bolster the State’s legitimacy (Freedman et al. 2004), but the public system in Oaxaca did not compensate for the breakdown of trust and co-operation in Oaxaca in the mid-2000s, and that breakdown undermined the system further (Interview, RCC-2 2008).

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The Istmo Region The Istmo of Tehuantepec (“the Istmo”) spans Mexico’s narrowest point, between the Pacific and the Atlantic, and incorporates parts of Oaxaca, Veracruz, Tabasco, and Chiapas. In this region of Oaxaca, local caciques – and later social and political organizations such as the C OCE I – carved out a “domain of sovereignty” somewhat autonomous from the Mexican federal government (although still connected to it) (Rubin 1997, 96). In the coastal town of Juchitán, peasants and workers were not incorporated into the P RI ’s national representative organizations, but retained an identity as Zapotec people which was later reinforced by CO CE I (Rubin 1997). In the nineteenth and twentieth centuries, cattle ranchers, coffee cultivators, and timber merchants exploited the region’s lands and forests, often displacing Indigenous peasants from their communal lands in the process. After the Mexican Revolution, some large landholdings (haciendas) were redistributed to peasantry as ejidos: land held by the government that peasants were entitled to farm collectively. Peasants established ejidos on land formerly owned by timber companies in the municipalities of San Juan Guichicovi, Matías Romero, and Ixtaltepec (Portador García and Solórzano Tello 2009, 50). Like ejidos, comunidades agrarias (agrarian communities) are collectively farmed property; their members, comuneros, have established that they exercised rights over the land before they were dispossessed by the haciendas (Merrill and Miró 1996). Conflicts over land rights were particularly fierce in the 1970s, and have continued into the present. In the north of the Istmo, cattle ranchers from Veracruz, Guanajuato, Michoacán, and Guerrero seized ejidal land, stripping thousands of hectares of forest in the process (Beas Torres 2005, 5). Comuneros fought to take repossession of their lands; villagers invaded haciendas and formed their own ejidos. The P R I responded to the land invasions and peasant resistance with a mixture of selective concessions and repression (Anaya Muñoz 2006). In some cases, land claims were recognized; in others, movement leaders were assassinated, tortured, and disappeared (Beas Torres 2005, 5). During this period, peasants, students and workers established independent organizations to fight for political change. As in the rest of Mexico, students and other marginalized groups were influenced by the 1968 Mexico City demonstrations and subsequent repression

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(Martínez Vásquez 2007, 22). The Coalition of Workers, Peasants, and Students of the Istmo (C OC E I ) formed to fight for the restoration of communal lands (Anaya Muñoz 2006, 47). CO CE I eventually won municipal government in Juchitán, and built “an enduring form of regional democratization” (Rubin 1997, 3). In 1985, a few years after C OC E I ’s first electoral success, another Indigenous organization, Ucizoni, was created in Matías Romero, an hour north of Juchitán. Ucizoni emerged from, and played a critical role in, peasants’ demands for access to land and Indigenous peoples’ demands for recognition. Its founders were part of a small group of teachers and health promoters who joined with peasants in their efforts to depose “El Tigre,” a cacique who had seized ejidal land and was linked to more than thirty assassinations (Beas Torres 2005, 5–7). Ucizoni was a crucial actor in the development of Indigenous identity in Oaxacan social movements. In 1989, it organized the first international forum on the human rights of Indigenous people not to have been sponsored by the Catholic Church or the government, bringing together organizations from across Mexico and the globe to formulate Indigenous demands (Anaya Muñoz 2006, 70). Twelve hundred delegates attended, representing 108 organizations (Beas Torres 2005, 11). At the forum, Indigenous peoples organized in order to “demand autonomy to determine their own forms of political and administrative organization, the restitution of communal land, bilingual education, the conservation of the environment in their territory, the recognition of their languages and healing practices, and respect for their human rights” (Anaya Muñoz 2006, 70). The Mexican organization known as 500 Years of Indigenous, Black, and Popular Resistance was created at this forum as well (Beas Torres 2008, 268). t h e h e a lt h c a r e s y s t e m : i m s s - o p o rt u n i d a d e s

Across Mexico, the I MSS-Oportunidades program serves over 10  million people, 3.4 million of whom are Indigenous (Cruz Martínez 2009 43). In Oaxaca, IM S S -Oportunidades services provide health care to approximately a quarter of the population, including more than half of the people who live in Indigenous municipalities (Castañeda Pérez 2010, 122). The service has five health districts, which contain 470 rural medical clinics4 and nine hospitals. Sixty per cent of I MSS-Oportunidades staff have permanent

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status; another 40 per cent are pasantes, or recent medical graduates doing their social service work (Interview, I M S S -O 2008). Unlike Guerrero, Oaxaca was exempted from the first wave of decentralization in the 1980s, and so kept its I M S S -Solidaridad (later renamed IMSS-Oportunidades) services, which were administered by the federal government and continued to provide health care in poor, remote, and Indigenous areas. Under the second wave of decentralization in the 1990s, however, “inequalities in the services provided grew and the quality of the services suffered” (Gutmann 2007, 25). Although Oaxaca was one of the states that escaped the initial decentralization, the I MSS-Solidaridad workers did not. Under the 1984 decentralization, employees of I M S S -Solidaridad were governed under a different regime from I M S S employees, and were thus left unprotected by the collective agreement (P I D H D D 2008). This situation was partially rectified in 2004, when 60 per cent of I M S S Oportunidades workers were brought into the collective agreement (Innova Consultores 2006, 4).5 IMSS-Oportunidades has suffered from the institutional drift that occurs when “a system has failed to be adapted to cover a set of risks that have newly emerged or increased in salience” (Streeck and Thelen 2005, 24–5). Drift is not a result of conscious political intention, but its absence: “institutions require active maintenance; to remain what they are they need to be re-set and re-focused, or sometimes more fundamentally recalibrated and re-negotiated, in response to the political and economic environment in which they are embedded” (24). I MSS-Oportunidades services have not kept pace with population growth, nor with the new requirements to provide medical services and health education to the recipients of the conditional cash transfer program (also called Oportunidades). With resources directed into Seguro Popular rather than I M S S Oportunidades, an official reported that “we haven’t expanded, nor changed, nor grown. Since the year 2000, not a single new medical unit has been constructed, except for one unit in Huajuapan de León about a year ago … so we’re still not able to support the growth [of the population]” (Interview, I MSS-o 2008).6 The clinics, constructed approximately thirty years ago, were not designed to provide a safe, comfortable place in which to give birth. Nor were they designed to accommodate more than five people – yet more than twenty at a time are expected to attend talks at the clinic in order to receive their Oportunidades payments. Castañeda Pérez (2010) notes that

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“the clinics are saturated, the quality of care has fallen, the medications don’t arrive, the clinics don’t attend to all of the population under their jurisdiction” (112). Between 2004 and 2008, I M S S Oportunidades transferred 59,604 people for attention at the S S O (112). Physicians, nurses, and Indigenous people have resisted this drift in just one jurisdiction: the Istmo-Palaopan Health Jurisdiction 5, which stretches from Salina Cruz on the Pacific coast to Palaopan near the Veracruz border, and serves approximately 120,000 people (Ucizoni 2008, 1).7 i m s s - o p o rt u n i d a d e s a n d t h e m o v e m e n t f o r “ a d i g n i f i e d , q u a l i t y h e a lt h c a r e s e r v i c e for the peoples of the istmo region”

In March 2008, after two years without specialists in the rural hospital of Matías Romero, more than 300 medical staff from across the Istmo region of southern Oaxaca stopped work and occupied the administrative offices of the hospital. Doctors, nurses, laboratory technicians, and other workers demanded that the I M S S Oportunidades program staff the hospital with the necessary specialists; improve the deteriorating infrastructure in the hospital and clinics; ensure that the clinics had adequate supplies of medication; and address corruption at the hospital (Ucizoni 2008, 1). The medical staff’s work stoppage and occupations were not only ways of demanding improvements to the health care system, but ways of protesting against the gap between the government’s claims about the system and the reality with which they were confronted. The movement gained support from the communities it served: thousands of people marched in Matías Romero in solidarity with the striking staff, and some accompanied them to Mexico City to plead their case with the head of I MSS. The workers’ union, the National Union of Social Security Workers (SN TSS), did not support the action – in fact, the union dismissed two of the movement’s leaders, who were consequently left jobless. According to one employee, “the union didn’t support us – because supposedly this was a struggle for social justice, not a workers’ struggle” (Interview, I MSS-MR 6. 2010). After two months of failed negotiations with I MSS officials in Oaxaca, approximately ninety employees, community members served by the clinics, and Ucizoni representatives took their case to the I M S S offices in Mexico City.

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There they camped in the lobby in the hope of speaking to the organization’s director-general, Juan Molinar Horcasitas (Interview, IMSS-MR 1 2010). A federal congressional committee, comprising Senators and Congressional representatives from left-of-centre parties, called on Director General Horcasitas to intervene in the dispute and resolve the problems with infrastructure, medicines, and lack of personnel, as well as to refrain from legal action against the striking employees (Senado de la Republica, 2008). Horcasitas did not meet with the doctors, however, and they returned to Oaxaca, with their supporters reduced to about forty (Interview, I M S S -M R1 2010). Back in Oaxaca, the doctors also demanded the reinstatement of their two colleagues who had been dismissed from the union, and hence their jobs, at the beginning of the dispute. This stipulation was not met; the two doctors were instead given positions in the SSO system, not because of a negotiated agreement, but due to a personal connection with governor Ulises Ruiz Ortiz. An interviewee stated: “After we left [negotiations with] the union, it was midnight or one in the morning, and we went to see a priest who … has a lot of connections and influence with the governor. He called [the governor] and said, listen, Ulises, I need two positions” (Interview, I MSS-MR 1 2010). People from the communities where clinics were located marched in the streets, blockaded highways, and occupied buildings in support of the medical workers’ demands. Community support can be attributed to the connections that Ucizoni had built during almost thirty years in the region. Ucizoni was the first organization that the doctors consulted with (Interview, I M S S -M R1 2008); it had 19,000 people associated with it in the region, and so was able to mobilize local communities (Interview, Ucizoni 2008). The politicized nature of the Istmo, which had been shaped by peasants’ struggles for rights to communal land, may also have been influential: one of the places that sent representatives to Mexico City was a comunidad agraria formed from land invasions in the 1970s. Support also came through connections that individual doctors had with their communities. In the I M S S -Oportunidades program, medical staff are mandated to work with citizens to improve their health. Some doctors had spent eight or more years working in the same location, and they were supported by the health auxiliaries, who act as intermediaries between the medical unit and the community, as well as by other community members (Interview, I M S S -M R5

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2010). Another aspect of the IMSS-Oportunidades program is that the community’s medical care is provided in exchange for its contribution to the service: that is, the cleaning of the medical unit, the washing of sheets, bandages, and linens, and the painting and maintenance of the building and area around the clinic. There is a gendered dimension to this exchange, however: it is women who do the laundry each week, dealing with soiled and sometimes bloodied linens; men do the outdoor work of building maintenance. When I MSS-Oportunidades workers took industrial action, they were not only protesting against inadequate material conditions, but the inability to fulfil the responsibilities that gave their work meaning. One of the protesting workers said: “It was worrying for us, how was it possible to receive a salary without resolving the situation? Obviously, we were employees, the solution [to the health system crisis] wasn’t in our hands, but we had to ask for improvements. We began to request that the authorities hire doctors for the hospital … We could justify it because there’d been many signs [of problems]: maternal death, infant and child death, deaths, including those of diabetics for example, because there weren’t internists who could refer and treat them adequately” (Interview, I M S S -M R6 2010). The doctors did not have the necessary supplies to attend obstetric emergencies. One doctor reported: “In the rural medical units, we don’t have the capacity to treat a rupture or other complications of the placenta. If a patient with bleeding, or pseudohypoglycemia, presents at the clinic, we couldn’t treat them … Now, as a result of all that’s happened, we’re just getting gelatine at each unit so that there are plasma expanders” (Interview, I M S S -M R1 2008). The doctors’ lack of medical supplies intersected with the poverty of communities, particularly in villages without transport. A doctor from another rural clinic said: “In the clinic where I work, I’ve had two maternal deaths. When I arrived at one of the births, there was not one car in the community. No one had a car, and the woman had a retained placenta and was bleeding profusely. The only supply I  had was Hartmann’s solution [i.e., a solution used to replace fluid and electrolytes]” (Interview, I M S S -M R 1–3 2008). The quotes above illustrate how the mechanisms for generating ­generalized and interpersonal trust were eroded in the Oaxacan I M S S -Oportunidades system. The doctors’ sense of responsibility for their patients’ care, and their discomfort with receiving financial compensation while being unable to adequately provide it,

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indicate the kind of commitment to patients that facilitates interpersonal trust. However, the lack of resources in the clinics and the community eroded doctors’ capacity to deliver these services, thus undermining trust in their capabilities and the system as a whole. The workers were aggravated by I M S S authorities’ failure to understand the issue from their perspective, and as a result the trust in their networks with other government actors was weakened. The doctors claimed that the I M S S authorities found it incomprehensible that they would walk off the job for non-financial reasons. One employee observed that an I MSS -Oportunidades administrator asked them if he owed them wages. If not, they should “dedicate themselves to working with what I give you”; the administrator said that they were not responsible for patients’ deaths if the citizens themselves were not protesting (Interview, I M S S -M R1 2008). The administrator’s message is that doctors are not responsible for their patients’ welfare. Moreover, the medical system’s resources are not institutional property, or the means of fulfilling a responsibility to IMSS-Oportunidades patients; instead they are bestowed personally by the administrator.8 In these circumstances, the organizational environment was not functioning to generate trust between health care providers and other actors in the system, nor was it working in the best interests of the patients. Another staff member reported a similar encounter, in which she was told to work with what she had, regardless of whether patients died. “Our intention was to pressure the authorities and call attention to what was really an emergency, what was happening to us. But oh surprise, oh deception: politics in Oaxaca is a politics of convenience; poor people count for nothing” (Interview, IMSS-MR6 2010). In the absence of specialists, patients who had been referred to the hospital were often transferred again, either to other regional hospitals in the towns of Juchitán, Coatzocoalcos, or Ixtepec, or to private hospitals or clinics. The protesting doctors claimed that some hospital staff in Matías Romero benefitted financially from transferring patients to private facilities (clínicas particulares) (Interview, IMSS-M R 1 2008). When patients were referred to private services from the hospital, the original referring doctor at the clinic might be blamed for private fees that the patient was unable to afford. In one case, the I MSS-Oportunidades doctor referred a pregnant patient to the hospital to treat an obstetric emergency, but the hospital then transferred her to a private hospital where she had to pay for

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services. In this instance and others, the patient’s family became aggressive towards the doctor for the initial referral to the hospital because it led to costs they could ill afford (Interview, I M S S -M R1 2008). The doctor’s effort to act in the best interest of the patient was undermined by actions in another part of the network, where, contrary to the goals and values of I MS S -Oportunidades, the patient was required to pay for her care. The organizational environment also undermined trust because of the disjuncture between employees’ experience of the system and the government’s claims about it. The staff took industrial action because of the government’s misrepresentation of the system that they worked in: “Our governments say that we have the best health care, the best medical attention in the communities where we’re working. That’s completely untrue. The movement arose because this is untrue. Because we know that the quality [of care] doesn’t exist, that the necessary supplies don’t exist, the necessary medicines, the resources to tackle the problems in the communities” (Interview, IMSS-MR1 2008). According to the doctors, State officials deceived not only Oaxacans, but their federal counterparts, about the condition of the system. In preparation for a visit from the IMSS-Oportunidades director, Carolina Viñales, two clinics were staged: Two medical units, San Juan Guichicovi and Boca del Monte, were set up. We say set up because it was a circus. The bosses called their doctor friends, they called up multipurpose infrastructure to be delivered to these two clinics, they painted them, they took curtains down from other clinics and hung them there. The joke is that they painted walls, they put down grass, so that when the director arrived, it would be a model clinic, which is a trick, a lie. At the hospital they did the same; they received her with a lot of hype, and all the obsequiousness that happens when one of the managers arrives … So, some of us went to the clinics, we went to make a scandal, and they said we were subversives, and undesirable for the program. (Interview, I M S S -M R1 2008) This action is another schism between the façade and the reality of the system; between the state and federal administrators; as well as between the state administrators and the striking employees – all of which are contrary to the generation of trust in the organization’s networks.

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Achievements of the Movement When I arrived in Matías Romero two years later, in June 2010, an extension had been added to the hospital. One of the staff from Ucizoni took me to the newly constructed albergue (guesthouse) where families could stay while their loved ones were in the hospital; a cleaner was scrubbing the floor from one end to the other. All of the participants I’d interviewed in 2008 agreed that there had been significant improvements to hospital infrastructure and the availability of medical supplies since they had taken industrial action. The clinics’ doctors were now also able to order medications that had not previously been available to them (Interview, I M S S -M R5 2010). In one rural clinic, the physician showed me a storage area packed with boxes of medicine and medical supplies, including the cherry-coloured box (caja guinda) and pink-coloured box (caja rosa) containing the medications to help resolve pre-eclampsia, eclampsia, and haemorrhage, respectively.9 However, the main issue of concern, the shortage of hospital specialists, was only partly resolved. Within sixty days of the industrial action, I M S S -Oportunidades contracted an internist, a gynaecologist, and an anaesthesiologist. Five months later, a paediatrician, another anaesthesiologist, and a surgeon were hired. Within a year, however, the gynaecologist had left, followed by one of the anaesthesiologists. Out of three eight-hour shifts at the hospital, one was covered by a specialist, but the other two shifts remained uncovered (Interview, I MSS -M R6 2010). As a result of the industrial action, N G O s and the health sector built new networks. But difficulties remained, particularly in the relationship between primary care doctors in the clinics and those in the Matías Romero hospital, as well as in the relationship between hospital patients and staff. During the strike, Ucizoni and the protesting medical staff demanded that representatives from the crucial hospitals and health centres, and from the N G O s, meet to ensure that patients could be treated in all of the institutions regardless of affiliation.10 The parties signed an agreement of collaboration, involving the IMSS-Oportunidades hospital at Matías Romero, the clinic (Centro de Salud) in Matías Romero, the subdirector of the hospital at Juchitán and representatives from the city’s health jurisdiction, the director of the hospital at Ixtepec, members of the various communities, and Ucizoni. According to Ucizoni: “Our experience with the hospital at Juchitán has been good, and the people at the Matías

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Romero clinic seem more aware, but in the case of the hospital at Matías Romero, the attention is almost the same, the personnel aren’t sensitized (sensibilizados)” (Interview, Ucizoni 2010). In 2010, a rural doctor also reported experiences in which patients she referred were not attended when they got to the hospital, in spite of the doctor having contacted her counterpart there. In some cases, a nurse had sent the patient away, and then a doctor or specialist at the hospital sought her out at the guesthouse for patients (when sending her patients to the hospital, the rural doctor had instructed them to go to the guesthouse if they were not admitted). Two of her patients had been turned away on the weekend because there wasn’t someone to attend them in Matías Romero. They had been told that the hospital would transport them to Juchitán (about 62 km distance), or Salina Cruz (128 km), but the patients instead attended private clinics because they did not wish to be so far away (Interview, IMSS-MR 5 2010). While these distances may not seem very large, a woman living in a village may have had to travel several hours to get to Matías Romero; the additional hour or two of travel may be an insuperable distance for her. Neither the regional nor the national agreement regarding the treatment of obstetric emergencies, or the 2008 commitment by Chiapas, Guerrero, and Oaxaca to exempt pregnant women from user fees, ensured that pregnant women were actually exempt from being charged. I MSS-Oportunidades services are free at the point of contact,11 but the hospital in Juchitán pertained to Oaxaca’s Ministry of Health, which charged user fees if the patient was not affiliated with Seguro Popular. If the patient met with a social worker who applied a means test, user fees were applied on a sliding scale according to income; but if the patient was not means-tested by the social worker, she could be charged full fees. In some instances, rural doctors advised patients who had been charged a large fee to return to the hospital for a means test to have the amount reduced (Interview, IMSS-MR 5 2010). This indicates that, in spite of agreements between the institutions and the extension of Seguro Popular, pregnant women were still being charged user fees; the size of those charges depended on both the availability of a social worker who could apply a means test, and the patients’ awareness that they needed to contact such a person in order to have her fees reduced. Although long-lasting relationships between the doctors and their communities meant that the latter supported the strike, another

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concern that could not be resolved by industrial action was the multiple demands placed on community members, particularly women, under the I M S S -Oportunidades program and the conditional cash transfer program, Oportunidades. In the latter program, women who received cash payments were entitled to free health care, provided that they, and their children, attended the required medical consultations and educational talks (pláticas) on health and hygiene.12 The two programs imposed two sets of responsibilities in order to receive Oportunidades payments: first, to contribute to the cleaning and maintenance of I M S S -Oportunidades facilites, and second, to attend the pláticas and comply with their guidelines in the home. The recipients did not understand why they had to continue contributing to the maintenance of the I M S S -Oportunidades services when they were complying with the requirements of the cash transfer program: “At times, people thought that they had paid because they boiled their water, they had a latrine, they kept their house clean … we had to make them see that it’s a commitment to the institution, that they will receive attention, but nevertheless they have to contribute to the institution” (Interview, I M S S -M R 1 2010). In both cases, women are more likely to be the ones labouring on a regular basis. The division of community labour for I M S S -Oportunidades services is also gendered: it is the women doing the washing of linens and doctors’ coats. Since 2010, however, there has been a small shift in the gendered division of responsibilities for the Oportunidades program. Men, as well as women, are now required to attend pláticas at the clinics (Interview, I M S S -M R 5 2010). Nevertheless, it is still women who have the primary responsibility for household hygiene and for ensuring that their children attend school and keep their health appointments at the clinic. While the gendered division of labour was not remarked upon by the doctors, the doctors who led the movement were nevertheless concerned about the failure of the Oportunidades program to recognize ethnic and age differences, or to address clientelistic practices in the distribution of welfare. In their petition, they noted that “the pláticas … many times don’t correspond to the profile of the beneficiaries, not taking into account their age or ethnicity” (Ucizoni 2008, 1). More problematic were cases in which “the benefits of [the Oportunidades program] have been conditional upon individuals’ political or religious militancy” (1).

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The strike by health care workers in the Oaxacan Istmo highlights the problems in the public health care system that erode generalized and interpersonal trust. The commitment of the striking doctors to their patients was indicative of a potential for strong interpersonal trust; it also motivated their industrial action. Their attitude towards financial compensation aligned with attitudes that generate trust, in Gilson’s (2003) terms; in contrast to letting treatment be determined by financial considerations, the medical staff felt uncomfortable receiving compensation without being able to ensure that their patients’ treatment was adequate. This commitment to patient welfare could not be fulfilled, however, in the absence of resources such as medication, surgical supplies, and, in the case of remote communities, access to transport. The I MSS-Oportunidades system suffers from deteriorating infrastructure and inadequate human and physical resources. With federal government resources directed toward Seguro Popular, it also suffers from “institutional drift” – the failure to adjust to the new challenges created by population growth and an expanded mandate – resulting in a declining capacity to provide adequate care. The intra- and inter-agency networks necessary to support generalized trust were also malfunctioning, and therefore adversely affecting interpersonal trust. If patients who were referred to other nodes in the system failed to receive appropriate treatment, they held the originating physician responsible. The lack of physicians trained in handling obstetric emergencies in the Matías Romero hospital meant that, in spite of I MSS-Oportunidades services being free at the point of service, patients were transferred to private facilities where they had to pay – thus undermining their confidence in the primary care doctor who initially referred them to hospital. Unlike the other cases discussed in this book, this chapter examined a rare case of industrial action taken to improve the system, and considered why such action may have arisen in Oaxaca rather than elsewhere in Mexico. The “movement for dignified, quality health care for the peoples of the Istmo region” had some successes: in its wake, there were improvements in hospital infrastructure and medical supplies. The reasons for political action can be traced to several factors: first, the region’s history of political mobilization; second, the recently achieved permanent status of the medical staff, who

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could act from a more secure base, and were committed to the system; and third, the fact that their demands were ultimately directed at the federal level, which was more likely to be responsive than the authoritarian state government. Nevertheless, human resources and trust issues have been difficult to resolve, with the hospital still having shifts uncovered, patients not being properly attended to, and people being referred to private services in the absence of public ones. Women’s ability to gain access to care is undermined if the barriers presented by geographical distance and poverty are reinforced by barriers within and between health care institutions. The differences in funding structures between institutions also created challenges. Because Seguro Popular was rolled out gradually, as late as 2010 women who were not affiliated with the program were being charged user fees, in spite of state commitments not to do so. The fees varied according to income, and also whether the patient was aware of the need to be means-tested by a social worker. Trust between health care workers and their patients may also have been adversely affected by the conflicting demands placed by different institutions on community members, particularly women. Although the striking doctors’ communities supported them, the doctors saw this relationship as potentially undermined by similar conditional demands arising from the C C T program, Oportunidades. Nevertheless, the movement for dignified, quality health care for Indigenous people has been a bright spot here, and an indication that change may result from militant action. It may also indicate, however, that militant action is necessary: not only for maternal health, but across the health sector, and in collaboration with the affected communities.

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Conclusion

The maternal health Millennium Development Goal (M D G -5) has motivated increased attention to maternal mortality on the part of both governments and NGO s. One of the ways in which M D G -5 has influenced maternal health policy in Mexico has been through its emphasis on quantitative measures of progress. In 2004, Mexico introduced a more rigorous system for the reporting of maternal death, which mandated that such incidents be declared to federal authorities. Local committees for the investigation of maternal mortality had existed in hospitals since the early 1980s, but in the postMDG era they were supplemented with a national-level committee, A IDEM, and the quantitative and qualitative data made available to other public organizations such as Coneval. The evidence that emerged from the new measurement regime had several knowledge effects. One was that it showed that the majority of deaths were occurring in public health care facilities, and not in those facilities run by the social security institutes, or at home. Two, this data reinforced the shift of paradigms underlying maternal health policy from an obstetric risk model to an emergency obstetric care (EmO C ) model. While a well-functioning health care system is important in both models, it becomes even more important in the EmOC model, because there it is the identification and management of obstetric emergencies, rather than the early identification of risk, that becomes critical. Three, the data about problems arising in the health care system was communicated to public health officials via technical forums organized by NGO s, which challenged existing assumptions that maternal death in these regions resulted from giving birth at home with a partera rather than in a medical facility.

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Because the provision of health care is not merely a technical act, but involves a relationship between the patient and provider, patients’ trust in health care systems is necessary for their effectiveness (and vice versa). There are three key institutions that foster trust in health care systems, thereby creating the possibilities for generalized trust and interpersonal trust between the patient and provider (Gilson 2003). The first is the existence of professional and ethical codes and licencing systems. In the Mexican case, there is a disjuncture between the skills required of nurses and physicians in rural and remote areas, and their professional qualifications. In wealthy countries, general practitioners would rarely have to manage an obstetric emergency – it would be resolved in a hospital. In rural Mexico, practitioners in poorly equipped clinics may have to try to manage emergencies, and face reprimand if they are not successful in saving the woman’s life. Recent graduates undertaking social service obligations, and new medical residents, may not have the experience or the appropriate supervision to undertake these tasks. Networks for transporting women to the closest hospital are one way of increasing the odds that they will be treated by a doctor with the skills and resources to manage an obstetric emergency, but although this may be so in the majority of cases, there are still reports that hospitals are unable to provide appropriate care (Coneval 2012b). In Oaxaca, the regional I M S S -Oportunidades hospital sent patients to private health facilities on the weekends when it lacked staff; in Guerrero, N G O s reported on medical negligence and human rights abuses at the regional state Ministry of Health hospital. The second institutional mechanism that may facilitate trust – or undermine it – is the nature of the funding system. Mechanisms that ensure that people have access to care regardless of their ability to pay, and which promote norms of social solidarity, are more likely to  inspire trust than those that do not (Gilson 2003). The Seguro Popular program, introduced in 2004, has incorporated a more just funding regime than what existed in the 1980s and 1990s. Nearly all individuals affiliated with the program enrol for free, meaning that it is de facto tax-financed, and affiliates receive a package of treatments that are free at the point of service. The discrepancy between the public funding for social security holders and the remainder of the population has been greatly reduced since the program’s introduction, and the amount of public funding for this latter half of the population has also increased. Seguro Popular can be seen as an

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example of second-wave neoliberalism (Ewig 2010) in that it is not a narrowly targeted program, but one that reaches tens of millions of Mexicans, and, although service delivery is provided by the states, the funding itself is largely from the federal government, which specifies the services to be delivered as a mechanism to direct health care provision in the states. In the case of maternal health, it has also used the measurement regime as a means of exercising control in a decentralized system. Nevertheless, there are still elements of the program which limit its universality and social solidarity and hence undermine the extent to which trust has been enhanced. While an impressive number of Mexicans have been enrolled in the program, because affiliation depended on the existence of nearby health facilities, the poorest and most marginalized people were the last to be affiliated. While Seguro Popular has expanded access to a package of health care treatment to millions of Mexicans who would otherwise have had to pay user fees for care, in 2010 women were still paying user fees for care in a number of circumstances: if they had not been able to register for Seguro Popular because they lacked documents; if they were redirected to the private sector because the public system could not accommodate them; or if they were referred from another system, such as IM SS-Oportunidades. I NE GI finds that 23 per cent of the population, or 26 million people, are not covered by an insurance program (I NE GI 2014, 19, table 2.1). Because Seguro Popular was layered onto the existing health care structure, the possibilities for risk-pooling, and cross-class collaboration in defence of public health care, were limited. Although the number of treatments covered under the program is much larger than under the Program to Extend Coverage (P A C ) in the 1990s, it is still a much less comprehensive package than the one offered by the social security services, and the quality of care is poorer. Public funding for those outside the social security system has increased, but financing for other health care programs – such as the Fund for Basic Health Services for individuals (F A SSA -P ), which provides funding to the states to provide services to the uninsured population – is deducted from Seguro Popular funding (SSA 2014, 93), meaning that the latter is less generous than it initially appears. Federal funding per individual also declined after a change in the formula in 2010. State have been able to avoid making a full contribution to the program (and they also have fewer resources to contribute, although it is difficult to know

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whether their failure to contribute “liquid” resources is a consequence of being unable or unwilling to pay). In the case of EmOC , further mechanisms have been introduced to overcome the barriers to care created by the existence of a fragmented system, in the form of an inter-institutional agreement to provide care for women who require it regardless of their institutional affiliation. While this agreement is a positive effort to overcome an institutional problem, it reflects the continued challenges presented by systemic fragmentation, and, in the areas I researched, its functioning still depends on communication between specific individuals. In Oaxaca, if a patient from an I M S S -Oportunidades clinic was transferred to a Ministry of Health hospital and encountered someone other than the specific physician to whom she had been referred, she might be sent away, in spite of the agreement. Other studies have found that health care workers were not aware that the agreement existed (OMM 2014b). This may reflect the need for appropriate training and communication to ensure that programs are implemented as intended. It may also indicate problems of high staff turnover, or be another example of “medical authoritarianism” in which those who are unable to pay receive poorer treatment than those who are (Castro 2014). The third key institution to encourage trust is the networks within the health care system, and the networks between the system and other actors, such as officials in other government departments (Gilson 2003). These networks, I would suggest, are affected by the other two key institutions, funding and licensing systems, as well as by mechanisms for the distribution of medical supplies, the existence of adequate supervision and support, and the resources available to other actors in the network. (To give an example of the latter, doctors in rural clinics need more than the appropriate resources; they also need to know that the hospitals to which they are connected will have the qualified staff and medical supplies necessary to deal with obstetric complications.) In each of the three states, doctors spoke about the lack of connection with other government departments, and the need for other agencies to act to combat maternal mortality. While this may partly reflect a reluctance on the part of health care workers to take responsibility for maternal death, it is also an indication of the lack of trust in the networks between public health agencies and other sectors of government, and it means that their organizational environment is unlikely to be a trusting one.

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In a context where individuals may not have the appropriate training, medical supplies, or infrastructure to manage an obstetric emergency, the regime for measuring maternal death may undermine health care providers’ trust in the organizational environment. This is not to say that sanctions should not be applied in cases of medical negligence; however, they are not being applied, and neither formal nor informal sanctions can be applied appropriately unless structures are in place to ensure that personnel can manage obstetric emergencies. In their absence, the governance effects (Merry 2011) of measurement may result not only in a sense of personal responsibility – which is appropriate when networks and resources are in place – but its evasion. If the responsibility is placed on individuals rather than the structures in which they work, they may feel that the networks to which they are connected are punitive rather than supportive, and the trustworthiness of the system may be undermined rather than enhanced. Networks between and within the health care system may also be adversely affected by links between the public and private sectors, such as when patients who are entitled to care under I M S S Oportunidades or Seguro Popular are referred to the private sector because the public system cannot accommodate them. A patient’s confidence that the practitioner is acting in her interest will also be undermined if the health care provider receives material benefits from referring her to a private clinic. This may erode trust within the network of health care providers, as well as between the patient and the provider – not only in the case of the doctor who refers the patient to private facilities, but also, in the event of a prior referral, in the case of the initial health care provider as well. This occurred in the case of I MSS-Oportunidades in the Istmo region of Oaxaca. While the nature of networks within the health care system may strengthen trust or weaken it, I would submit that networks between the system and its users are also important, particularly when the two are separated by geographic or economic barriers, by generalized lack of trust in the State, or by differences of class and culture (including understandings of pregnancy and birth that differ from the biomedical model). Women in the rural areas of Mexico, and their families, may choose to give birth with parteras because they cannot afford transportation and other costs associated with attending a medical facility, or because the road to the hospital is flooded or crumbling or non-existent, or simply because they would prefer

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to give birth at home, with a woman or man who understands their language and birth customs. It may also be the case that the pregnant woman herself would choose to attend a medical facility, but her husband or other family members are opposed to the idea. Parteras and health promoters have been regarded by the public health care system as geographically, culturally, and linguistically closer to women and their networks than medical practitioners (Rhodes et al. 2007). Ministry of Health and I M S S -Solidaridad services have tried to create or strengthen trust networks between their respective systems and the community networks in which parteras are embedded; however, these agencies have perceived parteras as means of reaching family planning and demographic goals, and identifying women at risk of obstetric complications. In the cases I have examined in Guerrero and Chiapas, N G O s with different goals have acted as intermediaries between public health care and parteras. N GO s have also seen parteras as a means of realizing particular health goals, but their goals have been somewhat different from those of the State, informed as they are by the paradigm of sexual and reproductive health and human rights codified at the Cairo and Beijing conferences in the 1990s. For the NGO s, parteras are thus a conduit for educating rural women about their sexual and reproductive health and rights, informing them of their rights in the health care system, and maintaining birth practices that are important to Indigenous women’s identity and well-being. While working to strengthen links between the health care system and the community, they have trained parteras in identifying obstetric emergencies, arranging transport if a woman needs to be transferred to hospital, working with her family and village authorities in the event that the family opposes a transfer, negotiating care at the hospital, and monitoring the care given to the birthing woman. All of these actions depend on the partera’s ability to inspire trust in her interlocutors, and among the members of her community ­networks. However, if the community is extremely poor, divided by religious or political affiliation, or governed by municipal leaders who are not committed to the health of their communities, local networks may not be enough. Unless the state government, or I M S S Oportunidades, has provided an ambulance in a community where there is no car, women facing obstetric emergencies cannot be transported. This is also the case if the owner of a private or municipal

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vehicle is associated with a political or religious group that is in conflict with one to which the pregnant woman belongs. The status of the partera herself, and therefore her authority in negotiating with families or medical staff, may be affected by her socioeconomic status, literacy, ability to speak Spanish, and gender. This raises the issue of NGO s’ role in the provision of social welfare. One criticism of the trend in development practice to emphasize the role of NGOs is that it entails a valorization of “the local,” romanticizing community and ignoring the degree to which social relations at the town or village level are shaped by broader social and political forces (Mohan and Stokke 2000). My argument in this book largely supports this critique. The initial emphasis of the Fox administration’s program, An Equal Start in Life, demonstrates the limits of devolving responsibility for fulfilling maternal health goals to N G Os and local networks. In determining that social networks could be employed to ensure that pregnant women were transported to medical facilities when necessary, Equal Start assumed that social resources, and private material resources, could substitute for public ones. It did not account for the divisions within marginalized communities that politicize and undermine local networks and block access to private (and sometimes public) resources, such as a car. In Guerrero and Chiapas, interviewees reported that in some communities private vehicles did not exist, or that women’s access to them was dependent on their political affiliation (for example, if a person in the village who owned a car belonged to one political organization, he might not lend the vehicle to a family from a rival group). Even public authorities at the local level could not necessarily be relied on to appropriately direct funds to build Posadas AME , or to allocate resources, such as ambulances, to improve maternal health. The transfer of vehicles to municipalities was also problematic – in Chiapas, the state Ministry of Health retook control of ambulances after they were put to other uses by local officials. The provision of a driver and fuel for a vehicle is not straightforward either, and an inability to pay for them might lead a family to delay seeking medical care. In Guerrero, the supply of funds for fuel, as well as for food and accommodation for family members staying near the regional hospital, was most readily available when the local health district used Seguro Popular and Oportunidades funds to finance the costs of transportation and accommodation for the pregnant woman’s family members.

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In some respects, the development or strengthening of local social networks to ensure that Indigenous women get to medical facilities could be seen as an example of the politics of recognition, in that those networks are assumed to embody the pregnant woman’s culture, language, and identity. The actual functioning of these networks, however, demonstrates the need for redistribution along with recognition. If, as the literature on trust contends, generalized trust is fostered by socioeconomic equality and the insulation of public policy decision-making from categorical inequalities, then the absence of these factors will undermine the existence of networks in which individuals are willing to place their lives in the hands of others (Tilly 2007; Rothstein and Uslaner 2005; Levi 1998). Intervention by the State may well be necessary to overcome material deprivation and social mistrust. Still, if local networks do not function well without the support of  the State, this is not to say that they should be abandoned. In a context in which the relationship between the State and its citizens is largely mistrustful, and in which there are numerous barriers between remote communities and the medical facilities they need, efforts to encourage linkages based on trust should be maintained. Indeed, the effort to foster such linkages preceded the neoliberal era, having been promoted in the 1970s. The use of N G O s as intermediaries may be effective at facilitating trust because they are interested in developing community capacity rather than ensuring that parteras meet particular institutional goals, such as the promotion of family planning. There is also a greater possibility of achieving the “partial integration” of trust networks with the State when networks are linked via NGOs, because such networks are neither subordinated to state goals, nor completely autonomous from them (Tilly 2007). My study also raises the question of N G O s’ role in advancing neoliberal strategies. In the cases I have examined, although N G O s are acting at the local scale, their actions there have been connected to broader efforts to demand greater State intervention to improve the health care system. The most dramatic example of this is in the case of Ucizoni in the Oaxacan Istmo, which collaborated with I M S S Oportunidades workers taking job action to improve the service they offered their patients. In the examples from Chiapas and Guerrero, the NGOs collaborated with state governments in the interests of improving maternal health. In all cases, N G O s adopted a critical attitude toward the State, but this has not stopped them from

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regarding its role as critical for citizens’ welfare, and engaging with it in a variety of ways. The Oaxacan example also defies the idea that the solutions proposed by NGOs are technical rather than social and political. In Chiapas and Guerrero, although the emphasis on training parteras could be seen as a technical approach to the maternal mortality problem, closer examination reveals that N G O s have grounded this training in a commitment to sexual and reproductive rights and gender equality, not only technical strategies. Because local N G O s were also part of coalitions for maternal and women’s health on the national level, they were advocating for more equitable arrangements to address the multiple dimensions of inequality that are reproduced in the health care system. While NGO s cannot address these issues without policy change at the national level, they can exert pressure, at multiple sites, on a State that often reinforces gender inequality through its policies. The structure of the health care system, and the gendered nature of the conditionalities associated with health and welfare programs, mean that women are disproportionately affected by poor-quality health care, and burdened by the labour required to receive health care and  other benefits – such as payments from the CCT program Oportunidades. Women who receive I M S S -Oportunidades services, and payments from Oportunidades, have to labour for both programs: to keep the local clinic clean in the case of I M S S Oportunidades, and to ensure their children’s health, hygiene, and school attendance in the case of Oportunidades. In the former case, they may also have to attend Health Assembly meetings; in the latter, they are required to attend monthly medical checkups and education sessions at the local clinic. The Oportunidades program also requires that physicians police women’s compliance with the program: doctors and pasantes must check off women’s attendance at clinics, and their payments may be suspended in the event of non-attendance. While this action may in itself undermine the trust between patient and provider, trust is further damaged when the care provided by the medical professional is poor because of a lack of supplies, lack of appropriate training, or both. The number of women dying in pregnancy and childbirth from preventable causes was much lower in 2015 than in 1990. Since 2000, the Mexican federal government has made increased efforts to combat maternal mortality, and NGOs have lobbied the government

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and participated in projects to strengthen trust networks at the local level. The Seguro Popular program has accorded millions of people in Mexico greater access to the public health care system, and has provided greater investment in it. Nevertheless, while asymmetries between the system for the insured and the uninsured have been reduced, the transformation has not been significant enough to remake the institutional mechanisms that support, or undermine, trust in the health care system. Although local mechanisms are necessary for building trust, they are not sufficient if the system itself is not trustworthy.

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Notes

introduction

  1 The word partera is normally translated as “traditional midwife” – that is, a woman (or man, in which case the Spanish term is partero) who attends women during pregnancy, childbirth, and the postpartum period, and who has learned his or her skills through mentoring or apprenticeship rather than a formal course of study. Because midwives who fit this definition in Mexico embrace a range of practices and methods of learning, I have chosen to use the word partera/o throughout this book rather than “traditional midwife.” The World Health Organization (WHO) refers to traditional midwives as traditional birth attendants (TB A s), defining them as “a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship to other T B A s” (1992, 4). However, some authors reject the term TB A in favour of the term “traditional midwife” in order to recognize the work of these men and women as, precisely, midwifery work, and to respect their selfidentification as midwives, while differentiating them from practitioners who have undertaken higher levels of midwifery education (Foster et al. 2004, 218).   2 Health promoters (promotoras de salud) are members of the community who work in collaboration with the local public health authority to help connect people to health services, to educate them about topics in which the promoters have been trained (such as family planning methods), and to distribute materials such as information about health and hygiene (Cabral Soto et al. 2001, 36–7).   3 A health care system is “the combination of resources, organization, financing, and management that culminate in the delivery of health services to

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Notes to pages 4–5

the population” (Roemer 1991, 31; quoted in Birn 2009, 584). In order to avoid too much repetition of this term, I will also use the term “health system,” or “medical system.”   4 The maternal mortality ratio indicates the risk of maternal death among pregnant and recently pregnant women; the maternal mortality rate reflects both the risk of death among pregnant and recently pregnant women, and the proportion of all women who become pregnant in a given year (Cook et al. 2001, 10). Studies indicate that most maternal deaths occur during birth, or within twenty-four hours postpartum (Li et al. 1996).   5 Maternal death is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (WHO 2011a, 156).   6 It should be noted that Mexico is not the only country with a discrepancy in maternal mortality between wealthy, urban regions and rural areas, and between non-Indigenous and Indigenous people. Nor is this issue confined to the Global South. In Australia, the M M R for Indigenous people is almost double that for non-Indigenous people (Verstraeten et al. 2015, E27). Indigenous people also have worse health outcomes than nonIndigenous people in Canada; however, no data on maternal mortality are gathered for Indigenous women (E29). Racialized women are also more likely to die in childbirth in some countries in the Global North. In the United States, the M M R for black women is higher than Mexico’s; the MMR for black women was 40.4 deaths per 100,000 live births, compared to 12.1 deaths per 100,000 births for white women (C DC 2017).   7 In 2004, the year I began my study, the national MMR was 60.9, and Chiapas, Guerrero, and Oaxaca were the three states with an MMR above 80. The next group of states had an M M R above 70. The MMR s for each state, ordered from highest to lowest, are as follows (OMM 2013, 7): State Guerrero Chiapas Oaxaca Durango Puebla Veracruz México Hidalgo Distrito Federal

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MMR 98.3 98.2 89.2 76.2 75.4 73.6 72.7 72.5 64.9

State Yucatán Guanajuato Jalisco Campeche Michoacán Quintana Roo Morelos Tamaulipas Baja California Sur

MMR 51.7 50.2 49.0 49.0 48.2 48 47.1 44.6 42.2

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Notes to page 5 State

San Luis Potosí Baja California Queretaro Nayarit Tlaxcala Tabasco Chihuahua

MMR 63.2 61 56.7 55.2 53.6 52.6 52.5

State Colima Sonora Sinaloa Zacatecas Coahuila Aguascalientes Nuevo León

173 MMR 39 38 36.3 31.5 29.9 21.5 15.2

  8 Indigeneity in Mexico is classified according to whether or not a person speaks an Indigenous language. Mexico’s National Institute for Statistics and Geography, I N EG I , states that in 2015 6.5 per cent of the Mexican population over the age of three spoke an Indigenous language (INEGI 2016, 1). However, 21.5 per cent of the population (over the age of three) identified as Indigenous, regardless of whether they spoke an Indigenous language (3).   9 The five states with the highest proportion of Indigenous people are Oaxaca, Yucatán, Chiapas, Quintana Roo, and Guerrero (INEGI 2016, 4). Indigenous people suffer from poverty and marginalization to a greater extent than the non-Indigenous population, and they lack services that the rest of the population enjoys: roughly 14 per cent of the Indigenous population lacks running water, compared to 4.2 per cent of the nonIndigenous population; a quarter of households with Indigenous inhabitants are not connected to public drainage systems, compared to 4 per cent of non-Indigenous households; and 13.4 per cent live in houses with a dirt floor, compared to 2.6 per cent of other Mexicans (11–12). Roughly 72 per cent of the Indigenous population is affiliated with Seguro Popular (5). 10 I use Gómez-Jauregui’s (2004, 43) definition of NGOs as organizations that “are private and independent from government (although they might receive its support and collaboration), are non-profit making and self-­ governing (with internal decision-making structures); and have a meaningful voluntary content (income, labour or management).” 11 Mexico has implemented maternal and infant health programs since the 1970s, when the federal Ministry of Health introduced the Program of Maternal and Infant Health Care (Programa de Atención Materno Infantil) (Alarcón Navarro 2001, 14). However, as I explain later in the chapter, the post-2000 programs were more focused on measuring and monitoring maternal mortality, using N GOs as intermediaries between communities and the health care system, and improving the performance of the system.

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Notes to pages 5–7

12 I will refer to the program by its English translation, “An Equal Start in Life,” or simply “Equal Start.” 13 There are numerous N G Os in Mexico working on sexual and reproductive rights and health, but they are not necessarily collaborating with government on the implementation of maternal health goals. There are also a number of organizations that have promoted traditional and professional midwifery, such as Partería Ticime and the Centre for the Adolescents of San Miguel de Allende (CAS A) hospital and professional midwifery school in Guanajuato, which opened a school in Guerrero in 2014. But these organizations, although they are accredited by the government and their graduates work in the public health system, have nevertheless operated separately from it. There are also organizations which work in Indigenous people’s health, but they are not focused on maternal and sexual and reproductive health. Since 2008, the Commission for the Development of Indigenous Peoples (CDI ) has expanded its program Casas de Salud de la Mujer Indigena to other states, so there are now NGOs collaborating with this program in other locations (CDI and Kinal Antzetik 2016). 14 The social security institutes are also public in the sense that they are supported by federal government contributions. However, because their services are only available to contributing individuals and their families (derechohabientes) – with some exceptions related to maternal health that I will outline later in the chapter – I shall refer only to state government, or I M S S -Oportunidades, services as part of the public health care system. 15 David Harvey (2007, 2) has defined neoliberalism as follows: Neoliberalism is in the first instance a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade. The role of the state is to create and preserve an institutional framework appropriate to such practices. The state has to guarantee, for example, the quality and integrity of money. It must also set up those military, defence, policy, and legal structures and functions required to secure private property rights and to guarantee, by force if need be, the proper functioning of markets. Furthermore, if markets do not exist (in areas such as land, water, education, health care, social security, or environmental pollution) then they must be created, by state action if necessary. But beyond these tasks the state should not venture. State interventions in markets (once created) must be kept to a bare minimum because, according to the

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Notes to pages 8–10

175

theory, the state cannot possibly possess enough information to second-guess market signals (prices) and because powerful interest groups will inevitably distort and bias state interventions (particularly in democracies) for their own benefit. 16 I will refer to the “State” with an uppercase “S” when I am referring to “the organization with a monopoly on the legitimate use of force within a given territory” (Weber 1946), in order to differentiate it from the state as a subnational unit of government. 17 All Spanish-language quotes, from interviews or documents, have been translated into English by the author. 18 The other agencies included the United Nations Population Fund (UNF P A ); the World Bank; the United Nations Children’s Fund (UNIC EF); the International Planned Parenthood Federation (IPPF); the Population Council; and Family Care International. 19 The Interagency Group was composed of the three conference sponsors – UNF P A , the World Bank, and W HO – plus UNIC EF, the United Nations Development Program (U N DP), and two NGOs, the IPPF and the Population Council (Starrs 2006). 20 Article 7.2 of the Cairo Programme of Action defines reproductive health as follows (I CPD 1994): Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.

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Notes to page 11

  Article 7.3 of the Programme of Action outlines the link between reproductive rights and reproductive health as follows (IC PD 1994): Bearing in mind the above definition, reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence. 21 Some authors view the achievements on abortion much more positively. Rosalind Petchesky (2003, 39) states that “on the highly contentious issue of abortion, the transnational women’s movements also gained some advances if we read the Cairo Programme and the Beijing Platform together.” While I do not disagree with her assessment that advances were made, neither conference was able to achieve a statement endorsing access to safe, legal abortion – and perhaps an international conference would not be able to reach such a consensus. 22 The Millennium Project was headed by economist Jeffrey Sachs. In 2002, Sachs, with assistance from the U N DP and Stan Bernstein of the UNFPA , commissioned ten task force reports on the MDGs. 23 It was Mexico’s commitments to the Cairo and Beijing Platforms of Action, rather than the Millennium Development Goals, which were important in legitimizing the campaign to decriminalize abortion in Mexico City (Mills 2010). In April 2007, the Federal District (D.F.) became the first jurisdiction in the nation, and one of the few in Latin America, to decriminalize abortion in the first trimester of pregnancy (Sánchez-Fuentes et al. 2008, 345). Between 1931 and 2007, although all states permitted abortion in the case of rape – and in some states, to save the woman’s life or health, or because of fetal malformation – termination of pregnancy for any other reason was illegal. The Mexico City policy sparked a reactionary response in the majority of Mexican states, however. Within two years of the decriminalization in the D.F., sixteen of Mexico’s thirty-two states had passed constitutional amendments protecting life from the moment of conception. Some states also banned the morningafter pill and the contraceptive intra-uterine device (IUD) on the grounds that these were abortafacients. The states of Jalisco and Guanajuato prohibited abortion even in the case of rape; Guanajuato, Puebla, Queretaro, and Quintana Roo have incarcerated women who had abortions (Torres

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Notes to pages 12–16

177

Ruiz 2009). With the exception of Chiapas, the constitutional amendments were passed in six states governed by the PA N, with legislative support from the PRI ; and in eight states governed by the PR I, with legislative support from the PAN . In the case of Chiapas, however, the state was led by the P R D; there was a unanimous vote from all parties in favour of the amendment (G I RE 2012). For further discussion of the Mexico City ­campaign, please see Mills (2010). 24 Giddens (1990, 80–8) refers to “faceless commitments” and “facework commitments,” which I believe are similar concepts to generalized and interpersonal trust. “Faceless commitments” entail faith in systems about which the trusting party is largely ignorant. She has confidence in the reliability of these system because of her belief in expert knowledge and / or codes of professional ethics that guide the practitioners of this knowledge. “Facework commitments” are trust relationships that arise between lay pay and experts in their face-to-face interactions. Birungi (1998, 1457) refers to these interactions as “access points” – points of connection – between abstract systems and the lay person. 25 It is difficult to think of an instance in which public policy decision-­ making is completely insulated from categorical inequalities, but Tilly would, I believe, see this as a continuum, with high levels of insulation from dominant class interests at one end, and no insulation from these interests at the other. 26 The “social state” is a particular combination of entitlements to education, health care, pensions, and transfers which, Filgueira argues, are not sufficiently developed in Latin America to comprise a welfare state; nevertheless, they form a variety of regimes that may be classified according to the level of expenditure, coverage, stratification, and quality of social services (2005, 9). 27 A corporatist arrangement is “a system of representation of interests in which societal groups are organized in a limited number of categories: unique, obligatory, not competitive, hierarchically ordered and functionally differentiated, recognized or authorized (even created) by the state. These categories are granted a deliberate representative monopoly in exchange for accepting certain controls in the selections of their leaders and limiting their demands” (Schmitter 1981, 179). Under Mexico’s corporatist structure, organized groups, such as workers’ and peasants’ organizations, were incorporated into the PR I in such a way as to minimize dissent. In exchange for their support of the party, incorporated organizations received material benefits (Teichman 1996, 1–2). 28 These figures are from 2010.

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Notes to pages 17–21

29 The I M S S program for the uninsured population, created by an amendment to the Social Security Law in 1973, has been renamed a number of times: in 1974, it was called the National Program for Social Security through Community Cooperation (Programa Nacional de Seguridad Social por Cooperación Comunitaria); from 1979, I M S S -C O P L A M A R (General Coordination of the National Plan for Depressed Zones and Marginalized Groups); from 1989, I M S S -Solidaridad (Solidarity); from 2002, I M S S -Oportunidades (Opportunities); and from 2014, I M S S Prospera (Prosperity) (I M S S Prospera 2015). I will usually refer to the program as I M S S -Solidaridad or I M S S -Oportunidades, its names during the periods I am discussing. 30 Rather than “second-wave neoliberalism,” Jenson (2009) argues that since the 1990s, a “social investment” perspective has prevailed in Latin America and Europe. This perspective differs both from the welfare state arrangements implemented in developed countries in the post–World War II period, and from the neoliberal policies promoted in the 1980s and early 1990s (449). In the neoliberal period, welfare was to be provided, in theory, by non-state actors via strategies of “responsibilization,” in which individuals and communities were exhorted to take action to ensure their own health and well-being. While the emphasis on partnerships with voluntary and non-­governmental organizations (the third sector) has continued, Jenson argues that “the major difference between the responsibility mix in the social investment perspective and that of neoliberalism is that the state is assigned some responsibility for ensuring that such investments are possible. There is a basic recognition that opportunities are neither equally nor equitably distributed. It may be necessary to provide services or transfers to ensure that children can be sent to school, to pre-school, or to the doctor, for example” (454). 31 In the case of painful uterine pressure, doctors or nurses were performing the “Kristeller manoeuvre,” pushing on the uterine fundus to facilitate vaginal delivery – a practice that has been found to have no benefits and a number of risks, including a risk of uterine rupture (Merhi and Awonuga 2005). 32 The experience of disrespectful, abusive, or neglectful treatment is not confined to Mexico. The W HO has reported that women undergo similar experiences worldwide, and that this may deter women from using health care services during pregnancy and delivery. While the experience of mistreatment within the health care system may occur at any stage of pregnancy, birth, or the postpartum period, it is mostly likely to be experienced during childbirth. Those who experience it are also more likely to be

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Notes to pages 26–35

179

young, unmarried, poor, members of an ethnic minority, or HIV positive (WH O 2014, 1). 33 Many of the maternal health organizations are now part of a formal Coalition for Women’s Health, but the maternal health coalition was informally constituted. 34 Layton et al. (2007) list seven organizations that formed a reference group for Fundar: the Population Council; the National Safe Motherhood Committee (CPM S R – Comite Promotor por una Maternidad Sin Riesgos); the National Forum of Women and Population Policies (FNMPP – Foro Nacional de Mujeres y Políticas de Población); the Consortium for Parliamentary Dialogue and Equity (CDPE – Consorcio para el Díalogo Parlamentario y la Equidad); Equidad de Género, Ciudadanía, Trabajo y Familia; Integral Health for Women (S I PA M – Salud Integral para la Mujer); K’inal Antzetik D.F.; and three academic researchers, Graciela Freyermuth, David Meléndez, and Martha Aída Castañeda Pérez (27–9). C I MA C , a news service focusing on issues of women’s rights and gender equality, also played an important role in the coalition; at various times, the Information Group on Reproductive Choice (GIR E – Grupo de Información en Reproducción Elegida), and Catholics for the Right to Decide (Católicas por el Derecho a Decidir) collaborated with the group (Layton et al. 2007, 29). Many of these groups later formed the Coalition for Women’s Health in 2007. 35 O MM is “an independent organization comprised of individuals, national and international N G Os, agencies of technical and financial cooperation, academic institutions, researchers, and government” (OMM 2015). chapter one

  1 As discussed in the introduction, Mexico implemented maternal and infant health programs from the 1970s onwards. Earlier programs were also influenced by international declarations on public health generally, or reproductive and maternal health specifically, such as the 1978 Alma Ata Declaration, the 1987 Safe Motherhood Conference in Nairobi and its successors (Lozano Ascencio et al. 2005, 183), and the Cairo and Beijing conferences (Jauregui 2010, 12).  2 The MD G s do not have the status of a treaty under international law. However, Alston (2005, 771) argues that they do have the status of customary international law, chiefly because governments “have reiterated the commitment so frequently, and on so many solemn occasions.” Some legal scholars have rejected this argument, such as Tomuschat (2003). However,

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Notes to pages 38–43

Tomuschat does not include any economic or social rights in his list of customary norms, and the M DG s may be seen as statements of economic and social rights. They differ from other statements of such rights, however, because of states’ repeated recitation of a commitment to them, and also because, Alston claims, no right that is essential for human dignity, and which can be achieved by governments with the support of the international community, should be absent from such a list (2005, 774).   3 Some authors have contested this view. Costello et al. (2006) have pointed out that vitamin A supplements led to reduced maternal deaths in Nepal, and that many developing countries do not presently have the resources and infrastructure to expand EmOC (1477). They argue that countries that cannot invest in E mOC need to be given alternative strategies. However, expanding EmOC does not mean that other strategies cannot be implemented; it does mean recognizing that these strategies will be less effective than they would in the presence of E mOC . While extremely impoverished countries have difficulty expanding access to E mOC , recognizing its importance in saving lives can help to raise the question of resource allocation and whether resources spent elsewhere may be better invested in the health care system.   4 Merry defines indicators as “statistical measures that are used to consolidate complex data into a simple number or rank that is meaningful to policy makers and the public” (2011, S86).   5 The National Public Health Council (CS G) includes the federal minister of Health and the health ministers from each of Mexico’s thirty-two states.   6 The National Health Council (CS N ) is distinct from the National Public Health Council (CS G ).   7 The National Population Council (CON APO – Consejo Nacional de Población) is made up of representatives from seventeen federal government departments and is responsible for demographic planning (Chemor Ruiz 2014, 9).   8 The information contained in the files is flawed; however, it has been possible for groups such as the National Centre for the Evaluation of Social Policies (Coneval) to make certain determinations based on the data.   9 While the overall maternal mortality ratio has diminished since 2005, as I will discuss further in the next chapter, the proportion of deaths occurring among those without social security coverage remains high: approximately 14 per cent of deaths occurred in social security institute facilities, whereas 47 per cent occurred in state health or I M SS-Oportunidades facilities, 13 per cent in private clinics, and 7 per cent at home (see chapter 2, table 2.8; using data from OM M 2014a, 56).

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Notes to pages 43–58

181

10 The first conference was held in Guerrero in 2006, and incorporated parteras as well as the families of women who had died. Federal and state officials, however, felt attacked and criticized at the event. Believing that co-operation with the federal government would be more constructive than confrontation, future conferences took the form of technical meetings, which were not open to the public. Activists believed that the strategy of co-operation encouraged the formation of agreements with state and federal governments (Interview, C I S C 2008; Interview, C D I 2008). 11 Whether this has been achieved in practice is another question. As I will discuss in the rest of the book, implementation has lagged behind commitment. Nevertheless, the commitment sets a benchmark against which governments’ achievements can be measured, and indicates an acknowledgment of the obligation to provide services. chapter two

  1 It should be noted that, before decentralization in the 1980s and 1990s, the federal Ministry of Health (S S A) provided health care services to the uninsured population, as did state Ministries of Health; starting in the 1970s, I M S S -Solidaridad (later renamed Oportunidades) also provided services to the uninsured. However, from the structural adjustment period onwards, the uninsured were charged user fees for SSA and state government health care services (Birn 1999). Seguro Popular affiliates do not pay user charges for the 285 health care interventions covered by the system (S S A 2014); those who are not affiliated with the system, or who require treatments not covered by it, still have to pay user charges.   2 The family members who are covered in the social security institutes are as follows: “spouse; dependent parents; dependent children (up to 16 in I MS S , to 18 in other schemes; students up to 25 in full-time education; disabled children, with no age limits” (O EC D 2005, 34).   3 More recent figures indicate that 48 per cent of the Mexican population is covered by one of the social security institutes (IMSS 2014, 7).   4 González Rossetti defines the five reforms as financial engineering; health service decentralization; doctor eligibility and performance incentives; family health insurance; and an opt-out option policy and contracting-out of services (2004, 77–8).  5 Although I M S S health care services were not privatized under the 1995 reform, the institute has increased subcontracting of services, which is permitted under legislative changes dating back to 1949. The IMSS spent

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Notes to pages 58–66

almost three times as much on subcontracted services in 2005–06 as it had in 2001–02 (Dion 2010, 189).   6 For a full discussion of the 1995 Social Insurance Law, see Dion (2010), chapter 5.   7 See Dion (2010), chapter 7 for a full discussion of this reform.   8 Though it is known as the Ministry of Health, it is still referred to by the same acronym, S S A.   9 Between 1979 and 1996, I M S S -Coplamar / IMSS-Solidaridad was partly funded by the federal government (60 per cent) and partly funded by I MS S (40 per cent). From 1996 onward the funding has come completely from the federal government (OECD 2005, 144). 10 C O P L A MA R – Coordinación General del Plan Nacional de Zonas Deprimidas y Grupos Marginados – means “Coordinating Agency of the National Plan for Depressed Zonas and Marginalized Groups.” 11 Referred to as parteras rurales (rural midwives). 12 While some studies have found statistically significant improvements in perinatal mortality as a result of T B A training, none have found statistically significant differences in maternal mortality, although non-statistically significant changes have been reported (Jokhio et al. 2005; Sibley et al. 2007). 13 The biomedical model has been defined as “a conceptual model of illness that excludes psychological and social factors and includes only biologic factors in an attempt to understand a person’s medical illness or disorder” (Farlex Partner Medical Dictionary, 2012). 14 I MS S -Solidaridad / Oportunidades / Prospera health care clinics in rural areas are called rural medical units (unidades médicas rurales), and in urban areas, urban medical units (unidades médicas urbanas). However, in order to avoid confusion when talking about very similar medical care facilities, I will use the word “clinics” to refer to both IMSS-Solidaridad and S S A  / state government primary care services. 15 In 2014, the program was again renamed, this time “Prospera,” by the administration of Enrique Peña Nieto (Secretaría de Desarrollo Social, 2014). Given that I will not be discussing the program in or after 2014, I will continue to refer to it as Progresa or Oportunidades, depending on the period I am discussing. 16 The thirteen health interventions were as follows: basic household sanitation measures; family planning; prenatal, natal, and postnatal care; nutrition and growth surveillance; immunizations; treatment of diarrhea by household; treatment of common parasitic diseases; treatment of acute

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Notes to pages 67–70

183

respiratory infections; prevention and control of tuberculosis; prevention and initial treatment of cervical cancer; prevention and control of hypertension and diabetes; prevention of accidents and initial treatment of injuries; and community training for health promotion. 17 The 1997 legislation created four additional funds to be channelled through Item (Ramo) 33 (Falletti 2010, 225): 1 The fund for basic education (Fondo de Aportaciones para la EducaciÓn Básica – FAEB) 2 A general purpose fund that would be allocated to the states (Fondo de Aportaciones Multiples) 3 A fund for the strengthening municipalities and the Federal District (Fondo de Aportaciones para el Fortalecimiento de los Municipio y del Distrito Federal – FAFOM U N ) 4 A fund for social infrastructure (Fondo de Aportaciones para la Infraestructura Social – FAI S ), which targeted both states (FA ISE) and municipalities (FAI S M ). 18 The terms System for Social Protection in Health (SPSS) and Seguro Popular – the latter being the central pillar of the SPSS – are often used interchangeably (OECD 2016). However, to reduce confusion, I will refer to this package as Seguro Popular. 19 Legislation to revise the General Health Law and introduce the SPSS was passed in 2003. However, a pilot program for Seguro Popular had begun in four states in 2001, and the program did not cover all states until 2005 (Sosa-Rubí et al. 2009). 20 As noted in this chapter, the Ministry of Health has reported higher affiliation rates than the National Institute for Statistics and Geography (INEGI). While I am unable to determine whether this makes the Ministry of Health affiliation rates incorrect, it is safe to say that there are at least 40 million people enrolled in SPSS / Seguro Popular, according to the INEGI (2014). 21 Nevertheless, the number of services is still limited compared to what is offered in the social security system, which provides comprehensive coverage. 22 Seguro Popular also covers 609 medications, vaccines, and other medical supplies (S S A 2014). 23 The Fund for Protection Against Catastrophic Expenses (FPGC ) accounts for 8 per cent of the federal social contribution and the federal and state social solidarity contributions. 2 per cent of the latter funds go “to infrastructure investments in poor communities,” and an additional 1 per cent of funds is held as a reserve (Frenk et al. 2006, 1529).

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Notes to pages 70–80

24 The formula for calculating the Social Quota was changed in December 2010; I will discuss the change and its impact in the next section of the chapter. 25 The exact figures are:



Total population

With health care coverage

Without health care coverage

Not specified

118,563,412

91,540,602

26,960,893

61,917

The population with health care coverage is distributed as follows: Type of affiliation IMSS

Population 40,000,144

ISSSTE Seguro Popular

6,174,281 41,145,824

Other public institution Private institution

3,372,089 848,264

  Source: I N E G I 2014, 19, table 2.1.

26 A researcher with the Universidad Autónoma Metropolitana Xochilimilco, Gustavo Leal F., has reported that Guillermo Soberón Acevedo, the president of the Mexican Foundation for Health (FUNSA LUD), a health policy think tank, proposed to President Fox that Seguro Popular should first be rolled out in cities with more than 100,000 people, because these residents would have the greatest capacity to pay (Leal F. 2002, 114). Julio Frenk was vice-president at FU N S ALU D when Guillermo Soberón Acevedo was president of the organization. 27 The O E C D notes that Mexico spends only 6.2 per cent of GDP on health; only 51 per cent of this spending is public, the lowest share of public spending in the OECD except for Chile and the United States (OEC D 2016, 57). 28 According to the I N S P (2011, 26), the state Ministries of Health operate 13,317 ambulatory care units (U AA). Of these: 8,334 units are rural health centres, and 1,801 are urban health centres. The remaining 3,182 are composed of: 1,849 mobile units, 625 mobile brigades, 142 health houses (casas de salud), 21 local consultation units (consultorias delegacionales), 51 Attorney General’s Office units (unidades del ministerio público), 63 Advanced primary care centres, 18 health centres with expanded services, and 313 specialty medical units. 29 Some of the pasantes are dental school graduates working in facilities providing dental care.

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Notes to pages 90–112

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chapter three

  1 That is, the state had the second-highest level of poverty and extreme poverty (Coneval 2013b, 15).   2 The “sending states” (estados expulsores) are Guerrero, Oaxaca, Chiapas, Morelos, Hidalgo, Puebla, Michoacán, Durango, Guanajuato, Zacatecas, Nayarit, Veracruz, San Luis Potosí, and the region of Chihuahua with a large number of Indigenous inhabitants (C IDH 2013, 36).   3 The action of students commandeering buses to travel to Mexico City was not new, but an annual event for the students of Ayotzinapa (Guillermoprieto 2015).   4 Since 2014, the program has been called IMSS-Prospera.   5 In this analysis, González-Block et al. (1989) grouped the population of Guerrero and Oaxaca into five income strata. In order to determine whether all groups had an equal chance of having their health needs met, they examined “general consultations; extension of service coverage, measured through first-time consultations; protection against pertussis, tetanus and diphtheria, measured through the application of the third dose of D P T vaccination; and antenatal care enrolment, measured through first-time antenatal consultations. The analysis assessed the per capita distribution of each variable among the non-insured at the municipal level” (309). Overall, the variables increased in Guerrero following decentralization, and decreased in Oaxaca (as a consequence of the economic crisis). The increase in Guerrero, however, masked deepening regional disparities. It was the top two income strata that benefitted from an increase in services; the service level for the middle strata did not change, and the poorest strata experienced a reduction in services. D P T vaccination was also interrupted for the latter group (311).   6 There is a state and municipal variant of this fund (Faletti 2010, 225).   7 Espinosa Damián (2004) has documented numerous instances of verbal and physical abuse against Indigenous women in the health care system.   8 Women’s need to work outside the home means that the forty-day lying-in period is not necessarily observed. Nevertheless, the parteras I spoke to in all three states tried to observe a lying-in period in which the new mother was relieved of all duties except taking care of the baby, she was brought food by the partera and family members, and she bathed in the temazcal each day.   9 According to a study by U N AM , 10.8 per cent of the Mexican population lacks a birth certificate. Guerrero, along with Chiapas, Oaxaca, Veracruz, Puebla, Morelos, and Michoacán, is among the states with the lowest

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Notes to pages 113–26

levels of birth registration (Camacho Servín 2012, 13). In Chiapas, approximately 39 per cent of children were not registered by their first birthday (UN News Centre, 2011). If a child is not registered within the first six months of his or her life, families may face fines of Mex$600 to $800 (approximately US$47 to $62), which deters late registration (Camacho Servín 2012, 13). Since 2011, UNIC EF has been working with the Mexican statistics bureau to analyze rates of birth registration and promote it throughout the country. In June 2014, the right to an identity was recognized in the Mexican Constitution, and birth certificates could be obtained free of charge (U N I CEF 2014). 10 In 2004 the S S A had 974 medical units, made up of 907 health clinics, forty-nine mobile health brigades (which travel to remote communities once or twice a month), eighteen basic community hospitals, and fourteen general hospitals (Meléndez Navarro 2005, 54). chapter four

  1 The first non-PRI governor in Mexico was elected in Baja California in 1989 (Ross 2009, 335).   2 Both of these regions were priority areas for the state government (Nazar Beutelspacher 2007).   3 Susan Stokes (2009, 604) has defined clientelism as “giving political goods in return for electoral support, where the criterion of distribution that the patron uses is simply: did you / will you support me?” Tilly (2007, 95) acknowledges that clientelism is one way in which trust networks that may have been insulated from the public sphere are connected to government. It is a less democratic form of integration because it “sacrifices accountability in favour of loyalty.” Politicians become less accountable for their policies; instead, citizens’ support depends on their receipt of private payments or benefits and their personal relationships with the office holder (95).   4 The full title in Spanish is Comisión de Concordancia y Pacificación (C O C O P A ), or the Commission for Harmony and Pacification.   5 Chiapas was divided into 111 municipalities until 1999, when the Re-municipalization Commission created seven additional municipalities (Government of Chiapas 2001).   6 The full title in Spanish is Vida Mejor Para Las Mujeres, Niñas y Niños de Chiapas (A Better Life for the Women and Children of Chiapas).   7 The government also introduced another program, a state-level version of Arranque Parejo en la Vida, called Healthy Pregnancy, Successful Birth

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187

and Infant Survival (ES PES I – Embarazo Sano, Parto Exitoso y Sobrevivencia Infatil). Like Arranque Parejo, it involved the development of social networks to transport women in need of medical care, and monitoring the health of pregnant women. It was initially implemented in nonIndigenous rather than Indigenous communities in the centre of the state, and was neither perceived as having an impact on maternal mortality (Freyermuth n.d.) nor mentioned in interviews.   8 In order to determine whether the infant deaths in Comitán at this time exceeded “normal” mortality rates, I examined a study published in 2003 which found that out of 3,645 births, 120 babies died, an average of ten per month; twenty-five deaths was therefore more than double the norm (Rivera et al. 2003, 688).   9 In an interview, an administrator from health jurisdiction 2 (Los Altos region) told me that the clinics that were closed in December – or, at least, which were not staffed by qualified personnel – included IMSS, IMSSOportunidades, and I S S S TE clinics, which would be classified as public rather than private. When we were discussing the issue, he said: “The other health systems, I S S S TE, IMSS, and IMSS Oportunidades, in that period of December, they didn’t have health personnel in the microregions or in their hospitals.” Me: “No personnel?” Interviewee: “None. We’re talking no pasantes [social service students], no doctors, no nurses, no gynaecologists, paediatricians, at work.” (Interview, 10 August 2004) 10 Frenk went on to indicate that his soon-to-be-launched health insurance program, Seguro Popular, would address these problems. 11 Frenk also said that “the risk of a newborn dying is almost eight times higher when the birth was attended by midwives than by medical personnel” (2003). 12 The full title in Spanish is Red Social Contra la Muerte Materna (Social Network to Prevent Maternal Death). 13 A C A S A C was established in 1995, and began programming in sexual and reproductive health in 1998 (ACAS AC 2016.). 14 C I S C was established in 1991 (CI S C 2016). 15 In Spanish, Luna Maya Birth Centre is Luna Maya Casa de Partos; it was established in 2004. 16 Of the forty-three health units that offered round-the-clock care, 365 days a year, Argüello examined three out of eleven general hospitals, three out of eleven basic community hospitals, and ten out of twenty-one health centres with hospitalization.

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Notes to pages 143–57 chapter five

  1 Figures from the National Institute of Statistics and Geography (INEGI) indicate that, in 2010, 56 per cent of Oaxacans had social security coverage, and 58 per cent were covered by Seguro Popular. This figure exceeds 100 per cent because some respondents reported that they had both forms of coverage (although Seguro Popular is intended only to cover those without membership in a social security institution) (INEGI 2010a).   2 Oaxaca, like the rest of Mexico, did go through the decentralization of Ministry of Health services in the 1990s; but as discussed in chapter 2, I MS S -Solidaridad / Oportunidades services were exempt from this decentralization (unlike in the 1980s).   3 In coalition with the Mexican Communist Party (PC M).  4 The I MS S -Oportunidades clinics are referred to as rural medical units (UMR s – unidades medicales rurales), but, as earlier, to avoid using multiple terms for similar facilities I will refer to them as clinics.  5 I MS S -Oportunidades employees had fought to have their collective bargaining rights restored. In 2003, 2,000 I MSS-Oportunidades staff occupied buildings to demand permanent employment status, and material and medicines for the rural medical units (U M Rs) (SUN-A EE 2003).   6 Since 2009, I M S S -Oportunidades has constructed eight new hospitals (I MS S 2013). While a commendable action, it is unlikely that this number of hospitals will address the gap in medical care.   7 It is not coterminous with the Istmo region, but nevertheless overlaps with it significantly.   8 Of course, what is being reported here may not be the exact words used by the IMSS-Oportunidades administrator. However, this is how the doctor heard what was being said; so, if this was not what the other party was trying to convey, there was an issue of miscommunication. Other IMSS employees, however, reported similar conversations with administrators.   9 Writing about the U M Rs in 2008, Castañeda Pérez noted that “neither the doctors nor the supervisors knew about the existence of the cajas guindas and rosas” (2010, 105). 10 This preceded a national-level agreement between the social security organizations and the Ministry of Health that was signed in 2009 (SSA , I MS S , and I S S S TE 2009). 11 As described above, they are provided in exchange for in-kind services. 12 Molyneux (2007) and Luccisano (2004) have argued that, in making mothers responsible for their children’s school attendance, health, and hygiene, the Oportunidades program reinforces a traditional gendered ­division of labour and increases women’s social responsibilities.

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216 References elsiglodetorreon.com.mx/noticia/15818.dos-mil-medicos-toman-­ instalaciones-del-imss.html. Sweetman, Carol, ed. 2005. Gender and the Millennium Development Goals. Oxford: Oxfam Publishing. Teichman, Judith. 1996. “Neoliberalism and the Transformation of Mexican Authoritarianism.” Presented at the workshop “Mexico in the Post-NA FTA Era: Democracy, Civil Society, and Societal Change,” York University, Toronto, 22–24 September 1995; C ER LA C Working Paper Series, January 1996. – 2008. “Redistributive Conflict and Social Policy in Latin America.” World Development 36 (3): 446–60. Thompson, Ginger. 2004. “Ex-President in Mexico Casts New Light on Rigged 1988 Election.” The New York Times, 9 March. Accessed 6 January 2013. http://www.nytimes.com/2004/03/09/world/ex-­ president-in-mexico-casts-new-light-on-rigged-1988-election.html. Tilly, Charles. 2005. Trust and Rule. Cambridge: Cambridge University Press. – 2007. Democracy. Cambridge: Cambridge University Press. Tomuschat, Christian. 2003. Human Rights: Between Idealism and Realism. Oxford: Oxford University Press. UC I Z O NI (and I M S S -Oportunidades employees). 2008. Letter to Lic. Carolina GÓmez Vinales, Titular del Programa IMSS-Oportunidades, 3 July. Ullah, A.N. Zafar, James N Newell, Jalal Uddin Ahmed, M.K.A. Hyder, and Akramul Islam. 2006. “Government-NGO Collaboration: The Case of Tuberculosis Control in Bangladesh.” Health Policy and Planning 21 (2), 143–55. UN News Centre. 2011. “Heeding U N I CE F’s Calls, Mexico Makes Progress towards Free Birth Registration.” Press Release, December 2. Accessed 24 February 2013. http://www.un.org/News/. UNR I S D (United Nations Research Institute for Social Development). 2010. Combatting Poverty and Inequality: Structural Change, Social Policy and Politics. Geneva: U N RI S D. Valdez Santiago, Rosario. 2013. El Abuso Hacia las Mujeres en Salas de Maternidad: Nueva Evidencia Sobre un Viejo Problema. Cuernavaca, México: Instituto Nacional de Salud Pública. Verstraeten, Barbara S.E., Jane Mijovic-Kondejewski, Jun Takeda, Satoni Tanaka, and David M. Olson. 2015. “Canada’s Pregnancy-Related Mortality Rates: Doing Well but Room for Improvement.” Clinical and Investigative Medicine 38 (1): E 15–36.

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Victora, Cesar, Jennifer Requejo, Aluisio Barros, Peter Berman, Zulfiqar Bhutta, Ties Boerma, and Mickey Chopra, et al. 2016. “Countdown to 2015: A Decade of Tracking Progress for Maternal, Newborn, and Child Survival.” The Lancet 387 (10032): 2049–59. Waage, Jeff, Rukmini Banerji, Oona Campbell, Ephraim Chirwa, Guy Collender, Veerle Dieltiens, Andrew Dorward, and Peter GodfreyFaussett, et al. 2010. “The Millennium Development Goals: A CrossSectional Analysis and Principles for Goal-Setting after 2015.” The Lancet 376 (9745): 991–1023. Walton, John, and Charles Ragin. 1990. “Global and National Sources of Political Pro­test: Third World Responses to the Debt Crisis.” American Sociological Review 55: 876–90. Washbrook, Sarah. 2007. “The Chiapas Uprising of 1994: Historical Antecedents and Political Consequences.” In Rural Chiapas Ten Years after the Zapatista Uprising, edited by Sarah Washbrook, 1–33. London and New York: Routledge. Watt, Peter. 2010. “Saving History from Oblivion in Guerrero.” Monthly Review 61 (10): 50–8. Weber, Max. 1946. From Max Weber: Essays in Sociology. Translated, edited, and with an introduction by H.H. Gerth and C. Wright Mills. Oxford: Oxford University Press. WH O (World Health Organization). 1992. Traditional Birth Attendants: A Joint WHO /UNFPA /UNICEF Statement. Geneva: WHO. – 2011a. International Statistical Classification of Disease and Related Health Problems. Geneva: W HO. – 2011b. “Universal Access to Reproductive Health: Accelerated Actions to Enhance Progress on Millennium Development Goal 5 Through Advancing Target 5B.” Accessed 20 February 2013. http://www.­ ibpinitiative.org/_include/PDF/WHO_RHR_HRP_11.02_eng.pdf. – 2014. “Prevention and Elimination of Disrespect and Abuse during Facility-Based Childbirth: W HO Statement.” Accessed 21 June 2016. http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_ eng.pdf. – 2015. “Trends in Maternal Mortality: 1990 to 2015. Estimates by WH O , U N I CEF, U N FPA, World Bank Group and the United Nations Population Division.” Geneva: W HO. Accessed 7 January 2017. http:// data.unicef.org/wp-content/uploads/2015/12/Trends-in-MMR -19902015_Full-report_243.pdf. Wilson, Amie, Ioannis D. Gallos, Nieves Plana, David Lissauer, Khalid S. Khan, Javier Zamora, Christine MacArthur, and Arri Coomarasamy.

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218 References 2011. “Effectiveness of Strategies Incorporating Training and Support of Traditional Birth Attendants on Perinatal and Maternal Mortality: Meta-Analysis.” British Medical Journal 343. doi: http://dx.doi.org/ 10.1136/bmj.d7102. Zúñiga Herrera, Elena, ed. 2005. “Introducción.” In México, ante los desafíos de desarrollo del milenio, edited by Elena Zúñiga Herrera 11–18. México D.F.: CON APO.

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Index

abortion, 4, 11, 176–7n23 A C A S A C , 131, 135, 187n13 Aguirre Rivera, Ángel, 95 A I D E M, 5, 41–2, 52, 139, 160 Arranque Parejo en la Vida (APV), 5, 36–42, 91, 98; and CN EG S R, 36; and maternal death registration, 5, 36–9; and M DG -5, 33, 36; and N G O collaboration, 5, 25, 37, 91; and obstetric risk model, 37; and transport, 37, 102–5, 116 Article 27 (of Mexican Constitution), 122 A S F . See Seguro Popular Auditor-General of the Federation, 78 Ávila Camacho, Manuel, administration of, 59 Bar Human Rights Committee of England and Wales, 94–5 Beijing Conference, 9; and abortion, 11; and gender inequality, 10. See also Cairo Conference birth certificate, 113, 185–6n9

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C A EO, 87–8 Cairo Conference, 9; and abortion, 11; and gender inequality, 10; and maternal mortality, 10; and reproductive rights paradigm, 10 Calderón, Felipe, 29, 94; administration of, 39; and Embarazo Saludable, 72; and Medical Insurance for a New Generation (SMNG), 44, 72 Casa de Salud de la Mujer Indígena, 91, 98–102, 174n13. See also K’inal Antzetik C A USES, 113 C DI: and Casa de Salud de la Mujer Indígena, 30, 99–100; and rehabilitation of partería (traditional midwifery), 46. See also Guerrero Co-ordinating Group for Indigenous Women; K’inal Antzetik Chiapas, 4, 6, 9–10, 118–42; accreditation of clinics, 77; and availability of health care supplies, 81; and “credited” vs “­liquid” health care spending,

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220 Index 74; and decentralization, 125–7; democratic transition in, 118; and health care spending, 63; history of, 121–5; infant deaths in Comitán, 126–7; internal conflict and displacement in, 122–5; and maternal mortality ratio, 5, 86; and N G Os, 26–7; number of beds per thousand population, 76; obtaining interviews in, 31; and parteras, 22–3, 48, 108; rates of migration from, 92; and technical meetings for the promotion of maternal health, 43–5, 47; and trust, 120–7 C I S C , 131, 135–7 clientelism, 120–1, 157; definition of, 186n3 Clínicas Si Mujer, 37, 138 C ND H : and lack of personnel in health care system, 80; and violations of the right to health, 76 C N E G S R : establishment of, 36; and technical meetings for the promotion of maternal health, 43. See also Uribe Zuñiga, Patricia Coalition of Workers, Peasants, and Students of the Isthmus (COCEI ), 145–8 C O C O P A , 123 Comitán Centre for Health Research. See CI S C Commission for the Development of Indigenous People. See CDI complementarity. See N G Os Comprehensive System of Quality in Health. See S I CALI DAD comuneros, 147 C O NA ME D, 82

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conditional cash transfers (C C Ts). See Oportunidades Coneval, 47–8, 84–5, 87 corporatism, 57–8; in Chiapas, 122; decline of, 53; definition of, 177n27; and gender, 16; and social security system, 54–5 Costa Chica (Guerrero), 22, 30, 91–3, 97–116. See also Casa de Salud de la Mujer Indígena; Guerrero Co-ordinating Group for Indigenous Women; K’inal Antzetik; Ometepec Coston, Jennifer, 119 Council for Public Health. See C SG, 40 CPMSR , 10, 27, 43, 179n34; and MacArthur Foundation, 43; and technical meetings on maternal health, 43–5 CS G, 40 Cué Monteagudo, Gabino, 145–6 cultural injustice. See cultural recognition cultural recognition, 21–3. See also Interculturalidad; politics of recognition CUR P (identity card), 112, 115 debt crisis, 17, 58, 62, 64, 122 de la Madrid, Miguel, 62, 96 democracy, definition of, 144 DGIS, 29, 39–41 Doña Maria case, 107 “dual regime,” 15 Echeverría, Luis, 93 ECO SUR , 128 ejidos, 58, 63, 121, 147 Elú, Maria Carmen, 10

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Index 221 Embarazo Saludable, 114. See also Medical Insurance for the Next Generation EmOC, 38; and Arranque Parejo en la Vida, 38–9; and General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies (C A E O), 163; and Integrated Strategy to Accelerate the Reduction in Maternal Mortality, 39; and need for a well-­functioning health care ­system, 30; and reporting of maternal mortality, 41, 52; and shift from obstetric risk model, 34, 39, 52, 160; and the three delays, 38–9 Equal Start in Life. See Arranque Parejo en la Vida eslabones críticos, 41, 139 E Z L N, 122 F A I S , 103 F A S S A , 67, 74, 88, 162 Filgueira, Fernando, 15–6. See also “dual regime”; Latin American social policy F O C A , 48 Fox, Vicente, 5, 25; and Arranque Parejo en la Vida, 102, 116, 166; and MD G s, 35–6; and Oaxaca rebellion, 145; and Oportunidades, 63, 65; and Zapatista conflict, 123 F P GC , 69–70, 78, 183n23 F P P , 70, 77 fragmentation of communities, 120, 123–4; health impacts of, 124

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Frayba (Centre for Human Rights Fray Bartólome de las Casas), 124 Frenk, Julio, 37, 67; and Arranque Parejo en la Vida, 37; and infant deaths in Comitán, 126–7; and Seguro Popular, 5, 67 Fundar, 26; and federal infra­ structure spending, 77–8; and MacArthur Foundation, 26; and maternal mortality measurement, 43 Fund for Basic Health Services, 67, 74, 88, 162 Fund for Budgetary Preparedness, 70, 77 Fund for Protection against Catastrophic Health Costs, 69–70, 78, 183n23 Fund for Social Infrastructure (FA IS), 103 Fund for the Strengthening of Municipalities and the Federal District (FA FOMUN), 103 G A TT (General Agreement on Tariffs and Trade), 122 General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies (C A EO), 87–8 generalized trust, 7, 12–14, 20, 32, 106, 152, 158, 161, 164, 167; definition of, 12. See also interpersonal trust; trust Gilson, Lucy, 11–15 “governance effects” of measuring maternal mortality, 34, 48–53; and trust, 49 Guerrero, 90–117; accreditation of clinics in, 77; and availability of

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222 Index health care supplies, 76–7, 113; and decentralization in, 96–8; Dirty War in, 93; drug war in, 93; and the forty-three missing students, 94–5; and I M S S Oportunidades, 61, 98; and I MS S -Solidaridad, 61–2; and maternal mortality ratio, 5, 90, 115; and N G Os, 23–4, 98–111; obtaining interviews in, 28; and parteras, 22, 90, 99–111, 117; rates of migration from, 92; and Seguro Popular, 112–17; and technical meetings for the promotion of maternal health, 43, 45; and trust, 90; and user fees, 66. See also Arranque Parejo en la Vida; Casa de Salud de la Mujer Indígena; Guerrero Co-ordinating Group for Indigenous Women; N G Os; ­parteras; Seguro Popular Guerrero Co-ordinating Group for Indigenous Women, 23, 98–109; and movement for Indigenous self-determination, 99. See also K’inal Antzetik health care system, 4–7, 11–15, 32; and availability of medications, 113; decentralization of, 40, 64, 66–7, 96–8; financing of, 72–6; fragmentation of, 55, 87, 89, 163; impact of structural adjustment on, 62–4; and IMSS-­ Oportunidades, 148–50; and infrastructure, 76–8; and measurement of maternal mortality, 33–4, 39, 43; and measures to improve quality of care, 82–3;

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and neoliberalism, 65–9; and NGOs as mediators, 25; NGO monitoring of, 105–12; and personnel, 78–81; structure of, 54–62; and supply of medications, 81–2; and third delay in seeking care, 38; and trust, 4, 15, 17, 23, 146, 158–69. See also Arranque Parejo en la Vida; ­General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies (CAEO); IMSS; IMSS-­Oportunidades; IMSS-­ Solidaridad; maternal health; Movement for “A Dignified, Quality Health Care Service for the Peoples of the Istmo Region”; OECD Review of Health Systems: Mexico; Seguro Popular health promoters: and Casas de Salud de la Mujer Indígena, 100; definition of, 171n2; and IMSSSolidaridad, 60; and monitoring of the health care system, 105–6; and NGOs, 11–12, 101; and Tenejapa Red Social, 132–5; training of, 132; and transfer to emergency obstetric care, 108; and trust networks, 5, 12, 31, 37, 91, 132, 140, 165; and Ucizoni, 148 health sector reform, 15–20, 54–89 identity card (C UR P), 112, 115 I FIs. See international financial institutions I M F (International Monetary Fund), 62, 64. See also World Bank

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Index 223 I MS S , 16, 44, 55–9, 63; and affiliation by gender, 16; negotiations with striking doctors in Oaxaca 150–1, 153; and pension privatization, 17; S N TS S opposition to decentralization, 98. See also General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies; health care system; I MS S -Oportunidades; I M S S -­ Solidaridad; Movement for “A Dignified, Quality Health Care Service for the Peoples of the Istmo Region” I MS S -Coplamar, 59. See also I M S S Oportunidades; I M S S Social Solidarity Program; I MS S -Solidaridad I MS S -Oportunidades, 51, 54, 59–62, 83, 87; and decentralization in Guerrero, 96; and gendered division of labour, 20; and maternal mortality ratio, 84; in Oaxaca 143–4, 148–68; re-­ establishment in Guerrero, 98; and transport, 87. See also I M S S Social Solidarity; I M S S Solidaridad; institutional drift; Movement for “A Dignified, Quality Health Care Service for the Peoples of the Istmo Region” I MS S -Prospera, 59 I MS S Social Solidarity Program, 17, 59, 60–2; and decentralization, 62–3, 66, 96; and parteras, 60 I MS S -Solidaridad, 17–18, 20, 31, 59–60, 101, 115, 125; and decentralization, 62–3, 96–8; and

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family planning, 61, 165; and primary health care principles, 60–1. See also IMSSOportunidades; parteras indicators, 39 Indigenous peoples: in Chiapas, 120; exploitation of, 120, 124; and identity formation, 99; rights to self-determination, 123, 148. See also Casa de la Mujer Indígena; Guerrero Co-ordinating Group for Indigenous Women; Indigenous women; K’inal Antzetik; Ucizoni; Zapatista Army of National Liberation Indigenous women: and Casa de la Mujer Indígena, 91, 98–105; and cultural injustice, 23, 111; and family planning, 61; and identity card (C UR P), 112; and movement for Indigenous women’s rights, 23; and NGO advocacy, 8; and NGO programs on sexual and reproductive rights, 165; and obstetric violence, 21, 105–7; and oppressive practices in communities, 23; and politics of recognition, 23, 167; and violation of reproductive rights, 61. See also Casa de la Mujer Indígena; Guerrero Co-ordinating Group for Indigenous Women; Indigenous women; K’inal Antzetik; Ucizoni; Zapatista Army of National Liberation institutional drift, 20, 143, 149–50, 158. See also IMSS-Oportunidades institutional pluralism, 127 interculturalidad, 47, 106, 135–8

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224 Index international financial institutions (I F I s), 8, 64, 66. See also I M F; World Bank interpersonal trust, 12–14, 20, 115, 152–3, 158, 161; and categorical inequalities, 13; and contingent consent, 13; definition of, 17; and health care system funding arrangements, 13; and universalism vs targeting, 14 I S I (import substitution industrialization), 15–6, 122; and social policy regime, 16, 101 I S S S T E , 16, 55–9; and affiliation by gender, 16; and beds per thousand population, 76; establishment of, 60; and health care system structure, 57; and pension privatization, 17. See also corporatism; General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies (CAEO); health care system; I M S S Istmo de Tehuantepec, 147–8, 150–9 K’inal Antzetik, 23, 26, 98–100, 106–8 “knowledge effect” of measuring maternal mortality, 33, 39, 52 Latin American social policy, 15–20. See also “dual regime” Levi, Margaret, 120 liberation theology, 122 local, the, 6–8, 24–5, 30–2, 100, 116; and community mobilization in Oaxaca, 151; and divisions in marginalized communities, 166– 9; and investigations of maternal

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deaths, 47–9; and the Tenejapa Red Social, 131–8; valorization of, 24, 166 López Portillo, José, 59 Los Altos (Chiapas), 118–19, 122– 3, 128–30, 138–41. See also Tenejapa Red Social low-intensity conflict; impact on health, 124 Lozano, Rafael, 39 Luna Maya Birth Centre, 132, 136 MacArthur Foundation, 6, 43, 99–100, 130–3; and the MDGs, 6; and NGOs, 26–7; and the Tenejapa Red Social, 130–3 Mahler, Halfdan, 9 Marie Stopes International, 128, 131 maternal death, definition of, 172n5. See also maternal mortality maternal health. See maternal mortality maternal mortality, 4–6, 46, 53, 84–7, 101, 160, 163, 168; and Arranque Parejo en la Vida, 36–8; in Chiapas, 118, 124, 131– 8, 141; definition of, 173n11; and E mOC , 38–9; and federal government strategies, 4–6; and global women’s movement, 9–11; in Guerrero, 90; measurement of, 33–4, 39–45, 48–52; misregistration of, 4; as a neglected tragedy, 9; and NGOs, 25–7, 116, 131; in Oaxaca, 143; and parteras, 46–8, 60; process for reporting, 40; revision of files, 41; reporting incidences of, 40. See also

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Index 225 Arranque Parejo en la Vida; Beijing Conference; Cairo Conference; health care system; MacArthur Foundation; maternal death; M DG -5; N G Os; Observatory for Maternal Mortality; parteras Maternal Mortality Committees (local), 40, 160; quality of advice, 47 maternal mortality measurement, 39–45, 47, 52, 160, 162, 164; and E mOC, 43; and qualitative information, 41; and quality of care, 42–3. See also governance effects; knowledge effects; maternal mortality; M DG -5; Merry, Sally Engle Maternal Mortality Observatory. See O M M maternal mortality ratio (M M R), 5, 84–6; definition of, 172n4; ­highest in Chiapas, Guerrero, Oaxaca, 5, 27, 43, 172n7; in municipalities, 45; in poor and / or Indigenous regions, 28, 36; in Tenejapa, 130–1. See also maternal mortality Matías Romero, 147–8, 150, 153– 8. See also Movement for “A Dignified, Quality Health Care Service for the Peoples of the Istmo Region”; Ucizoni MD G-5, 4–11, 35, 52, 160; and maternal mortality measurement, 33; and Mexico, 35–9; and reproductive rights, 8–9, 11; and influence on maternal health policy in Mexico, 43; and target 5B (universal access to reproductive

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health services), 11. See also maternal mortality; maternal mortality measurement; maternal mortality ratio; MDGs MDGs, 4–6, 8–11, 26, 29, 33, 43, 160; and C ONA PO, 36, 42; and Vicente Fox, 36; and importance of quantification, 36–40; and measurement, 36–40; and Mexico, 4, 33–53. See also Beijing Conference; Cairo Conference; Lozano, Rafael; MacArthur Foundation; MDG-5 medical authoritarianism, 21, 163 Medical Insurance for a New Generation (SMNG), 44, 69–70, 72, 74, 113; and coverage of pregnant women, 44. See also Embarazo Saludable; Seguro Popular Merry, Sally Engle, 34, 39 Millennium Development Goal 5. See MDG–5 Millennium Development Goals. See MDGs Ministry of Health, federal, 59–62 Molinar Horcasitas, Juan, 151 Movement for “A Dignified, Quality Health Care Service for the Peoples of the Istmo Region,” 150–9 Murat Casab, José, 145 N A FTA , 64, 122 National Commission for Human Rights. See C NDH National Commission for Medical Arbitration. See C ONA MED National Crusade for Quality in Health Services, 82

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226 Index National Safe Motherhood Committee. See CPM S R National Union of Social Security Workers (S N TS S ), 150 neoliberalism, 23–5, 58, 62–7, 88, 122, 162, 178n30; definition of, 174n15; second-wave, 18, 63, 162. See also decentralization; debt crisis; structural adjustment; user fees New Federalism, 67 NGO s, 5–6, 8–11, 12, 22–7, 31–7, 43, 45–52, 160–1, 165–8; and Casa de Salud de la Mujer Indígena, 98–101; in Chiapas, 118–19, 127–38, 140–2; complementarity with the State, 119; continuum of relationships with the State, 119, 127–8; and cultural norms, 102; and feminism, 24–5; in Guerrero, 98–110; and the MacArthur Foundation, 26–7; and neoliberalism, 23–6; in Oaxaca, 146, 155; and the State, 23–6. See also Fundar; K’inal Antzetik; MacArthur Foundation; Ucizoni Oaxaca, 143–69; and 2006 rebellion, 146; and APPO, 29, 146–7; and Coalition of Workers, Peasants, and Students of the Isthmus (COCEI), 145–8; and Ministry of Health (SSO), 150–1; and Movement for “A Dignified, Quality Health Care Service for the Peoples of the Istmo Region,” 150–9; and National Union of Education Workers (SNTE), 146; subnational authoritarianism

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in, 145. See also IMSSOportunidades; IMSSSolidaridad; institutional drift; Istmo de Tehuantepec; Ucizoni Observatory for Maternal Mortality (OMM), 29, 87 obstetric violence, 20–3; definition of, 20; and Indigenous women, 21, 105–11; NGO monitoring of, 105–11 OE C D Review of Health Systems: Mexico, 78, 81, 89 OMM (Observatory for Maternal Mortality), 29, 87 Oportunidades, 18–9, 63–5, 70, 72, 104, 116, 157; characteristics of, 18; conditionality of, 20; demands on women’s labour, 157–9, 168; health component of, 70, 73–4. See also IMSSOportunidades; Progresa; Pronasol PAC (Program to Extend Coverage), 66, 68 PAN, 145–6, 176–7n23 parteras: and Arranque Parejo en la Vida, 37; definition of, 171n1; and integration with health care system, 118–19, 129–38; and measurement of maternal mortality, 47–8, 52; and monitoring of health care system, 105–7; and NGOs, 5, 11, 23, 31–2, 167; and rehabilitation of partería, 45–8; and responsibility for maternal mortality, 42, 46–8; training of, 60–1, 133–5, 168; transporting women to medical care, 22–3, 47, 108–9; and trust

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Index 227 networks, 11–12, 22–3, 91, 105, 108, 118, 140–2, 164–5. See also Casa de Salud de la Mujer Indígena; K’inal Antzetik; Luna Maya Birth Centre; politics of recognition; Tenejapa Red Social; trust; trust networks pasantes, 79–80, 83, 114–5, 149, 168; endangerment of, 80 peso crisis, 58, 64 politics of recognition, 23, 167 Posadas A M E, 37, 102–5, 127, 166 P R D , 91, 95, 130, 145, 176–7n23 P R I , 5, 55, 59, 63, 91–2, 121–3, 125, 130, 143–7, 176–7n23, 177n27 Program to Extend Coverage (P A C ), 68, 88 Progresa, 18, 63–5; and redistribution, 19. See also Oportunidades; Pronasol promoters. See health promoters Pronasol, 18, 63–4 Ramo 12, 69 Ramo 33, 67, 103–5 Red Social. See Tenejapa Red Social Rosario Castellanos Centre, 46–7 Ruíz, Samuel, 122 Ruíz Ortiz, Ulises, 146, 151 Salazar Mendiguchia, Pablo, 118 Salinas de Gortari, Carlos, 58, 63 second-wave neoliberalism. See neoliberalism: second-wave Seguro Popular, 5, 7, 54–89, 104, 112–18, 156, 169; and affiliation by gender, 16–17; and affiliation rates, 19, 54, 112–14; and C A US ES , 113;

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comprehensiveness of services, 55; and democratization of health care system, 5; and family quota, 70, 74; financing, 19, 72–5; and health care infrastructure, 76–8, 83; and health care service quality, 19; higher maternal mortality ratios among affiliates of, 43; implementation in Chiapas, 138–40; implementation in Guerrero, 112–15; and Indigenous people, 71; and “layering” over existing institutions, 15, 19, 55; “liquid” and “creditable” state contributions, 70, 73–4; and maternal health, 84–9; and medications, 81–2; and neoliberalism, 67–8; and personnel, 78–81; and quality improvement programs, 82–4; and social quota, 70, 72–3; states’ financial contributions, 19; and state solidarity contribution, 73; and trustenhancing mechanisms, 55; and universal health care coverage, 19. See also General Agreement on Interinstitutional Collaboration to Provide Care for Obstetric Emergencies (C A EO); health care system; trust sexual and reproductive health, 11; and NGOs, 26, 100, 128, 165; violation of right to, 21. See also Beijing Conference; Cairo Conference; MacArthur Foundation; parteras sexual and reproductive rights. See sexual and reproductive health S IC A LIDA D, 83, 89

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228 Index S NT S S . See National Union of Social Security Workers social policy regime. See Latin American social policy social security system, 16, 55–9; and corporatism, 55–7; funding compared to public health care system, 68. See also IMSS; ISSSTE “social state.” See “dual regime” S P S S . See Seguro Popular SSA. See Ministry of Health, federal structural adjustment, 17, 24, 30, 58, 62–4, 88, 112–22; and health care spending, 58, 62. See also debt crisis; neoliberalism Task Force for the Reduction of Maternal Mortality, 41 Tenejapa Red Social, 129–38 Tilly, Charles, 11–12, 91, 116, 118, 144 transport (to emergency obstetric care), 22, 102–5, 116, 124, 132– 3. See also Arranque Parejo en la Vida; Casa de Salud de la Mujer Indígena; parteras; Tenejapa Red Social; trust networks trust: and failure to sanction negligence, 107; and health care system financing mechanisms, 54; and health care system functioning, 11–15; and physicians’ misregistration of death, 4. See also generalized trust; interpersonal trust

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trust networks, 99, 111, 116–18; definition of, 11–12; integration with the State, 12; and NGOs, 23, 107–9, 118–19. See also generalized trust; health care system; interpersonal trust; parteras; Seguro Popular; Tilly, Charles; trust Ucizoni, 144, 146, 148, 150–1, 155, 167 U NIC EF, 46, 64 universal social policies, 7, 14, 18–20 Uribe Zuñiga, Patricia, 42 user fees, 55, 65–6, 81, 88, 96–7, 101, 114–15, 156, 159, 162, 181n1; and decentralization of health care system, 63, 97; and pasantes, 97 Vida Mejor, 118, 125–6. See also Chiapas; Seguro Popular war on drugs, 124 welfare state. See Latin American social policy World Bank, 42, 62, 64, 66 World Health Organization (WHO), 9, 42, 79 Zapatista Army of National Liberation. See ELZ N Zedillo, Ernesto, 58, 66

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