Intercultural health: what we overlook in health care for indigenous peoples. Reflections from Peru.
By MSc MPH Fiorella Farje
The health of indigenous peoples has been the subject of research and global concern for decades with additional attention in recent years. Evidence of health inequalities between indigenous people and non-indigenous people is abundant and despite the efforts of governments to address them, cultural barriers continue to limit indigenous peoples’ access to health services.
Disciplines such as medical anthropology and sociology have focused intensively on trying to understand the health care preferences of indigenous groups, gaining valuable insights into traditional and ancestral practices. This knowledge has contributed to a better understanding of the importance of culturally inclusive and respectful services. However, there is something that has escaped the attention of researchers: the education and training of health professionals in interculturality. In this short article, we will reflect on intercultural competence and its indispensable (yet overlooked) role in addressing indigenous health inequalities.
There are approximately 476.6 million indigenous people in the world, 46.4% of whom live in lower-middle income countries, and 11.5% in Latin America and the Caribbean. Globally, 18.2% of the indigenous population lives in poverty (less than US$1.90 per day), compared to 6.8% of non-indigenous people (1). In Latin America, the population belonging to the indigenous groups is around 45 million and comprises more than 800 ethnic groups (2). Despite representing about 10% of the population and 40% of the rural population of the region, they have been marginalized and are highly vulnerable in terms of health, human rights, and social and economic equity (2). They present a disproportionately higher incidence of poverty and extreme poverty, illiteracy and unemployment, and poor health indicators compared to the non-indigenous population (2). Barriers to access to health care for the indigenous population are many, including but not limited to: differences in language, lack of understanding of their practices and costumes and illiteracy, followed by financial limitations to pay for the services, preventing access even if the health services are available (3).
Since the 1990s, most countries in Latin America have elaborate policies, strategies, plans and interventions to incorporate an intercultural approach in the health system and guarantee intercultural health care and services and provide medical staff with intercultural competencies (3). Considering the cultural asymmetry between indigenous and non-indigenous, the intercultural approach has implied reconceptualising the practices of “the other” with a focus on respect and non-discrimination. The challenge of this approach is to achieve a system with an equitable and respectful dynamic between cultures (4), something that would seem achievable, but which has represented a profound problem for decades in the countries of the region.
Cross et al. (1989) define cultural competence as “the set of congruent behaviours, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations” (5). The intercultural approach and competency in the medical staff are especially relevant in Peru where indigenous peoples represent 19.2% of the total population, organized into 55 indigenous or native populations, of which 51 are from the Amazon and 4 from the Andes. Although the government recognized that one of the key areas in which the intercultural approach should be incorporated is in human resources in health, “interculturality” is still a concept under construction (6). Due to the lack of guidance and the complexity of this concept, there is evident confusion among health professionals and health authorities. Available international literature on the incorporation of cultural competence in health workforce education is skewed towards high-income countries like the United States, Canada, Australia, or New Zealand (7). The experiences in these countries provide evidence that the incorporation of cultural competencies has had a positive impact on the confidence of health professionals to provide health services to indigenous populations and improve their attitude and awareness regarding indigenous people’s health problems and disparities. It also led to a more open attitude, increased awareness, better sensitization, and preparedness to face the challenges of working with these populations, as well as improved skills to establish more horizontal relationships with the service users.
In Peru, it has been identified that intercultural competence is not an integrated component of the basic education and training of health professionals (8). In several Peruvian universities, likely in many Latin American universities as well, there are elective courses (mainly taught in the social sciences) in which the intercultural approach to health is taught. However, this component is not systematically integrated into the training of future health professionals. A review of policies and regulatory guidelines suggests that the efforts made by the Peruvian government have focused on the re-valorisation of traditional medicine and the improvement of mainly intercultural maternal health services, for example, through maternal waiting houses (9). In that sense, and despite the significant indigenous population in Peru, health policies do not focus on the production of human resources with intercultural competencies, nor on the development of materials or infrastructure that would allow for the development of culturally sensitive health personnel.
Finally, another aspect that contributes to the poor training of health workers in interculturality is the lack of integration of the indigenous workforce into the health system. Within the international context, it has been shown that indigenous staff members could increase adherence and improve the health outcomes of indigenous patients, for instance, in cancer treatment (10). This improvement has been made possible through a strong intervention in health facilities, strengthening the leadership of indigenous health workers, creating an Indigenous Health Unit to ensure that Indigenous staff are adequately supported, multidisciplinary team inclusion, and a culture of respect among others (10). In Peru, on the other hand, the only programme identified for indigenous health professionals is a training programme for nurses implemented by AIDESEP. As the only programme, it faces countless difficulties, many of them linked to the hermeticism of facilities and staff to incorporate alternative approaches.
For instance, once an AIDESEP-trained nurse is working in a health centre, he/she has difficulties in proposing and implementing what he/she has learned due to resistance from non-indigenous health staff who are not sensitised to the approach. The medical hierarchy also limits their role as intercultural agents, as nurses are one of the least empowered roles to implement changes in a health facility. This makes it difficult to incorporate mechanisms to offer a service that is pertinent to the needs and customs of indigenous people. As the literature reveals, this seems unlikely to happen without innovative policies and strategies to support and integrate indigenous staff into the health system workforce.
When thinking about indigenous health and inequities, we must not only consider which practices and services are culturally relevant but rather more systematically questioning:
- how education integrates intercultural competencies into the training of health workers and medical staff;
- how the health system integrates and implements clear guidelines on how these competencies should be put into practice; and finally,
- how the indigenous health workforce is integrated into the health care system.
Interculturality is often used in a utilitarian way to achieve health indicator targets, but this will not contribute to reducing inequalities if it is not organically integrated into the country’s education and health care system. The challenge ahead of us is still huge.
- International Labor Organization. Aplicación del Convenio sobre pueblos indígenas y tribales núm. 169 de la OIT: Hacia un futuro inclusivo, sostenible y justo [Internet]. Geneva, Switzerland; 2019. Available from: https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_735627.pdf
- CEPAL. Los pueblos índigenas en America Latina. Avances en el último decenio y retos pendientes para la garantía de sus derechos [Internet]. Vol. 1, Naciones unidas. 2014. Available from: http://repositorio.cepal.org/bitstream/handle/11362/37050/S1420783_es.pdf?sequence=4&isAllowed=y
- United Nations. The State of the World’s Indigenous People. Indigenous peoples’ access to health services. [Internet]. 2015. 190 p. Available from: https://www.un.org/esa/socdev/unpfii/documents/2016/Docs-updates/SOWIP_Health.pdf
- Pan American Health Organization. La salud de los pueblos indígenas de las Américas: conceptos, estrategias, prácticas y desafíos [Internet]. 2009. Available from: https://www.paho.org/hq/dmdocuments/2009/53-SPI-conceptos-estrategias.PDF.pdf
- Cross T, Bazron B, Dennis K, Isaacs M. Towards a Culturally Competent System of Care [Internet]. Washington D.C.: National Institute of Mental Health,Child and Adolescent Service System Program (CASSP), Georgetown University Child Development Center; 1989. Available from: http://files.eric.ed.gov/fulltext/ED330171.pdf
- SERVINDI. Interculturalidad: Desafío y proceso en construcción [Internet]. LIma, Perú; 2005. 122 p. Available from: https://indigenasdelperu.files.wordpress.com/2015/09/interculturalidad-proceso-construccion.pdf
- Clifford A, McCalman J, Bainbridge R, Tsey K. Interventions to improve cultural competencyin health care for Indigenous peoples of Australia,New Zealand, Canada and the USA: a systematicreview. Int J Qual Heal Care. 2015;27:89–98.
- Salaverry O. Interculturalidad en salud. Rev Peru Med Exp Salud Publica. 2010;27(1):80–93.
- Farje F. Human resources for health with intercultural competency for the provision of health services to indigenous population in Peru. KIT Royal Tropical Institute and VU Vrije Universiteit Amsterdam; 2020.
- Taylor E V., Lyford M, Parsons L, Mason T, Sabesan S, Thompson SC. “We’re very much part of the team here”: A culture of respect for Indigenous health workforce transforms Indigenous health care. Baysari MT, editor. PLoS One [Internet]. 2020 Sep 22 [cited 2022 Aug 17];15(9):e0239207. Available from: https://dx.plos.org/10.1371/journal.pone.0239207
 Interethnic Association for the Development of the Peruvian Rainforest (AIDESEP)
About the author
UNDP Peru, SGP Peru/Maria Paz González – Link