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As the mother of three children under the age of 12, Raquel Tello faces the difficulty of providing healthy meals on a daily basis to her family in Huallhua, a tiny farming community in Peru's Andes Mountains. Although child malnutrition and anemia rates have generally dropped  in Peru over the past half-dozen years, they remain stubbornly high in the southern Andes.

A program operated by the Lima-based non-profit Chirapaq (Centre for Indigenous Cultures of Peru), helps families like Tello's combat child malnutrition by increasing the use of traditional foods. Tello and her neighbours participated in the program and learned how to prepare a more varied, balanced diet using traditional or local Andean crops such as quinoa, wheat, beans, and tubers. “I used to just make soup with those foods, but I learned to make main courses, too,” she says.

In Peru and other Latin American countries, health authorities are committed to implementing intercultural health programs as a means to eliminate the health differences between indigenous peoples and the rest of the population. IDRC-supported researchers are studying Chirapaq and other initiatives to understand the implementation challenges facing these programs. Learning from good practices and addressing the factors that hinder implementation, including social inequity, is essential to their success.

Community members in San Juan de Chito
Community members in San Juan de Chito, Ayacucho, learn how to use traditional crops to prepare a more varied and balanced diet for their families.

Nutrition and cultural identity

Chirapaq works to improve the health of Andean families and reinforce their cultural identity by increasing food security, said Newton Mori, who heads the indigenous organization’s Advocacy, Culture, and Policy Program.

Government health centres provide regular checkups and nutritional supplements for these families’ children, but mothers rarely  take advantage of them. Some avoid health centres because the staff do not speak Quechua, the local language. Others skip the supplements, fearing side effects or criticizing the unpleasant taste.

Chirapaq has successfully promoted and increased the consumption of traditional crops for better nutrition. But their impact on child malnutrition and healthy eating habits was muted by factors beyond their control, underscoring the need for policies to ensure the gains are not lost, said medical anthropologist Carmen Yon, the researcher who coordinated the studies carried out by the Instituto de Estudios Peruanos (IEP). Her study found that good nutrition goes beyond diet and depends on socio-economic factors such as good living conditions, safe water, and health centres where staff are sensitive to cultural issues and speak the local language.

Tello explained that in her village of about 180 families, the nearest spring is just a trickle. It can take hours to fill a bucket, making it difficult to collect enough water to ensure good hygiene and keep vegetables from shriveling in the dry mountain air. Other nutrition-related tasks, such as raising small animals for protein, add work to the women's already long days of tending to children, home, and crops.

Training in intercultural health

Part of the IDRC-supported effort, Yon’s assessment also included a training program in intercultural approaches for indigenous nurse technicians working in remote Amazonian villages. Led by AIDESEP, an indigenous umbrella organization, the training program aims to bridge the gap between "Western-style" medicine and traditional practices in government-provided health services.

The curriculum includes the study of plant-based and indigenous medicines, which form a vital part of Amazonian culture, as well as indigenous practices for delivering babies, caring for newborns, and treating illnesses. The training also emphasized respect for indigenous medical knowledge and practices; dialogue with the community and its leaders; mutual understanding between indigenous and conventional health care practitioners; and the ability to speak, read, and write the local language.

In villages where intercultural nurse practitioners were assigned, the relationship between health centres and local residents improved and trust in health services increased, the IEP study found.

Practitioners who reach out and understand

Health centre staff and users in Churcampa, Huancavelica
Health centre staff and users in Churcampa, Huancavelica, try out the vertical birthing method commonly used by Amazonian and Andean indigenous peoples.

Ever Mucushua, a graduate from the AIDESEP program, said in an interview recorded by the IEP researchers that he was initially met with resistance, especially from pregnant women. “But after I explained that I was trained in intercultural health, spoke their language, and was just another member of the community, that solved the problem.”

The villagers that IEP surveyed said the intercultural nurse technicians listened to them talk about their needs, fears, and reasons for distrust; provided better explanations; understood them; and respected their knowledge and culture. The nurse technicians also served as intermediaries with colleagues who lacked intercultural training.

Gerardo Tukup, who was also trained in the AIDESEP program, adapted his health centre’s birthing room to accommodate the traditional vertical delivery position. He also worked closely with traditional midwives and community health promoters to increase the number of births attended by health personnel in his jurisdiction. These measures can improve the safety of deliveries by reducing the risk of complications for both mother and newborn.

But the study found that the AIDESEP program could not compensate for the shortcomings of a system where cultural sensitivity is a value stated in its policies, but missing from the fundamental design. The lack of incentives for intercultural health illustrates this disconnect. Turnover is high in Amazonian health posts that are remote and poorly equipped. In addition, the health system uses results-based performance evaluations that only measure services offered to insured patients. Uninsured indigenous patients who received care that may have included intercultural approaches are omitted from the health system’s calculations for funding renewal, the IEP study reported.

Making intercultural health policies work

Gerardo Tukup, an indigenous nurse technician from the Wampis community
Gerardo Tukup, an indigenous nurse technician from the Wampis community, presents their demands and proposal to Peruvian ministry officials.

Yon and her team are ensuring that the study’s findings and recommendations for improvements reach health authorities. As part of their advocacy efforts, they held a national meeting where indigenous nurse technicians shared their experiences, achievements, and difficulties with health ministry officials.

Decision-makers are beginning to listen to their message. In the Amazonas region, an ordinance issued in June 2016 added intercultural training and knowledge of indigenous language to the evaluation criteria in the recruitment of healthcare personnel in the region. As well, the Amazonas Regional Education Office agreed to recognize intercultural healthcare as a specialty and to issue certificates. Official recognition makes the program more valuable to the participants — and makes the intercultural nurse technicians more valuable to the health system, said Nery Zapata, a member of AIDESEP's national leadership board.

“Intercultural health means that conventional medicine and indigenous medicine must go hand in hand,” said Zapata. “That concept and practice must be effectively incorporated into national health policies.”

Thanks to assessments like this one, evidence is guiding efforts to integrate intercultural practices and approaches into Peru’s health system, and helping to address the bottlenecks that keep people from using these vital services.

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Top image: Daniel Bachhuber / Flickr