Torri. Multicultural Social Policy and Communityparticipation in Health - New Opportunities Andchallenges For Indigenous People PDF

INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT
Int J Health Plann Mgmt 2012; 27: e18–e40.

Published online 12 August 2011 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/hpm.1094
Multicultural social policy and community

participation in health: new opportunities and
challenges for indigenous people
Maria Costanza Torri*
Social Sciences, University of Toronto, Toronto, Canada
SUMMARY
Community participation in local health has assumed a central role in the reforms of public
healthcare, being increasingly associated with the issue of decentralization of the health system.
The aim of this paper is to raise questions regarding the structural approaches to multicultural
social policy in Chile and to analyze the results of its implementation. The article analyzes the case
study of Makewe Hospital, one of the pioneering experiences of intercultural health initiative in
Chile. The Makewe Hospital, which involves the indigenous community of the Mapuche,
provides interesting insights to understand the dynamics of multicultural social policy and
presents an example of a successful initiative that has succeeded in involving local communities in
multicultural health policy. This case study discusses the effectiveness of grassroots participation
in multicultural healthcare provision and presents the main strengths and challenges for the
replicability of this experience in other settings. Copyright © 2011 John Wiley & Sons, Ltd.
KEY WORDS: health; community participation; intercultural health; indigenous people
INTRODUCTION
The idea of community participation in local health systems has been around for
decades and is one of the most important issues of public healthcare reform.1 The
support by almost every Latin American country for community participation in
* Correspondence to: M. C. Torri, Social Sciences, University of Toronto, 1265 Military Trail, Toronto,
Canada. E‐mail: mctorri@yahoo.it
1
Even though community participation in local health systems became more popular with neoliberalism, its
history started with the Declaration of Alma‐Ata of 1978, which was an attempt to develop an action strategy
for the development of a comprehensive system of primary healthcare in all countries, with priority given to the
most needy population groups. This was formulated by leading world health organizations such as the Pan
American Health Organization (PAHO) and the World Health Organization (WHO). In fact, the Alma‐Ata
declaration was a result of the realization that the main problem of health in recent decades was not a general
supply of healthcare but its unequal distribution and the exclusion of the poor, especially in nondeveloped
countries (INE, 2005). Therefore, the Alma‐Ata declaration’s central organizing principle was a low‐cost
strategy utilizing paraprofessional health workers to administer preventive and simple curative measures in the
countryside. With this approach, leading health organizations throughout the world have sought to extend
inexpensive health coverage to rural areas, to promote community participation in health and to achieve no less
ambitious a goal than “health for all by the year 2000” (Walsh, 2002).
Copyright © 2011 John Wiley & Sons, Ltd.

SOCIAL POLICY AND COMMUNITY PARTICIPATION e19
primary healthcare derives from both political and economic reasons. During the
past decade, most Latin American countries have experienced economic crisis and
consequent economic adjustment measures,2 which carried severe repercussions for
the health sector.
The health sector in many countries of Latin America faces severe governmental
budget constraints, whereas population growth and deteriorating economic and
social conditions tend to increase the need for social services, including health
services (Triandis and Trafimow, 2001; Walsh, 2002).
At the same time, Latin American states politically faced strong pressure from below
for a more democratic administration of the public sector, which was perceived to suffer
low morale, absenteeism and little interaction between workers and users (van
Wieringen et al., 2002). As a result, democratization in most Latin American countries
in the 1990s created a favorable environment for a more participatory administration of
public health in order to make the public sector more transparent and open.
Chile is an interesting case in the issue of decentralization in health services
because of its long history of the centralist state (Angell et al., 2001), which would
bring inevitable challenges for the state to reduce its own power and control over
social policy. Although the Chilean state is the main actor of reform in social
programs and intends to maintain its centrist control over social sector, the policy of
decentralization in health sector has mainly relied on non‐governmental organiza-
tions or civil organizations (Weinstein, 1997; Johnson et al., 2004). Especially, the
intercultural program in health contains strong emphasis of participation from
indigenous communities as its key element. The inequalities in the health sector are
remarkable when we look at the health situation of indigenous peoples. Many
available but incomplete epidemiological data show that municipalities with the
largest concentrations of indigenous populations have more serious health indicators
than the rest of the country (PAHO, 1999; Hall and Patrinos, 2005).
This paper raises some questions regarding the structural approaches to multicultural
social policy due to increasingly diverse and mixed reactions and results from
multicultural social policies in Chile. The existing literature on multicultural health
policy interprets the policy as a mere health policy reform. This article affirms that
multicultural health policy is complex and should involve the improvement of social
service delivery to citizens and the expansion of multicultural citizenship.
The case study presented in this paper is Makewe Hospital, one of the first examples
of intercultural health initiative in Chile involving the indigenous community of the
Mapuche. The Makewe Hospital is managed by the Mapuche and supported by strong
community participation and minimal intervention from the state. Looking at the
procedure of the formation of the program and the development of specific community
2
Structural adjustment programs of the 1980s affected the health sector in two aspects. First, those
programs reduced household income, particularly of the poorer groups in the population, eliminating
direct and/or indirect subsidies from the state. The decrease of household income brought serious
problems because people, particularly those at the lowest income level, experienced deterioration in their
diets and nutritional status and increased morbidity risk. Second, economic adjustment measures reduced
the health services provided by the government (Hall and Patrinos, 2005). Therefore, the emphasis given
by international health agencies on inexpensive healthcare alternatives through community participation
had a ready audience in the region.
Copyright © 2011 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2012; 27: e18–e40.
DOI: 10.1002/hpm
e20 M. C. TORRI
participation in the local health system, this case enables us to understand the dynamics
of multicultural social policy when indigenous communities succeeded in mobilizing
strong participation from the grassroots. Exploring this case also elucidates how effec-
tive the initiatives from grassroots levels are to participate in social service provision and
what made this program successful and in what sense it is replicable or not.
The IX Region, where the Makewe Hospital is located, provides an interesting
site for this investigation. The region has the poorest health situation in Chile and
the largest Mapuche population. Of the total population of 867 873 people, 203 950
are indigenous—mostly Mapuche, representing 23.5% of the total population of the
region. The region has a demographic concentration of indigenous population, and
this population is poorer compared with the non‐Mapuche population (Laveist and
Nuru‐Jeter, 2002; INE, 2005).
MULTICULTURALISM AND SOCIAL POLICY IN HEALTH
The urgent need for transformation of the health sector to make it more effective and
accessible and the strong political demand for democratization of the social sector
incorporating needs from historically marginalized populations gave birth to
different social policy programs under neoliberalism. The intercultural health
program is one of these social policy programs targeting indigenous population
in Chile.
These programs seek to recognize indigenous people’s need in the health sector,
redefining the state as democratic, humanitarian and pro‐cultural rights (Montenegro
and Stephens, 2006). In order to promote a better health service for the indigenous
peoples, the Chilean health system introduced the Bilingual Information Services to
serve the Mapuche population in the IX Region and the Patient Care Services
designed to greet and accompany patients and their families from admission to
discharge at the hospital. From the perspective of the state, a bilingual office within
hospitals, hiring indigenous health workers and allowing some input from
indigenous communities in hospital administration was expected to improve the
accessibility of the service and reduce the inequality between indigenous population
and non‐indigenous population. This becomes the key aspect of the intercultural
health program and remains the key target for such multicultural social policy. The
focus of the state on multicultural social policy remains the expansion of social
rights of indigenous population rather than the promotion of their cultural rights
(Morgan, 2001).
At the same time, by building bilingual offices in public clinics and hospitals and
hiring bilingual workers, the state seeks to increase the accessibility of health service
for indigenous people. Rather than expanding the public health system, which is
already stretched because of budget constraints, the state attempts to utilize local
knowledge and local health professionals to reach out to indigenous populations.
Thus, the intercultural health programs in Chile emerged as a solution to the chronic
problems of Chilean healthcare system dealing with the long marginalized
indigenous population as well as the urgent need for expanding citizenship to
indigenous peoples to democratize/legitimize the state.
DOI: 10.1002/hpm
The meaning of participation for indigenous communities and their state is
different. On the one hand, for the state, community participation is not only for
intercultural health program but also for general reform on health sector. Individual
responsibility becomes a crucial element of the primary care (Paley, 2001; O’Neil
et al., 2006), and partial privatization of health insurance has been maintained since
1989. In these efforts, the state emphasizes the responsibility of communities to take
care of their own health issues with reduced intervention from the state. On the other
hand, indigenous communities cautiously seek changes in community participation
to transform it into democratic governance for indigenous communities, that is,
autonomy, especially in the local level (Birn et al. 2000; Bossert et al. 2000).
The growing demand from the grassroots on political recognition of “culturally
differentiated groups” as well as the apparent willingness to grant the political
recognition of these groups are significant—if not the most significant—political as
well as social issues. This issue can be translated into how to expand citizenship to
reach multicultural citizenship (Kymlicka, 1995) or how to modify liberal democracy
in order to combine its universalistic approach with the pluralistic reality of the value
(Taylor, 1994; O’Neil et al., 2006).
As Habermas (1994) points out, multiculturalism means the struggle of oppressed
ethnic and cultural minorities, and it is certainly not a uniform phenomenon.
Different ethnic groups have different goals that are derived from different historical
and political conditions. Multiculturalism draws either from the endogenous
minorities who become aware of their identity and demand recognition or from the
new minorities who are a direct result from migrations in this globalized world
(Habermas, 1994: 118, Paley, 2001).
The literature on community participation shows that the link between
participation and improvement of social service delivery can be incomprehensible
if we do not approach the program’s political implication: the change of the
relationship between the state and the civil society in general (Gilbert, 1987;
Casebeer et al. 2000; Cornwall, 2004).
Although Gilbert (1987) generally agrees with the benefits of popular
participation, he believes that its achievements in practice have often been vastly
exaggerated and its outcomes have often damaged the interests of the weaker groups
in society, mainly because its advocates have often played down the political
dimension of community participation.
In Latin American societies, there are many examples where governments have
used community participation to maintain existing power relations (Morgan, 1993).
Morgan (1993) points out that the benefits to be derived from participation depend
primarily on the political interests involved and concludes that participation can be
very dangerous when placed in wrong hands.
For the state, it appears that the main aim of community participation programs is
less about improving conditions for the poor or to modifying forms of decision
making than maintaining existing power relations in society and ensuring the silence
of the poor. Community participation is often used by governments as a means of
legitimizing the political system and as a form of social control. The level of
commitment by many governments to community participation has often been
dubious or extremely limited. Formal channels of community participation have not
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e22 M. C. TORRI
always generated major benefits for local communities (Casebeer et al. 2000; Hardy
et al., 2000).
Morgan (1993) elucidates the fact that often community participation programs
start as an attempt to reform the social service sector but end up serving the state in
terms of reducing political and economic costs of neoliberalism by offering “free”
labor from the civil society and co‐opting the grassroots into the state. Participation
can be crucial to determine the success of a social policy program offering an
opportunity to increase participation or to sensitize the state to demands from citizens.
However, it is not clear from the existing literature how the state and the civil society
actually end up creating a feasible atmosphere to boost possibly the positive aspects
of the community participation program without falling into the realm of being a
“typical” neoliberal policy: transferring the burden to “civil society” without
delegating any real power (Dresser, 1991; PAHO, 1998).
Very often, it is the most visible and vocal, wealthier, more articulated and
educated groups that are allowed to be partners in development without serious and
ongoing attempts to identify less obvious partners. Gaventa (2004) has warned
against the practice of many development agencies to engage exclusively with
particular groups as community representatives, whereas Cooke and Kothari (2001)
also mentioned that poor community penetration by non‐governmental organization
and other development organizations is one of the main impediments to community
participation. Because many community organizations are not democratically
elected, the involvement of local leaders often represents the voice of a group of
self‐appointed people and may not accurately reflect the views and the perspectives
of the broader community. This easily runs the risk of the project being co‐opted by
certain groups or interests, leaving development workers with a feeling that the
beneficiaries consulted were the wrong ones.
The literature on multiculturalism also tends to emphasize the pessimistic
outcomes of multicultural social policy (Taylor, 2000; Cooke and Kothari, 2001;
Daly, 2003). It offers detailed discussion of how multiculturalism has emerged as
possible results from democratization under neoliberalism. Even though there is
ongoing debate on whether democratization derives from elitist attempt to legitimize
their power or from constant struggle of indigenous peoples in the region, most
scholars tend to agree with the fact that the democratization couples with
neoliberalism, and this somewhat uneasy combination ultimately poses the most
serious constraints against full guarantee of multicultural citizenship rights. In other
words, because of the very nature of neoliberalism that emphasizes individual and
market‐oriented solutions to social problems, the goals of multiculturalism, such as
to expand collective rights to one’s own culture and identity, becomes significantly
limited in policy implementation (Gustafson, 2002; Hale 2002; Postero 2004).
Therefore, most scholars of multiculturalism emphasize the possible danger of
multicultural social policy under neoliberalism as an attempt to co‐opt indigenous
movements allowing only “indios permitidos” (Hale 2003: 17) to join the state while
grossly ignoring more crucial and core aspects of multiculturalism.
As Roberts (2004) points out, new types of social policy promoted in Latin
America reduced the direct reliance on the state and increased more open space to
citizen participation. This new policy generates opportunities as well as limitations.
DOI: 10.1002/hpm
Roberts argues that the primary limitation is the reduction of the role of the central
government in redistribution and in ensuring equity. However, it also opens
opportunity because it is a social policy “that is potentially more attuned to local
needs and priorities and can build upon local capacities” (Roberts 2004: 422). The
issue is how to exploit these opportunities without falling into limitations of
multicultural social policy under neoliberalism.
Another major issue in intercultural health is how can a health system be both
universal (treat people as equals) and particular (respond to people’s different
needs)? The solution may, in part, lie in the participation of different groups in the
political processes of the health system. According to Taylor (1994), the political
process is often a better way to resolve issues than through the procedural or
legislative process (characteristic of bureaucracies), because in politics, compro-
mise, and hence flexibility, is possible if not essential (Parekh, 2000). The equity of
the political process is, then, determined by the degree to which citizens participate
in the process. For Taylor (1994) and Jayasuriya (1993), then, effective participation
is in itself the goal, and the task is to bring about the conditions by which all citizens
are able to participate in a meaningful way. For Jayasuriya, this becomes a revised
model of multiculturalism based on the notion of citizenship. He stated that
citizenship embodies notions of needs, rights, resources and opportunities, which are
articulated and achieved by individuals through their full participation in the
political, civil and social processes of society. According to Jayasuriya, new
directions in health should include the effective participation of ethnic minorities in
the processes of the health system and should not just be about improving language
services. Through participation, individuals and groups have greater opportunity to
place their own particular aspirations and needs on the public agenda (Cohen, 1999;
Anderson, 2000).
Although there is an obvious logic in the notion that citizenship rights are
expressed through involvement in the conflict and negotiation over resources, all
groups do not enter the debate in a way that makes them equally able to argue that
their particular needs should be met. Rather, the domination of the values of the
most powerful group(s) usually means that minority groups are expected to abandon
their own particular ways in order to blend into the ways of the dominant group.
Herein lies a problem with the concept of citizenship if it is applied with no regard
for the power differentials between groups.
Allen and Cars (2001) point out that because most modern Western democracies are
culturally heterogeneous, it is reasonable to conclude that citizenship is variously
experienced, dependent on the degree to which a person’s identity is subsumed by the
dominant national identity. For example, in a bureaucratic system, where processes
are standardized, the particularistic characteristics of people become irrelevant (as
discussed previously). Although this standardization ensures that all people are treated
the same, regardless of their age, gender or ethnicity, those whose values are closer to
the standard are, by default, better served. Furthermore, the standard that is adopted is
most likely to be derived from the values of the dominant group, rather than some
“average” value of the combined groups (Hall, 1996). Hence, the result is assimilation,
where the culture of the dominant group is maintained, whereas members of minority
groups have to change and adopt the dominant group’s ways (Modood, 2000).
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Existing literature on multicultural social policy either narrowly focuses on one

aspect of such policy or overemphasizes the power of structure or the state. It
becomes evident that more research on communities and their role in participatory
forms of intercultural health is needed in order to understand the complexity of
multicultural social policy as well as the causes of its mixed results.
At this point, it is interesting to see how the lack of regulation of shamans
(machis) in Chile could be contrasted with a comparative example from Africa, in
order to see how the regulation of traditional health practitioners is being developed
in a country such as South Africa.
South Africa, on the contrary of several countries in Latin America, has made
important steps toward the inclusion of traditional care into the national healthcare
system by a traditional medicine directorate within the Department of Health, a
traditional medicine research institute, postgraduate education in herbal science and
a draft policy for the institutionalization of African traditional medicine, including a
national institute.
The South African Traditional Health Practitioners Act 1 defines traditional health
practice as the performance of a function, an activity, a process or a service based on
a traditional philosophy that uses indigenous African techniques and principles that
include traditional medicine or practice, including the physical or mental preparation
of an individual for puberty, adulthood, pregnancy, childbirth and death. Traditional
health practitioners who are registrable under this act include herbalists, traditional
surgeons who mainly do circumcisions and traditional birth attendants.
The purpose of the Traditional Health Practitioners Act is to establish the Interim
Traditional Health Practitioners Council of South Africa, to provide for the
registration, training and practices of traditional practitioners and to serve and
protect the interests of those who use these services (Peltzer and Henda, 2006). This
process still has a long way to go. Regulation is a key to professionalizing and
protecting the reputation of traditional health practice. However, there is no common
diagnostic nomenclature, therapeutic method or curriculum, and thus, attempts to
create accreditation have failed. Traditional healing is still unregulated because there
is no established accreditation procedure.
There has not been much enthusiasm in terms of integrating the two systems in a
manner that allows cross‐referral and joint care. Devenish (2005) notes that
“Although the Department supports a system of collaboration on Primary Health
Care and HIV and AIDS prevention and education, at present the Department does
not support referrals from the formal health system to traditional healers, principally
because of a lack of research and regulation around the dosage and efficacy of
traditional treatments,” but not much has followed to evaluate this role rigorously
for possible scale‐up.
Traditional medicine and allopathy remain fairly separate and parallel in South
Africa. Yet, there should be an increased cooperation between the two when
appropriate (Meissner, 2004; Peltzer et al., 2006).
In this respect, case studies such as the Makewe Hospital could provide
interesting insights in terms of integration and harmonization between different
health systems, which closely involve local communities both for Latin American
and African countries.
DOI: 10.1002/hpm
CASE STUDY
The rural Makewe Hospital is located in Makewe‐Pelale, in the municipalities of

Padre Las Casas and Freire, a historical Mapuche territory 25 km south of Temuco.
This territory includes 80 Mapuche communities with a population of approximately
10 000 inhabitants. The vast majority of the people living in these communities are
small‐scale farmers, with an average distribution of land in the area of about 1.5 ha
per capita.
Being located in the middle of Mapuche community, more than 90% of the
patients of Makewe Hospital are represented by indigenous people. The Makewe
Hospital provides a range of Western health services under the direction of a
Western‐trained Mapuche medical director. The services include full‐time physician
services that are supported by nurses and nurse auxiliaries, midwives, visiting
specialists, a dental clinic and a social work department. An intercultural health
worker is on staff, and patients are seen by a Mapuche staff member and a Western
physician to ensure that if patients have health needs that can only be met by
traditional medicine, they are referred appropriately.
The administration of the hospital belongs to the Indigenous Health Association
of Makewe‐Pelale (the Asociación Indígena de Salud Makewe‐Pelale: the
Indigenous Association), an indigenous organization consists of 35 member
communities, lonkos (community leaders) and machis (Mapuche shamans) of the
area. This association is accountable to a Council of Mapuche Community
Presidents from the surrounding Makewe region.
The Health Association of Makewe‐Pelale is a non‐profit corporation and as such
sells Western health services to the government.
In the hospital, there are 30 staff members in the hospital including two doctors,
one dentist, three midwives, one kinesiologist, six paramedical health workers, four
custodial workers, three secretaries, three cooks, three drivers and one assistant for
the dental service (PAHO, 2001). Also, this hospital has developed a special
connection with traditional health specialists such as machis, who are religious,
spiritual and medical authorities in Mapuche culture. These traditional Mapuche
health specialists participate in various events of the hospital as a symbol of
Mapuche culture and advise the Indigenous Association about how to formulate
intercultural healthcare. The hospital transfers to machis the patients whom doctors
believe need care from traditional Mapuche health specialists (PAHO, 2001).
Although linked to the work of the hospital, Mapuche medicine is not provided in
it, and machis and other healers are not paid by the association. The rationale is that
each medicine should be provided in its own context and that the machis are
validated and supported by their own community, not by the official entities like the
association or the government. Nonetheless, the Makewe hospital provides linkages
to the machis. For example, physicians work with the intercultural worker when
they see a patient to help determine if she or he suffers from a Mapuche (spiritual or
emotional) or winka illnesses (Western based, psychological). Patients who have
been diagnosed by either a Western physician or a machi have the choice of
selecting herbal medicine instead of Western medications or as a complement to
the latter.
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A third component of the intercultural initiative is the traditional clinic and

pharmacy (Farmacia Homeopática Herbolaria Makewelawen) in Temuco managed
by the Makewe Hospital Association. This pharmacy, for which there is no state
funding, operates entirely on a fee‐for‐service basis. Its clients are represented by
both Mapuche and non‐Mapuche populations. A formally trained pharmacist, who
subsequently learned Mapuche medicine, supervises the pharmacy in Temuco,
which also has a well‐equipped laboratory that produces medicines according to
standard formulas.
METHODOLOGY
The fieldwork has been conducted in Chile in 2008 between February and April in
the Makewe Hospital. The data were collected through formal individual interviews.
To complement the data collected in the interview process, we have also used
participatory observations, such as attending village organizations’ meetings,
observing how their members interacted with each other. Our ethnographic
approach is thus based on systematic observations, partly through participation and
partly through various types of conventional interviews.
Following the ethnography approach, our research has been conducted in a
naturalistic field setting. This permitted us to have access to multiple viewpoints in
the different stakeholders (Werner and Schoepfle, 1987; Gopal and Prasad, 2000;
Charmaz and Mitchell, 2001). The ethnography approach orients the research
toward a “thick description” (connotational significance of the findings) (Geertz,
1973; Gopal and Prasad, 2000). The research is based on a sample of 42 semi‐
structured and open‐ended interviews. These were conducted with Mapuche patients
(35), doctors (four) and nurses (three) in the Makewe Hospital. Four traditional
Mapuche’s healers (machis) have also been interviewed. Respondents were
selectively sampled based on their representativeness and willingness to participate.
First, the patients have been selected on the basis of parameters such as ethnic
belonging and gender. Second, in‐depth interviews have been made with the main
actors of each intercultural health programs, health officials from regional and
municipal governments in Temuco with which the Makewe hospital interact and
negotiate as well as Mapuche leaders in Makewe. Third, observations in the
hospitals and participant observations have also been conducted. The interaction and
the attitude between the health workers and the patients in the lobby, in the waiting
area as well as in doctor’s offices have been observed with permission from doctors.
In doing this ethnographic observation, particular attention has been paid to waiting
time and the attitude of patients toward patients and vice versa.
Several seminars on intercultural health programs in Makewe and various
community meetings and governmental workshops have been attended in Temuco.
The staff interviewed at the hospital were selected using a snowball technique.
Some of the hospital management staff who worked in the area were asked to point
us to some members of the medical and administrative staff whom we could
interview. Their suggestions were based on the active involvement of these persons
right from the outset of the initiatives organized by the Makewe Hospital and who,
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for this reason, were considered knowledgeable resources. Because the villagers to
interview were pointed out by the management staff at the hospital involved in the
study, we have extended the sample in order to reduce the risk of bias. Half the total
sample was matched with a sample of randomly selected patients and staff who were
taking part in this initiative of intercultural health. While selecting interviewees, we
tried to keep a balance between the socio‐economic variables deemed relevant (e.g.,
gender, economic backgrounds).
All interviews were semi‐structured or unstructured with open‐ended questions
divided on different themes. The interviews were held in Spanish, and most were
tape recorded and later transcribed. These in‐depth interviews focused on the
process of implementation of intercultural health at the hospital and its challenges,
on the different interpretations of the meaning of intercultural health. Part of the
interview also aimed at understanding the perceptions of Mapuche patients
regarding the health service available at the hospital and the mechanisms through
which the participation was taking place.
The participants in the research process were made aware of the purposes of the
research and how the information provided by them was to be used by the researchers.
Any participant was free to withdraw from the research at any time. In order to assure
data confidentiality, the names of the interviewees have been omitted or changed.
To analyze the interview transcripts, a content analysis has been used. The themes
that emerged from the data were grouped in categories such as different meanings
given to intercultural health, participation in the process of the management of the
hospital, implementation of intercultural health and related future challenges.
COMMUNITY PARTICIPATION IN MAKEWE HOSPITAL
One of the most notable characteristics of the Makewe Hospital is not only its
intercultural health program but also the strong participation of Mapuche
communities in the administration of the hospital through the Indigenous
Association. The Indigenous Association was formed in 1997 based on the
mobilization of the communities around the Makewe‐Pelale area. The Indigenous
Association took control of the hospital in 1999, as up to this date, the hospital was
administered by the local Anglican Church.
The Indigenous Association has developed various mechanisms to induce more
participation from communities. First of all, it has various committees to hear voices
from the communities. One of them is the Committee of the Wise (Comité de los
Sábios), which consists of lonkos of the communities. A lonko is usually an elderly
person who has legal and social authorities. The Committee of the Wise plays a
significant role in shaping the health model of the hospital and giving legitimacy to
the proposal of the Indigenous Association. The director of Makewe emphasized the
importance of the Committee of the Wise:
“I believe that lonkos are very important for our community. They know the
Mapuche culture very well. I always talk to them and ask their advice, especially
regarding the issues of intercultural health”.
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e28 M. C. TORRI
The Committee of the Wise meets whenever an important issue emerges. Often,
the officials of the Indigenous Association visit important lonkos in the area when
lonkos could not visit the hospital for a meeting. Also, Makewe organizes frequent
general meetings of all members of the communities. Those meetings are held
occasionally when the hospital needs support or inputs from the communities.
In addition to the Committee of the Wise and the general meetings, every last
Friday of the month, the officials of the association have a meeting at the hospital.
These members are usually representatives of communities in the area of Makewe‐
Pelale. Therefore, during the meeting, they deliver public opinions from the
communities about the services of the hospital. The officials are elected by 35
member communities of the Indigenous Association. Also, the officials of the
Indigenous Association, especially the director, regularly visit communities in the
area of Makewe‐Pelale to discuss the administration of the hospital.
Although direct participation of the members of communities in the administra-
tion is limited to occasions when the hospital needs strong support or input from the
community, however, the leaders of each member community are frequently invited
in various meetings and often asked to be a member of the governing body of the
association. The secretary of the association explained this web of participation.
“In order to be able to administer the hospital it was important to form an
indigenous health association. I was elected secretary but I started as a member …
We take good care to inform the other members of the communities of our
meetings and they can take part in the meetings too, so that they can express their
opinions and participate”.
The communities close to the hospital show a higher level of participation because
the proximity to the hospital meant greater accessibility to information. The officials of
the Indigenous Association also told me that it is hard for them to reach to communities
in the remote area because there is no good transportation system in the area. However,
the overall participation rate is still high. Thirty one per cent of households in the area of
Makewe‐Pelale said they had participated in community meetings that discussed
Makewe, whereas 59% of the households that live close to Makewe reported that they
have participated in the meeting where they discussed Makewe.
A method that the Indigenous Association uses to expand participation from
communities is constant monitoring of their service. Even though the members of
the communities have limited chances to directly participate in the administration of
the hospital, they have various channels to evaluate the services. Each community
that receives medical service in their community from the hospital evaluates the
service and passes it along to the association.
Because the Indigenous Association consists of community leaders, people also
feel free to contact the officials of the Indigenous Association directly. In the
interviews with the patients, various people stated that they would meet the
president of the hospital or the officials of the association if they have any complaint
or suggestions about the service. The staff members of the hospital also know that if
patients have any complaints, they would talk to the officials directly.
However, the fact that the Indigenous Association relies heavily on strong
community participation also poses significant threat to the sustainability of the
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program. Because the Indigenous Association cannot afford to lose the support of
communities, it is reluctant to increase the fee for the service despite the fact that it is
the only viable financial source that they have. Because the communities themselves
are underprivileged, they cannot offer any feasible economic support to the hospital.
Therefore, the state becomes the only source of stable financial support. On the one
hand, the state agrees with the Indigenous Association in terms of the importance of
autonomous administration of the hospital by communities. The state does not want
to give the impression of intervening constantly in the administration of a hospital,
which is supposed to be a hospital that belongs to the communities.
MEANING OF INTERCULTURAL HEALTH
The need for a culturally diverse hospital derives from the reality that the state has
limited resources to build new hospitals or clinics. Because of the problem of
absolute lack of hospitals and clinics in the rural areas, the issue became how to
make existing facilities more “accessible” to indigenous people in order to improve
the efficiency of facilities. The first answer was the elimination of any discrimination
against indigenous peoples.
Health workers should have some understanding and respect toward indigenous
culture. Also, the hospital structure and policy should be sensitive about indigenous
culture. That is why “official” intercultural programs have heavily focused on the
education of health workers about indigenous culture and on the installation of a
bilingual service center within the hospital. Elimination of discrimination is also a
priority of Mapuche communities. Institutionalized racism against the Mapuche in
education, in health and in labor markets attracted national attention because of the
growing conflicts between Mapuche communities and the state.
In addition, the intercultural health program seeks to combine medical knowledge
from various cultures. Many scholars argued that the combination of the two
medicines would enhance indigenous peoples’ health as well as non‐indigenous
population’s health by expanding options to treat illnesses (Citarella, 2000).
As Pablo, a Mapuche community leader, explained, intercultural health means
“Through this experience at the Makewe hospital we have shown that Mapuche
medicine can be as good as the one of Chileans. We have obliged of living in an
intercultural context since our childhood. It is the time now that Chileans learn to do
the same thing.” Because the Mapuche approaches the intercultural programs as a
way of reconciling the two worlds (Mapuche/Chilean), many Mapuche leaders
refused to consider governmental initiatives to use “bilingual” signs or hire
bilingual specialists (facilitators) in the hospital as an intercultural health program.
Given the political and cultural meanings of combining the two medicines, it is
not surprising that the strongest resistance against intercultural health programs
occurs in the Chilean mainstream medical community as well as in certain
indigenous communities.
To increase cultural sensitivity as well as the diversity of the service, the
Indigenous Association emphasizes the importance of changing the attitudes of
health workers toward Mapuche patients and Mapuche culture.
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e30 M. C. TORRI
The director of Makewe affirms, “Intercultural health does not just mean
combining two medical systems. It means respecting both cultures.”
Respect for Mapuche culture manifests itself in the administration of the hospital.
All the signs are written both in Mapudungun, the Mapuche language, as well as in
Spanish. The hospital follows religious holidays of Mapuche culture such as
We Tripantü (New Years Day for Mapuche) and organizes religious ceremonies
within the hospital. The hospital has a ruka, which is a traditional Mapuche house,
and uses it as a meeting place.
It also has a rewe,3 the most important symbol of Mapuche religion, in the front
yard. But more importantly, the Indigenous Association encourages the health
workers to acquire knowledge about Mapuche culture and especially about
Mapuche medicine.
The combination of Mapuche medical knowledge with the Western medical
knowledge in the hospital has been shaped by the interactions between strong
community participation and the relatively distanced yet supportive state.
Intercultural health programs aim to combine Western and non‐Western medical
knowledge. However, the combination of multiple medical knowledge is not
discussed as the main point of the intercultural program in governmental documents.
According to the Health Program of Indigenous People (el Programa de Salud de
Pueblos Indígena) of the Ministry of Health, the absence of discussion on how to
combine Western medicine with indigenous medicine stems from the state’s lack of
knowledge about indigenous medicine. The state simply cannot give guidelines to
combine those medicines because it does not know much about indigenous
medicine (INE, 2005).
Although legal status does not allow the practice of indigenous medicine within
the hospital, indigenous communities do not offer any clear solution about how to
combine Western medicines with their medical knowledge because there is no
consensus about how to combine Mapuche medical knowledge with Western
knowledge. Each community has a different tradition and practice with respect to
medical ceremonies and knowledge. As a result, the interpretation of medical
tradition varies from community to community. In the absence of guidelines by the
state as well as the lack of consensus among indigenous communities about how to
combine the two medicines, the way of combining both medicines depends heavily
on who decides and how it is decided.
However, despite the fact that it is “illegal” to have a machi within the healthcare
system, the participation of machis in healthcare is clear in Makewe. There are
11 machis in the area of Makewe‐Pelale, and six of them have strong ties with
Makewe. Doctors often tell patients to consult with a machi. If necessary, doctors do
not hesitate to transfer a patient to a machi, whereas machis of the area constantly
transfer their patients to Makewe if they find the need for Western medicine for
patients. Once the transfer happens, doctors and machis visit each other and discuss
3
The rewe (or rehue) is a tree trunk set in the ground and surrounded by canes of colihue located in row
and adorned with white, blue or yellow flags and branches of trees. At its summit, it has a representation
of a human face with seven steps rising up from the earth to this summit. It symbolizes the connection
with the cosmos. This rehue is a symbol of great importance that is used in important celebrations like the
Machitun, Guillatun, We Tripantu (Mapuche New Year) and others.
DOI: 10.1002/hpm
the patient. The hospital offers transportation for patients who wish to see a machi
(PAHO, 2001). Despite the strong participation of machis in the administration of
the hospital as well as in its actual healthcare, Makewe does not violate any health
code nor has it upset any community in the area.
For those who imagine an intercultural hospital as a hospital where you could see
machis and doctors together within a doctor’s office, this arrangement might sound
strange. However, communities around the hospital welcomed the decision not to
place machis or herbalists in the hospital itself. According to Mapuche culture, the
spiritual power of machis comes from their land and is limited to their territory. If
they leave the land, they lose the spiritual power. Therefore, they need to see
patients in their territory where they can receive the power from the land.
The interviews show how the concept of participation is often linked to the
concept of self‐determination or autonomy. This implies that people in local
communities can understand best of all, the proper solution to the problems in the
area, thus calling for local participation. The director at the Makewe Hospital has
coined the term internal autonomy as representing the hospital’s position. This
implies local development in terms of “recuperation of cultural control” and
“strengthening of the organization for territorial autonomy”.
The initiative in the Makewe Hospital has opened a field of opportunities that the
Mapuche make use of and define according to their own needs. Using the framework of
the intercultural health system, they have created elaborated locally based projects
offering both Mapuche and Western medicines in the area. Within these projects, the
Mapuche strive for re‐valorization of their medicine as an acknowledged medical
system. Simultaneously, they, as a people, express their culturally defined needs in a
broader socio‐political perspective, stressing a wider holistic view within these projects.
Within these projects, the Mapuche struggle for the re‐instatement of their
medicine as a recognized medical system. Simultaneously, they express their
culturally defined needs in a broader socio‐political perspective, stressing a wider
holistic view within these projects.
The concept of intercultural heath is large and vague, which makes it open to
multiple interpretations and degrees of control from various sectors of society
(Sleath and Rubin, 2002; Sleath et al., 2003). Therefore, the use of these terms can
provide an illusion of agreement despite radically different interpretations and
practices (Morgan, 1993; Paley, 2001; Triandis and Trafimow, 2001).
In terms of local governance within the Indigenous Association, it is very
important, however, to ensure that community participation represents the wider
community, not the small groups within the community that might have a vested
interest in continuing traditional practices. One can question up to which point the
Mapuche Association and the Committee of the Wise are truly representative of the
point of view of the whole Mapuche community. The Mapuche Association is elected
in the community and attempts to represent its members by taking into account the age
and gender, but the Committee of the Wise is mainly composed of elderly people.
“Community participation” and “democracy” are cases in point (Morgan, 1993;
Paley, 2001; van Wieringen et al., 2002). Community participation initiatives
provide avenues for real political action, but their success depends on both the
capacity of the community to ensure democratically functioning mechanisms in its
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e32 M. C. TORRI
organizations and the openness of governments and states to accept the political
demands and consequences that these initiatives engender.
PERCEPTIONS OF MAPUCHE PATIENTS OF THE HEALTH SERVICE IN

THE HOSPITAL
In the interviews concerning their satisfaction with Makewe, patients showed a high
level of positive opinions about the hospital. One of the questions explored in the
interviews was why people used the service from Makewe. Because the hospital had
been a private hospital up until 2004, the residents of the community can choose one
of various health institutions available in the area. For example, a resident of the
municipality of Padre las Casas can choose between the Municipal Clinic of Padre
las Casas and Makewe. The majority of the interviewees, 28 out of 35 who use the
hospital, answered that they chose the hospital because of the high quality of its
service. Twelve households said they chose the hospital because of proximity. Four
households responded that they chose Makewe because of lower cost.
One of the reasons why people positively react to the service provided by the
hospital is that the hospital tackles not only the problem with social service delivery
but also the cultural problems inside the service delivery system. This point becomes
clear with the issue of the clarity of doctors’ explanation of the illness. When asked
how clear the explanation was provided by doctors about their health problems, 29
out of 35 households, users of the Makewe Hospital, answered that the explanation
the doctors gave to them was clear. Only two households answered that it was so‐so,
and one household answered that it was not clear. The perception that doctors’
explanation are clear stems from the fact that doctors try to understand better the
cultural aspects of the Mapuche. The director of technical team of Makewe could
speak fluent Mapudungun.
According to the director of the Health Service of Araucania, it is important to
focus intercultural programs on the education of health workers about indigenous
culture and on the installation of a bilingual service center within the hospital. This
concern is also linked with the reduction of social discrimination, which also
represents a priority for Mapuche communities. In order to foster cultural sensitivity
as well as diversity of services, the Indigenous Association highlights the
importance of changing the attitudes of health workers toward Mapuche patients
and culture. As the director of Makewe emphasize, “… Intercultural health is not
just about the combination of medicine. It is about respect for both cultures.”
The case study shows effectively that although there are different systems of
medical knowledge being anchored in considerably diverse cultural beliefs and
socio‐political arrangements, it is still possible to make a comparison between them.
Comparative studies of systems of medical knowledge disclose repeatedly and in
great detail that sickness is socially constructed (Fabrega, 1974; Kleinman et al., 1978).
In the popular everyday setting of the family and social nexus, sickness is best
conceived as symbolic or semantic networks in which the linguistic labels applied by
laymen loosely associate beliefs about cause and expectations about treatment to actual
illness experiences, “typical” social predicaments believed to predispose one to or result
DOI: 10.1002/hpm
from sickness and sanctioned patterns of healthcare‐seeking behavior (an extended
discussion of this subject is found in Good, 1977). These symbolic networks organize
illness experiences as therapeutic options in particular fields of meaning.
Overall, many patients stated that they feel “known” in this hospital because nurses
and doctors “know” them. This familiarity also facilitates communication between the
doctors and the patients. Again, we could see that the high level of satisfaction is
closely related to the feelings of the patients about the service. Makewe is an old
hospital with limited resources as well as staff. It is not by any means the best hospital
in the area. However, the patients give the highest marks to the service of the hospital
because of the fact that they feel comfortable and safe in the hospital. Makewe also
incorporated many innovative policies in the administration of the hospital. For
example, unlike the other hospitals in Chile that strictly restricts time for family to visit
hospitalized patients, Makewe encourages family members to come and stay with
their ill relatives. Some health workers expressed concern because letting family
members in the hospital at all times often impedes their work. But these workers did
not deny that it had been good for the patients.
CHALLENGES IN INTERCULTURAL HEALTH
Community participation in health projects is a complex and fragile process, and

there are many factors that might operate to diminish their success. The literature
emphasize that two of the most well‐known are the nature of actual communities
themselves and the realities of collective human participation.
Communities are very heterogeneous entities, not only in their demographic
composition but also with respect to their interests and concerns. This diversity can
have an important impact with regard to the community participation process. The
diversity of those groups, called communities, can also create problems for the
selection, representation and accountability of individuals.
Another set of problems arises when a minority group itself prefers not to be fully
engaged in the participatory process. This paradoxical finding has been reported by
Stone (1992) who states that it is precisely the poor and disadvantaged who may
discount participatory processes. When disadvantaged minority groups are
accustomed to being bypassed, then it is hardly a surprise that they will have
little interest in being involved (Taylor, 2000; Walsh, 2002).
This avoidance of the participatory process has been observed in the international
disability context where rural villagers have refused to participate in community‐
based rehabilitation projects (Lysack and Krefting, 1994).
The second major problem is that communities are rarely a homogeneous entity.
Many segments of the population can be isolated from mainstream political and
social organizations, including the organizational structures of the health system.
Hence, some groups within the community will be unaware of opportunities for
participation or find it hard to break into the system (Triandis and Trafimow, 2001;
Peltzer et al., 2006).
The third problem relating to the nature of the community revolves around the
matter of representation itself. Who has the right to speak for the “community”?
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e34 M. C. TORRI
Who are legitimate community representatives? As it pertains to the process of

community participation, representation becomes an issue when community health
workers need to be selected and when community leaders need to be identified
(Allen and Cars, 2001).
Individual prejudices, stereotypes and social and political ideologies can create
problems that seriously impair the ability to organize in pursuit of better health
(Whitehead, 1992).
Theoretically, when groups within a community lack the requisite skills or power to
represent themselves, efforts to increase their abilities in this area can be undertaken.
However, determining how the so‐called community needs are identified and how
solutions to them are identified continues to pose most serious challenges to
community participation in health (Gaventa, 2004).
In the case of the Makewe Hospital, having underlined the positive aspects of this
intercultural health experience, there are still some challenges that need to be
identified and that could undermine the success of this initiative, as well as of similar
experience of community involvement in intercultural health initiatives.
Contrasting religious practices and beliefs

Although the Catholic Church is at present more receptive and open toward the
Mapuche medicine, the evangelical churches still oppose the Mapuche healing and
practices. The opposition of evangelical groups to intercultural programming in the
Makewe Hospital was quite strong, especially in the initial phases of acquiring and
reorganizing the hospital. Evangelical churches have “demonized” all the Mapuche
medical ceremonies. The interviews also reflect this tendency. If a participant is an
evangelical or belongs to any protestant church, she or he tends not to visit machis,
and the reason for not visiting machis is largely related to one’s religious beliefs.
There are several evangelical or protestant nurses and workers in the hospital. The
workers who have worked in the hospital from the time the Anglican Corporation
administered the hospital are mostly Protestant. Such workers did not have anything
against the study of herbal medicine or the use of herbal medicine in the hospital but
expressed uneasy feelings toward machis.
Discrimination from the Western health system

Another problem is represented by the fact that generally, health professionals do
not receive appropriate initial or ongoing training in cultural sensitivity and often
lack the understanding of indigenous population. This aspect has been emphasized
by several doctors interviewed who emphasized their difficulty at the beginning to
understand ideologies and practices that are often radically different from those of
the developed world. Physicians are not comfortable with referring patients to
Mapuche healers because of concern that the College of Physicians might censure
them. Despite increased acceptance of intercultural health programs by physicians,
particularly in the last several years, a concerted effort is still required to develop
medical curricula that engage students in medicine as well as in other health
professions in increasing their understanding of the traditional Mapuche medicine
system and cosmovision.
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The legal system also constrains the articulation of the two systems because the
sanitary code makes it illegal to practice medicine without a license, and there is no
provision to license machis. Traditional Mapuche health providers practice
extensively throughout rural Chile, particularly in Region IX (Araucanía), which
has high proportion of Mapuche residents. More recently, they are also practicing in
some urban communities that have large Mapuche populations. According to current
Chilean law, these individuals are practicing medicine without a license. There is no
apparent peer evaluation process for traditional practitioners, but there is clearly
monitoring and sanctioning by the community for wrongdoing.
Indigenous community factors

The interviews with some members of the Mapuche’community emphasized a
certain degree of apprehension among this indigenous group about whether
traditional medicine should be practiced in intercultural health clinics or should be
restricted to original community‐practice environments. Likewise, the opinions
regarding the commercial marketing of traditional medicines and the creation of the
Makewelawen pharmacy have not been homogeneous. Some of the people
interviewed, especially the younger ones, feel that the separation of traditional
medicines and healers from the community environment is not appropriate and
indeed may undermine the effectiveness of healing.
On the contrary, some other members of the community feel that mainstreaming
traditional medicine and practices is an appropriate means to enhance community
development and self‐reliance through the reaction of commercial activities such as
the Makewelawen pharmacy. Seeing these discrepancies in the different orientations
among the Mapuche community, it is clear that there are delicate and sensitive
issues that indigenous communities must resolve. Should the opportunity of a
political and social environment arise that is supportive of intercultural health
legislation and regulation, the lack of resolution of the indigenous debate on the
usefulness of institutionalizing traditional medicines and practitioners might become
problematic. Thus, it is important for indigenous populations to undertake or expand
on processes to advance the issue of how access to traditional systems in
contemporary society should evolve in order to avoid a loss of cultural integrity.
Regulatory environment
Three out of four doctors interviewed emphasized how in Chile, constitutional or
legal changes that recognize traditional medicine have resulted in minimal or no
secondary legislative developments in terms of the establishment of clear regulations
about how the healthcare system might best interact with traditional indigenous
practitioners. According to their point of view, such a situation leaves both
traditional healers and Western physicians without guidance and at risk for litigation
when adopting intercultural health practices. Western‐trained physicians who do
participate in practices with cross‐referrals to indigenous practitioners are at risk of
losing their license to practice medicine.
At the same time, traditional practitioners interviewed have explained how they
can be accused of practicing without a license and/or contravening health regulations.
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e36 M. C. TORRI
Thus, it is essential that clear legislation and regulations be developed for adopting
intercultural health practices as well as clarifying the relationship between traditional
healers and state health regulations.
The development of the Makewe intercultural health program required the
Mapuche communities to organize politically around the topic of health. Although
there had been previous organizational efforts to promote economic development,
the Makewe initiative required a new discussion on the value and role of traditional
medicine, the responsibility of community health leaders and the role of the state in
intercultural health. Chile’s government provides some funding for intercultural
health programs, which, as it has been emphasized by the administrators of the
Makewe Hospital, is minimal.
The economic support from the governmental health agency is insufficient leaving
the hospital to suffer severe financial difficulties. As it stands today, the Makewe
Hospital is a private hospital run by the local Mapuche Association. Even if the state’s
intercultural development program has received funding for intercultural healthcare,
the hospital will have to accept government administration in order to receive any
extended economic support, a solution the Mapuche Association would want to avoid.
There has been no indication from the health‐related government agencies that the
program will be maintained with ongoing health ministry funding once the financing
is over. Given the ministry’s limited overall budget and, in particular, the limited
resources available for indigenous programs, it is not clear how the Mapuche
projects could be replicated on a broader scale.
Kahssay and Oakley (1999) emphasize the intersections between participation and
health‐sector reform, arguing that community involvement needs to become a central
component of national health systems through intervention with policy makers. This
could be seen as a pragmatic response to earlier attempts that placed responsibility
solely on community members, when in fact those people rarely had the power to
effect dramatic structural change. Their final recommendations are directed not only
toward community mobilization but also toward the need to incorporate community
involvement “principles” into health‐sector planning and evaluation.
The Special Section on Indigenous Health of the Ministry of Health is currently
working on a program that will provide the Treasury with direct budget lines to fund
traditional indigenous programs, thus relieving the problem of inappropriate
reporting methods. In terms of management, the Makewe initiative is providing
positive health management experience to indigenous organizations.
The articulation of intercultural health in Makewe, which incorporates historical
Mapuche holistic approaches to health grounded in a community context and the
formal health system, provides the Mapuche with a reliable and nonthreatening
platform on which to achieve a level of interdependence with the state and general
society, while at the same time maintaining independence of thought and vision.
Sustainability of traditional medicinal practices

Traditional health systems, based historically on a system of reciprocity, have had a
sustainable existence for thousands of years. Potential traditional practitioners respond
to a spiritual “call to service” and therefore are not motivated by financial gain. The
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belief is that failure to respond to such a call could result in serious illness. One common
reason for not answering the call is lack of family and resources to take on the role of
healer, which requires life‐long dedication whether in the role of traditional healer
(machi, shaman, uachac), herbalist, bonesetter or midwife (comadrona, partera).
As the machis interviewed have highlighted, the role of a healer is a calling rather
than a profession or a job. This may be an important factor in the sustainability of
traditional practices. Nevertheless, the issue of economic sustainability of intercultural
health experiences is a more complex question that needs to be examined from the
perspective of the indigenous communities as well as the government.
The issue of sustainability of traditional medicine among the Mapuche communities
is also a delicate issue. Communities want to continue to rely on and support traditional
health systems for those conditions that are appropriate and culturally based, but at the
same, time they want access to allopathic services when needed for diseases that have
not historically been managed by traditional practitioners.
CONCLUSION
The concept of intercultural heath is large and vague, which makes it open to
multiple interpretations and degrees of control from various sectors of society.
Therefore, the use of these terms can provide an illusion of agreement although there
could be radically different interpretations and practice (Kleinman, 1980).
Intercultural practices can be understood as a framework that deals with bridging
cultural differences based on knowledge systems, values and practices, or it can be
seen as a concept that encompasses cultural differences from the perspective of
unequal power relations as historically constituted in society. As it is shown in this
paper, in the vision of the Mapuche’s communities, the concept of intercultural
practices encompasses both. However the emphasis by governments tends to focus
on the former. It therefore reproduces the conception of culture that has been
critiqued (Kymlicka, 1995; Adler and Newman, 2002).
The potential contribution of intercultural practices depends on wider political
processes. In health, similar potentially liberating concepts have been used as the
basis of health advocacy, planning and policy (Jeffery, 2007).
The intercultural health program in Makewe presents an important case of
multicultural social policy, which is based on strong community participation with a
relatively passive intervention from the state. This relatively autonomous status of
the Indigenous Association brought about various positive impacts on intercultural
health policy. The Indigenous Association could enhance cultural diversity as well
as health workers’ cultural sensitivity. Furthermore, the intercultural health model of
the Indigenous Association created a new way of combining Mapuche medicines
with Western medicine, which is innovative but not necessarily in conflict with the
current Chilean legal system.
The Makewe hospital has been successful in expanding cultural rights in their
healthcare model. Many patients stated their content not only because the care itself
is effective and speedy but also because they do not need to worry about
discrimination against Mapuche or the poor. It shows the importance of achieving
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e38 M. C. TORRI
multiple goals of multicultural social policy. Multicultural social policy aims at

accomplishing both social rights and cultural rights. The improvement in social
rights needs to accompany the expansion of cultural rights and vice versa.
In many instances in Latin America, intercultural health is linked with indigenous
forms of medicine (CIESS and Reyes‐Heroles, 1987; Fernández Juárez, 1999). The
promotion of indigenous medicine is considered a fundamental aspect of the process
of intercultural health, because it lies at the basis of the respect for other cultures. It
is important to point out that intercultural approaches to health are not only related
to the indigenous medical systems. In other words, the term intercultural practices,
on the one hand, emphasizes the importance of “cultural rights” and, on the other
hand, points to the government’s responsibility to provide adequate healthcare
through access to institutional medicine.
Community participation in the intercultural health program in Makewe facilitates
the creation of an autonomous relationship between the state and the Indigenous
Association. It improves the flexibility and the creativity of the administration,
which allows tackling both cultural rights and social rights within the healthcare
system. Nevertheless, some outstanding issues still remain. Can communities,
largely poor and underprivileged, be a viable option for the sustainability of the
program? So far, the Indigenous Association has managed to overcome the major
problems of sustainability with constant and persistent negotiations with the state
based on massive participation and support from communities. A constant and
strong participation from communities and a state, which needs to gain political
legitimacy within the communities, is crucial to replicate similar experiences.
ACKNOWLEDGEMENTS
The author is most grateful to the Mapuche communities with whom she worked
with. The author would like to thank the reviewers as well for their useful comments
and suggestions.
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INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt 2012; 27: e18–e40.

Multicultural social policy and community

KEY WORDS: health; community participation; intercultural health; indigenous people

Copyright © 2011 John Wiley & Sons, Ltd.

MULTICULTURALISM AND SOCIAL POLICY IN HEALTH

Existing literature on multicultural social policy either narrowly focuses on one

The rural Makewe Hospital is located in Makewe‐Pelale, in the municipalities of

A third component of the intercultural initiative is the traditional clinic and

COMMUNITY PARTICIPATION IN MAKEWE HOSPITAL

MEANING OF INTERCULTURAL HEALTH

PERCEPTIONS OF MAPUCHE PATIENTS OF THE HEALTH SERVICE IN

CHALLENGES IN INTERCULTURAL HEALTH

Community participation in health projects is a complex and fragile process, and

Who are legitimate community representatives? As it pertains to the process of

Contrasting religious practices and beliefs

Discrimination from the Western health system

Indigenous community factors

Sustainability of traditional medicinal practices

multiple goals of multicultural social policy. Multicultural social policy aims at

Adler N, Newman K. 2002. Socioeconomic Birn E, Zimmerman M, Garﬁeld S. 2000. To

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