Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala

Although there has been a trend of economic growth and improved health outcomes, Latin America continues to be a region characterized by deep-rooted inequalities where indigenous groups bear a disproportionate burden of poverty, ill health and preventable mortality, despite accounting for only about 8 % of the total population [1]. Disparities between indigenous and non-indigenous groups are compounded by widespread social exclusion and discrimination. This is manifested in denial of rights, racist and prejudicial treatment, and limited access to quality public services [2]. The systematic marginalization indigenous people face in the region reflects long-standing historical and social processes of dispossession of land, labor exploitation and exclusion from political participation [3].

Guatemala has one of the highest proportions of indigenous groups in Latin America, and approximately 45 % of the population belongs to one of the 23 ethnic groups. About 95 % of the indigenous people identify as Maya, the main victims of the internal civil conflict that engulfed the country in the second half of the 20th century. It is estimated that 83 % of the two million victims of the war belonged to one of the different Maya groups, who suffered geographical displacement and were the systematic target of rape, torture, and mass killings [4, 5]. Two decades have passed since the signing of the 1996 Peace Accords, and despite the call for equitable social and economic development for all Guatemalans, Mayans continue to face barriers to participate in public decision-making, including politics. These ethnic groups are underrepresented in government, industry and in almost every occupation except subsistence farming [6, 7]. Limited access to formal education contributes to lack of opportunities, and limited social mobility communication for indigenous Guatemalans, as many of them are not able to communicate effectively in the country’s official language- Spanish [7]. These intersecting social determinants, together with isolation from political and economic life, as well as communication barriers, contribute to the stark levels of inequities in the health of Guatemalans, where indigenous women are more than twice as likely to die in childbirth than their non-indigenous counterparts (with maternal mortality ratios of 163 and 78, respectively) and overall, the life expectancy of indigenous people is 13 years less than that of non-indigenous Guatemalans [8].

In this context, strategic efforts to provide Universal Health Coverage (UHC) acquire the moral imperative to improve equity, with specific focus on meeting the needs of indigenous population groups [9]. In Latin America, health systems tend to be structurally segmented, with private, social security and public sub-systems providing services for different population groups. Public healthcare services are the main source of care of the indigenous population in Guatemala. However, public facilities are chronically underfunded, have health worker shortages, regular stock-outs of medicines and supplies, and inadequate infrastructure [10, 11].

Improving health equity levels requires removing the multiple barriers indigenous populations encounter when seeking care, and tackling such barriers has been a central focus of Latin American UHC strategies. Despite such efforts, studies show that cultural barriers continue to limit indigenous people’s access to quality care. Research done in Bolivia, Nicaragua and Guatemala has documented the mistreatment and abuse indigenous women experience during child delivery, highlighteding how such treatment negatively influences patients’ willingness to utilize health services [12–14]. Indigenous men and women have reported differential treatment and provisions of services based on ethnicity in Mexico and Peru. They describe being shamed by providers who treat them as ignorant or inferior, and being denied care [15, 16]. Language barriers have also been highlighted as an important constraint to receiving, or even seeking healthcare [17, 18]. Understanding the discrimination and abuse indigenous people experience may lead to a reduction of the cultural barriers to UHC, and can help to create a health system able to address the needs and expectations of vulnerable and marginalized groups [3]. Our aim in this study, was to explore whether indigenous patients and their family perceive abuse and discrimination when accessing public healthcare services in rural Guatemala.

Three themes were identified through the analysis of the episodes of mistreatment documented in this study. Episodes narrated and discussed by participants pointed to discrimination in access, abusive treatment, and neglect of professional ethics in health care services. Table 2 presents the number of episodes that talked primarily about each of these themes, which are described in the following sections.

The experience of discrimination, mistreatment while seeking healthcare is not exclusive to the Guatemalan setting. Non-consented care, neglect, and verbal and physical abuse are among the most commonly reported complaints in rural areas of Africa, where about a third of women report at least one form of disrespect when delivering a child in a public facility [25–27]. Qualitative studies show that discrimination and abuse play a prominent role in women’s experience of institutional childbirth [27]. Women in Guatemala and in Ghana have highlighted the humiliation and suffering experienced as a result of verbal and physical abuse. For them, the treatment they received was understood as the way through which providers punish them for their culture and ethnicity [3, 28, 29]. In addition, the abuse makes women feel ashamed of their poverty, their way of dressing, hygiene and their use of traditional medicine [29].

Although the body of literature documenting discrimination, mistreatment and abuse of patients continues to grow, it is limited by its focus on care during childbirth Our study contributes to the expansion of barriers that keep patients from seeking care as a broader phenomenon that affects access to quality care for men, children and women that seek non-obstetric care. As Universal Health Coverage continues to gain steam in global health discussions, particularly those around the Sustainable Development Goals [9, 30], so must our understanding of the different barriers that keep patients and families from accessing the care they need. Indeed, without a deep understanding of mistreatment and abuse, we may repeat the same mistakes already identified in the reductionist, indicator-centric Millennium Development Goals [31, 32].

Our study also contributes to the body of knowledge that shows that discrimination plays a prominent role in the experiences that indigenous people have when accessing healthcare services [1, 2, 33]. The experiences expressed by the participants in our study provide insight into how discriminatory practices can restrict access to quality healthcare, of the verbal, psychological and physical abuse experienced, as well as the neglect of professional ethics in providers’ treatment of patients. In Guatemala, where most healthcare providers belong to the dominant, non-indigenous ethnic group, experiences of discrimination are framed in the broader social exclusion situation that support the perceived inferiority of the indigenous people, based on their ethnicity, educational level, and socioeconomic status [3, 5, 34]. In addition, the power differentials that exist between patient and provider contribute to the chasm of social distance between providers who earn a salary and are educated, and patients, who are poor and illiterate or with limited formal education [29].

A previous study found that rural, indigenous patients felt that the mistreatment they receive within the healthcare system is systemic and reflects long-standing racial issues [3]. When these abuses are shared at the community level, it shapes the environment in which future health seeking decisions are made, and contributes to feelings of distrust of the health system based on ethnicity [35–40].

Although all authors strived to present a holistic view of the phenomenon of discrimination of indigenous patients based on the instances described, we would like to present the limitations to our study. We used qualitative data collection methods with predominantly indigenous population in rural Guatemala. Our findings can not be generalizable. Further quantitative studies could provide insight into the prevalence of experiences of mistreatment, however, such household survey techniques should be approached with caution due to the sensitive nature of the issue. During our fieldwork we only sought to collect the views of patients and their families, and we did not interview any service provider about their views on this issue. Further studies are needed to understand the health provider-side of this issue, and we are planning a second study that will explore the perception of providers in order to offer a more comprehensive view of the phenomenon of mistreatment and to identify contextually-relevant strategies for promoting respectful care that is accessible to all.

This study has documented episodes in which indigenous people using public health care services experience discrimination and abuse from providers. In order to promote respectful and dignified care within the Guatemalan health system, a human rights-based approach to UHC can provide a basis for developing a more inclusive and equitable health system for the entire population. Through the use of human rights as the normative base for health policies, practices of abuse and discrimination as the ones described in this study, would be seen as violations to basic rights of freedom from violence and discrimination. In addition, it is relevant to further explore and understand the structural determinants within society and public policies, that contribute to the existence of discrimination and abuse in health and other public services.