Mapuche health experiences in Primary Health Care from health workers and users in urban Chile

This study describes experiences and perceptions on interculturality in Primary Health Care (PHC) from the perspective of health workers and Mapuche health users. For this purpose, a qualitative systematization of these experiences was carried out in a PHC Intercultural Health Program at an urban commune in Chile. Data were collected by means of individual and group interviews, respectively, with 19 users and 13 professionals. The semantic content analysis was performed. While service users perceive Mapuche health positively, assimilating it to the concept of interculturality, health workers reported that Mapuche health is respected but no integrated work is promoted. As barriers, participants cited administrative aspects, lack of integration, and scientific issues. In conclusion, recognition of indigenous health and greater occupational training on indigenous health and interculturality is necessary.


Introduction
According to the last Population Census (INE, 2017), Chile is a multiethnic, multicultural and multilingual country; 12.8% of the population self-report to belong to some indigenous people, among whom 79.8% self-report to be Mapuche. Despite having a significant population representation, there is a cultural and political asymmetry that marks the relations between the national society and the indigenous world. For example, indigenous people have less access to health and poor results in critical health indicators (Heise et. al, 2009;Oyarce et al., 2009;Moloney, 2010).
The Mapuche medicine perceives health from its cosmovision of life; as regards wellbeing, they consider both origins and spirituality, as well as the balance with nature. Therefore disease involves the rupture of this balance (Diaz et al., 2004). In response to the need for belonging in health care and improved access, intercultural health becomes relevant as a public health strategy to provide care to indigenous peoples.
In 1992, the Mapuche Population Health Program (Programa de Salud con Población Mapuche, PROMAP) was created, and in 1996, the National Health and Indigenous Peoples Program (Programa Nacional de Salud y Pueblos Indígenas) was implemented. Some authors consider that these intercultural health programs were oriented to solve health problems by integrating resources from different medicines. However, they received little recognition from an administrative point of view, weakening their implementation.
In 2008, the Special Health Program for Indigenous Peoples (Programa Especial de Salud para Pueblos Indígenas, PESPI) was created, aimed to consolidate an intercultural health system, which previous programs failed to install, accepting the existence and validity of other healing systems complementary to the existing health systems (Manríquez-Hizaut et al., 2018). This program aims to: Contribute to the reduction of inequity gaps in the health status of indigenous peoples, through the participatory construction of health plans that recognize cultural diversity, promote complementarity between medical systems, and provide adequate health services responsive to specific needs, rights and epidemiological profiles. (Minsal, 2013, free translation).
Three main axes are established for the PESPI execution: Equity, Intercultural Approach to Health, and Indigenous Social Participation (Minsal, 2013). These principles are consistent with the guidelines of the Primary Health Care (PHC) Model existing in Chile (Minsal, 2012).
It is worth mentioning that the Chilean Health System is made up by subsystems, a public system (which covers more than 70% of the population) that has a health insurance called FONASA, and several health care centers throughout the country that make up the Assistance Networks administration. The second subsystem is the private system, made up of the Social Security Health Institutions (Instituciones de Salud Previsional, ISAPRES), which manage private health insurance (covering more than 20% of the Chilean population), and also counts on health care centers. The FONASA population may receive care in private health care centers through the free choice modality, but both systems operate independently under the regulations of the Chilean Health Authority.
It is particularly striking that the Chilean intercultural health programs mentioned above have only been designed and developed in the Public Health System, not being mandated to be implemented in the private system, although the indigenous population could opt for private health institutions (both insurance and care centers).
Studies in the Chilean health system expose a criticism towards the normativization or bureaucratization of the Mapuche health under the institutional logics of the Chilean State (Alarcón et al., 2004;Anigstein;López, 2006;Boccara, 2007), and the professionalization of indigenous cultures' knowledge (Bolado, 2012) as a lack of recognition and assimilation of these to the practices and ideologies of the Western medicine. Other studies identify communication issues between health professionals and Mapuche health agents, lack of referral mechanisms, and lack of training in the Mapuche cosmovision (Alarcón et al., 2004;Vásquez, 2009).
This study was conducted in the context of primary health care, in an urban commune of Santiago de Chile, together with the Mapuche community Kallfulikan that has been implementing the PESPI program for 20 years. The aim of this study is to describe the experiences and perceptions about interculturality in PHC, from the perspective of health workers and the Mapuche health care providers.

Method
A case study was conducted, systematizing the experience as a participatory research process carried out with the Mapuche community that leads the experience studied. This specific scientific communication considered the interviews of workers and users related to the Mapuche health, in the context of PHC.

Design
The systematization of experiences corresponds to a participatory research process. Through qualitative methodology, the experience of workers and users in relation to the Mapuche health, in the context of PHC carried out in "La Ruka" (traditional Mapuche house that serves as a place for the preparation of medicinal herbs) of the Mapuche community Kallfulikan, was surveyed. In order to describe the whole experience, quantitative and qualitative data were systematized to rescue 20 years of implementation of a Mapuche medicine program in the context of PHC. In that program, social actors think over and review the processes, recovering local knowledge through a critical understanding of the factors that made them possible (Jara, 1994). This methodology has been recommended for these purposes (Hasen, 2012).

Participants and context
This study on the implementation of a Mapuche health program in the PHC context was conducted in an urban commune of Santiago, Chile. The fieldwork was developed from August to November 2017. Nineteen users participated in individual semistructured interviews. For PHC workers, three group interviews were conducted, with a total participation of 13 people from different professions and roles, with non-medical professionals presenting a numerical prevalence ( Table 1). The final number of interviews allowed saturating information to respond to the objective of this study.

Analysis
Interviews were transcribed and reviewed before the next data production journey, in order to investigate emerging areas of interest to the project.
A semantic content analysis was conducted on the experiences of PHC users and workers. The preliminary results of this study were analyzed with the Mapuche community in charge of the program, as part of the overall systematization process of the experience through a day of results presentation and discussion of the main findings. For this communication, this instance allowed validating the interpretations shown in results which, although not corresponding to their own stories as a community, seemed to be coherent in the global context of the experience. On the other hand, these results contributed to an internal analysis by the community, which is not part of this communication.

Ethical considerations
This study sought to know the experience of people linked to Mapuche medicine in PHC valuing and respecting their opinion. The research process was carried out jointly with the Mapuche community in charge of the program. All participants were volunteers, and a process of informed consent was carried out with each of them. Participants were identified with their age or profession and gender, respecting their anonymity. The results of this communication were discussed with the Mapuche community in charge of the program that authorized its publication, respecting their autonomy and following the agreements reached during dialogues between the community and the facilitating team. It should be noted that this study contributed with information for the internal analysis by the Community in charge of the program, pursuing greater engagement with the western health.

Results
Of the total number of participating users, 6 self-reported to be Mapuche and, of the workers, only one person identifies their Mapuche origin, but indicates to not keep any cultural practice (Table 1). Both groups present a positive vision of the Mapuche health and different opinions regarding interculturality and its application in PHC. They highlight the positive aspects of working with a Mapuche health team, identifying barriers to the recognition and valuation of Mapuche health in coexistence with biomedical practices. Following a description of Mapuche health experiences and intercultural health practices is disclosed, highlighting their characteristics, barriers and facilitators.

Mapuche health linkage experiences
Users access the Mapuche care optimistic about its effectiveness. Most have received recommendations from acquaintances and relatives, so they present high expectations, as reflected in the following statement: "I don't mind waiting all afternoon, because it will work" (man, 60 years old).
Those who have been receiving care for longer (6 months to 5 years) positively evaluate the care provided by the Machi (spiritual authority for the Mapuche people's culture) because they recognize improvements in their lives, such as a decrease in pain, and better state of mind. A woman (60 years old), with emotion in her eyes and voice, relates her first care process; "he (machi) sees your life". For her, the care with the machi was revealing. He discovered and inquired about aspects of her life that she thought were irrelevant to her current health situation. She was surprised that the machi "sees the urine and knows so many things".
For users, the Mapuche health is understood as natural medicine. They value its accessibility, since it is easy to book a visit and there are no age or residence requirements. There is no costs for them, they do not ask for exams or purchase of medicines. So, there is no associated out-of-pocket expense, as it happens in the Chilean health system. In addition, they value "natural medicine" agreeing that the use of herbs is a non-industrialized therapy and, therefore, is better than the use of drugs. This is expressed in this statement "water is water" (woman, 70 years old).
There is a belief that herbs, being natural, are healthier because they do not harm the stomach and have no side effects; "pills are good for one thing and bad for others" (woman, 67 years old). They also add they do not have to take herbs for every illness. Herbal water, in its diverse and secret preparations, acts on different ailments.
A woman (39 years old) reports that since the first week she felt changes in her organism, for her "coming to the Ruka is relaxing". The respondents reported to believe in the Mapuche medicine, trusting that it will heal them of all their ailments because of its natural character. They also have general knowledge about the Mapuche cosmovision related to the holistic understanding of health, the use of herbs as natural medicine and its effects on the body. However, none of them participated in other Mapuche traditions, more due to lack of time than for lack of interest.
Regarding the PHC workers, most of them are linked to Mapuche health because of their current work activity; when they arrived to work at the PHC center, the Ruka already existed. Some of them were introduced to this program, and others report to have participated in trainings on Mapuche cosmovision, although this is not an experience shared by all of them.

Intercultural health in PHC
For one user, intercultural health is the encounter of cultures, with the recognition of ethnic culture and its valuation in dialogue between health systems. Based on this belief the user identifies the lack of interculturality in the Chilean health system and in the country in general, as reflected in her statement: "is that there is no intercultural health, there is a lack of merging both, they have to work together and for that there is a lack of more dissemination and for people to stop seeing Mapuche medicine as something esoteric, schools should teach Mapudungun (Mapuche language) so that since childhood children grow up with that" (woman, 38 years old).
For the other users, intercultural health is synonymous with Mapuche health, it is materialized in the Ruka, "this is intercultural health" (woman, 39 years old), as an alternative system, with different means and ends; "The Mapuche do not have the same technology as public health, they can do complex procedures, each one does their own thing and each health system fulfills different purposes" (Male, 87 years old) Healthcare practices recognized by users do not account for interculturality as a dialogue between different cultural understandings of health. For example, there is no clear referral from the PHC center, nor do they receive information about this medicine, not even those who self-report to be a Mapuche. Although in the Ruka people are instructed to continue with medical treatment, some of them point out that they should stop the pharmacological treatment because they prefer herbs, but they do not report it in their medical check-ups at the PHC.
Regarding workers, most of them recognize intercultural health as the encounter of different cultures in dialogue, respect and complementarity. They identify positive experiences of linkage in the context of health promotion and prevention, and in family and/or individual referral, as well as recognize barriers for a better implementation of interculturality in the PHC (Table 2).   Health professionals recognize that they do not perform anamnesis or provide differential care for people belonging to Mapuche communities. They even consider that it is not necessary since from their perception the Mapuche population does not request it, and they are adapted to the practices of the western system. On the other hand, they consider that interculturality takes greater importance to address the care of foreign population; "[...] here we have perceived with our foreign users, Haitians; they do not perceive health as self-care, they perceive it differently [...] so perhaps knowing not only our ancestral cultures but also knowing these new brothers who are arriving, also allows us to know how to approach this person from the point of view of health" (Woman, midwife) They recognize "cultural clashes" with migrant population, especially with the Haitian population, both due to language barriers and lack of knowledge of the health practices and beliefs of this population, which hinders the encounter with PHC activities in Chile; " [...] in fact, the Haitian pregnant women are checked late because they are not used to having a preventive birth control" (Woman, midwife) When professionals consider the possibility of incorporating changes in health care practices, they identify that the existing barriers would not allow local changes without changes in the national PHC guidelines and policies. Even when these policies indicate that approaches such as integrality and interculturality should be incorporated, for professionals the care at the Ruka is more comprehensive and generates stronger link with users, in comparison with what is done at the PHC center. This is associated to the management based on health goals that do not incorporate interculturality and, in addition, to the inflexible timetable definition that hinders community work or coordination with the Mapuche health agents. Another aspect that hinders joint action is the unsuccessful instances of health workers training, whose experiences have not been continuous or universal and some of them have had problems with certification. This meant they were not recognized and therefore participation was discouraged.
On the other hand, in order to formalize a joint work some workers propose that the "Ruka services", such as the Machi's care and the delivery of medicinal herbs, should be incorporated to the PHC services basket and thus institutionalize the practices as a form of recognition. On the other hand, the Mapuche health agents should participate in team meetings held to coordinate management or address complex cases, thus contributing with their vision and being considered as a single team.

Discussion
The Mapuche health experience in an urban commune is positively valued by users and by primary health care workers who are bound to it. These experiences, however, reflect a gap in the incorporation of interculturality in PHC, since users do not recognize dialogue between cultures or health knowledge. Workers identify a lack of recognition and joint work attributable, on the one hand, to administrative aspects of the Chilean health model that do not allow for flexibility in their practices and adaptation to a different health worldview. On the other hand, it is attributable to the will and attitudes of some professionals regarding the lack of scientific validity of the Mapuche medicine, and the risks that this would imply for the population's health. Similar results are reported in contexts of maternal and child health in Colombia, where health professionals consider that indigenous women are not aware of the health risk involved in pregnancy and particularly childbirth (Castillo-Santana et al., 2017). It clearly evidences a hegemony of biomedical health as a standard of quality in health, based on its scientific effectiveness, and a difference in the understanding of physiological processes that in the indigenous worldview may be considered part of the life cycle of women (Castillo-Santana et al., 2017).
This study shows a parallel coexistence of two health systems, which enable access to Mapuche health in the city, both for the Mapuche and non-Mapuche population. As another study points out, the experience of urban context allows the maintenance of cultural projects strategically aligned with the guidelines of the Chilean system for access to resources. This, however, implies greater control, subordination and standardization of the Mapuche health system (Anigstein;López, 2006). Other studies have identified the asymmetry of the Chilean biomedical system with the Mapuche health system, and the lack of theoretical and practical clarity about the concept of intercultural health as main barriers for the implementation of interculturality (Pérez;Nazar;Cove, 2016). Asymmetry is common in other contexts, and demonstrates the unwillingness of health personnel to make room for indigenous health, relying on structural and ideological biomedical hegemony (Castillo-Santana, 2017;Mendes et al., 2018).
In the Latin American experience, an analysis of planning for equity in health points out that, although the countries consider the "marginalized" population, less than half address indigenous peoples and only in four cases the attention to migrant population is explicit (Kavanagh et al., 2021). On the other hand, comparative case studies in the region (Mignone et al., 2017) point out that, despite the attempts to articulate cultural approaches within the broader health system, it is not as effective, evidencing institutionalized racism in hospitals and other sectors of the health care system.
In general, interculturality policies in health has been considered of low impact, either due to weak social participation, lack of continuity and satisfaction with care and the need for intercultural dialogues for the articulation of knowledge, as reported in the case of Brazil (Pedrana et al., 2018;Mendes et al., 2018), or due to lack of resources and the sequence of arbitrary and exclusionary policies, as found by a study in Mexico (Campos;Peña;Maya, 2017). In particular, as in our study, the lack of trust between traditional health agents and Western health professionals is identified as an obstacle to intercultural work, pointing out in some cases not only a resistance from medical systems, but also religious ones, even if they seemed to be not so influential (Mignone et al., 2017).
The challenges for primary care in Chile to effectively incorporate interculturality are: first, to allow spaces for integration in which indigenous health agents participate in the health team on equal terms and without the need to adjust or validate their practices; second, to strengthen the initial and continued training of health professionals and workers on interculturality and Mapuche or indigenous health in general; and, third, to know the cultures present in their territories, especially, due to the coexistence with other cultures due to migration. Workers participating in this study recognize this last, which has been the subject of interventions that include cultural competencies to perform the health anamnesis (Chepo; Astorga-Pinto; Cabieses, 2019). Fortunately, new doctors in Chile show interest in practicing in indigenous settings precisely because of the interculturality experience (Mignone et al., 2017).
This study corresponds to a particular experience; therefore, its results are not transferable to the national reality of implementation of the indigenous health program in Chile. Other studies have clearly stated the need to increase research in indigenous population, pursuing a reversal in inequalities of access, and resolving inequities in indigenous morbidity and mortality indexes (Kolahdooz et al., 2015;Cortés-García, 2020). In Chile, new studies should investigate experiences of intercultural health implementation in rural areas and other regions of the national territory.
Finally, we should consider that neoliberal policies, deepened after the dictatorship, fostered the bureaucratization of indigenous health practices (Bolado, 2012), and reflect the barriers imposed by the Chilean State on the implementation of programs that seek to recognize and maintain the coexistence of indigenous health. Therefore, even if progress is made in intercultural health policies, without a comprehensive and structural response that overcomes fragmented policies on indigenous rights, which attempt to separate environmental issues and territorial claims from health issues, a situation common to all of Latin America (Martínez, 2015), it will be impossible to comply with international treaties that protect and recognize the rights of indigenous peoples, signed by Chile.