The Region of the Americas is characterized by a vibrant multi-ethnic and multi-cultural richness, which includes an estimated 45 million indigenous peoples from 826 indigenous, in addition to Afro-descendants and Roma communities. These communities are incredibly diverse in their cultural practices and spoken languages but too often share the experience of discrimination, poverty, and poor access to social services, including health and education. As a consequence, indigenous communities across the Americas are disproportionately affected by trachoma along with other development issues that trap communities in cycles of poverty.

In recent decades, many countries in Latin America and the Caribbean have recognized health as a human right and acted on that recognition through amended constitutions to guarantee citizens the right to health. In 2014, total public health spending accounted for an average of 14.2% of GDP in the Region of the Americas. Public expenditure on health also increased in 22 countries between 2010 and 2014. Out-of-pocket expenditure as a percentage of total health expenditure in Latin America and the Caribbean decreased from 52% in 2006 to 33% in 2014 and between 2014 and 2015. Alongside this, levels of health services coverage is now high across many countries in the region with 98% in Chile, 95% in Colombia, 80% in Mexico, and 73% in Peru, allowing more people to access health services and affordably.

Despite an overall increase in health and well-being in the Americas over the past decade, the exclusion of indigenous communities in social programs has led to disproportionate poverty and significant social inequities. Indigenous groups currently account for 17% of those living in extreme poverty, despite representing less than 8% of the general population of the region. Moreover, 62.6% of indigenous children in the region live with insufficient access to clean water, in contrast to 36.5% of non-indigenous children. The lack of clean water is a particularly significant barrier to trachoma elimination targets in Brazil, Colombia, Guatemala and Peru, where over 5.2 million indigenous people are at risk, 4.9 million of whom live in remote areas of Brazil.

Resolving these challenges is a necessary step to achieve global targets set by World Health Assembly Resolution 51:11 calling for the elimination of trachoma as a public health problem, as well as broader development targets codified in the 2030 Agenda for Sustainable Development. Through the Pan American Health Organization (PAHO), Member States are actively taking steps to address health inequities and develop national and regional plans to improve health among indigenous communities.

In September 2017, at the 29th Pan American Sanitary Conference, PAHO Member States unanimously approved the Policy on Ethnicity and Health. Through the policy, Member States agreed to guarantee an intercultural approach to health and equitable treatment of indigenous peoples, Afro-descendants, Roma populations, and members of other ethnic groups. The policy compliments and supports the Strategy for Universal Access to Health and Universal Health Coverage approved by PAHO Member States in 2014, which includes commitments to ensure that all peoples and communities have access, without discrimination, to comprehensive, appropriate, and timely, quality health services. Some countries, including Colombia, Guatemala and Peru have implemented specific projects and activities to offer services adapted to indigenous communities within an intercultural health model, however more work is needed to involve these communities in the development of public health policies.

The commitments from Member States to work with indigenous communities to develop inclusive, collaborative solutions to address health gaps is significant. Representatives from indigenous peoples, Afro-descendants, Roma populations, health ministries and multilateral organizations participated in the development of this policy and committed to supporting its implementation.

The diversity between different indigenous groups across language, cultural and societal norms, means that there can be no “one size fits all” solution to delivering health services to indigenous communities. In terms of trachoma, interventions need to be designed and tailored to the people they seek to benefit, which cannot be achieved without strong collaboration with the communities themselves, forging trust and working relationships with indigenous leaders. In doing so programs are sensitive to local customs and beliefs.

In Colombia, the Ministry of Health is training health workers for its trachoma program from the same district as indigenous communities, so that interventions can be explained and delivered in a local language and community structures and education levels are better understood. The approach improves communication and increases trust between program staff and community leaders. Inclusion of indigenous communities in the design of programs is particularly important when communities are nomadic. Colombian health workers identify travel routes and work closely with neighbouring health ministries to overcome challenges caused by migration. Working with neighbours means that interventions can be provided regardless of what side of the border a community might be travelling. 

Achieving the elimination of trachoma as a public health problem, the 2030 Agenda for Sustainable Development and Universal Health Coverage will require nuanced, innovative and comprehensive policies at the national and regional levels to ensure indigenous populations have access to interventions and that programs are culturally sensitive and appropriate to the people they serve.  The Policy on Ethnicity and Health makes the Region of the Americas the first WHO region to acknowledge the importance of adopting an intercultural approach to address inequities in health, but hopefully not the last.

In 2017, Mexico became the first PAHO member state to be validated by WHO for achieving the elimination of trachoma as a public health problem, however considerably more work needs to be done to reach the most remote and marginalised people in the Region.  Experience of trachoma elimination efforts in the PAHO Region also demonstrates that progress across trachoma and health can be achieved while transitioning from international financing to domestically financed health care. Lessons across policy development and implementation programs to ensure access for marginalised populations must continue to be documented to better share lessons and understand where gaps remain in order for us to support national, regional and global progress.

This blog was written by Dr Martha Saboya, Advisor on Neglected Tropical Disease Epidemiology, Pan American Health Organization