SPE 84 - Studies in Political Economy

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INDIGENOUS CONTROL OVER HEALTH CARE IN THE MIDST OF NEOLIBERAL REFORMS IN COLOMBIA : AN UNEASY BALANCE Javier Mignone, Jorge Nállim, and John Harold Gómez Vargas Introduction1 In recent years, numerous studies from different academic fields have thoroughly explored the neoliberal economic model adopted across Latin America throughout the 1990s. This scholarship has detailed the overwhelmingly negative social and economic effects of free-market reforms on the vast majority of the population.2 More interestingly, it has also shown how those reforms gave birth to, or strengthened social movements (involving landless peasants and unemployed workers, for example) that protested the reforms, and formed the backbone of political movements that eventually reached power in several countries. Among them, the scholarship has focused on the mobilization of Indigenous populations throughout the region as they demanded and reclaimed their place in their respective nations.3 These contradictory processes are captured by the Indigenous peoples of Colombia and their experience with health care reform. In 1991, a new constitution simultaneously recognized long-standing demands for Indigenous rights and promised to establish universal health coverage. This system was implemented in the following years through a managed competition model, a neoliberal type of policy that had a negative impact on the Colombian population. On the other hand, Colombian Indigenous peoples, building upon their historical experience of mobilization and newly recognized rights, seized the legal framework of neoliberal reforms of the health sector in Colombia to manage their own health insurance companies and health delivery entities. Although the reforms have yet to reach the full coverage Studies in Political Economy 87

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of the population, and key health indicators and disease control programs appear to have deteriorated, the Indigenous organizations seem to have made important progress in gaining control over their own health care.4 Nonetheless, what this means in terms of real control is still not clear because the initiatives are fraught with a number of tensions. Besides, positive achievements should not obscure the fact that the Colombian Indigenous peoples continue to face major violence and repression derived from the multiple conflicts that affect the country. This paper analyzes the experience of Indigenous Health Promoting Enterprises (Empresas Promotoras de Salud (EPS)). It does so from a theoretical perspective that combines EPS analysis from a health care perspective with a historically grounded framework regarding changes in state-society relations and the ambiguities created by neoliberal reforms. In particular, it seeks to understand how popular organizations utilize institutional reform for their goals. It examines the tensions that arise and the power relations at play vis-à-vis the state and other players, and assesses the implications of Indigenous self-governance in health care. In doing so, it sheds light on the fact that health care is another arena for contentious struggles of power, culture, identity, and citizenship. Colombian Health Reform and Indigenous EPS The experience of the Indigenous EPS is rooted in a tradition of active political participation by Indigenous groups in Colombian history. They played an important role in the civil wars between Conservatives and Liberals in the nineteenth century, fighting for their place within the nation that would allow them to preserve their customs and communal forms of land ownership. This activism and visibility experienced setbacks in the late nineteenth and early twentieth centuries, as the Indigenous communities were affected by the consolidation of the central national state based on the principles of French liberalism that considered diversity as anathema to a national state, the development of an export-oriented Colombian economy, and related national racial ideologies that emphasized Indian backwardness. Indigenous resistance and activism did not disappear, however; it played a major role in the different twentieth century movements related to the violent conflicts around 94


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the repossession of land illegally appropriated by large landowners. Eventually, this participation in class-based movements gave way to Indigenous organizations that added more explicit ethnic and cultural issues, exemplified by the foundation of the Consejo Regional Indígena del Cauca (CRIC) in 1971, whose goals included repossessing and expanding communal lands (resguardos), preserving and promoting Indigenous culture and values, and strengthening organization and institutions. The process of Indigenous activism along these lines led to attempts to create institutions to represent the Indigenous peoples at a national level, represented by the foundation of the Indigenous Organization of Colombia Indians (ONIC) in 1982.5 This process of Indigenous organization and activism unfolded in the context of the violent and factional struggles that, while having roots in the nineteenth century, have characterized Colombian history since the second half of the twentieth century. Stretching over decades, a multidimensional conflict evolved according to different periods, actors, and issues, varying in intensity and scope in relation to both chronology and geography. Traditional conflicts over access to land, marked by ethnic and regional characteristics, were subsequently deepened by a relatively closed political system restricted to political elites, the rise of guerrilla groups, and the appearance of counterinsurgent movements that found their most recent and brutal expression in paramilitary groups. In addition, the spread of coca cultivation since the 1980s not only gave birth to new actors, but has had widespread political, economic, and social effects on all participants in the conflict. These historical developments have brought profound transformations to the country, from the economy to a human rights crisis that includes widespread use of terror and violence and the displacement of large sectors of the population. Moreover, at a fundamental level, they have resulted in a fragmented and weakened national state and the rise of virtual “para-states” in which power is exerted by a cohort of armed groups, with special prominence of Right-wing, counterinsurgent paramilitary groups.6 The Colombian constitutional reform of 1991 occurred at a critical juncture, when the national government, facing the state’s bankruptcy, the rise of violence, and demands for reform, sought a solution to the conflict through negotiation. For this article’s purpose, the constitutional reform is 95



important because it brought the Indigenous struggles for rights together with the reform of health care in a contradictory relationship that set the basis for the complex experience of the Indigenous EPS. The new constitution granted Indigenous communities significant rights in terms of politics, culture, and economics, including recognition of the territorial integrity and autonomy of Indigenous resguardos.7 The Colombian constitutional reform of 1991 concurrently decentralized state institutions and enshrined the right to health and social security, leading to the reform of the health care system in 1993 (Law 100). The specific shape of this reform was influenced by wider state reforms promoted by the International Monetary Fund and the World Bank, resulting in the creation of a general system of social health security through the implementation of decentralized health insurance, with the intention of achieving universal coverage within a decade.8 Nonetheless, access inequities still remain and universal coverage has yet to be obtained. By the year 2006, the highest estimates were that 83 percent of the total population had received coverage.9 As scholars have been arguing, the system has not improved equity, increased efficiency, or shown a positive impact on quality; rather it has increased health expenditures while public health programs in Colombia have deteriorated. Critics contend that, at the very least, the National Congress and the central government should pass law reforms and avoid persisting in the ideological obstinacy of free markets.10 Simultaneously, the constitutional reform also recognized the ethnic and cultural diversity of the Colombian nation (art. 7) and Indigenous peoples as collective entities.11 This aspect of the reform was a result of years of mobilization and struggle by Indigenous organizations, such as CRIC, ONIC, and the Movimiento de Autoridades Indígenas de Colombia (AICO), not to mention its forerunners, and many others. Law 100 created Health Promoting Enterprises (i.e., the EPS) financed through two different systems. The contributory regimen is for segments of the population who can afford it, mainly the formally employed (who contribute 4% of their salary with the employer contributing 8.5%) and the self employed (who contribute 12.5% of 40% of their gross income) for health insurance. The subsidized regimen is expected to cover “the most vulnerable population with less economic capacity.”12 It is funded by an 96


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input from the contributory system and by government subsidies. Initially, it was foreseen that by 2001 the benefits offered by the subsidized regimen would equal those of the contributory regimen. The Obligatory Health Plan, managed by the EPS, covers a package of health interventions.13 The subsidized system’s package, however, is half of the contributory system’s, covering only essential clinical services, some surgical interventions, the treatment of near catastrophic diseases, and it includes health promotion and disease prevention as “pillars of the system.”14 Under the subsidized regimen, the EPS can function as not-for-profit health insurance organizations, although most are for-profit under both the subsidized and contributory regimen. The EPS are responsible for the financial resources, contracting for health promotion, and for the organization and delivery of medical services. The contracting is done with health care delivery organizations (Instituciones Prestadoras de Servicios de Salud (IPS)) and the autonomous former public hospitals and health centres (Empresas Sociales del Estado (ESE)).15 The IPS can be public, private, or mixed, and for-profit or not-for-profit. Over the years, six Indigenous not-for-profit EPS have been created by Indigenous organizations from different regions of Colombia. These are Anas Wayuu, with headquarters in Maicao, La Guajira; Asociación Indígena del Cauca (AIC), Popayán, Cauca; Dusakawi, Valledupar, César; Mallamas, Ipiales, Nariño; Manexka, San Andrés de Sotavento, Córdoba; and Pijaos Salud, Ibagué, Tolima. The total number of insured is slightly more than one million, ranging from 100,000 at the lowest to 260,000 at the highest.16 The first Indigenous EPS were Dusakawi, created in 1997, and AIC in 1998. These entities reflect a particular type of process in which Indigenous communities and organizations were able to join forces to create their own Indigenous EPS.17 Nonetheless, despite commonalities in the process of creation and the organizational structure of the six entities, there are noteworthy distinctions. All Indigenous EPS have themselves spurred the creation of Indigenous IPS with whom they hire services. As well, they contract with other IPS and with the autonomous former public hospitals and health centres (ESE). The mission statement of Dusakawi encapsulates what appears to be a shared vision of all six Indigenous EPS: “Strengthen 97



our traditional knowledge, and the results and autonomy of Indigenous peoples in the territories. Defend and promote our policies, organizing and administering the resources dedicated to health, to guarantee services in accordance with the socio-cultural characteristics of our peoples.”18 The organizational structures of the Indigenous EPS suggest a crucial difference with other EPS of the subsidized regime, with respect to the political nature of their origin and representation. For instance, Dusakawi represents its organizational structure as a tree, where the roots represent the traditional and spiritual authorities that delineate the broad political and spiritual direction for Indigenous health. The main trunk of the tree represents the Association of Cabildos (Cabildos are the local governments of Indigenous territories) of César and La Guajira, which is the instance of political decisionmaking. The Association of Cabildos represents four Indigenous ethnic groups, Kogui, Wiwa, Arhuaco, and Yukpa. The middle trunk of the tree depicts the Managing Council in charge of implementing and executing the political decisions of the traditional authorities and the Association of Cabildos. The upper trunk represents the administration and legal structure of the EPS and the branches. The branches portray different aspects of the EPS.19 Anas Wayuu was created by two Indigenous associations representing 120 Indigenous communities: the Association of Cabildos and/or Traditional Authorities of la Guajira, and the Sumuywajat Association. The administration of Anas Wayuu is accountable to these associations in terms of its direction. It contracts services with 18 IPS (five of which are Indigenous IPS), some private IPS, and nine ESE (hospitals). AIC is part of the health program of CRIC. Although it has a substantive presence in terms of resources and function, Graph I shows that it is subsumed unequivocally under the political direction of CRIC. CRIC represents 115 Cabildos and 11 Cabildo Associations.20 Given that 78 percent of the Indigenous population lives in rural areas, the Indigenous IPS have prioritized the extension of services to these areas.21 In addition, Indigenous IPS have close relations with a number of resguardos (Indigenous communities), and on a regular basis they organize health brigades that reach the most isolated communities. As well, all Indigenous 98


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EPS fund networks of community health promoters through the Indigenous IPS. These workers develop and implement prevention and health promotion initiatives in the communities, and for the most part, they are community members themselves. Furthermore, the Indigenous EPS support initiatives related to food sovereignty, restoration of traditional crops, traditional health practices, and intercultural health care (all of which clearly have broader political and cultural implications related to the identity and power of the Indigenous groups vis-à-vis the health care system and Colombia as a nation). For instance, Wintukwa Indigenous IPS of the Arhuaco people of de Sierra Nevada de Santa Marta (linked to Dusakawi EPS) seeks to develop an Arhuaco Indigenous health delivery system with the view of recovering traditional medicine, while increasing the coverage of western health care that takes into consideration Arhuaco customs and cultural traditions.22 Dusakawi has members in 20 municipalities. The services provided are attention and assistance to the user; bilingual guides; recovery houses; training of users; coordination of the network of services; health promotion and illness prevention programs; initiatives to strengthen traditional medicine; 99



preservation of Indigenous language and culture; and so on. The Indigenous health program of CRIC is financed by AIC and implemented by the Indigenous IPS. Its main goal is to rescue and maintain ancestral practices of food autonomy and traditional medicine in accordance with the world view of the different Indigenous peoples. Among the food autonomy initiatives are support for traditional crops, rescuing traditional food preparation methods and nutritional practices, and encouraging family production leading to food self-sufficiency. The support of traditional medicine implies individual, family, and community rituals, cultural health practices, own classification of illnesses, and so on. Furthermore, they seek to adapt programs socially and culturally and to develop holistic models of health care. While some studies have documented these developments,23 there is a lack of empirical evidence assessing the extent, success, and impact of these initiatives. Indeed, the lack of funding allocated for evaluation and research within the EPS limits their capability of producing rigorous evidence. One clear, limiting factor is the rigid funding allocation structure (geared to medical practices) that the EPS must adhere to, which curtails the wider implementation of these initiatives. In summary, there is evidence of a number of positive developments. For instance, putting health care in the hands of these Indigenous organizations has improved access to health care services, enhanced effective communitybased health promotion and preventive services, as well as intercultural health initiatives, bilingual services, and the collection of social and culturally relevant individual, family, and community-level information related to social determinants of health.24 Furthermore, within the constraints of the legal framework, the Indigenous EPS have sought to support traditional Indigenous medicine. As well, the fact that public hospitals are now contracted by the EPS for services has, to some extent, forced the former to treat Indigenous patients and their families with more cultural and social respect. In a certain sense, it could be argued that, through their EPS, Indigenous peoples have gained leverage vis-à-vis public and private hospitals. Discussion The experience of the Indigenous EPS poses relevant questions that deserve examination. Has the creation of Indigenous EPS increased 100


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Indigenous peoples’ control over their health care resources and modes of practice, and increased access and coverage? Has the creation of Indigenous EPS strengthened the capacity of Indigenous organizations to leverage resources and achieve autonomy? In other words, has the utilization of an institutional space such as the Indigenous EPS meant a shift in the power relations at play vis-à-vis the state and other players, and what are the tensions and limitations associated with this system? At a theoretical level, the experience of the EPS sheds light on the ambiguous effects of neoliberal reforms on Latin American societies. As different scholars argue, neoliberalism has been a “double-edged sword” in that the deeply negative consequences of its related policies—such as freemarket economics and the state’s retreat from public and social policy—for vast sectors of the population nevertheless provided the space and conditions for new forms of popular organizations and movements.25 This analytical approach, more attuned to the contradictions inherent in any historical experience, allows a more accurate evaluation of the achievements, shortcomings, and tensions of the experience of the Indigenous EPS in Colombia. On one hand, the creation of the Indigenous EPS seems to have contributed to increasing the leverage of Colombian Indigenous organizations. This can be seen, for instance, in the case of AIC, which falls under the political representation of the Consejo Regional Indígena del Cauca (CRIC). CRIC also spurred the creation of six IPS with whom AIC contracts delivery services. Because of the political representative nature of CRIC, the communities are not simply users of the system, but through CRIC they take part in broad decisionmaking processes related to AIC and the six IPS. Moreover, the governance and operational structures of the Indigenous EPS, together with the different services offered to traditionally marginalized groups, seems to challenge de Groote’s statement that the “Colombian reform aggravated this situation of undermining people’s attempts to develop community health services.”26 The experience of the EPS also suggests important achievements that go beyond the specific issue of health care. Building upon their collective and individual rights recognized by the Constitution of 1991, the Colombian Indigenous EPS fit into Yashar’s analysis of how Indigenous movements in Latin America are 101



redefining citizenship. Following Yashar’s insights, the Indigenous EPS are part of the redefinition of citizenship in terms of including Indigenous peoples as members of the Colombian nation, recognizing their individual and collective rights and forms of mediation with the state, and including rights that are not only political, but also civil and social.27 While these achievements are undeniable, on the other hand other aspects of the health care reform and the experience of the Indigenous EPS also show the limits and challenges they face regarding the consolidation of their power. A number of issues remain that not only curtail the autonomy of the Indigenous organizations, but limit the potential for improved care and coverage, ultimately putting the entire system into question. First, as has been noted, decentralization under neoliberal models has basically passed duties and responsibilities that had been traditionally associated with the state to private individuals and groups, including Indigenous communities. This relates to the fact that neoliberalism goes beyond economic and social policy to constitute, at its very core, a system of governance based on conceptions that emphasize the predominance and autonomy of the individual. In this sense, power gained in terms of autonomy is counterbalanced by the fragmentation and divisions these reforms generate.28 In the case of Colombia, rather than fostering solidarity among the Indigenous EPS, the system essentially provides incentives for competition (as should be expected from a system based on a managed competition model). For instance, some Indigenous EPS have recruited members within the catchment area of other Indigenous EPS [information obtained through personal communication with the authors]. Although, to some extent, the Indigenous EPS have restrained their competition for membership, it has created some degree of tension and may have harmed the possibility of more enhanced collaborations. This situation mirrors broader developments related to Indigenous organization and that relate to the factious nature of Colombian political struggles. Indeed, the project of a national organization to represent the Indigenous peoples has not been fulfilled, as in the 1990s ONIC was challenged by the creation of other organizations with the same goals, such as AICO (1990), the Indigenous Social Alliance (1992), and the Movimiento Indigena Colombiano (1993).29 102


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Second, the fact that the subsidized regimen has yet to achieve full coverage suggests that the state has not fulfilled the commitments set out in the constitutional reform of 1991.30 This lack of full coverage has forced the Indigenous EPS to use their limited resources to provide some type of services to individuals for which they do not receive funding (called vinculados). Furthermore, the government has refused to regulate legislation, such as law 691, that stipulates a differential unit of payment for Indigenous populations. As well, it has not fulfilled its commitment to adjust the Obligatory Health Plan to include socially and culturally appropriate services to Indigenous populations. In fact, this sheds light on the fact that many of the progressive provisions advanced by the constitution of 1991 have not been actually implemented or recognized by the state, as traditional parties, the legislature, and postconstitution administrations have successfully restricted the possibility of concrete participation in many areas.31 Third, the system is so highly regulated that innovative initiatives, for instance those related to intercultural health that require additional costs, have to be covered from overall funding (not to mention that funding for health information systems has to be carved out of administration).32 Finally, working within the system set up by the state does not preclude conflicts, highlighting problems in the relationship between the Indigenous communities and the state. The risk of working within the framework of a neoliberal state is evident, although for many it does not close the possibility of acting outside that framework. As the Portuguese scholar de Sousa Santos argues, in order to not “waste experience,” it is necessary not only “to fight within the state when the circumstances are appropriate,” but also “to always work and fight outside the state.” According to this author, this strategy of creating “situations of dual power or dual institutionalization” is necessary because “the privatization of the state is important, if not irreversible.”33 The key point of conflict is that state recognition of a variety of identities does not necessarily mean that the state would eventually support those new identity groups in upsetting the existing social and economic structures. In this sense, the constitution of 1991 not only has not been fully implemented, but did not touch the question of distribution of wealth, which actually worsened under the neoliberal reforms of the 1990s. As 103



Histrov sharply points out, as soon as the Indigenous groups act against the interests of landowners or corporations in their historical claims for land, state support is withdrawn and Indigenous peoples’ actions are dealt with as a matter of public security and repression.34 In fact, the main challenge for the Indigenous peoples and their organizations in different areas, including health care, is the relentless violence that has been inflicted upon them by different combatant groups, especially by the military, paramilitaries, and landowners, but also by guerrillas and drug-trafficking groups. More than 400 Indigenous leaders were assassinated between early 1970 and 1996, in a context in which 3,500 trade unionist leaders had been murdered by state and para-state forces in 1986−2002. The situation has deteriorated since then, as Alvaro Uribe’s “democratic security” policies in 2002−2010 have strengthened military and paramilitary groups. ONIC has denounced that, in 2010 alone, 122 Indigenous people were assassinated, 10 disappeared, and 1,146 were forcefully displaced, adding to the large number of Indigenous peoples in the more than four million Colombians displaced from their lands.35 In this sense, the violence exerted against the Indigenous communities by multiple actors seriously undermines the redefinition of citizenship advanced by the constitution of 1991 and represented by the Indigenous EPS. Besides, while Indigenous EPS continue to work within the system and have seized the opportunity to improve the health and well-being of their communities, some Indigenous organizations have nonetheless become increasingly critical of working with the system. Indeed, in its General Assembly of May 2009, CRIC defined a strategy of opting out of the system. While what this would actually mean in practice is still not clear, it signals an unambiguous statement that the pursuit of more autonomy by Indigenous organizations in the governance of their health care is central to their struggles. Conclusion Recent events, such as the Colombian government declaring a state of social emergency in late 2009 and the subsequent rejection in early 2010 of this measure by the Colombian Supreme Court, together with the lack of significant improvement in health care coverage and health 104


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indicators, suggest a relative failure of the privatization of the health care system established by Law 100. 36 In the midst of this system, Indigenous organizations have forged an institutional space of governance over health care with the EPS and IPS. The Indigenous EPS have produced a number of positive developments, such as the provision of effective and efficient, culturally appropriate health care services, increased access to health services, the creation of skilled employment opportunities for Indigenous workers in the health field, the successful management of social enterprises, and the increased participation of women in the health sector, among others. Nonetheless, several serious issues remain. Any progress regarding the Indigenous EPS and other forms of organization has to be measured against the brutal violence experienced by the Indigenous peoples, which has limited their efforts to achieve greater autonomy, independence, and sovereignty. Besides, the managed competition model underlying the entire system favours for-profit companies and limits the options and coverage of the subsidized regimen not-for-profit EPS. The inherent contradiction in the system threatens the achievements of the Indigenous EPS, not to mention the potential political use of the health care legislation and resources by the government to punish “unruly” Indigenous organizations. The biggest irony is that while the Colombian state favours free enterprise in health care, it seeks to constrain the options of social enterprises such as the Indigenous EPS. Interestingly, international donors have also been reluctant to support these authentic community-driven health insurance and delivery organizations. Donors, while paying lip service to participation in health, do not appear willing to fund health programs decided upon by the organizations authentically representing Indigenous communities. Their preference to work with non-representative and “non-political” NGOs is consistent with what seems to be their true motto: “you participate, I decide.” While the Indigenous EPS are part of the institutional space, the representative nature of their governance is the fruit of their ongoing mobilization and struggles outside of the state, and, as such, a threat to the neoliberal agenda.

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Notes 1. 2.

3.

4. 5.

6.

7. 8.

9. 10.

11. 12. 13. 14.

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All quotes originally in Spanish were translated by the authors. J. Petras and H. Veltmeyer, Social Movements and State Power: Argentina, Brazil, Bolivia, Ecuador (London: Pluto Press, 2005); M.A. Centeno and K. Hoffman, “The Lopsided Continent: Inequality in Latin America,” Annual Review of Sociology 29 (2003), pp. 363−390; A. Portes and K. Hoffman, “Latin American Class Structures: Their Composition and Change During the Neoliberal Era,” Latin American Research Review 38/1 (2003), pp. 41−82. D. Yashar, Contesting Citizenship in Latin America: The Rise of Indigenous Movements and the Postliberal Challenge (Cambridge: Cambridge University Press, 2005); G. Collier and E. Quaratiello, Basta! Land and the Zapatista Rebellion in Chiapas (Oakland: Food First Books, 2005); J.A. Lucero, Struggles of Voice: The Politics of Indigenous Representation in the Andes (Pittsburgh: University of Pittsburgh Press, 2008). T. De Groote, P. De Paepe, and J.P. Unger, “Colombia: In Vivo Test of Health Sector Privatization in the Developing World,” International Journal of Health Services 35/1 (2005), pp. 125−141. J. Sanders, “Belonging to the Great Granadan Family: Partisan Struggle and the Construction of Indigenous Identity and Politics in Southwestern Colombia,” in N. Appelbaum, A. Macpherson, and K. Rosemblatt, (eds.), Race and Nation in Modern Latin America (Chapel Hill: University of North Carolina Press, 2003), pp. 56−86 and Contentious Republicans. Popular Politics, Race, and Class in Nineteenth-Century Colombia (Durham: Duke University Press, 2004); P. Wade, Blackness and Race Mixture: The Dynamics of Racial Identity in Colombia (Baltimore: Johns Hopkins University Press, 1993); B. Larson, Trials of Nation Making: Liberalism, Race, and Ethnicity in the Andes, 1810−1910 (Cambridge: Cambridge University Press, 2004); J. Jackson, “Colombia’s Indigenous Peoples Confront the Armed Conflict,” in C. Rojas and J. Meltzer, (eds.), Elusive Peace: International, National, and Local Dimensions of Conflict in Colombia (New York: Palgrave Macmillan, 2005), p. 188; J. Rappaport, “Civil Society and the Indigenous Movement in Colombia: The Consejo Regional Indígena del Cauca,” in E.F. Fischer, (ed.), Indigenous Peoples, Civil Society, and the Neo-liberal State in Latin America (New York and Oxford: Berghahn Books, 2009), pp. 107−123. F. Hylton, The Evil Hours in Colombia (New York: Verso, 2006); N. Richani, Systems of Violence. The Political Economy of War and Peace in Colombia (Albany: State University of New York Press, 2002); C. Rojas, “Elusive Peace, Elusive Violence: Identity and Conflict in Colombia,” in Rojas and Meltzer, Elusive, pp. 209−237. Sanders, “New Granadan”; Rappaport, “Civil Society.” H.E. Restrepo and H. Valencia, “Implementation of a New Health System in Colombia: Is this Favourable for Health Determinants?” Journal of Epidemiology and Community Health 56 (2002), pp. 742−743; R. Rodríguez-Monguió and A. Infante Campos, “Universal Health Care for Colombians 10 Years after Law 100: Challenges and Opportunities,” Health Policy 68 (2004), pp. 129−142. F. J. Yepes, “The Persistence of Health Inequities in Colombia,” FOCAL Point 8/7 (2009), pp. 9−10; “Cobertura en salud, cerca del 83%. Temas Especiales,” El Tiempo (Bogotá, 31 May 2006). N. Homedes and A. Ugalde, “Las reformas de salud neoliberales en América Latina: una visión crítica a través de dos estudios de caso,” Revista Panamericana de Salud Pública/Pan American Journal of Public Health 17/3 (2005), pp. 210−220; A. Cardona, L. M. Mejía, E. Nieto, R Restrepo, “Temas críticos en la reforma de la Ley de seguridad social de Colombia en el capítulo de salud,” Revista de la Facultad Nacional de Salud Pública 23/1 (2005), pp. 117−133. J.H. Gómez Vargas, Legislación Indígena Colombiana (Fundación Gaia, Bogotá, 2002). Rodríguez-Monguió and Infante Campos, “Universal Health Care.” De Groote, De Paepe, and Unger, “Colombia.” Colombia, Ministerio de Salud de Colombia, Dirección General de Aseguramiento, Organización Mundial de la Salud, Organización Panamericana de la Salud, “Evaluación


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17. 18. 19. 20. 21. 22. 23. 24. 25.

26. 27.

28. 29. 30. 31. 32. 33. 34. 35. 36.

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Integral del Equilibrio Financiero del Sistema General de Seguridad Social en Salud” (Bogotá, 2001). While the ESE are also IPS, they are called ESE to distinguish between private and public IPS. Public IPS are known as ESE. N. Mazars, “Multiculturalismo y ‘Descentralización Participativa’ Dentro del Sistema de Salud Colombiano: Estudios de Casos sobre Tres Entidades Promotoras de Salud Indígenas (EPS-I),” unpublished paper presented at the Congress of the Latin American Studies Association (LASA) (Río de Janeiro, June 2009). C. Gros, “Reformas del Estado, Neoliberalismo y Movimiento Social: El Caso de las Empresas Indígenas de Salud en Colombia,” unpublished working document (2008). Dusakawi EPSI-Asociación de Cabildos Indígenas del César y la Guajira, “Misión,” (accessed October 2009). Ibid., “Estructura Organizacional.” Consejo Regional Indígena del Cauca (CRIC), “Somos Pueblo de la Tierra. Somos Pueblo de la Vida. Somos Pueblo de la Resistencia,” PowerPoint Presentation, Popayán, n.d. Mazars, “Multiculturalismo.” G. Torres Izquierdo, A.M. García Carrillo, and A. Izquierdo Gelvis, “Sistema de Atención de Salud Indígena Arhuaco y Recuperación de la Medicina Tradicional,” unpublished document, Wintukwa IPSI (Valledupar, 2006). J. Mignone, J. Bartlett, J. O’Neil, and T. Orchard, “Best Practices in Intercultural Health: Five Case Studies in Latin America,” Journal of Ethnobiology and Ethnomedicine 3/31 (2007). Mignone, Bartlett, O’Neil, and Orchard, “Best Practices.” Collier and Quaratiello, Basta; J. Bandy and J. Bickham Mendez, “A Place of Their Own? Women Organizers in the Maquilas of Nicaragua and Mexico,” in H. Johnston and P. Almeida, (eds.), Latin American Social Movements. Globalization, Democratization, and Transnational Networks (Rowman and Littlefield, Oxford, 2006), pp. 131−144. De Groote, De Paepe, and Unger, “Colombia,” p. 138. Yashar, Contesting Citizenship; M.C. Ramírez, “The Politics of Identity and Cultural Difference in the Colombian Amazon: Claiming Indigenous Rights in the Putumayo Region,” in D. Maybury-Lewis, (ed.), The Politics of Ethnicity: Indigenous Peoples in Latina American States (Cambridge, MA: David Rockefeller Center Series on Latin American Studies, 2002), pp. 135–168. Collier and Quaratiello, Basta; Rappaport, “Civil Society;” E. Fischer, “Introduction. Indigenous Peoples, Neo-Liberal Regimes, and Varieties of Civil Society in Latin America,” in Fischer, Indigenous Peoples, pp. 1−18. Jackson, “Colombia’s Indigenous Peoples,” pp. 194−196. De Groote, P. De Paepe, and Unger, “Colombia.” Jackson, “Colombia’s Indigenous Peoples,” p. 193. Mignone, Bartlett, O’Neil, and Orchard, “Best Practices.” B. De Sousa Santos, Renovar la Teoría Crítica y Reinventar la Emancipación Social: Encuentros en Buenos Aires (Buenos Aires: Universidad de Buenos Aires, CLACSO, 2006), p. 107. J. Histrov, “Social Class and Ethnicity/Race in the Dynamics of Indigenous Peasant Movements: The Case of CRIC in Colombia,” Latin American Perspectives 167/36 (2009), pp. 41−63. Jackson, “Colombia’s Indigenous Peoples,” 194−197; El Tiempo, “122 Indígenas Fueron Asesinados en Colombia durante 2010”(15 January 2011), . Asociación Latinoamericana de Medicina Social- ALAMES, “Colombia Profundiza la Exclusión en Salud- Declaración No. 4-2010” (2010).

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