Bill & Melinda Gates Foundation

A Field Visit to the Kuna Territory in Mesoamerica

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April 30, 2013

On a recent trip to Panama to look at innovative health investments, we visited the communities of Carti and Wichub-Huala, in the San Blas Islands archipelago, an autonomous territory of the Kuna Peoples.

The Kuna participate in the Salud Mesoamerica 2015 initiative (SM2015) that the Gates Foundation is jointly funding with the Carlos Slim Health Institute, the Inter-American Development Bank (IADB), the Governments of eight Mesoamerican countries, and the Spanish Bilateral Aid Agency. SM2015 is a catalytic initiative that uses an outcomes-based funding approach to support Mesoamerican governments in implementing pro-poor policies and programs that improve the health of women and young children in rural areas.

At the first community we visited, we were greeted by Mr. Gardi Sugdub, First Sahila (Chief) of the tiny islet of Carti, who was chosen by the community to lead their public affairs because of his proven wisdom and ability to articulate the People’s rich oral tradition as “keeper of metaphor.” Shaila Sugdub highlighted the high value the Kuna people place on protecting the health of their women and children. However, he also underlined the need for respecting Kuna traditions because, as he put it, “people who lose their tradition, lose their soul.”

We also met Ernesto Harris, Secretary of Carti’s Kuna Council. Ernesto went to college in the United States and, upon returning to the Kuna Territory, became part of the community’s leadership. Having “seen the world,” he felt his responsibility was to serve as a connector between his people’s needs and the external sources of knowledge that can benefit them. He reminded us that, in order to have lasting impact, investments in Carti’s local health system should not only consider valuable elements like a functioning infrastructure, available supplies, and well-trained personnel but, also, clean water and education.

Our conversations with these two local actors highlighted some of the challenges and opportunities faced by the SM2015 initiative in all eight participating countries and territories. We know, for instance, that traditions can be at odds with population health. The consequences of this conflict can be exemplified by delays in the management of complicated pregnancies which often contribute to the high number of maternal deaths among the poorest populations in Mesoamerica. To respond to these types of cultural challenges, SM2015 is taking into account existing social norms and behaviors of the local communities when implementing its health programs. 

Ernesto also reminded us that health is determined by many factors in addition to behavior – including the supply of health products and services. Like him, we believe that for the Gates Foundation’s work to truly act as a catalyst for change and have a lasting impact, we need to do a better job at putting together investments that integrate multiple sectors like water, hygiene, and health.  The SM2015 partnership is a great example of how to do this, as different sponsors have the complementary resources and knowledge to oversee a comprehensive program for maternal and child health.

At the end of our visit we spent time with Ernestina Scott, Carti’s local nurse who moved from Panama City to the Kuna Territory 20 years ago and never left. Ernestina has a true passion for her work, and this passion motivates her to stay despite obviously difficult conditions. Through our interactions with Ernestina and other local health care providers we got a glimpse into Carti’s primary health care system.

As we reflected on the interactions we had with local residents, community leaders, and health care providers, we were left with a strong sense of optimism as the local health system in Carti –and across the other seven countries involved in the SM2015 Initiative – start implementation of this unique program.

We believe that this program’s innovative outcomes-funding approach can create powerful incentives for improving the policy and financial environment across Mesoamerican health systems. However, its ability to drive lasting impact at scale will ultimately depend on the ability to effectively encourage local health care providers and households to improve their practices and behaviors.

We were genuinely impressed by the positive energy and the degree of commitment to improving population health that was evident among the people that we met in Carti. We were also humbled by the wisdom of this ancient community and their capacity to survive under conditions of extreme hardship.

 
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