Why women don't go

Material Information

Why women don't go influencing poor quality of care and low attendance in free reproductive health care services in Bolivia
Otis, Kelsey Elizabeth
Place of Publication:
Denver, Colo.
University of Colorado Denver
Publication Date:
Physical Description:
ix, 107 leaves : ; 28 cm

Thesis/Dissertation Information

Master's ( Master of Arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Anthropology, CU Denver
Degree Disciplines:
Committee Chair:
Brett, John
Committee Members:
Scandlyn, Jean
Clark, Lauren


Subjects / Keywords:
Maternal health services -- Bolivia -- Yapacaní ( lcsh )
Medical care -- Utilization -- Bolivia -- Yapacaní ( lcsh )
Women -- Social conditions -- Bolivia ( lcsh )
Maternal health services ( fast )
Medical care -- Utilization ( fast )
Women -- Social conditions ( fast )
Bolivia ( fast )
Bolivia -- Yapacaní ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Includes bibliographical references (leaves 99-107).
General Note:
Department of Anthropology
Statement of Responsibility:
by Kelsey Elizabeth Otis.

Record Information

Source Institution:
|University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
123127854 ( OCLC )
LD1193.L43 2006m O74 ( lcc )

Full Text
Kelsey Elizabeth Otis
B.A., Northwestern University, 2003
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts

This thesis for the Master of Arts
degree by
Kelsey Elizabeth Otis
has been approved
Jean Scandlyn
Lauren Clark

Otis, Kelsey Elizabeth (M.A., Anthropology)
Why Women Dont Go: Structural and Social Factors Influencing Poor Quality of
Care and Low Attendance in Free Reproductive Health Care Services in Bolivia
Thesis directed by Assistant Professor John Brett
In 2002, Bolivia implemented a locally controlled maternal-infant insurance
program, Seguro Universal Matemo Infantil (SUMI), which completely covers the
costs of pregnancy related care in governmental health services for ah women.
Bolivia has the highest maternal mortality rate in South America, and the goal of
SUMI is to ensure equity in access to quality reproductive health care in order to
decrease pregnancy related mortality risk. Despite these free services, many
pregnant women in the rural, tropical municipality of Yapacanf remain home to
give birth. This study uses qualitative methods, including participant observation
and semi-structured interviews with community members and regional experts, to
identify the main reasons for the low rate of institutional birth in Yapacanfs public
health care sector from a socio-ecological, critical medical anthropology
perspective. Results of the study reveal that the low quality of care offered in
governmental health services, including poor treatment of women by health care
personnel and lack of resources, is the main reason that many women do not give
birth institutionally. Political-economic and large scale social influences on this
low quality of care in Bolivias decentralized health care system are identified and
discussed. Initial results of the study were shared with regional health care
administration in the province of Ichilo (of which Yapacanf is one municipality),

who subsequently formulated recommendations for the improvement of
reproductive health services in the region.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.

My thanks to my advisor, John Brett, for his dedication to making sure I developed
and completed a successful research project. He went above and beyond the call of
duty and even traveled by plane, taxi, and motorcycle to visit me in Yapacanf to
help design the research. Huge thanks go also to all those at CEPAC who helped
me with my research, and to all of the key interviewees who offered endless
insights. Thank you to Jean Scandlyn and Lauren Clark for reviewing my thesis
and offering valuable comments and expertise. I would also like to acknowledge
the Institute of International Education for the receipt of the 2005 Petry scholarship
which allowed me to travel to Bolivia to complete this research; and the
Anthropology department at UCD for the additional financial contribution to my
trip. Finally, thanks to my family for their overwhelming encouragement and
support of my education.

1. INTRODUCTION.!..................................................1
Maternal Mortality in Bolivia................................3
Bolivian Health Care System..................................6
CRITICAL MEDICAL ANTHROPOLOGY..................................15
Socio-Ecological, Political-Economic Examinations of
Maternal Mortality..........................................17
3. METHODS........................................................28
Setting: Yapacani, Bolivia..................................28
Research Design and Qualitative Methods.....................31
Data Collection Methods................................33
Data Analysis..........................................38
Failed Plans for Institutional Birth........................42
Why Do Women Not Go to the Health Service to Give Birth?.43
Lack of Perceived Need for Health Services.............44
Ability to Physically Access Services at Time of Birth.48

Receiving Adequate Care When a Facility Is Reached.50
Structural Constraints on Yapacanf s Health Resources...53
Design of Bolivian Health Care System and SUMI:
Where Are We Going to Get Money to Make SUMI
Function Like We Want It To?Yapacanf Doctor......55
Design of Bolivian Health Care System and SUMI:
Politics......................................... 61
Faulty Functioning of a Decentralized Health System:
Politics Curb the Many Advantages [of Decentralization]
Representative of Yapacanf Government..................68
Authoritative Knowledge and Poor Treatment by Personnel.72
Not Knowing: Lack of Provider Knowledge of
Culturally-Appropriate Services....................73
Not Being Able To: Provider Inability to Offer
Culturally-Appropriate Services....................73
Not Wanting To: Unwillingness to Respect
Culture of Rural Bolivian Women....................74
6. CONCLUSION.................................................88
Reactions of Health Administrators to Research Findings.91
A. ACRONYMS..................................................95
B. SEMI-STRUCTURED INTERVIEWEE FORM..........................96

1.1- Bolivian Health Care System (MSD 2002)...............................11
3.1 Location of Yapacanf Within Bolivia (CEPAC)..........................29
4.1 Why Do Women Not Go to the Health Services to Give Birth?............44

1.1 Maternal mortality ratios (UNFPA 2005)................................4
3.1 Categorization of female interviewees by location and birthing status.35
3.2 Categorization of male interviewees by location and wifes birthing
3.3 Key interviewees organizations......................................37
3.4 Category 2 interview data codes......................................39
3.5 Full code list for grounded-theory approach..........................41
6.1 CECARI recommendations...............................................93
A.l Acronyms ............................................................95

This research has taken place through a collaboration with CEP AC (Centro
de Promotion Agropecuaria Campesina, Center for the Promotion of Farmers), a
grassroots non-governmental organization (NGO) that works in rural municipalities
within the department of Santa Cruz, Bolivia. One of CEPACs missions is to
strengthen the quality and administration of existing governmental health services,
including hospitals and sanitary posts, to improve the health of the Bolivian
population. They accomplish this goal through close collaboration with
governmental health administrators in the rural areas of Santa Cruz. For example,
CEPAC and regional health administrators convene for monthly meetings to
monitor municipal health indicators and devise solutions to identified problems
(i.e., low rates of institutional birth or high prevalence of tuberculosis) and also to
conduct supervisory visits to health posts and hospitals in order to monitor the
quality of care in the region and offer advice and encouragement to health workers
in rural areas. This organizations work in Bolivia illustrates the growing
cooperation of NGOs and national ministries of health in the provision of health
services in the developing world.
As a volunteer intern with CEPAC in the summer of 2005,1 worked in
Yapacam, a tropical, rural municipality that, according to the local hospital, has
approximately 52,500 total residents. During my internship, I learned that statistics
collected by governmental health workers in Yapacam indicate that few women
(37% of the pregnant female population) utilized the governmental reproductive
health services when giving birth in 2004. The remaining 63% of women can be

assumed to have paid for private sendees, remained at home to give birth, or
traveled a significant distance to other municipalities health services. Given that
birthing services are free of charge for all pregnant women in governmental health
facilities under Bolivias newly implemented SUMI (Seguro Universal Matemo
Infantil, Universal Maternal Infant Insurance) insurance program, and that many
women access Yapacanfs governmental health services for prenatal visits (80% in
2004), the low rates of institutional births in governmental health settings in
Yapacanf are perplexing and deserve further investigation. It is important to note
that, to my knowledge, no other organizations provide reproductive health services
free of charge in this highly impoverished municipality. This investigation into the
low utilization of services at time of birth is also important given that, according to
health officials, the Bolivian Ministry of Health and Sports (Ministerio de Salud y
Deportes, MSD) set a national goal of 80% coverage of institutional births in 2004,
which was not met by Yapacanf.
This low utilization of services at time of delivery has also been identified
as a problem by the staff of CEPAC and the manager of the governmental health
administration in Yapacanf, who are both concerned about the potential risks to
women giving birth without access to emergency obstetric care. Therefore, this
research took place with the support and collaboration of both CEPAC and
Yapacanfs governmental health administration.
From a socio-ecological medical anthropology perspective, political-
economic factors, geographic factors, socio-cultural factors, and individual factors
influence womens utilization of public reproductive health services in Yapacanf at
the time of delivery. My study aims to elucidate the way in which these factors
interact, causing pregnant women to not access free reproductive health services
provided by the Bolivian government. I do not aim to generalize this analysis of

one rural context in Bolivia to the entire country; however the study is an important
step in understanding the successes and failures of governmental reproductive
health interventions in the context of persistently high maternal mortality rates.
Carol Boenders (2000) research in urban Bolivia identified factors that influence
the continued occurrence of home births in the capital city of La Paz regardless of
the existence of free maternal health care services. Similar studies, discussed in the
next chapter, have taken place in other countries. Therefore, my research adds
perspective from rural Bolivia and highlights similarities with findings in urban
Bolivia and other international settings.
Maternal Mortality in Bolivia
The United Nations Millennium Development Goals represent a global
consensus on the eight priorities for reducing global poverty and ill-health by the
year 2015. Millennium Development Goal Number Five is to improve maternal
health by reducing the global maternal mortality ratio by three-quarters (UN 2005).
Currently, more than half a million women, the majority of whom live in poor
countries, die each year due to pregnancy-related complications (UN 2005). While
the United Nations has reported progress towards its goal of reducing global
maternal mortality, it is important to consider why these improvements are not
distributed evenly among pregnant women across the globe. Bolivias maternal
mortality ratio of 420 per 100,000 live births is extremely high in comparison with
other countries in Latin America, making it a particularly appropriate setting for
this study (See Table 1.1) (UNFPA 2005).

Table 1.1 Maternal mortality ratios (UNFPA 2005)
Country Maternal Mortality Ratio (per 100,000 live births)
Argentina 82
Bolivia 420
Chile 31
Equador 130
Peru 410
Complications that can lead to death occur in about 15% of pregnancies in
the world, and, given the nature of complications (infections, obstructed delivery),
screening procedures are not as effective as getting adequate care at time of
delivery in preventing deaths (Bames-Josiah et al. 1998). The disparities in
mortality ratios between developed and developing countries as reported by the
United Nations (UN 2005) underscore the largely preventable nature of these
deaths and the importance of access to a medical setting where pregnancy and birth
complications can be managed. Most maternal deaths occur during childbirth, and
delivering in a biomedical institution with trained medical staff is associated with
lower rates of maternal mortality and morbidity than giving birth at home
(Stephenson et al. 2006). Receiving medical care in a health facility has several
advantages over giving birth at home, including the ability to identify relevant risk
factors and resolve complications and emergencies, and the presence of,
presumably, hygienic conditions (Sesia 1996; Paul and Rumsey 2002). Because
the successful resolution of obstetrical complications can significantly reduce the

likelihood of maternal mortality, the majority of previous investigations into the
factors that influence disparities in maternal mortality distribution have used rates
of delivery in a biomedical facility as a proxy for mortality risk (Stephenson et al.
2006; Berry 2006; Mavalankar and Rosenfield 2005; Kyomuhendo 2003;
Stephenson and Tsui 2003; Paul and Rumsey 2002; Griffiths and Stephenson 2001;
Amooti-Kaguna and Nuwaha 2000; Midhet et al. 1998; Thaddeus and Maine
As Sesias (1996) study with midwives (parteras) in Mexico has shown, the
integration of traditional or ethno-medical' with biomedical systems of
reproductive health care has been limited by several aspects of these contrasting
knowledge bases. For example, ethno-medical perspectives of childbirth view the
relationship between midwives and women as egalitarian and view childbirth as a
natural process without many inherent risks. In contrast, Western biomedicine
values hierarchical relationships between patients and caregivers, and views
childbirth as medicalized and risky (Sesia 1996). Given these difficulties, it is
reasonable to assume that until efforts to successfully link traditional birth
attendants (also called parteras in Bolivia) with biomedicine are realized, the
greatest likelihood of a woman surviving pregnancy occurs when women access
well-equipped (i.e., sanitary, and with trained staff and resources for resolving
obstetric emergencies) biomedical facilities at time of delivery. Therefore, in this
study I use the rate of utilization of biomedical (rather than ethno-medical) health
care services as a proxy for the degree of risk for maternal mortality. This is not a
perfect proxy given the sometimes low quality of biomedical reproductive care in
Bolivia which complicates efforts to promote institutional births, as will be
discussed below.

The Bolivian context for studying maternal mortality is particularly
interesting due to the countrys history of political unrest and economic instability,
along with deep ethnic-based and class-based conflicts, all of which may influence
the provision of health care services and the distribution of maternal mortality.
Maternal health disparities are manifested in the rates of births attended to in an
institutional setting in different socio-economic classes (data from 1998); 19.8% of
women in the poorest quintile of the population are attended to by a skilled health
care professional versus 97.9% of women in the richest quintile (UNDP 2005).
Also, maternal mortality ratios in Bolivia have been estimated to be 274 per
100,000 live births in urban areas versus 524 in rural areas, highlighting inherent
inequalities in maternal mortality based on geographic location (PAHO 2003).
These inequalities presumably stem from the existence of fewer medical clinics in
rural areas, economic disparities between urban and rural contexts, and
cultural/class/race differences between largely-Indian rural populations and
Western-trained, mestizo medical staff which can influence the success of maternal
health interventions. This research into reproductive health care in a poor, rural
Bolivian context is particularly appropriate given these disparities in mortality
Bolivian Health Care System
Bolivia is also an important setting for examining maternal mortality given
that the government has recently implemented various iterations of a maternal-child
health program, beginning with the National Maternal Child Insurance Program
(Seguro Nacional de Matemidad y Niiiez, SNMN) in 1996, followed by the Basic
Health Insurance Program (Seguro Basico de Salud, SBS) in 1998, and culminating

in 2002 with the universal insurance plan SUMI. All of these iterations have been
aimed at reducing maternal-child mortality and ensuring equity in access to health
care (Rosseau 2004; MSD 2004). Through the 1980s in Bolivia, social security
pensions that only covered roughly 20% of the population (those employed in the
formal sector) had been the only government-subsidized health service available
(Library of Congress 1989). Also, strict neoliberal restructuring in the 1980s,
including the commoditization of health through privatization and user fees, limited
the access of the population (largely agricultural and informal economy workers) to
health services (Rosseau 2004). Bolivia has prioritized pregnant women and
children in their recent attempts to increase the populations access to health care
and to address the Millennium Development Goals set forth by the United Nations
(UN 2005). The primary health care movement which was introduced following
the Alma Ata Declaration of 1977 is the model for these maternal-health
interventions (Lewis et al. 2004). It emphasizes prevention and basic care as an
efficient and affordable way to deliver health care to low income populations in
developing countries.
These primary health care reforms are described in the Bolivian Ministry of
Healths document National Health Politic: health, a right and responsibility of
air (MSD 2004). They include (translated from Spanish): 1) Design and
implementation of public insurance systems, including SUMI; 2) Implementation
of a management system which relies on an evaluative and sectorial control
mechanism in a decentralized system; and 3) Quality and regulation, which have
led to better quality of care and the designing of valuable instruments for the
integrity of the system in order to support communities exercising their right to

health (MSD 2004).1 However, the Ministry of Health recognizes that the
successes of these health care reforms have been limited to a few establishments
and that true transformations will be challenging (MSD 2004). Evaluations of
SNMN and SBS (SUMIs predecessors) by the Pan American Health Organization
(PAHO) concluded that they did not reach the poorest population groups; that they
were not publicized or well-known, especially in rural areas; that municipal
governments were very slow to pay for the services; that the availability of medical
supplies was a problem; and that there were disparities in the use of municipal
funds (PAHO 2001). The ability of the three Bolivian health reforms (universal
insurance, decentralized management and quality control at the local level) to
ensure successful implementation of the new comprehensive maternal-health
insurance program (SUMI) remains to be fully evaluated by the government or
other researchers. Chapter five addresses this need by discussing various
complications inherent in implementing SUMI that are similar to those indicated in
SUMIs predecessors by PAHO (2001).
The neoliberal strategy of decentralization is aimed at reducing the
inefficiency of a centrally-based system of power. As a direct effect of the national
Popular Participation Law (Ley de Participation Popular, LPP) of 1994, Bolivias
health care system has been decentralized and responsibility and resources for
service provision have been delegated to the level of the municipality. Under this
law, which encourages the participation of the Bolivian people in all aspects of the
government, the administration of the governmental health care system is under the
control of DILOS (Direction Local de la Salud, Local Directorate of Health)
committees in each municipality. DILOS committees are made up of a
1 All translations are done by the author.

representative from the municipal government (e.g., Yapacanf s mayor), a
representative from SEDES (Servicios Departamental de Salud, Departmental
Health Services) (e.g., Santa Cruz regional health administration), and a
representative of the comite de vigilancia (vigilance committee) which is composed
of various community and neighborhood organizations. The system continues to
be fundamentally vertical, with the national Ministry of Health and Sports
(Ministerio de Salud y Deportes, MSD) in La Paz, the capital city, having ultimate
control over many key resources (e.g., health workers salaries) and administration.
The Ministry of Health delegates resources to the departmental level (e.g., Santa
Cruz) that then sends them to the municipal level (e.g., Yapacanf) and oversees
their dissemination. The main effect of decentralization is that the municipalities
have the potential to prioritize certain projects pertaining to health. In theory,
representatives from each community in a municipality (for example, in Yapacanf,
there are 10 different communities in addition to the urban center) get together each
year and prioritize the way that resources will be used in the municipality. In this
way, community leaders from Territorial Organizations (Organizaciones
Territoriales de Base) contribute to the formation of the municipalitys POA (Plan
Operativa Anual, Annual Operative Plan) which designates the municipalitys
financial plan for the year. Further discussion in Chapter five will analyze the
functioning of Bolivias complex decentralized health system and its ability (or
inability) to meet the goals of LPP in relation to reproductive health care.
In terms of the provision of services, there are three levels of health care
centers: the Third Level (Tercer nivel de atencion), which includes highly
specialized hospitals with the most modem resources generally only found in
departmental capital cities (e.g., Santa Cruz and La Paz); the Second Level
(Segundo nivel de atencion), which includes small hospitals with health personnel

from the four basic specialties of pediatrics, gynecology-obstetrics, surgery, and
general medicine; and the First Level (Primer nivel de atencion), which includes
sanitary posts and health posts with minimally-trained health workers (auxiliares)
and sometimes one general doctor. In addition to health care centers, community
health volunteers (Responsables Populares de Salud, RPSs) serve as an
intermediary, facilitating the access of the community to health services. Their
presence is especially crucial in rural communities without health care centers. The
RPSs job is to provide education and promote healthy practices, not to give out
medicine; they evaluate risk and can make references to health posts, but cannot
actually provide services themselves. See Figure 1 for a diagram of the Bolivian
health care system.
The governmental health care system is designed such that resources (i.e.,
medicine, money) are allocated from the national level based on the monitoring of
services provided by municipalities. Each municipalitys health centers must keep
track of the services that they provide (e.g., fifteen births attended to, twenty
diarrheas identified and treated, etc.) in order to get reimbursed. In theory, the
information is passed up the vertical ladder of the health system, from municipality
to departmental SEDES to national MSD in the form of monitoring forms, and the
money then goes down the ladder back to the municipality. Because of this,
governmental health workers at the local level spend much of their time filling out
forms to document the type and amount of medical attention that they give (a
potential problem discussed in Chapter five).
The last goal of the governmental health reform is the monitoring of the
quality of services provided at the local level by municipal health administrations.
In other words, the central government transfers quality control efforts to the local


^ iNsmuios
i "
Mciik wi
, tradition*!
Figure 1.1 Bolivian Health Care System (Figure Adopted From MSD 2002)

level in order to ensure proper functioning of the decentralized system. In
Yapacani, the NGO CEP AC contributes to this goal through their project
Strengthening of Quality and Management (Fortalecimiento de Calidad y Gerente)
whose goal is to lower the maternal-infant mortality rates (and improve other health
indicators) through the betterment of the health administration in Yapacani and
surrounding municipalities in the provinces of Sara and Ichilo. This project
includes: 1) assisting municipal health services with their Information Analysis
Committees (Comites de Analysis de Information, CAI) which meet periodically to
review health indicators and prioritize areas of need; 2) working with health
administration to monitor the quality of health services in municipalities through
site visits; and 3) providing technical assistance in management, administration,
and logistics to the health authorities in the provinces of Sara and Ichilo (of which
Yapacani is one municipality).
In accordance with the national politics explained above, SUMI is managed
and implemented by the 328 municipal governments throughout Bolivia. The
central Ministry of Health remains responsible for the salaries of health care
workers, and the regulation, control, and supervision of SUMIs implementation.
Municipalities themselves are responsible for maintaining the infrastructure and
supply costs of implementing the SUMI program. SUMI is maintained by three
funding sources: 1) the National General Treasury (El Tesoro General de la
Nation) which provides salaries for human resources; 2) 10% of LPP funds given
to municipalities from the central government which are specifically designated for
SUMI medicines and supplies; and 3) up to 10% of The Special Fund of the 2000
Dialogue (La Cuenta Especial del Dialogo 2000), established with the goal of
alleviating poverty after Bolivia was relieved of its debts in 2000, which can be
used for improving the quality of public health services, including infrastructure,

equipment, supplies, and training (MSD 2002). Additional funds needed for the
functioning of SUMI and the health system must be generated independently by the
With the initial implementation of SUMI, health care workers and
administrators were given in-depth training on the legal framework (including the
laws explained above in relation to SUMI); the management model (including
explanations of the responsibilities and functions of the different levels of the
system; i.e., MSD, SEDES, DILOS, and the community Vigilance Committees); a
detailed explanation of SUMIs coverages, exclusions, and funding sources; and
instruction on how to fill out SUMIs monitoring forms (MSD 2002). The stated
expenditures allowed under SUMI are: 1) essential ambulatory care; 2)
hospitalization; 3) complementary medical and surgical diagnostic and treatment
services; 4) supplies, essential medicines, and traditional natural products; 5)
transportation for gynecological/obstetrical and pediatric emergencies; and 6)
coverage of expenditures of other national programs for the SUMI population (e.g.,
malaria, syphilis care for pregnant women) (MSD 2002).
The SUMI Implementation Manual (MSD 2002) emphasizes that it is a
universal, essential, and free initiative for 1) pregnant women from the beginning
of their gestation period until six months after they give birth, and 2) children from
their birth until they are five years old. It also emphasizes that, when appropriate,
SUMI will accommodate itself to the incorporation of traditional medicine. It
states that SUMI expenditures are adapted to the uses, customs, languages, and
dialects respecting identity, cultural bases, and a focus on gender (MSD 2002).
Specifically, via trainings, health workers are said to receive information about
provision of humanized birth services (partos humanizados) which respect
Bolivian womens cultural preferences in position and ambiance at time of birth in

SUMI care. Chapter five discusses reasons for the lack of inclusion of humanized
births and traditional medicine at the local level in Yapacanfis reproductive health

This research is grounded in a socio-ecological medical anthropology
framework which views health as the result of a complex interaction between
ecological, biological, and social factors (Janes and Chuluundorj 2004; McElroy
and Townsend 2004; AbouZahr et al. 1996). Ecological models in medical
anthropological research assess how events, processes, and factors occurring
across the social scale get into the body through a series of interactions (Janes
and Chuluundorj 2004:231). They are concerned with describing social conditions
in order to give context to individually-based risk factors and describe what puts
people at risk of risks (Link and Phelan 1995:80). From this viewpoint, maternal
mortality is understood to take place within a specific social, cultural, geographical
and political context, and is not simply the result of proximal medical factors such
as hemorrhage, sepsis, infection, eclampsia, obstructed labor, or unsafe abortion
(UN 2001). The social and ecological factors influencing poor reproductive health
must be teased out in any in-depth analysis in order to accurately describe problems
and suggest potential solutions. Link and Phelan (1995) point out that such
research has the potential to increase the success of large-scale health interventions
such as SUMI by illuminating fundamental social influences on morbidity and
This research is also grounded in critical medical anthropology or political
economy, a complementary approach to a socio-ecological understanding of health.
Medical anthropological political economy is a critical perspective which examines
the health consequences of global power relations (McElroy and Townsend 2004).

This perspective takes into account the social and historical roots of disease and
health care, with particular attention to the existence of stratified social relations
within a world economic system (Morgan 1993:2). It is a macro-level approach
whose analyses emphasize the influence of broad social factors (such as poverty
and power) and the world economic system on individual health rather than
focusing on individual choices and susceptibility to disease at the community level
(McElroy and Townsend 2004). Political economy in anthropology does not
blindly focus on macro-level, structural factors at the expense of ethnographic
details of individual experience and culture, but rather seeks to understand the
dialectical relationship between political-economic factors and social actors (Morsy
The ecological and political-economic perspectives in medical anthropology
are synthesized nicely in Millards (1994) causal model of child mortality based on
research from rural Mexico, Central America, and Africa. This model
contextualizes child mortality as a result of proximate, intermediate, and ultimate
tier influences which interact to influence whether or not a child dies. Proximate
causes include biological causes of individual death, intermediate causes include
behavior and aspects of general living conditions that influence childrens exposure
to proximate causes, and ultimate influences are the broad political-economic
forces that lead to social inequalities and differential access to resources necessary
for child survival (Millard 1994). While this model is specifically designed to
explain high rates of child mortality, its basic premise of proximate, intermediate,
and ultimate tier influences can be utilized to describe causes of maternal mortality.
An example of a political-economic analysis in medical anthropology is
Lynn Morgans ethnography of health policy in a rural banana-growing Costa
Rican community (Morgan 1993). She documents how health policy related to

community participation in health in international primary health care has
become politicized, influencing its success at the community level. Morgan shows
that the interactions between different levels (international, national, local) are
interdependent and dialectical in relation to the successful implementation of
community participation at the local level.
In relation to maternal mortality, the political-economic perspective
considers the macro-level, structural determinants which influence whether or not
pregnant women survive childbirth (or, in the case of this research, receive
appropriate institutional care at the time of birth). Complementing the ecological
perspective of maternal mortality, political-economic consideration of the macro-
level forces involved in reproductive health care policy (specifically SUMI) allows
for a more complete analysis of the many factors influencing whether or not
women give birth in an institutional setting in Yapacanf, Bolivia. Like Morgan, I
seek to consider the dialectical interactions between international, national, and
local levels that influence the implementation of health policy. In my case, the goal
of the research is to understand the various factors influencing successful provision
and utilization of services for pregnant women in Yapacanf, Bolivia.
Socio-Ecological, Political-Economic Examinations of Maternal Mortality
Previous research has used a socio-ecological theoretical framework to
examine maternal mortality and to describe the interacting factors influencing its
prevalence. Bames-Josiah et al. (1998) developed the Three Delays model from
their work in Haiti, a country with maternal mortality rates even higher than
Bolivia. This model provides a way to understand pregnancy-related mortality as a
result of delays in 1) deciding to seek appropriate medical help for an obstetric

emergency, 2) reaching an appropriate obstetric facility, and 3) receiving adequate
care when a facility is reached (Barnes-Josiah et al. 1998). It allows for analysis of
the complex interplay between womens personal perceptions and decisions, the
difficulties they experience in reaching an appropriate facility, and the quality of
care they receive once they arrive (Barnes-Josiah et al. 1998). Within the Three
Delays Model, three different sets of factors influence whether or not women
access quality biomedical health services when giving birth. These include 1)
personal perceptions and decisions; 2) logistical factors in accessing health
services; and 3) structural factors influencing quality of care at existing health
services (Barnes-Josiah et al. 1998). The Three Delays model assumes that
preventable maternal mortality occurs primarily because of a lack of access to
quality, culturally-appropriate reproductive health care services, and thus seeks to
explain the multi-level factors that prohibit women from accessing these services
(Barnes-Josiah et al. 1998).
Much research into maternal health, primarily in Africa, India, Bangladesh,
Pakistan, Mexico, El Salvador, Bolivia and Guatemala, has been done on the three
levels of factors represented in Barnes and Josiah et al.s (1998) Three Delays
Model (Berry 2006; Stephenson et al. 2006; Mavalankar and Rosenfield 2005;
Kyomuhendo 2003; Stephenson and Tsui 2003; Paul and Rumsey 2002; Griffiths
and Stephenson 2001; Amooti-Kaguna and Nuwaha 2000; Boender 2000; Castro et
al. 2000; Schneider and Gilson 1999; Midhet et al. 1998; Thaddeus and Maine
1994). These studies have identified health infrastructure, socioeconomic
environment, neglect and abuse in the medical setting, individual perception of
services, previous birth experience, influence from spouse and family members,
concepts of normal versus abnormal pregnancy, womens role in the decision
making process, geographic distance, fertility preferences, and cultural birth-related

knowledge as factors that influence womens decision to seek care and their ability
to access biomedical care at time of delivery.
Boenders (2000) study in urban Bolivia revealed that economic barriers
(the second delay in Three Delays Model (Bames-Josiah et al. 1998)) did not
directly influence womens birth setting, but rather that womens personal
decisions and assessment of risk (the first delay in Three Delays Model (Bames-
Josiah et al. 1998)) were the most important. The research concluded that both
structural and ideological factors influenced womens decision making, and that
fear and embarrassment (vergtienza) to be cared for in an institutional setting
played a large role womens assessments of the risks and benefits involved in going
to the health service to give birth.
Many studies conclude that the nature of care offered in governmental
reproductive health services (the third delay in Three Delays Model (Bames-Josiah
et al. 1998)) is the largest determinant of whether or not women access these
services at the time of birth. For example, Schneider and Gilsons (1999) research
in South Africa revealed that, although free reproductive health services offered
beginning in 1994 were aimed at reducing inequalities in health status in post-
apartheid South Africa, basic gaps in quality of care still existed. Their in-depth
study of health care facilities in 13 diverse sites throughout South Africa revealed
attitudinal barriers to womens access and utilization. These included a strong
reaction against free care policies from front-line providers. A survey of health
care providers documented the presence of powerful beliefs that
Free care leads to abuse of care is encouraging
women to become pregnant...patients attend services to collect free
drugs and then resell them to others...and foreigners will come to
South Africa to use free services (98).

This led community members to frequently cite hostile and judgmental attitudes of
front-line providers as a reason for not utilizing the free services (Schneider and
Gilson 1999:98). The appropriate infrastructure for maternal care (i.e., free
services being available) is not sufficient for an increase in womens access to
quality care and subsequent decrease in maternal mortality rates in this context.
This issue of health professionals attitudes is discussed further in Chapter five.
Similarly, Bames-Josiah et al.s (1998) study in Haiti found that a lack of
faith in modem obstetric care was common, due to the poor quality of care
perceived by pregnant women. They define the various aspects of quality health
care as provider competence, provider-woman information exchange, interpersonal
relations, and mechanisms to ensure continuity of care (1998:987). Additionally,
Sesias research in Mexico revealed that that great majority of village women view
ethno-obstetric values of the parteras as authoritative, and therefore it is a
challenge to get them to buy into a strict biomedical system (1996). Unfortunately,
Despite a formal discourse to the contrary, institutional MHC
[maternal child health] policies and services at the primary-care
level continue to be largely directed by an ideology that strives for
modernization, sophisticated technology, and the medicalization of
pregnancy and childbirth (Sesia 1996:134),
and thus almost no women take advantage of free reproductive health services.
This culture clash between communities with non-Westem cultures and Western-
trained medical providers is thus one of many potential social factors negatively
influencing access to care in various contexts throughout the developing world, and
will be discussed further in Chapter five.
A study by Sargent and Bascope (1997) in Jamaica revealed that women
also showed strong dissatisfaction with their experiences delivering in a hospital in
the capital city Kingston. Considering the pressure to have an attended birth,

women were unattended, even if they were in the hospital, and family were not
allowed in the delivery room. Similarly, they conclude that a combination of
factors, including shortage of staff and supplies and a decline in the Jamaican
economy and efforts to eradicate lay midwifery, influence the poor experiences by
patients in the Kingston hospital. Women also experienced similar devaluation of
their own knowledge about their bodies and described being handled rough by
the nurses who disputed their judgments about their own bodies being ready to
deliver. Women even complained of being criticized or slapped by the nursing
staff. Therefore, it is clearly documented (as demonstrated by the above examples
in South Africa, Haiti, Mexico and Jamaica) that giving birth in an institutional
setting can be viewed as risky by women who perceive quality of reproductive
health services as low. This represents a fundamental disconnect with the
biomedical reproductive health conceptualization of risky home childbirth, and
poses a challenge to raising utilization rates of health services in settings where it
may in fact be risky to give birth institutionally.
Previous political-economic studies in various international settings have
shown that providing free maternal health care through public health interventions
is not sufficient on its own to guarantee universal improvements in maternal health
indicators (e.g., Schneider and Gilson 1999; Homedes and Ugalde 2005a,b,c). This
is mainly because the quality of health services, both in terms of medical
equipment and staff, can vary widely and create barriers to access, especially for
impoverished women not accustomed to Western biomedical culture. Health
services themselves are therefore often the problem when they are poorly delivered,
inaccessible or insensitive to the cultural context. This study in Yapacanf seeks to
illuminate the situation in Bolivia regarding the quality of biomedical services and

other factors influencing the success of reproductive health policy (SUMI) aimed at
reducing maternal mortality.
Background on some documented macro-level influences on the quality of
care for pregnant women in the developing world follows. High rates of maternal
mortality are known to persist in poor countries like Bolivia because reductions in
maternal mortality require much better developed infrastructure, including
culturally-sensitive modifications, in order to produce the same decreases in
mortality that have been seen in children (Hyder and Morrow 2001). Bames-Josiah
et al. state: The women discussed here died...not because their complications
coincided with isolated or chance breakdowns in the medical system, but rather,
because they coincided with systematic deficiencies of that system (1998:990).
Additionally, large scale social issues, such as class, race, and the institutionalized
authority of the biomedical conceptualization of birth, can influence the care that
poor women receive at the local level. Thus, we know that structural problems
inherent in national reproductive health programs (including Bolivias SUMI
program) are distant but important determinants of maternal health because they
affect the public health sectors ability to effectively provision culturally-
appropriate services.
Langer et al.s (2000) research addresses the conflicting goals of health
sector reform and reproductive health policy. Current global health sector reform
since the 1990s has aimed to make health services more efficient and effective
through decentralization, increased access, and an increasing private sector role
(Langer et al. 2000). The publishing of the World Banks 1993 World
Development Report subtitled Investing in Health was a watershed event in
health policy history, representing a shift in power away from the World Health
Organization (WHO) and towards multinational development institutions often

motivated by classical macroeconomics and efficiency rather than a consideration
of social processes and inequalities (Janes 2004:459). The reproductive health care
model is a separate global initiative implemented based on client-centered,
gender-sensitive, high-quality health care, universal access, and free and informed
reproductive choice guided by a human rights framework (Langer et al.
2000:669). These two parallel global processes have the potential to be
complementary, based on their shared goals of equitable access to high quality care.
However, financial and political interests in health sector reform, including a push
towards cost-effectiveness, threaten to dominate the human rights focus of
reproductive health policy (Langer et al. 2000).
Reviews of Latin American health reform have revealed that
decentralization of health services has not accomplished much of an improvement
in equitable access to health services. One review with in-depth case studies of
Colombia and Chile concludes that decentralization has rarely been able to
accomplish its goals of 1) allowing local decision-makers to respond to community
needs without costly errors by distant bureaucrats, 2) involving the community in
planning and supervision of local services through a democratic process, and 3)
using resources more efficiently by allowing local needs to dictate services
(Homedes and Ugalde 2005a). Another review discusses the Bolivian context (pre-
SUMI), stating:
The current degrees of decentralization have not produced major
changes in performance, as measured by available data on equity,
efficiency, quality, and financial soundness. Decentralization has
not been the panacea that advocates have claimed (Bossert et al.
The World Health Organization has also found that decentralization requires
greater technical and management capability at all levels of the health system and

strong, efficient structures to link local and district-level systems to the national
level (Langer et al. 2000:670). These deficiencies create gaps between rhetoric
and practice in the implementation of universal reproductive health care
programs, and have led to poor outcomes in the successful transfer of decision-
making to the local level and improved equity in access to services. Arbona and
Kohl (2004) describe the effects of decentralization in the Bolivian context. They
say that social inequalities have been exacerbated by political corruption and
decentralization that devolve responsibility to marginal areas under the guise of
autonomy, while also maintaining] elite space and protecting] political coalitions
One aspect of health care reform and decentralization, community
participation, has been well analyzed in the literature in terms of its ability to
ensure true engagement of local people in health decision making and ultimately
improvement of community health (Janes 2004; Jewkes 1995; Rahnema 1992;
Chambers 1983; Cornwall and Tendler 1975). The concept ideally involves equal
participation of community members, organizational representatives, and
researchers in the design, implementation and evaluation of health programs, in
order to distribute power among these actors (Israel et al. 1998). However,
participation can be a political symbol used by different actors advancing
conflicting goals. The ideal elements of participation are sometimes
underemphasized in a more utilitarian perspective, which focuses on pragmatism,
not equity. Institutions are increasingly motivated to use participation because it is
shown to enhance effectiveness and save time and money in the long term
(Cornwall and Jewkes 1995). According to this perspective, community
participation in health and development uses community resources to offset the
costs of providing services (Morgan 2001). Shallower attempts at participation

tend to be those that are grounded in a more utilitarian perspective and are not as
useful in meeting the goals of empowerment and relief of health and social
disparities. Institutional requirements pose the danger of raising false hopes and
ignoring true needs of the community, as in health research when participants are
often asked to identify needs for primary health care, but not curative services
(Cornwall and Jewkes 1995). As discussed by Rahnema (1992), governmental
motives for participation may not be as innocuous as they are made out to be and
may even co-opt local people. Rahnema suggests that participation has become
an economically appealing proposition to indebted countries that are competing in
the foreign aid market, and that participation has become a buzzword often
disembedded from the sociocultural roots which had always kept it alive
This scenario seems likely in Bolivia, where the local governments are now
responsible for infrastructure through the neoliberal LPP, but in poor areas are not
given enough money from the national level to appropriately develop basic services
for their communities. The biggest challenge is that powerful private and
governmental institutions advocating for such utilitarian participation have no real
incentives to change their ways and become more sensitive to culture and local
situations because of structural and bureaucratic limitations (as those discussed by
Tendler 1975).
Additionally, the idea of community is vague and complicated by the
diverse needs, cultures, and viewpoints of individuals in a given community.
Rhetoric emphasizing participation tends to conceive of communities as
homogenous and well-bounded, even though in reality power relations and
differing opinions abound (Cornwall and Jewkes 1995). Because of this, not
everyone in a community is always motivated to or able to participate in decision-

making, and conflicting interest groups may exist, as well as suspicion or mistrust
on the part of all parties (Botes and vanRensburg 2000). Gate-keeping by local
elites and various person biases discussed by Chambers (1983) can lead to lack
of participation of the disenfranchised. For example, socially-marginalized persons
in rural communities may be so full of despair and without additional resources to
engage in collective meetings that their voices are not heard in matters of health
Additionally, the overall political-economic context of impoverishment in
Bolivia, and especially in rural areas such as Yapacanf, influences the ability of
health care systems to work with limited resources to realize improvements in
reproductive health. As Craig Janes points out, The acceptance of health care [in
poor contexts] is further complicated by competing financial demands with higher
prioritymost often food, fuel, water, and shelter (2004:457).
Therefore, it is clearly documented that macro-level policy problems,
including those inherent in decentralization and overall lack of economic resources,
manifest themselves at the local level as poor health for the majority of Bolivian
women, due to the fact that the development of comprehensive service packages
such as SUMI is a difficult process requiring a balance of national and local health
priorities with available resources (Langer et al. 2000:671). Langer et al. rank
Bolivia as Intermediate in terms of progress of the health sector reform goals
(such as decentralization), but Poor in terms of status of reproductive health
(2000:669). New national policies have demonstrated Bolivias ability to expand
coverage and increase health care spending, although not always to improve
efficiency, equity, and quality at service delivery level. Structural barriers (e.g.,
fragmentation, inadequate human and financial resources, lack of communication
between different levels of the system) are known to inhibit effective provision of

equitable, comprehensive maternal health services at the local level (Langer et al.
2000), and these will be discussed in Chapter five in the context of SUMI and
Yapacanf. It is important to understand the various structural elements that need to
be put into place before a huge transformation like implementing SUMI can take
place successfully. The specific effects of SUMI (within the context of the
Bolivian health care system) on access to quality reproductive health services have
not yet been well analyzed, and this study aims to elucidate the mechanisms by
which maternal mortality continues to be high in Yapacanf, Bolivia regardless of
free care for pregnant women.

Setting: Yapacanf, Bolivia
The municipality of Yapacanf is a tropical, lowland area located within the
province of Ichilo in the northeast zone of the department Santa Cruz in Bolivia.
See Figure 3.1 for a representation of Yapacanfs location in relation to the
departmental and national levels. It is surrounded to the north by the forest reserve
El Chore, to the south by the Amboro National Park, to the east by the Yapacanf
River, and to the west by the Ichilo River. Yapacanf has a population of 52,500
residents (according to the Yapacanf Hospital in 2005), and the average family has
five children (CEPAC 2006). In general, men work on the land and women work
in the home caring for children and doing domestic labors. The majority of
families in Yapacanf are peasants who have migrated from the impoverished
highland interior of the country (i.e., the departments of Potosf, Cochabamba,
Chuquisaca, Oruro, La Paz) in search of opportunities to work in the agricultural
sector cultivating rice, com, yucca, bananas, and citrus fruits; or the livestock
sector, raising and selling animals and animal products. One interviewee described
Yapacanf as a staging area where people temporarily settle before gaining the
resources necessary to move to the economic center of Santa Cruz. These migrants
from the interior of Bolivia are typically referred to by those native to Santa Cruz
as collas. While there are various sub-cultures in Yapacanf due to the number and
diversity of migrants, the overwhelming cultural divide is between the immigrant
colla majority and the camba Santa Cruz natives. This divide is primarily cultural,

Figure 3.1 Location of Yapacanf within Bolivia (Figure Adopted From CEPAC)

but also class-based given that the majority of cambas in Yapacanf are middle to
upper class compared to the lower class colla migrants. Several natives of Santa
Cruz that I spoke with described the collas as closed-minded and prone to
protesting and blockading roads when pro-business decisions are made in the
country. Culture, class and race differences in this migratory zone of Yapapacnf
influence relationships in the social arena of health care.
According to CEPACs website (2006) municipal health in Yapacanf is one
of the poorest in the department of Santa Cruz (as judged by the low quality of the
basic sanitation infrastructure, poor distribution of health posts, poor nutritional
security, and high level of illiteracy). In the municipality of Yapacanf, there were
only First Level health services at the time of this research, although the hospital in
the urban center of Yapacanf has since been upgraded to Second Level (see note in
Conclusion). The First Level hospital in Yapacanf was very small relative to the
population and always very crowded. I visited many of the rural communities in
Yapacanf, all of which are reached by bumpy dirt roads (made inaccessible by
rainfall) and have streams, grassy areas (with vipers!), and only the basic
infrastructure (including usually a school and a soccer field, and occasionally a
shack selling basic supplies and a health post). The level of poverty in Yapacanf is
summed up in the following quote by a representative of the municipal
government. He says,
Right now we are at the production level of survival, in other words
we arent gaining anything, [what we have] only lasts for daily
living. And there is nothing left over for saving.. .when a person
gets sick no one knows how to cure them. Its a huge problem, no?

Research Design and Qualitative Methods
This study was designed to be an inductive, exploratory inquiry into why
women do not use governmental reproductive health services in Yapacam, Bolivia
at the time of birth. Given the broad nature of the question and that I encountered
the possibility for doing this applied research while interning for CEPAC (without
full access to other literature on the topic), it was not appropriate to begin with any
existing theories or hypotheses about the research question. Exploratory, inductive
research is used to make initial probes into poorly understood topics such as this
one, while explanatory, deductive research involves testing theories that have
already been established in the literature (Johnson 1998). The goal of induction is
to allow themes and statements of relationship to emerge from a systematic
analysis of data; however, it is important to keep in mind that there is necessarily
an interplay between induction and deduction given the fact that researchers never
enter into the interpretation of data with a blank slate and without personal biases
(Strauss and Corbin 1998).
This study utilizes qualitative methods in attempt to inductively understand
issues surrounding low utilization of governmental reproductive health services in
Yapacam. Qualitative methods in medical anthropology allow for exploratory
research without the constraint of pre-determined categories of analysis, and
produce in-depth, detailed, people-oriented understandings of health-related issues
(Patton 2002). According to Patton,
The task for the qualitative researcher is to provide a framework
within which people can respond in a way that represents accurately
and thoroughly their points of view about the world, or that part of
the world about which they are talkingfor example their
experience with a particular program being evaluated (2002:21).

While analysis of extensive, variable, open-ended interview and observational data
is challenging and can at times seem unwieldy, the result when done rigorously and
thoughtfully by a skilled researcher is a nuanced understanding of the range of
peoples points of views about a particular health issue and a representation of the
social, ecological and political-economic factors related to the research question.
The goal of qualitative research is not to produce generalizable data about a
particular topic, but rather to provide an in-depth understanding of an issue in a
particular context. In this case, the goal is not to produce universal conclusions
about womens experiences giving birth in governmental reproductive health
services globally, or even in all of Bolivia, but rather to offer an in-depth case study
of Yapacanf which adds more insight to the existing literature surrounding maternal
health in a globalizing world. Whereas many previous studies of factors
influencing rates of institutional births have used multivariate statistics to correlate
socioeconomic and demographic characteristics with birth setting (e.g., Stephenson
et al. 2006; Ezechi et al. 2004; Stephenson et al. 2003; Boender 2000; Midhet et al.
1998; Bhatia and Cleland 1995), the use of qualitative methods allows for a more
personal and detailed understanding of the many entwined reasons why women do
or do not give birth in an institutional setting. Qualitative methods allow a
researcher to elicit not only on individual factors (such as income, race, etc.), but
also contextual and macro-level factors influencing mortality-risk as measured by
rates of institutional birth.
The use of several complementary qualitative research methods is an
approach used by anthropologists to comprehensively address a research question
(Patton 2002). Data come from three types of methods utilized in this study: in-
depth, open-ended interviews; participant observation; and analysis of written
documents. Through the process of fieldwork, the qualitative researcher becomes

immersed in a particular community (in this case, Yapacanf) and constantly collects
data which will be combined to form a nuanced, intimate understanding of the
research question.
Data Collection Methods
1. Participant observation
Participant observation includes non-medical observations of supervisory
visits to health posts in Yapacanf (1 full day), attendance at administrative meetings
of the municipal health service and CEPAC (lx/week for 2 months), and non-
medical observations of daily routine at health posts and the hospital in Yapacanf
where reproductive health services under Bolivias SUMI program are offered (at
least lx/week for 2 months). These observations allow for a detailed understanding
of daily routines, beliefs and relations within the health care system that cannot
always be fully expressed verbally by interviewees. Non-verbal and indirect
expression leads to in-depth familiarity with the daily functioning of the system and
gives context to the themes related to accessing reproductive health care as
expressed by interviewees.
2. Semi-structured Interviews with Women and Husbands
The nine health posts and one hospital in Yapacanf are all situated in very
different contexts (with respect to paved-road access, dispersion of population,
resources, and cultural backgrounds) which are important to consider with respect
to utilization of health services. The study includes interviewees from three distinct

areas: l)urban Yapacanf, 2)rural Yapacanf where health services exist, and 3)rural
Yapacanf where no health services exist within at least a five kilometer radius.
This is a purposive sampling strategy in which women and men from all of the
three areas in Yapacanf were specifically sought out. While this strategy is not
representative in a statistical sense, it ensures maximum variation of the sample in
terms of location in the municipality of Yapacanf (Bernard 2000). Unique qualities
of these three groups are considered, but central themes that cut across the variation
are the central focus.
These interviews were conducted with forty-four women who have children
under five years old and eighteen men with children under five years old. Half of
the sample consists of women who most recently gave birth (or whose wives most
recently gave birth) in a governmental health service in Yapacanf and the other half
have most recently given birth at home. See Tables 3.1 and 3.2 for a categorization
of interviewees based on sex, location and birthing status (home birth vs.
institutional birth). Interviewees from each group were identified through
collaboration with nurses in each of the three areas listed above and by going door
to door in Yapacanfs communities. In all but a few cases, each interviewee
represents a different household. These interviews utilize a guide of open-ended
questions to elicit information from women and their husbands (separately, in cases
where they were from the same household) about their most recent experience
giving birth in Yapacanf, and their reasons for giving birth either in a health service
or at home. Open-ended questions in qualitative research allow people to express
themselves freely without having to choose from pre-determined categories (Patton
2002). These interviews also ask women and their husbands if they are familiar
with the benefits of SUMI and what changes they would like to see in the health
service in their community. See full interview guide in Appendix B.

Table 3.1 Categorization of female interviewees by location and birthing status
Women with institutional birth Women with home birth Total: 44
Area without health service Area with health service Area without health service Area with health service
7 Urban Rural 8 Urban Rural
6 11 5 7
Total: 24 Total: 20
Table 3.2 Categorization of male interviewees by location and wifes birthing
Men with institutional birth Men with home birth Total: 18
Area without health service Area with health service Area without health service Area with health service
3 Urban Rural 3 Urban Rural
4 3 2 3
Total: 10 Total: 8
Each individual was interviewed once and interviews lasted approximately 20-30
minutes. The majority of interviews were conducted by the principal investigator
who is fluent in Spanish, and some interviews were conducted by two Bolivian
assistants from CEPAC. Interviews were recorded through hand-written notes,
annotated following each interview, and typed into a word processing file by the
principal investigator at the end of each day. As needed, a translator mediated
between the interviewer and Quechua-speaking interviewees. Additionally, basic
demographic information (age, level of education, occupation) was collected.
While the sample was largely homogenous in terms of occupation (women working
in the home and men doing agricultural work) and low educational status, ages
ranged between sixteen and forty-nine years.

3. Open-ended Interviews with Local and Regional Key Interviewees Involved in
Management and Provision of Governmental Health Services
According to Patton, key interviewees or key informants are people who
are particularly knowledgeable about the inquiry setting and articulate about their
knowledgepeople whose insights can prove particularly useful in helping an
observer understand what is happening and why (2002:321). In the case of this
research, key interviewees are people who are particularly able to illuminate macro-
level issues related to the structure and functioning of the health care system and
SUMI in Bolivia.
These interviews with eight key interviewees included open-ended
questions regarding the management, provision, and design of governmental
reproductive health services in order to elicit responses that elucidate political-
economic and large scale social influences on access to health care for pregnant
women. They also included questions regarding key interviewees opinions about
the household level factors influencing womens utilization of services. This
strategy aims to link local level barriers as identified by the women and husbands
with macro-level influences on health care access as identified by professionals
familiar with the current policies in the healthcare system regarding care of the
pregnant woman and the changes that have taken place in the past fifteen years.
Each professional was interviewed formally once in Spanish and length varied
between thirty and ninety minutes depending on knowledge, interest, and
availability of interviewee. Additional informal conversations with these key
interviewees, as well as other CEPAC and Yapacanf health service employees,
were annotated and included in the analysis as well. Key interviewees are shown in
Table 3.3.

Table 3.3 Key interviewees organizations
Description and Number of Key Interviewees2 Method of data
City Government Officials (2) Tape-recorded
CEP AC Representatives (2) Tape-recorded
Doctor (1) Tape-recorded
SEDES Representative (1) Tape-recorded
SOBOMETRA Representative (1) Written notes
Regional Health Administrator (1) Written notes
4. Collection of Written Documents
Throughout the course of the research I collected various documents
published by the Ministry of Health and other health-related institutions in Bolivia,
including descriptions of the Bolivian health care system, a SUMI implementation
manual, tracking forms used by the health system for billing of services and
epidemiological purposes, and a brochure from SOBOMETRA, the traditional
medicine organization that works in coordination with Santa Cruz departmental
health administration.
2 The description of key interviewees is general on purpose in order to protect their confidentiality.

Data Analysis
Tape-recorded interviews were transcribed and all other interviews and
notes were transferred to word processing files. Category two interviews (see
above section) with women and their husbands were analyzed inductively in the
field to identify key factors in a socio-ecological framework that were related to
womens access to reproductive health care. The coding of the data was based on a
grounded-theory approach in which themes are identified in the texts and concepts
from the data are linked (from the ground up) to existing theories and findings of
related studies in the field of international reproductive health care (Strauss and
Corbin 1998). Linking of this category two data to related studies did not happen
until after my departure from Bolivia; although the initial inductive analysis of the
interviews was shared with local administrators from CEPAC and the
governmental health system in August of 2005. Upon arrival to the United States,
a literature search confirmed that many of the same factors I had identified in
Yapacanf were similar to those in other international settings. Table 3.4 presents
the inductive codes developed in this part of the analysis along with citations from
the literature which confirm the existence of such factors in other settings. The
codes do not represent macro-level influences on womens birth location because
women did not tend to articulate these more distant influences on their personal
situations, but rather discussed more immediate reasons for where they gave birth.
The macro-level influences are described in the following chapters based on the
analysis of key-interviewee responses and the existing literature.

Table 3.4 Category 2 interview data codes
Code Citations
Author and Date Location of Study
Economics (Economia) Orji et al. (2001) Nigeria
Etuk et al. (2000) Nigeria
Ezechi et al. (2000) Nigeria
Amooti-Kaguna and Nuwaha (2000) Uganda
Thaddeus and Maine (1994) Literature Review
Geography (Geografia) Orji et al. (2001) Nigeria
Etuk et al. (2000) Nigeria
Ezechi et al. (2000) Nigeria
Amooti-Kaguna and Nuwaha (2000) Uganda
Midhet et al. (1998) El Salvador
Thaddeus and Maine (1994) Literature Review
Bhatia (1993) India
Easy Birth (Parto Facil) Berry (2006) Guatemala
Orji et al. (2001) Nigeria
Ezechi et al. (2000) Nigeria
Amooti-Kaguna and Nuwaha (2000) Uganda
Etuk et al. (2000) Nigeria

Table 3.4 (Cont.)
Code Citations
Author and Date Location of Study
Care (Atencion) Berry (2006) Guatemala
Ezechi et al. (2004, 2000) Nigeria
Kyomuhendo (2003) Uganda
Orjietal. (2001) Nigeria
Etuk et al. (2000) Nigeria
Amooti-Kaguna and Nuwaha (2000) Uganda
Midhet et al. (1998) El Salvador
Thaddeus and Maine (1994) Literature Review
Fright (Miedo) Boender (2000) Bolivia
Embarrassment (Vergiienza) Boender (2000) Bolivia
In order to analyze the observational and key interviewee data, I began with
the codes I had developed in the field (see Table 3.4) and throughout the coding
process, additional themes emerged that were added to the original codebook in the
form of new codes or sub-codes which were relevant to my socio-ecological
theoretical framework. Qualitative analysis in the grounded-theory tradition is an
iterative process by which themes are linked together through memoing (a method
for recording relations among themes) and theoretical models are created out of the
data (Strauss and Corbin 1998). Table 3.5 presents the full code list used in this

analysis. Qualitative data analysis software ATLAS.ti (Muhr 2000) was used in the
process of systematically identifying and extracting key themes.
Table 3.5 Full code list for grounded-theory approach
ACCESS: Care Health System: Flaws
ACCESS: Economics Health System: Indicators
ACCESS: Geography Ichilo Health Service
ACCESS: Easy Birth LPP: Benefits
ACCESS: Embarrassment LPP: Flaws
ACCESS: Recommendations Politics: Alcaldfa Role
Authorities Mentality Politics: Corruption
Authorities View of Women Politics: Health System Design
Birth Background Politics: Personnel
Birth Stories SUMI
CEPAC SUMI: Benefits
CEPAC: Current Role SUMI: Familiarity
CEPAC: Past Program in Reproductive Health SUMI: Flaws
Confidence in System SUMI: Traditional Medicine
Cultural Aspect SUMI: SEDES
Health System Yapacanf
Health System: Comite de Vigilancia

Failed Plans for Institutional Birth
Women and husbands were asked about their experience planning where
their birth would take place and about the realization (or not) of that plan. Many
people reported home birth even if they claimed to have wanted to go to a Yapacanf
health service. While the interview data do not indicate the extent to which
families who claimed to plan where they wanted to give birth actually planned for
the birth, it is clear that nearly a quarter of people were unable to give birth in their
preferred setting. Women told stories of failed attempts to arrive at health centers
and problematic attempts to find childcare during the time of birth. For example, a
woman from a rural community in Yapacanf with no health service said,
I wanted to go to the hospital and I stayed for a week in Yapacanf
[urban center] but I returned home because there was no one who
could watch my girls and because in the hospital they told me I had
twenty more days to go. The baby was bom two days after I
returned home.
A husband of another woman from the same rural community said, The baby was
bom fifteen days early and we didnt get to the hospital because the bus only comes
three times a day. A woman from a rural community with a health post pointed
out the difficulty of receiving the care she wanted, even when the health post was
only a block away from her house. She said,
We planned to have the baby in the health post, but when we went to
the health service no one was there. We went to the hospital in
Yapacanf [urban center] where we arrived at four oclock in the
morning. I was there for six hours without any control and then they

told me that I could leave and come back later. I went to the house
of a midwife in Santa Fe [fifteen minute taxi ride away] because of
the poor care in the hospital, and I had to pay 250 bolivianos
[equivalent to approximately thirty-one dollars] for the birth.
Thus, although many families did not plan to give birth in the health
service, there were some that did and were not able to realize that plan. This
introduces the difficulties faced by women who choose to go to the health service
and are unable to. Other issues surrounding women who did not plan to seek care
in a health service will also be addressed in this chapter.
Why Do Women Go to the Health Service to Give Birth?
In order to avoid coming across as confrontational or judgmental, the
interviewees were asked about why women in general do not go to the health
services to give birth rather than asking them about their personal decision or
experience. This produced data about families perceptions of the situation rather
than their personal experiences. However, it is likely that many responses were
based on personal experience, and that this strategy may have elicited more honest
responses from women and husbands due to the generality of the question Why
dont women go to the health service to give birth? (see full question guide in
Appendix B). After closely reviewing the interviewees responses, the following
five principal reasons for the lack of births in the health services were identified
and their frequency extracted from the interview data: 1) fear or embarrassment to
be attended to in the health services, 2) economic issues preventing arrival or
utilization of health services, 3) distance or geographical issues preventing arrival
to health services, 4) an unperceived need for health services due to the experience

of parto facil (easy birth), and 5) poor quality of care received in the health care
services. See Figure 4.1 for information on the percentages of responses in each
Poor quality of service
B Geography
Economic issues
B "Parto facil"
Figure 4.1 Why Do Women Not Go to the Health Services to Give Birth?
Lack of Perceived Need for Health Services
According to the Three Delays Model (Bames-Josiah et al. 1998), the first
of three delays involved in unnecessary pregnancy-related mortality is the delay in
seeking appropriate medical help for an obstetric emergency. While Bames-Josiah
et al. (1998) lump delayed and never-made decisions to seek institutional care
together in the analysis of their twelve case studies with women in Haiti, the results
of my study indicate the importance of never-made over delayed decisions to seek

health care in Yapacanx. As Bames-Josiah et al. (1998) point out, delayed decisions
to seek care may be the result of crucial decisions made in the context of scarce
resources (such as lack of transportation). Discussion of those material and
logistical factors influencing whether or not women arrive at a health service at the
time of birth are discussed in the next section; however, my results do not indicate
that these factors played a crucial role in interviewees initial decision to seek care
or not. This discussion focuses on peoples intentional decisions not to seek care,
and demonstrates the process by which this first delay in unnecessary mortality
occurs. Results from my interviews with women and husbands show that many
women do not seek out health services at the time of birth because of fear,
embarrassment, lack of confidence in the health care system, and/or the belief that
they do not need to go to the health service because they have easy births (partos
faciles). In order to explore this issue further, a discussion of different elements of
the decision at the time of birth follows.
The most frequent response to the question of why women do not go to the
health services at the time of birth was fright (miedo) or embarrassment
(vergiienza). Women reported being scared or embarrassed about three different
aspects of seeking medical attention. First, many discussed fear and
embarrassment surrounding unfamiliar practices in the health services. For
example, one woman said, In the hospital, everyone looks at us and they open our
legs. Many interviewees stated that they were scared of the doctor and that they
were used to being attended to by a family member or midwife (partera).
Interviewees also explained that the quality of service in health centers scared them
because The woman can die in the hospital. One woman said, I am scared that
they will scold me in the hospital because Ive only gone to one prenatal control.
As one key interviewee pointed out, it is very unlikely that women will stand up to

a doctor who is treating her badly and so poor care in the hospital ends up
manifesting itself as a lack of attendance at time of birth by women. Lastly,
interviewees believed that women were scared or embarrassed to go to the health
services because they didnt know what to expect when they arrived. This lack of
information, along with the lack of confidence in the health care system and the
customs of the women, interact to create fear and embarrassment among many
women of being attended to in a governmental health service. Further discussion in
the next chapter will illuminate the links between this fear and lack of confidence in
the system and the state of the care given in health care settings, including attitudes
of health personnel and resources available to provide adequate SUMI services.
Another reason that women decide not to seek institutional care at the time
of birth is that they perceive the birthing process as easy. Many interviewees stated
that women have partofacir which means that they do not have complications
with birth and do not see the need to go through the hassle of going to a health
service. Several women stated things like, I dont go [to the health service]
because I have an easy birth.. .if it were difficult, I would go. An interview with a
representative of CEPAC pointed out that women do not perceive the risk involved
in giving birth because even if the overall rate of maternal mortality in Bolivia is
high, at the local level in Yapacanf only occasionally do women actually die in
childbirth. Therefore, it seems that lack of biomedical understanding of the risks of
obstetric emergency influences womens decision to remain at home to give birth.
The view of birth as a natural process is a more challenging influence for health
care professionals to address in their efforts to ensure that women reach a health
service at the time of birth because it represents a fundamentally different
conceptualization of childbirth, as will be discussed in the next chapter. In addition
to a lack of knowledge of obstetric risks and a view of birth as a natural process,

the ever-present influence of poverty and lack of education also influences whether
or not women place importance on the information they receive from health
personnel. A key interviewee from the local government in Yapacanf explained the
futility of public health education in the following quote:
We give out information about preventative health care practices
[referring specifically to the risks surrounding childbirth].
Theoretically, they [the family] would do it, no? But in practice, the
family doesnt do it [i.e., doesnt go to health service to give birth].
They dont value it, not because she doesnt want to, or he doesnt
want to, but rather because those are the conditions due to the lack
of education...because of not going to school...that is the day to day
survival in Bolivia.
One key interviewee from a local NGO commented on the fact that many women
do not even think about going to the health service because they do not perceive
childbirth as risky, stating: Maybe you have realized that the issue is more a
problem of the health services [who want women to come to give birth] than a
problem of the women. Because the women really don't worry too much. Thus,
the overall climate of dire poverty and lack of education can mean that public
health messages are not necessarily families top priority.
Interviews with the husbands included a question about where he preferred
that his wife give birth (either at home or in the health service). The common
speculation among health care professionals before this study began was that many
women do not give birth in a health service because their husbands do not allow
them to. However, more than three quarters of the men interviewed responded that
they prefer their wife to give birth in the health service. Thus, it is clear that, while
a man may influence his wifes decision to seek care in some cases, the majority of
the home births cannot be accounted for by the opinion of the husband.

Another possible reason that women choose not to seek help at the health
care service is that they are unfamiliar with SUMI and the free services available to
pregnant women. Only a little more than half of the interviewees (women and
husbands) said that they were familiar with the benefits of SUMI. Some expressed
the fact that they had heard about SUMI, but that they felt it was a lie (mentira).
This lack of information about SUMI and the inability of SUMI to live up to
peoples expectations is another principal cause of the low coverage of institutional
births in Yapacanf.
Ability to Physically Access Services at Time of Birth
The second delay identified by Bames-Josiah (1998) is the failure to reach
an appropriate health care facility once a decision has been made to seek care. In
the case of an obstetric emergency, this is an obvious challenge for residents in
Yapacanf because of the fact that no Second or Third level health service exists.
Therefore, in the case of some emergencies, the only option is to travel at least two
hours by taxi to Santa Cruz where specialized health services exist. Even within
the municipality of Yapacanf, women expressed difficulty in arriving at a First
level health service due to economic and geographic issues. For example, in most
rural communities, buses only pass through a couple of times daily such that people
that arent within walking distance of a health service have limited transportation
options for arriving at the time of birth. The distance of Yapacanf s rural
communities to health services poses other logistical problems such as the
following identified by interviewees. One person said, There is no one to leave
my children with and there is nowhere to stay in Yapacanf [when waiting to be
admitted to the hospital]. Another pointed out that, Many women give birth

quickly. There is no time and you can give birth on the way [to the health
Many interviewees articulated the difficulty in planning transportation and
child care in preparation for arriving at a health service, because one never knows
exactly when it will be their time to go into labor. One woman said, You dont
know when the pains going to hit you... what can we do? Thus, on top of basic
problems of distance and rough, un-paved roads, women face the uncertainty of not
knowing when to make plans to arrive at the health service. It is clear that the
physical access of women to services is more than a matter of their planning to
access them, but rather also requires sufficient infrastructure, such as transportation
and childcare options.
Additionally, while the economic barrier was supposed to be alleviated by
the implementation of SUMI in governmental health services, interviewees pointed
out that other costs can inhibit arrival to or utilization of health centers. For
example, people feel that it is necessary to stay near the hospital for a few days
after giving birth before going home because Its dangerous to leave [right away]
due to the movement on the ride home. Other costs such as transportation and lost
days of work can add up as well. Another large aspect of the economic barrier is
that many interviewees pointed out that SUMI is not in fact 100% free. Many
people told stories of having to pay for medicine in the hospital pharmacy and
being charged small amounts for things like cotton sheets, gas for the ambulance,
laundry service, and food. A more in depth discussion of the failure of SUMI to be
completely free of charge is in the next chapter. Given the overall state of poverty
in Yapacanf and the rest of rural Bolivia, economic accessibility is even more of a
problem than in urban settings since families must constantly work to meet their
needs with small incomes made from husbands work in the agricultural sector.

Receiving Adequate Care When a Facility Is Reached
The last delay identified by Bames-Josiah et al. (1998) is receiving
adequate care when a facility is reached. Few people in Yapacanf were satisfied
with the care provided at time of birth in a health service. More than half of the
interviewees had complaints about the care provided in the health services,
including issues surrounding the birth environment (i.e., who is allowed in room,
position of woman during birth); health care personnel; health center resources; and
rapidness/availability of medical attention. Therefore it is clear that the quality of
care in the health services in Yapacanf is so poor as to actually in some instances
give women the impression that it is safer to remain home to give birth. A lack of
confidence in the system was an issue articulated by most interviewees, including
women, their husbands, and key interviewees involved in administration or health
care provision. While some of the reasons given for a lack of confidence were
largely based on a lack of resources or technical capacity of the health services
(such as ambulances, medicines, sufficient beds, room for family members to stay,
etc.), a more complicated and prevalent concern expressed is that the services
provided are not culturally-appropriate and welcoming. There was much talk in the
interviews with key interviewees about the fact that the majority of people in rural
communities such as Yapacanf often sees the health service as strange and not
respectful of its culture and needs such that there is a clash (choque) between the
existing services offered and the desires of the largely peasant population.
According to one health care professional, They dont treat the woman like they
should in the hospital, and they [women] arent understood [for their language and
customs]. Also, there is a lack of confidence in the doctors.

This section demonstrates what women and their husbands mean when they
say they [health personnel] dont provide good care (no atienden bien"). First
of all, doctors and nurses often do not speak the indigenous Quechua language of
the many highland migrants in Yapacanf and are unfamiliar with (or unwilling to
administer) any services other than those in the Western biomedical tradition. For
example, one woman said: They leave us with pain, there are no remedies from
the countryside [e.g., mate, hoja de palta, colgullo de manga] that are hot and make
us sweat so that the baby will be bom. One has to wait in the hospital until the
baby is bom. Another commented that The doctors dont know how to
accommodate the baby if its in a bad position. Interviewees were also concerned
with unfamiliar medical practices, such as tying down women and using
machines that give more pain to the belly. One woman pointed out that when the
baby is in a bad position, the doctor will operate and this deters many women from
going to the health services, along with radiographs and urine analysis.
A few women voiced their viewpoint that the hospital is a risky place to
give birth and that they would prefer to stay home or pay to go to a midwife. They
told stories of bad things that had happened to women and children in the hospital
and some spoke of the lack of training and poor bedside manners of the doctors and
nurses. Other descriptions of poor care had to do with the way that the doctors and
nurses treat the women, typically without respect and thoroughness. For example,
There is no one constantly helping there is at home. One particularly
potent quote from a woman who had recently given birth follows: Not all doctors
are the same, some are tiresome and they scold the women. They leave them
screaming and they tell them suck it up now like you did with your husband.
Another woman commented: They dont attend quickly, only when they feel like
it, and people can die in the hospital. The doctors leave the women in the stretchers

alone...the nurses are around but they look at [the women] and dont do anything.
One woman spoke of her sister-in-law who had vowed not to return to the health
service to give birth because she thinks that the tablets that they gave her in the
hospital so that the birth would accelerate killed her baby. In this context, one
wonders if it is in fact safer to give birth in the health service than at home.
As shown in Figure 4.1 above, quality of services is the second most
frequent reason cited by interviewees for womens not utilizing SUMI services in
governmental clinics/hospitals at the time of birth. However, all of the reasons
already discussed are also related to the quality of care given in Yapacanf s health
sector. For example, womens fear may stem from perceived quality of service (as
discussed above); distance and economics may pose problems because of the lack
of resources available in health services (e.g., even if the health post has an
ambulance, many times it does not have a phone or radio such that women cannot
contact them for a ride); and unperceived need for help from trained professionals
may stem from a lack of outreach by the health centers. Thus, the findings of this
study reveal that the quality of the governmental health services is the most
important determinant of whether or not women use SUMI when they give birth.
The findings also indicate that the quality of health services are not up to par with
the ideals of the government primary health care reforms, thus shedding light on
the need for improved services to lessen womens risk of maternal mortality in
health centers. The next chapter is dedicated to understanding the determinants of
quality of care in order to offer suggestions for improvement.

Many macro-level factors influence the poor state of governmental health
services in Yapacani as described in the previous chapter. The design and structure
of the national health system in Bolivia affect the experience of pregnant women at
the local level by determining the framework in which SUMI is implemented and
the resulting services provided. Additionally, the overall neoliberal political
strategy of decentralization in Bolivia influences the functioning of the health care
system and affects peoples access to quality reproductive health care services.
Lastly, the health care personnels training and attitude regarding the process of
birth and the provision of services in rural areas such as Yapacani greatly
influences the treatment that women receive when going to a health service for
reproductive health services. In order to illuminate the inability of governmental
health services to generate confidence in the community, a discussion of these three
components follows.
Structural Constraints on Yapacani's Health Resources
The local governmental health system in Yapacanf works in collaboration
with CEPAC to improve the quality of services for pregnant women in order to
encourage them to give birth using SUMI resources in an institutional setting. I
observed regular CAI (Information Analysis Committee) meetings which are held
to monitor health indicators (such as percentage of institutional births) and set
priorities for community health improvement, as well as CECARI (Ichilo Province
Training Center) meetings in which the administrators of Yapacani and

neighboring municipalities unite with representatives from CEPAC to discuss
programs and norms and standards developed by the Ministry of Health. Through
my observation of these attempts to ensure the quality of services at the local level,
it became clear that many barriers inherent in the design, structure and functioning
of the health care system inhibit their success.3 One representative from CEPAC
commented on the difficulty in ensuring that Ministry of Health and Sports (MSD)
norms are implemented at the local level:
The norms are in a book this thick [motioning the large size of the
book] such that when it arrives to the hospital, they put it in a drawer
and never read it...what needs to be achieved in the services is that
the norms arent a theoretical concept written in a book, but rather
they need to enter into the daily activity of the services.
Offering traditional medicine remedies or practices to pregnant women as part of
SUMI would be an example of a norm to be put into practice. However, during my
stay, I never heard anyone focus on making sure culturally-appropriate services are
being implemented.
There was also much talk of Strategic Plans (Planes Estrategicas) and
Annual Operative Plans (Planes Operativos Anuales) which were other strategies
for monitoring quality of services through long-term prioritization. One key
interviewee highlighted the most noble part of helping to create a strategic plan
with other managers within the health system:
3 The nature of the relationship between NGOs and governmental health care systems in the
developing world is problematic given NGOs non-neutral stance as technical purveyors of
international health expertise that is influenced by global economics and politics. This phenomenon
is another potential macro-level influence on the successful implementation of SUMI at the local
level, given the close collaboration between NGOs such as CEPAC in monitoring quality of
services. However, a discussion of this relationship and its potential effects on the functioning of
governmental health care systems is beyond the scope of this project.

We have five years, and the mission and vision are elaborated
[during the planning meeting]...The vision refers to the most noble
part of our work that has principles and values.. .for example
solidarity with co-workers, or our patients...For example I want
Yapacanf in five years to be a population with less illness.. .that all
people that access the hospital dont have barriers...How are we
going to achieve this? For example working with trainings,
education, information, etc.
Despite the noble efforts of the governmental health system to ensure the good
health of communities, there remain structural challenges to successful provision of
quality services at the local level. This section explores the political, economic,
and organizational barriers inherent in the Bolivian health care system that
authorities face at the local level. A health system is defined as the combination
of resources, organization, financing and management that culminate in the
delivery of health services to the population (Roemer 1991, quoted in Mills and
Ranson 2001). An analysis of these elements of the Bolivian health care system
sheds light on the conditions described in the previous chapter by interviewees and
the challenges faced in implementation of SUMI.
Design of Bolivian Health Care System and SUMI: Where Are We Going to Get
Money to Make SUMI Function Like We Want It To?
Yapacam Doctor
According to UNICEFs State of the Worlds Children Report, the Bolivian
government has 3% central government expenditure for health compared to the 6%
average for Latin America and the Caribbean and 14% average for industrialized
countries (UNICEF 2001). The fact that Bolivia is a highly impoverished country
with a lack of funds available for allocation within the health system to begin with,

coupled with the low proportion of governmental expenditure on health, creates a
situation of extremely limited resources for comprehensive health plans such as
The primary health care movement initiated by the Alma Ata declaration in
1977 emphasizes that universal care packages such as SUMI should be based on
cost-effectiveness and the use of unpaid lay health workers [RPSs in the case of
Bolivia] as a referral system in cases of emergency (Janes 2004). However, the
implicit assumption that there is a demand for primary health care services and that
local institutions and community health workers can handle their implementation in
a cost-effective manner is largely taken for granted (Lewis et al. 2004). Justice
(1986) has demonstrated in Nepal that the expectations of the lay health worker are
unreasonable due to limited time and resources, and that a focus on meeting a quota
of home visits discourages actual time spent relaying thorough health information
to families. Based on my case study in Yapacanf, the effect of this macro-level
primary health care policy in Bolivia seems to be a universal yet under-funded
and poorly executed (see discussion below) reproductive health package. Janes
points out that such comprehensive primary health plans also suffer from the price
of commodities in a neoliberal context such that clinics are undersupplied with
essential medicines and equipment (2004). He points out:
The minimum-package in this case is truly a minimum: doctors
without supplies or drugs, unable to provide any but the most basic
of preventive care, acting as a referral service for people who may
not have the means to enter the secondary or tertiary sectors of the
system (Janes 2004:461).
According to the director of a Bolivian NGO, the relief of Bolivias external
debts under the HIPC (Heavily Indebted Poor Countries) initiative in 2000 has
posed further challenges to the procurement of monetary resources because Bolivia

is expected by the international community to generate its own funds for health
instead of receiving outside aid:
Instead of us paying the external debt, they have pardoned the debt
and now the government has to hand out social works from its own
generation of resources, instead of paying the debt. But this process
is very slow. Because its not the same thing to have to generate
money and invest it as it is to receive money as a gift. At times what
is generated isnt enough.
The drought of external aid as a result of debt relief poses a serious challenge to
health officials who need to reorganize to be able to generate their own funds. It
takes significant effort on the part of the nation to ensure that money saved due to
debt relief under the HIPC initiative is redirected to improve the health of the poor
(IMF 2006). Additionally, other priorities in the government, such as education,
economic development and defense, often overshadow health, and this is a problem
identified by several key interviewees. For example: There is a limit to what the
Ministry of Health can pay health care personnel because the country doesnt
receive enough [in taxes]...and because health isnt considered important. It is
within this context of scarcity that SUMI has been implemented.
As a result of the overall financial climate in the Bolivian health care
system, SUMI legislation alone is unable to ensure successful provision of
universal reproductive health care services. Many women complained of being
charged for services such as cotton sheets and laundry, even though they were told
that it would cost them nothing to receive care under the SUMI insurance program.
Other women were charged for medicines and supplements that should have been
covered under SUMI. These problems, which contribute to the lack of confidence
in reproductive health services in Yapacanf, stem from the lack of funds for
infrastructure built into SUMI legislation, and most likely also involve a healthy

dose of corruption in the health centers. SUMI only provides money for local
health services to cover costs of consultations and basic medications, but does not
include money to make sure that the health posts themselves are properly equipped
with basic infrastructure (e.g., ambulance, electricity, laundry service, food service,
proper equipment to facilitate traditional birthing positions). Additionally, SUMI
does not provide additional funds for health services to hire more personnel, even
though one would expect more demand on the health care system with the
implementation of a free reproductive health care program. Also, SUMI does not
include funds for prevention and education in the community so that women will
understand the importance of giving birth in the health service and will understand
what they are entitled to under SUMI. One health care administrator commented:
SUMI doesnt have resources to complete what we call...
Communication for Behavior Change...there are no resources
for.. .letting people know both in the urban and rural areas about
SUMI, that it is free and that its for everyone, no matter where
theyre from.
Additionally, SUMI legislation does not take into account the differential economic
climates of Bolivias municipalities. Whereas urban municipalities, such as those
near Santa Cruz, tend to have additional economic resources available to
supplement SUMI (by improving health posts or hiring additional personnel),
impoverished municipalities like Yapacanf cannot generate extra funds to help
improve the setting in which SUMI is applied. SUMI cannot stand alone in its
efforts to provide universal reproductive health services, but rather must be
accompanied by the proper equipment, medicine and other resources in existing
health care centers in Bolivia. These hidden costs have impeded successful
implementation of SUMI at the local level.

A representative of the Santa Cruz departmental health administration
(SEDES) explained one result of the lack of funds available in small municipalities
like Yapacanf for health care infrastructure.
In many municipalities there are resources left over, and these
resources according to the law [SUMI] can be invested in supplies
and infrastructure. This is not as positive as it seems. If money is
left over, it means that we are not covering the necessities of the
population. One. Secondly, if its left over, the municipalities
arent doing many diffusion activities to capture more patients in the
health establishments.
In other words, if municipalities receive money for the services that they reported
having previously providing under SUMI, and they do not use all of that money to
provide more services, but rather to buy supplies, the goal of SUMI (to improve the
health of pregnant women and their children) is not immediately being met.
Because of the lack of infrastructure, or explicit SUMI funds for infrastructure,
oftentimes health services are dissuaded from recruiting people to use services
because it costs them money they could potentially use for day to day costs and
infrastructure. Municipal government representatives also pointed out the
importance of building roads so that people can access health services. Thus, it is
clear that even if SUMI is well-designed, a lack of basic infrastructure and supplies
in rural, impoverished areas make it difficult to provide services.
An additional challenge to the lack of infrastructure in Yapcanf is the rapid
rate of population growth. According to one interviewee, Yapacanf used to have
about 10,000 residents when the hospital was built, and now it has about 50,000
due to the high levels of migration discussed above in Chapter three.4
4 The Bolivian Instituto Nacional de Estadfstica (National Statistics Institute) projected that the
population in Yapacanf would be 37,527 in 2005 (INE 2006) based on growth rates calculated

Not only is there a lack of funds for infrastructure, but allocating coveted
SUMI funds efficiently to meet the demands of the population is also a problem. A
representative from CEPAC who works closely with the governmental health
administration described the problem of lack of medicine in rural communities in
the following quote:
When there are disbursements from the mayor, there are people that
find out quickly...that is a form of corruption, no? That there are
people that because of a secret information system find out more
quickly about the benefits...and when the most poor families that
dont have a sweetheart in the hospitals arrive from the most far
places, they find un-stocked pharmacies, services that are not
available, that are suspended because of a lack of resources, no?
Also because of the impoverished state of Yapacanf and other poor, rural
municipalities, and because of corruption and inefficiency in local governments,
many times resources allocated for SUMI are spent by the municipal government
for other things such as the mayors salary. Although I do not have direct evidence
of local governmental corruption, it seems to be commonplace, especially in the
context of decentralization and local control over resources. One interviewee
familiar with the local health system in Yapacanf spoke of the corruption involved
when government officials receive international aid money for projects targeted at
Sometimes once they [the municipal government] have the money,
they do other things, they pocket it, those involved in health and
other areas...if they [the outside agency] give them all the money
right away, they dont do anything, they rob it [the aid money].
before 2000. The discrepancy between this number and the number estimated by the Yapacanf
hospital (52.500) is likely due to an increased growth rate since the year 2000 in Yapacanf.

Additionally, several people spoke of corruption within the health system such as
pharmacists robbing thousands of dollars from the Yapacanf hospital.
Design of Bolivian Health Care System and SUMI: Politics
Filling Out Paperwork
Political issues in the design and functioning of the health care system
affect the success of SUMI. One complaint frequently voiced by health care
providers and administrators is that SUMI and other governmental health programs
are largely based on keeping track of indicators and statistics. Many people
pointed out that filling out paperwork in hospitals and health posts in order to
justify the funds to be received from the national government takes up an enormous
amount of time and can divert time and energy away from actually providing
services. In my visits to the Yapacanf hospital, I observed that oftentimes health
workers from distant Yapacanf communities would be in the central hospital,
abandoning their posts for the sole purpose of turning in monitoring sheets so that
their health posts would eventually be reimbursed for services provided under
SUMI. At one point during my stay in Bolivia, I accompanied some health
workers on a four-hour round trip excursion to turn in paperwork to SEDES in
Santa Cruz with the invoices from Yapacanf and surrounding municipalities in the
province of Ichilo. According to a representative from the local Yapacanf
government, There are a lot of registries. This lowers the potential for good care
from the health care personnel. Without computers or even radios in the health
services, just keeping track of the services provided in order to ask for money from
the central government by going up the chain from municipality to province to

department to national level becomes a full time job. According to a doctor, They
expect results from you, no? Numbers, coverage, coverage, coverage...There are
lots of papers, and it gets boring. And we dont have computers, so its magic what
gets done. This person is is sarcastically pointing out the burden of paperwork by
saying that one would need magic powers in order to accurately and promptly
accomplish all that is required by the health care system given the lack of time and
resources available.
Another important issue is that many women in Bolivia are encouraged to
have cesareans instead of giving birth naturally, and this is something that many
families said was a deterrent for families deciding whether or not to give birth in
the health service, even if they were willing to go for prenatal care. Ezechi et al.
(2004) also found that cesarean section aversion was a predictor of home birth in
Nigeria among women that had previously come to the hospital for prenatal care.
One potential reason cited by a key interviewee in this study for the frequent
occurrence of cesareans is that local health services receive more reimbursement
for performing cesareans than for attending natural births. This is a striking
example of the ways in which corruption and poor planning within the health care
system can act out upon womens bodies; putting them at risk of needless,
complicated surgery for greeds sake or because the system is so poorly designed
that health services are desperate to document cesareans to receive the funds they
need for daily functioning.
Political Priorities
Regardless of the overall economic climate, several interviewees pointed
out that the Bolivian health system could manage its money more efficiently and do

better with the resources that it has. One doctor pointed out that Here no one has a
political science career, and because of that there is not broad knowledge about the
situation in the country [among government officials], there is not good planning
and the government has other priorities. As a result of this, and for other reasons
such as a desire to develop and professionalize in a Western capitalistic sense
such as that outlined in the history of medicine in the United States by Paul Starr
(1986), the Bolivian government does not seem to always design health legislation
with local needs in mind. One key interviewee pointed out that there are no
Bolivian-specific protocols or norms within the health system, but rather everything
is designed by international and national officials concerned with bringing Bolivia
up to the standards of the Western world. Even though debts are relieved and
Bolivia is now more responsible for the procurement of its own resources for
health, the tradition of mentoring by Western nations in the design of government
programs continues. Bilateral relations with the European Union, the United
States, Japan, and the Nordic countries; cooperation with the United Nations
system (PAHO, UNICEF, World Food Program, UNFPA, United Nations
Volunteers) and other agencies; funding from foreign NGOs; and projects
implemented by multilateral development banks (World Bank and EDB) combine to
determine the design and functioning of the Bolivian health care system (PAHO
2001). Because of this, the reproductive health care system in Bolivia remains
fundamentally biomedically influenced and not necessarily adapted to local needs.
In the past 5-10 years, there have been efforts to incorporate traditional
practices into maternal health care in Bolivia, as is laid out in the SUMI
implementation manual (MSD 2002), but in practice it has not happened yet. Key
interviewees mentioned isolated integration instances in Oruro and La Paz (other
Bolivian departments), but it is clear that full-scale integration of ethno-medicine

and biomedicine has not been accomplished in Bolivia. The main reason for this is
the authoritative attitude of governmental health care personnel and administrators
who are reluctant to accept such integration in their places of work. This will be
discussed at length below in the section on health care personnel and authoritative
knowledge. However, regardless of the attitudes of those providing SUMI
services, system-level political barriers also influence the integration of ethno-
medicine and biomedicine in the Bolivian health care system. Incorporating
traditional birth attendants (parteras) into the government health system and/or
training health workers in traditional practices is an expensive and time-consuming
task. Training is especially challenging given the large turnover in health care
personnel and the need for extra equipment, such as proper chairs for women that
prefer to give birth sitting down. Additionally, as one administrator from SEDES
pointed out, there are not yet protocols for the use of traditional medicines within
SUMI. Creating norms for who will give traditional medicines in what cases is a
barrier to successful integration of traditional medicine into the Bolivian health
SEDES (Santa Cruz health administration) is beginning to coordinate with
the organization SOBOMETRA (Bolivian Society for Traditional Medicine) to
begin training natural medicine practitioners (naturistas) and traditional birth
attendants (parteras) about SUMI and its protocols so that they can start caring for
pregnant women in the government health services. A representative from
SOBOMETRA whose desk was in the SEDES office brought up some issues
surrounding the integration of traditional practitioners into SUMI. One of these is
that the integration is often one-sided, in other words it feels as though traditional
medicine is being allowed into the framework of SUMI only if its practitioners are
properly trained by Western medical standards, rather than having a two way

process where government health workers are also trained in traditional medicine
practices (see discussion of authoritative knowledge below). Additionally, the
representative from SOBOMETRA pointed out that only recently had SEDES
formed a coalition with them to work on incorporating traditional medicine into
SUMI, even though the SUM1 program had been implemented two years prior.
Thus, the current situation represents a stage of transition in which the government
administration must work to successfully implement a culturally-appropriate
system with integrated ethno-medical and biomedical components.
Politics and Personnel
It is clear from discussions with key interviewees that health personnel (i.e.,
hospital directors, administrators, doctors, nurses) are appointed by local or
regional governments and therefore can be considered political appointments rather
than necessarily the most qualified employees. The political power of the
governments over health positions limits what the health services can accomplish.
Because of the large amount of turnover in Bolivia between political parties (for
example, the national government in Bolivia changed two times from 2004 to
2005), health workers and administrators also change frequently, making training
and planning difficult. For example, according to the director of a local NGO, a
few years ago health workers were funded by the government to get Masters in
Public Health degrees, but then were unable to stay in public health because of
political turnover. Another result of the political appointment of health personnel is
that the doctors are not necessarily the most qualified. A quote from a local
representative of the mayors office demonstrates the frustration of trying to train
employees and realize long term planning and improvements in quality:

The human resources might be well trained, but when there is a
change in personnel, they dont know the norms or about
communication anymore. [The personnel] must talk a lot with the
users [of health services], and thats why there is a lack of
confidence on the part of the clients who dont leave satisfied with
the care that they receive.
This quote links these personnel issues with the poor quality of services received by
pregnant women at the time of birth, and indicates how political forces can
influence maternal health at the local level.
Not only is there political turnover of human resources in health, but there
is also the problem of a lack of health personnel to begin with. A representative
from the Yapacani mayors office spoke of a law passed by the Ministry of Health
which states that health workers are only required to work six hour days.
According to him, Because of social pressure [blockades], [a health syndicate] has
influenced the Ministry of Health to create a law approving of the six hours of
working.. .and the health workers are paid for eight hours. There is a complete
contradiction. The purpose of the law is so that governmental health personnel
have time for their own private practices, to continue to educate themselves, and to
go into the community and do public health prevention in the community.
However, according to this key interviewee, the reality is that health personnel who
do not have their own private practices rarely use the extra two hours a day for
anything but free time.
Additionally, a political strategy aimed at addressing the problem of lack of
personnel is to divide ITEMS (salaries for health workers provided by the national
government) in half so that two doctors in two different rural areas can work for the
price of one. The problem is that doctors working in rural areas end up working
full days for half price because of the demands of the community, given that there

are usually only one or two personnel in rural health posts. Or, if the doctor does
work only half-time, this translates into poor quality of service in the eyes of the
community due to this political strategy. According to the director of health
programs from CEPAC, When a doctor goes' to the countryside maybe he/she says
I am going to work until noon and after that I dont work. No, he/she ends up
working the whole day and all night. And if he/she doesnt work, the community
gets angry. This key interviewee was hopeful that full ITEMS would soon be
implemented for the rural doctors in Yapacanf, but until then the lack of paid
workers in rural areas is a serious barrier to the improvement of quality of services.
Another problem is that the distribution of human resources is not in
accordance with the population within the municipality of Yapacanf. It seems that
politics play into the way in which ITEMS for personnel are allocated to different
communities within the province of Ichilo. According to a representative from
Since Buena Vista [a neighboring municipality to Yapacanf] has
almost always been the capital of the province, a certain percentage
of human resources always remain in Buena Vista. And Buena
Vista is one of the smallest municipalities. SEDES should
redistribute ITEMS; 60% [of human resources] should go to
Yapacanf but now Yapacanf has about 35-40%.
This problem is augmented by the high rates of migration into Yapacanf. The
population in Yapacanf is quickly growing as people migrate there from the less
fertile interior parts of Bolivia looking for work in the agricultural areas, as
discussed above, and this is an added stress to the limited health care workers in the

Faulty Functioning of a Decentralized Health System: Politics Curb the Many
Advantages [of Decentralization]
Representative of Yapacani Government
In order to consider the quality of reproductive health services and
understand womens lack of utilization of these services, it is necessary to consider
SUMI as parallel to the decentralized Bolivian health system. SUMI has been
implemented according to the Popular Participation Law (LPP), as discussed in the
first chapter, such that responsibility for the provision of services and resources is
decentralized to the local level. While the goal of decentralization is to allow local
people more involvement in their health care system, the decentralization of
publicly funded health services places a high burden on poorer regions, such as
Yapacani, where people are generally less healthy and less likely to have economic
resources (Sandiford 1999). The richest states, provinces, and municipalities are
able to top up central government funding with their own revenues or from user
charges (Sandiford 1999:2). In other words, increased demand in poor regions
like Yapacani is not met with increased funding from the central government and
inequity in access to quality services persists.
There are a number of benefits to the decentralization of health services,
according to several key interviewees. According to a representative of the
regional health administration, decentralization to the local level has allowed
municipalities to be responsible for the infrastructure, planning, and allocation of
resources associated with the health care system. Interviewees pointed out that the
decentralization had allowed more health centers to be built in rural areas.
According to one nurse in a rural community of Yapacam, the people in her
community organized to raise money (supplemented greatly by a private non-profit

organization) for a new health center which was built a few years ago thanks to her
community's ability to gain approval from the local government. A representative
from CEP AC stated that,
It seems to me that the final outcome [of LPP] is positive, because
ten years ago it was almost unthinkable that the farthest
communities would be able to have an opinion about their access to
health. In other words, now the people have critical opinions,
favorable or not, because a health system now exists which is close
to their reality. Ten years ago, it was impossible to imagine this. I
imagine that the current problem is peoples level of satisfaction,
whereas before LPP, the presence of the health service didnt even
According to a local government representative in Yapacanf, The people from the
rural areas...are improving themselves now and demanding that [the health
workers] are good and professional.
However, despite these stated benefits of the LPP, many interviewees
painted a picture of a fragmented health care system in which different levels of the
hierarchy are not communicating and communities do not articulate with the
system. One problem is that, while decisions are decentralized so that
municipalities request and allocate resources based on their needs, the resources
themselves (including medicine, SUMI supplies, and personnel) are not
decentralized. According to a representative of CEP AC, The decisions are
decentralized, but not the resources. In other words, the same investment in
resources reaches all municipalities, such that you can accomplish less if you have
fewer resources. A political barrier specific to Yapacanf was expressed by a
representative from the municipal government who described a situation in which
his administration inherited debts from the past administration (who presumably
accrued them because of corruption or poor communication between different

levels of the government), such that the current government receives fewer funds
from the national level with which to run the municipal government.
The prioritization of local needs by the municipalities under the LPP is
problematic for several reasons. First of all, municipalities often prioritize things
like soccer fields or new plazas because people find these things more desirable
than something like improved health care infrastructure. In other words, local
community groups that comprise the vigilance committee (comite de vigilancia),
whose representative is the authority that serves as a go between for the community
and the municipal government and has a say in the budgeting of community
resources, do not necessarily express the need for things such as higher quality of
health care services. Many people are interested first in new soccer fields, and
municipal authorities themselves often neglect to buy medicines for hospitals (even
when money is available), according to one local health system administrator.
Also, many people are unaware of their right to participate under the LPP,
such that they fail to express their opinions to the comite de vigilancia and feel
helpless. According to one interviewee,
The articulation between the community and political decisions
doesnt happen because LPP is only applicable to people that
understand the law. The community leaders know the law and they
articulate themselves. If everyone else knew, they could demand
their rights and participate in the LPP.
Thus the situation is one in which the entire community is not represented by the
LPP and a skewed percentage of the population participates. A comite de salud is
designed as a group of representatives from each community that express health
concerns to the Yapacanf government through a representative of the comite de
vigilancia. However, it seems that these committees do not regularly meet and lack

community participation according to the regional health administrator with whom
I attended health center site visits.
Also, the communication between different levels of the health system
hierarchy (municipal, provincial, departmental, and national) is problematic,
causing delays in funding at the municipal level. Another result of the lack of flow
between levels is that local health authorities in Yapacanf have been unable to get a
response from the national level regarding possible revisions and complaints that
they sent in regarding SUMI legislation (e.g., lack of money available for food and
laundry for patients who have just given birth). I received a smirk from a
representative of SEDES in Santa Cruz when I asked her about the ease of
coordination as an intermediary between the national and local levels. She pointed
out that the complex system of local documentation of care under SUMI for
reimbursement by the central government (as discussed above) causes delays in the
process of providing funds to local municipalities who struggle to do their job and
fill out mountains of paperwork. Because of the challenges of administration in a
multi-tiered health system, DILOS (local level administrative body of the health
care system) meetings are used to calculate debts and inventories, rather than to
prioritize local needs in health.
Another problem with the representative of the comite de vigilancia, one
member of DILOS, is that he/she has the potential to be a biased representative of
the community in administrative decisions. The representative of the comite de
vigilancia whom I spoke with in Yapacanf had an office within the municipal
government building and it was clear from conversations with community members
that he was close friends with the mayor. This has the potential to influence
whether or not he voices the true concerns of the community, as conveyed by the

comite de salud (when they manage to organize themselves), and truly fights for
their participation in the government process.
Thus, the decentralized health care that I witnessed in Yapacanf is wrought
with political influence, lack of resources in poor areas, lack of true community
participation, and the difficulty of communication up the hierarchical ladder of
administration. SUMI, a law designed to function within the ideal decentralized
system, is influenced by these problems which play a role in understanding the
poor quality of reproductive health services for women in Yapacanf at the local
Authoritative Knowledge and Poor Treatment by Personnel
A large component of the poor quality of health services in Yapacanf, as
articulated by the women and their husbands who were dissatisfied with these
services, is the unwelcoming and degrading treatment that they receive from health
care workers. Although SUMI advertisements created at the national level and
distributed in rural communities warmly encourage women to visit health services,
upon arrival women are often met with indifference and hostility. In this context, it
is not a surprise that women are afraid and embarrassed to give birth in a health
center. This section explores the reasons for the disrespectful, culturally-
insensitive actions of many health care providers by considering insights from key
interviewees involved in the provision and administration of health services, along
with a discussion of literature on authoritative knowledge. It is important to keep
in mind that the SUMI implementation manual issued by the government
emphasizes that, when appropriate, SUMI will accommodate itself to the
incorporation of traditional medicine and the traditional practices of the largely

indigenous Bolivian population (MSD 2002). Key interviewees were well aware of
the cultural barrier which had translated itself into poor quality of care in the
hospital regardless of the SUMI rhetoric, and were very interested in the results of
this study. The director of health projects at CEPAC articulated the health
personnels three motives for not doing the things that they should do: Not
knowing, not being able to, and not wanting to. This provides a helpful
framework for understanding the poor care received by women at the time of birth.
Not Knowing: Lack of Provider Knowledge of Culturally-Appropriate Services
It is possible that many health care providers are unaware of the SUMI
rhetoric which stresses the accommodation of services to the cultural needs of
pregnant women (i.e., allowing women to give birth in different positions and
allowing the use of traditional remedies). A representative from the local
government pointed out that When there is a change in personnel, [the new
personnel] dont know the norms or how to communicate such that untrained
health workers are unprepared to provide culturally-appropriate services. This
problem is linked to the politics surrounding frequent staff turnover in health
services. Women themselves even pointed out that many doctors are inexperienced
and know how to charge more than they know how to attend to patients.
Not Being Able To: Provider Inability to Offer Culturally-Appropriate Services
It is also possible that even if the health personnel are familiar with SUMIs
norms and goals, they are overburdened and lacking resources such that it is
impossible for them to provide such services. Several key interviewees pointed out

that the infrastructure needed to provide ideal SUMI services is not in place, and
that the rapid population growth in Yapacanf means that the health services
available are wholly insufficient for the population size. In addition, interviewees
pointed out that there is a lack of health care workers available to provide services,
both in the urban hospital and in the rural health posts, due to the small number of
ITEMS. Health workers funded by municipal funds do not receive the same
benefits (e.g., vacation) and therefore tend to bum out and be less likely to take the
time to provide quality services. Also, un-licensed health workers (auxiliares)
often attend to births in the rural sectors because of the lack of available doctors
and nurses and are unlikely to have the knowledge and experience necessary to
provide adequate services. This second set of reasons for health care workers not
doing their job is largely determined by the macro-level factors discussed in the
previous section of this chapter.
Not Wanting To Unwillingness to Respect Culture of Rural Bolivian Women
The last reason for health workers not performing their jobs to the standard
of SUMI rhetoric is that they are unwilling to do so. Interviewees identified three
related reasons for this unwillingness. First, health workers may not be empathetic
and may have motives other than caring for people. The director of the hospital in
Yapacanf discussed the fact that doctors, nurses, and auxiliares oftentimes view
their job as a good way to make a living (working in the field of health is one of the
most lucrative professions in Bolivia), and forget the moral responsibility they have
in taking care of peoples lives, as summed up in this quote:
Why are they working? Not to have and make money, but rather so
that there is a decrease in the number of illnesses and so that the
population is well attended to. Maybe the health personnel dont

know that work, that mission. We, as authorities, have been to
many workshops, and we know [that mission].
In the same interview, the director pointed out that health workers often do not
have polite, friendly bedside manners and thus are incapable of making pregnant
women feel comfortable at the time of birth. She said, There is a lack of other words of attending as though [the woman] were another
person, no? We treat them as objects.. .its a cultural barrier.. .because of the lack
of knowledge of the doctor. The director gave a hypothetical example of the
typical insensitive treatment of women by those working in the health professions.
If someone from the community arrives [at the health service], and
they are pregnant, and they go and say I want a doctor to attend to
me. And the receptionist says to her...You are pregnant
again?!...Then the people that are there look at the woman and she
feels like they havent respected her...generally you wouldnt come
back after that.
Additionally, class and race conflicts may also influence predominantly
camba (Santa Cruz native) health care professionals treatment of colla women
who have migrated to Yapacanf from the interior of the country and who tend to
have darker skin and be poor. Several women and key interviewees mentioned that
one of the reasons colla women are treated poorly in the health service is because
they are from the campo (countryside), meaning because they are of a different
culture, race and class. Judith Justice (1986) documented similar conflicts between
urban providers and the poor, rural people that they serve in Nepal where the health
post staff people had not received appropriate training to sensitize them to the rural
working conditions. She connects this policy-level failure to ensure health worker
preparedness with the poor morale of health workers, their weak ties to the
community and poor communication with patients (Justice 1986).

The final reason for unwillingness to respect and incorporate traditional
medicine is that health workers have been trained in the Western tradition of
biomedicine which stresses the medicalization of birth and the status of the
pregnant woman as an inferior patient. According to Cecilia Van Hollen, the
medicalization of childbirth is,
The process whereby the medical establishment, as an institution
with standardized professional guidelines, incorporates birth in the
category of disease and requires that a medical professional oversee
the birth process and determine treatment (2003:11).
By pathologizing the natural process of childbirth, the professional doctor gains the
sole authority for providing reproductive health care. The training of doctors in the
Western biomedical tradition is common practice in Bolivia and in other
developing nations. Because of this, the incorporation of traditional medicine and
humanized births (partos humanizados) is unlikely to take place outside of the
parameters of Western medicine. A discussion of Jordans (1993) concept of
authoritative knowledge will elaborate on this inability to incorporate traditional
medicine into the Bolivian health care system. An additional complication is, as
one interviewee pointed out, the culture clash in Yapacanf between the largely
migrant colla population and the health care personnel and health care design that
are largely based on the camba culture (which tends to emphasize development and
Cultural Conceptions of Childbirth
Different conceptualizations of childbirth influence and justify the elements
of the birth process in different cultures, such as birth location, appropriate

personnel, the use of medication and technology, and the locus of decision-making
power (Jordan 1993). Social scientists conceptualize two different paradigms of
care of pregnant women: medical model and midwifery model (Fiedler 1997;
Lichtman 1988; Rothman 1984); or the technocratic model and holistic model
(Fiedler 1997). The technocratic model views birth as pathological or as a
problematic mechanical process in danger of constant malfunction and the
woman as an object (Fiedler 1997:163). For example, the definition of birth as a
medical procedure in the United States justifies the birth location as the hospital,
the appropriate personnel as medical professionals, and the locus of power in the
doctor and medical technology. In a medical conceptualization of birth, the
pregnant woman is viewed foremost as a patient obliged to seek help for her
condition (Jordan 1993). Critical and sociological examinations have revealed that
Enlightenment thinking was the driving force for the establishment of biomedical
approaches to birth in Europe and the U.S. (Van Hollen 2003).
The holistic model on the other hand views childbirth as a normal
physiological process with emotional and spiritual dimensions and tends to favor
childbirth taking place at home (Fiedler 1997). In Mayan cultures for example,
birth is conceived of as a normal yet stressful part of life which can take place at
home with the assistance of a midwife and family (Jordan 1993). Sargent and
Bascopes (1997) fieldwork in a rural Mayan Mexican community supports
Jordans earlier work in a similar Mayan community. They both describe situations
in which the knowledge of various parties is equally valued (the nurse midwifes
limited technical knowledge, the womans knowledge of her own body, and the
other adult womens expertise on childbirth). This holistic understanding of
childbirth can be one reason that women in Yapacanf and other places do not feel

the need to seek institutional care at the time of birth. As Berry has shown in
The problem is frequently not that Mayan midwives, their clients
and families fail to understand the biomedical information about
dangers in birth, but rather that this information fails to fit into an
already existing social system of understanding birth and birth-
related knowledge (2006:1958).
Authoritative Knowledge
In situations of contact between technocratic and holistic conceptualizations
of birth, Jordans concept of authoritative knowledge explains how one system
becomes dominant. She states that
For any particular domain several knowledge systems exist, some of
which, by consensus, come to carry more weight than others, either
because they explain the state of the world better for the purposes at
hand (efficacy) or because they are associated with a stronger power
base (structural superiority), and usually both (1997:56).
Paul Starr defines authority as the possession of some status, quality, or
claim that compels trust or obedience (1986:9). In his discussion of the rise of the
authoritative modem American medical system he asserts that its power is based in
its practitioners perceived competence in an era of scientific reason (Starr 1986).
While modem medical advancements such as immunizations and penicillin are
indisputably positive in terms of their benefit to the entire world, childbirth is an
example of a biological process that has been subsumed under the authority of
modern medicine even though medicalized pregnancy might not be beneficial to
all. Because professional medical authority has the ability to assert its authority as

political privilege in the United States (Starr 1986), one can imagine that this power
extends to international relationships of power between the United States (and other
Western nations) and so-called developing nations such as Bolivia.
Because of international development efforts aimed at modernization, many
developing countries are adopting increasingly medicalized (Western) approaches
to care at the time of childbirth. Given the economic and ideological power of
development efforts to modernize developing countries, Western technocratic
knowledge surrounding childbirth becomes authoritative and devalues non-
authoritative systems of traditional knowledge of childbirth. The process referred
to as misrecognition by Bourdieu and Passeron (1977) describes how
authoritative knowledge systems become natural and legitimate rather than socially
relative (Jordan 1997). Authoritative knowledge about medicalized childbirth
becomes seen as natural and reasonable rather than just one way of viewing the
process of birth.
In the technocratic system of childbirth, the technologically based
knowledge of the physician is inaccessible to the pregnant woman; this creates a
hierarchical system of knowledge and decision making, compared with a more
equitable midwife-based or ethno-obstetric birthing knowledge system in which the
woman has more ownership in her own birth (Jordan 1997). In technocratic birth,
The womans bodys natural responses are systematically erased and then
reconstructed under the disinterested tutelage and coaching of the medical staff
(Jordan 1997:74). As described by Fiedler (1997), the obstetricians superior
cultural status in Japan and U.S. validate his authoritative knowledge over that of
midwives, lending power to a technocratic childbirth system.
Chalmers describes the situation in the former Soviet Union in which
patterns of medical attention at time of childbirth are becoming increasingly

Westernized to the point where New mothers are subjugated, not allowed to trust
themselves or their bodies during childbirth or afterward (1997:274). While the
situation I encountered in Bolivia was perhaps not as extreme and my data are not
extensive enough to generalize about the degree of commitment to medicalization
in the Bolivian health care system, it is clear that the attitudes of doctors described
by interviewees fit within the notion of a medicalized conceptualization of birth.
The goal of 80% institutionalized births by the Bolivian Health Ministry is a strong
indication of their commitment to medicalized birth, in which, as previously
discussed, the inclusion of trained lay midwives is a small part, subject to certain
conditions defined by the dominant Western medicine paradigm.
Mutual accommodation of opposing conceptualizations of childbirth is
difficult in developing countries. Jordan speaks of a moral requiredness of health
systems which makes its proponents incapable of considering other ways of
treating the process of childbirth, such that the dominant system does not allow true
representation of traditional beliefs and the population does not fully accept a new,
modernized system (1993:122). Because of differences in belief systems between
cosmopolitan and indigenous birthing systems, there is often resistance to Western
health care by the indigenous population, and often resistance to the incorporation
of traditional medicine by the medical community, both of which I have shown to
be the case in Yapacanf.
Similar to Yapacanf women who expressed distrust in a health care system
that would perform surgery (cesarean sections) and insist on supine position,
Jordan noted that Mayan women only go to the hospital to give birth in extreme
situations, and many times when it is too late (1993). Because of hospital practices
including attendance by young male physicians, genital exposure, routine
episiotomies, and separation from family, women choose to stay home to give

birth, even if they have gone to the health service for prenatal care (Jordan 1993).
According to Jordan, Discrepancies between the local and the medical definition
militate against the utilization of hospital-based resources even for the cases that
most clearly fall into the medical realm (1993:133).
Alternatively, incorporating a respect for traditional, holistic childbirth
practices is difficult. Health care professionals in Yapacanf could not believe that
women would want a midwife to position their baby for them rather than coming
into the hospital. Jordan states:
I would argue that underlying the medical staffs blindness to the
cultural and material realities of peoples lives is an imperialist view
of the world which simply dismisses the local culture and its
solutions. This attitude, of course, in no way is to be thought of as
resulting from the personal deficiencies of the staff members.
Rather it is inherent in their socialization into the medical profession
that claims reproduction as one of its areas of expertise (Jordan
Health care workers in a medicalized system are blind to the cultural traditions of
the indigenous population (which, in the case of Bolivia is the majority) and are
unwilling to incorporate differing knowledge systems into authoritative
medicalized knowledge. Jordan points out that because the Western medical
institution continues to be a symbol of modernity and progress, traditional ways of
dealing with health issues, such as childbirth, are devalued and considered
backwards (1993:131). Thus, mutual accommodation of technocratic and
holistic birthing systems is difficult to achieve, as shown in Yapacanf.

Effects of Authoritative Knowledge in Developing Countries
As Jordan points out (1993), the inclusion of cosmopolitan medicine in
development programs has an unarguable benefit of controlling infectious disease,
eradicating malnutrition, eliminating parasites, etc. through simple programs such
as vaccination campaigns and development efforts to increase sanitation and
improve access to food. However, once adopted for the benefits mentioned above,
the standards of a medicalized model of health care extend to all health problems
and subsequently devalue all indigenous traditional practices, including those that
have to do with childbirth (Jordan 1993). Additionally, because developing
countries are increasingly implementing Western health care systems, they also
inherit problems related to shortage of health care personnel and resources,
medicines, and technology which create malfunctioning health care systems as the
one I have been describing in Bolivia (Jordan 1993). Realities such as untrained
staff, insufficient drug supplies, etc. mean that technocratic obstetrics cannot
function, and negative iatrogenic (resulting from harmful or inappropriate medical
treatment) and nosocomial (resulting from a hospital stay) effects are sometimes
inevitable (Jordan 1993). Given this, it is understandable that the women I
interviewed believed that the hospital is a dangerous place to give birth. Starr
(1986) backs up this point by describing the inequalities inherent in the power
relations of the medical system. He states that people from different social classes
have interactions with medical professionals that vary in their dependency, power,
and trust (Starr 1986). Namely, poor people are likely to be alienated by cultural
differences in communication and language barriers and, because of the high status
associated with being a physician, a sense of powerlessness (Starr 1986).

An effect of adopting Western medical paradigms into Bolivian medical
schools, according to one key interviewee (who is a doctor), is that nurses are seen
as incapable of attending to pregnant women alone, creating another source of
tension in hospitals where health care personnel are already lacking. Starrs (1986)
work supports this Bolivian doctors observation by describing the authority that
physicians exercise over nurses, technicians and other subordinates. In settings
where fully trained doctors are present (hospitals as opposed to health posts), this
can contribute to the poor quality of services given that a limited number of doctors
are available to provide care.
Jordan also points out that developing countries are often behind in the
diffusion of new medical practice from the very Western societies from which their
modem health systems are designed. Because of this, in her experience, and in
mine in Yapacanf, the practice of not allowing husbands and family members into
the birthing room is outdated even though its importance is now widely accepted in
modem Western obstetrics (Jordan 1993).
Integration of Traditional Knowledge into a Medicalized Health Care System
We must consider the history of development efforts and the concept of
authoritative knowledge when attempting to understand the Bolivian Ministry of
Healths limited success in incorporating traditional medicine into the SUMI
insurance program, as demonstrated by this case study in Yapacanf. The primary
health care model opened the door for development strategies of community-based
service delivery and participation in health, such as that exemplified by Bolivias
decentralized SUMI system, and also supported programs for the training of
indigenous practitioners as health auxiliaries (Pigg 1997). According to Pigg

(1997), the inclusion of local healers and practitioners was conceived as a practical
strategy for reaching closed societies. She states, They were discovered to be like
us as fellow health promoters, but crucially not like us in that they are
characterized as trusted cultural insiders who can carry development messages into
the hidden heart of traditional societies (Pigg 1997:238). This shift was seen as an
opportunity for the incorporation of non-Westem health beliefs into developing
countries health systems. However, in reality many development planners goal is
to utilize the indigenous system as a vehicle for accomplishing the objectives of
modem obstetrics (Jordan 1993; Sesia 1996). Additionally, working with local lay
health practitioners also offers an inexpensive solution to the shortage of trained
personnel in rural areas.
Ironically, in trying to create culturally-sensitive programs that are mindful
of local conditions, oftentimes a lot of what local people believe and do is actually
filtered out (Pigg 1997). In the incorporation of local ideas and practices" into
development discourse, according to Pigg, Traditions are systematically
rendered as isolated beliefs and customs with little social basis aside from the
fact that they are features of a traditional society (1997:249). This
decontextualization is due to research which emphasizes the exotic (i.e., focuses
on the practices most distinctly different from Western tradition), privileges rules
over practice (i.e., focuses on rules and prohibitions likely to be clearly articulated
by traditional practitioners), and reifies cultural identity (i.e., extrapolates certain
practices observed in research to a large group of people) (Pigg 1997:249-50).
The content of training programs in developing countries designed to
integrate traditional health workers into the larger medical system are part of the
authoritative knowledge of development and modernization, and are viewed by
authorities in developing countries as opportunities to become modem (Pigg

1997: 248). Training programs for traditional midwives present modem obstetrics
as authoritative, and assume that indigenous knowledge is illegitimate. Local ideas
and practices enter into primary health care as something to be scrutinized and
judged, while the medical message is presented as unassailable. There is little
scope for dialogue or an exchange of ideas. Information flows from biomedical
obstetrics to local trainees, but not from women to obstetrics, as Pigg (1997) has
demonstrated in the case of Nepal, Sesia (1996) has demonstrated in the case of
Mexico, and I have found in Bolivia. Parteras and naturistas must leam how to
legitimize themselves by using the language of the official health care system.
While much of what traditional birth attendants know about attending births
is empirically and experientially gained, training programs targeted at upgrading
traditional knowledge are based on Western educational paradigms (verbal/written
presentation of principals) which do not fit within traditional points of view (Jordan
1993:134). While anthropologists have demonstrated through cross cultural studies
that the social aspect of childbirth cannot be separated from the physiological,
training for traditional birth attendants insists that they become medicalized and
separate the physical from the social/spiritual (Pigg 197:247). Pigg comments on
her work in Nepal: The varying social, emotional, protective, or polluting roles the
trainees might actually be playing are subsumed under the role of managing birth
itself (1997:246). For example, the role of the woman in cutting the umbilical
cord is regarded in trainings merely as a way to ensure the health of the mother and
child; the ritual significance in Nepal of carrying away ritual pollution associated
with birth is ignored (Pigg 1997:246). By not considering the fact that different
worldviews exist between the opposing systems of care during childbirth, the
trainers of midwives are completely oblivious to the fact that the training programs
are unsuccessful due to this fundamental problem. Instead, as Jordan (1993) points

out, they cite ignorance as the reason for difficulties in implementing programs or
getting midwives and women to go to the hospital.
Thus, the concept of primary health care offers developing countries a
solution to the challenges of implementing health services, but does not necessarily
seriously incorporate local beliefs (Jordan 1993) or encourage women to attend
these services, as I have demonstrated in Yapacanf. According to Jordan (1993),
This concept [primary health care] has also been co-opted by
planners who, ignoring the need for social and political reforms,
instead concentrated on extending cosmopolitan medical services to
rural areas, thereby laying the groundwork for the biomedical
colonization of communities.
In other words, biomedical training of village-level health workers is less
threatening to the interests of the authoritative power structure than fundamental
system reforms including true mutual accommodation of biomedical and traditional
beliefs (Sesia 1996; Jordan 1993; Justice 1986). Development discourse aimed at
incorporating traditional medicine into the dominant medical system is likely to
decrease program effectiveness, as has been demonstrated in Nepal and Mexico
(Pigg 1997; Sesia 1996), and as in this case of Bolivia where only limited efforts
have been made to actually incorporate traditional medicine into the dominant
paradigm. Womens discomfort with biomedicine in Yapacanf, where no
successful integration of traditional medicine has taken place yet, continues
manifest in their embarrassment, fright, and unwillingness to go to health centers at
the time of birth.
In conclusion, it seems that just as the United States underwent a cultural
revolution as recently as the 19th century which ultimately resulted in the
dependence on a professionalized, medicalized health care system (Starr 1986),
Bolivia is in a stage of transition. Whether or not the Bolivian population will fully

accept a Westernized professional medical system in the future is uncertain.
However, it is clear that they are in the process of maneuvering through various
knowledge systems parallel to those in the United States described by Starr (1986).
They face the difficult challenge of either inspiring in the entire population a
cultural revolution against traditional birth practices or accomplishing a true mutual
accommodation of technological and holistic birthing systems. As discussed, both
of these tasks are wrought with difficulties posed by lack of resources prohibiting
quality reproductive health services and their accessibility, stark cultural
differences, and the co-opting of the primary health movement by development
practitioners. The intensely personal nature of childbirth and its cultural
importance make it a sensitive litmus test for the status of this transition throughout
Bolivias health care system. In order to encourage more women to utilize
governmental services at the time of birth, this issue of complete cultural revolution
or mutual accommodation must be resolved, and the necessary resources must be
made available to ensure a properly functioning health care system.

All of the social, cultural, geographical and political-economic factors
discussed in Chapters four and five come together to answer the question of why
women do not think to utilize, are unable to utilize, or explicitly do not want to
utilize free reproductive health services provided by SUMI at the time of birth in
Yapacanf. As discussed in Chapter four, the low quality of care offered in
Yapacanf s health services is the most important reason cited for non-utilization of
health services. Chapter five explained how different social and political-economic
factors, including the design and structure of the national health system, the overall
neoliberal political strategy of decentralization in Bolivia, and the health care
personnels training and attitude regarding the process of birth and the provision of
services, interact to cause this low quality of care. The difference between the
percentage of pregnant women in Yapacanf utilizing prenatal care services (80% in
2004) and the percentage giving birth institutionally (37% in 2004) is dramatic.
This discrepancy highlights the importance of quality of care specifically at the
time of childbirth, the most crucial and potentially life-threatening moment in the
reproductive health timeline.
While some women expressed satisfaction with the care they had received
in a Yapacanf health service, the overall feeling from many of the interviewees was
that there was more suffering in the hospital than at home, due to incompetent and
unwelcoming health personnel and insufficient resources, making attempts by the
health services to convince women of exactly the opposite extremely challenging.
One aim of this study was to find out about the way that women would like to be
attended to when giving birth, in order to give the local governmental health

administrators a feel for possible ways to modify services for pregnant women.
The following recommendations from women and their husbands were presented to
the local health administration and CEPAC employees in August 2005.
The majority of the women and husbands interviewed prefer that a woman
(doctor or nurse) attend the birth, while more than a quarter of interviewees say that
they want someone who attends well, regardless of gender. Thus, it is important to
have female health professionals available to attend births, and to make sure that all
personnel are well-trained on the correct, sensitive way to attend to a birth. The
following are recommendations from women and their husbands surrounding four
different aspects of care in the health services: environment of birth setting, health
personnel, equipment, and duration.
Quotes regarding the environment of the birth setting include comments
about the position of birth, which the majority of time was biomedicine style, lying
down on a stretcher. For example, I want to be attended to on my knees on the
floor, not in the bed, because lying down it is hard to give birth. Women also
frequently complained about the rule that their husbands were not allowed in the
birthing room. For example, I would like my husband to be there so that he is
aware of the suffering and for more security. One woman voiced concerns about
the cleanliness of the hospital, saying that, I would like the hospital to be very
clean. Some women have gotten infections and they have more pains in the
hospital. My observations of the health posts and hospital in Yapacanf reveal that
in fact many of the birthing rooms were unclean in addition to the fact that there
was a lack of beds available, such that women often had nowhere to wait
comfortably before giving birth, and many were in fact turned away until the last

The second issue discussed by women is that the doctors and nurses do not
attend births well. One young mother commented that, There is no one constantly
helping like at home...they dont give us importance...I want them to attend
voluntarily and give more care to the woman. Another pointed out that there was
no one helping the nurse that attended to her birth and said that it would be helpful
to have more birth attendants because women with pain cant...control themselves
and they go half crazy. Several women referred back to their descriptions of
doctors scolding women and treating them poorly because they are collas from the
countryside, and reiterated that they do not want to be treated in that manner.
In terms of equipment and resources in the hospital and health posts in
Yapacanf, several women pointed out that there is a lack of available medicines,
even those supposed to be covered under SUMI, and that medical attention is not
entirely free. Finally, women recommended that the health services be more
available, in terms of providing more services such as a 24-hour pharmacy and 24-
hour health post, and also suggested giving preferential care to people from the
countryside who are unable to wait in long lines and allowing women to stay at
least two days in the health service after giving birth until the body matures. The
need for fast care once a pregnant woman arrives at a health service was a prevalent
theme in the interviews. Once mother said, Sometimes the health workers tell
women to come back later. In that case, I would prefer not to go. During visits to
health posts in Yapacanf, I observed that they were often closed, and oftentimes I
ran into health workers from distant Yapacanf communities in the urban hospital
for meetings, etc., indicating that posts were often left unattended.
Thus, the lack of availability of health services, in addition to the
environment of the birth setting, the available equipment, and the nature of care
given by health workers, are all issues to be addressed when attempting to increase

womens utilization of reproductive health services in Yapacani. In this context,
one wonders if giving birth in a medical setting such as this is truly the safest
option for women. These basic requirements of cleanliness, sufficient space and
resources, and respectful care are crucial in ensuring that SUMI is a successful
primary health care intervention that is able to offer comfortable care to women
who arrive to give birth in the hands of health care personnel.
Reactions of Health Administrators to Research Findings
As discussed in previous chapters, there are many macro-level and socio-
cultural issues influencing whether or not health services are able to accommodate
themselves to these recommendations. The principal aim of this research is not to
provide an answer for the alleviation of all the daunting, entwined problems it has
outlined, but rather to share the results of this ecological, political-economic study
with those in Yapacani concerned with improving maternal health so that they are
aware of the situation and can make whatever changes possible to encourage
women to utilize SUMI services at the time of birth. The details of the
dissemination of and reactions to the studys results follow.
In August of 2005,1 attended a meeting of CECARI (Ichilo Training
Center) with the hospital directors and some health care providers from the
hospitals in the province of Ichilo (including Yapacani and other municipalities),
the manager of the Ichilo provincial health service, and personnel from CEP AC.
After presenting the results of my study (as laid out in Chapter four), there was a
discussion of the results and the following recommendations for the improvement
of services in order to address the study results were made by all those present.
The representatives from municipalities other than Yapacani assumed that the