The Right to Health in Indigenous Guatemala: Prevailing Historical Structures in the Context of Health Care

Harvard FXB Health and Human Rights Consortium Student Essay Competition 2015.

University of Connecticut’s winning essay was written for the course “The Right to Health in Latin America,” taught by Professor César Abadía-Barrero, Spring 2015.

Alexander M. Lawton

Introduction

Many Latin American countries have been plagued by a history of conflict between repressive regimes and powerless civilians subjected to state violence. Guatemala’s history closely follows this trend, given the bloody armed conflict that occurred in the second half of the 20th Century. The country’s indigenous communities (composed primarily of Mayan descendants and making up close to half of the country’s population of 15 million) were particularly vulnerable to the State-sponsored violence.¹ Some studies show that, of the 200,000 killed or disappeared, 83% were indigenous.² Lasting effects of the civil war and a failure of the government to institute necessary reforms have created a dire health situation for Guatemala’s indigenous people.

In this review paper, I examine the poor health outcomes of these people in a historical context and under a right to health framework, focusing specifically on the violence of the civil war and the neoliberal health care reforms mediated by international financing institutions (IFIs) like the World Bank and the Inter-American Development Bank (IDB). I first give a summary of the historical events that led to a gradual marginalization and repression of Guatemala’s indigenous communities, including the colonial, post-colonial, and civil war eras. I then describe the evolution of Guatemala’s health care system, recounting some of the events that have led to the fractured system that exists today. I then discuss the unequal health outcomes experienced by Guatemala’s Mayan groups, linking these poor statistics to the historical framework. I conclude by arguing that the Guatemalan government has not created an environment in which these peoples can fully realize their right to health.

Colonial and post-colonial era

Before the arrival of Spanish rule, the Guatemalan population was predominantly a collection of Mayan indigenous groups, such as the Q’eqchi, the Quiché, the Cakchiquel, and the Mam.³ The arrival of Hernan Cortes and Pedro de Alvarado in the 16th Century marked the beginning of the colonial period, which would last until 1821, when Guatemala declared its independence from Spain. Guatemala’s various indigenous groups were collectively submitted to the power of the Spanish Crown and gradually lost much of their land and ruling power to a small group of wealthy elites. After declaring independence from Spain, Guatemala briefly formed an alliance with other Central American states to produce the United Provinces of Central America, which lasted until 1839. The dissolution of this republic led to a series of authoritarian rulers who controlled the country through the 20th Century.⁴

Guatemala’s 19th and 20th Century rulers helped connect Guatemala’s economy to international markets, primarily through exports of coffee and bananas. The US-based United Fruit Company

(UFCO), recognizing Guatemala’s potential for crop cultivation, underwent political negotiations with national leaders at the start of 20th Century, when they were hired to manage the country’s postal service.⁵ By this time, the US already had a well-established presence in Latin America, and the UFCO was one of the many powerful actors that helped to maintain its influence. Since the US economy was largely dependent on the success of Latin American export industries during this time, the North American country supported the authoritarian governments that opened their economies to foreign investment. In 1931, Guatemalan general Jorge Ubico became president and ruled for over a decade, serving to further protect the landowning interests of the UFCO. In 1944, Ubico fled the country due to popular unrest, and a leftist revolution established the country’s first democratic constitution, voting university professor Juan José Arévalo into office.⁶

The newly elected president made reforms in labor rights, education, and land ownership, quickly establishing his popularity among the low and middle classes. Arévalo’s reforms were furthered by left-wing candidate Jacobo Arbenz, who took office in 1951. Arbenz extended his predecessor’s land reform efforts, redistributing uncultivated or unused lands to poor, rural peasants. The revolutionary changes implemented by Arbenz and Arévalo were important in proportioning civil, political, and social rights to Guatemala’s large indigenous population: “Indians obtained full rights as citizens, and many benefited greatly from social welfare legislation, new labor laws, and the agrarian reform.”⁷ Despite these improvements, the gains of the revolution were limited; indigenous communities often had little agency in the reform process, and as a result many of their problems were not adequately addressed.⁸ Therefore, perhaps the most important effect of the revolution was the mobilization of the indigenous population around improving their living conditions and regaining their land.

While Guatemala’s working and peasant classes were generally receptive to the social and political reforms, the UFCO and its parent nation saw these institutional changes as direct threats. McCarthyist attitudes in the US, coupled with perceived threats to economic dominance, provoked the US to intervene. In 1954, a group of CIA-backed Guatemalan exiles led by Carlos Castillo Armas invaded Guatemala and seized control. While there was initial populist resistance to the occupation, the military refused to back Arbenz in preventing the invasion. Eventually, Arbenz resigned, wishing to avoid a full-fledged military conflict, and operating under the false assumption that the gains of the revolution would be maintained.⁹ Armas declared himself ruler and remained president until 1957, at which point he was assassinated. This marked the start of a decades-long civil war that lasted until 1996, when a series of peace negotiations were carried out between state and guerilla forces.¹⁰

Civil war and post-civil war

From 1960 to 1996, Guatemala was marked by a bloody period of political unrest, social instability, and structural violence. During this time, the country saw a new leader come to power every few years, and the majority of the revolutionary reforms were overturned. Under the Armas regime, 99.6% of the land that had been expropriated was returned to its former owners, most notably the UFCO.¹¹ In the first few years of the “counterrevolution,” socially organized political parties were also forced underground, and guerilla factions began to form. By the early 1960s, several left-wing guerilla groups had emerged, including the Guatemala Labor Party (Partido Guatemalteco del Trabajo, or PGT), MR-13, and the Frente Guerilla Edgar Ibarra. These groups remained in contact throughout the 1960s, uniting for a period to form the Rebel Armed Forces (Fuerzas Armadas Rebeldes, or FAR).

In the early 1960s, the State began to implement its counterinsurgency campaign, which often included violent killings of guerillas and their sympathizers. This movement was largely fueled by the US, who provided training, resources, and in some cases even manpower to ensure the failure of the revolution.¹² Death squads, a significant player of the far right, often composed of members of the military, operated outside of the constraints of the State (although sometimes under its guidance), with virtually complete impunity. Both State military and paramilitary forces used a variety of tactics, including assassinations, torture, and enforced disappearances to repress the “rebels” and prevent “subversive behavior.” While the guerilla forces began to respond with violence of their own, state-inflicted casualties marked the majority of the killings; reports by Guatemala’s Historical Clarification Commission (Comisión de Esclarecimiento Histórico, or CEH) estimate that State forces were responsible for 93% of the atrocities committed in Guatemala at this time.¹³

Although Guatemala’s indigenous population had certainly been active in armed resistance to State-led violence in the 1960s, it didn’t truly emerge as a player until the mid-1970s. In this decade, indigenous participation dominated several important groups (guerilla and otherwise): the Guerilla Army of the Poor (Ejército Guerrillero de los Pobres, or EGP), the Revolutionary Organization of the Armed People (Organización Revolucionario del Pueblo en Armas, or ORPA), and the Committee for Peasant Unity (Comité de Unidad Campesina, or CUC). Some historians have identified two events of the late 1970s as a turning point for indigenous involvement in the war. In 1978, State-run armed forces responded to a peaceful Kekchí land eviction protest in Alta Verapaz, a highland province in central Guatemala, by open firing on the crowd, killing over 100 people. Two years later, a group of indigenous workers from the province of Quiché (just west of Alta Verapaz) went to the Spanish Embassy in Guatemala City to protest the rising tide of violence. Again, the State responded brutally, burning the embassy and its 37 indigenous occupants alive. These massacres gave rise to a significant social response, including massive strikes and protests, and an upturn in indigenous participation in guerilla warfare.¹⁴

In 1982, the guerilla struggle was further organized—the EGP, ORPA, FAR, and a guerilla faction of the PGT all joined to form the Guatemalan National Revolutionary Unity (Unidad Revoluciononaria Nacional Guatemalteca, or URNG), establishing concrete goals and furthering civilian participation. The early 1980s was also the period in Guatemalan history with the most severe human rights violations: “The major thrust of the counterinsurgency campaign…was the scorched-earth war in the highlands from 1981 to 1983.”¹⁵ Much of the violence of this era occurred under the presidency of General José Efraín Ríos Montt, who seized power in 1982 through a military-led coup. The military, under Ríos Montt’s guidance, destroyed 440 villages, resulting in the death or disappearance of 100,000 civilians, and the internal displacement of 1 million—one-eighth of the entire population.¹⁶

Vinicio Cerezo, a civilian politician, was elected in the 1985 presidential election that followed the Ríos Montt regime. While he initially made a significant effort to decrease political violence, his term came to be marred by further human rights violations. Additionally, social problems continued to plague the country’s poor. Although the armed forces were still largely in control under Cerezo’s leadership, his presidency marked a downturn in the violence of the Ríos Montt era. A series of democratically elected leaders succeeded Cerezo, some of whom made attempts at improving relations with the indigenous and eliminating corrupt officials from the government. While the gradual democratization that occurred in the late 1980s did not end Guatemala’s political violence, it did mark a transition toward peace and reconciliation.¹⁷

The path toward peace was first initiated in 1989, when the Guatemalan government formed the National Reconciliation Commission (Comisión Nacional de Reconciliación, or CNR), which gave civilians a route to vocalize some of the atrocities that had been committed against them. The CNR began to negotiate with the URNG in a series of talks mediated in Oslo, where, in 1990, they signed a document committing both parties to strive toward a peace negotiation. These talks continued through the early 1990s, and were important in legitimizing the URNG as an actor in the negotiation process. While civil society and the government were both represented in the peace talks, the private sector also had some influence, markedly the large agricultural corporations that represented the interests of the country’s elites. By the end of 1996, the involved parties had agreed upon 11 total accords, which laid the foundation for reconciliation between the armed forces and the guerilla groups, and made plans for the implementation of new solutions to various social and structural issues.¹⁸ One of these solutions was the plan for a new health care system, which would ideally benefit the poor, marginalized populations that had had little access to health care services throughout the war.¹⁹

Evolution of Guatemala’s health care system

The health care system accessible to indigenous Guatemalans is currently an ineffective collage of elements from the civil war-era system, the post-1996 system, and traditional (indigenous) medical practices. In this regard, a unified, effective health care system has yet to be established. During the internal armed conflict, the Guatemalan government was largely removed from health care provision, especially to those populations fueling the guerilla soldiers. As the violence of the war started to wane amid attempts at democratization in the early 1990s, the government began to assume more authority for the health care system, which had endured a de facto privatization due to the State’s detachment from civil society.²⁰

The Guatemalan health care system prior to 1996 was composed of a tiered hierarchy of treatment. This system operated at four main levels: specialized hospitals at the national level, department hospitals at the regional level, health centers/posts at the municipal level, and health promoters at the hamlet level. Unfortunately, a range of key problems limited the system’s success. Rural, indigenous populations were least likely to receive adequate health care due to issues such as a lack of available transportation, language barriers, mistrust in the providers, and continued reliance on local curanderos and traditional healers. Local and municipal health care was administered in large part by promotores de salud or health promoters, who were trained through a 140-hour course set up in 1985 by the Guatemalan government, and are in some cases still active.²¹

In 1996, following the Peace Accords, the health care system of the civil war era was completely revamped, although a lot of the hospitals, community health centers, and health promoters from the previous system remained active. Many of the changes were promoted by the neoliberal structural adjustment programs of the IFIs, most notably the IDB. While many neoliberal reforms had already been implemented in the Guatemalan political and economic landscape in the 1980s, the IFIs saw the accords as an ideal opportunity to further integrate their free-market policies into the developing nation. As with many of the Latin American countries in which neoliberal reforms were mediated, the “era has been characterized by a gradual weakening of the state and an enhanced penetration by transnational institutions into the domestic political economy.”²² The IDB coordinated closely with the government to establish a new health care system, while the public remained largely uninformed as to the changes.²³

The Peace Accords dictated the formation of the Comprehensive Health Care System (Sistema Integral de Atención en Salud, or SIAS). The efforts of the SIAS focused on transferring the role of the State in administering health care to private entities. This was largely motivated by the government’s lack of resources and contact with marginalized communities, and the fact that many civil society organizations were already operating autonomously in these areas. In 1997, the Ministry of Health and Social Assistance (Ministerio de Salud Pública y Asistencia Social, or MSPAS) which is responsible for administration of the SIAS, divided the population into a patchwork of jurisdictions. Each region, composed of 10,000 inhabitants, would be served by a different NGO. Members of the MSPAS (including community health workers) protested the initial model because it put all responsibility on non-state actors, leaving little to no room for state physicians. As such, a “mixed-contract model was included in which an NGO is contracted as a health services administrator… to function as an administrator, financial manager, and payer for a separate health provider team that may consist of both MSPAS and NGO personnel.”²⁴ As a result, many NGOs began to function less as health care providers and more as administrators.

On paper, the SIAS spread rapidly to provide coverage to Guatemalans: by 2002, 88 NGOs had contracts with the government to cover 3 million Guatemalans.²⁵ Some estimates suggest that the number of uncovered individuals decreased from 46% to 9% from 1996 to 1999, although these figures do not take the quality of care into consideration.²⁶ Even with these comprehensive reforms “this system offers minimal state investment in health and extremely limited services for the poorest Guatemalans.”²⁷ Initially, the SIAS was supposed to be tested in a small number of communities, so the government could confirm its efficacy before expanding it. This plan was soon forgone, however, as the program was widely and rapidly instituted. As a result, the funds to pay NGOs were often insufficient, and providers sometimes had to suspend their services. The National Health Advocacy Platform, a coalition of NGOs in Guatemala, has criticized the State for transferring its responsibility as caregiver of the people to private organizations. Since there is a financial incentive ($5 per patient, per year), some NGOs with little experience in health care have been contracted by the government, although unable to adequately provide health care to their constituents.²⁸

Unequal health outcomes in Mayan Guatemala

Despite the implementation of the new health care system in 1996, Guatemala’s indigenous population has remained at risk for poor health outcomes. Poor health in these individuals is due to a larger pattern of inequality between Guatemala’s rural and urban populations, including differential access to education, employment, and adequate infrastructure.²⁹ For example, 15% of rural indigenous households have access to sewage systems, compared to 68% of urban non-indigenous households.³⁰ Indigenous families also have little access to clean water compared to people in urban settings. Respiratory illnesses are not uncommon in rural indigenous households, where food is frequently cooked over open fires. In contrast, urban households have more access to electricity, eliminating the need for smoky cooking methods.

Working conditions for indigenous people in Guatemala are also very poor. Many work for the agro-export industry, which has acted according to the interests of the country’s wealthy elites, with little regard for indigenous well-being. Many Mayan groups, whose land was “purchased” or downright taken by the large agricultural corporations, have had no choice but to work the crops as contracted farmers, earning menial wages. Those who still subsist on individual farming have less and less land on which to grow food. The lack of healthy foods has given rise to a chronic malnutrition problem in non-urban highland regions: the prevalence of chronic malnutrition in indigenous children was 59% in 2008-2009, compared to 30% in non-indigenous children.³¹

One of the major issues that has led to poor health outcomes for indigenous women and infants is a lack of adequate birthing services. Hospitals and birth attendants trained in modern medicine are rare in rural areas, and as a result 75% of births in these regions occur in the home, where conditions may be far from adequate.³² As a result, Guatemala has the highest infant and maternal mortality rates in Central America.³³ Even when indigenous populations have access to modern health professionals, language barriers can prevent adequate communication from occurring between the patient and the health worker. Approximately 40% of Guatemalans do not speak Spanish, the country’s official language, as their primary language.³⁴ Many of the state-directed doctors and nurses do not speak any of the Mayan languages, and are thus unable to understand the needs and complaints of the indigenous communities they serve.³⁵ This has generated a lack of trust in the physicians of the State health care system, often causing indigenous people to rely on traditional healing techniques.

Discussion

While it is important to examine the historical events that had a detrimental effect on the lives of the indigenous, it is also essential that we draw connections between these factors and the current situation. As chronicled by Diane Nelson in War By Other Means, in Guatemala the “emerging postwar structures of inequality layer on to the still unsettling effects on health and economy of the years of lost crops and missed education when people were displaced, and the loss of family members […] murdered, starved, exiled, disappeared, or who are barely functioning because of war trauma.”³⁶ While the government has taken efforts to alleviate these problems, a permanent mark has been left on the psyche and lives of Guatemala’s indigenous. As I have outlined here, the civil war has generated a massive schism both in Guatemala’s health care system and in its communities. On paper, Mayan descendants may have access to a MSPAS community health care worker or health post remaining from the pre-reform era, an NGO contracted by the government through the new SIAS system, or a local curandero, who can administer traditional Mayan medicine. While indigenous communities may be theoretically “covered” by all of these structures, it is unlikely that they will receive continuous, comprehensive care.

Even in situations where NGOs or governmental workers are available and have adequate resources, the legacy of the civil war has weakened their contribution. A climate of fear and mistrust has persisted in post-civil war indigenous Guatemala. This has made members of these

communities reluctant to make use of the SIAS services, as limited as they may be. One of the main issues yet to be resolved following this conflict is the impunity of State officials. Many of the most repressive leaders or generals have not been brought to trial, in part due to the long judicial process; as of 2009, 96% of cases remained unresolved.³⁷ Just as impunity has remained the norm in Guatemala, many families still have little knowledge about disappeared or murdered relatives. This lack of information can produce feelings of intense depression, and further discourages people from participating in State-run social programs, such as the SIAS. While the government has made efforts to encourage public participation in policy planning, the indigenous are still underrepresented: at the national level, they constitute only 11% of the representation, although they make up over half of the country’s citizens.³⁸ To establish a more balanced power relationship, the government must enact further measures to improve indigenous involvement in the SIAS.

Setting aside the problems with Guatemala’s health care system in addressing the needs of the indigenous population, a broader examination highlights the presence of socio-historical factors that have prevented these poor communities from surmounting poverty and improving their health. Due to the overwhelming dominance of the agro-export industry and the institution of neoliberal reforms in the 1980s, indigenous Guatemalans have been driven off their land and forced to work for low wages, leaving them in destitution. Being isolated from urban centers, the country’s Mayan descendants, who reside principally in the Central and Western Highlands, have had to rely on their little remaining land as their only real access to capital. Unfortunately, evidence suggests that the trend of land acquisition by large corporations has continued, even after the end of the civil war. One estimate claimed that land “given” to palm oil plantations increased by 146% between 2005 and 2010.³⁹ Additionally, the few social welfare programs that existed during the civil war were largely restricted as IFIs took over the economy in attempts to reduce spending and foreign debt.

The agricultural industry, which still has a dominant hand in Guatemalan affairs, has fiercely fought legislation which would restore indigenous land and improve employment opportunities in rural areas. In 2012, a rural development law reached Congress, which would have enacted many measures to begin to alleviate some of these concerns; it was not passed. To this day, the United Nations Development Programme reports that 80% of the fertile land of Guatemala resides in the hands of 5% of the population.⁴⁰ The continued dominance of large agricultural companies in the state and economic sectors has prevented the institution of necessary reforms. Regardless of the efficiency of the health care system, the indigenous of Guatemala will remain disproportionately subject to poor health outcomes if they are landless and destitute.

Taking into account all of these factors, the Guatemalan government has yet to develop a framework in which members of Mayan communities can fully realize their right to health: “Indigenous people remain less likely than nonindigenous to utilize services and this disparity cannot be attributed solely to rural geography.”⁴¹ The Guatemalan government has ratified the International Covenant on Economic, Social, and Cultural Rights, a legally binding resolution that guarantees “right of everyone to the enjoyment of the highest attainable standard of physical and mental health” without discrimination.⁴² In 2007, Guatemala also voted in support of the United Nations Declaration on the Rights of Indigenous Peoples, which, although not “hard law,” commits the State to providing equitable health care to its indigenous residents.⁴³ In order to fulfill these commitments, the government must make major changes to its current health care system and make larger structural changes that empower its poor constituents and move away from neoliberalism.

Conclusion

Why do indigenous Guatemalans still suffer from considerable poor health indicators? An analysis of the complex interaction of various historical, economic, and social factors has shed some light on the current health situation of indigenous communities in Guatemala. Mayan groups in Guatemala have been marginalized and oppressed since the beginning of the Spanish colonization. In the 20th Century, their situation worsened significantly due to a loss of land to international corporations like the UFCO. Although attempts at reform were made during the political revolution of 1944 and the decade that ensued, any changes were reversed early in the civil war, which was provoked and fueled in part by the US.⁴⁴ The country’s Mayan descendants, who became significantly involved in the conflict in the mid- to late-1970s, were subject to extreme violence and repression by the military and other, non-state actors. The consequences of the armed conflict have persisted through the present day: although the 1996 Peace Accords between the guerilla factions and the government laid out plans for social and political reform, implementation of these changes has been scarce. The country’s health care system, or SIAS, which was restructured as part of this process, continues to be largely removed from indigenous people. Poor implementation of the new health care system, remaining elements of the previous state-sponsored health care system, and the government’s decentralization have generated a fractured structure that fails indigenous people and often causes them to rely on traditional medicine. In order to improve the health of these groups, social welfare programs and land reforms that move away from neoliberal politics seem the only way to help grant indigenous people better and healthier lives.

Acknowledgements

The author thanks Professor Abadía-Barrero for his continued guidance and support.

Alexander M. Lawton, BS, BA, is a recent graduate of the University of Connecticut who has studied human rights, biology, and Spanish.

Please address correspondence to the author c/o Alexander M. Lawton, 61 Magna Lane, Westbrook, CT, USA 06498, email: alexmlawton@gmail.com

Competing interests: None declared.

Copyright © 2015 Lawton. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

1. Minority Rights Group International (MRGI), Guatemala overview: Maya. (July 2008). Available at: http://www.minorityrights.org/2555/guatemala/maya.html.

2 . Comisión para el Esclarecimiento Histórico (CEH), Informe de la Comision para el Esclarecimiento Historico, Guatemala: Memoria del silencio (Guatemala: Oficina de Servicios para Proyectos de las Naciones Unidas, 1999), vol 12. Also published in English as Guatemala: Memory of silence. Report of the Historical Clarification Commission (Washington, DC: American Association for the Advancement of Science, 1999). Available at https://hrdag.org/wp-content/uploads/2013/01/CEHreport-english.pdf

3. MRGI, 2008 (see note 1).

4. G. Lovell. Conquest and survival in colonial Guatemala: A historical geography of the Cuchumatán highlands, 1500-1821, 3rd ed. (Ithaca, NY: McGill-Queen’s Press, 2005).

5. P. M. Sonnenburger, “United Fruit Company” in M. E. Paige (ed), Colonialism: An international social, cultural, and political encyclopedia (Santa Barbara, CA: ABC-CLIO), pp. 600-601.

6. J. Gonzalez, Harvest of empire: A history of Latinos in America (New York, NY: Penguin Group, 2011).

7. S. Jonas, The battle for Guatemala: Rebels, death squads, and US power (Boulder, CO: Westview Press, 1991), p. 37.

8. Ibid.

9. Ibid.

10. Gonzalez (see note 6).

11. Jonas (see note 7), p. 42.

12. Ibid, pp. 42, 70-71.

13. CEH (see note 2).

14. Jonas (see note 7).

15. Ibid, p. 149.

16. Ibid.

17. Ibid.

18. E. Alvarez and T. P. Prado “Guatemala’s peace process: context, analysis and evaluation. Owning the process – Public participation in peacemaking,” Accord, An International Review of Peace Initiatives 13 (2002), pp. 38-43. Available at http://www.c-r.org/sites/default/files/Accord%2013_7Guatemala%27s%20peace%20process_2002_ENG.pdf

19. J. N. Maupin, “‘Fruit of the accords’: Health care reform and civil participation in Highland Guatemala.” Social science & medicine, 68/8 (2009), pp. 1456-1463.

20. J. C. Verduga, “The failures of neoliberalism: Health sector reform in Guatemala,” in M. P. Fort, M. A. Mercer, and O. Gish (eds), Sickness and wealth: The corporate assault on global health (Cambridge, MA: South End Press, 2004), p. 59.

21. M.D. Jones, “The solution is prevention: The National Rural Health Care System in Nahualá” in W. R. Adams and J. P. Hawkins (eds), Health care in Maya Guatemala: Confronting medical pluralism in a developing country (Norman, OK: University of Oklahoma Press, 2007), pp. 86-99.

22. P. Rohloff, A. K. Diaz, and S. Dasgupta, “‘Beyond development’: A critical appraisal of the emergence of small health care non-governmental organizations in rural Guatemala.” Human Organization, 70/4 (2011), p. 427.

23. Maupin (see note 19).

24. Maupin (see note 19), p. 1458.

25. G. M. La Forgia, P. Mintz, and C. Cerezo “Is the perfect the enemy of the good? A case study on large-scale contracting for basic health services in rural Guatemala.” World Bank Working Paper, 57 (2005), pp. 9-48. Available at http://www.who.int/management/country/latinamerica_carribean/HealthSystemInnovatonsCentralAmerica.pdf?ua=1#page=21.

26. M. Gragnolati and A. Marini, “Health and poverty in Guatemala.” World Bank Policy Research Working Paper, 2966 (2003) p. 31. Available at https://openknowledge.worldbank.org/bitstream/handle/10986/19187/multi0page.pdf?sequence=1.

27. Verduga (see note 20), p. 61.

28. Maupin (see note 19).

29. Ibid.

30. MRGI, State of the World’s Minorities and Indigenous Peoples 2013 – Guatemala (September 2013). Available at: http://www.refworld.org/docid/526fb749b.html.

31. Ibid.

32. Ibid.

33. Central Intelligence Agency (CIA) “Guatemala.” The CIA World Factbook (2015). Available at https://www.ciawes.gov/library/publications/the-world-factbook/geos/gt.html.

34. Ibid.

35. Rohloff, Diaz, and Dasgupta (see note 22), p. 429.

36. C. McAllister and D. M. Nelson (eds), War by other means: Aftermath in Post-Genocide Guatemala (Durham/London: Duke University Press, 2013), p. 295.

37. W. Flores, A. L. Ruano, and D. P. Funchal, “Social participation within a context of political violence: Implications for the promotion and exercise of the right to health in Guatemala.” Health and Human Rights, 11/1 (2009).

38. Ibid.

39. MRGI, 2013 (see note 30).

40. Ibid.

41. Rohloff, Diaz, and Dasgupta (see note 22).

42. International Covenant on Economic, Social and Cultural Rights (ICESCR), G.A. Res. 2200A (XXI), Art. 12. (1966). Available at http://www2.ohchr.org/english/law/cescr.html.

43. Declaration on the Rights of Indigenous Peoples, A/RES/61/295 (2007), Articles 21 and 24. Available at http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf.

44. Jonas (see note 7), p. 31.32. Ibid.