Beth A. Uzwiak Creative Research and Evaluation, Philadelphia, PA (E-mail: [email protected]) Siobhan Curran Pavee Point Traveller and Roma Centre, Dublin, Ireland

Gendering the Burden of Care: Health Reform and the Paradox of Community Participation in Western Belize Belizean health policy supports a primary health care (PHC) strategy of universal access, community participation, and multisectoral collaboration. The principals of PHC were a key part of Belize’s emergent national identity and built on existing community-based health strategies. Ethnographic research in western Belize, however, reveals that ongoing health reform is removing providers from participatory arenas. In this article, we foreground a particular moment in Belizean health history—the rise and demise of multisectoral collaboration—to question what can constitute meaningful community participation in the midst of health reform. Many allied health providers continue to believe in the potential of PHC to alleviate the structural causations of poor health and to invest in PHC despite a lack of state support. This means that providers, the majority women, are palliating the consequences of neoliberal reform; it also means that they provide spaces of contestation to the consumer “logic” of this reform. [primary health care, Belize, community participation, gender, neoliberal health reform]

Introduction We have an appointment to interview Eloise, a veteran community health worker, known locally as a community nurse aide (CNA).1 We missed the one afternoon bus to her village, so we walk the dusty road from the town of San Ignacio and cross the rope footbridge over the Belize River. Before the bus route connected this village to San Ignacio, residents walked or canoed into town for hospital care. We cut through a field and pass in front of the closed doors of the community center, which, at the height of state-supported primary health care (PHC), doubled as a health center. Many rural residents in the western Cayo region of Belize rely on monthly mobile health clinics and CNAs like Eloise for primary care. According to policy, the government of Belize continues to support a PHC strategy of universal access, community participation, and multisectoral collaboration (PAHO 2012).2 The ethnographic data we discuss in this article, however, reveal a decrease in state MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 30, Issue 1, pp. 100–121, ISSN 0745C 2015 by the American Anthropological Association. All rights 5194, online ISSN 1548-1387.  reserved. DOI: 10.1111/maq.12195

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support for PHC and an increase in for-profit private sector health provision under the guise of health reform (Homedes and Ulgade 2005). Eloise has been a CNA for nearly 20 years. Five years ago, she watched the doors of her community center close. For more than a year, she did not receive her monthly stipend from the Ministry of Health. Yet Eloise remains a stalwart PHC supporter. She knows that recent changes to the public health care system make it more difficult for her neighbors to access care at the nearest hospital. Often, it is up to her to ensure they receive what basic care she can provide. A decline in state support for CNAs, coupled with her commitment to PHC, means that Eloise works more hours with less material resources and little to no strategic collaboration with other health care providers. Eloise’s situation is a salient point of departure to discuss how the participatory rhetoric of PHC evident in Belize’s health policy is at odds with experiences of health providers as the state undergoes neoliberal health reform. It also prompts the question: How do PHC providers in western Belize respond to ongoing public sector health reform? Before health reform, Eloise experienced the gains of PHC firsthand, the principals of which were a key part of Belize’s emergent national identity. In many places worldwide, PHC was never fully implemented due to the interference of structural adjustment and neoliberal reforms (WHO 2005). In Belize, the global primacy of PHC coincided with its independence from Great Britain in 1981. The nascent country supported PHC even as it became embroiled in debt re-servicing—a commitment both ideological and material. Assad Shoman, minister of health for the new nation-state, affirmed health—“a state of complete physical, mental and social wellbeing”—as a fundamental human right. His ministry devoted resources to the provision of primary care, “which involves bringing health care as close as possible to where people live and work” (Shoman 1995:318). Below, we foreground a specific moment in Belizean health history—the rise and demise of multisectoral collaboration and its impact on PHC providers—to question what constitutes meaningful community participation in the midst of neoliberal health reform (Kano et al. 2005). Due to prior multisectoral successes, CNAs and other health care providers continue to endorse the ideals of PHC, effectively buffering the impact of recent state cutbacks. We argue, therefore, that health reform creates a “paradox of participation” for those previously involved in successful PHC in western Cayo; their perseverance signals a space of contestation against the commodification of health. Continued efforts to deliver care operate as a form of resistance to the state’s co-option of “participation.”

Background to Research The data discussed in this article are part of a larger two-year ethnographic study in the western Cayo region of Belize, the purpose of which was to ascertain the impact of ongoing health reform on both PHC provision and access. Belize has the fifth lowest satisfaction level out of 20 Latin American countries in relation to the availability of quality health care (Government of Belize 2010). Ethnographic research (qualitative interviews, focus groups, surveys, and participant observation) from the larger dataset includes the perspectives of people who provide health services and create and implement health policy as well as those who seek health

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services from the public health system. Here, we concentrate on data from PHC providers to capture changes in community participation in response to a decline in state-supported multisectoral collaboration. The overwhelming majority of PHC providers are women whose work to meet the changing demands of health delivery is largely invisible (Boehm 2005; Lamphere 2005). During the course of our research, we studied health care sites from rural clinics to urban hospitals to ascertain how changes in the public primary system altered patterns of health-seeking behavior. Our goal was to identify health disparities, but with the understanding that reduced state support for PHC leads to heightened demands on providers (Horton 2006). We observed how providers responded to cutbacks and an overall reduction in state support for PHC initiatives. An urban area surrounded by rural villages, western Cayo is particularly well suited to examine the consequences of health sector reform. In the heart of the Cayo District, two towns—San Ignacio and Santa Elena—make up Belize’s second largest urban area. Belize’s current population is around 330,000, with more than 70,000 persons living in Cayo (Statistical Institute of Belize 2010). Western Cayo has a private and public hospital (now a polyclinic), private and public clinics, private pharmacies, practicing herbalists and natural healers, and proximity to Guatemala and health services there. The area embraces a mixed and rapidly growing demography including Mestizo, Creole, Indigenous, Mennonite, Garifuna, Asian, and East Indian populations, with a number of people who identify with multiple ethnic categories. Poverty increased between 2002 and 2009 from 34% to 41% countrywide, with an increase in indigence of almost 50%. Nearly half the population lives in rural areas where poverty is substantially greater than in urban areas (Statistical Institute of Belize 2010). Despite a rising population and an increase in poverty, less government resources now attend to the social causations of poor health than 20 years ago (PAHO 2012).

Belize: A Cautionary Tale Belize’s story is a common one: Worldwide, structural adjustment programs immiserate as they undermine public sector services (see Pfeiffer and Chapman 2010). Belize’s economic trade agreements opened its health care markets to transnational corporate entities including pharmaceutical companies (Richardson 2007). Yet Belize also offers a poignant case study to appraise what is lost when the state reverses genuine investment in PHC. In the 1980s, as the newly independent government made a political commitment to address the social causation of poor health and to recognize health as a human right, it simultaneously funded PHC provision, including training CNAs and integrating them into local health teams. District health coordinators formalized mechanisms to bring the work of CNAs into conversation with village-based health committees, rural nurses, and NGOs. As discussed below, these entities also generated community-based health education and prevention activities, cementing communication chains and working relationships that later proved vital during a cholera outbreak in the 1990s and, more recently, the HIV epidemic. Despite Belize’s previous success with multisectoral collaboration in PHC, this article is, in part, a cautionary tale given the conflicts between the definition and

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implementation of “community participation” in health policy (Morgan 2001). We take seriously the potential of community participation and PHC efforts more broadly to promote health equity. The social justice and human rights principles embedded in PHC allow us to understand health inequity not as behavioral or biological but as enmeshed in power relationships, including economic resources, political transparency, and policy decisions (Yamin 2005). At the same time, we argue that a continued emphasis on community participation in health policy documents— without meaningful multisectoral support from the government—obfuscates the fact that neoliberal health reform displaces the burden of care from the public system to the individual—not just those accessing services, but those providing them (Linden 2010). Belize’s new health reform documents also emphasize personal responsibility to maintain good health, citing lifestyle and behavioral choice as reasons for individual poor health. The recent policy Promoting Knowledge and Behavioral Change aims “to increase knowledge of health risks, adoption of healthier behavior and careseeking behavior” (Belize Ministry of Health N.d.). In addition, the ongoing Health Sector Reform Program (HSRP) will move some service provisions to the private sector through a National Health Insurance (NHI) plan, while downsizing and decentralizing existent public health services. An increase in choice of providers through the provision of private health services, however, is not an increase in access to primary care for most residents and, in fact, signals a decline in community participation in PHC. This dissonance between rhetoric and reality raises the question: Why does the state continue to mobilize discourses about PHC at the same time that it emphasizes lifestyle and individual responsibility? The answer is threefold. First, policy emphasis on behavior masks the consequences of neoliberal reforms as frontline health practitioners and civil society—in this case, community members and NGOs—attempt to palliate reductions in state services (Buse et al. 2002; Hyatt 2001). Those involved in PHC delivery struggle to remain effective, “band aiding” fissures in service delivery in the face of growing community hostility and diminishing work conditions (Foster 2005). Doctors and nurses work overtime, often supplementing their government income with private sector work, while those who work in more grassroots capacities—CNAs in particular—go without sufficient support from the Ministry of Health. This situation echoes McKenna’s (2012) concern that “irreconcilable contradictions” exist within the theory and practice of PHC in a neoliberal culture. Second, discourses of consumer choice operate as a gloss for passing on the cost of neoliberal reforms (Foley 2009), in effect shifting the burden for ameliorating health status from the public system to the individual—in this case, both residents and providers. Important to our discussion here, research indicates that even as blame for poor health is located within the bodies, choices, and values of individuals, the burden of care for providers increases (Bourgois 2009; Farmer 2004). Third and last, empowering residents to take care of their own health needs through discourses of lifestyle and behavior obscures the continuing role of state action in producing social inequalities and structural violence (Hyatt 2004). As outlined in the following sections, Belize retains an ideological commitment to PHC, bound as it is to its post-colonial identity. In turn, those who were involved

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in PHC at the height of state support recall its successes with nostalgia—not just for the ability of multisectoral collaboration to better address local health concerns, but because it brought people together with a shared vision of “Equal Health for All.”3 In a sense, continued state emphasis on community participation distracts from just how far the nation-state has moved from its post-colonial ideals.

The Primary Health Care Movement and Multisectoral Collaboration Many of the tenets of equality and access that underpinned the global PHC initiative of the 1970s were already present in Belize, including community participation (MacPherson 2009a). Well before the Alma-Ata Declaration, the government of Belize provided free basic health services, including some preventative care. These services manifested from the grassroots efforts of women volunteers and the legacy of Black Cross Nurses (MacPherson 2009b). Black Cross Nurses emerged during the social reform era of the 1920s and 1930s as part of the Universal Negro Improvement Association, formed by middle-class, progressive Creoles. Belizean Creole leaders emphasized social respectability, an end to colonial dependency, and policies of racial uplift. Although largely focused on class-based social reform through changing individual behavior, early efforts at primary care held the government responsible for providing basic health services (MacPherson 2009a). Black Cross Nurses were instrumental in bringing attention to structural causes of ill health such as abysmal housing, low income, and lack of adequate nutrition. In 1944, the Medical Department established the Rural Health Nurses (RHN) Program. The first four trained nurses were midwives, and they took charge of four village health posts. By 1948, 12 trained RHNs were at work, and by 1950, 19 rural health sites existed. RHNs brought new experiences of state-sponsored health care to rural communities, raising hopes and expectations. As the state expanded, so did the demand for health services. In addition, women’s use of health services fueled criticism of a colonial state that provided too little and judged too much (MacPherson 2009a). In the 1950s, women used their new voting power to help elect nationalists who moved forward an anti-colonialist movement. The struggle for national independence was both long and contentious. In the late 1960s, a group of Belizean students returned from schooling in the United States where they were active in the Black Power and anti–Vietnam War movements. They formed several organizations to challenge neocolonialist underpinnings of the nationalist movement. Together, their critiques of social marginalization and a lack of distributive justice provided counterpoints to the prevailing decolonization project. Importantly, these activists connected the legacies of colonialism to endemic poverty, and to growing foreign economic dominance. In 1970, two leaders—Said Musa and Assad Shoman—became members of the prominent political party and ministers of government; both were instrumentally involved in the negotiations and lobbying leading to independence, while Musa later became prime minster (1998–2008). Although unable to prevent the economic strangulation of structural adjustment, they simultaneously promoted redistributive efforts and policies to foreground the alleviation of structural poverty, such as PHC. Assad Shoman moved PHC policy forward through his own office as health minister as well as through his involvement with the Unity Brigade, a group of

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young people mobilized to support PHC initiatives. Under the Unity Brigade and coordinated health initiatives, teams were taken to villages to both provide health services and to interact with community members. Shoman’s drive and commitment to the spirit of Alma Ata can perhaps best be seen in a speech from 1982: “Our commitment to primary health care, to ‘public health’—that is, to the public’s health, to the people’s health, demands from us a political commitment to truly democratize our society, to bring about a redistribution of wealth and of economic and political control in our society” (Shoman 1995:325). The goal of state-supported PHC in the 1980s was to strengthen existing community-based participation through multisectoral collaboration with a focus on addressing inequality and poverty to improve health status (Shoman 1994). The Ministry of Health recognized “the entire socio-economic system determines the quality of our health” and actively sought the participation of residents in the promotion of their health. To solidify their PHC program, the ministry held extensive consultations with health workers at all levels and with community members throughout the country (Shoman 1995). At this time, large-scale funding from USAID, CARE, PAHO, and other international organizations spearheaded post-independence infrastructure development, social programs, and health policy, including the development of the Health Education and Community Participation Bureau (HECOPAB). HECOPAB was created as part of Belize’s adoption of a primary health care strategy in 1983, with technical and financial support from UNICEF. As the health promotion arm of the Ministry of Health, HECOBAB plans, coordinates, and implements health promotion programs, projects, interventions, and activities throughout Belize. At the height of Belize’s PHC approach, HECOPAB coordinated communication between allied health personnel, including representatives from government ministries, NGOs, village-based health councils, and health agencies such as PAHO. Until 1995, HECOPAB operated as a single unit from Belize City. Health educators traveled to the other districts to conduct health promotion activities in collaboration with the primary health care district coordinators. In 1995, the Ministry of Health amalgamated HECOBAB with the Primary Health Care Program and established HECOBAB units in each district. This undertaking enabled district health educators to supervise CNAs directly and to connect local health activities to the structured health system through village-based health committees. Community Nurse Aides: The Bridge that Links Belize’s PHC program envisages CNAs as the first point of contact between residents and the health care system. A 50-page manual details the diverse duties of CNAs and includes conducting home visits, assisting health facilities in their communities, visiting schools, coordinating clean up campaigns, and performing basic patient care. CNAs assist medical teams in community outreach activities and support partner agencies such as the National Emergency Management Organization, the Belize Red Cross, and other agencies in their programs (PAHO 2013). In the words of Suzanna, a primary health nurse, multisectoral collaboration allows those working in the hospitals to “know exactly what is happening out there.” For example: “If a

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CNA tells you that there is an outbreak of gastrointestinitis, you will tell your other nurses. We would then make sure the CNAs had enough rehydration salts.” Through structured support, CNAs became catalysts for change in western Cayo communities (Population Council 2004:17). Our data corroborate that CNAs provided health services and screenings for malaria, dengue fever, HIV, and mental health and obtained complex understanding of the factors that influence peoples’ health decisions. They worked with fellow residents to provide nutrition education, basic maternal and child health services, and improvements in water and sanitation such as building community water tanks. They also provided the less visible assistance often necessary to access health services such as child care while a parent goes to the clinic, Spanish or indigenous language translation, or bus fare. During one of many conversations, Carletta, a former PHC district coordinator, described CNAs as “the ones that are out there; they are the bridge. That is what I used to always tell them: You are the bridge that links.” During a cholera outbreak in Cayo, CNAs went from house to house to conduct cholera prevention education (PAHO 2002). Primary health nurses taught CNAs venipuncture for the administration of fluids to severely dehydrated patients who did not have immediate access to health centers and hospitals. According to Carletta: “Community Health Nurses and CNAs saved a lot of lives because we had people getting cholera [ . . . ] and they started their IVs, they rehydrated that person, and that person got here to the hospital alive.” Multisectoral collaboration with CNAs also allowed the public health system to better meet the health needs of individuals with chronic or infectious diseases. Epidemiological data indicates that Belize has a 2.3 HIV prevalence rate countrywide (UNICEF 2012). Epidemiological knowledge, once disseminated, is intended to increase public awareness of health risks to make behavioral interventions more effective (Frankenberg 1993:233). Without efforts to change social inequity, however, dissemination of epidemiological data can depoliticize health disparities and create stigma when an individual cannot or does not change perceived risky behavior. CNAs can provide education that addresses local beliefs and attitudes about behavior without removing choice from its economic and social contexts. For example, in the early days of the HIV epidemic, CNAs talked to their fellow residents about sexual health and prophylactics, taboo subjects and seldom discussed in Belize’s Catholic school system. As Carletta explains, in Belize “it is difficult to talk to people about sex, especially in our communities. It is a very touchy subject [ . . . ] but CNAs would figure out how to get the target groups.” As Perez and Martinez (2008) argue, CNAs are natural researchers who can recount the realities of health access and exclusion and propose remedies for it. Multisectoral PHC filters information back into the health system so policymakers can better understand health decisions as rational given the circumstances of peoples’ lives. This process of translation is particularly relevant for the more invisible public health concerns such as domestic violence and sexual abuse. Because there is potential for trust between CNAs and community members, CNAs can often identify and address public health issues that may otherwise elude assistance. Over time, CNAs in western Cayo built relationships with allied health professionals and began work with the Department of Human Development to deliver domestic violence workshops. Dorthea, a CNA, recalls: “We used to sit

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down with other departments and have meetings and organize how we can do our activities together in the communities.” CNA-generated collaborations were then reported back to the government via multiple departments, prompting the Ministry of Human Development to institute gender-based violence education programs.

Structural Adjustment and Health Reform: State-supported PHC Meets Its Demise Although PHC showed positive results on the ground, the international arena criticized it as both impractical in its comprehensive scope and potentially compromising corporate profit (WHO 2005). Redirection of international funds through selective primary health care (SPHC) deemphasized the social and political dimensions of PHC by concentrating on low-cost measurable interventions to reduce mortality and morbidity (Hall and Taylor 2003; Smith-Nonini 1997). Intended as an interim model, SPHC suppressed PHC long-term goals, which have never been fully recovered (WHO 2005). Community participation, while desirable, was also considered politically threatening (Heggenhougen 1984). Ronald Reagan’s presidency in the United States corresponded with Belize’s first decade of independence. At this time, the U.S. government targeted both the Caribbean basin and Central America as areas of political investment and domination (in part to prevent, by force if necessary, the establishment of socialist governments in the area). The United States became Belize’s primary trading partner and its main source of investment funds through the USAID program. Reagan’s Caribbean Basin Initiative expanded exports through U.S. private enterprise (Sutherland 1998). As Belize adopted economic growth as measure of development through the expansion of exports, government rhetoric equated interests of investors with national interests (Medina 1997). These national interests involve controlling inflation, reducing fiscal deficits, opening economies to international trade, increasing labor market flexibility, and reducing direct government spending and service delivery in social policies such as health policy (Armada et al. 2001). In the late1990s, the government began an in-depth assessment of the health sector as part of an economic package to reduce public external debt by reorganizing the health system (Public Services International 2001). The resultant HSRP “continues to support primary health care initiatives, with the overarching goal of producing a more efficient, sustainable, and equitable national health system which incorporates the participation of communities in the planning, implementation, and monitoring of their own health care systems” (Belize Ministry of Health N.d.). In reality, “the participation of communities” is difficult when health reform endorses an efficiency-based model of health care (Janes 2004). As Public Services International (2001:31) summarizes, health reform will “reduce the number of health care clinics, health care posts, and district hospitals; reduce primary care to minimal, standardized fee-based packages; and severely restrict access to secondary care.” Dr. Martinez, a prominent local physician, believes that over the past decade the western Cayo region has experienced an overall decline in health care and access due to decreased funding. “Ten years ago,” he states, “the hospital had a lot more to offer in medication and the quality of nursing care, the quality of the doctors was a lot better then, too.”

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In 2000, the Ministry of Health began to cultivate private sector sources to provide basic and supplementary heath care through an NHI program, a process that at the time of research was steeped in controversy over the misuse of public funds. As a former Ministry of Health worker elaborates: “The idea behind it was for the Ministry of Health to purchase those services that were not provided by the Ministry of Health from private providers.” However, Suzanna, a public health nurse suggests: “One could argue that the same monies that you are paying the private providers you could hire additional public health nurses.” And, as Dr. Martinez argues: “We are not a rich country, so they procure on the lowest bid and sometimes that is not the best one.” Further, while many of the country’s health needs can be meet with basic medicine, medical equipment is touted as the cure-all. As basic services deteriorate, money is earmarked or misappropriated for technology without consulting health providers.4 The Ministry of Health now purchases select health services from the private sector and regulates, rather than runs, many health services including the main hospital, Karl Huesner, in Belize City. HSRP regionalized the country into zones, each with one main hospital; existing hospitals, like the San Ignacio Public Hospital in Cayo, were accordingly downgraded to serve as referral hubs, in this case to the regional hospital in Belmopan, for some a two-hour bus journey. A nurse in San Ignacio explains: “If patients [in western Cayo] need hospitalization they will now be referred to Belmopan. The new polyclinic is just like an emergency hospital with a maternity clinic attached to it. So they will be doing deliveries but hospital patients cannot be accommodated for too long.” Yet public ambulances that service the western Cayo region are often not operational, without equipment or trained technicians (Parks 2009). In the midst of global economic restructuring, and with the subsequent limited financial and human resources available to the health system, the privatization of health services may seem a logical government decision (Pfeiffer and Nichter 2008). Privatization, however, undermines the public health sector in several ways. When public hospitals and health services compete with commercial providers for funding, less money flows into the public system (WHO 2005). Typically, the public sector is left to care more for those who cannot afford to access private care while contending with funding cuts (Smith-Nonini 1997). For-profit private providers do not supply unprofitable health care. The inevitable result is less focus on underlying causation of poor health: The public sector has limited resources to support multisectoral collaboration, while the private sector is not interested in it (Sexton 2001).

The Collapse of Multisectoral Collaboration We scrape chairs into a circle and wait for other members of the Village Health Committee to arrive. We convene at the school library, once the site of weekly multisectoral meetings that included residents, CNAs, district health coordinators from HECOPAB, and members of allied NGOs. Now, residents tell us, they meet only to plan local festivals and an occasional health fair. As soon as residents take chairs and open windows to clear the stale air, they begin to lament. Although members’ opinions differ, a common theme emerges: Once, not long ago, villagers worked collaboratively with HECOPAB to organize educational programs. CNAs

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and villagers identified families and individuals who were in need of additional assistance with food or money for medications. A resident recalls: “Everybody used to meet and each village, each area used to voice their concerns when it came to the health of the district.” Ministry of Health officials attended their monthly meetings at least five times per year, informing residents on policy initiatives such as statewide HIV testing. Now “we hear nothing from them,” one resident complains. “And we don’t know what is happening, not even here at our own clinic,” another rejoins. In the past, residents felt part of a health planning; now they feel isolation and distance from state policy. While HECOPAB ostensibly remains responsible for training CNAs, supervising multisectoral health interventions, and supporting village-based health councils and allied efforts with NGOs, data reveal that in western Cayo, these efforts are now fragmented at best. The Ministry of Health budget for HECOBAB is currently less than 1% (PAHO 2013). Rather than coordinated primary care, “resources have been re-allocated towards appropriate information systems and health promotion including risk behavior interventions” (Belize Ministry of Health 2006:22). At the time of this research, there remained 15 practicing CNAs in the area studied, although many had not interfaced with the Ministry of Health or other CNAs for more than a year. CNAs are still required to attend refresher courses, but according to data, these are infrequent and attendants are now tasked with covering their own transportation costs. CNAs report that they are no longer provided with resources such as kits to measure blood pressure, glucometers, and batteries (PAHO 2013). Laurel, a CNA from a remote village, confesses: “The biggest challenge is sometimes we really don’t have enough support from the ministry. Sometimes I get frustrated and I just want to leave everything and forget about it. Sometimes it is really hard when you want to do something but you don’t have the materials to work with.” During the time of our fieldwork, the CNA district coordinator post based out of San Ignacio had been vacant for more than three years. This person once coordinated multisectoral meetings and visited CNAs in their villages to support them. She also ordered supplies and basic medication like expectorant and rehydration salts to distribute at monthly meetings. The post for the Women’s Department, a Ministry of Human Development position that worked closely with multisectoral health efforts such as CNA-facilitated domestic violence workshops, had also been vacant for more than two years. The primary health care district coordinator position was defunct. A few village-based health councils were operational; many, like the one described above, express a marked decline in participation with other sectors of PHC. Many allied health organizations such as the National Drug Abuse Council were also defunct. Without resources, adequate funds, and ongoing training it is difficult for CNAs in western Cayo to operate at their full capacity and to provide critical communication between their communities and the health system. Since the demise of multisectoral collaboration, there have been fewer referrals coming from CNAs into the health system and less training for CNAs coming from the health system. Unsurprisingly, residents who live in rural locations suffer the most from this disconnection. Victoria, the VCT (volunteer counseling and testing) nurse in San Ignacio recalls:

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When I was working in the field, I used to get a lot of referrals from the villages through the community health worker. We used to have educational sessions with them and we taught them how to recognize signs of mental illness, and they used to refer the patients, they used to notice and capture these patients and they used to refer them to me. But now we don’t have that happening anymore. The problem is that the patients are not been recognized because they are in the village and they will stay there. Fragmenting Provision In reality, ongoing market-focused reforms create a gap between poor-quality primary care and inaccessible secondary and tertiary services, resulting in a fragmented public system (WHO 2008). As residents take on the cost of a fractured system, so do providers. Dr. Martinez’s description of working conditions at the public hospital sums it up: “At the end of the day, what we have in Belize is a lack of human resources. So you have an overburdened, overworked, frustrated bunch of people who are screaming to get out.” At the same time, due to low pay and local health care needs, some providers supplement long hours in the public system with private work, often seeing patients that the public system fails. All of our study participants—from residents to pharmacists and doctors—are well aware of the decline in PHC and the divide between the promise and delivery of public services. Yet, the realities of poor PHC at times make private options necessary—even PHC providers pay for private doctors or travel to neighboring Guatemala for services there. In addition, Belize has no national school of medicine and depends largely on utilization of medical training institutions in Cuba. The University of Belize supplies other non-physician health care providers through its Faculty of Nursing and Allied Health Sciences. However, Belizean-trained health providers increasingly seek employment in the United States and Canada due to higher pay and career incentives (PAHO 2009). “Our nurses are leaving our country. They go to the U.S., they go to different areas,” one administrator complains. Severe human resource shortages have led to the recruitment of health professionals from within and outside the Caribbean. According to some study participants, new doctors, and nurses: “Don’t understand the old ways,” and “Don’t get to know our people.” A few CNAs, including Eloise and Dorthea mentioned above, feel that newer doctors and nurses do not seek their input and look down on them as being “from the village.” Newer health care workers, in other words, did not experience previously successful multisectoral collaboration and the respect it engendered. The increasing lack of human resources makes both prevention and disease maintenance less viable options for PHC delivery. Victoria, the VCT nurse, provides an affecting example: The people with HIV and AIDS are not getting cared for properly. We don’t have a steady doctor; we don’t have a trained doctor who is looking after these people. We have free anti-retroviral medication through the Global Fund; patients who have been identified as having HIV are getting [medication] but they are not being monitored in the right way. Because if

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the doctor can’t come in on a Friday he picks up the phone and says, “Nurse I can’t come in today, just give the patients their medication and I will see them in two weeks’ time.” And sometimes people come in and they really need an evaluation, their medication isn’t working and they are having side effects and I can’t help them. Here we see doctors unavailable to help patients navigate side effects, illustrating the downsides to pharmaceutical-based treatment and SPHC interventions more generally. Further, interviews reveal that health care workers feel that fragmented services deprive them of their full capacity to heal. Practitioners express exasperation when they are not able to provide a full diagnostic treatment but only short-term solutions, knowing that the underlying causes of illness are not being addressed. Screenings and preventative medicine take a back seat when the bulk of resources must address immediate symptoms. Patricia, a nurse in San Ignacio laments: “We are not teaching people how to prevent getting illness. I don’t think we are being very effective because we are leaving out, we are forgetting about prevention.” A recent PAHO (2013:v) assessment in Belize suggests that enhancing (we would say reinvesting in) CNAs and multisectoral collaboration would alleviate many of the above-mentioned burdens because CNAs “can be specifically trained to administer basic medications and manage uncomplicated patients” and assist in “chronic disease management and amelioration,” thereby reducing “patient loads of rural nurses and physicians at health centers and health posts, who could then administer a higher level of care.” Given the acknowledged shortage of nurse and doctors, “scarce human resources in health would be substantially better utilized with an effective CHW [CNA] program.”

Gendering the Burden of Care It is most often women—as community leaders, caregivers, and health providers— who become the “shock absorbers” of neoliberal reforms (Anglin 1998; Harrison 1997; Hyatt 2004; Sassen 2003). Women, through maternal and child health services, access the primary system more frequently. It is also often women, through the “household production of health,” who take on the burden of seeking health care, often postponing their own care to pay for private services for male family members and children (Inhorn 2006). It is also, ironically, women and the poor who become pathologized for poor health and the target of behavioral intervention. One goal of Belize’s health reform is to “encourage behavioral changes towards healthier lifestyles among beneficiaries, especially women, children and the poor population” (Belize Ministry of Health N.d.). It is now more difficult for residents to access the primary and preventative services that would help them obtain these healthier lifestyles. Ethnographic research in the United States about safety net sites—places that serve low income and uninsured patients—can also reference CNAs and other health workers in Belize whose “invisible work subsidizes the system” (Horton 2006:2703). With a lack of support for PHC, it falls to the poor to insist on care and for PHC providers to find alternative ways to procure medicines and treatment

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for those they know are ill. Reforms increase the burden on the providers who assume responsibility for helping patients navigate the structural barriers neoliberal reforms overlook. This “gap-filling” is not always possible. We heard stories of CNAs pooling money to pay for a resident’s taxi-cab fare to the hospital when the ambulance had two flat tires and no gas; nurses calling the private pharmacy to ask for free samples when the hospital had yet another pharmaceutical stock-out; doctors advocating for patients to be transferred to the private hospital despite a family’s inability to pay for life-saving surgery. We also heard stories of children dying from misdiagnosis (Humes 2009b), deaths on the highway when no ambulance was available (Parks 2009), and a woman who died during childbirth due to prolonged waiting times at the hospital. For providers, what Lamphere (2005:7) identifies as “emotional labor and an ethic of care” often persist despite structural changes in health delivery, amounting to a buffering that makes the restructured system work. In Belize, buffering also results from ideological commitment, a refutation of seeing health as a commodity. Ethnographic data in western Cayo reveal differences within and between how providers take on additional responsibilities or explain changes in the public health system and the impact of these on residents (Lamphere 2005). One trend, however, is striking: Providers who were previously involved in multisectoral collaboration are the ones who attempt to mitigate the fallout of allied health. From busy clinic waiting rooms to village health posts, providers recognize that recent reforms exacerbate underlying causation of poor health. Many providers retain ideological commitment to PHC and resist the recent policy emphasis on lifestyle or behavioral change as the primary way to ensure good health. Rather, they continue to recognize poverty as the primary determinant of good health. As Eloise, the CNA mentioned in the opening paragraph, states: I think the biggest problem is there are a lot of people who are very poor. And sometimes we are just ashamed of saying what’s happening but it’s the truth. People who don’t have enough income usually go to the public clinic or hospital. And sometimes they don’t get no attention, and sometimes there is no medication. Victoria, the VCT nurse sums it up: “Lifestyle changes are related to socioeconomic problems.” We can understand previously successful multisectoral collaboration as filling gaps in public health provision. CNAs can provide what the official health system lacks, such as indigenous language translation, opportunities to discuss family disputes and domestic violence, basic supplies such as vegetables and canned goods for those out of work, child care during a parent’s visit the doctor, and medications like Tylenol. They also buffer interactions with stigmatized services such as mental health counseling and HIV treatment and offer confidentiality for those seeking information about sexual and reproductive health. Previously successful PHC relied on the work of mostly women to be effective, yet efforts were state sanctioned and intentionally supported as intersectional components of health provision. In the past, allied health providers identified their “invisible” care work as part of an operative communication chain; now, without linkages to collaborative health

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efforts and the health system itself, their work subsidizes reform and removes the transgressive (socio–political) potential to address underlying causations of poor health. In the past, providers discussed access to resources, water, and housing as components of health at allied health meetings. Now, rhetorical commitment from the government without structural coordination renders such work untenable. Providers now speak of PHC “failure” because their work can do little to cushion residents from the consequences of reform and even less to address structural barriers to access. Nurse Victoria confesses: “I don’t think that we are taking care of our population properly. I say we because I am part of it. But I really and truly think that we are failing.” Many providers “came of age” during the era of radical decolonization and nation building, when Belize’s commitment to redressing social inequalities was both ideological and material. According to Joanna, a former PHC district coordinator, the PHC provision brought people together with a shared ethic of care, a vision of equal health for all. Now, providers are well aware—and some are angry—that the government’s commitment to community participation is largely rhetorical. “I hear politicians talking when it comes to health, they talk primary health care but they don’t do it,” contends Joanna. Nurse Victoria agrees: “When it comes right down to it they don’t really focus on primary care. We had a primary health care office here and since the officer retired we don’t have anybody.”

Allied Health and the Paradoxes of Participation Community input is vital to PHC and can challenge the assumption that principles of market competition, rather than principles of health as a human right, better redress underlying causation of poor health. At the same time, it is essential to question what community participation can actually mean when the state supports neoliberal policies (Homedes and Ugalde 2005). Research reveals the contradictions of NGO and civil society participation in public health systems and in health reforms, as structural adjustment often redirects monies from the public system to nongovernmental coffers in its push for privatization (Janes 2004; Maupin 2009; Pfeiffer 2003). The rhetoric of participation can be transformed into a technocratic project sheared of its radical connotations resulting in policy without material expenditure or coordinated support (Cooke and Kothari 2001; Morgan 1993, 2001). As the public sector cultivates private services, it relies on health providers, community members, and NGOs to take on responsibilities once under the purview of the state (Hyatt 2001). For example, the reality of health reform means that CNAs in western Cayo work more as the state provides less. Participation, in this instance, can mean incorporating people into agendas that they are unable to question (Yamin 2009). Yet, national allied health efforts simultaneously provide local advocacy and training opportunities otherwise unrealized, creating a series of paradoxes as the rhetoric of participation translates to action. Even in the midst of privatization, allied health providers in Belize strive to ensure that communities are heard (Janes 2004). We suggest that these sites of collaboration, once fully operative and now contentious, remain points of resistance to the commodification of health, even as frontline health practitioners and allied health agencies attempt to assuage reductions in state services.

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At the time of Belizean independence, many international agencies funded national NGO advocacy campaigns, thus supporting multisectoral collaboration in PHC, including training programs for CNAs (Population Council 2004). Allied health NGOs gained representation on selected national councils, task forces, and boards, facilitating access to government ministries and policymakers (Witter 2004). Recently, funding has declined and with it many allied NGO health activities. A PAHO representative in Belize corroborates, “It is not only in Belize, a lot of agencies that were supporting Primary Health Care initiatives are no longer in the region, MSF, USAID—all of those agencies have actually pulled out. Some of the initiatives were sustainable and they still exist, but the organizations left and there is no additional money being pumped in.” Since the decrease in government support and international funding in Belize, national NGOs struggle to secure monies for services and programs (Campbell N.d.). As the state provides less social programming and the immediacy of social distress increases, NGOs may have to prioritize small-scale projects over large-scale movements, inadvertently limiting communities’ engagement with long-term collective action. NGOs that promote long-term social change and critical advocacy are often unable to gain funding as they are seen as a threat. In short, neoliberalism can depoliticize NGO advocacy (Fisher 1997). For this reason, it is crucial to recognize that community participation in PHC is not synonymous with social justice, nor does it inevitably attack entrenched inequalities. Participation has rhetorical cache with a great number of actors, including international development agencies, supranational organizations such as the World Bank, and ministries of health. In practice, participation is often a mixed bag, creating class-based affiliations or supporting paternalistic views of “less deserving” community members (Cooke and Kothari 2001; Creed 2007). Communities themselves are often contested spaces (Wayland and Crowder 2002). While participation in “invited spaces” (Yamin 2009:12)—those created and substantively controlled by health planners and policymakers—can facilitate social change, they can also reinforce existing privilege and preclude alternative perspectives. Merrill Singer’s (1995:90) distinction between system-correcting praxis and system-challenging praxis is helpful here: “Though system-correcting praxis tends to obscure the causes of suffering and sources of exploitation, system-challenging praxis is concerned with unmasking the origins of social inequity. Moreover, this type of praxis strives to heighten rather than dissipate social action and to make permanent changes in the social alignment of power.” System-challenging praxis can open spaces for critical intervention to confront neoliberal policies and address the concerns of “structurally marginalized”5 populations. In Belize, examples of longstanding system-challenging NGOs are at risk due to funding cuts, specifically the campaigns of national NGOs Belize Family Life Association (BFLA) and Women’s Issues Network-Belize (WIN-Belize). Both organizations were formed during the heyday of international funding and multisectoral collaboration from existing advocacy networks. WIN-Belize collaborates with organizations throughout the country concerned with women’s rights and issues impacting women such as HIV/AIDS and gender violence. WIN-Belize and its associated activists are responsible for many social and legal protections and policy reforms (Moore 2007:214). BFLA was established

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in 1985 as an affiliate of the International Planned Parenthood Federation. BFLA initiated a Community Involvement Project in the 1990s to recruit and train CNAs to provide sexual and reproductive health education and referral (Population Council 2004). Through direct support of CNAs, BFLA devolved power, thus facilitating a link between community members and policy arenas. Now BFLA is the only organization in Belize that focuses exclusively on sexual and reproductive health. At the end of our field research, we worked collaboratively with advocates at WIN-Belize and BFLA to use and disseminate our collected data in ongoing health campaigns. Against the odds, both organizations continue to provide an advocacy platform for health issues in part because of prior connections to existing allied health efforts and to previously successful multisectoral collaborations. Decades of community building via state support, and the trust these processes engender, underpin current advocacy campaigns. In short, many health advocates believe in the potential success of multisectoral participation because they experienced it firsthand. In Belize, allied health providers, including NGOs, still attempt to collaborate, stretching reduced budgets to address growing health concerns. At the time of our fieldwork in western Cayo, CNAs still provided basic care to fellow residents, often without supervision; village-based health councils still met, if infrequently; public health providers including doctors, nurses, and clinic staff worked overtime with few resources. These efforts prompt the question: How do we measure participation in the midst of neoliberal reform? In this case, continued participation does not mean success, it means striving. It means working in broken systems. It also means covering for state reductions. On the one hand, we can conclude that continued community participation becomes a handmaiden to neoliberalism. Data indicate that without structured state support, participatory efforts do little to address the underlying social causations of poor health. On the other hand, research participants vocalize an awareness of the cost of neoliberal reform; most express anger and grief about the divide between the continued rhetorical support for PHC and the erosion of state support and proceed with their efforts anyway. Fractures reveal that residents persist in holding PHC efforts accountable, not to cost effectiveness through behavioral intervention but to the social causations of ill health. Continued efforts to provide PHC even in the midst of neoliberal reform indicate nodes of struggle and resistance—efforts to actualize health as a public good rather than as a market commodity (Rowden 2009).

Conclusions WHO has returned yet again to the idea of PHC. Its 2008 report, Primary Health Care: Now More than Ever states, “Few would disagree that health systems need to respond better—and faster—to the challenges of a changing world. PHC can do that” (WHO 2008:xi). Although this report reinforces the original principals of PHC, it does not, as Alma-Ata did, call for a new international economic order (Sanders et al. 2009). Without meaningful state support for multisectoral collaboration, rhetoric like this masks the consequences of neoliberal reform for PHC efforts. The state retains symbolic support for PHC without making major expenditures in public services and infrastructure (Paley 2001:159). Participatory rhetoric in health

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policy documents obscures how neoliberal health reform displaces the burden of care from the public system to the individual, residents and providers alike. State-supported PHC facilitated opportunities for community members in western Cayo to conceive of themselves as rights holders (Flores et al. 2009). Research participants including health providers, community members, and CNAs like Eloise mourn the decline in PHC for its ability to bring residents, health providers, and allied NGOs into decision-making arenas with the Ministry of Health. Further, data convey that previously successful PHC collaboration in western Cayo allowed the public health system to better meet the health needs of individuals who have difficultly accessing health services, such as those with chronic illnesses or mental health concerns. In Belize, health reform has focused on reducing public expenditure so the government can better service its international debt. A team of technocrats facilitated the reform with little to no opportunity for vigorous public debate (Public Services International 2001). The resulting increase in private for-profit health providers and decrease in multisectoral primary care removes providers and residents from participatory arenas. Reform subsequently increases barriers to primary care. For PHC to truly succeed in the spirit it was intended, it must account for historical and ongoing structural inequalities (Heggenhougen 2009). Education, outreach, and prevention are intrinsic to PHC—programs that address choice, behavior, and lifestyle as components of good health. However, these efforts must be tied to issues such as land tenancy rights, adequate housing, water, sanitation, and people’s ability to choose their livelihoods (Yamin 2005). Multisectoral strategies must confront the unequal distribution of power and resources within communities, between communities and the state, and between the state and international financial institutions (Flores et al. 2009). Effective health activism means getting political (Erikson 2008). While health policy rhetoric may embrace PHC, the government does not encourage the dissent that inevitably accompanies real community participation (Smith-Nonini 1997); rather, they encourage individualized explanations of poor health. As the colonial history of Belize demonstrates, residents want the health system to address the underlying causes for poor health, including poverty (MacPherson 2009a). Further, the state cannot fully retreat from the undergirding principals of PHC—in particular community participation—because of its deep connection to Belizean national identity and its independence movement. In the past, residents demanded government responsiveness and accountability to secure health services. Residents and providers defined health programs, policies, and decisions that directly bear on their own wellbeing (Shoman 1994, 1995). State-supported multisectoral PHC was successful in western Cayo because it built on these existing community-based health strategies. These sites of collaboration, once operative and now contentious, remain points of resistance. In the Belizean case, neoliberal reforms create a series of paradoxes precisely because prior PHC efforts were successful. Many allied health providers continue to believe in the potential of PHC to alleviate the structural causations of poor health. Therefore, participants continue to invest in PHC despite a lack of state support. This means that they are band aiding a fractured system and thus operating as palliatives to the consequences of

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neoliberal reform; it also means that they provide spaces of contestation to the consumer “logic” of this reform. For those who experienced multisectoral coordination firsthand, the loss of state support for PHC is poignant. As Lydia, a former primary health district coordinator states, “It breaks my heart. I know the value of preventative care. I know the value of coordinated health. I saw it first hand for our communities. If we want to see progress in health, we really need to put supports in place and revive them. The communities need the support from the health department.” As the state continues to support neoliberal policies, however, participation requires activism to ensure the involvement of those most in need of health care as well as state accountability to the structures of PHC it claims to value.

Notes 1. All names have been changed or eliminated to preserve confidentiality. 2. The Alma-Ata Declaration, adopted at the international conference on Primary Health Care in 1978, asserts primary care as key to attain “health for all” in the spirit of social justice. The primary health care model recognizes the importance of community participation and intersectoral action to address underlying causation of poor health. 3. While minister of health, Assad Shoman created the Ministry of Health motto: “Equal Health for All.” 4. In 2009, charges of corruption were leveled against the board and management of Belize’s main hospital, Karl Huesner, for unapproved purchases of equipment and supplies in the private market. See Humes (2009a). 5. We use the term structurally marginalized here to indicate community members who have been marginalized by colonial history and nation-state policies.

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