Decentralisation in the post-conflict environment of Guatemala: a critical examination of the evaluation process of community participation in a health sector reform context

Abstract

This thesis focuses on a critical and comprehensive analysis of community participation within a health sector reform process in a post-conflict environment. The aim is to examine how evaluation of such processes should be guided, how decentralising policies should be implemented, and how the assumptions of existing evaluations limit their relevance and effectiveness. The thesis argues that comprehensive analysis demonstrates the need for a much deeper and more extensive understanding of the multiple complexities present in post-conflict environments than is often achieved. It is necessary to carry out a historical, comparative and analytical evaluative exercise, beyond mainstream structural-functionalist evaluations, because the latter generally do not address relevant external and internal variables affecting the conditions of the community. Utilising this proposed approach fieldwork in the communities of San Juan Chamelco and San Miguel Tucurú (in the northern department of Alta Verapaz) examined examples of the limitations of and potentials for the incorporation of traditional medicine into the institutional healthcare system. This fieldwork is used to inform development of a comprehensive framework for evaluation with wide potential as a technical-conceptual tool. The Guatemalan case is presented as an illustrative example of how this tool can be developed and elaborated within a specific historical, political, social and cultural context. Building on the findings of a sectoral evaluation carried out under the auspices of the Ministry of Health the comprehensive evaluation presented identifies key problems that prevented health decentralisation policies from having a significant and positive impact at the local level. In this complex post-conflict environment, local organisation and community participation are shown to be still in their infancy having been obliterated by the counter-insurgency policies during the course of prolonged conflict.