This section presents our findings on the network qualities of the citizen-led initiatives and their relation to mobilization of collective action and accountability outcomes in Concepcion, Santana and Tolima. First, we present a comparative overview of the network characteristics of these groups, drawing on participants’ accounts of what the ties connecting them represent. Then we explore the motivations and the issues that unite them in collaborative efforts, and we examine how the initiatives’ networks provide resources in their collective action gathering evidence of health system problems and engaging with authorities. Finally, we consider how the resources that participants gained from their networks contributed to accountability outcomes and their plans for strengthening them.
Profile of social position of initiative participants
The groups of initiative participants gathered for the study in the three municipalities were similar in number (10-13 participants), but the profiles of the roles they held in their communities varied (Table 1). Concepcion participants included representatives from several women’s community-based organizations (CBOs), as well as actors with roles in different municipal institutions and the district nurse from the health center. In Tolima, participants from urban civil society, who were active in community organization roles, joined with indigenous authorities and members of a traditional birth attendant (TBA) organization, who were from remote villages. While in Santana, most of the participants were leaders from different small villages with supporters from urban civil society and two rural community organizations.
Participants’ diverse roles provided the initiatives with connections to different segments of the population of users of services as well as authorities. The social positions of village leaders, leaders of women’s CBOs, and TBAs were useful for convening the population to raise awareness about health rights and providing a point of contact for users of services to voice a complaint. In Concepcion, the lead defender described that their collaboration with diverse actors allowed her to be a voice for health in different activities and spaces, so that their work can “connect to more people and help more people.” The TBA association in Tolima played a key role in connecting the defenders from urban civil society with the fairly large and disperse population of users of health services through their role as traditional health providers and recognized figures in the villages. The collaborators from municipal institutions in Concepcion and the indigenous authorities in Tolima were also regular participants in municipal decision-making spaces and served as a resource for gaining audience and efforts to influence local authorities. In Santana, many participants held similar roles as village leaders, but they were from four different remote communities, each with a local health post. They described that they used their space in community-wide assemblies and meetings with other community authorities to educate about rights and how to report complaints about services.
Nature of interconnections: Relational and structural qualities of initiative groups
The nature of interconnections within the groups was reflected by the density of ties, the types of relationships and frequency of communication (Table 2). In Concepcion and Tolima, the higher density scores indicated that the majority of participants knew many of the others, while in Santana there were more participants who knew few of the others. Overall, the participants were connected by a mix of strong and weak ties. Participants were more likely to describe their relation to others as distant or work-related than friendship or family. Reports of the frequency of communication between participants indicate that at least one-third of relations reported were fairly distant, with contact only one to four times in the last year. However, in Concepcion and Tolima, there was also a substantial proportion of relations (50 and 40%, respectively) where communication occurred at least monthly. These relational qualities of higher density of ties and more frequent communication indicate a greater degree of cohesiveness and a stronger history of coordination among participants in these initiatives. In Santana, the lower density of relational ties and less frequent communication reflect that participants share less collective history as a group, at least in part due to the distances between villages.
The group degree centralization (GDC) scores are relevant for understanding the structure of interconnection in each group. The groups in Concepcion and Tolima had lower centralization, which reflects a more even distribution of ties among participants. Santana’s higher centralization reflected that a few participants dominated the ties more than others. The structure of participants’ ties in collaborative action are shown the network maps in Figure 1. These maps show a higher density of ties among participants in Concepcion and Tolima, reflecting more history of collaboration within and across subgroups with similar profiles. This pattern reflected more frequent interaction in broader efforts for health among groups like the leaders from women’s CBOs with actors from municipal institutions in Concepcion and the TBA association with urban civil society in Tolima. In Santana, the history of collaboration among participants was not as strong, with not even all defenders reporting collaboration ties with each other. The lower density and higher centralization in Santana reflect how three more central defenders played a key role in bringing the others together, who did not interact otherwise.
Focus of collaborative efforts
Participants’ accounts indicated the histories and motivations behind the ties of collaboration shown in Figure 1. In both Concepcion and Tolima, participants were collaborating for the right to health, but they were also collaborating in other ways. Collaboration in Concepcion was driven by a desire to see their municipality develop, and they worked together in different sectors to “tackle any problem that presents – it doesn’t matter if it is education, security, health, anything.” While in Tolima, many of the participants had roles in health promotion and they were motivated by first-hand contact with their people’s health needs and their grievances with the health system. One of the TBAs described that when you see the severity of people´s needs, “there is something in your heart that makes you stand up”. They feel an imperative to do something because “we can’t sit by and do nothing.” Their work together involved coordinating care for patients and supporting them to seek health services. The history of collaboration in Santana was more limited because the ties represented a coordination among village leaders who had not previously worked together. In this case, the group was brought together by their interest in improving the health services in their villages. They described themselves as watching out for their rights because if they do not, no one will. One defender described that it has been challenging to get more people to support their efforts due to poverty and the burden of losing a day’s work. But he states that:
“knowing your rights is also part of (getting ahead in) life, because just look at how things are going…people are realizing about the manipulation and the corruption… Our history obligates us to fight for the rights we have as Guatemalans.”
Mobilization of network resources in action for accountability
Collective action for the right to health across the three municipalities had a common focus on gathering evidence of health system problems and engaging with authorities to seek resolution. The mobilization processes emerged from the interaction between the resources offered by the initiatives’ network, the dispersion of the population and health services, and the receptivity of local authorities.
Initiative participants’ connections to the population bolstered action to gather evidence of health system problems. In addition to Concepcion participants’ positions as leaders of women’s CBOs and village leaders, the small geographical area and the receptivity of district health authorities facilitated contact with users of services through regular monitoring visits at the health center. Occasionally actors from municipal institutions and village leaders accompanied the defenders on these visits to give more visibility to problems like inadequate infrastructure and lack of medicines. In Santana, even though relational ties were weaker and more centralized, the geographical distribution of the network permitted coordination of extensive documentation of problems in the health services via monitoring visits and collection of user reports. Participants in Tolima also facilitated connection to a more disperse population, with village TBAs referring the defenders to interview service users with complaints. The ties connecting the members of the TBA association and the defenders enabled the collection of many reports of abuse and mistreatment in the district hospital in Tolima. Through their role accompanying their patients, the TBAs had experienced this problem first-hand. One described that they were:
“treated like worthless garbage…They throw people on the beds, even nude…Particularly the student doctors treat people like dogs, telling them there is nothing wrong with them. They don’t care where someone has pain”.
The TBA collaborators provided a key connection to patients because the hospital authorities in Tolima were not open to monitoring visits.
The evidence of local problems gathered through their connections with communities provided the basis for going to authorities to advocate for solutions. The maps in Figure 2 show the variation in the participants’ engagement with authorities across the three cases. In both Concepcion and Santana, participants had interacted with municipal and district health authorities, as well as regional level authorities. Their advocacy with municipal and regional authorities focused on similar problems of medicine shortages and deficient infrastructure, and both groups had also engaged with district directors to seek response to user complaints of mistreatment. In Concepcion, defenders participated regularly in the municipal council and presented petitions for improvements to the health center and supplementing the medicine supply with backing from their collaborators. They attributed their ability to be heard in these spaces to the municipal authorities’ recognition of their role as “representatives of the people for health” and the influence of key collaborators who they mobilized to accompany them. Even though the municipal authorities were receptive to their participation, “many times they don’t fulfill their obligations”. Through the collective action of the participants, “they feel a little pressured to help the health services”. In Santana, a smaller group was engaging with authorities and their interactions were less frequent compared to Concepcion. The defenders had a position to participate in the municipal council meetings, but they were not always included and local political rivalries made it challenging to align supporters. They presented petitions for repairing the roofs of the health posts with municipal authorities as well as regional authorities. And the lead defender maintained regular communication with the regional and district health directors and vice minister of health about the status of the medicine supply in the health posts.
Interactions with authorities in Tolima took shape differently, with defenders, indigenous authorities and members of the TBA association interacting with the mayor and filing complaints in legal institutions to seek solution for the mistreatment both the TBAs and their patients were experiencing in the hospital. Even though defenders participated in municipal council meetings with some network allies, the authorities were not responsive in seeking a solution. And hospital authorities were not open to giving them audience. As an alternate route, they would support service users who were interested to file a legal complaint with the public prosecutor. The defenders and the TBA association also filed a collective grievance about the abuse and mistreatment at the hospital at the regional office of the Commission against Discrimination and Racism (CODISRA). At the time of the second study visit, a representative from CODISRA had been sent to investigate but no action had been taken.
Value of network resources for accountability outcomes
The processes that the initiatives adopted to mobilize their networks in collective action involved long term engagement and continual adaptation of strategies. In both Concepcion and Santana, the initiatives were able to leverage community-generated evidence and iterative interactions with different authorities to gain influence. Municipal resources had been mobilized in these cases for resolving different health system problems, including infrastructure improvements and medicine supply, and the initiatives had facilitated improved coordination between municipal and district health authorities.
Concepcion’s dense mix of strong and weak ties with collaborators in positions to communicate to the population and to lend their influence to petitions with authorities enabled the initiative’s work to gain recognition and credibility in this small community. Their action plan for strengthening their network focused on coordinating intersectoral action for health with current and new collaborators, which reflected their strategies of approaching health in an integral way by “joining forces and having unity among those who work in different areas” and presenting broad backing for health issues to increase the “legitimacy and validity of their proposals”.
Santana’s network of mostly weak ties enabled the initiative to link up participants in positions to give voice to rural service users’ problems with a central subgroup that was actively communicating with authorities at different levels to coordinate support. As a group of mostly remote village leaders, they faced a greater power differential in interactions with authorities, but they contributed to an improved coordination between regional and district health authorities in medicine delivery. They attributed the influence they have gained to their way of engaging:
“They listen because we are a group that is trained to be able to present, to listen and negotiate for what we want, and how to collaborate more than anything”.
The extensive evidence they collected also gave them credibility as a voice of the people. Their action plan focused mainly on strengthening their community base through involving influential community leaders and developing an alliance with a rural women’s network.
In Tolima, the initiative faced more challenging local sociopolitical conditions. Though they had gathered substantial evidence and had the support of indigenous authorities and the TBA association, they had not been able to obtain a response from local authorities. The nature of their problems in the hospital reflected dynamics of racism and discrimination. They were not able to engage directly with hospital authorities, but they did seek legal recourse for several cases of rights violations and gathered reports about many more. Their action plan focused on convening influential community leaders to discuss the problem and nominate a committee to follow up on their collective grievance filed with the Commission against Discrimination and Racism (CODISRA) and seeking alliance with a regional TBA network to provide a broader base of support. Their efforts resulted in CODISRA sending another representative from the national level and an intervention with the hospital director. However, while defenders reported some improvements, the problems of mistreatment were not yet not fully resolved at the time of completion of this study.
Across the three cases, participants and CEGSS field staff reported that the maps were useful for seeing the range of actors they were working with and being able to “evaluate their relationships”. There was concern among field staff that some of the participants did not fully understand the maps, but they also expressed that the maps provided useful tools for planning action and working with the defenders to see “how their networks are doing…so they can be strengthened and their actions can have better results”.