Health initiatives aimed at Indigenous populations in Mexico: a critical perspective

Abstract

Background

Governmental action in Mexico has sought to understand and address the health situation of Indigenous Peoples (IPs) primarily through an intercultural perspective. However, intercultural approaches focused mainly on cultural aspects may obscure the historical and structural origins of health inequalities. Since the 1980s and during the early years of the new millennium, a series of political and institutional processes shaped a context that was central to incorporating IPs into the national health agenda.

Objective

The aim of this article is to conduct a critical analysis of health initiatives targeting IPs developed within this context (2000–2012).

Methodology

We carried out a qualitative critical analysis on the basis of a multi-source documentary review to analyse four specific initiatives, selected because they sought to include the participation of Indigenous leaders and explicitly incorporated an intercultural perspective.

Results

The government-led initiatives APV, PROSANI and EEM reproduced cultural essentialisms through a functional and relational intercultural approach and did not contribute to improving the situation of traditional medicine actors, such as midwives. In contrast the CAMIA initiatives have a community-based origin and, for more than two decades, have been a fundamental space for the health and rights of Indigenous women.

Discussion and conclusions

The incorporation of interculturality in most initiatives appears to respond to a State discourse strategy embedded in narratives of what is considered “politically correct,” aimed at legitimizing programs and actions. The perspective from which health initiatives targeting Indigenous Peoples are designed, developed and implemented, as well as the actors involved in these processes and the degree of power and control exercised by both governmental actors and potential users/beneficiaries, determine their transformative potential. Initiatives built upon critical interculturality and with strong community foundations have had a significant impact on health and on other areas of Indigenous women’s lives. There is an urgent need to rethink healthcare approaches for Indigenous Peoples in Mexico by adopting more critical intercultural frameworks that enable Indigenous self-determination and decolonial health perspectives.

Background

Since the 1940s, institutions such as the Secretaría de Salubridad y Asistencia -Department of Health and Assistance back then, today Secretaría de Salud (SSA) (Ministry of Health) and the Instituto Nacional Indigenista (INI) (National Indigenous Institute) –today the Instituto Nacional de los Pueblos Indígenas (INPI) (the National Institute of Indigenous Peoples), have promoted a so-called intercultural perspective within the health policies, programs and interventions1 aimed at Indigenous Peoples (IPs) [1–3]. This approach, centred on cultural differences and the interaction between diverse medical systems, has privileged symbolic and communicative aspects in healthcare, showing lesser interest in the structural causes behind health inequities [3].

Since the 1970’s and 1980’s, and even more prominently during the 1990’s, the concept of interculturality gained centrality in public policy across Latin America. In the Mexican health sector, this translated into efforts to articulate biomedicine with traditional medicine, recognizing indigenous knowledge as legitimate within health-illness-care processes [3].

While the consideration of cultural aspects is relevant in shaping health policies aimed at IPs, the intercultural framework adopted by the health sector has often reduced inequality to a matter of symbolic and cultural difference. By positioning culture as the primary explanatory axis, fundamental structural dimensions – economic, social and political – have been largely overlooked. These dimensions place IPs in a subordinate position within the health system and society more broadly. As a result, a limited understanding of interculturality prevails, one that fails to examine processes of social stratification rooted on ideologies such as racism, classism and patriarchy, which shape structural inequalities and perpetuate profound inequalities in access to healthcare, treatment and outcomes for Indigenous Peoples [4, 5].

Jaime Breilh’s contributions to Latin American social medicine and collective health are central to questioning conventional approaches to health issues, particularly to Indigenous health. His proposal of critical epidemiology is inspired by the struggles of Latin American peoples seeking to overcome “a social regime centred on the accumulation of wealth.” It focuses on understanding and addressing health problems as the outcome of social, political, and economic structures, power relations, inequalities and the coloniality of knowledge [6].

Drawing on Catherine Walsh’s work on decolonial intercultural thinking, Breilh advances a conception of interculturality that moves beyond a narrow focus on ethnic issues. Instead, he emphasizes the construction of dialogical relations of equality among individuals and collectives from different cultural communities. This is not an approach centred on individual interactions, but rather one that understands such relations as embedded within broader socioeconomic structures and cultural and biological processes that shape health–disease–care dynamics. This perspective also incorporates a critical examination of the origins of knowledge and its validity, questioning who produces knowledge and whose interests it serves [6].

This perspective is particularly relevant in contexts such as Mexico, where interculturality has historically been incorporated as a discursive and instrumental tool for the recognition of “the Indigenous,” often without challenging underlying structural conditions. In contrast, Breilh’s proposal calls for conceptualizing and operationalizing critical interculturality in ways that promote shifts in epistemological paradigms and political participation, validate Indigenous knowledge and agency, and advance structural change toward social justice and equity.

This article presents a critical analysis of some of the major health initiatives targeting IPs in Mexico from 2000 to 2012,2 focusing on the intercultural framework on which they are based. Our departure point is the premise that various social, political and economic developments in previous decades generated a new context that required a redefinition of policies and institutional discourses on “the Indigenous.” To situate this analysis, we first outline key historical events that shaped this context.

Political, economic and social context

Independent Mexico emerged with a deeply stratified social structure, with Indigenous Peoples occupying the lowest rung of the hierarchy. This structure emerged from a process of conquest and three centuries of colonialism, during which Indigenous Peoples experienced various forms of systematic oppression, including racist attitudes [7].

However, at the beginning of the 1980s, Indigenous leaders and community members gained greater political participation and began to perform mediating roles between their communities and administrative institutions [8]. Meanwhile, a neoliberal economic and political model was implemented in 1983 [9]. The State sought ways to offset the effects of these neoliberal policies through assistance programs targeting the most vulnerable groups [9].

One of the most important social policies directed toward IPs was launched in 1988 through the Programa Nacional de Solidaridad (PRONASOL –National Solidarity Program) which sought to involve IPs in defining priorities in various areas, including health [8–10]. A year later, the National Indigenous Institute (INI) developed a health policy for IPs on the basis of the recognition of the coexistence of different health systems in Indigenous regions: institutional biomedicine, traditional indigenous medicine and domestic medicine [9].

Subsequently, in the 1990s, Mexico experienced significant social movements and political changes. The National Human Rights Commission was established, and the North American Free Trade Agreement (NAFTA) came into effect [11]. The Constitution was amended to recognize Mexico as a pluricultural nation “sustained originally on its Indigenous Peoples” [12], and various processes of political mobilization and collective struggles for recognition among Indigenous communities gained momentum. In 1994, the Zapatista uprising—led by the Ejército Zapatista de Liberación Nacional (EZLN, Zapatista National Liberation Army)—marked a turning point in the historical recognition of the conditions and demands of IPs in Mexico [13].

In 2001, President Vicente Fox, motivated by the dialogues that had emerged with the EZLN and IPs, made improving the situation of IPs a central component of his agenda. The Plan Nacional de Desarrollo (National Development Plan) 2001–2006 outlined strategic lines guiding governmental actions toward building an inclusive country that respected cultural diversity and IPs [14].

Constitution articles 1, 2, 4, 18 and 115 were amended to recognize Indigenous rights to self-determination and autonomy in their different social, political and economic expressions. However, these amendments were rejected by the EZLN and Congreso Nacional Indígena (National Indigenous Congress) as insufficient and falling short of the demands of IPs [15].

The National Indigenous Institute (INI) was dissolved in 2001 and replaced by Comisión Nacional para el Desarrollo de los Pueblos Indígenas (CDI—National Commission for the Development of Indigenous Peoples), which operated until 2018, when it was succeeded by INPI. Both institutions experienced a loss of core jurisdictional powers, limited resources and faced diverse criticism from indigenous communities [16]. In the same year, the Coordinación de Salud para los Pueblos Indígenas (Indigenous Peoples’s Health Coordinator) was created within the Ministry of Health to design programs for IPs. In 2022, it was restructured as the Dirección de Medicina Tradicional y Desarrollo Intercultural (DMTDI—Directorate of Traditional Medicine and Intercultural Development) [16]. Overall, these events contributed to the integration of Indigenous Peoples in political agendas, including the health sector.

Notwithstanding these actions, health inequalities between Indigenous and non-Indigenous Peoples have persisted. For instance, Indigenous women face a maternal mortality risk three times higher than that of non-Indigenous women [17]; their life expectancy is 6 years shorter, and both general and infant mortality rates are higher [18]. In predominantly Indigenous regions, infectious diseases associated with poverty and marginalization persist – for example, residual diseases such as trachoma in the state of Chiapas [19].

A meta-analysis of studies examining health disparities between Indigenous and non-Indigenous Peoples in Latin America found that infectious diseases remain the leading contributors to mortality and morbidity among IPs while chronic degenerative diseases are increasing. Conditions such as malnutrition, anaemia, cardiovascular problems and chronic kidney disease disproportionately affect IPs [20].

Regarding healthcare in the country, it has been widely documented that, in Indigenous contexts, health services are insufficient: there is a lack of equipment and supplies to effectively provide care, health personnel do not meet service demand, medication shortages are frequent and supervision and regulation of the health system are weak [19]. Additional challenges include (1) lower vaccination coverage, (2) limited access to maternal healthcare and (3) inadequate follow-up for patients with diabetes [21].

In light of these persistent health inequities affecting IPs, it is necessary to examine the perspectives that have shaped health initiatives. The objective of this article, therefore, is to conduct a critical analysis of initiatives aimed at Indigenous Peoples within this context.

Methodology

The research team has extensive experience in intercultural approaches and Indigenous health. Previous research and fieldwork carried out with indigenous communities and health institutions informed the analytical perspective proposed in this article.

We conducted a qualitative critical analysis on the basis of a multi-source documentary. Our analysis focuses on initiatives implemented and promoted within the Mexican public health sector, particularly those aimed at Indigenous Peoples between 2000 and 2012. These initiatives were selected on the basis of the following criteria: they belong to the health sector, have a defined timeframe within the relevant context previously described, seek the involvement of Indigenous leaders, incorporate an intercultural perspective and they aim to improve access, cultural relevance, health outcomes among Indigenous Peoples.

The selected initiatives were: (1) Casas de Salud de la Mujer Indígena (CAMI—Indigenous Women’s Health Houses) / Casas de Salud de la Mujer Indígena y Afromexicana (CAMIA—Indigenous and Afromexican Health Houses), (2) Programa de Arranque Parejo en la Vida (APV—Equal Startup in Life Program), (3) Programa de Salud y Nutrición para Pueblos Indígenas (PROSANI—Health and Nutrition for Indigenous Peoples Program) and (4) Encuentros de Enriquecimiento Mutuo (EEM—Mutual Enrichment Gatherings).

A qualitative documentary analysis was conducted to compile information that allowed for the description and critical examination of each initiative. To support this analysis, a documentary review was conducted as an analytical tool to compile and systematize information about each initiative and to identify relevant theoretical frameworks. Documentary sources were reviewed as an analytical input rather than as an end in themselves.

Scientific literature was identified through searches in academic databases using relevant keywords, as well through previously identified key references in the field, recommendations from the author’s academic committee and citations suggested by other researchers. Grey literature and institutional documents were essential to reconstruct the origin, objectives, approaches and characteristics of initiatives, as well as the forms and degree of indigenous participation.

We identified various types of governmental documents containing information on the initiatives, including policy documents, regulations, program evaluations, National Development Plans, implementation instruments and institutional reports from the Ministry of Health and of Directorate of the Traditional Medicine and Intercultural Development (DMTDI), as well as INI, CDI and INPI. Scientific articles, theses, book chapters and web-based materials were also consulted.

The collected materials were analyzed to examine the initiatives’ origin, how interculturality was conceptualized and operationalized, how indigenous actors were included in decision-making processes or not and their outcomes and limitations. The purpose of this methodological approach was not to produce a comprehensive review of the state-of-the-art, but to generate a contextualized and critical understanding of the initiatives and their implications on the basis of diverse documentary evidence.

A thematic content analysis was conducted (see Table 1) [21]. Information extracted from the texts was organized into analytical matrices used to structure and manually analyze the data. A codebook was developed for the selection and analysis of information (see Table 2). The coding process was based on the limited evidence and information explicitly available in the documentary sources describing and evaluating each initiative. A deductive framework was applied to ensure consistency and comparability across initiatives, relying on clearly articulated objectives, strategies and intervention components.

Table 1.

Content analysis plan applied in this study

Frequent steps in the content analysis	Steps undertaken in the current research
1. Specify the object or topic of analysis	1. The object of analysis was defined as health initiatives directed toward Indigenous Peoples (IPs) in Mexico
2. Determine documents to analyse	2. Operational instruments, reports from relevant institutions, scientific articles, theses, book chapters and web-based materials were reviewed
3. State code-making rules	3. For the description and analysis of the initiatives, different codes were deductively defined:  •Descriptive: type of initiative, implementation timeframe and location of implementation  •Analytical: conceptualization of the intercultural health approach, participation of Indigenous Peoples, scope and limitations
4. Categorization	4. Based on the previously defined codes, five categories were established:  •Descriptive characteristics of health initiatives aimed at IPs  •Origin of the initiatives  •Conceptualization of the intercultural approach in health  •Participation of Indigenous Peoples  •Outcomes of the initiatives (identifying their scope and limitations)
5. Inferences	5. This refers to the conclusions or inferences drawn from the analysis of the texts. In this article, these inferences are presented in the discussion and conclusions sections

Table 2.

Codes and definitions

Code	Definition
Type of initiative	Key information about whether it is a policy, program or action, and its objectives
Implementation timeframe	The implementation period is documented (whether it is still active or not)
Location of implementation	Information was gathered about the regions of the country where the initiative currently operates or operated
Origin of the initiatives	This category refers to the origin of the initiatives, how they were created, who designed them and a brief account of their development and trajectory
Conceptualization of the intercultural approach in health	This category contains information related to the concept of the intercultural approach. Such information may be explicitly or implicitly mentioned in the initiative documents. It aims to examine the underlying concept or definition of interculturality in the design and implementation of each initiative, as well as the perspective from which this approach was addressed
Indigenous participation	This category includes information that sheds light on the roles and forms of participation of Indigenous Peoples (IPs) in the initiatives. The goal is to explore whether IPs actively participated in the formulation, design and implementation of the initiatives or, conversely, were only considered as recipients
Scope	This code refers to the available information on the scope or outcomes documented for the initiatives
Limitations	This code refers to the available information on the challenges and limitations documented for the initiatives

The main analytical categories were the conceptualization of interculturality underpinning the initiatives and the degree of participation of Indigenous Peoples (IPs) within them. In addition, the origin of the initiatives was incorporated as an analytical axis.

The origin of an initiative is fundamental, as it allows for an understanding of how it was conceived, who designed it and whether the participation and decision-making power of the populations it targets were included. These initial aspects are decisive, as they shape key elements such as legitimacy, relevance and the degree of appropriation, which in turn influence the sustainability that such initiatives may achieve among Indigenous Peoples.

Information was also collected on the participation of IPs in the initiatives, as well as on their main achievements and limitations, based on the available evidence. Integrating this information provided a key analytical input to assess outcomes and to identify persistent shortcomings across initiatives, thereby linking empirical findings with the critical analysis developed in this article.

In addition, information was gathered to broaden their description and understanding. Accordingly, data were also documented regarding the type of initiative to which each case corresponds, whether a policy, program or specific action. Descriptive information on the initiatives is presented in the supplementary material.

Results

Table 3 presents information on the description, timeframe and location of implementation for each initiative. Information on the remaining categories is presented subsequently.

Aspect	Initiatives
	Indigenous and Afromexican Health Houses—CAMIA	Equal Startup in Life Program (APV)	Health and Nutrition for Indigenous Peoples Program (PROSANI)	Mutual Enrichment Encounters (EEM)
Type of initiative	A community-based action embedded within an institutional program. It was part of the Programa de Acciones para la Igualdad de los Pueblos Indígenas (Program of Actions for the Equality of Indigenous Peoples) [22] Its main objective is to prevent gender-based violence and promote sexual and reproductive health among Indigenous and Afro-Mexican women through an intercultural approach [23]	A specific action program focused on maternal and child health Although it was not specifically directed at Indigenous Peoples, its implementation was prioritized in areas of high marginalization and poverty, many of which had a predominantly Indigenous Its objectives were [24]:  – Achieve universal coverage and equitable access to quality care for women during pregnancy, childbirth and the puerperium, as well as for girls and boys up to 2 years of age  - Reduce maternal mortality, prioritizing regions with the highest incidence and number of deaths  – Decrease neonatal and infant mortality and prevent birth defects  – Coordinate the efforts of society and government for the implementation of the APV Program	Specific action program focused on the health and nutrition of Indigenous Peoples in the country. It was part of the ten strategies established in the 2001–2006 National Health Program [25] Its overall objective was to improve the health and nutrition levels of the country’s Indigenous population, thereby reducing the gap observed in health indicators compared with the rest of the population [25] Some of its specific objectives were:  – Promote a harmonious and respectful relationship between institutional medicine and traditional and domestic Indigenous medicines  – Support local and regional health and nutrition communication programs with a gender perspective, designed on the basis of formative research and evaluated by women  – Train healthcare personnel in the intercultural approach and gender perspective, understanding the vision and conception of the health-disease process to provide better care  - Adapt health services to the social, cultural, religious and spiritual values of Indigenous Peoples	An intercultural educational action–methodology focused on collaboration between traditional and allopathic medicine practitioners Its main objective was to establish dialogues on relevant topics related to health, illness and care processes, with the particular characteristic that no participant would present their perspective as an absolute truth over others. Instead, the different viewpoints were to be heard and enriched by one another to reach “agreements of interrelation” [26]
Implementation framework	From 2003 to the present. Afro-Mexican women were included in 2019	From 2001 to 2012; subsequently, the mandatory implementation of its substantive components in public and private health services was established through publication in the Official Gazette of the Federation (DOF)	2001–2006	2004–2008
Location of implementation	Currently, there are 35 Houses located in various states across the country: Chiapas, Oaxaca, Puebla, Baja California, Michoacán, Veracruz, Yucatán, Querétaro, Nuevo León, Sonora, San Luis Potosí and State of México [27, 28]	Present in all 32 states, prioritizing the states with most Indigenous presence	Present in 361 municipalities with high or very high marginalization in 13 states: Campeche, Chiapas, Chihuahua, Durango, Guerrero, Hidalgo, Jalisco, Nayarit, Oaxaca, Puebla, San Luis Potosí, Veracruz and Yucatán. The operational document established that in the following years, the program would be progressively extended to the remaining municipalities with Indigenous Peoples	Campeche, Chiapas, Chihuahua, Durango, México, Guerrero, Hidalgo, Jalisco, Michoacán, Morelos, Oaxaca, Puebla, San Luis Potosí, Tabasco, Tlaxcala, Veracruz and Yucatán and México City [29]

Table 3.

Summary analysis of the conception of interculturality and participation of Indigenous Peoples in the initiatives

Initiative	Conceptualization of intercultural health approach	IP participation	Previous analysis—discussion
Indigenous Women’s Health Houses (Casas de Salud de la Mujer Indígena-CAMI)/ Indigenous and Afromexican Health Houses (Casas de Salud de la Mujer Indígena y Afromexicana-CAMIA)	It is explicitly mentioned Framework adopted from the PAHO, in which the most relevant elements are: dialogue, listening, non-imposition, respect and exchange Its application was reflected through the Participatory Model Central element: respect for the cultural and linguistic identity of women	Active community participation of Indigenous women, midwives, promoters and activists Linkage with Civil Society Organizations (CSOs) for technical and training support Ongoing exchange between institutional and community actors	It was clearer in including a perspective of a more horizontal dialogue CAMIA had a higher level of institutionalization and continuity. The leadership of Indigenous women was central and presented a more political stance than the other initiatives. From the testimonies of women leaders of CAMIA, it can be seen that they have managed to take ownership of these spaces; however, this has not necessarily happened thanks to government support
Equal Startup in Life Program (Programa de Arranque Parejo en la Vida-APV)	The inclusion of an intercultural perspective is mentioned partially explicitly, but the underlying conceptual framework is clearly defined. Its application is primarily technical and limited The aim was to improve material conditions and communication to bring pregnant women closer to health services (through their model of “posadas” and AME transport, as well as the MATER modules)	IPs in general largely participated as beneficiaries. Some participation occurred through linkage mechanisms, including the incorporation of bilingual midwives in referral and counter-referral processes	No clear or coherent conceptualization and application of the interculturality was identified. Intercultural elements appear to have been incorporated superficially, with participation framed mainly in terms of linkage and service utilization rather than decision-making or co-management
Program of Action: Health and Nutrition for Indigenous Peoples (Programa de Acción de Salud y Nutrición para los Pueblos Indígenas)	It is not mentioned explicitly Interculturality is not explicitly defined. The program refers instead to “cultural sensitivity” and the need to recognize the Indigenous worldviews. In theory, it aimed to promote complementarity between biomedical and traditional medicine There is no evidence of how Indigenous Peoples were integrated during the operation of the program	In theory, its design was based on forums and consultations with Indigenous Peoples from nationwide Strategies included: promotion of harmonious relationships between health service actors and traditional medicine practitioners and training of health personnel in the interculturality approach	While the importance of IPs participation and knowledge was acknowledged, no clear definition of the interculturality or concrete mechanisms for participation were established The program reflects an intention to recognize IPs world views, but it remains unclear how these we operationalized in practice
Mutual Enrichment Encounters (Encuentros de Enriquecimiento Mutuo-EEM)	It is mentioned explicitly The intercultural health approach is mentioned as incorporating methodology, horizontal relationships, respect, complementarity, synergy and knowledge from actors involved in traditional and biomedical health models	Traditional doctors and midwives participated in encounters designed for the exchange of knowledge and experiences, using an educational methodology grounded popular education principles Agreements for linkage were generated, although no systematic without follow-up was documented	The initiative prioritizes a pedagogical and formative dimension of interculturality rather than direct health services provision It main contribution lies in promoting processes aimed at transforming relationships between actors in traditional medicine and biomedical health systems

Indigenous Women’s Health Houses (Casas de Salud de la Mujer Indígena—CAMI)/ Indigenous and Afro-Mexican Women’s Health Houses (Casas de Salud de la Mujer Indígena y Afromexicana—CAMIA)

Origin of the initiative

This initiative emerged from the actions and movements of civil society organizations (CSOs), Indigenous women and traditional midwives within a specific Indigenous context: Chalchihuitán, Chiapas. During the 1990s, the United Nations Development Programme (UNDP) requested that the Ministry of Health develop and promote projects to address domestic violence against women [30].

In 2002, researchers Graciela Freyermuth and Soledad González developed a project that articulated the response to domestic violence with sexual and reproductive healthcare. The development of the proposal was grounded in the work experience of the traditional midwife Sebastiana Vázquez from Chalchihuitán, whose practice revealed the close relationship between health problems and the violence faced by Indigenous women [30].

In 2003, the Indigenous Women’s Health Houses (Casas de Salud de la Mujer Indígena, CAMI) began to be implemented. The National Commission for the Development of Indigenous Peoples (CDI) participated in this project led by the Ministry of Health, which was funded by UNDP. The CAMI model “comprised four areas of action: (1) communication, (2) linkage, (3) service provision and (4) research” [31].

These health houses were created with the aim of improving Indigenous women’s health and sexual and reproductive rights, as well as maternal health, through the provision of culturally appropriate, non-discriminatory, accessible and high-quality health services. The program was implemented in the states of Oaxaca, Chiapas, Guerrero, Chihuahua and Baja California [30].

In addition to service provision, the program included activities aimed at strengthening advocacy and training for women in the prevention of violence and the promotion of reproductive health. The proposed activities emerged from the women who participated in the health houses themselves [30].

Between 2006 and 2012, 14 additional health houses were created, with Indigenous women’s organizations assuming their direction and management. In 2012, the project was incorporated into the Program of Actions for Gender Equality with Indigenous Peoples (Programa de Acciones para la Igualdad de Género con Población Indígena, PAIGPI). By 2013, there were 22 CAMI operating in 14 states across the country, many of which continue to operate today. After 1 year, PAIGPI was discontinued, and the CAMI were incorporated into the Indigenous Rights Program (Programa de Derechos Indígenas) [31].

From 2019 onwards, following the constitutional reform that recognized Afro-Mexican peoples and communities as part of the country’s pluricultural composition [30], the CAMI were renamed CAMIA to include Afro-Mexican women [31]. The CAMIA are based on a Participatory Model for the Care of Violence and Reproductive Health in Indigenous Areas. Currently, 35 CAMIA continue to operate in several states across the country, under the management of Indigenous and Afro-Mexican women.

Conceptualization of interculturality

The operational instruments mention that the intercultural approach is applied within the framework of the Participatory Model because it targets culturally diverse Indigenous Peoples that differ from the “mestizo national society” [23, 32]. The perspective is assumed to have enabled the development of strategies aligned with the cultural characteristics and the social and material conditions of the women served by CAMIA [23].

The concept of interculturality used is that proposed by the Pan American Health Organization (PAHO):

“...a vision and dialogue with the other, based on dialogue, listening, and the possibility that each party takes what can be taken from the other, respecting their particularities and individualities. It is an approach for agreement, not imposition; therefore, interculturality implies an exchange to build something new.” [23, 32].

Participation of Indigenous peoples

The Participatory Model for the Care of Violence and Reproductive Health under which the CAMIA operate constitutes a key instrument and mechanism, and working tool that enables the achievement of the objectives of this initiative. The Model was designed to facilitate the design, planning, implementation, monitoring and evaluation of projects led by women. One of its defining characteristics is its flexibility, which allows it to be adapted to the specific contexts, conditions and needs of the communities in which each CAMIA operates [23].

The Model also incorporates perspectives of social participation, gender, interculturality and human rights. It recognizes autonomy as a legitimate demand of Indigenous Peoples to make decisions regarding their organizational and working processes [23]. In this regard, the leadership and management of the CAMIA are the responsibility of the Indigenous women who participate in them. Each CAMIA maintains specific external partnerships; however, these are generally established with civil society organizations [33].

In addition, this instrument seeks to “establish a mechanism to articulate institutional work with the self-managed processes of organizations and groups of women responsible for the CAMIA, as well as with the civil society organizations that accompany them” [23]. Through the Participatory Model, inter-institutional actions are expected to be coordinated with women’s organizations and civil society organizations in order to expand sexual, reproductive and maternal health services, as well as to strengthen violence prevention efforts [23].

Achievements

According to CAMIA women leaders, their work, has contributed to the empowerment of other Indigenous women and the identification and attention of violence situations. They view CAMIA as an opportunity for personal and professional growth and self-realization. They emphasize that “cultural and linguistic congruence” has been crucial for women to approach CAMIA instead of other services [34].

CAMIA has created spaces for inter-institutional exchange, helped make Indigenous women and their work visible to national and international institutions, contributing to their social and political recognition. They have also encouraged women to critically recognize violence and discrimination historically experienced and to feel more empowered to defend their rights before authorities [22].

A significant achievement of the CAMI located in Chalchihuitán is that, beginning in 2008, results were reported indicating that women began to have greater political participation. They assumed administrative positions within the municipal government and held offices such as health councillors (regidoras de salud), roles that had previously been occupied exclusively by men. Likewise, between 2012 and 2015, women held coordination positions in municipal programs for older adults, as well as within the Municipal System for Integral Family Development (Sistema para el Desarrollo Integral de la Familia, DIF). Other women continued to occupy political positions, including serving as elected councilors (regidoras propietarias) and even holding a municipal presidency [30].

Overall, women who participate in the CAMIA carry out important work in the promotion of and care for maternal health, sexual and reproductive health and the prevention of and response to violence against Indigenous women [33].

Across the different CAMIA operating throughout the country, the care provided includes practices from traditional medicine and midwifery, such as massages and “sobadas;” the assistance of uncomplicated (eutocic) births; the identification of pregnancy-related risks and obstetric emergencies; and the appropriate referral to health services when needed. They also provide accompaniment to pregnant women and manage their transportation to health facilities. Some CAMIA function as temporary shelters for women and their families before or after childbirth. Groups of midwives participating in the CAMIA also carry out health promotion activities focused on maternal health and women’s rights, engaging not only women themselves but also their families and local authorities [33].

The women who collaborate in the CAMIA speak local Indigenous languages and generally belong to the communities where the Health Houses are established. In addition, the participation of traditional midwives and healers facilitates trust and communication with women who seek care for sexual and reproductive health issues and in situations of gender-based violence [33].

The fact that community health promoters and midwives conduct health promotion activities within the communities brings care closer to women who are geographically and socially distant from institutional health services. The work carried out by CAMIA women has facilitated women’s access to other institutions to address pregnancy-related emergencies and has contributed to increasing the number of births attended in health centres and hospitals [33].

Limitations

Several limitations of CAMIA have been documented. These include lack of formal employment conditions for Indigenous leaders, unclear roles for all actors involved, scarce resources and funding and little transparency regarding the origin of funds and their administration [22, 34]. Excessive bureaucracy has also been identified as a barrier to expense reimbursement [34].

Another challenge is facilitating collaboration between Indigenous women and institutional actors, including local authorities, given the persistence of sexism and gender biases [22].

It is also necessary to overcome the perception that CAMIA’s functions are limited to language translation, as activities within these spaces have a broader scope. Authorities need to be informed about the roles women leaders perform in CAMIA. Similarly, greater recognition of the work of women sustaining CAMIA is needed [22].

Violence should also be positioned more explicitly as a public health issue rather than a private matter. Accordingly, the health sector’s co-responsibility for addressing violence against women must be made explicit and formalized. Other documented barriers include lack of political continuity and a paternalistic vision [22].

Currently, the CAMIA face financial uncertainty, as their budgets are allocated for 6-month periods and they do not have a dedicated budgetary program. This situation poses a risk to their continuity and potential disappearance. For this reason, it has been recommended that CAMIA be formally included in the Federal Expenditure Budget (Proyecto de Egresos de la Federación) in order to ensure their permanence, given their critical importance for the provision of healthcare to Indigenous and Afro-Mexican women [31].

Equal startup in life program (Programa de Arranque Parejo en la Vida—APV)

Origin of the initiative

This action program was created by the federal government in 2001 with the aim of addressing the maternal health challenges faced by the country at that time. Consequently, the development of its actions was based on the status of maternal health indicators, including maternal mortality, neonatal mortality, disability and birth defects, among others [24]. In 2004, through an agreement of the General Health Council (Consejo de Salubridad General), the implementation of its actions became mandatory for both public and private health institutions [35].

Its design was grounded in the Health Sector Programs for the periods 2001–2006 and 2007–2012, during which the program was implemented [24, 36]. The actions of these programs were based on the objective of promoting “equal opportunities and reducing the conditions that hinder universal access to quality, timely health services based on the most recent scientific evidence at both the international and national levels” [36].

Conceptualization of interculturality

In the first program document (2001–2004), there is no explicit mention of an intercultural perspective in the program design. However, it highlights the importance of including traditional midwives and training them  to identify warning signs and symptoms during pregnancy and carry out referral procedures to first- and second-level care [24].

In the second period (2007–2012), the operational document introduces the inclusion of the intercultural perspective. One of the program’s main strategies during this second period was engagement with community actors such as traditional midwives, intercultural liaisons and translators [36].

The need to create and disseminate messages with an intercultural and gender perspective was made explicit. Continuous support on intercultural issues was established for care networks where such topics needed to be addressed, although criteria were not clearly defined. There was also no further definition of interculturality beyond the inclusion of Indigenous languages [36].

Participation of Indigenous peoples

The importance of involving community actors is emphasized. Particularly, the participation of traditional midwives was sought to train and certify them in identifying warning signs and symptoms and to assist in counter-referral processes when needed [36].

During the second implementation period, the participation of Indigenous leaders and intercultural liaisons acting as translators in health services was sought [36].

Achievements

An evaluation conducted in 2005 in four states – Chiapas, Sonora, Guerrero and Hidalgo – found the following [35]:

• Favourable changes in indicators were observed between 2001 and 2004, but there was insufficient evidence to attribute these changes directly to the program.

• APV actions appeared to be more effective in areas with stronger state follow-up and staff retention.

• State authorities played an important role in resource management and support for Civil Society Organizations (CSOs), especially for the proper functioning of maternity homes.

• Transportation support was highly appreciated by pregnant women.

• Risk Pregnancy Care Modules (MATER) improved obstetric care.

• Maternal mortality committees improved underreporting of maternal deaths.

• First-time prenatal consultations increased significantly, though this was not necessarily related to quality of care.

• The work of midwives was highly valued by rural and Indigenous Peoples.

Limitations

The main barriers, challenges and limitations identified for program improvement were [35]:

• Although maternal and neonatal health training were provided, they were technical, sporadic and limited to second-level care.

• Midwives faced significant challenges owing to prejudices from health personnel.

• The program stipulated the creation of State APV Committees for community participation; however, at evaluation time, only one state had formed such a committee.

• Some limiting factors for community participation included geographical barriers, long distances to health units and adverse climate conditions. Cultural barriers included language differences, beliefs about health determinants and approaches to care.

• Response capacity for childbirth care remained limited in marginalized areas.

• Low availability of medicines was noted in first- and second-level care in rural and Indigenous jurisdictions.

• Training for midwives was insufficient.

Program of action: health and nutrition for Indigenous peoples (Programa de Acción de Salud y Nutrición para los Pueblos Indígenas—PROSANI)

Origin of the initiative

This initiative was created by the federal government as a Specific Action Program and formed part of the ten strategies established in the National Health Program 2001–2006. It was part of the second strategy: “Reducing health gaps affecting the poor.” Its overall objective was to improve the level of health and nutrition among the country’s Indigenous population and, consequently, to reduce the gap between their health indicators and those of the rest of the population [25].

Conceptualization of interculturality

The operational document does not explicitly define the concept of interculturality on which the Program is based. However, it mentions that health personnel’s lack of knowledge about the Indigenous Peoples’ (IPs) world view of the health–illness process causes misunderstanding and, therefore, conflict between the IPs’ perspective and allopathic medicine. For this reason, the Program proposes the need to create management, organization and health service delivery models for IPs with “cultural sensitivity” that allow “finding points of convergence and complementarity between these two visions of the health–illness process and thus improve the quality of services provided to this population” [25].

One of its objectives mentions that elements respecting the values and conceptions of IPs were incorporated, and it prioritizes considering the “cultural and gender situation” of service users [25].

Participation of Indigenous peoples

The document states that the National Indigenous Institute (INI) held 33 citizen meetings in 23 states, collecting 6000 proposals, 1523 of which related to health and nutrition. The Ministry of Health also conducted 143 forums to consider IPs’ demands [25]. The program’s design and development were theoretically informed by these demands.

Among the program’s strategies, action lines included linkage with indigenous organizations, midwives, traditional doctors and linguistic and intercultural liaisons [25].

Achievements

No national evaluations on the health impact of this Program were found. However, data have been documented regarding assigned resources, provision of supplements, training, implementation of other activities and construction of some facilities [37].

Between 2001 and 2002, 90 million pesos were allocated and spent on the program; in 2003 and 2004, 85 million pesos were allocated solely for acquiring micronutrients. From 2001 to 2003, a total of 118 health units were constructed [37].

Achievements include the distribution of 13,000 manuals for micronutrient supplementation operations, 7000 brochures for children and pregnant or breastfeeding women, and 15,000 program dissemination posters. In 15 states, 3870 latrines, 210 full bathrooms and 1292 ecological stoves were built [37].

Intercultural health service networks were created between one hospital and 10 first-level health units in areas with a high concentration of Indigenous language speakers. A total of 775 health personnel were trained, including providers, educators, directors and Indigenous community volunteers [37, 38].

Limitations

No national documentation of limitations was found, but a state-level analysis in Jalisco documented the following weaknesses [39]:

• Scarce resources and equipment for health activities in rural contexts

• Poor adherence to scheduled community visits by service providers

• Medication shortages

• Excessive bureaucracy in medication dispensing and institutional procedures

• Insufficient medical and nursing staff to cover vacancies in Indigenous communities

• Lack of cultural and linguistic knowledge among providers

• Food supplements delivered only to beneficiaries of the Oportunidades program

• Lack of substance abuse prevention programs for Indigenous youth

Other identified weaknesses were that the program was practically limited to providing food supplements without prior approval from users. The cultural appropriateness of such nutritional intervention was not tested or considered [40].

After the implementation of this program, the Ministry of Health itself recognized the need to question “paternalistic, colonialist and one-directional strategies” towards IPs. Coherent with this view, the Ministry endorsed for future action an intercultural framework where IPs appear as collaborators and not only as beneficiaries [40].

Mutual enrichment encounters (Encuentros de Enriquecimiento Mutuo—EEM)

Origin of the initiative

This initiative is an intercultural educational methodology created in 2004 by the Ministry of Health, with the objective of opening spaces for dialogue and exchange between health personnel and traditional healers and midwives and health service users [26].

It emerged from the need to dismantle cultural barriers that hinder access to health services for pregnant women and to eliminate practices of violence against traditional midwives that discourage them from referring patients with risks and complications to institutional health services [26]. The Mutual Enrichment Encounters (Encuentros de Enriquecimiento Mutuo, EEM) were implemented most intensively between 2004 and 2008. Evidence was found indicating that virtual meetings were promoted during the coronavirus disease-19 (COVID-19) pandemic [41], and more recently, an EEM among midwives in Chiapas was promoted by the Ministry of Health [42]. No evidence was found regarding the total number of EEM implemented nationwide or the way participation within these encounters has been structured.

Conceptualization of interculturality

The methodology is based on the intercultural health model developed by the Ministry of Health, which recognizes cultural diversity and promotes horizontal relationships among users, therapists, traditional midwives and other actors within hegemonic medicine. This conception of interculturality establishes that the knowledge of the other is valued and that learning is possible through exchange among these actors [26].

It was considered important that, in articulating health services with traditional medicine, midwives own procedures, spaces and specific conceptual frameworks be recognized from the outset [13]. Essential elements to promote exchanges between traditional medicine and the conventional medical model included recognition of diversity, respect for differences, synergy, horizontality and complementarity [26].

As part of the justification for creating these spaces, it was argued that some causes of maternal mortality among Indigenous Peoples were related to health services, programs and personnel lacking cultural competencies, which caused Indigenous women to avoid services. The SSA assumed that eliminating or reducing cultural barriers would facilitate users access services, thereby increasing treatment adherence [13, 26].

An important component of this methodology was “cultural competence,” defined as the capacity to interact with and negotiate the types of services provided to people from different cultural backgrounds [26].

Participation of Indigenous peoples

Traditional medicine practitioners were included as collaborators in the encounters, enabling them to express their needs, knowledge and recommendations to health service providers. Through the use of popular education tools, they were assigned a more active role in the exchanges [26].

Achievements and limitations

No evidence from evaluations on the achievements and limitations was found. However, SSA reports document that the encounters generated agreements for coordination between the traditional healthcare model and allopathic healthcare. In San Luis Potosí, a training encounter with representatives from 15 federal entities identified cultural barriers influencing maternal mortality [26].

Other achievements listed include [43]:

• Workshops with traditional midwives in Chiapas and Morelos

• Definition of the Traditional Midwives School with assistance from Indigenous midwives from Cuetzalan, Puebla

• The 2012 National Encounter of Traditional Midwives, where the systematization of traditional midwifery from the Mutual Enrichment Encounters was presented, and traditional competencies were proposed

The only limitation mentioned in the document is that there was no follow-up on the agreements resulting from the Mutual Enrichment Encounters [43].

Summary analysis of health initiatives

Table 3 presents a comparative summary analysis of the conception of interculturality and the participation of Indigenous Peoples.

Discussion

Most of the initiatives analyzed have a governmental origin, with the exception of the CAMIA. PROSANI and APV were developed and implemented within the framework of Health Sector Plans and were designed on the basis of the indicators that were prioritized at the time of their creation and implementation, which lends them relevance in addressing specific health needs. However, this does not necessarily mean that they responded to the priorities, organizational forms and/or world views of Indigenous Peoples (IPs), as they were designed and implemented from an external, state-driven and vertical perspective.

The operational document of PROSANI states that the program was based on the demands and needs of Indigenous Peoples, derived from multiple forums held in 23 federal entities. Nevertheless, insufficient information was found to allow for a more detailed understanding of how these demands were incorporated into the program’s design. Similarly, the EEM action was proposed by the Ministry of Health. Overall, for these initiatives, no evidence was found regarding strategies to integrate Indigenous participation during the design stages, decision-making processes or the management of the initiatives. In the cases of APV and PROSANI, Indigenous Peoples played a more passive role as beneficiaries.

The limited evidence regarding Indigenous participation in the design of the four initiatives analysed is consistent with the observations made by Freyermuth, who notes that consultation mechanisms with Indigenous Peoples in the health sector in Mexico, remain unclear [31]. Although institutional narratives have increasingly incorporated discourses on human rights, the right to health, and cultural and reproductive rights, significant gaps persist between these discourses and the actual conditions for the exercise of such rights, thereby limiting the effectiveness of health initiatives targeting Indigenous Peoples [31].

These issues gain particular relevance in light of international and national legal instruments, such as Convention No. 169 concerning Indigenous and Tribal Peoples in Independent Countries of the International Labour Organization (ILO), the United Nations Declaration on the Rights of Indigenous Peoples [44], Article 2 of the Political Constitution of the United Mexican States [45] – including its 2024 reform – and Article 6 of the General Health Law [44]. These normative frameworks recognize Indigenous Peoples as subjects of rights to self-determination and autonomy, including the right to decide on their health processes on the basis of their own organizational systems, cultures, and the use of traditional medicine.

In contrast to the other initiatives, CAMIA was the only one that emerged from a model of care and actions promoted by civil society organizations and Indigenous midwives. In response to the precarious conditions, poor quality of care, and lack of cultural relevance of public health services, the creation of CAMIA was driven by the need to establish spaces and services that could address these deficiencies and more adequately respond to the needs of women in Indigenous communities [30].

Given their community-based origins and leadership by women from the communities themselves, the CAMIA have achieved strong social legitimacy, cultural relevance and ownership among those who coordinate them, those who participate in the provision of services and accompanying processes, as well as among women users. These factors have been key to their sustainability, as evidenced by their continued operation 22 years after their creation.

The CAMIA have become essential spaces for the provision of sexual, reproductive and maternal healthcare for Indigenous and Afro-Mexican women, as well as for the prevention of and response to gender-based violence and the defence of sexual and reproductive rights. Their impacts extend beyond the health sector, as they have contributed to strengthening political participation, empowerment and the development of women’s leadership within their communities.

Most initiatives (with the exception of APV) address interculturality through dialogue, encounter and a horizontal, synergistic exchange and mutual recognition of knowledge between traditional medicine and institutional biomedicine. In the APV program, the inclusion of midwives aimed to bring Indigenous women closer to health services; therefore, their inclusion was used as a means to gain acceptance of the services, but it was not considered as an objective in itself.

The predominance of a culturalist orientation in the analyzed health initiatives should not be interpreted merely as a conceptual limitation or an incomplete understanding of health inequities. Rather, this emphasis on cultural difference can be situated within a broader political and ideological framework in which interculturality operates as a form of state-led recognition. In line with critical analyses of intercultural policies in Latin America, this approach reflects a governance strategy that foregrounds cultural identity and symbolic inclusion while leaving largely unchallenged the historical, economic and institutional structures that produce and sustain health inequalities affecting Indigenous Peoples. From this perspective, the incorporation of interculturality into health programs functions less as a transformative tool and more as a mechanism for managing diversity within existing policy frameworks, thereby reproducing a culturalist bias that aligns with broader patterns of neoliberal multiculturalism observed across the region [46].

In most initiatives (APV, PROSANI and EEM), intercultural actions have focused on technical aspects such as: translation of Indigenous languages, training of health personnel and traditional doctors/midwives, dissemination of culturally relevant health materials and promotion of knowledge exchange. Although these actions can facilitate the approach of Indigenous Peoples and traditional medicine to the health system, they do not represent profound changes in health services or in the health conditions of Indigenous Peoples. The characteristics and narrative behind these actions indicate that the interculturality approach has been used from a more relational and functional perspective rather than a critical or transformative one.

Walsh describes that interculturality can be explained from three different perspectives: relational, functional and critical. The relational perspective refers to the exchange between people of different cultures. Generally, it does not give importance to contexts of power, domination, coloniality and tensions that exist between the people involved [47]. The functional perspective is based on the recognition of cultural diversity and difference, aiming to include it within a given social structure. Both perspectives omit the social, political, economic and epistemic structures that place “cultural difference” in a position of subordination or domination [47].

We contend that the intercultural actions of the initiative (with the exception of CAMIA) correspond to these two perspectives. On the one hand, the relational, as they are basically based on promoting exchanges, encounters and relationships between health service providers and traditional healers without realizing structural adjustments to the health system. On the other hand, the functional, because they seek to improve the acceptance of institutional biomedical services among Indigenous Peoples through the intercultural actions they promote.

In the APV program, one intercultural action was to promote the participation of midwives. However, this occurred through translation and operational support tasks, and not from a more leading and horizontal role. In addition, it was documented that barriers and prejudices persisted among health providers toward midwives.

A study by Sesia and Berrio, published in 2024 and conducted with 257 midwives from Chiapas, Guerrero, Oaxaca, Yucatán, Quintana Roo and Veracruz, documented that the conditions under which midwives carry out their work are precarious. They must travel long distances along difficult routes to attend births, face contexts of violence and insecurity, cover their own transportation and care-related expenses and receive no remuneration. In addition, most are of advanced age or live with chronic illnesses, lack social security and receive little or no support from the communities they have served for decades. This situation is further aggravated by the precariousness of local health services, such as clinics and community health centres that face recurrent shortages and have limited capacity to provide care, thereby worsening midwives’ overall conditions [48].

Regarding their relationship with the health system, midwives do not receive basic supplies, recognition or a salary. Training activities, although valued by the midwives, function more as mechanisms of control than as opportunities for strengthening their knowledge, as attendance is mandatory in order to maintain their official registration. All of this takes place within persistent dynamics of racism and classism that reinforce both the omission of and the lack of recognition for the contributions of traditional midwifery to Indigenous maternal health [48].

Within APV, the participation of traditional midwives was largely limited to serving as bilingual intermediaries in referral and counter-referral processes. Although training and certification activities are mentioned, no evidence was found of their incorporation into direct childbirth care or, more broadly, of their integration into a more active role within maternal healthcare. In both the Ministry of Health and the IMSS-Bienestar system, midwives continue to receive training. In the latter case, midwives receive a small monetary incentive, which has functioned as “a mechanism of control” aimed at reducing the number of births they attend and repositioning them as community auxiliaries rather than autonomous care providers [49].

In Mexico, beginning in 2002 – 1 year after the creation of APV – the promotion of hospital-based births for all pregnant women was strongly encouraged. This measure responded to global maternal health guidelines and reinforced the logic that only within hospital settings do physicians possess the necessary competencies to attend childbirth [49].

The EEM, for their part, promoted the participation of physicians and traditional midwives in spaces for the exchange of knowledge and experiences with actors from the health services, with the primary aim of eliminating the violence exercised against traditional midwives. However, studies conducted with midwives have documented that attitudes toward traditional midwifery in the country remain discriminatory and are characterized by control, harassment, paternalism and indifference. In hospitals of both the Ministry of Health and the IMSS-Bienestar system, midwives have been prohibited from attending births, and when they have done so, they have been reprimanded. Midwives report experiences of humiliation and rejection by medical personnel for multiple reasons: their Indigenous origin, their living conditions marked by poverty and perceived “backwardness” and the lack of recognition of their knowledge as valid within the biomedical framework [49].

Regarding the Health and Nutrition Program (PROSANI), although its design was based on a participatory process with people from Indigenous communities, there was no clear evidence on how intercultural actions were carried out nor on the fulfilment of its objectives related to the inclusion of Indigenous Peoples. Actions such as the delivery of nutritional supplements and educational materials, as well as the construction of health units and training of health personnel, were prioritized over other possible actions aimed at addressing the root causes behind food insecurity and malnutrition.

PROSANI neglected determinants such as poverty and unequal access to land. Its operational document makes no mention of any actions linked to local and traditional food production and consumption practices – issues especially relevant to the identity of many Indigenous Peoples in Mexico. A critical view of the causes of malnutrition experienced by Indigenous Peoples was absent as well as any mention of the need for a profound transformation of the agri-food system in favour, for example, of food sovereignty.

Thus, the term interculturality has become part of a bureaucratization process and a functional element of the State to legitimize its actions, but not to pursue social justice through structural transformation [47]. The existence of these omissions regarding the deep causes of problems affecting Indigenous Peoples in health initiatives (with the exception of CAMIA) reinforces what authors such as Tubino have warned about intercultural policies in Latin American states: they tend to be marginal, superficial and do not address the roots of the historical exclusion of Indigenous Peoples [50].

The PROSANI, APV, and EEM initiatives do not address the structural causes of inequality and, moreover, there is no evidence that allows attributing to them significant transformations in the power structures that have historically relegated traditional medicine and its actors. At the same time, the information demonstrating their impact on improvements in health indicators among Indigenous Peoples (IP) is limited (with the exception of some advances in maternal health associated with APV). This situation is consistent with the findings of Paulo and Cruz, who highlight the scarce availability of epidemiological data in regions with a high presence of Indigenous Peoples [51].

In 2019, upon reviewing the records of the General Directorate of Epidemiology, Paulo and Cruz found that there was no available information on health indicators in areas predominantly inhabited by speakers of Indigenous languages. Likewise, in territories where comprehensive hospitals with traditional medicine modules were operating, they did not find disaggregated data on Indigenous Peoples. In light of this, the authors questioned the criteria used to evaluate the intercultural health policy implemented by the Mexican government [51].

The researchers identified that only one of the objectives established in the intercultural health policy was linked to the indicators defined by the Ministry of Health for its evaluation. While this objective is relevant – by focusing on community participation in the planning and evaluation of services – fundamental aspects of quality of care, such as efficiency, effectiveness, equity, accessibility and patient safety, were left unaddressed [51].

Furthermore, although the importance of evaluating satisfaction and participation among Indigenous Peoples was acknowledged, no evidence was found of the existence of clear tools or mechanisms capable of generating effective processes of communication and exchange between those implementing the policy and the communities that are its potential beneficiaries [51].

Within this framework, various analyses argue that the health sector has instrumentalized the discourse of interculturality as a means of justifying its actions toward Indigenous Peoples. In the words of Paulo and Cruz, they identify it as “a rhetorical and racializing policy that, by codifying Indigenous Peoples as ‘marginal’ and exoticizing them, tends to silence the historical relations of economic and political subordination” [51].

In contrast, the Casas de Atención a la Mujer Indígena (CAMIA) have proven to be an initiative that has made a strong contribution to the construction of a critical and transformative interculturality. Walsh defines this intercultural perspective as a stance and a process that involves transcending the idea of including “difference” within the “Western-colonial” social order, bringing to the forefront the need to dismantle and rethink the social, political and epistemic structures of power that generate and sustain inequalities, racialization and discrimination [47].The CAMIA represent a concrete example of how it is possible to advance toward this type of interculturality, as they have challenged power relations and organized to confront the violence experienced by Indigenous women as leaders, midwives and women. This is a model of care and accompaniment that emerges from and is managed at the community level and that has been conceived by and for women.

Research on the current state of Indigenous midwifery in Mexico has documented that the organizational processes promoted by the CAMIA have played a central role in the defence and strengthening of traditional midwifery. Since their inception, this initiative has sustained a network of organized midwives who have not only ensured maternal healthcare for Indigenous women, but have also developed strategies that have enabled them to recognize and legitimize their work (issuance of certificates, credentials, and their own information record formats). Through these actions, midwives have become important actors who articulate with health services to demand timely and dignified care for women [52].

At the same time, the exchanges that CAMIA midwives engage in with other midwifery networks, as well as the training spaces in which they participate, have contributed to expanding the tools they use in the care they provide. These spaces have also strengthened their knowledge and the exercise of their rights, both as midwives and as Indigenous women [52].

Being organized, feeling recognized and being supported by their networks and communities has been a crucial factor in strengthening their confidence when facing situations of discrimination and violence, both in their role as midwives and more broadly as women. In this sense, they have developed collective learning processes to respond to practices of violence exercised against them by health service providers [52].

Regarding the uncritical, functional and culturalist vision of the interculturality approach, it has been widely discussed that this perspective also promotes a negative phenomenon known as cultural reductionism or essentialism. Essentialism frames societies as a set of cultures considered fixed, static, and incompatible with other “reference” cultures, which are usually dominant Western ones [53].

From an essentialist viewpoint, culture is understood as “a set of beliefs” that is fixed and determines certain established actions [22]. According to Langdon and Garnelo: “such a rigid idea results in the incapacity to recognize differences between distinct Indigenous groups, Indigenous agency, the vitality of their ethnopolitics and their ability to recreate and reinvent their traditions.” [54].

In this sense, according to Menéndez, some developers of interculturality in health in Mexico did not consider the internal sociocultural heterogeneity of peoples and intergenerational transformations [3]. The analysed initiatives promote this essentialist view by mainly focusing on the articulation between traditional medicine actors and institutional biomedicine. This aspect limits participation and agency power of Indigenous and non-Indigenous Peoples, as it excludes the entire population who are not traditional therapists or do not have specialized knowledge of traditional medicine or biomedicine.

This way of implementing interculturality implicitly assumes that all people of Indigenous origin have knowledge of traditional medicine, are shamans, midwives or healers, and can only contribute to community health from that position. This idea is as rigid and erroneous as assuming all non-Indigenous Peoples share knowledge of some medical speciality.

By focusing on improving the relationship between these two medical knowledge systems, it leaves out the possibility for the participation of other actors committed and experienced in community settings, with knowledge situated in territories that may be relevant for care processes and the exercise of the right to health in Indigenous contexts.

Another reductionist assumption discussed by Eroza and Carrasco is that the interaction between traditional medicine and Western biomedicine will generate such complementarity that Indigenous health problems will be solved. From this interaction, it is expected that health providers will not exclude Indigenous knowledge and practices and will promote dignified treatment, which in theory would increase Indigenous acceptance of public health services [55].

This aligns with the fact that most analyzed initiatives (with the exception of CAMIA) assume that through the intercultural actions they promote, problems related to service quality, user distrust and conflicts between traditional and biomedical medicine can be reduced, thereby solving Indigenous health problems. This suggests that Indigenous well-being depends on how well-trained and sensitive health personnel are, rather than on the sociohistorical conditions affecting this population group [55].

Health initiatives targeting Indigenous Peoples (IP), grounded in an essentialist, functional and relational view of interculturality – such as the approach adopted in initiatives like APV, EEM, and PROSANI – primarily seek the acceptance and legitimation of state action among Indigenous Peoples. However, they do not recognize Indigenous Peoples’ capacity for agency, their heterogeneity or their organizational processes. A clear example of this can be found in APV, where traditional midwives are assigned only a liaison role, without validating their knowledge, experiences or contributions to maternal health. In this sense, cultural essentialism can serve to justify their participation solely as translators of Indigenous languages.

By contrast, the experience of the CAMIA demonstrates that, beyond cultural relevance, the women who lead these initiatives have actively questioned and confronted power structures. Through their organization, the exchanges they promote, the accompaniment they provide and the networks and strategies they have built, they have deployed a diversity of roles that reflect a path far removed from essentialist perspectives.

The documented limitations in the four analyzed initiatives result from a design and implementation guided by an uncritical and apolitical intercultural view, reflected in CAMIA’s budget precariousness, the more technical and biological resolutions of the Health and Nutrition Program, the lack of follow-up on the Mutual Enrichment Encounters’ agreements and the secondary role relegated to midwives in the APV program.

Our findings suggest the need to broaden perspectives and courses of action in health initiatives aimed at Indigenous Peoples, toward forms of participation that recognize and include the diversity of experiences and knowledge present in Indigenous communities. This implies breaking with the dichotomy of the relationship between traditional medicine and institutional biomedicine. In contrast, it is necessary to appeal to change the sociopolitical structures that undermine the exercise of the right to health among Indigenous Peoples, as well as to strengthen community organization forms and open opportunities for training based on what Indigenous Peoples themselves demand.

In this sense, developing a health policy based on critical interculturality could be an alternative to transform the health situation faced by Indigenous Peoples. Critical interculturality implies transcending the idea of including “difference” within the “Western-colonial” social order, bringing to the forefront the need to dismantle and rethink social, political and epistemic power structures that generate and sustain inequalities, racialization and discrimination [47].

A similar proposal has been outlined in English-speaking contexts through the operationalization of the concept of “structural vulnerability,” which seeks to bridge structural violence determinants with the micro-practices, subjectivities, and ways of being of “those positioned socially in an inferior status within a prevailing social order” [56]. Structural vulnerability has influenced the “structural competency” approach in health and medicine, a recent, flourishing methodology which aims shifting culturalist paradigms and enabling health personnel to recognize “forces that influence health outcomes at levels above individual interactions” [57]. A need to establish dialogue and cross-fertilization between Global North and South discussions around healthcare radical transformation has been flagged out and addressed by some authors (Piñones Rivera, Quesada and Holmes 2019 [58]; Muñoz Martínez and Sesia 2024 [59] and we hope this article can contribute to this conversation.

Our intention, then, is not to discard the interculturality approach but to reclaim and transform it by leveraging its potential to address inequality structures through counter-hegemonic frameworks of action (not only theoretical) built from the voices of those historically subordinated.

Conclusions

The analysis of the origin of the initiatives, the conception of interculturality on which they were based and the participation of Indigenous Peoples (IPs) in them, together with the review of their main achievements and limitations, allowed for a critical discussion on how the narrative and perspective underlying the design and implementation of health policies, programs, and actions for Indigenous Peoples are fundamental determinants of their legitimacy, relevance, impact and sustainability.

Based on this comparative analysis, important differences were identified between initiatives of governmental origin and those of community origin. APV, EEM and PROSANI, which originated within the State apparatus, failed to achieve their objectives of strengthening the participation of traditional medicine actors in health–disease–care processes, as well as of improving their relationships with health personnel.

At present, these initiative no longer exist. Although one of the most significant achievements of APV was the establishment, through the Official Gazzet of Federation (Diario Oficial de la Federación, DOF) of the mandatory implementation of its substantive components in public and private health services, it did not fulfil its objectives related to strengthening and integrating traditional midwifery. In addition, most initiatives were characterized by insufficient resources, lack of medical personnel, high institutional bureaucracy and lack of follow-up on actions.

Regarding the use of the interculturality approach, not all initiatives included it explicitly nor clearly defined its conceptual framework and implementation mechanisms. Nevertheless, most initiatives displayed elements that emphasized cultural determinants as central aspects of Indigenous healthcare (with exception of CAMIA). While attention to cultural aspects is important, this culturally centred approach has historically been one of the main limitations of Indigenous health policies, as it tends to obscure the need to address structural determinants such as racism and unequal access to health services.

Interculturality has generally functioned as a strategy aimed at facilitating the acceptance of biomedical health services in Indigenous contexts. However, this perspective has been incorporated into the health system in an uncritical manner, recognizing cultural differences but without adequately acknowledging discrimination, racism and the place that Indigenous Peoples have historically occupied in the social structure as central causes of inequality and ill health. As a result, actions labelled as intercultural often focus on facilitating access to health services rather than addressing the structural conditions that shape health inequities.

In contrast, in the case of the CAMIA, their origin, community appropriation, and the autonomy exercised by the women involved are key factors explaining their continuity to the present day. Community leadership has translated into the response to specific needs, with cultural, social and also political relevance. The CAMIA constitute important spaces for access to healthcare and to justice – particularly by midwives – demonstrates that it is not possible to guaranteeing the right to health without dismantling the racist ideologies and violent practices reproduced by the health system toward IPs.

Based on these lessons, it is necessary to reflect on the directions that public health policy for Indigenous Peoples should take moving forward. We propose to reclaim the critical interculturality approach which Walsh conceptualizes as a political, social and epistemic project aimed at the radical transformation of structures, institutions and relations shaped by colonialism, racism and neoliberalism [47]. From this perspective, the goal is not merely to include difference within a social order but to transform that order by rethinking ways of life, knowledge production and power relations [47].

These ideas, when applied to the field of health, resonate with the arguments developed by through critical epidemiology which understands health problems as rooted in socio-environmental processes linked to dynamics of wealth accumulation. This perspective involves critically questioning systems that render access to healthcare and well-being a privilege for a few, while others remain unjust conditions of inequality and subordination. Critical epidemiology thus seeks to promote emancipatory actions oriented toward a “sustainable, sovereign, solidary and healthy/biosecure society” the four “S’s” of life while integrating the vision of “buen vivir” (good living/living well) [60]. Advancing toward health policies grounded in decolonial epistemologies is therefore essential to promote justice and equity through alternatives ways of understanding, caring for and living health.

Study limitations

The aim of this study was not to conduct an exhaustive or systematic review of the topic, but rather to use a range of documentary sources as analytical inputs. Therefore, the findings do not represent the state of the art of the academic debate on intercultural health initiatives for Indigenous Peoples.

The analysis was based exclusively on secondary sources and did not include fieldwork, which limited the possibility of incorporating the direct experiences and voices of key actors involved in these initiatives. Accordingly, this study does not constitute an evaluation, but rather a critical reading of selected health initiatives directed at Indigenous Peoples in Mexico.

The available evidence for most initiatives was limited, fragmented and uneven across cases, and in some instances lacked transparency owing to its reliance on official government sources. This constrained the ability to clearly and critically reconstruct the processes of design, implementation and evaluation of the initiatives.

Finally, the results of this analysis are not intended to be generalizable to all intercultural health experiences or initiatives in the country. Instead, the study sought to identify, question and critically examine specific trends, patterns and structural tensions present in the initiatives analysed, which are consistent with broader critiques of health policies, programs and actions targeting Indigenous Peoples in Mexico.

Abbreviations

IPs

Indigenous peoples

SSA

Secretaría de Salud

INI

Instituto Nacional Indigenista

INPI

Instituto Nacional de los Pueblos Indígenas

PRONASOL

Programa Nacional de Solidaridad

NAFTA

North American Free Trade Agreement

EZLN

Ejército Zapatista de Liberación Nacional

CDI

Comisión Nacional para el Desarrollo de los Pueblos Indígenas

DMTDI

Dirección de Medicina Tradicional y Desarrollo Intercultural

CAMI

Casas de Salud de la Mujer Indígena

CAMIA

Casas de Salud de la Mujer Indígena y Afromexicana

PROSANI

Programa de Salud y Nutrición para Pueblos Indígenas

EEM

Encuentros de Enriquecimiento Mutuo

APV

Arranque Parejo en la Vida

PAHO

Pan American Health Organization

CSO

Civil Society Organization

Author contributions

BPV, SMN, LM and AME conceptualized the main idea of this article. AME conducted the literature review (search and selection), performed the analysis and synthesis of the literature. AME drafted the manuscript. BPV, SMN and LM contributed to the manuscript by providing conceptual input, reviewing the text, and improving the writing and clarity of the ideas. BPV, SMN and LM supervised the study and critically revised this article. All the authors reviewed and approved the final version of this manuscript.

Funding

This work was supported by a scholarship to the PhD candidate from the National Council of Humanities, Science and Technology (CONAHCYT) in Mexico, CVU 556967. Not additional funding was specifically received for conduct this research.

Availability of data and materials

Not applicable to this article as no datasets were generated or analysed. The information and evidence presented in this literature mapping were obtained from available and published sources, which are cited in this article.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Declaration of AI use

The use of artificial intelligence AI is declared for reviewing the writing style of some sections of this article and for the translation of this article into English, which was subsequently reviewed by a human person. We used AI tools for the formatting of the references according to journal guidelines.