Politics, practical logic, and primary health care in rural Haiti

During the 1980s, an ambitious project for health development restructured medical services throughout rural Haiti. The "Rural Health Delivery System" (RHDS) pursued several goals of primary health care, including dispensary-based maternal and child health services and the provision of low-cost drugs. Based on fieldwork in a single village, this article examines how local residents pushed the project in unpredictable and ironic directions. People did not regard dispensary services-which were planned and financed by international health agencies-as essentially foreign elements in the local health-care system. They rather engaged with the dispensary according to long-standing local strategies for prestige and economic advance. Despite the dramatically new shape of biomedicine introduced by the RHDS, the dispensary remained for most people a recognizable arena to gain access to state resources or to contest state control over their lives. The "success" of clinic services, and the "failure" of the project to distribute essential drugs arose more from people's practical routes to symbolic and material power than from the formal plans of health planners or state bureaucrats. This practice-based analysis provides another dimension to both the liberal and neo-Marxist critiques of international health development.