Growing interest in how marginalized citizens can leverage countervailing power to make health systems more inclusive and equitable points to the need for politicized frameworks for examining bottom-up accountability initiatives. This study explores how political capabilities are manifested in the actions and strategies of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala.

The results affirm the critical importance of sustained, long-term processes of engagement with marginalized communities and representatives of the state to enable grassroots leaders of accountability initiatives to develop the capabilities needed to mobilize collective action, shift the terms of interaction with the state, and build more equitable health systems.