Community health worker
Here is a video produced by TulaSalud, which provides an overview of their many programs:
When we founded the Tula Foundation in 2001, we knew our priority would be health given my career experience in health systems. We were particularly concerned with the issue of health equity in low-income countries, and knew that we wanted to focus on a global region that was well matched to our technical capabilities. Due to a combination of factors, we chose the region of Alta Verapaz in the central highlands of Guatemala as our starting point. One of the main reasons for our selection was the presence of the national school of nursing – La Escuela Nacional de Enfermeria de Coban (ENEC) – in the regional capital of Coban. ENEC impressed us then, as it does now, with their expertise and dedication to their service area, which includes remote indigenous (Mayan) communities that consistently display poor health outcomes.
I visited Guatemala in early 2003, and by the following year we officially began our work with two Canadian partners; the Canadian International Development Agency (CIDA) and the Centre for Nursing Studies (CNS) in Newfoundland. The goal was to train a critical mass of auxiliary nurses (similar to licensed practical nurses in Canada) living in remote communities in Guatemala; communities which frequently lack basic health services. Based upon a distance education model that combines internet-based communication and local clinical tutorials, rural youths could be trained and hired as auxiliary nurses in their home communities. To ensure that nurses were not only educated, but also hired within the health system, we work very closely with the Ministry of Health at the national and regional levels.
By 2006, CIDA had begun to scale back its involvement, so we decided to increase our support in response. By 2008, the Tula Foundation had become the sole funder of the program. At the same time, we recognized that the Guatemalan team was capable of running their programs independently. Accordingly, we established a Guatemalan non-profit organization, Fundacion TulaSalud, staffed entirely by local professionals. The Tula Foundation continues to provide funding, advice and technical assistance to TulaSalud where necessary, drawing upon our network of advisors and volunteers in Canada.
Since then, the distance education program has expanded beyond Alta Verapaz to many additional communities in Guatemala. More than 1,300 health professionals, including auxiliary and professional nurses, have graduated and approximately 82% work in the health system.
We are determined to see health care go the ‘last mile’ to isolated communities. To that end, we continue to work with the Ministry of Health to provide supplementary resources for supporting health personnel in rural communities. Most recently, the Tula Foundation introduced a mobile health, or mHealth, system, which uses smartphones to support the delivery of health services. Trained and equipped with smartphones, health personnel in Guatemala’s most remote and challenging communities are able to coordinate the transfer of high-risk patients, consult with a network of health professionals, collect community health data, and use digital media to provide health education.
In 2016, the Tula Foundation was awarded $7.6 million in co-funding as part of Global Affairs Canada’s Partnerships for Strengthening Maternal, Newborn, and Child Health. This award came at an opportune moment, as we prepared to support TulaSalud in expanding the mHealth program to additional regions in Guatemala. Receiving this award and witnessing improved health outcomes in communities served has been encouraging for the program in Guatemala, specifically in the area of maternal and infant health.
Since 2016, nearly 1,000 health personnel, mostly indigenous, have been training and equipped with smartphones and are responsible for monitoring nearly 3,000 communities throughout Guatemala. Health personnel have registered 38,624 calls (including clinical consultations and urgent patient transfers), 234 malnourished children, and 1,522 adolescent pregnancies. Most importantly, communities receiving mHealth services have shown significant reductions in both maternal and child mortality.
Over the years, we have always maintained focus on the goal of improving health outcomes in rural communities in Guatemala. Technology is merely a means to the end, the end being improvement in health outcomes. Nonetheless, we do believe that appropriate technology can be of great benefit to health care professionals (including nurses of course) in rural Guatemala, who are spread so thinly across a complicated landscape.
Other Sources of Information
There are many good sources of information on Guatemala and its health system challenges, which contain much more definitive and up to date information than we can offer here.
- The Pan American Health Organization (the arm of the World Health Organization that serves Latin America)
- The United States Agency for International Development (USAID): Guatemala Health System Assessment 2015
- The World Bank: Guatemala – Closing Gaps to Generate More Inclusive Growth
- The Guatemalan Ministry of Health (in Spanish only)
The people of Guatemala have endured a difficult history; most recently, a brutal civil war that raged over most of the second half of the twentieth century and left much of the country’s health system, and other social services, in disarray. Despite signing the 1996 Peace Accords, followed by a decade of reasonable political stability and moderate economic growth, Guatemala remains at or near the bottom of Latin America’s development indicators, including those related to poverty, inequality, violence, health, corruption, and human rights. These threats are often experienced at a greater severity for women, indigenous peoples, or rural populations.
Nonetheless, our experiences working in Guatemala over the last decade have been uniformly positive. At all levels of the health system, we find professionals and community health workers who are as capable and dedicated as their counterparts in Canada or anywhere else in the world. We are inspired by the leadership and energy we see throughout the system, and remain encouraged to provide support when and wherever we can.
There have been five different administrations during our time in Guatemala: Presidents Portillo, Berger, Colom, Molina, and Jimmy Morales who will serve until 2020. We have been able to work effectively with each administration, and we expect it to be no different with President Morales. In 2016, the newly elected President announced a national target of reducing chronic malnutrition by 10% by 2020. As the Ministry of Health works towards this goal, the Tula Foundation is pleased to continue our support for health personnel in remote communities in Guatemala.
National Health System
Guatemala’s health system is characterized by multiple public and private institutions, which operate largely independently. We concern ourselves only with parts of the health system that affect the rural poor. Health service delivery in Guatemala is operated, governed, and paid for by the Ministry of Health, or Ministerio de Salud Publico y Asistencia Social (MSPAS). Health services are most frequently delivered at local health centers or health posts, or centros de salud and puestos de salud, which are scattered throughout Guatemala’s remote landscapes. Despite being the primary entry point for community health care delivery, health posts often contend with lack of basic infrastructure and health personnel and medication shortages. These inconsistencies limit the Ministry of Health’s capacity to provide adequate health services, and foster public distrust in the public health system.
Health and Social Indicators
Guatemala is best understood as a country divided in two; one Guatemala is urban, non-indigenous, educated, wealthy, and formally employed, the other Guatemala is rural, indigenous, less educated, impoverished, and living on subsistence farming. This pattern remains consistent for indicators of health, with the later Guatemala contending with higher levels of poor health outcomes, such as child malnutrition, maternal and infant death, and many other non-communicable diseases. The north and northwest regions of the country are the most severely disadvantaged, having the highest percentages of rural and indigenous communities.
Guatemala is divided into 22 departments (or provinces in the Canadian context). The Tula Foundation concentrated its first efforts in the department of Alta Verapaz, and since then, has extended that work to several other departments that face similar challenges. These include Huehuetenango, El Quiché, and Solola. The four departments of Alta Verapaz, El Quiche, Huehuetenango, and Solola are, relative to the country as a whole, characterized by larger indigenous populations, and poorer economic and public health indicators.
Alta Verapaz is among the poorest and most neglected departments in the country, and along with El Quiché and Huehuetenango, suffered the worst ravages of the civil war. The capital city of Alta Verapaz is Cobán. Alta Verapaz comprises 16 municipalities each of which has a health centre that serves as a center for treatment, administration, and nursing education.
More than 1.1 million people live in Alta Verapaz, with 78% in poverty and nearly 90% self-identifying as indigenous. The primary Mayan language in Alta Verapaz is Q’eqchi’, but with many Poqomchi’ speakers in the southernmost municipalities.
El Quiché is another one of the largest and most populated departments in Guatemala. The capital city of El Quiché is Santa Cruz del Quiché. Larger than Alta Verapaz, El Quiché comprises of 21 municipalities. Unlike its neighbours, administration of health in El Quiché is divided into 3 separate health areas; Ixcán, Ixil, and El Quiché Central.
Approximately 955,705 people live in El Quiché, with 72% living in poverty and 87% self-identifying as indigenous. The primary Mayan language in El Quiché is K’iche, as well as Ixil, Uspantek, Sakapultek, as well as Poqomchi’ and Q’eqchi’ in the North-East.
Huehuetenango is one of Guatemala’s most ethnically diverse regions and is contiguous with the Southern border of Mexico. Huehuetenango’s capital city shares its name with the department. Another of Guatemala’s larger departments, Huehuetenango comprises of 31 municipalities.
Approximately 846,544 people live in Huehuetenango, with more than 60% living in poverty and nearly 60% self-identifying as indigenous. Huehuetenango is home to the greatest number of Mam Mayans in Guatemala, which is also the primary Mayan language in the department. Other Mayan languages spoken in Huehuetenango include Q’anjob’al, Chuj, Jakaltek, Tektik, Awakatek, Chalchitek, Akatek, and K’iche’.
The department of Solola is characterized by Lake Atitlan, which is surrounded by various volcanos. Solola’s capital city also shares its name with the department. Despite being one of Guatemala’s smaller departments, Solola comprises of 19 municipalities.
Approximately 307,661 people live in Solola, with more than 78% living in poverty and 97% self-identifying as indigenous. The population of Solola is made up of two primary Mayan ethnic groups; the Kaqchikel people and K’iche’ people, who each speak their own languages.
When we first assessed the issues and opportunities in Guatemala in 2002 and 2003, it was evident that without trained health personnel in the countryside nothing was possible. The objective was to train a critical mass of nurses willing and able to work in the remote indigenous communities in Guatemala. We adopted the following strategy:
- We recruited students who had roots in rural indigenous communities, so they would be comfortable working there; and because they knew the language, culture and environment, they would be much more effective than outsiders.
- We first concentrated on training auxiliary nurses, because that could be done relatively quickly. In addition, we trimmed the auxiliary curriculum to match the needs of rural communities. A student graduates as an ‘auxiliary nurse’, after eighteen months of part time study.
- We decentralized the education process so that prospective nurses could receive training close to homes.
- We used the municipal health centers as local training venues for nurses. Professors based at ENEC delivered lectures via Internet-based distance education. A local professional nurses at the health centers acted as tutors and the health centers were used for clinical experience.
- We offered support in indigenous languages where needed.
- We worked with the Guatemalan Ministry of Health and NGOs to ensure that graduating nurses were trained and employed where they are needed.
Although the details and the teaching technology have changed over the years, the basic strategy remains the same. Since we started the auxiliary nurse training program, the Tula Foundation has expanded the types of training programs offered to health personnel, at the request of the Ministry of Health. These have included training courses for health personnel on maternal, newborn, and child health, child malnutrition, and mHealth strategies for health care. We continue to work with the Ministry of Health to identify training needs and ensure that health personnel are capable of delivering necessary health services in their rural home communities.
Since the distance education program started, more than 1,300 health professionals, including auxiliary and professional nurses from rural communities, have graduated, and approximately 82% work in the health system. Graduates are men and women, young and not so young, and all committed to serving their communities and honoring their traditions.
In the early years, we focused exclusively on nursing education, which matched the priorities of the senior funding partner CIDA. The Tula Foundation was however, always very interested in the deployment of expertise that would make a difference in rural communities that were not well served by the existing health system, as evidenced by their poor health indicators. By 2007, we were ready to launch our first independent program, then known as TeleSalud (or Telehealth). Initially piloted in a few municipalities, the program grew year by year to encompass many of the priority communities in the department of Alta Verapaz, serving a population of more than one million people.
The TeleSalud program initially worked as follows:
- Candidates were selected from among the existing community health workers (CHW) and provided with ongoing training.
- Each CHW was provided with a cellular telephone.
- CHWs were integrated into a communications network that includes in particular their municipal health centers, which are the source of advice, consultation, ambulances, and second level care.
All parties worked to ensure that CHWs were effectively integrated as bona fide members of the health care team. These efforts included meetings with the local health center staff, rotations through hospitals, protocols for escalating problems, standards for reporting and data collection, etc. In particular, CHWs were advised to maintain good relations with the comadronas (Mayan midwives) and other traditional health workers in their communities.
While the Tula Foundation continues to implement the TeleSalud program with the same core principles, the program has expanded considerably since its inception. Most recently, the program has started using smartphones. Trained and equipped with smartphones, health workers in Guatemala’s most remote and challenging communities are better able to coordinate the transfer of high-risk patients, consult with a network of health professionals, collect community health data, and use digital media to provide health education. In recent years, the TeleSalud program has focused in particular on maternal and infant health, where its impact on health indicators has been most impressive.
Since 2016, nearly 1,000 health personnel, mostly indigenous, have been training and equipped with smartphones and are responsible for monitoring nearly 3,000 communities in Alta Verapaz, El Quiche, and Huehuetenango. Health personnel have registered 38,624 calls (including clinical consultations and urgent patient transfers), 234 malnourished children, and 1,522 adolescent pregnancies. Most importantly, communities receiving mHealth services have shown significant reductions in both maternal and child mortality
Kawok is a mobile application and web site that supports nurses, doctors, supervisors and epidemiologists in their daily work.
The core component of Kawok is a mobile application used by nurses to create and manage cases. The application was developed in close collaboration with the Guatemalan Ministry of Health. Kawok is based on CommCare by Dimagi, a leading mHealth technology platform for low resource settings. Kawok is made possible by a strong partnership between Tula and Dimagi, started in 2012.
The Kawok mobile application is a job aid for healthcare professionals, following Ministry of Health guidelines and using culturally appropriate multimedia content to improve usability and educate both users and patients. Significant attention is paid to make the application very simple to use and feedback has been extremely positive. Bona fide epidemiological results are evident from the resulting data, which is automatically and securely synchronized over the internet. At any time, thousands of pregnant women and children are being monitored, enabling nurses and doctors in health centers and elsewhere to respond to what is happening at the community level.
Simple and actionable reports and maps are produced daily. Customized reports are prepared for health districts, health areas, supervisors and epidemiologists. Some reports are aimed to improve the effectiveness and efficiency of clinical monitoring (e.g. making sure women are receiving timely and appropriate prenatal care and counseling), while others are aimed to improve the effectiveness and efficiency of health worker monitoring (e.g. making sure nurses are interacting with communities as expected and investigating any potential issues).