Community health worker
Here is a video produced by TulaSalud, which provides an overview of their many programs:
When we founded the Tula Foundation at the end 2001 our priority was health given my career experience in health systems. We were particularly interested in the problem of health and equity in developing countries. We wanted to focus on a specific region that was well matched to our capabilities, and because of a combination of factors we chose the department of Alta Verapaz in the central highlands of Guatemala. One of the main reasons for that choice was the presence in the main town of Coban of the national school of nursing–La Escuela Nacional de Enfermeria de Coban, or ENEC for short. ENEC impressed us then, as now, with their expertise and dedication to their service area, which includes remote, rural indigenous (Mayan) communities that have consistently shown poor health indicators.
I visited Guatemala in early 2003 and we officially began work in 2004 with two Canadian partners, the Canadian International Development Agency (CIDA) and the Centre for Nursing Studies (CNS) in Newfoundland. By 2006 CIDA had begun to scale back its involvement so we increased our support. Since 2008 the Tula Foundation has been the sole funder of the program.
Over the years we have focused on the following interconnected topics, all ultimately with the goal of improving health indicators in rural communities:
- We provided funds and technical expertise to help ENEC develop and extend programs to educate auxiliary nurses (similar to licensed practical nurses in Canada) in their home communities. This decentralization of education is supported by internet based distance education in combination with local tutors and local clinical experience in rural health centers. The education program has now extended beyond Alta Verapaz to many additional departments. Close to one thousand auxiliary nurses have graduated or are in courses now. That program is known by the acronym CAEC (Curso de Auxiliaries de Enfermería Comunitaria).
- With the leadership of ENEC the distance education program was extended to professional nurses in 2008. Two hundred professional nurses have graduated or are in courses now.
- We were very concerned that nurses not only be educated but also hired within the health system so they could apply their training for the good of their communities. We therefore work very closely with the national Ministry of Health and the Health Area of Alta Verapaz (DASAV) to ensure that graduates are hired, deployed to target communities and supported on the job.
- We are determined to see health care go that ‘last mile’ to isolated communities. To that end we have worked with DASAV to supplement their resources training up a cadre of existing community health workers. These workers are trained in mobile health with support from Tula Salud, integrated into the formal system, equipped with a field kit and a cell phone, and deployed in the service of the most remote and challenged communities.
- The improvement in health indicators in the communities served has been encouraging, especially in the area of maternal and infant health, which is one of the Millenium Development Goals, and therefore a particular area of focus for Guatemala.
- Technology is merely a means to the end, the end being improvement in health indicators. 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.
By 2008 we recognized that the Guatemalan team was becoming capable of running their programs themselves. Accordingly, we established a Guatemalan NGO, Fundacion TulaSalud, staffed entirely by local professionals. The Tula Foundation continues to provide funding, advice and technical assistance where necessary, drawing upon our network of advisors and volunteers in Canada. In 2013 TulaSalud celebrated their five-year anniversary.
In 2010 we agreed to extend and expand support for programs in Alta Verapaz for an additional five years. Based on the positive outcomes we more than doubled the scope of the Telesalud initiative, working even more closely with the Ministry of Health and DASAV.
Other Sources of Information
There are many good sources of information on Guatemala and its challenges in health care, 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 Guatemalan Ministry of Health (in Spanish only)
The people of Guatemala have endured a difficult history, most recently the brutal civil war that raged over most of the second half of the twentieth century. But the Peace Accords were signed in 1996, and since then there have been a number reasonably orderly national elections. There have been governments of different political stripes, but through it all Guatemala remains at or near the bottom of the Latin American tables for poverty, inequality, violence, poor health indicators, corruption and human rights abuses.
Our experiences working in Guatemala over the last decade have nonetheless 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.
There have been four different administrations during our time in Guatemala: Presidents Portillo, Berger, Colom, and Perez Molina, who will serve until 2016. We have been able to work effectively with all governments, and we expect it to be no different with President Perez Molina. The initial indications are that his government may be quite progressive in the area of health care.
The population of Guatemala in 2012 was about 15 million. Roughly 52% of the population is under 20 years of age. There are 22 different Mayan dialects spoken in the country.
We concern ourselves here only with the parts of the health system that affect the rural poor. Coverage is all governed and paid for by the ministry of health, the Ministerio de Salud Publico y Asistencia Social or MSPAS. There are two components to this system. One part is delivered via the Health Centers and Health Posts (Centros de Salud and Puestos de Salud) that are owned by MSPAS. The other part, created by the Peace Accords is delivered by a network of NGOs contracted by MSPAS. This latter system is known as the Programa de Extension de Cobertura or PEC.
The poor receive attention with from the Centros de Salud under MSPAS or from the PEC under the NGOs. Currently about 54% of the rural population is treated via the PEC. There are 67 NGOs in the PEC, in 206 municipalities. The functional unit within the PEC consists of a Basic Health Team–Equipo Basico de Salud or EBS, which includes institutional and community personnel. The institutional personnel comprise an ambulatory doctor or nurse, an institutional facilitator and educator, an accountant and an information assistant. The community personnel consists of community facilitators, comadronas, vigilantes de salud and madres consejeras and is augmented by an auxiliary nurse.
The key thing to note is that the PEC is a system of mobile delivery of health care. It is agreed that the PEC must either be strengthened or abolished. This debate will be following via the blog.
Health and Social Indicators
There are strong correlations among the following factors: being indigenous, living in a dispersed rural community, being in poverty or extreme poverty, having poor indicators for maternal and infant mortality and chronic malnutrition. 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. The Tula Foundation concentrated its first efforts in the department of Alta Verapaz, and then extended that work to several other departments that face similar challenges.
The capital and chief city of the department is Cobán. 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 years of civil war. Alta Verapaz comprises 15 municipalities each of which has a Centro de Salud (Health Center) that serves as a center for treatment, administration and now nursing education.
The population of Alta Verapaz was given as 958,417 in 2004, an increase of 22.5% from 1999. The population of Alta Verapaz is predominantly indigenous with the exact percentage depending on how ethnicity is defined. The majority Mayan language in Alta Verapaz is Q’eqchi’, but with many Poqomchi’ speakers in the southernmost municipalities.
The three departments Alta Verapaz, El Quiche and Huehuetenango are, relative to the country as a whole, characterized by larger indigenous populations, and poorer economic and public health indicators.
When we first assessed the issues and opportunities in Guatemala in 2002 and 2003 it was evident that without trained manpower in the countryside nothing was possible. The objective was to train a critical mass of nurses willing and able to work in the remote rural indigenous communities in north central Guatemala. We (initially in support of ENEC, CIDA and CNS) 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 a ‘community auxiliary nurse’, after eighteen months of part time study.
- We decentralized education so that prospective nurses could receive training close to homes.
- We used the municipal Centros de Salud (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. In Guatemala the program is now known as the Curso de Auxiliaries de Enfermería Comunitaria or CAEC. Roughly one thousand auxiliaries have now been educated under the CAEC program. There has recently been discussion in Guatemala of the need for two thousand additional auxiliary nurses to serve the needs of the Ministry and of the five-year $32 million United State Agency for International Development (USAID) Community Nutrition and Health Care Project for the Western Highlands of Guatemala, which is just getting under way. We are currently discussing with those parties the role TulaSalud will play in those initiatives.
The CAEC has over the years grown into a huge program. We don’t always see its scope because it consists of small groups learning together in their own communities. They all come to Coban for the graduation ceremony and it is then that the scale of the program becomes manifest. The 2011 graduation ceremony shown below was held in the only venue large enough for it–the basketball arena. Can you spot the Tula Foundation’s Ray Brunsting among the graduates and dignitaries? These graduates come from rural communities all across the northern highlands of Guatemala. As you can see, they are men and women, young and not so young, 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 being well served by the existing system as evidenced by their poor health indicators. By 2007 we were ready to launch our first independent program, then known as telesalud (telehealth). Initially piloted in a few municipalities, the program has grown year by year and will soon encompass most of the priority communities in the department of Alta Verapaz and serve a population of approximately one million.
The Ministry of Health (MOH) serves rural communities via the Health Extension Coverage program (or PEC for its Spanish acronym), which has been the model since the Peace Accords were signed in 1996. Under the PEC the first point of contact with the health system is the Community Health Worker (CHW). The CHW is paid a stipend by either the local Community Development Council or the local NGO health care provider. We reasoned that we could improve the performance of the system at the local level by giving the CHW more capability, particularly in the area of tools and training for emergency care.
Here is how the TeleSalud program works:
- Candidates are selected from among the existing CHWs and provided with ongoing training.
- Each CHW is given a cellular telephone.
- CHWs are integrated into a communications network that includes in particular their municipal health centers, which are the source of advice, ambulances and second level care.
- CHWs are given a stethoscope, a blood pressure cuff and a botoquín (a chest of basic drugs and supplies).
- The CHW’s salary is supplemented to reflect these added responsibilities.
All parties work to ensure that CHWs are effectively integrated as bona fide members of the health care team. These efforts include meetings with the local health center staff, rotations through hospitals, protocols for escalating problems, standards for reporting and data collection, etc. In particular, CHWs are advised to maintain good relations with the comadronas (Mayan midwives) and other traditional health workers in their communities.
A CHW often dedicates part of the family home as a dispensary/surgery as did Ernesto Tiul, one of our pioneer CHWs, from the village of Tuzam in Lanquín municipality.
Right: Ernesto inside his home nursing station, with the tools of his trade on the table and his supply cabinet in the background, speaking the Q’eqchi’ language, discusses his role in his community.
In recent years the TeleSalud program has focused in particular on maternal and infant health, where its impact on health indicators has been impressive. There therefore a desire on the part of the MOH to extend the program in one form or another to the other Highland departments.
Tula agrees with the following quote from from this blog posting:
Our actions are inline with the contents of the “One Million Community Health Workers: Technical Task Force Report”
The MOH is showing signs that it may move away from the PEC in favor of a more traditional health system structure based more on auxiliary nurses in health posts (Centros de Convergencia) rather than CHWs in the communities. In theory, rural communities would receive more professional service in this model; in practice, it may sacrifice the benefit that round-the-clock, in-community CHWs has offered. Ideally a blended model could be supported, with CHWs for responsiveness and auxiliaries for professionalism. In any case, TeleSalud will need to adapt to any changes in the strategy of the MOH.
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 (MoH). 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 MoH 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).