Bringing Healthcare Home: Community Health Dialogues are Changing the Conversation in Guatemala

In the Indigenous villages of rural Guatemala, frontline nurses are the primary providers of healthcare. These nurses are often born and raised in the regions they serve and are well-versed in local language and customs—an important advantage in a country where over 22 Mayan languages, including K'iche', Q'eqchi', and Kaqchikel, are spoken. 

According to the Pan-American Health Organization (PAHO), healthcare outcomes have improved since the turn of the millennium, with maternal mortality declining 37 percent between 2000 and 2020, and infant mortality falling by over 55 percent during the same period. Since 2004, TulaSalud has trained over 2,800 frontline healthcare workers in 13 Guatemalan provinces—known as departments—and equipped many of them with a smartphone-based digital health app called Kawok. 

The program has likely played a role in the country’s improved health outcomes. But a continuing challenge, says TulaSalud president Christy Gombay, has been engaging and consulting with local communities to secure buy-in and cooperation for health initiatives—whether disease vaccinations or efforts to battle malnutrition and child and maternal mortality. 

“Healthcare delivery in Guatemala has historically been vertical and centralized,” says Gombay. “Communities are asked for information and then told what is best for them. But different departments have different burdens of disease, different problems that they're trying to face. That becomes even more fragmented as you get down to the local, village level.” 

To begin to address this, Gombay notes that for the past three years TulaSalud has been using community surveillance data from the Kawok app and presenting it to rural villagers in forums known locally as “Community Situation Rooms.” In these forums, the data gathered by nurses on mortality, disease, and local health initiatives are presented in a simplified form and translated into the regional language. 

“The nurses’ concern is save the patient, save the patient, save the patient,” says Gombay. “What we're able to do through Kawok is return the data in an aggregated form so that nurses can come to the community leaders and say, ‘You know, compared to the last year there's been a real spike in adolescent pregnancies,’ or ‘We’re seeing way more malnourished kids at certain times of year.’”  

The point of Community Situation Rooms, says Gombay, is to give local people a chance to learn about, and then help guide and direct, health priorities.

“It may not sound revolutionary, giving input in this way, but it’s really trying to engage authentic, local voices,” says Gombay. “When nurses who are aware of their cultural context convey the data clearly in the native language, that leads to getting people on board. Participants in the meeting can understand and say, ‘Oh, this is why you guys are trying to do this.’”

From the 1960s to the mid-1990s Guatemala was riven with a civil war that killed over 200,000 people and displaced another 1.5 million—most of them Indigenous people living in the rural highlands. Building trust between local populations and government entities like the Ministry of Health has taken decades, says Gombay. Community Situation Rooms are part of this long-term process, and so far the results are promising. 

Ofelia Paau is a technical assistant at a health post in Chicoj, in the department of Alta Verapaz, where a Ministry of Health outpost opened in 2017. Community participation with the outpost was very limited at first, she says, but since then local leaders have formed a health commission with a community member as president and a local midwife as an advisor. 

“As we gained experience along the way, the community leaders started getting involved,” says Paau. “People are much more open and supportive now.”

Local leaders have helped Paau and her colleagues reach out to pregnant women who weren’t coming for check-ups, coordinate garbage collection efforts, and gather children for weight and height monitoring.

“Now, thanks to the support from Tula, we have the Situation Room, which is very practical because it includes many images that are easy for people to understand when they come to participate,” says Paau. “We concentrate more on explaining the visuals within the situation room. The information is also much easier now—we can just download it through the Kawok telephone.”

Mayra Chocooj is the president of the local health commission in Chicoj and a frequent participant in Community Situation Room gatherings with Ministry of Health frontline healthcare workers. Chocooj points out that progress has been made focusing on  inclusiveness and equity in these processes. 

“What I feel and value is that now women are given space to participate in these matters of health,” she says. “In the past, women didn’t have those opportunities. But now that we do, we are able to support other women this way.”

She credits TulaSalud with the benefits of connecting the community with Ministry of Health personnel. 

“Now we know how many boys and girls are growing well and which ones are not. That’s one of our achievements—we’ve learned to identify those cases,” Chocooj says. 

Chocooj also notes that the community events help children overcome their fear of vaccines and give healthcare workers a chance to assess whether children are thriving. “We also analyze the overall health situation—what we’ve achieved and what we still need to work on in the community,”  she says.

PAHO was impressed enough with the early results of Community Situation Rooms that it co-financed scaling the programup to 477 different communities across three Guatemalan departments. 

Looking ahead in her own community, Chocooj says she would like to see more robust health service with permanent staff—and greater outreach to teen boys and girls about birth control and pregnancy. 

“We want our youth to receive that knowledge in time,” she says. “Thanks to the Community Situation Room meetings, we now have access to that information.”