The Guatemala Community Health Worker Program

After the signing of the 1996 Peace Accord, Guatemala’s health system created the Comprehensive Health Care System (Sistema Integral de Atencion en Salud, or SIAS). Mobile Health Team let by NGOs and made up of a physician or professional nurse, auxiliary nurse, Rural Health Technician, and CHW served jurisdictions across the country. Over 27,000 CHWs had been deployed as of 2003 and the SIAS program made a positive impact on basic health services and health inequities. Despite its success, the government ended the program in 2013 and has yet to replace it with a similarly well structured approach.

Background
Guatemala has been extending health coverage through community health workers for more than half a century. After the signature of the 1996 Peace Accord, the health system went through an intense health reform which produced the Comprehensive Health Care System (Sistema Integral de Atencion en Salud, or SIAS). The main objective of the system was to increase service coverage, focusing on the most hard-to-reach populations by contracting out to non-governmental organizations (NGOs) as service providers.

Implementation
In 1997, the Ministry of Health reorganized services by dividing the population into a patchwork of jurisdictions. Each jurisdiction, composed of 10,000 inhabitants, would be served by a different NGO. The SIAS program provided primary health care (PHC) coverage through Mobile Health Teams made up of a physician or professional nurse, an auxiliary nurse and a Rural Health Technician (Técnico en Salud Rural). These Mobile Health Teams made monthly visits to rural hard-to-reach communities. In each of these communities there was a CHW who linked with these Mobile Health Teams. There were 27,000 of these CHWs in 2003. Unfortunately, the government closed this program in 2013 and has not yet replaced it with a similar program of well-developed outreach PHC services.

Roles/responsibilities
CHWs facilitated service provision to Mobile Health Teams during their monthly visits, provided basic health services in between team visits by identifying cases for referral, maintained the community census and epidemiological monitoring, and raised awareness on health issues.

Training
Training within the SIAS program was carried out by health staff. Técnicos en Salud Rural
(Rural Health Technicians) trained the CHWs. The SIAS training courses were based on a standardized curriculum: they focused on preventive care and referral of sick patients to a higher level of care. The CHWs in the SIAS program were not trained in curative care medicine and were only permitted to dispense packets of oral rehydration salts (for treatment of diarrhea) and aspirin.

Incentives and remuneration
The main incentives for CHWs were community recognition, family support (including approval from the CHW’s husband), and a government stipend of US$ 50 per month.

Supervision
CHWs were supervised by the Mobile Health Team. CHWs also reported directly to a Técnico en Salud Rural who was under the supervision of a physician or professional nurse.

Impact
The main impact of the SIAS program was the improvement in access to basic health services and a reduction in health inequities among the rural indigenous Mayan population of Guatemala. The effects of closure of the SIAS program are not yet documented.

Author Affiliations

• Alfonso Rosales is a Senior Adviser for Maternal and Child Health, World Vision US.
• Mario Valdez works at Curamericas, Guatemala, Calhuitz.
• Henry B. Perry is a Senior Scientist at Johns Hopkins School of Public Health.

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