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CHAMUCHUJL, Guatemala — For 20 years, Frederico Pop Pop has been the go-to guy for medical issues ranging from snake bites to emergency c-sections to chronic diarrhea in Chamuchujl, a village of about 800 people at the end of a dirt road in Guatemala’s north central Sierra de las Minas Mountains.
Pop Pop is not a doctor or nurse. His medical training consists of a patchwork of courses provided by NGOs, and he stocks his own basic medical supplies. But he can tell you the name and location of every pregnant woman in the village, when she's due and how many children she has had. He has the number of the nearest clinic saved in his phone, and the best ways to get to the hospital. He knows who has died in the last five years, and what killed them.
Pop Pop is one of Guatemala's approximately 26,000 community health workers; a legion of civilians who serve as first responders and vital connectors between urban medical services and a largely rural population. It's a difficult position — the public health system in the country has never been adequate — but in the past two years the situation has gone from bad to worse under a health ministry in crisis.
Starting in 2014, Guatemala’s Ministry of Health terminated contracts with more than 80 NGOs that had been providing health services to 2.4 million people across the country. In early 2015, the roughly $80 monthly stipend that community health workers like Pop Pop had been receiving dried up. More recently, a successful tele-health program that the ministry promised to finance was abruptly stalled because of budget problems.
President Jimmy Morales, a first-time politician who was elected in a surprise victory in November, has so far offered no clear strategy on how the country will tackle its most pressing health concerns. And in the meantime, lives hang in the balance.
Despite having one of the highest GDPs in the Americas, Guatemala spends only about 2.6 per cent of that on healthcare. The country's largest public hospital is 100 million dollars in debt, and since 2012, Guatemala has had four different presidents, each with new health ministers and management teams. This system in disarray has been impotent in the face of the problems. Almost half of children under five are stunted due to chronic malnutrition. Diarrhea is among the top five killers. Guatemala has one of the highest rates of maternal mortality in the Americas, behind only Haiti, with 159 deaths per every 100,000 live births. For most of the past century, officials have left these national healthcare problems to NGOS.
When Pop Pop became a community health worker back in 1997, the Guatemalan government had just adopted a new regulatory framework – the Programa de Extension, or PEC — that allowed the Health Ministry to contract out health services to private not-for-profit organizations. This included NGOs, church-backed charities and international development agencies. Their primary goal was to lower the child and infant mortality rate by increasing the number of hospital deliveries, rates of immunization, and access to medication for common and easily treatable illnesses such as diarrhea.
At the time, Pop Pop was 26 years old, was newly married and had just had his first child. He says he simply wanted to help. “There were no nurses, no help at all in our community,” he says. Over the years, he took training courses from three NGOs so he could attend births and give injections. His certificates are framed on the wall of his home, which serves as a makeshift clinic. “I always try to get as much information as I can, to learn.”
In 2012 he was one of 460 community health workers in Alta Verapaz, his department, or state, recruited to take part in an innovative new tele-health program. Managed by a local nonprofit, TulaSalud, and funded by a Canadian charity, the Tula Foundation, the program gave health workers smartphones with unlimited data and calling plans.
Downloaded on the phone was an open-source app, Kawok, that allowed the community health workers to create patient profiles and access educational videos and best-practice protocols. They had direct lines to a doctor who worked for TulaSalud, whom they could call any time of day or night in an emergency, and the numbers of auxiliary nurses at nearby health centers. The idea was to create a network of professionals, resources and emergency services that community health workers could reach at the touch of a button.
“Anytime I could call and ask for help, and they gave it to me,” says Pop Pop. “It was a really useful tool.”
To understand why, it’s important to understand something about the cellphone economy and the geography of rural Guatemala. In the area that Pop Pop covers, for instance, there are six villages (with a total population of about 1,600) that are separated by dirt roads and foot trails that hug steep volcanic mountains. Only a handful of people have private vehicles, and although cellphones are ubiquitous, calls are prohibitively expensive. The average low-income Guatemalan might be able to put the equivalent of $2 of credit on his or her phone at a time. That could buy a few dozen instant messages but just a few minutes of a phone call.
Once, Pop Pop says, he got a text from a man whose wife was going into labor. His village was a two-hour walk away, so Pop Pop called a friend with a truck to take him there. Once he arrived, he took her vital signs and noticed she had extremely high blood pressure, a sign of a dangerous condition called eclampsia that can cause seizures during labor. He called a doctor and was told he should take her to a hospital immediately. The doctor called the nearest medical center to arrange an ambulance, and the woman safely delivered her baby.
While he participated in the program, Pop Pop says that not a single woman in his territory died from complications in pregnancy or childbirth. According to Dr. Moisés Faraón Chen Cruz, who helped launch the program and served as the ministry’s area health director, maternal mortality in Alta Verapaz dropped from 94 cases in 1997 to 53 cases in 2015.
“The biggest change was that help arrived quick,” says Chen. If a woman ran into problems during birth, she was more likely to get to a hospital in time. And if she got to a hospital in time and returned healthy, that helped disprove a common perception in many rural communities that people go to the hospital only to die. In turn, that made other women more likely to consider a hospital instead of home delivery.
The technology was important in other ways as well. “If [community health care workers] couldn't talk through a problem, they could send a picture or a video,” says Chen. Pop Pop says that after one birth, it seemed as though the woman’s placenta hadn’t fully discharged from her uterus. He called Chen, who “talked me through a massage technique to help it,” he says. “when that didn't work we sent the woman to the hospital.”
From its inception, TulaSalud’s tele-health program was intended as a pilot that would eventually be financed by the Health Ministry and institutionalized as part of the primary health system for the entire country. Negotiations for the handover began in the spring of 2015, and the estimated cost of the program was around $400,000. By that summer, TulaSalud had withdrawn its phones from the field, and the ministry had begun to distribute its own, nearly 1,000 in total, to the original program participants as well community health workers in other states.
Some community health workers had their new phones for only a few weeks when, in November, ministry field technicians took them all back. According to TulaSalud, it was told by ministry officials that costs were higher than expected and that there was no money to pay for the plans.
It was a huge blow for Pop Pop and other community health workers who had come to depend on them. “I worked with four organizations now,” he says. “They exist for an average of six or seven years, and then they leave. Now I’m afraid that Tula will leave too.”
Although there is still hope — the Canadian government recently announced $7.6 million in funding to help strengthen the tele-health initiative — the impasse that community health workers now find themselves in is emblematic of how difficult it is to mobilize health reform in Guatemala.
Part of the problem is lack of personnel and supplies. The official Health Ministry strategic plan counts among its assets 4,506 health establishments. But half of those were outposts run under contract with NGOs — the contracts that the government has been terminating since 2014.of which were cancelled later that same year.
Societal obstacles can also prove challenging. Community health worker Jorge Che says that in his village, there are girls getting pregnant as young as 11 and 12. “I want to fight the deaths of young mothers,” he says. “But the education is not coming from parents … They get upset if you’re talking about sex.”
Prevention is where community health workers can have the biggest impact — if they’re given resources. But so far, they have been limited. When NGOs started training and deploying community health workers in the mid–20th century, not only were they given more responsibilities in terms of identifying basic illnesses and prescribing medication, but also there was much more emphasis on their role as educators and organizers, says Jonathan Maupin, an anthropologist who has studied culture and medicine in Guatemala’s indigenous Maya communities for nearly three decades.
With the creation of the PEC in the mid-1990s, the Ministry of Health put more focus on curative care, relying on community health workers as referral points to clinics and hospitals and nurses. “It’s mainly providing access to pharmaceuticals,” says Maupin — and the cost for those drugs falls on the shoulders of individuals.
Regardless of the systems’ flaws, he says, “the big question going forward is what is going to happen to all these people who were recruited and engaged to serve as community health workers? At this point, there are tens and tens of thousands of individuals who have served as a community health workers through the PEC. Now that it has collapsed, what happens to them?”
Diaz and Chen say they still receive calls, two or three a day, from community health workers using their own phones and credit. “They’re like, ‘Hey, doctor, I need to ask you something. Can you call me back?” says Chen. “I’m covering expenses out of my own pocket too.”
Guillermo Cucul has been a community health worker for seven years in Champtecá, Alta Verapaz. Since his phone was taken away he’s organized a calendar of due dates for all the pregnant women in his community. That way, when they come around, he can make sure he has enough credit on his phone to make an emergency call if it comes to that. Despite his careful planning, he's concerned about the future.
“I do this for the pleasure of serving my community,” he says, “but I’m thinking about retiring. It’s the time and the money … I can’t afford it, and I’m not sure how much longer I can do it.”
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