Divergent Models of Community Health Workers in Highland Guatemala
Maupin, Jonathan N., Human Organization
Community Health Workers (CHWs) are central to Primary Health Care initiatives, serving the essential function of extending access to health services in rural communities. In 1997, the Guatemalan government implemented the Sistema Integral de Atención en Salud (Integrated Health Care System) (SIAS). Central to SIAS is the guardian de salud (health guardian), a CHW whose role is to refer individuals in their communities to higher levels of care. SIAS is highly effective in recruiting guardianes (guardians), with over 25,000 in 2003. Yet, there are several types of established CHWs throughout Guatemala with different training and abilities. The presence of existing CHWs, particularly the promotor de salud (health promoter) which specializes in curative services, strongly influences participation in new programs as they set local expectations of the position. In this paper, I analyze the implementation of the guardian in the municipality of San Martin Jilotepeque, focusing on how expectations of the position influence participation as well as how CHWs negotiate their practices in relation to these two models. I argue that differences in the ability to provide curative medicine effectively reinforces a dualistic model of CHW in rural Guatemala, creating conflict between established CHWs and SIAS guardianes de salud.
Key words: Guatemala, community health workers, health reform, community participation
The 1996 Peace Accords, signed between the government and guerrilla representatives, set forth an ambitious agenda for healthcare in Guatemala. Specifically, the accords call for the extension of health services to the 46 percent of the population that lacked access in 1996 and a reduction in maternal and infant mortality rates by half of their 1995 values through increased investment into preventative care (MSPAS 1997, 1999; PAHO 1999). To accomplish this, the accords mandate comprehensive health reform to address the inequalities and inefficiencies of the Ministerio de Salud Pública y Asistencia Social (Ministry of Public Health and Social Care) (MSPAS). In response, the government, funded by the Inter-American Development Bank, implemented the Sistema Integral de Atención en Salud (Integrated Health Care System) (SIAS), a decentralized model of healthcare delivery based on governmental contracting of Non-Governmental Organizations (NGOs) to provide basic services to rural populations (Maupin 2008, 2009).
Central to SIAS is the guardian de salud (health guardian). The guardian comprises the base of the SIAS referral network and is the principal mechanism to extend access in rural Guatemala by constituting the essential link between rural communities and the formal healthcare system. Democratically elected by their respective communities, guardianes (guardians) ideally serve as a means of community organization and participation, "empowering" communities to identify and address their own health needs.
Community health workers (CHWs) have long been a central feature of Primary Health Care (PHC), and numerous studies have compared the processes of CHW recruitment, training, and performance, in addition to their relationship with formal health systems. However, few studies examine the relations between different types of CHWs in the same locale (Smith-Nonini 1997). There are numerous types of CHWs throughout Guatemala, with different training and abilities. The presence of existing CHWs strongly influences participation in new CHW programs as local expectations of the position are based upon established models.
In this paper, I address these issues by analyzing the implementation of SIAS through the position of the guardian de salud in the municipality of San Martin Jilotepeque, focusing on the articulation between the identity and practices of the guardian with local models of CHWs, specifically the position of promotores de salud (health promoters). I explore how differences between the model of guardian and health promoter influence participation in SIAS, and how individuals attempt to negotiate their identities and practices in relation to these two models. …