Jacobo Vicente Méndez, a 54-year-old farm worker, heard from a passing car with a loudspeaker that a nurse would make a monthly visit to his small mountain community of La Unión, in Guatemala's western department of Quetzaltenango. The population of 1,700 subsists by growing basic food crops, such as beans and corn, at an altitude of 2,100 meters above sea level.
Knowing that tetanus was a hazard because of accidents during farm work, he walked to a small health clinic, known as the Centro de Convergencia, that shares a building with the village courthouse. He asked for the inoculation from the visiting nurse and received it on the spot, no payment required.
Walk-in checkups are available for children at the health clinics.A woman passing by with a baby, noticing the clinic open in the late afternoon, asked the nurse to check and weigh her child. This was done immediately.
The vaccination and infant care services are part of a prolonged government effort to bring health care to where it is needed most, the poorest of the poor living mostly in rural, indigenous communities, especially in the country’s rugged mountain highlands.
Some three million people, about one-fourth of Guatemala’s population, qualify to receive assistance under the plan because of their low incomes. Launched in 1987, the program’s sources of funding have been irregular?it still depends in good measure on international assistance. The plan, called the Integrated Health System, received new impetus and additional national and international resources following the 1996 Peace Accord that ended armed violence in the country.
“One way this program is different is that it brings health services to the communities, saving people the cost of transporting as many as four or five children in a family to a health center many kilometers away,” says Dr. Manuela Hernández, coordinator for health extension services for the department of Quetzaltenango, one of the country’s poorest areas. “The old system was to wait for people to walk to a health center.”
Dr. Manuela Hernández says the program saves people the cost of a long trip to the nearest hospital.NGOs and “Health Monitors”. The village of La Unión is an example of the difficulty that rural residents have in gaining access to health care. It is eight kilometers by bumpy, unpaved mountain road from San Juan Ostuncalco, the nearest city, which in turn is another 15 kilometers by paved road from Quezaltenango, the departamental capital where the nearest fully equipped hospital is located.
To bring health services to isolated rural areas, the Health Ministry enlisted the support of nongovernmental organizations. It divided poor rural areas into health districts with 10,000 residents each and contracted NGOs to provide health services for each district.
Each district is assigned one physician, or, when not enough medical doctors are available, one trained nurse. They are assisted by a network of community health assistants with different levels of training, including “health monitors,” who can administer first aid, provide pediatric and prenatal care and teach residents basic sanitation, such as purifying water. The monitors, in turn, receive support from community residents with a higher level of training who are called “health facilitators.” Midwives are the third category of trainees in the program.
Ideally, a rural health district of 10,000 persons has 70 trained health monitors, 10 health facilitators and 10 midwives, supported by five small clinics, the Centros de Convergencia, and one larger community health center, known as a Centro Comunitaria, located typically in the nearest city. In practice, both personnel and facilities fall short of the formal guideline.
One of the health monitors at the Centro Comunitario en La Unión, San Juan Ostuncalco.Hernández says the eventual goal is to consolidate the three levels of care?primary, secondary and advanced (hospital level)?into a sustainable, institutionalized system with measurable results and reliable sources of funding. As part of the program, the government has taken a census of the population in the rural areas to help assess health services. The recent acquisition of computerized monitoring and evaluation systems are strengthening the program, which is constantly building on lessons learned from its experiences.
The IDB supported the program as part of its overall assistance for Guatemala’s health reforms with three loans, two for a total of $38.6 million approved in 1995 and another for $55.4 million approved in 1999. In addition to financing services for the needy in rural areas, the resources also helped strengthen the Ministry of Health, modernize the Social Security administration and improve the quality of hospital services.
A series of evaluations on Guatemala’s health system commissioned recently by the United States Agency for International Development (USAID)?a major contributor to the country’s health reform programs?reported that health indicators in the country have improved dramatically in the past two decades. For instance, the infant mortality rate declined from 75 for each 1,000 live births in 1987 to 53 per 1,000 live births in 2002. Nevertheless, the evaluations also warned that statistically Guatemala is ranked among the countries in Latin America with the most serious deficiencies in health and nutrition, particularly among rural and indigenous groups, and that substantial ongoing corrective measures need to be taken.
In addition to the IDB and USAID, other donors active in supporting health reform in Guatemala have been Germany, the European Union and UNICEF.
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