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Jonathan Maupin is an associate professor of anthropology at Arizona State University. For the last decade, he has dedicated his research program to studying the history of community health worker (CHW) programs in Latin America. He has a deeply personal connection to this movement, since his grandfather was Carroll Behrhorst, one of the founders of the global primary health care movement in the 1960s. In fact, Behrhorst’s development of CHW programs in Guatemala was cited by the World Health Organization in 1976 as “one of the 10 most effective global models for working with the rural poor.” However, over the years, primary health care initiatives, and CHW programs in particular, throughout Latin America were deeply affected by social and political violence. Recently, in the last 15 years, the move towards privatization through neoliberal reform of Latin American Ministries of Health has also had a major impact on these programs. In Guatemala, where Maupin primarily works, the end of a long civil war in 1996 led to a major expansion of CHW-based programs–now with the explicit difference that they were funded directly by the Guatemalan government through subcontracting relationships with nongovernmental organizations (NGOs). This out-sourcing initiative–known as the Sistema Integral de Atencion en Salud (SIAS)–has had mixed results.
Here, I sit down with Maupin to discuss in greater detail his view of the history of primary health care initiatives and CHW program in Guatemala and Latin American. Our discussion covers a broad range of topics, including the historical factors which led to the emergence of the model, as well as the effects of first civil wars and revolutions and then neoliberal health care reform.
Tell me a bit more about your background.
Well I went to Tulane University initially for pre-med as an undergraduate – before realizing that medicine wasn’t for me! My interest in Guatemala and healthcare – and in Tulane specifically – was that my grandfather Carroll Behrhorst once taught there. He went to Guatemala in the late 1950’s as a Lutheran medical missionary. However in the 1960’s he separated from the Lutheran Church and opened a clinic in the department of Chimaltenango, which then developed into a very well known clinic, the Behrhorst Clinic. Subsequently, I went to SUNY Albany, where I did my PhD dissertation looking at community participation in health care programs. The dissertation focused primarily on community participation after the [end of the civil war] in Guatemala. Now, I’m looking at a historical perspective of primary health care initiatives in Guatemala, using the Behrhorst Clinic as an ethnographic case study to examine these issues from the 1960s to 1970s, where there was really a boom in primary health care initiative — in terms of a push for integrative development, and the number of CHWs and NGOs involved. Then I look at violence during the civil war, which decimated the clinic and the health promoter program, and which was also very formative in changing the idea of what a health promoter was. Finally, going through the 1990s, I look at the end of violence and the neoliberal health reform that went with it.
Can you elaborate a bit more on the history of the Behrhorst Clinic? Because the founding of the Behrhorst Clinic is really a foundational moment in global health.
The clinic was innovative and unique, but it was also part of this growing movement in Latin America for primary health care initiatives and ideas about comprehensive health and development programs. There’s always a bit of debate whether the Behrhorst Clinic was really the first health promoter program What was going on in Guatemala was also going on with [other community health worker programs] in Mexico and other programs throughout Central America. These movements coalesced in the 1960s and 1970s and were influential in developing the primary health care model.
The Behrhorst Clinic started out as a curative clinic. My grandfather first opened up a small clinic in Chimaltenango, he had a lot of patients coming in every day with basically the same illnesses. He would provide medicine, people would get better, and then they would come back in a month with the same issues. There was then a big turning point in his philosophy; rather than just focusing on curative medicine inside a clinic, he felt there needed to be more interventions in rural communities where people were living, focusing on they exposures and conditions that were producing bad health. So the Behrhorst Clinic started a pilot program, where they sent a group of 3 Kaqchikel Maya women who were working as nurses in the clinic to a [rural community]. They started doing community surveys, finding very high rates of tuberculosis and very poor dietary quality. That was the start of the CHW program. They recruited a couple of community members to start coming to the clinic to receive basic biomedical training so that they could diagnose common illness and provide medication. After that trial period, in the mid 1960s, they started a much larger health promoter program, recruiting participants throughout the department to come to the clinic and get a year of training in the clinic before returning to their communities.
It really does seem that health promoter programs started first in Latin America and then spread around the world? Or is that an unfair characterization? What was it about the 1960s in Latin America that allowed this model to emerge?
I think the model of what we think about as a CHW definitely has its roots in Latin America. There are other examples however from around the world that are similar; for example the “barefoot doctor” in China was going on at about the same time. In Guatemala in particular in the 1960s you had a lot of activism. There was a growing campesino movement as well as the Catholic Action movement. These factors coalesced around ideas about health and community participation to produce something that was unique.
How did these first programs get off the ground?
Funding initially was a big issue. For the Behrhorst Clinic, a private donor, World Neighbors, played a big part in financing. The Catholic Action movement was also influential, especially in the selection of the first health promoters. One misconception of CHWs that I always have a problem with is the idea that they were democratically elected and representative of their communities. But for the most part, it is hard to find programs where [that actually occurred]. In the 1960s when programs first started most of the individuals who became CHWs were nominated either by Peace Corp workers or through existing connections with the Catholic Church, where they worked as catechists as part of Catholic Action. So there was a selection of people who were already active outside of their own communities. So there was some reinforcing of power structures that already existed.
How does the history of CHW programs, in Guatemala for example, go from this initial boom in the 1960s and 1970s to where we are today?
The [civil war in Guatemala] was fundamental in transforming CHWs and health and development programs in the region, and it shaped expectations about what a CHW is. The Guatemalan government started its own program of CHWs in the 1970s, but there is very little information about it to this day. There was a point where the Behrhorst Clinic was hired to train government CHWs, but there was a lot of tension, in terms of ideas about the quality of training and responsibilities. By the late 1970s and early 1980s with the increasing scale of the violence, a significant number of CHWs were identified as being subversives just because of their acts of community organizing and health education. There were a lot of accusations of CHWs providing health care to the guerrilla…but that was really a very small portion of CHWs. The majority of CHWs were somewhat caught in the middle. So the role of CHWs during the violence is very complicated. But one pattern that came out of the time of violence, is that many CHWs were killed or disappeared or fled their communities. And those who did stay in their communities restricted their practices away from this integrative development, and they really just focused on curative medicine. So by the mid 1980s, that was largely the role and function of CHWs. And so I think that legacy continues today in rural communities in terms of what people see as a CHW position.
What happens after the war, especially as privatization and neoliberal health care reform takes off?
I think that now CHWs in the current neoliberal adjustment are being picked up on again because they have this symbolic and ideological tie to notions of democracy, stakeholding, citizen participation, which was something that was very big with primary health care in the 1970s. There are some people in the mid to late 1990s who feared that neoliberal economic reforms would essential destroy the position of the CHW, mostly because of arguments from cost effectiveness. But I think the reality is the opposite. They are cost effective, although mostly because they are now given less training than they should be, so training costs are reduced. They sort of maintain this symbolic relationship between rural communities and the government. In Guatemala at least, there is this idea that after the war, that CHWs are a means for the government to go to rural communities and try to cooperate with them and have this process of democratization.
Is this just rhetoric?
I think so. In the interviews that I’ve conducted with CHWs, I have had not had any who talk about these larger themes. Within rural communities I don’t think that people associate the [CHW model] with these larger ideas.
Now let’s turn specifically to the Guatemalan government’s efforts to outsource Ministry of Health (MOH) functions to NGOs through the SIAS program. This program has been viewed as an important model for how to conduct health care reform in the new millennium.
Under SIAS, many CHWs have been contracted, but their role has become incredibly circumscribed. The role of the CHW in the primary healthcare model as it was introduced in the 1970s was largely based on the idea that they would also serve as points of referral to higher levels of care. However a big difference was that back then CHWs [were also allowed] to provide basic curative services themselves. I think this is a world-wide pattern, that CHWs are now very restricted in what they are allowed to provide, especially in terms of medicine. In Guatemala, the SIAS system is incredibly restricted; CHWs are basically allowed only to provide only aspirin and oral rehydration therapy. So they are authorized to provide less than things that people can get for themselves.
Another element of SIAS is attempting to set up a better referral network, but I don’t know how effective that referral system is. If people who are ill do not recognize that they need to go to a higher level of care, I’m not sure how much CHWs and their referral advice actually impacts peoples’ decisions to seek higher levels of care. With the SIAS program this is sort of a numbers game. If you have a CHW who is responsible for 20 households, then you have a major proliferation of CHWs, which serves as the basis for the claim that the government are expanding rural access to healthcare very quickly even though access really hasn’t changed.
Another aspect of the SIAS program that is interesting is the adoption of conditional cash transfer approaches, mostly modeled on successful deployments of these schemes in rural Mexico.
I have mixed feelings about this. On the one hand, conditional cash transfer programs do encourage people to send their children to school, because the director of the school has to sign off on attendance forms which mothers can then turn into to receive incentive payments. Also women in rural communities have to go and have preventative health exams each month with SIAS CHW staff; staff sign off on their forms which allows them to get their monthly stipend. So this is helping some by increasing preventative care and getting children into school. But this also creates a sense of self regulation and self monitoring. Women, for example, may not want to receive certain services, such as pap smears. The CHW team is clear that they don’t have to receive the service, but if they don’t they will not receive their stipend. This forces some women; it may be encouraging preventative care, but it is a lot more regulation on people. If women are not able to attend, there is a sense that “It’s your fault.” If the child is not able to go to school, that is very much blamed on the mother. As the amount of surveillance in rural communities is increasing through this system, it is really targeted at mother. You never really see men coming in. Mothers are the sole focus. Any critiques of lack of improvement fall on the mothers.
What is the future for primary health care initiatives and CHWs programs – not just in Guatemala, but also elsewhere in the world?
My own view is that CHWs can do so much more. This idea of them being just a point of contact for initiating referrals without the training or ability to provide basic medications is a huge limitation. There is a lot of discounting the abilities of CHWs, based on the argument that it is too dangerous to allow them to provide medication or to diagnose illness. However, the evaluations of CHWs in the 1960s and 1970s were quite positive. So in my view, the role of CHWs could be expanded, especially towards providing basic curative services. Instead of being just a point of referral, they could be a source of care. There are some NGOs in Guatemala that still work with this model, but they are very few. As SIAS expands and as more NGOs opt for subcontracting relationships with the Guatemalan MOH, the CHW role will become more and more limited.
And this, in your view, is a loss?
I think so. In some municipalities in Guatemala there are still a lot of CHWs who were trained in the old model, and they are still operating their rural clinics and pharmacies. Many of them are still called “little doctors.” I don’t argue that CHWs should gain the knowledge and skills to be able to provide curative skills and then become totally independent. There needs to be some oversight. However the way CHWs are used in the SIAS program right now is a real waste of the position and doesn’t serve the needs it could.
Do you think NGOs and civil society organizations could use CHWs in more effective way?
At least in the region of Guatemala where I work, the possibility is vanishing. The history of funding for these programs has really limited the ability of NGOs to continue with CHW programs that are independent of the SIAS subcontracting model. A lot of NGOs who were opposed to the SIAS model originally have mostly converted because of the lack of funding from other sources.
Another issue is that many of the NGOs who now subcontract with the Guatemalan MOH have no experience in healthcare. Many are contracted just to serve as administrators. Part of the original deal with the SIAS model was that NGOs would continue to integrate their other more comprehensive services into the SIAS “minimal package” model. However the NGOs I’ve talked to in fact have very little integration of their subcontract responsibilities with their other core activities They mostly just work as administrators for SIAS, they are not really amplifying the basic package.
This is what has happened with the Behrhorst Clinic. They tried to remain independent at first. They were very opposed to SIAS and government contracts, and they tried to provide NGO-based alternatives. However, by the mid 2000s, primarily because of the lack of funding from other sources, they accepted the SIAS contracts. But their work as a comprehensive clinic is completely separate from their rural health work under SIAS. There is not even necessarily a referral system where the CHWs they contract and supervise under SIAS can refer patients to their clinic. So the clinic, which is historically known for its community health work and integrative approach, is now completely separated from their rural health work under a government subcontract.
This sounds tremendously unfortunate. Isn’t the whole point of being an NGO the ability to be innovative, different, focused on advocacy?
I don’t think that participating in SIAS undermines an NGO’s mission statement or philosophy towards social justice, but it also doesn’t expand it at all. NGOs that accept these contracts – the ones that I’m familiar with – they do it because of the financial security that comes along with the government contract. Even if they have a social justice philosophy, that doesn’t affect the way they approach the government contract.