Deploying and Supporting Nurses in the Field
Our broad goal is the improvement of the health care provided to rural remote communities in northern Guatemala. The first objective was to increase the supply of suitably trained nurses, which we have done, and continue to do as described elsewhere on this website. We then looked at how to deploy and support them to maximize the benefits they provide.
Many of our nurses fill available slots in the Health Centers run by the Ministry of Health in each municipality. Other nurses find jobs with the various NGOs who provide services under the SIAS program. As described elsewhere on this website, under the SIAS program, health teams make monthly visits to selected rural communities. Our nurses will provide great service in either of these programs. However, despite the services provided by the Health Centers and the SIAS program, many regions of the country continue to show problems and poor health indicators, particularly for infant and maternal mortality.
Discussions with our Guatemalan partners showed that there were still serious gaps in coverage for certain communities, particularly as regards urgent care. For illustration, we focus on an example municipality, Cahabón, in the department of Alta Verapaz.
- The town of Cahabón has a municipal Health Center that is open 24 hours a day, 7 days a week. The Health Center has doctors, nurses, an ambulance, and resources needed to handle most emergencies. The Health Center can refer patients to the district hospital in Coban where advanced (by Guatemalan standards) services are available.
- In addition, health teams from the NGO Cafesano visit many remote communities each month under the SIAS program.
Where is the gap in service that explains the poor health indicators?
- Although a problem community may be, for example, only 40 or 50 km from the municipal Health Center, the roads are in terrible shape and there is no public transport, no commercial vehicle traffic, and no vehicles in the community, meaning that it is many hours or even days away.
- There is no telephone service in the community to notify the Health Center to request an ambulence or other assistance.
- No emergency service is available through the SIAS program.
- There is little if any resident health expertise in the community itself.
Consequently, when there is an emergency such as a birth complication, tyically no timely help is available, and there is a bad outcome. Moreover, because there is no effective communication with health authorities, outbreaks of infectious diseases such as rabies, dengue fever, etc., can go undetected for several days or weeks.
TeleSalud
Our Guatemalan partners at the ENEC nursing school proposed the following program, now known as TeleSalud.
- Graduating auxiliary nurses would be paid to work within their home communities.
- A nurse would be given a simple equipment kit (stethoscope, blood pressure cuff, etc.) and a supply cabinet containing basic medicines, sutures, etc.
- A nurse would typically dedicate part of the family home as a dispensary/surgery.
- A nurse would be given either a cellular or satellite telephone, depending on what services are available. (Cell phone coverage, even in remote areas, is becoming common.) The telephone would connect the nurse the rest of the health care system in Alta Verapaz. A professional nurse at the ENEC nursing school would be available help route the rural nurse’s query to the best destination.
- Most importantly, all parties would work to ensure that these nurses were effectively integrated into the health care system. These efforts would include meetings with Health Center staff, rotations through hospitals, protocols for escalating problems, standards for reporting and data collection, etc.
- In particular, nurses would be instructed to maintain good relations with comadronas (Mayan midwives) and other traditional health workers in their communities.
TeleSalud nurses are known offically as telefacilitators. (The district epidemiologist calls them his ‘rural epidemiologists’, in recognition of the valuable role they play in health surveillance.)
In the pilot study, which was begun in 2007, 19 telefacilitators are employed in the TeleSalud program. In communities in the following municipalities of Alta Verapaz: Cahabón, Lanquín, Fray Bartolomé de las Casas, Chisec, and San Christóbal Verapaz. As of June 2008, there has been dramatic improvement in the health indicators—notably in infant and maternal mortality statistices—in those communities served by TeleSalud. Because of this success, the program is being expanded to problem communities in other municipalities of Alta Verapaz. If the program continues to show benefits, it will be expanded beyond Alta Verapaz, to other departments in the north.
Update December 2008. Because of demonstrated success, the program has been doubled to 40 telefacilitators. New municipalities in Alta Verapaz, selected by the Ministry of Health, are Campur and Senahú. Tula has also funded the hiring of an additional epidemologist by the department of Alta Verapaz to support the program.
TeleSalud: Nurse Ernesto Tiul (center-right in white shirt and brown trousers) outside his home, which doubles as the nursing station, in the village of Tuzam, Lanquín, Alta Verapaz, Guatemala, with community leaders and staff from ENEC.
Nurse Ernesto Tiul, inside his nursing station, with the tools of his trade and his supply cabinet, speaking Q'eqchi', discusses his role in his community.
Spartan ambulance (a modified 4WD pickup truck) for use on the backroads of the municipality of Cahabón, Alta Verapaz, Guatemala.