Shifting identities: The transformation of community health workers in highland Guatemala

Guatemala is one of the first countries in the Americas to establish community health worker (CHW) programs, and CHWs have served a central role in both large-scale national programs and small-scale nongovernmental organization (NGO) projects. The role of CHWs, including their training, responsibilities, and idealized identities, has never been uniform, and has fluctuated over time in response to changing international health paradigms, national socioeconomic and political processes, and local-level power structures and expectations of the position. In this paper, I examine the changing nature of CHWs in the Central Highlands of Guatemala by focusing on the case of the Behrhorst Clinic in Chimaltenango, Guatemala. The Behrhorst Clinic was one of the first to implement a CHW program in Guatemala, and is one of the few NGOs in the region to operate continuously since the 1960s, providing a unique case study to examine the history and transformation of CHWs in three distinct sociopolitical periods: the Primary Health Care era (1960s1970s); the sociopolitical violence (1970s1980s); and the aftermath of the violence (1980s2000s). This longitudinal analysis of the Behrhorst health promoter program highlights central, ongoing issues facing CHW programs in Guatemala and beyond including: the political susceptibility of community participation and empowerment programs; community participation and representation; and the long-term and intergenerational impact of CHW positions that function as a mechanism for socioeconomic advancement through the provision of curative services.