Distance Education

When we first assessed the issues and opportunities in Guatemala in 2003, it was evident that without trained health personnel in the countryside nothing was possible. The objective was to train a critical mass of nurses willing and able to work in the remote Indigenous communities in Guatemala. We adopted the following strategy: 

  • We recruited students who had roots in rural Indigenous communities, so they would be comfortable working there; and because they knew the language, culture and environment, they would be much more effective than outsiders.
  • We first concentrated on training auxiliary nurses, because that could be done relatively quickly. In addition, we trimmed the auxiliary curriculum to match the needs of rural communities. A student graduates as an ‘auxiliary nurse’, after eighteen months of part time study.
  • We decentralized the education process so that prospective nurses could receive training close to homes.
  • We used the municipal health facilities as local training venues.
  • We offered support in Indigenous languages where needed.
  • We worked with the Guatemalan Ministry of Health and NGOs to ensure that graduating nurses were trained and employed where they are needed.

Although the details and the teaching technology have changed over the years, the basic strategy remains the same. Since we started the auxiliary nurse training program, TulaHealth has expanded the types of training programs offered to health personnel, at the request of the Ministry of Health. These have included training courses for health personnel on maternal, newborn, and child health, child malnutrition, epidemiology, and digital health strategies for health care. We continue to work with the Ministry of Health to identify training needs and ensure that health personnel are capable of delivering necessary health services in their rural home communities.

Community Health

In the early years, we focused exclusively on distance education, which matched the priorities of the senior funding partner CIDA. TulaHealth was however, always very interested in the deployment of expertise that would make a difference in rural communities that were not well served by the existing health system, as evidenced by their poor health indicators. By 2007, we were ready to launch our first independent program, then known as Telesalud (or Telehealth). Initially piloted in a few municipalities, the digital health program grew year by year to encompass many of the priority communities in the department of Alta Verapaz, serving a population of more than one million people.

The TeleSalud program initially worked as follows:

  • Candidates were selected from among the existing community health workers and provided with ongoing training.
  • Each CHW was provided with a mobile telephones.
  • Community health workers were integrated into a communications network that includes in particular their municipal health centers, which are the source of advice, consultation, ambulances, and second level care.

While TulaHealth continues to implement the TeleSalud program with the same core principles, the program has expanded considerably since its inception. Most recently, the program has started using smartphones. Trained and equipped with smartphones, community health workers in Guatemala’s most remote and challenging communities are better able to coordinate the transfer of high-risk patients, consult with a network of health professionals, collect community health data, and use digital media to provide health education.



The core component of TulaHealth’s community digital health system is a mobile application and website called Kawok. Kawok supports nurses, doctors, supervisors and epidemiologists in their daily work by allowing them to create and manage cases. The application was developed in close collaboration with the Ministry of Health in Guatemala. Kawok is based on CommCare by Dimagi, a leading digital health technology platform for low resource settings. Kawok is made possible by a strong partnership between Tula and Dimagi, started in 2012.

The Kawok mobile application is a job aid for healthcare professionals, following Ministry of Health guidelines and using culturally appropriate multimedia content to improve usability and educate both users and patients. Significant attention is paid to make the application very simple to use and feedback has been extremely positive. Bona fide epidemiological results are evident from the resulting data, which is automatically and securely synchronized over the internet. At any time, thousands of pregnant women and children are being monitored, enabling nurses and doctors in health centers and elsewhere to respond to what is happening at the community level.

The Kawok application in action.
The Kawok application in action.

Simple and actionable reports and maps are produced daily. Customized reports are prepared for health districts, health areas, supervisors and epidemiologists. Some reports are aimed to improve the effectiveness and efficiency of clinical monitoring (e.g. making sure women are receiving timely and appropriate prenatal care and counseling), while others are aimed to improve the effectiveness and efficiency of health worker monitoring (e.g. making sure nurses are interacting with communities as expected and investigating any potential issues).

TulaSalud’s technical innovation team, supported by TulaHealth in Canada, have become experts in the development and deployment of digital health technologies. In 2015, the Kawok mobile application and the reporting system were both significantly improved and expanded. Kawok was fully redesigned to take advantage of the capabilities of Android, including the phone camera and GPS.