Table 1. Challenges, Opportunities, and Solutions for Implementation of Diabetes Programs in Guatemala.

Challenge	Opportunities	Solution
Cultural and linguistic barriers to biomedical care for indigenous Maya population	Rising number of educated young Maya professionals experienced in issues related to language, cultural, and health advocacy	Employ exclusively native speakers of Mayan languages as front-line health providers
Low physician density	Large labor pool of indigenous nurses	Nurse-driven diabetes protocols
High cost of diabetes medications	Dynamic generics industry in Guatemala	Limited formulary of locally purchased generic drugs
Low availability of laboratory diagnostics	Validated point-of-care tests available on the local market	Use of point-of-care laboratory testing for hemoglobin A1C
Patients live in rural, difficult-to-access villages	• Availability of open-source electronic medical record platforms • Extensive, reliable cellular network coverage throughout country	Deployment of smart-phone-based data entry and open-source electronic medical record
Low levels of education and health literacy	• Patients often work from home or return to home during day • Culture in which home visits are normalized	Home visit program by diabetes educator using locally adapted curriculum
Patients present late in disease course, often with significant end-organ damage	Excellent subspecialty care available in capital city	Centralized case management system to coordinate referrals from rural health workers to pre-selected subspecialty clinics
Chronic disease care is expensive and requires long-term commitments to beneficiaries	Blended financing models are emerging in global health	• Crowdfunding provides funding for extraordinary and catastrophic care • Grant-based fundraising allows for exploration of new areas of clinical innovation • Cross-training of primary care staff allows for coverage of core salary obligations from general operating funds