Community Participation in Health Systems for Responsiveness:

Program-based Research from Liberia and Guatemala

Kristina Gryboski, Henry Perry, Alan Talens,Nene Dialo, and Marthe Akogbeto

Third Global Symposium on Health Systems ResearchCape Town, South Africa

2 October 2014

Outline of Talk

• Two examples of operations research projects conducted through NGO/University partnerships supported by USAID through the Child Survival and Health Grants Program– Maternity waiting homes in Liberia (Africare in

collaboration with the University of Michigan)– Census/community-based, impact-oriented

approach and casa maternas in Guatemala (Curamericas Global and Johns Hopkins University)

How community participation creates responsiveness in these examples

• Communities identify and act upon their problems, preferences and needs for improved health, and actively shape services

• Communities build upon their cultural, traditional systems of support and strengthen their connection with formal services

Maternity Waiting Homes in Rural Liberia

JR Lori, G Williams, ML Munro, C Boyd, N Diallo

Africare and the University of Michigan

I-ROPE

• Innovations, Research, Operations, and Planned Evaluation (I-ROPE)

• USAID-funded Child Survival grant (2010-2014)

• Aims to address maternal mortality and neonatal death in Liberia by establishing the effectiveness of maternity waiting homes

Setting

• One rural county in Liberia, West Africa– County population

333,000

– 11 catchment areas with a population of 80,000

– 18,000 women of reproductive age

Integrated Community Approach• Engage traditional

midwives – a well-respected cadre of health workers—to become part of the healthcare team

• Built on the strong relationships that traditional midwives have with women in their villages

• Transition from “birth attendant” to “birth supporter/birth team”

Mixed Methods Design• Matched cohort design• Five rural PHC facilities with

MWHs (intervention group) and five without (comparison group) matched by:– Distance to a paved road– Catchment population– Tribal affiliation

• All clinics provide standard services including BEmONC and referral services according Liberia’s Rebuilding Basic Health Services program

I-ROPE Approaches

• Communities pledged raw materials– Bricks, sand, labor– Donation of food/cooked meals

• A Traditional Midwife Council was elected by the community for the day-to-day operation of the MWH

• Skilled Birth Attendant at the clinic responsible for oversight

I-ROPE Approaches

• MWH free of charge – Access not dependent

on referral or distance

• Traditional midwives and family members encouraged to accompany women

• MWHs available for extended prenatal or postnatal stays

I-ROPE Approaches

• Each MWH has a minimum of eight beds

• Beds and mosquito nets• Screened porch• Outdoor cooking facilities

– Utensils– Sheltered area for firewood

• Outdoor toilet facilities

Data Collection

• Collaborated with the community for data collection

• Traditional Midwives and Skilled Birth Attendants transferred real time data using cellphones

Lori, JR et al. (2012). Cell Phones to Collect Pregnancy Data from Remote Areas in Liberia. Journal of Nursing Scholarship

Munro, ML et al. (2014) Knowledge and Skill Retention of a Mobile Phone Data Collection Protocol in Rural Liberia, Journal of Midwifery & Women’s Health

Data Collection• Quantitative data collected

from logbooks at rural clinics completed by SBAs:– Referral patterns– MWH use– Team births (those attended

together by a TM and a SBA)– Perinatal and maternal

outcome indicators

• Qualitative data collected through in-depth focus groups with TM from communities with MWHs (n=46)

Team Births (SBA & TM) Before and After MWH Construction

Qualitative Data Analysis

Two major themes emerged:

– Linking communities with facilities

– Safe delivery

Stronger linkages between communities and facilities

• More openness about birthing (women are not as “hidden” as they used to be)

• Communities are more encouraging to women to obtained skilled care for delivery

“We have beds that even many of the women don’t have in their own home… They have mattresses that are clean, they have clean beddings. And for some of the women that come…they want to stay more days here resting before they are carried home with their babies.”

Safe delivery

• Reduces the burden felt by traditional midwives

• Provides a “safe space” for mothers and traditional midwives

“For now we are happy to see this building, it releases a burden on us. The reason that people should come here to deliver is because we [TMs] are not here to handle complications such as bleeding, anemia, convulsions, and all those things.”

Discussion• Maternity Waiting Homes appear to be an attractive

option for women in rural Liberia leading to increases in skilled birth attendance

• A strong cultural preference for TMs still exists in Liberia• Involving TMs with MWHs recast and solidified their role

as birth supporters and community health promoters• Through TMs, women were informed and encouraged to

use the MWHs• Significant efforts have been made by the Liberia

Ministry of Health to integrate and coordinate services with community involvement and participation

18

The Curamericas Global Operations Research Project in Guatemala:

Strengthening Health Systems with Community Participation

Mario Valdez, Ira Stollak, and Henry Perry

Curamericas Guatemala, Curamericas Global, and Johns Hopkins University

The Problem• 86% of births occur at home,

delivered by comadronas (traditional birth attendants)

• Nearest referral facility 4-6 hours away

• Under-5 mortality rate in project area: 48.5 per 1,000 live births (national rate: 32)

• Maternal mortality in 2013: 1,005 per 100,000 live births, and PP hemorrhage leading cause (national rate: 140)

• Birth complications of newborns cause 29% of under-5 deaths

• Childhood pneumonia causes of 40% of under-5 deaths

The Setting

• “Triangle of death” in an isolated highland area of Guatemala

• Population– Municipalities of San Sebastián Coatán, Santa Eulalia, and San

Miguel Acatán– Total population: 98,000– 40,692 beneficiaries consisting of 28,058 women of reproductive

age and 12,634 under-five children• Ministry of Health service delivery system weak

– High turnover of staff– Facilities usually 1-2 hours away from most villages– Cultural barriers

The Approach: CBIO + CGs

• USAID-funded Child Survival grant (2011-2015)• Aims to improve maternal and child health

using community participation and community-based primary health care

• Participatory operations research to document effectiveness of the approach and strengthen the methodology

• CBIO: census/community-based, impact-oriented

• Care Groups

• Vital events registration and visitation of all homes are central components

CBIO + Care Groups

Casa Maternas

• Two present at outset of project, serve 19 of the 58 communities in the project area (2 more just completed)

• Built by community, staffed by auxiliary nurses with supervision of project staff, managed by community committees

• Comadronas accompany women for delivery - trained by the project to advise and monitor pregnant women, recognize danger signs, and bring them to the CM - in exchange for their usual fee

• Ready local transport system for referral of complications (19 referrals in 2013, no maternal deaths)

Defining Program Priorities with CBIO

• Community priorities– Childhood

pneumonia– Childhood diarrhea– Lack of transport for

medical emergencies– Lack of medical

attention

• Epidemiological priorities– Maternal mortality– Birth complications

of newborns– Childhood

pneumonia

Mixed Methods Findings(Oct 2011-Sept 2013)

• Knowledge of at least two pregnancy danger signs increased from 22% to 73%

• Knowledge of 3 essential actions newborn care actions during pregnancy increased from 6% to 59%

• Percentage of deliveries attended by a trained attendant increased from 15% to 28%

• Percentage of children with signs of pneumonia who received medical attention increased from 26% to 40%

• 65% of births in the 19 communities with a casa materna took place in a facility, and 82% of women had 4 antenatal checks and 92% had a post-partum check within 48 hours

Findings from Focus Group Discussions with Beneficiaries, Community Leaders,

Comadronas and Project Staff• “Respondents largely believed that the methodology (CBIO+CGs+

casa maternas) was a sustainable approach to increasing access to basic health services, and they recommended that specific steps be taken to engage the Ministry of Public Health in efforts to scale up the project.”

• Comadronas Comadronas - trained by the project to advise and monitor the pregnant woman, recognize danger signs, and bring her to the clinic - in exchange for her usual fee

• Changes in population coverage of interventions and changes in maternal and under-5 mortality to be assessed in September 2015

Conclusion• Collaboration with communities in program planning,

implementation and evaluation increases community ownership and effectiveness of the program

• Both projects (in Liberia and Guatemala) are contributing to efforts to strengthen rural health services nationally

• Having high-quality, locally generated evidence on the effectiveness of new program approaches is a powerful tool to strengthen health systems, especially in difficult to reach areas

• Methods for this type of research need to be more fully developed for health systems strengthening