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 Research
Cape 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