Creating an equitable and inclusive

rural health system in partnership with the Guatemala Ministry of Health

Ira Stollak MA MPH Program Manager for Latin America

Curamericas Global CORE Conference, May, 2016

irastollak1777@gmail.com

An Introductory Story

In February 2016, Curamericas Global, our in-country partner Curamericas Guatemala, and the local representatives of the Guatemala Ministry of Health (Ministry), convened a meeting with the leaders of the Mam Maya communities of the municipality of Comitancillo in San Marcos department. The agenda: secure their participation in our innovative rural health system, the Maya Community Health Network (Red Comunitaria Salud Maya). The Network features Casas Maternas, community-built and –owned birthing centers that respond to the very high maternal mortality in the rural Maya population.

The communities had already been informed of the Network and this meeting was to formally secure their participation. After introductory remarks by the Curamericas and Ministry staff, one of the leaders rose and spoke.

An Introductory Story - Continued

“Thank you for coming here and considering us. And thank you to my parents who allowed me 3 short years of schooling, enough to enable me to speak to you all in Spanish.” “We do not understand how we are to believe what you are saying, that by working with the Ministry we can save the lives of our mothers and children. When we bring our mothers and children to your government clinics there are no medicines or vaccines for our children. Sometimes we travel for hours and find the clinics are closed. Nurses used to come to our villages once a month to provide care but last year they stopped coming.” “Yet you ask us to contribute our blood and sweat to build this Casa Materna? Why should we take that risk? How do you expect us to trust you after the way the Ministry has treated us? Thank you again, but I am opposed to this.” Then the majority of leaders voted to reject the project.

How did we get here?

Curamericas Global partners with under-served communities in resource-poor countries to help them make measurable improvements in their health.

But our partnerships also include local NGOs, our implementing partners, and the local Ministries of Health, to not only help them realize their goals, but to work with them to create not “projects”, but INTEGRATED HEALTH SYSTEMS.

Our Implicit Model: Future Generation’s SEED-SCALE

From the Future Generations website (www.futuregenerations.org): “Our long-term studies of community development worldwide show that

success results when communities work from the bottom up, when officials work from the top down, and when experts work from the outside in. All three roles are needed.”

Government – enabling laws and policies; material and logistical support

Outside experts – NGOs, PVOs, FBOs, universities, etc. – to catalyze and guide

The communities – the grassroots work to improve their lives and own their future

The Context We Are Working In- Indigenous Rural Guatemala

With USAID (Child Survival Health Grants Project) and private foundation funding, we and our partner Curamericas Guatemala have been working with isolated Maya communities in the remote Western Highlands in the departments of Huehuetenango, San Marcos, and Solola to reduce maternal mortality and child malnutrition and

morbidity as bad as any found in Sub-Saharan Africa.

Huehuetenango

San Marcos Solola

GUATEMALA

Huehuetenango Department, Western Highlands

The Political Context We Are Working In

• Guatemala is in the midst of a political crisis. In the recent election huge popular unrest has ejected a government rife with corruption. The last president and vice-president are both being prosecuted for corruption.

• The Guatemalan government is starved of sufficient funds to meet human needs and to properly enforce the laws. •This results in impunity for corrupt politicians and and administrators.

MASSIVE DEMONSTRATION IN GUATEMALA CITY AGAINST GOVERNMENT CORRUPTION

The Political Context We Are Working In- Ministry of Health

• These issues have manifested strongly in the Ministry of Health.

• The Ministry already suffered from bureaucracy that often stifles local initiative, and from the segmentation and fragmentation of its services.

• The Ministry lacks the resources it needs to fulfill its legal mandates to provide health services, particularly to indigenous people and to women. Its budget can cover at most 40% of need.

• Consequently $5.20 of every $10.00 spent on health comes from the pockets of end-users, which disproportionally affects the poor. 60% of the lower wealth quintile have experienced catastrophic health expenses.

• This privatization of health care has resulted in excellent care for the wealthy but has not served the rural poor who cannot access or pay for essential care at public clinics that are too distant or private clinics that are too costly.

• This has been worsened by corruption. For example, Guatemalan newspapers have exposed “puestos fantasmas” whereby high level health administrators allegedly pocketed the salaries of hundreds of non-existent health staff.

A Dysfunctional Ministry of Health- Local Manifestations

• This national level dysfunction impacts even the remote rural mountain areas where we have been working in Huehuetenango department, where local Ministry staff struggle under difficult conditions. •Stock-outs of essential medicines at the local Ministry clinics have become pervasive - children often go untreated for pneumonia and other infections for lack of antibiotics. The worst stock-outs have been for vaccines for children. Stock-out rates are 15-19% for essential medicines. • Staff at the Ministry clinics where we work have gone unpaid for months, causing clinic closures. •In the town of San Miguel Acatan, the local people stormed the Ministry clinic when it closed and forced the staff to open and provide services.

How Do We Transcend These Challenges?

Despite this daunting context, we have made huge strides towards meeting the health needs of the rural Mayan people we serve, by:

1) Taking advantage of Ministry programs that are working and integrating them into our model.

2) Creating community-based alternatives, not to by-pass the Ministry, but to work in partnership to demonstrate for the Ministry more effective ways to meet its goals.

3) Nurturing “champions” among local district and departmental Ministry staff who support our vision and who take advantage of the current crisis to exert their local autonomy to work with us.

#1- Taking advantage of Ministry programs that are working- The Extension of Coverage Program (PEC)

• PEC was a bold new Ministry effort to 1) bring primary health care services

directly into rural villages and 2) pioneer partnering with the non-profit private sector to decentralize its services.

• PEC sent ambulatory nurses directly into the villages where they provided primary health care services such as antenatal and post-natal care, child growth monitoring, Vitamin A, contraceptives, treatment of sick children and childhood immunizations.

The Extension of Coverage Program (PEC)

• These services were provided by NGOs under contract with the Ministry, with each NGO assigned a specific territory and paid per services provided.

• PEC was hugely empowering to community-based NGOs such as our partner Curamericas Guatemala, who implemented PEC in two of the municipalities we have been working in.

• It was a ground-breaking program that made significant contributions to improving the health of rural indigenous communities located far from government clinics.

#2- Creating community-based alternatives

• We are creating what we are now calling, the Maya Community Health Network (Red Comunitaria Salud Maya).

• We mobilize communities using our Community-Based Impact-Oriented (CBIO) methodology, to organize themselves to improve their health.

• We generate demand for services, change health behaviors, and empower women to improve their own health with Care Groups.

• Most importantly, we initiate Casas Maternas.

• Ministry clinics are too distant and costly to access, and provide culturally unacceptable and often disrespectful services – consequently they are rarely used, contributing to high maternal and child mortality.

• Casas Maternas are accessible culturally-adapted birthing centers/mini-clinics that offer respectful care from Mayan health workers in the Mayan language. They are community-built, -owned, and -operated.

The Casa Materna

Casa under construction, with Community Health Committee directing the construction

Above, mother with newborn in Casa Materna birthing room

Left, completed Casa Materna

The Maya Community Health Network

The “Four-legged Table” of our integrated service platform

CBIO - Mobilizes communities; utilizes community maps and registers to monitor need and equitable fulfillment of need; creates demand by raising awareness of community health priorities; and engages community participation in monitoring their health indicators.

Care Groups - Mother peer educators teach participatory lessons to their neighbors to facilitate adoption of healthy behaviors and stimulate demand for health services.

Casas Maternas - Accessible, affordable, culturally adapted community-built and operated birthing centers that fulfill the demand for maternal/neonatal care and, recently, treatment of pneumonia and diarrhea. Sends emergency referrals to local Ministry clinics and the Ministry hospital in city of Huehuetenango. Uses task-shifting of personnel – Auxiliaries rather than RNs - to achieve high cost-effectiveness. Extension of Coverage (PEC) – Supported by the Ministry but implemented by NGOs like Curamericas Guatemala, sent ambulatory nurses into rural villages to fulfill demand for primary health care services.

CBIO – A Community Health Committee Care Groups – A Neighborhood Women’s Group

Casas Maternas- The Santo Domingo Casa PEC- Ministry Health Post where services provided

13.4%

63.2%

21.7%

65.0% 67.7%

64.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

At least 4 Antenatal CareChecks

Vaccination for tetanus Iron/folate 90 days

Baseline to Endline Changes in Indicators of Antenatal Care- Child Survival Health Grants Project - Intervention Area

Baseline KPC Survey Jan 2012 Final KPC Survey -June 2015

16.4%

6.0%

9.4%

28.7%

39.0%

20.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Delivery in health facility Delivery w. EssencialNewborn Care

Delivery w. AMTSL

Baseline to Endline Changes in Delivery Care- Child Survival Health Grants Project - Intervention Area

Baseline KPC Survey - Jan 2012 Final KPC Survey - June 2015

66.6%

11.7%

43.1%

2.3% 1.3%

97.7%

28.0%

45.0% 44.7%

34.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Correct POUWater TX

Correct POUWater Storage

CorrectDisposition of

Feces

Household w.Handwashing

Station

Handwashingat 4 CriticalMoments

Baseline to Endline WASH – Child Survival Health Grants Project - Intervention Area

Baseline KPC Jan 2012 Final KPC- June 2015

Our USAID-Project TRACtion-funded operational research, recently published in Global Health Science and Practice, showed that in the catchments of the Casas Maternas, we increased coverage of health facility deliveries from 30% to 70% and reduced maternal Mortality from 508 (n=3) in 2012 to 0 (n=0) in 2015.

But….

While PEC contributed hugely to improving health outcomes in our municipalities, working with the Ministry was a challenge:

• PEC funding was insufficient and very erratic, changing every four years with each new administration.

• Goals were set from the top down instead of responding to the local situation.

• Providers were paid for outputs rather than outcomes.

• Paperwork was onerous; payments often were delayed.

• Stockouts – particularly of antibiotics, contraceptive methods, vaccines, and oxytocin – were frequent and lengthy.

• And then: in October 2014, the funds for PEC were cut by the Congress and the program was abruptly ended nationwide.

Effect of Termination of PEC- Child Survival Project

31.4%

4.2%

70.9%

79.1%

19.2%

76.3%

29.5%

10.5%

53.5%

60.2%

28.7%

70.6%

45% 50%

80% 80%

50%

85%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Currentcontraceptive use

among non-pregnant mothers

of under-2 children

Zinc treatment forunder-2 children

with diarrheaepisode in past 2

weeks

Children 12-23months with

completevaccination

coverage

Children 12-23months with

measlesvaccination

coverage

Post-partum carefor mother and

newborn <48 hrsafter delivery

Vitamin Asupplementationfor children 6-23

months

Baseline KPC survey- Jan 2012 Final KPC survey- June 2015

End-of-Project Goal

National and Regional Effect of Stockouts and Termination of PEC

79.9% 78.6% 83.3%

90.6%

61.9% 60.5% 59.5%

45.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rural Indigenous NorthwestRegion

Huehuetenango

Children 12-23 months Vaccinated for Measles

2008 DHS 2015 DHS

74.6% 71.9%

79.2%

86.7%

57.6% 56.1% 57.0%

43.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rural Indigenous NorthwestRegion

Huehuetenango

Children 12-23 months Completely Vaccinated

2008 DHS 2015 DHS

Replacing the missing “leg”- another community-based alternative

• The stock-outs and then loss of PEC meant the loss of its critical demand-fulfillment services and so we looked to another community-based alternative.

• We received funding from Medicines for Humanity to establish in the Casas Maternas “boutiquines”- small pharmacies – sustained by a Rotating Drug Fund (RDF).

• They also provided a critical supply of oxytocin.

• The Casa Materna staff began to treat sick children, as well as do child growth monitoring, Vitamin A and deworming, and other primary care functions formerly provided by PEC.

#3- Nurturing “champions”

A “champion” is someone outside of your organization who not

only appreciates and supports your vision, but who actively engages in its realization.

Nurturing Champions

• Our main strategy: engage local (District and Area) Ministry staff as intimately as possible in our work to 1) cement good inter-personal relations; 2) share information; and 3) give them an opportunity to experience and appreciate first-hand our approach.

• In the municipality of San Miguel Acatan, the Ministry District Director, Dr. Marroquin, became one of our first champions.

• We recruited to our operational research advisory committee Dr. Danilo Rodriguez, the Departmental Director for San Marcos Department. • And Dr. Fernando Gomez, the Departmental Epidemiologist for Huehuetenango Department.

Crisis = Opportunity

• Our long-term plan for sustainability is for the Ministry to adopt our approach and support the scale-up of the Maya Community Health Network in the rural indigenous regions of Guatemala.

• But the current political crisis has the new ministers still trying to root out corruption and establish new, more effective approaches.

• Our champions are taking advantage of this window of opportunity to exercise their autonomy.

Dr. Marroquin is partnering with us and two other NGOs to create a “model municipality” in San Miguel Acatan, with a network of Casas Maternas: our current one in Tuzlaj Coya and three new ones that we will help him establish.

Dr. Rodriguez is committing Ministry resources under his control to help us expand the Maya Community Health Network to the municipality of Tajumulco in San Marcos department.

San Miguel Acatan, Huehuetenango

Triangle of Death

Tajumulco, San Marcos

Top left, Tajumulco; left, San Mateo in the Triangle of Death; top, signs for Casa Materna in Tuzlaj Coya, San Miguel Acatan

Again, Adapting and Integrating A Ministry Program

• The Ministry has decided not to reinstate the PEC Program.

• Instead, it is shifting to a health facility-based model.

• Fortunately this includes staffing and strengthening the rural Health Posts, which have been grossly underutilized.

• The Ministry plans to staff each Health Post with 2 Auxiliary Nurses (rather than using RNs as with PEC).

• Working with Drs. Rodriguez and Marroquin, we are adapting this to the Maya Community Health System.

• With the engagement of the surrounding communities, we will convert the Health Posts to Casas Maternas, with the Auxiliary Nurses also providing safe clean culturally-adapted deliveries and referrals of complications, as well as other basic primary health care.

To Conclude

• Curamericas creates integrated rural health systems in partnership with communities, working from below, and with Ministries of Health, supporting from above.

• In the Western Highlands of Guatemala we are creating the Maya Community Health Network.

• This work has been challenged by the current issues facing the Guatemala Ministry of Health

• We have been transcending this by:

1) Selectively integrating successful Ministry programs;

2) Creating community-based alternatives for the Ministry to adopt;

3) Cultivating “champions” among Ministry staff who share our vision and exercise their local autonomy.

Links to Sources

• Llanque, Ramiro. Integration of Extension of Coverage Program (Programa Extensión de Cobertura, or PEC) into the Child Survival Project. In Perry HB, Valdez M, Stollak I, and Llanque R. 2016. Focused Strategic Assessment: USAID Child Survival and Health Grants Program “Community-Based, Impact-Oriented Child Survival in Huehuetenango Guatemala.” Curamericas Global, Inc. Raleigh, NC, USA

https://www.curamericas.org/wp-content/uploads/2016/01/Appendix-13-Effects-of-the-Integration-of-the-Extension-of-Coverage-Program.pdf

• Stollak, Ira, M. Valdez, K Rivas, and H Perry. (2016) Casas Maternas in the Rural Highlands of Guatemala: A Mixed Methods Case Study of Their Introduction, Utilization, and Equity of Utilization by an Indigenous Population. Global Health: Science and Practice. Volume 4. Number 1. http://www.ghspjournal.org/content/4/1/114.full

• Avila, Carlos, Rhea Bright, Jose Gutierrez, Kenneth Hoadley, Coite Manuel, Natalia Romero, and Michael P. Rodriguez. Guatemala Health System Assessment, August 2015. Bethesda, MD: Health Finance & Governance Project, Abt Associates Inc.

https://www.hfgproject.org/guatemala-health-system-assessment-2015/