Creating an equitable and inclusive rural health system in partnership with the Guatemala Ministry of Health

1. 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

2. 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.

3. 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.

4. 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.

5. 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

6. 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

7. 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.

8. MASSIVE DEMONSTRATION IN GUATEMALA CITY
AGAINST GOVERNMENT CORRUPTION

9. 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.

10. 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.

11. 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.

12. #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.

13. 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.

14. #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.

15. 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

16. 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.

17. 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

18. 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 Care
Checks
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

19. 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. Essencial
Newborn 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

20. 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 POU
Water TX
Correct POU
Water Storage
Correct
Disposition of
Feces
Household w.
Handwashing
Station
Handwashing
at 4 Critical
Moments
Baseline to Endline WASH – Child Survival Health Grants Project -
Intervention Area
Baseline KPC Jan 2012 Final KPC- June 2015

21. 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.

22. 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.

23. 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%
Current
contraceptive use
among non-
pregnant mothers
of under-2 children
Zinc treatment for
under-2 children
with diarrhea
episode in past 2
weeks
Children 12-23
months with
complete
vaccination
coverage
Children 12-23
months with
measles
vaccination
coverage
Post-partum care
for mother and
newborn <48 hrs
after delivery
Vitamin A
supplementation
for children 6-23
months
Baseline KPC survey- Jan 2012 Final KPC survey- June 2015
End-of-Project Goal

24. 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 Northwest
Region
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 Northwest
Region
Huehuetenango
Children 12-23 months Completely
Vaccinated
2008 DHS 2015 DHS

25. 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.

26. #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.

27. 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.

28. 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.

29. 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

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

31. 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.

32. 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.

33. 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/