U.R.C. Protocol Translation_P.M

Protocol:
Improvement of nutritional and maternal and child health services through an
integrated network of services. Results from the Health Area Ixil, Guatemala
USAID/TRAction Project
Guatemala, 26 January 2013
Primary Researcher:
Hernán Delgado
Primary Co-researchers:
Ana María Rodas
Héctor Chaclan
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1 OBJECTIVES
1.1 General Objective
To systematize the processes and results of implementation of the integrated network of health services
for the improvement of nutrition and maternal and child health within the framework of the strategy
1000 Days , with a focus on continuous quality improvement , in three districts in the health area of Ixil
and subsequent expansion to prioritized municipalities for the USAID|TRAction Project.
1.2 Specific Objectives:
a) Formulate the technical proposal of implementation of integrated networks of health
services to improve nutrition and maternal and child health within the strategy 1000
Days , from the community level to tertiary-care level.
b) Define a set of indicators for monitoring the functionality of the integrated network of
health services.
c) Determine the current situation of the network of services in the health area Ixil, in
aspects such as: geographic characteristics, demographic characteristics,
epidemiological profile, and access to the network; organization and functions of the
services, enabling environment, relationship between components of the network, social
communication and participation, as well as support systems, in order to provide care in
nutrition and maternal and child health.
d) Define improvement plans to intervene in critical points based on baseline evidence.
e) Document practices, interventions, and actions to improve the operation of the
integrated network of services in the Ixil health area.
f) Expand the experience to other districts/DAS prioritized for the project in 2013.
2 JUSTIFICATION
In Guatemala in general and in the Western Altiplano region in particular, considerable lag persists in
nutrition and health, as evidenced by high rates of child malnutrition and maternal and child morbidity
and mortality (1-4). Considering the scarce resources the State allocates to health, systemic
optimization and introduction of cost-effective and culturally appropriate interventions are crucial to
reduce the inequities that mostly affect the rural area's population, indigenous groups, and women,
including adolescents and girls.
The Government of Guatemala defined the Zero Hunger Pact as a national priority, identifying the
strategy 1000 Days as the integrating axis, which includes interventions in nutrition and health from
before conception to up to two years of age that would reduce maternal and child morbidity and
mortality (5).
Based on the above and in accord with the technical cooperation requested by the health sector, it is
proposed to put into practice an integrated network of services in the health area and districts of Ixil
focused on the strategy 1000 Days, that include management of actions for prevention and care in
nutrition and maternal and child health.
This implementation research will facilitate ordering and optimization in the use of resources,
contributing to the evidence-based application of, preventive and care models in maternal and child
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health and nutrition, integrated in a network of health services, that actively link families, communities,
and health services. Implementation will use the continuous quality improvement methodology and the
technical guidelines proposed by PAHO and the WHO regarding integrated health service networks.
3 INTERVENTION: INTEGRATED NETWORK OF HEALTH SERVICES
The project USAID|TRAction will systematize processes and results of implementation of an
integrated network of health services, in which the strengthening of key attributes will be promoted,
such as enabling environment, referral and response system, monitoring system, management for
results, and continuous improvement of quality of care within the framework of the strategy 1000
Days.
To that end, in the context of technical cooperation activities, understood as direct technical assistance,
instruction, and training of human resources, applied research, social and behavioral change, and
mobilization of financial and non-financial resources, research will be developed in implementing an
Integrated Network of Health Services Model focused on the strategy 1000 Days in three municipalities
of the health area Ixil. Specific activities of cooperation include the search for data on the enabling
environment, referral and response system, degree of articulation with local networks, monitoring of
nutrition and maternal and child health, and the level of compliance of prenatal, natal, perinatal, and
neonatal care processes and those for children under two years of age.
Subsequently, cooperation will be undertaken with local health authorities in the formulation of a
strategic plan and in the implementation of actions to improve the situation found, conducting quarterly
monitoring of advancements in the strengthening of the network and implementation of health care
models, counting on the participation of representatives of service providers, community leaders,
traditional suppliers, and service users.
Based on the gaps and weaknesses found and starting from the situation discovered in the diagnostic
assessment., health personnel will be updated or trained and accompanied in key elements of the
network.
4 BACKGROUND
Operationalization of actions to improve nutrition and maternal and child health requires
implementation of integrated networks of nutritional and maternal and child health services that
facilitate the continuum of care of mothers, newborns, and children, strengthening the life-cycle
approach from adolescence, prior to and during pregnancy, birth, postpartum, the neonatal and
breastfeeding periods, and childhood. An integrated network of health services has been defined as “a
network of organizations that provides, or makes arrangements to provide equitable and
comprehensive health services to a defined population and that is set up to account for its clinical and
economical results and for the health status of the population it serves.” (7)
Thus the interrelationship between all levels of care is promoted, including the community level, which
improves the population's accessibility to health systems, reduces fragmentation in provision of
services, and avoids duplication of infrastructure and services, reducing costs of production and
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facilitating response to the population's needs and expectations.
Based on an extensive literature review, PAHO and the WHO propose 14 attributes to consider for the
networks, which consist of four areas of approach:
• A health care model, including population and territory, the network of facilities, first-
level characteristics, availability of specialized services, coordination, and service user-
centered care,
• Governance and strategy that consider unique governance, broad social participation,
and intersectoral action that addresses determinants of health and equity,
• Organization and management, which include the integrated management of support
systems, human resources, the integrated information system, and management for
results,
• Pay and incentives that consider adequate financing and financial incentives.
4.1 Situation in the Ixil Health Area
11111 Context
The health area of Ixil, one of two health areas in the department of Quiché, is composed of the
municipalities of San Juan Cotzal, Chajul, and Nebaj. It is located north of the department of El
Quiché. The total population of the three municipalities, estimated from 2002 census projections, is
approximately 155,000 to 160, 000 . According to estimates of geometric population growth, the
population of the three municipalities will double in under 20 years. Most of the population live in
communities of fewer than 500, 52% of the area's 211 more populated places. Two-thirds live in the
rural area of Quiché. Approximately 93% are indigenous and predominantly monolingual, with Ixil and
Spanish the languages spoken in the region.
11111 Service Network Organization
The following table presents data on the health services available in each of the districts in the health
area of Ixil:
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Ixil Area Network of Services
Municipalities Populated
Places
Jurisdictions Primary Care
Centers
Health
Posts
Health
Centers
District
Hospital
Chajul 62 1 16 7 1
San Juan
Cotzal
45 1 14 5 1
Nebaj 104 5 54 12 1
Total 211 7 84 24 2 1
The resident population in the communities of the health area of Ixil mainly receives care through
primary care centers of the Coverage Extension Program (C.E.P.), which receive periodic visits,
generally on a monthly basis, from mobile units of N.G.O. health personnel, and from health posts,
which offer daily services. In the health area of Ixil, four different primary care models coexist: a) the
Traditional Coverage Extension Program, b) the Improved Coverage Extension Program, c) the Simple,
Traditional, and Institutional Model, and d) the Strengthened Institutional Model, which includes the
Basic Health Model or Inclusive Health Model (I.H.M.). These models have been implemented at
different times by the Ministry of Public Health and Social Assistance with the aim of improving access
to the health system, promoting equity and universalization of health services to the entire population.
The second level of care in the health area has two permanent care centers (P.C.C.s), one in Chajul,
the other in San Juan Cotzal, and a district hospital in Nebaj. Each one of the centers has the capacity to
attend to deliveries without obstetric complications and capacity for initial management of
complications. Referrals for these services are attended to by the District Hospital of Nebaj and the
Departmental Hospital of Santa Elena, in the health area of Quiché.
These services are accompanied by health committees, organized originally to support mobilization in
the event of obstetric and neonatal emergencies. In December 2011, seven health commissions were
identified in Chajul, 11 in Cotzal, and 32 in Nebaj, which shows evidence of a good level of
community organization.
11111 Health Situation
Data on the health and nutritional situation in the health area of Ixil are limited,
essentially dependent on data obtained from the health facilities, based on demand for services. The
most recent national survey (ENSMI 2008-9) only presents data representative of the situation and
determinants at the level of Guatemala's departments; in other words,data on the department of Quiché
but not specific to the health area of Ixil nor to its three municipalities.
According to what has been communicated in epidemiological reports from 2008 to 2010, the main
causes of infant and child morbidity in the health area of Ixil are respiratory infections, diarrhea, skin
diseases, and intestinal parasitism.
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Prevalence of chronic malnutrition, estimated through the census of schoolchildren's height conducted
in 2008, was approximately 78% en Chajul, 78% in San Juan Cotzal, and 82% in Nebaj.
In this same period, the maternal mortality ratio in the department of Quiché, which includes the three
municipalities in the health area Ixil, was estimated at 196 per 100,000 live births, higher than the
national average, which was calculated at 139.7 per 100,000 live births. The primary causes of
maternal mortality were hemorrhage, retention of the placenta, and hypertensive disorders.
The rates of neonatal, post-neonatal, infant, and child mortality in the department of Quiché are 20, 20,
40, and 63 per 1,000 live births respectively and are higher than the national estimate for the 10-year
period prior to the ENSMI. Deaths in children less than seven days old are associated primarily with
respiratory disorders and sepsis.
According to the Health Information Management System (HIMS) of the Ministry of Public Health, the
proportion of deliveries in a health facility under the charge of physicians or nurses, in the three
municipalities, is one of the lowest in Guatemala, 10%, compared with the higher national average of
30% in 2008. From the ENSMI 2008-2009 survey, doctor- and nurse-attended births in the department
of Quiché was 20.3%, compared with the national average of 51.5%.
5 SPECIFIC OBJECTIVES AND RESEARCH QUESTIONS
Specific Objective 1: Understand how the integrated network of maternal and child health will
be implemented in the health area Ixil.
Question 1: What is the model of the integrated network of services that will be implemented
in the health area Ixil?
Question 2: What institutional factors (personnel training, provision of supplies and inputs,
management of quality, and management of information) must be strengthened to build the integrated
maternal and child care network?
Specific Objective 2: Explore the attitudes of health care providers toward the integrated
network of health services.
Question 1: How does the attitude of health care providers affect the general operation of
the integrated network of maternal and child health services?
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Specific Objective 3: Analyze the factors that affect demand for maternal and child health
services in the health area Ixil.
Question 1: What are the factors that affect or influence selection of health service
providers?
Question 2: What are the types of mistreatment and abuse that are prevalent in health care
services?
Specific Objective 4: Understand the role of social participation in the implementation of the
integrated network of services.
Question 1: How does the promotion of social participation in health (through exchange
of information, consultation, involvement, collaboration, and empowerment) contribute to
strengthening the integrated network of maternal and child care services in Ixil (considering coverage
and adherence, quality, and cost of services)
Research related to questions 3 and 4 will be conducted jointly with the Nutri-Salud project.
5.1 Type of Study
The study design will be prospective, descriptive, and analytic, including in-depth follow-up of
population and facility samples, selected by random and convenience sampling of the population and
existing services in the health area Ixil in the context of the existing health system.
5.2 Target Population
Beneficiaries of services: Women of child-bearing age, pregnant, and postpartum, neonates,
breastfeeding infants, and children under two years of age.
Health facilities: As indicated, in the health area Ixil, there are seven jurisdictions (of approximately
10,000 inhabitants each) in which 84 primary care centers have been established for the Extended
Coverage Program and which receive monthly visits from N.G.O. health staff; 24 health posts; 2
permanent care centers, a district hospital, and a departmental referral hospital in the health area
Quiché.
Social networks/Community organization: In the Ixil area, health services are connected to the
community health committees, schools, productive linkage projects, municipalities, municipal and
community councils for development and nutritional food security, traditional healers, and community
leaders.
The identification of these organizations and of the local staff would be carried out through mapping by
services, and the interviews would be done by convenience, prioritizing the communities where the
most maternal, neonatal, and child health complications have been reported.
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5.3 Study Design
In order to answer the indicated questions, qualitative data will initially be gathered, which will be
obtained from services and at the population level through participant observation, interviews, focus
groups, and documentary analysis of data available from services, gathered by Nutri-Salud and data
previously obtained by U.R.C. Based on the qualitative data, the quantitative methodology will be
developed, integrated in forms containing the most valid and highly reliable data.
Each one of the health districts has data on the total population and on the 211 populated places,
including women of childbearing age, a list of pregnant women, registries for follow-up, population
censuses in places that have extended coverage, postpartum women in consultation, and children under
two years of age. In order to answer the questions mentioned above, a sentinel surveillance system,
starting with the selection of communities and sentinel facilities.
Selection of study communities: sentinel communities. For implementation research purposes,
populated places will be randomly selected of approximately 1,000 inhabitants (+/- 250), based on the
information from the National Institute of Statistics and health services. One community from each of
the three terciles of categorized communities, based on access to health services (low, medium, and
high), will be selected in each health district, so that a total of nine communities will be studied in the
Ixil health area. In order to select the communities, the populated places and health and education
facilities of each health district will be geo-referenced beforehand, with access estimated based on the
distance and time it would take the population to reach the health facilities in order to manage health
risks and obstetric, neonatal, and pediatric complications. Depending on the size of the communities'
population, they would be able to be added in each district. In each community, population census data
and data on families' socioeconomic and cultural characteristics will be gathered, as well as
longitudinal follow-up done during the research period through surveys and interviews, with varying
frequency depending on the research topics, concluded with an endline, conducted approximately nine
months after the baseline. This community data, added to data from the health facilities (the sentinel
facilities) will allow for studying the proposed variables in the three beneficiary groups of the
implementation research, i.e. beneficiaries of the services, health facilities, and social
networks/community organization.
Service Demand
In each of the three communities selected, appropriately trained and standardized personnel, baseline
census data will be collected of all resident families, obtaining data on health and nutrition, as well as
on families' social, economic, environmental, and cultural characteristics, utilizing qualitative and
quantitative methods. From the census data, longitudinal follow-up will be conducted, obtaining data
with varying frequency on all the families in the community or a randomly selected sample of
sufficient size to be able to detect changes in relation to seeking health services that occurred over the
course of successive quarterly measurements.
Baseline data, obtained from the initial census of the community, will allow categorization of each
family based on its use (high, medium, or low) of health services; the data will achieve greater depth
through qualitative research, around the determinants of families' decisions such as economic, social,
cultural, attitudinal determinants, and others. This information will also allow identification of families
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that use or do not use services and determination of the factors that occur in their practices
(methodologies such as positive deviation and “doers/non-doers are appropriate for these comparison.).
In the longitudinal, follow-up phase and the final census, changes will be studied in the these different
groups of families as responses to the interventions defined based on the analysis of baseline data
(comparison before and after and between groups). These include changes in indicators , like service
use for maternal and child health complications (for example, hypertension, hemorrhage, sepsis,
pneumonia, diarrhea and dehydration, and severe acute malnutrition), achievement of preventive goals
(complete immunization schedule, consultations for growth promotion, prenatal care, exclusive
breastfeeding in the first six months, and complete emergency plan, among others). Finally,
approximately nine months after the baseline, an endline census will be conducted in the same
communities to analyze changes that occurred.
In periodic visits to families, qualitative data will be obtained (for example, perceptions about
individual and family health, quality, and expenses that have been incurred by using traditional/popular
and official services, satisfaction from services received, including negative aspects, such as lack of
respect, abuse, and others with curative and care services, comprehension of messages on health and
nutrition coming from different sources, recommendation to improve health services) and quantitative
data (related to nutritional diet and status, health status, physical anthropometrics, and housing, water,
and sanitation characteristics).
Health Service Providers
As with the community studies, a sample of sentinel facilities will be selected (primary care posts,
health posts, and health centers) that geographically relate to the communities that will be selected. In
these facilities an in-depth, baseline assessment will be performed of conditions of efficiency, and later
a prospective, follow-up on improvements (or the absence thereof), that occurred during the study
period, concluding with a cross-sectional study at the end of the study.
For the measurement of compliance with standards of processes for care, L.Q.A.S. (lot quality
assurance sampling) methodology will be applied, according to which a random sampling of 19 files
or dossiers will be selected monthly in the chosen health facilities or 19 families at community level
that are part of the catchment areas of these facilities. Qualitative and quantitative data will be collected
from samples of families on coverage measures, adherence, service user satisfaction, quality, and costs
of care.
As in the case of the sentinel communities, in sentinel facilities, a baseline will be established on
conditions of efficiency and capacity to offer or provide quality services based on the each one's level
of complexity, with the gaps between expected and actual results identified and plans for improvement
defined.
The data obtained monthly from these facilities will allow detection of changes in the capacity of
services to resolve health problems as well as the response capacity of health staff. Additionally, these
data, related to that obtained from sentinel communities, will be useful to service providers for
measuring quality of services provided by health facilities in the management of complications and
regarding their capacity for improvement during the research period, as well as about the coverage of
services and the population's perception of those services.
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Social Networks/Community Organization
Populated places in the health area Ixil have community organizations with a varying degree of
development and involvement in activities that pertain to the population's nutrition, health, and well-
being. Additionally, formal and informal social networks exist between families, which determine
society's behavior on matters of health and nutrition.
In sentinel communities, as well as families that will be visited periodically through L.Q.A.S. surveys,
baseline and prospective data will be gathered on the population's involvement in health activities, with
communities categorizable according to their development in these areas. Furthermore, through
qualitative, longitudinal study and focus groups, changes that occurred during the research period will
be documented and analyzed. Depending on the development of social networks and community
organization, monographs and case studies will be produced, which will serve to document the
situation found and draw lessons from the changes that occurred during the study period.
5.4 Description of Methodological Aspects to Answer Research Questions
11111 General Points
Methodological aspects considered to answer the specific objectives and research question are
described below:
Specific Objective 1: Implementation of the Integrated Network:
Based on individual and group interviews with the authorities in the health area Ixil, as well as with
health personnel and other area authorities, a situational diagnostic will be prepared on the current
state of the network, using as its base the 14 attributes mentioned above (See page 4.), for the four areas
of approach: care model, governance and strategy, organization and management, and pay and
incentives. Each one of the parameters will be evaluated on an ordinal scale, with the following
categories: fragmented network, or bad; partially integrated network, or regular; and integrated
network, or good. This evaluation will permit estimation of a baseline of the general development of
health services and the attributes and domains of approach in which the organization of health services
is most deficient. Taking into consideration the results of this baseline assessment and the gaps
identified, the model to be implemented in the Ixil health area will be defined. The whole diagnostic
process and the process of implementing the model will be documented and systematized.
On the other hand, an evaluation of the conditions of efficiency or enabling environment, will be
carried out in health facilities, relating expected (or desired) results in each type of facility, depending
on the level of complexity of the services that it should offer with results found at the baseline. Based
on information obtained from the health posts, health centers, and district hospitals, the aspects that
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require strengthening will be identified. Periodic evaluations of the health facilities will permit
measuring the degree and speed with which the gaps found are corrected.
Specific Objective 2: Providers' Attitudes
Evaluation of conditions of deficiency will include a diagnostic model on the attitude of providers
regarding services currently provided and their proposals for improvement. These baseline data will
allow identification of the aspects that in the service providers' opinion are most critical and should be
improved. Based on the feasibility of implementing improvement cycles, the continuous quality
improvement plan will be proposed. The evaluations that will be conducted periodically on these
services will permit measurement of the magnitude and speed of changes achieved. The changes in
quality of care, measured by good case management and users' satisfaction, will be evaluated through
review of clinical records and conducting house visits.
Specific Objective 3: Health Service Demand
The baseline community survey and those carried out prospectively in sentinel communities and in
families sampled by the L.Q.A.S. method will supply information about users' opinion of care received
in different health facilities. The same baseline survey will collect data on the main cultural,
socioeconomic, and demographic characteristics of families and individual residents in sentinel
communities. For analysis of factors that influence selection of health service providers, the
population will be classified based on what services were used, the dependent variable, and it will be
related to independent variables, potential determinants, through multivariate analyses. In the
prospective phase, data will be gathered on the specific health problems, and through qualitative
research, it will go in depth into the criteria used for selecting one health service provider or another.
Health service user satisfaction, as well as user opinion on abuse and mistreatment, will also be
explored through in-depth interviews and, if necessary, through focus groups.
Specific Objective 4: On the Role of Social Participation
In the baseline and prospective evaluations, data will be collected on the communities' social networks
and social participation in health. In addition to the information obtained in health services, interviews
will be conducted with municipal authorities and organized community groups through interviews and
focus groups.
Table 2 presents the research methodologies that will be utilized in research on implementation of
integrated network of maternal and child health services.
Methodological aspects of the main areas to research include:
• Evaluation of providers and the conditions of efficiency or enabling environment and health
services' referral and response system
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• Cultural appropriateness and user satisfaction
• Community organization
• Articulation of services
• Access to services
Table 2. Research Methodology
Elements to
Explore
Area Proposed for Measurement
Source of Data / Elements to Measure
Tool
Characterization of
barriers and
strengths that affect
implementation of
the model:
- Organizational
factors
- Human
resources
- Community
organization
- Level of service
use by users
(mothers and
children) and
satisfaction with
care received
Area: Providers, enabling environment, and referral
system
Data source:
 In-service observation
 Interview of key informants
 Review of kardex cards and BRES forms
 Situation Room Review
Elements to measure:
• Identification and mapping of the target population
• Schedules and days of care
• Characteristics of the population's health facility units
and basic services
• Determination of essential obstetric and child care
performance
• Availability of inputs (surgical physician and medical
laboratory technician)
• Availability of medications
• Availability of basic equipment
• Availability of human resources
• Review of the network's referral and response system
• Checklist for
reviewing the
enabling
environment and
referral system
• Interview guide
for key
informants in
health services
(physician,
professional
nurse, auxiliary
nurses) about the
enabling
environment and
referral system
Area:
Cultural appropriateness of services and satisfaction of the
network's mothers and children with care received
Data source:
 Data available from Nutri-Salud (Interviews of
female health service users in the community and
direct observation)
• Health personnel speak to service users in the users'
language
• They respect users' dress.
• Guide for the
checklist of
service
conditions
(language in
which the
consultation is
conducted,
reception of
patients, and
care)
• Interview guide
geared toward
service users in
the community
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Elements to
Explore
Tool
• Personnel guarantee privacy.
• Amount of time for care is reasonable
• They allow the midwife or relative to accompany the
mother during delivery or child care.
• Cultural appropriateness of maternal and child diets
• The mother can choose the position in which she
delivers.
• They give the placenta to families that request it.
• Postpartum bath with hot water
• Elements of routine newborn care
• Exploring social and cultural aspects that women
consider important determinants of whether or not
they visit health facilities in Ixil (community center,
health posts, centers, and hospitals), and aspects they
think would improve services
• Degree of use of network services for prenatal, natal,
and child care for children up to two years of age
(prospective follow-up of pregnant women or
retrospective among postpartum women in the first 48
hours)
• Interview guide
geared toward
health service
providers
Area: Community organization
Data source:
 Interviews of key informants geared toward leaders of
health committees, community development councils,
and nutritional and food security councils, among
others
• Number of health committees that are functioning
• Number of committees linked to the community
development councils and nutritional and food
security councils
• Support for referral of complicated cases (pregnant
women, delivery, newborns, sick and malnourished
children)
• Number of referrals made in the last
year/quarter/semester
• What aspects have facilitated or made it difficult to
send referrals for health services?
• What aspects should be improved to facilitate referral
and care for complications?
• Family/community emergency plans for health
complications in pregnant women, newborns, and
children under two
• Interview guide
for key
informants at the
community level
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Elements to
Explore
Tool
Area: Articulation of services
Data source:
 Interview
 Situation Room
 Other referral records
• Coordination of midwives, traditional healers, and
others involved in health services for prenatal, natal,
and pediatric care
• Coordination with committees for referral of
complicated maternal and child cases
• Interview guide
geared toward
health service
providers
• Interview guide
eared toward
midwives
• Checklists
Area: Access to services
Data source:
• Villages identified by the Nutri-Salud project
• Census from the National Institute of Statistics
• Geographic accessibility of communities with the
greatest service demand from obstetric
emergencies and emergencies in child health for
children under two
• Latitude and longitude of each populated area
relative to the network of services (geo-
referencing)
• Characterization of mechanisms that these
populations have in order to have access to health
services upon detecting a child health or obstetric
complication
5.4 Data Collection:
11111 Stage 1 – Situational Analysis
A literature review is proposed for the design of the proposal of the Integrated Network of Health
Services to implement the strategy 1000 Days.
This proposal will also include qualitative data obtained, starting from February, from the community
visits and facilities selected in each of the health districts. Lastly, a list of indicators will be developed
to monitor the the network's operation. All of the above will be complemented with training of staff in
methodology for continuous quality improvement in order to reduce identified gaps in each network
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component reviewed.
Once the indicators have been defined, the forms or checklists will be developed to collect data at each
level of the network.
11111 Stage 2 – Validating Preliminary Data
The next stage is validating the proposal with technical staff in the health areas of Ixil and Quiché, prior
to validating study instruments and data collection.
11111 Stage 3 – Characterizing the Network's Status
Initial visits and programmatic meetings with the health teams are meant to characterize the state of the
network in Ixil and identify gaps, with respect to the validated proposal. The aspects to be considered
in characterizing the network include: opinion of the health area authorities, assessment of the
conditions of service efficiency, perception and satisfaction of service users, social participation in
actions taken for nutrition and health, and the potential for coordination with other public and private
sectors, among others. The sources of data include review of records, other sources of primary data,
statistics, work reports, self-evaluations by service staff, and interviews of key informants.
11111 Stage 4 – Collection of Baseline and Prospective Data
During project development, initial baseline and prospective data will be collected with varying
frequency, at the community and sentinel facility levels. Data to be collected monthly include the
detection of new pregnancies, audit of deliveries and births, and obstetric and pediatric complications,
which the health situation room, located in the health facilities, will update. In cases of death of women
of childbearing age and child under two, oral autopsies will be performed to determine the cause of
death and the characteristics of case management at the family, community, and health service provider
levels. Other data on services and the community will be obtained quarterly or solely at baseline and
planned endline.
11111 Stage 5 – Endline of Data Collection
In the last quarter of the implementation research, an endline survey will be conducted in services and
sentinel communities, with the aim of measuring specific changes that occurred during the
implementation of the integrated network of services, as much in providers as in services, beneficiary
population, and organized civil society.
5.5 Data Analysis and Development of Improvement Plans
The qualitative and quantitative data, collected at baseline in sentinel communities and facilities, as
well as prospective data obtained periodically from both sources, and endline data collected will be
included in data bases and analyzed following standard procedures. Qualitative analyses will use
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qualitative analysis packages.
The quantitative data will be presented descriptively and according to the model of the integrated
network proposed, estimating the current status of essential attributes of the network and the degree of
compliance with defined standards and indicators. Quantitative analyses of longitudinal data will
explore the trends and significance of changes, utilizing parametric and non-parametric analyses.
Community and facility baseline data will be analyzed to explore causes of differences observed
between population groups or facilities with favorable characteristics, compared with those that
demonstrate less favorable characteristics. Likewise, through multivariate analyses, behavioral
determinants of health will be explored among families that most utilize health services, compared with
those who least use them, for example. This analysis will be a starting point for the development of
improvement plans that aim to change the situation found. The positive deviations found will serve to
model the interventions.
5.6 Documentation of Improvement and Lessons Learned
This aspect of the study sets out a plan for follow-up by the area's technical team and health services,
the degree of implementation of improvement plans, and consecutive measurements to see the degree
of progress in reducing gaps found. This will serve to support expansion to other prioritized
municipalities.
After the experience of Ixil's network of services has been documented, the results of this study will be
shared with central-level authorities in order to have the support of institutionalizing the process
through expansion to the rest of the municipalities that the project, which the project has as its scope of
work in the health areas of Quiché, Huehuetenango, San Marcos, Quetzaltenango, and Totonicapán.
16

6. REFERENCES
1. Minister of Public Health and Social Assistance et al., Fifth National Survey of Maternal and
Child Health (ENSMI) 2008-2009, Guatemala, December 2010
2. Delgado, H.L. Health and nutrition at national level in five departments of Guatemala's Western
Altiplano (San Marcos, Quetzaltenango, Totonicapán, Huehuetenango, and Quiché): Situation,
challenges, and proposals for their improvement. U.R.C. 2012
3. Williams, D.B. et al., 2012. Reviews of the nutritional state of boys and girls, ENSMI 2008/2009.
Technical Report. Published by the U.S.A.I.D. Nutri-Salud and TRAction projects. Bethesda, MD.
University Research Co. L.L.R. (U.R.C.).
4. Minister of Public Health and Social Assistance. Work report. Guatemala. Guatemala 2011
5. Government of Guatemala. Plan for the Zero Hunger Pact. Guatemala 2012
6. H.C.I./U.R.C. Continuous improvement of quality
7. Pan-American Health Organization. Integrated Networks of Health Services. Concepts, options, and
roadmap for their implementation in the Americas. Washington, D.C. 2010
17

Appendix: Timeline
Activities and dates for
reporting
October 2012 to March 2014
O.12
N.12
D.12
J.13
F.13
M.13
A.13
M.13
J.13
J.13
A.13
S.13
O.13
N.13
D.13
J.14
F.14
M.14
Literature review and
definition of technical
elements for the network
proposal
X X X
Design of the model of
ntegrated health
networks
X X X
Validation of the
proposal with the
echnical team of the
Ixil area
X X
Update of district
personnel regarding the
continuous quality
mprovement
methodology and
mprovement in analysis
and review of medical
records and clinical files
X X
Accompaniment of local
monitoring committees
for review of cases of
maternal, neonatal, and
child death analyzed by
he health committees
with the critical links
methodology
X X X X X X X X X X
Accompaniment in
quarterly, multi-sectoral
meetings to review the
functioning of the
ntegrated network of
services, monitoring,
management of services,
and follow-up of cases
X X X X
18

reporting
O.12
N.12
D.12
J.13
F.13
M.13
A.13
M.13
J.13
J.13
A.13
S.13
O.13
N.13
D.13
J.14
F.14
M.14
Accompaniment of the
health area for
developing activities of
supportive supervision
of services: follow-up of
advances in
mplementation
X X X X X X X X X X
Design of the protocol X X
Review and approval of
he protocol by the
TRAction technical
eam
X X
Definition of alliances
with training schools,
Nutri-Salud, and other
partners to develop a
field phase
X X
Presentation of the final
proposal to the technical
eam of the Ixil area for
approval of the field
phase and programming
of activities
X X
Design of interview
guides for key
nformants, health
service users, providers,
and local leaders
according to research
areas (Pending number
of instruments)
X X
Validation of X X
19

reporting
O.12
N.12
D.12
J.13
F.13
M.13
A.13
M.13
J.13
J.13
A.13
S.13
O.13
N.13
D.13
J.14
F.14
M.14
nstruments
Selection of
communities and sample
of service beneficiaries,
community leaders, and
providers
X X
Programming of visits to
communities and service
sites
X X
Training of project
personnel administering
surveys in the Ixil area
X X
Collection of baseline
data on services
X X X
Collection of baseline
data: interviews of
service users, leaders,
and enabling
environment
X X X
Second measurement:
nterviews of service
users, leaders, and
enabling environment
X X
Processing of collected
data
X X X X
Development of the
report on the initial
situation
X X
Sharing the situation X
20

reporting
O.12
N.12
D.12
J.13
F.13
M.13
A.13
M.13
J.13
J.13
A.13
S.13
O.13
N.13
D.13
J.14
F.14
M.14
found at the local level
Implementation follow-
up
X X X X X X X X
Participation in
quarterly meetings with
hose involved in health
service to review the
mplementation situation
of the network, lessons
earned, and
nterventions that
facilitate or hinder the
process
X X X
Design of the final
report
X X
Sharing results at the
central level of the
M.P.H.S.A. to expand
he experience to other
prioritized
municipalities
X X X
Training personnel in
prioritized
municipalities in Stage
II, for the
mplementation of the
ntegrated network
based on experience
from the Ixil area
X X
21

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