1. Using systematized tacit knowledge to prioritize implementation challenges in existing maternal health programs
Dra. Jacqueline Alcalde
Mtro. Victor Becerril
National Institute of Public Health (México) 1

2. Background Maternal mortality is still a global health concern
Despite numerous policies and programs only a few countries reached MDG5 – 75% reduction of maternal mortality between 1990 and 2015
In 2013, the maternal mortality ratio in developing regions was 14 times higher than in developed regions
Mexico and Nicaragua, did not meet MDG5

3. Where are Mexico and Nicaragua located ?

4. Implementation research
Two approaches
Implementation research
Tacit Knowledge

5. Implementation research
In low and middle income countries, even when policies and programs are usually designed based on available evidence, it is not common to find evidence on how interventions are implemented.
Implementation
Supplies
Results
Maternal programs
Health facilities
In low- and middle-income countries (LMICs), although the design of policies and programs is increasingly based on available scientific evidence, it is not yet very common to find evidence-based decision making about the implementation of public health interventions(Gonzalez-Block et al. 2008; 2011).
Human resources

6. Tacit Knowledge
Knowledge and views derived from the direct experience of the diverse stakeholders participating in maternal health programs.
They are near to the implementation problems
Everyone has their own knowledge

7. Objective
To assess the feasibility of using the tacit knowledge methodology to prioritize challenges to implementation of current maternal health programs and inform the post MDG agenda in LMICs.

8. Methodology
Creation of six communities of practice (CoPs) in three states of Mexico
and three departments of Nicaragua
Managers
Champion
Facilitator
Researchers
Personnel in
contact with patients

9. Methodology
2. CoPs receive training in face-to-face and online workshops
3. Concept Mapping was used to obtain CoP´s tacit knowledge
First workshop: Initial brainstorming to answer the focus question:
What are the main problems of the state or departmental health system that represent an obstacle to reach the expected results of your maternal health programs?
Second workshop: Training on the use of the Concept Systems Global online platform
Online activities:
a) sorted the 98 statements in conceptual groups following his or her own criteria
b) rated each statement according to its importance and the feasibility of solving it
4. We generated conceptual clusters using multi dimensional scaling and a correlation matrix

10. Metodología – Comunidades de práctica
Idea
idea
Tacit knowledge
idea
IDEAS
idea
idea
idea
Comunity of practice

11. Plattform Concept Systems Global
Concept mapping
Sub-grupo 4
Lluvia de ideas
On line
Plattform Concept Systems Global
Sub-grupo 3
Lluvia de ideas
Sub-grupo 2
Lluvia de ideas
Sub-group 1
Brainstorming
Integración de ideas por estado
Integración de ideas por estado
Final pool of problems 98
Sub-grupo 4
Lluvia de ideas
Integración de ideas por estado
Sub-grupo 3
Lluvia de ideas
Pool of Problems by CoP and country
Sub-grupo 2
Lluvia de ideas
Sub-group 1
Brainstorming
Rating of each statement according to its importance and feasibility of solution
Sub-grupo 4
Lluvia de ideas
Sub-grupo 3
Lluvia de ideas
Sub-grupo 2
Lluvia de ideas
Sub-group 1
Brainstorming
Elimination of duplicates
and redundancies
n = 202 participants
Mexico = 82
Nicaragua = 120
6 CoPs
Sub-grupo 4
Lluvia de ideas
Sub-grupo 3
Lluvia de ideas
Sub-grupo 2
Lluvia de ideas
Sub-group 1
Brainstorming

12. Concept Map – Points map1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
Sorting exercise, we generated clusters or conceptual groups using multidimensional scaling and a correlation matrix

13. Results Concept map – 10 clusters 1 2 3 12 14 23 25 26 42 46 48 52 5662 72 76 86 96 5 30 43 49 73 87 89 9 19 20 21 47 74 75 4 7 10 16 24 32 34 61 71 80 88 6 8 11 35 36 67 69 13 15 17 33 37 39 40 53 60 65 68 92 94 97 18 28 29 31 57 58 59 63 77 78 81 82 83 93 22 45 50 51 55 84 38 41 85 90 91 95 27 44 54 64 66 70 79 98
1. QUALITY OF HEALTH CARE 2.
EXCESS OF PATIENTS
DEMAND 3.
ARTICULATION
BETWEEN
FIST AND
SECOND
CARE
LEVELS
4. SOCIAL AND EDUCATIONAL LEVEL 5.
PERCEPTION OF USERS ABOUT HEALTHCARE 6.
LACK OF HUMAN
AND FINANCIAL
RESOURCES 7.
FINANCE INFORMATION 8.
CORRESPONSABILITY OF MUNICIPAL
AUTHORITIES IN MATERNAL HEALTH
9. PROMOTION AND
SOCIAL PARTICIPATION
10.
LACK OF FACILITIES FOR
PREGNAT WOMEN
Results
Concept map – 10 clusters

14. Concept map – Importance rating

15. Concept map – Feasibility rating

16. Correlation Diagram: Importance – Feasibility

17. Priorities FACTIBILIDAD DE RESOLUCION IMPORTANCIA 4.04 3.55 2.6 3.41
Consultations for risk pregnancies are established in distant dates and even after the delivery date 2
Deficient valuation of pregnant women by the personnel who receives them (physicians and nurses) 3
Negative attitude during care of personnel towards pregnant women 6
Pregnant women and their families fail to make a timely detection of alarm signs 12
Bad reception of pregnant women in emergency cases by surveillance personnel in health units 13
Problems with the distribution of delivery care inputs 14
Deficient quality of care during pregnancy, delivery and postpartum 23
High rate of refusal of care for pregnant women in health units 25
Lack of follow-up of postpartum by health care personnel 26
Lack of compliance to Official Norms and Practice Guides 35
Pregnant women fail to attend to antenatal control 42
Long waiting time for pregnant women’s care in health units 46
Inadequate follow-up of obstetric complications 48
Inadequate identification of obstetric risk by health personnel 49
Lack of follow-up and evaluation of maternal health care processes 56
Lack of human attitudes in health personnel responsible for pregnant women’s care 58
Obstetric emergency and general care equipment is in bad conditions 72
Limited follow-up of pregnant women in the first level of care 77
Lack of drugs for normal and emergency obstetric care 86
Lack of follow-up in pregnant women’s care to guarantee an integral care 87
Human resources for health are badly trained during their studies 89
Health personnel lacks training 90
Sexual education programs for adolescents are not implemented 91
Community personnel linked with maternal health programs lacks training 96
Negligence on the part of health personnel 1 2 3 6 12 13 14 23 25 26 35 42 46 48 49 56 58 72 77 86 87 89 90 91 96 4 8 9 10 16 17 18 22 24 28 30 31 32 34 38 40 50 52 55 66 67 74 75 84 85 92 94 98 5 7 11 15 27 33 36 39 41 43 44 45 53 54 60 62 68 69 70 71 73 76 79 80 82 95 97 19 20 21 29 37 47 51 57 59 61 63 64 65 78 81 83 88 93
4.04
3.55
2.6
3.4
3.97
4.52
r = 0.44
FACTIBILIDAD DE
RESOLUCION
IMPORTANCIA

18. Conclusions
Tacit knowledge is a feasible and potentially valuable approach to improve the implementation of programs.
To involve health personnel and decision makers in research legitimizes the research results.
This innovative approach can significantly contribute to improve the quality and accessibility of health services