Dra. Jacqueline Alcalde Mtro. Victor Becerril National Institute of Public Health (México)

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

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 developedregions • Mexico and Nicaragua, did not meet MDG5

3. Where are Mexico and Nicaragua located ?

4. Two approaches • Implementationresearch • TacitKnowledge

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 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 sixcommunities of practice (CoPs) in three states of Mexico and three departments of Nicaragua Managers Champion Facilitator Researchers Personnel in contactwithpatients

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 focusquestion: 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? • Secondworkshop: 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. Concept mapping On line Plattform Concept Systems Global Sub-grupo 4 Lluvia de ideas 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 Integración de ideas por estado Sub-grupo 4 Lluvia de ideas Pool of Problemsby CoP and country Sub-grupo 3 Lluvia de ideas 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 map Sortingexercise, we generated clusters or conceptual groups using multidimensional scaling and a correlation matrix 35 6 8 16 4 36 62 11 2 56 32 10 3 69 61 23 48 76 96 14 67 80 25 46 34 88 12 86 1 72 26 71 7 24 42 5 52 30 49 73 85 95 9 75 90 43 89 41 91 87 47 74 53 38 19 27 60 45 21 40 33 97 15 20 22 44 54 50 84 70 94 39 17 64 92 68 65 98 13 51 79 66 37 31 82 58 28 83 77 29 55 78 81 57 59 63 18 93

13. Concept map – 10 clusters Results 35 6 1. QUALITY OF HEALTH CARE 8 16 4 36 62 11 2 56 32 10 3 69 61 23 48 76 96 14 67 80 25 46 34 5. PERCEPTION OF USERS ABOUT HEALTHCARE 88 12 86 1 72 26 71 7 24 42 2. EXCESS OF PATIENTS DEMAND 5 52 4. SOCIAL AND EDUCATIONAL LEVEL 30 49 73 85 95 9 90 43 89 75 41 91 3. ARTICULATION BETWEEN FIST AND SECOND CARE LEVELS 87 47 74 9. PROMOTION AND SOCIAL PARTICIPATION 53 38 19 27 60 45 21 40 33 97 15 20 22 44 54 50 84 70 94 39 17 64 92 68 6. LACK OF HUMAN AND FINANCIAL RESOURCES 65 98 13 51 79 66 37 31 82 LACK OF FACILITIES FOR PREGNAT WOMEN 10. 58 28 83 77 29 55 78 81 57 59 63 8. CORRESPONSABILITY OF MUNICIPAL AUTHORITIES IN MATERNAL HEALTH 18 93 7. FINANCE INFORMATION

14. Concept map – Importance rating

15. Concept map – Feasibility rating

16. Correlation Diagram: Importance – Feasibility

17. Priorities r = 0.44 4.04 14 26 48 2 89 72 25 46 62 86 23 6 49 5 43 87 77 76 42 12 27 90 54 13 FACTIBILIDAD DE RESOLUCION 96 3 58 1 69 71 35 44 91 33 56 97 15 80 7 73 41 95 79 36 70 45 82 53 60 68 11 39 92 17 3.55 98 83 8 59 22 75 34 61 66 50 52 19 38 93 29 65 30 88 9 63 21 81 94 67 28 47 20 78 84 24 31 74 40 64 10 85 18 57 32 37 55 51 4 16 2.6 3.4 3.97 4.52 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