In this episode we hear about a participatory action research project in Guatemala, funded by the Director's Catalyst Fund at LSTM, that co-designed a tool for health leaders and community partners to assess and improve urban health governance.  

The project was based in two Guatemalan urban municipalities; Villa Nueva and Mixco. We speak with Guillermo Hegel, the project lead who was also the Health Director at Villa Nueva Municipality at the time of the project. We also hear from Yaimie Lopez and Cintia Cansado who coordinated and evaluated the project. They share their experience of participatory research and working with policy makers.  

The research team together with co-researchers who were urban health stakeholders looked at 4 domains, Governance, leadership accountability and multi-sectoral action. They first defined what these terms were, then they co-analysed existing tools to measure governance performance and designed an online tool which could be used to rank current performance and areas for improvement which could then track over time.  

The tool involved a number of qualitative questions that required discussions and reflections about governance in their work and required a level of trust and transparency which is further explored by our guests.  

This Episode features: 

Wesam Mansour (co-host) - Health Systems Researcher, Liverpool School of Tropical Medicine 

Wesam is a Health System Researcher with research expertise in health workforce and health systems strengthening in fragile contexts using qualitative research and participatory action research approaches. Her work includes working in the areas of gender, equity and justice and how to apply those concepts to develop gender-equitable, resilient and inclusive health systems. She is currently working, in LSTM, on the ReBUILD4Resilience project which is health system research in Fragile and Shock-Prone (FASP) settings in 4 countries (Nepal, Myanmar, Sierra Leone, and Lebanon). In ReBUILD, they worked with the Close to Community (CTC) providers in FASP settings to explore how participatory action research can support CTC providers to address gender norms and power relations within their communities and in the health systems in Lebanon and Nepal. 

Links:

LSTM - Wesam Mansour

ReBUILD Consortium

ReBUILD - Gender Project

Guillermo Hegel, Project Coordinator, INCAP 

Since 2020 Guillermo has been a researcher at CIIPEC. He coordinates a participatory action research project in collaboration with the Liverpool School of Tropical Medicine. From 2014 to early 2020, he was health director of the municipality of Villa Nueva, Guatemala. A core part of his tasks was to articulate 'Health-in-All Policies' and to improve the primary health care system in urban setting through participatory processes. Between 2008-2013, he worked at PAHO/WHO Guatemala, as an advisor for social determinants of health and the ´Healthy Cities´ initiative, leading and contributing to several programs in Guatemala and Latin America. He began his career in public health in 2000, promoting small-scale projects at the community level with an environmental and inter-sectoral approach. Since 2016 Guillermo holds a master's degree in public health from the Institute of Tropical Medicine, Antwerp, Belgium, in addition to a previous master's degree in development (2011) and a BA in environmental science (2004), both from Universidad del Valle de Guatemala. As of 2018 he is a member of Health Systems Global and Emerging Voices for Global Health. 

Yaimie López, Research Assistant, Centre for Health Studies, Universidad del Valle de Guatemala 

Yaimie is a biologist from Guatemala with research experience in vector borne diseases and strengthening of health systems. She has been involved in several quantitative research projects focused on the biological side of the diseases, and in one qualitative project to understand the perception of key actors involved. The qualitative project was done with the participatory action research methods, with municipal stakeholders acting as co-researchers. The aim of the project was to develop a tool that would help to measure and improve the governance, leadership, multi-sectoral action and accountability of two municipal health systems. The project used PAR for the development of the tool, including the co-selection of questions, rating criteria and the visual presentation of the tool. 

Ms Cintia Cansado-Utrilla, PhD student, Liverpool School of Tropical Medicine  

Cintia comes from a background in molecular biology. Her bachelor’s degree is in Biotechnology and her master’s degree is in Medical Parasitology and Entomology. Most of her expertise involves lab work with some field work in Guinea, studying mosquitoes. At the beginning of her PhD, she enrolled in an MRes in Global Health where she acquired translational skills and became interested in qualitative research. She had the opportunity to participate in the GOBLAR project with Kim, Guillermo, Yaimie and the rest of the participants and she cites it as a very positive experience for her. She believes there is a gap between basic and applied science, and although her PhD focuses on molecular biology of mosquitoes, she would like to incorporate some qualitative methods to her research to understand the perceptions of novel mosquito control methods from a community perspective and contribute to close this gap.  

For more information about the tool mentioned in this episode, see this video on our YouTube channel:

https://youtu.be/nXxOoN74OAc

This episode is dedicated to the memory of Oscar Hernandez. 

Guillermo and Yaimie, who worked with Oscar (mentioned in the episode), pay tribute to their valued and much missed co-worker;

 “Oscar Hernandez was a medical doctor from Guatemala who died in 2020 while working in the front lines against the Covid-19 pandemic. He believed so much in his work that he had isolated from his family while working in the hospital to avoid infecting them. He was one of the first people to be on the participatory action research team and worked hard to lay the foundation of the project.

Oscar was a highly energetic person, eager to learn. He knew how to see the bright side of difficult situations. He was very funny, always making jokes.” 

Follow Connecting Citizens to Science on your usual podcast platform or YouTube to hear our equitable global health research podcast connect discussing how researchers connect with communities and people to co-develop solutions to global health challenges. The series covers wide ranging topics such as TB, NTD’s, antenatal and postnatal care, mental wellbeing and climate change linked to health.  

If you would like your own project or programme to feature in an episode, get in touch with producers of Connecting Citizens to Science, the SCL Agency.  

The project discussed in this episode applied a participatory action research approach to co-design an online

The research team together with co-researchers who were urban health stakeholders, looked at four domains of governance; governance

To start their research, they first defined what those terms meant for them within Guatemala, within two urban municipalities.

They then together looked at existing tools to measure governance performance and used these to design their own

The tool involved a number of qualitative questions that required discussions and reflections about governance in their work.

This required a level of trust and transparency, which is further explored by our guests in this episode

Hello listeners and welcome to the Connecting Citizens to Science podcast.

Welcome, if you're brand new and welcome back if you're one of our regular listeners.

This week's episode is a project that is funded by the Director's Catalyst Fund at the Liverpool School of Tropical Medicine.

This is a really interesting funding mechanism because firstly, it's funded through donations to the institution

So it's a small pot of funding where early career researchers can design a project, implement it, report on

Today we're going to hear about one of those projects that used participatory reaction research approach in Guatemala to improve

So let's begin by meeting our guest, Guillermo Hegel, welcome.

Tell us a bit about yourself.

Hello, Kim.

Thank you for the invitation.

My name is Guillermo Hegel.

I worked in the Institute of Nutrition for Central America Panama.

I was collaborating in developing this project here in Guatemala.

Thank you, Guillermo.

The interesting thing about Guillermo's role, is that you are actually a policy maker when this project started.

You had this kind of dual role where you were responsible for delivering health within a municipality as well

Yes, that's correct.

I was working in the municipality of Villa Nueva as Health Director starting from 2013, I believe, until 2020.

Perfect.

Thanks very much.

So I'm interested to hear that dual role, we love talking to policy makers.

Then when our project started, Yaimie Lopez, you came along as project coordinator.

Would you like to introduce yourself?

Thank you Kim.

Hello everybody, and thank you for the invitation.

I am Yaimie Lopez.

I am a biologist by training.

I was a project coordinator for this project.

It was my first time doing a qualitative research and I have research experience with biological projects.

Thanks very much.

It'll be interesting to hear cross-disciplinary reflections that you had coming from a biologist background into this kind of research.

Cinita, you did a qualitative evaluation of this study because you wanted to understand how to use more

Would you like to introduce yourself?

Hello, Kim.

That's right, I'm a biologist and my background is very molecular; I work mainly in the lab and I was actually part of this

I very much enjoyed the experience of learning a bit about qualitative research and learning from this amazing

Happy to share everything I learned in this project.

That's great.

Thanks very much, Cintia.

Last but not least, we have our co-host, which our listeners might recognise from our gender and health series.

Wesam, and welcome back to the podcast.

I also believe you have an interest in the Director's Catalyst Fund yourself, tell us about yourself

Thanks, Kim.

I am Wesam Mansour, a health systems researcher at Liverpool School of Tropical Medicine.

I consider myself lucky to be awarded the LSTM Director's Catalyst Fund to start a new project

I'm really interested to join you today.

I will learn a lot from your experience on using participatory action research with the community and policy makers.

Thanks Wesam.

I think for listeners, it would be useful to understand a bit about how you managed to secure that funding.

Was it just a straightforward application process or was it a bit more complex?

I have applied for this grant three times.

It's really hard, it's a learning process.

It's important to identify what kind of work you want to study or work on.

I believe that peer review is a really good idea and it helped me a lot.

At the end, I got the fund and I'm happy that I will start with this study in Egypt, although it's really a sensitive issue

That's great Wesam, I think you're right, the focus of this funding to help early career researchers to transform

It's nice that you kept applying and it sounds like you've really honed those skills because now you have the funding and

Wesam, do you want to start with some questions?

I think at a start we might need to get an overview about the health system in Guatemala.

Guillermo, would you please provide us with a very brief overview about the health system there?

Guatemala is located in Central America.

It's a small country.

We have around 18 million people, and a little bit less of half of the population is located in

We have a very high out of the pocket expenditure.

We have a Ministry of Health that is covering around half of the population.

There's a lot of groups that are not being attended or reached by the health system.

We have an organised social security, like an insurance, that is compulsory, but only for those that have a formal

We have this situation in which there's no collaboration between the Ministry of Health and

They work by themselves and we have the private that it's growing more and more over, over the years.

Within all that we have this rapid urbanisation that is going on all around our region.

This is, uh, a problem that is as well something we need to tackle.

On top of that we have 21 different cultures in our country.

So that means that we speak different languages in different regions and that makes it a little bit more complex.

I know there's a lot of listeners with different backgrounds, so just to add a bit more, we have at least

Other vector-borne diseases, I know Cinitia is interested in this, and maybe other people from the audience; we

We are one of the few remaining countries in Latin America that have rabies transmitted by dogs.

We hear this all the time, this double burden of disease because, Guillermo, I know non-communicable diseases are

Was that right?

That is right.

They have different numbers depending who is expressing the data, but it's, uh, between 12 and 20.

This is interesting as well because the amount of people that have a formal job, it's above 30%.

That means that there's a group of population that has a formal job, but they don't have access to the

I think that brings us quite nicely onto this idea of understanding governance.

As I introduced earlier, the project was to try to measure and improve governance in urban municipalities.

Do you want to tell us a little bit about the study and why it came about and the model it used as well of participatory action research?

When we were working in Villa Nueva as Health Director, we started to understand that

We had more than 700,000 population people in residence in Villa Nueva.

We had only, uh, four clinics from the Ministry of Health, and only one clinic from the social insurance.

The mayor decided to start a network of health services to provide a better quality of service to the population.

While we were doing that we found out that we didn't have a Commission for Health, so we founded a Commission for Health at municipal level.

From that commission we started to ask what was the needs that they found as important for improving health itself.

After a while we understood that, um, even working and developing more and more clinics was not going to be enough, so we decided with

We used a methodology called Urban Heart from the World Health Organisation.

It happens to be that, um, conditions related to governance and this methodology was not too well described.

We were struggling a lot to develop this municipal policy.

We almost took three years.

With that lessons learned, we found out that it could be really interesting to develop a tool that could help us

We built this project and the idea was to try to understand better different tools that talked about health

To, to being able to identify it if there was enough information to develop a policy or a plan, for example.

And that was for me, it was an excellent experience because we got a lot of ideas out of that and how

That's great.

Thanks very much.

Yaimie, I wondered if you wanted to come in here.

Participatory action research is the model of co-production that was used and I believe it was with policy makers and

Can you describe participatory action research from your experience in this project?

For me, it was the first time I had listened about that approach to do research.

I was very interested in learning how to do it, and I still think I need to improve a little bit more.

It was a great experience.

I find it a bit, I'm not gonna say complicated, but complex, because it's not a linear process.

It's a horizontal work.

It's not a vertical work, so it's a horizontal one, that we all act as co-researchers.

Nobody's above anybody and we all share our experiences.

As a citizen I'm not living in those municipalities, but I had never heard of a municipality doing this kind of work before.

So I think one, it was innovative.

Second, the approach was also the power up approach was also innovative, and third, engaging with people that were policy makers.

It was also a new experience for me because I had engaged with people in the communities, in households, so it was very different than doing

I think at the end, people understood what we were trying to do so that everybody could be heard and the opinions could be heard, even if

It was a very interesting process, seeing how every time it changed and everybody just was engaging each time.

Could you tell me what were the objectives of the program?

Do you think they were achieved very well or not?

I guess another question is, how did you manage the expectations of stakeholders that were involved in this project?

Our first idea was to develop, uh, a tool that could somehow make a summary of the understanding

This was the main objective, and the idea was to use the participatory action research method to engage different actors.

We believe that we have achieved the goals in general because we managed to develop the tool.

We managed to connect with those actors and the learning process was there.

We felt it went short in the process of piloting the tool, because we managed to use that only once.

I believe that was mostly because of Covid 19, because it happens just in these times when we were finalising the project.

I believe that, in general, we managed to learn and to reach the goals to understand better how health governance

I think just add a little bit of context there, the tool; it's a series of qualitative questions that policy makers can ask themselves.

The tool, was an app that you could use where these questions could be answered and built on, and you

Yaimie, I know you want to come in here, maybe you could come up with some examples of the kind of questions we were asking.

Just to add a bit to what the Guillermo said, I think that we also achieved empowerment of the

It wasn't part of a goal, but it was very important as well to see how people started, yeah, to collaborate and

About the tool, some of the questions were very self-reflective because people were policy makers, so they had to think about their

I think the most general question was, is there a health policy in your municipality?

I think that only, correct me if I'm wrong, of the 340 municipalities in Guatemala, only Villa Nueva can reply, "yes, there is one that at

Starting from there are there health plans on your municipality and how is the citizens included in accountability process, um, how

Great, and I think there was a ranking system?

So a traffic light is, a green, yellow, and red, so you could see where your improvement needed to happen.

Cintia, you have some comments?

Yes, because when Yaimie and Guillermo were talking about this participatory action ,um, research,

They were very aware that this process was horizontal and cyclic.

These were literal words that they used.

I think you were right, Yaimie, they absolutely understood the concept of the whole process.

There was lots of sense of ownership of this project and empowerment from the participants.

Yeah, I think you really succeeded at implementing this model into this project from the participant's point of view at least.

Yes.

I still want to know more about how you manage the expectations of a stakeholder, how you manage these power dynamics.

I'm starting to speak with people in Egypt and I anticipate, or I can see, how high their expectations are, so I want to learn

I think the first part of the process is very important.

In Villa Nueva for us, because we had already developed the municipal health policy and there was some gaps of needs that the parts, that

It was easier to try to brainstorm whom, because this was the way we did it, whom could participate and contribute

In the case of Mixco, it was a little bit more difficult, because we had some contact with them.

They knew us because they were a municipality as well, and they meet in different types of spaces.

They were really wanting to know what they want to come out of this process, and it was nothing data specific, but it was important

So trying not to promise something really important or funding was going to come out of this, but really the process and the learning

For example, um, how engaged was the citizens in collaboration to the municipality?

They wanted to connect and understand, but they didn't have this type of connection that we had in Villa Nueva with the citizens.

We're trying to show them this is possible and this is an opportunity for you to try to build that trust with the citizens and develop other

I believe that was part of our pitch to the municipality, and the Ministry of Health was already interested because

That was how we manage those expectations and these power issues.

It wasn't a smooth process at all times because of course Covid hit part way through.

So Yaimie, I think it's really useful to talk about engagement process and keeping policy makers embedded

If you could also add the sensitivities because it was a governance project, and you're talking about government and

At the beginning it was very nice because we were all meeting in person and in person dynamics are very different.

You express yourself different and you have the feel of, of them, of the environment when you are in a, in an in person meeting.

For the first in person meeting we had in Mixco, it was a complete success because we had stakeholders, many

Not only from departments of the municipality as an institution, but other institutions I think and citizens were also there as well.

So it was a huge event.

We had a lot of people, and you can see all the tables just discussing and everybody talking and

However sadly, COVID hit and the regulations from the government were that we could not meet in person anymore,

We did Zoom meetings with the people from the each municipality.

We divided them because the perspectives were different in Villa Nueva, they already had infrastructure, we already knew the gaps

We also wanted to start piloting and improve the questions, so we couldn't do it with flip charts and presenting each

We sent them to all the people that we had already recruited and we were expecting them to not only to improve the

We had a lot of success on that because people took their time, they wrote, and mostly because, like in Mixco,

We collected information in the Google forms and then we presented that on the online meetings in Zoom.

That's when we start to see the little bit of people were uncomfortable, sometimes, not uncomfortable with the project,

People that were still working for a municipal institution, were afraid of expressing their own opinions or having their name

So they told us like, "could I just add this in the chat?"

"Could I send this to you"?

"Could I not speak"?

"Could I change my name so that nobody knows I'm here, but I really want to participate to improve our municipality"?

It was a challenging point that people were still trying to collaborate and to give their own opinions, so we, of course,

So yeah, that was one of the things.

The other, because we were doing the Zoom meetings after work because of course we couldn't ask all the people to

Still we collected information, but the number of people that started until what we had when I left it was it had reduced more than half.

Still we managed to do it, and people were connecting, were on time.

It was very interesting, even if we were just five, six people, it was a very interesting dynamic.

Everybody was speaking.

Of course, when the number reduced, the people that remained were of course more interested in doing this.

It was a safer space so everybody opened again, their microphones, their cameras, because it was

So yeah, that's one of the main challenges we, we had.

That's great.

Cintia, please...

I think Yaimie summarised really well the opinions from the participants.

During the reflection stage, during the interviews, actually participation was one of the main challenges that they talked about.

Of course, Covid was one of the main reasons why participation decreased.

They said that obviously they enjoyed more the in person activities, so obviously people like to gather and be together, but also

Also as you mentioned, and Guillermo mentioned, the politics situation with the change in the government was another thing.

The participants also talked about this and their fear of speaking sometimes and the lack of time because of the

Just to build on that, Cintia, what were some of the things they gained from being involved in the process?

This is actually the big question, right?

Because lots of the conversation was around this, so the participants were really excited about this whole participatory research.

They gain a lot for their professional development, but also for their personal development.

None of them had done this kind of process before, so that's the first thing.

I think, as I mentioned before, they understood the concept perfectly and one of the things that they valued more is that they feel as

Something that they mentioned as well is that this kind of methodology could be implemented in other types of projects,

I think this also leads to something that Guillermo mentioned before about trust between the authorities and the population, that this

In the personal level what they gained was first knowledge about all this that they didn't have before, but also, they

Not just like from a judgment, but more of, a reflection on their own learning process and, above all, empowerment, which

They really had this sense of empowerment over this.

Overall, they consider this as very valuable methodology for this project and another projects as well.

Thank you.

Yeah, the participatory process is very reflexive and it's good to hear that they found that space as well.

Guillermo, do you have something to add?

Yes, I was just reflecting a little bit of how we were organised; we were a core group of researchers that were more

There were a group from Villa Nueva and a group from Mixco.

With them, we did this identification of other stakeholders that were participating in the workshops as well.

I think that was very good because that managed to get the co-researchers very empowered and understanding

That's really useful.

Just before I hand back to Wesam to close up, Yaimie, did you have anything you wanted to add there?

I think, coming back to the challenges, I think also we were hit on a personal level because we lost one

He was a medical doctor fighting in the front lines.

When he was there, he got exposed and sadly he died.

So this also, obviously was very sad, it it put us, we had to pause a bit on the project.

They also makes, made us reflect on the importance of this project because, if some of the policies or some of the

So it was also a big challenge for us and I think we always kept him in mind when we were continuing to do this project, and to

And I actually wanted to ask, Kim, what did you learn?

How was your experience with the project in Guatemala?

A lot of the research that I've done is, is participatory research, but less so with policy makers, and

I think growing through this, I learned how important the political environment is to consider.

I learned so much from Guillermo as a policy maker, who had taken three years and was so passionate about

I think working with communities requires expertise around managing power dynamics, but it was a whole new level for this

I learned so much from how you did that.

I remember you coming with the idea of Google Forms and saying," try a different way", " We want to keep people engaged" and I learned

Thank you for that question.

Wesam, would you like to close this session up for us?

This is really interesting.

I'm more interested now to see the tool and learn more about it and how you used it.

I also hope you disseminate your research findings and we can learn from this on a more broad spectrum.

Finally, I want you, I want to ask you all, what advice would you be giving others thinking about working with policy makers

Okay from my side, I will tell that flexibility is very important.

It's important to, to acknowledge that and how different stakeholders want to engage into that for us was very exciting process.

For example, we had at the beginning, an idea of making a ranking of questions and then you come out with

What they said, because of power balance, they wanted to have the discussions saved and a voting process to get to

This flexibility as well allowed us to put this as part of the process and was very important for

I think adding to that, is perseverance because we found many challenges and many opportunities when we could

Unexpected situations happened, and that cannot mean the end of a project, especially when it's going to benefit many people.

Okay, Cintia, do you want to add to that?

For me, it's more learning about Guillermo and Yaimie's answers rather than giving my own opinion, so thank you for that.

I intend to apply some of these methods in the future for my own research in vector-borne diseases.

I think Cintia, what you can tell us is, you know it's so interesting, we work with biologists and people involved the

So what made you think about it differently?

This is policy makers, so it's very different to even engaging with communities.

For me, this project completely changed my mind because I come from a basic science background.

And sometimes I think when you spend so much time in the lab doing basic research, you really forget

For me this project has made me stick a lot into that thought of the potential application of what my project could have.

Therefore, I cannot stop thinking of the acceptance of the application of my research in the field, and if I'm studying a certain aspect of

I want to know if the people out there is going to accept this potential control method, right?

There's no point in doing that research for me if the people in the field are not going to accept that.

I think it's really important to engage with communities and with policy makers and really know their opinion and use that

That's something that I think would fill a little bit the gap between basic and applied.

Thank you so much, uh, that, that advocacy for co-production, again, is really nice to hear and what we're

I think one of the key things we did have throughout this project was reflexivity, and having

Reflexivity is a lot about assessing power dynamics, and through reflexivity in our joint meetings, our joint

My, my piece of advice would be, don't forget reflexivity.

It's a way to document the process and a way to examine power.

So that's all from me and also good luck with your project in the future Wes.

Thank you to everyone for joining us, and as always, to our listeners, without our listeners, we cannot continue

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Sign up your grandmother, sign up whoever you can!

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Thank you for listening and thank you to our guests.

Bye for now.

Thank you and best of luck.

Bye.