Mortalidad materna y morbilidad severa en Indonesia rural. Parte II. Implementación de auditorías comunitarias / Maternal mortality and severe morbidity in rural Indonesia Part 2: Implementation of a community audit

Introduccion: en ausencia de marcos conceptuales u operativos unificados, se han hecho llamamientos para compartir experiencias practicas de participacion comunitaria en salud (pcs) para documentar el contexto y la dinamica de la practica participativa. Objetivos: en este articulo se describe la implementacion de un enfoque participativo basado en la comunidad de auditoria de la atencion en emergencias obstetricas que se llevo a cabo en zonas rurales de indonesia. Metodos: cuatro grupos provenientes de distintas aldeas se reunieron para revisar una serie de casos de muerte materna y discapacidad Para formular recomendaciones para la planificacion sanitaria. El analisis narrativo tematico de las transcripciones de las discusiones fue empleado para describir la participacion en lo ocurrido. Resultados: la participacion fue compleja y dinamica y evoluciono a lo largo del estudio. Aunque la culpa y la actitud defensiva caracteriza las primeras discusiones, con el tiempo, los participantes condenan menos a las personas y mas a los sistemas y servicios, situando las conductas individuales en el contexto del sistema de salud en general. Los participantes tambien compartieron cada vez mas sus experiencias personales, generando evaluaciones ricas y explicitas sobre la atencion. La obtencion de esta informacion estuvo supeditada a la facilitacion habil, asegurando el anonimato e “inculcando” entre los participantes el permiso para criticar. Tiempo suficiente tambien estaba obligada a transmitir los principios necesarios y consuelos. A pesar de la evidencia, el proceso ha dado lugar a que las mujeres y los miembros de la comunidad esten mas preparados e informados y sean sensibles a las emergencias obstetricas en los pueblos. La naturaleza de corto plazo del estudio significo que la aplicacion y evaluacion de las recomendaciones no fueron posibles. Sin un enfoque sostenido y permanente, el potencial para el impacto, la prevalencia y la autonomia fue limitado. Conclusiones: el estudio demuestra que si es cuidadosamente implementado, la participacion comunitaria en la salud (PCS) puede rendir cuentas ricas y explicativas de los eventos adversos a la salud, proporcionando informacion irremplazable para la planificacion sanitaria. Recomendamos el uso rutinario del metodo para la planificacion distrital de la salud, configurado como un proceso continuo caracterizado por la autonomia, autoridad, independencia y la participacion de los excluidos por los sistemas de salud y seguridad social. A pesar de su potencial y relevancia, la pcs autentica puede verse amenazada por las condiciones socio-economicas y politicas de su contexto, asi como por la evidencia de jerarquias existentes dentro de la investigacion en salud publica. Recomendamos la implementacion de politicas y mas investigacion para establecer una base mas firme para definir precisamente este concepto de salud publica, progresista aunque opaco. Palabras clave: salud materna, participacion comunitaria en salud, indonesia. Abstract Introduction: In the absence of unifying conceptual and operational frameworks, there have been calls to share practical experiences of community participation in health (CPH) to document the contexts and dynamics of participatory practice. Objectives: this article describes the implementation of a participatory community-based audit of care in obstetric emergencies that was conducted in rural Indonesia. METHODS: Four village-based groups were convened to review a series of cases of maternal death and disability and to develop recommendations for health planning. Thematic narrative analysis of the discussion transcripts was employed to describe how participation occurred. Results: Participation was complex and dynamic and evolved over the course of the study. Although blame and defensiveness characterized the early discussions, over time, participants became less condemning of individuals and more so of systems and services, situating individual behaviors within the wider health system context. Participants also increasingly shared personal experiences, generating rich and explicit assessments of care. Eliciting this information was contingent on skillful facilitation, assuring anonymity, and instilling ‘permission to criticize’ among the participants. Sufficient time was also required to convey the necessary principles and reassurances. Despite evidence the process had resulted in women and community members being more prepared, informed, and responsive toward obstetric emergencies in villages, the short-term nature of the study meant that implementation and evaluation of the recommendations were not possible. Without a sustained and ongoing approach, the potential for impact, sustainability and empowerment were limited. Conclusions: the study demonstrates that when carefully implemented, CPH can yield rich explanatory accounts of adverse health events, providing unique information for health planning. We recommend the method for routine district health planning, configured as a continuous process characterized by autonomy, authority, and self-reliance, and involving those excluded by health and social systems. Despite its potential and relevance, authentic CPH may be threatened by wider socio-economic and political conditions, as well as by prevailing evidence hierarchies that exist in public health research. We recommend policy and research to establish a firmer foundation for this progressive, yet obscured, public health concept. Keywords: Maternal Health; Community Participation In Health; Indonesia. Abstract Introduction: in the absence of unifying conceptual and operational frameworks, there have been calls to share practical experiences of community participation in health (cph) to document the contexts and dynamics of participatory practice. Objectives: this article describes the implementation of a participatory community-based audit of care in obstetric emergencies that was conducted in rural indonesia. Methods: four village-based groups were convened to review a series of cases of maternal death and disability and to develop recommendations for health planning. Thematic narrative analysis of the discussion transcripts was employed to describe how participation occurred. Results: participation was complex and dynamic and evolved over the course of the study. Although blame and defensiveness characterized the early discussions, over time, participants became less condemning of individuals and more so of systems and services, situating individual behaviors within the wider health system context. Participants also increasingly shared personal experiences, generating rich and explicit assessments of care. Eliciting this information was contingent on skillful facilitation, assuring anonymity, and instilling ‘permission to criticize’ among the participants. Sufficient time was also required to convey the necessary principles and reassurances. Despite evidence the process had resulted in women and community members being more prepared, informed, and responsive toward obstetric emergencies in villages, the short-term nature of the study meant that implementation and evaluation of the recommendations were not possible. Without a sustained and ongoing approach, the potential for impact, sustainability and empowerment were limited. Conclusions: the study demonstrates that when carefully implemented, cph can yield rich explanatory accounts of adverse health events, providing unique information for health planning. We recommend the method for routine district health planning, configured as a continuous process characterized by autonomy, authority, and self-reliance, and involving those excluded by health and social systems. Despite its potential and relevance, authentic cph may be threatened by wider socio-economic and political conditions, as well as by prevailing evidence hierarchies that exist in public health research. We recommend policy and research to establish a firmer foundation for this progressive, yet obscured, public health concept. Keywords: maternal health; community participation in health; indonesia.