Achieving the Health Millennium Developing Goals using GIS Knowledge Networks: the case of Maternal Health in Mozambique

Zeferino Benjamim Saugene Department of Informatics, University of Oslo, email: zeferins@ifi.uio.no Abstract The World Health Organization (WHO) report on Maternal and Child Health (MCH) inequality in Mozambique (January 2007), identified a number of factors as potential causes of obtaining high maternal mortality rate including a number of socio-economic factors such as education, wealth, occupation, access to information and area of residence. A study performed by Medicus Mundi Catalunya on Maternal Health, in Gaza province (Mozambique), has revealed that the health sector needs to adopt different approaches to tackle inequities in MCH. For instance, in order to improve maternal health, as encapsulated within the Millennium Development Goals, the focus must be on improving coverage and quality of antenatal care by reducing barriers to accessing health services. The study also served as a catalyst for utilization of Geographic Information Systems (GIS) in analyzing the health data in Mozambique. The use of GIS is important in maternal health mapping for its data integration capability, its ability to generate spatial variables such as distance measurement with proximity analysis (for example, distance to nearest health facility), overlay analysis (for example, in seeking to understand the association between service use and population density). In Mozambique efforts have been articulated by different institutions to collect spatial data. However, this has been most of the times in isolated manner. In attempting to contribute to a better understanding of maternal health, this paper aims at describing the different approaches that can be used to make GIS useful to the institutions dealing with maternal in Mozambique. Therefore, to successful adopt GIS there is a need to create partnerships (communities) aiming at sharing knowledge/experience in a proper way. These strategic partnerships will create the environment for cooperation. Activities intended to increase the knowledge base such as applied research under knowledge sharing circumstances have a high potential for building capacity among partners. In spite of the various types of building blocks required to successfully create, operate and maintain Knowledge Networks, Communities of Practice is presented in this paper as the main building block of any of them. In conclusion, the paper points out the critical success factors and the strategy for ensuring use of GIS is feasible in countries with minimal resources and a scarcity of GIS professionals, such as Mozambique. Keywords: Maternal Mortality, GIS, Knowledge Networks, Communities of Practice. 1. INTRODUCTION The reduction of maternal mortality is one of the most important Millennium Development Goals (MDGs). Although most developing countries have already established strategies to tackle this key development target, current trends indicate that mortality ratios remained almost unchanged in the most affected countries (DSC 2000). However, only countries such as Bolivia and Egypt, managed it in recent years (WHO 2005). The Mozambican government for example has been engaged in extending coverage of health care, in fact, the rate of assisted births rose from 25% in 1992 to 45.1% in 2003 (DSC 2004). However, about 16 years after the civil war, the health

system has not yet reached a level that allows significant reduction of maternal morbidity and mortality. About 84% of women have access to antenatal care regarding the use of obstetric care, 48% occur in the facilities, these 81% in urban areas and 34% in rural areas. 14.2% of births in rural and 3.1% in urban areas are assisted by traditional birth attendants (INE 2004). This demonstrates that the current coverage of obstetric care and maternal health at community level is weak (DSC 2004). Achieving good maternal health requires quality reproductive health services and a series of well-timed interventions to ensure a womens safe passage to motherhood (UN 2010). In attempting to contribute to a better understanding of maternal health, this paper aims ate describing the different approaches that can be used to make GIS useful to the institutions dealing with maternal in Mozambique. GIS are one of the most widely used information technologies in government and is increasingly becoming a standard tool for information management, storage, and data interpretation in most countries like Mozambique. GIS was first used in Mozambique in the 1980s supported by foreign experts for the elaboration of the nation-wide forest, soil, climate and land inventory(Reddy and Mussage 1985). Today, many of the relevant government and private departments have GIS software packages running on at least one computer. In the previous years in Mozambique, most of the data was derived from digitizing analogue maps, or from direct data entry. The National Center for Remote Sensing (CENACARTA) was the institution that started with the production of spatial data by digitalizing analogue maps. Currently, a large amount of information is distributed in digital formats, and, most institutions have their own equipment to create the spatial data after its collection (using GPS, analogue maps, satellite images, etc) from the field. These units are in charge of maintaining the spatial databases in each unit updated. So, to successfully adopt this tool, spatial data across disciplines and organizations needs to be collected, organized, and shared. In this study, it is argued that while all this is true, theres also a need to consider collaboration issues and knowledge management system to support access, query, sharing, and updating of spatial data. This rest of the paper is organized as follows: the section two, briefly discuss some important issues raised in the literature on knowledge, sharing, and community of practice. In the third section, the key methods and techniques used to perform this study are introduced and defined. In section four, spatial data sharing and maternal mortality in Mozambique case studies are expanded. The analysis and discussion of the findings is presented next. The final section presents a conclusion from the study. 2. THEORETICAL FRAMEWORK According to (Fonseca and Egenhofer 1999), the cost of building knowledge bases from scratch is high. (Heches et al. 1991) suggest that it is difficult to lower this cost and it is better to focus research on sharing the acquired knowledge. In this section its reviewed work about sharing practices within networks of knowledge. 2.1. Knowledge Sharing

This research examines knowledge sharing among organizations with overlapping geographic areas of interest. (Darr and Kurtzberg 2000) consider knowledge sharing as a process where people acquire knowledge by learning others experience. (David 2000) defines knowledge as information that is relevant, actionable, and based at least partially on experience.

According to (Nonaka and Takeuchi 1995), knowledge has both explicit and tacit components. The implicit knowledge resides in the heads of the members of the communities and can be shared with others through processes of socialization (sharing experiences), externalization (articulating implicit knowledge into explicit concepts), combination (synthesizing and systematizing fragments of explicit knowledge), and internalization (turning explicit knowledge into tacit knowledge by applying it in real situations) (Nonaka and Konno 1998; Nonaka and Takeuchi 1995; Nonaka et al. 2000) while the explicit knowledge includes its documents, recorded discussions, decision strategies, conceptual models, and defined workflows. Meanwhile, by exchanging knowledge, organizations can continually increase work efficiency. In these environments, sharing geographic knowledge is often characterized as either a technological problem or an organizational one. Most of the times, the sharing technological problems are related to data compatibility issues (e.g. differing formats, definitions, or scales) which often complicate the task of bringing together separate knowledge. However, the organizational aspects of knowledge sharing are related to collaboration, consensus building, and coordination. The importance of knowledge sharing is not only beneficial to innovation, but also to efficiency raising (Wang and Chen 2006). The sharing relationship generally links groups that have different goals and tasks, but whose concern for a valuable shared natural resource encourages them to work together, to coordinate their efforts, to learn from each other, and to build some kind of infrastructure to facilitate these activities. While exploring the spatial data produced and used by the GIS community in Mozambique for example, we can see that access to GIS means more than just access to data, but a wealth of valuable information. Obtaining the most current data is a question of resource and single agency will not be able to provide that on continued basis. However, the question most widely asked in these inter-organizational relationships is why organizations enter into cooperation relationships. (Oliver 1990) articulates this question as discoveries of the contingencies that motivate organizations to establish relationships. According to (Evans 1997), the benefits of collaboration for individual organizations include economies of scale, lower overhead, reduced risks - all in the interest of increasing efficiency and thus surviving in a complex ecology. (Alexander 1995) adds to it by saying that collaboration is facilitated by a clear interdependence between two or more organizations: this interdependence may involve pooled resources, sequential tasks, or transferring resources. Despite the benefit, it can sometimes be difficult to share knowledge efficiently due to several reasons. According to (Croswell 1989) these obstacles seem to be behavioral, rather than technical. (Davenport and Prusak 1998) adds to it by identifying seven barriers: lack of trust; different cultures, vocabularies, and frames of reference; lack of time and meeting places; status and rewards going to knowledge owners; lack of absorptive capacity in recipients; belief that knowledge is the prerogative of particular groups; the not-invented-here syndrome; and intolerance for mistakes or need for help. Some scholars like (Szulanski 1996) state employees wont have willingness to share knowledge if they dont trust each other. The literature shows a complex set of factors affecting inter-organizational collaboration: some of these factors pertain to individuals, some to organizations as a whole, others to relationships between organizations, and still others to the broader political and social context (Evans 1997). Simultaneous, by reviewing (Ruggles 1998) research, different organizational culture will also influence the efficiency of knowledge sharing. Hence, knowledge sharing is encouraged by several practices

which include among others group or communities. Thus, effective knowledge sharing need several conditions, such as recipients absorptive capacity, rich channels, motivations, free environment, etc (Wang and Chen 2006). Following (Worldbank 2010) communities are the heart and soul of knowledge sharing in the organization due to the wealth of experiences, insights, and perspectives - the social and organizational capital of any organization. 2.2. Community Of Practice

Community of Practice (CoP) is a term used to suggest that organization facilitates exchange of knowledge through a common vocabulary that is used in formal and structured documents within the organization(Al-Sayed and Ahmad 2006). In language acquisition for example this term was used to suggest that one can acquire language if there was to be a common ground between the larger linguistic community and the individual learners and that once the learner has accomplished the mastery of language, his or her contribution to the community will increase(Al-Sayed and Ahmad 2006). A CoP is a particular type of network that features peer-to-peer collaborative activities to build members skills as well as organizational and societal capabilities (Kamensky and Burlin 2004) or knowledge. The networks that are created to build knowledge are spectrum of structures that involve two or more actors and include participants from public, private, and nonprofit sectors with varying degrees of interdependence to accomplish the goals that otherwise could not be accomplished independently (Kamensky and Burlin 2004). By focusing on a grassroots innovation efforts where innovating community groups have the opportunity to come together and share how they have solved problems (Kamensky and Burlin 2004), this approach helps build knowledge from people who have. Above all, a community of practice - a group of people who share a set of problems, or passion about a topic, and who deepen their knowledge and expertise in a given area, by self motivation interacting on an on-going basis(Wenger et al. 2002) - shares a common language that facilitates interaction amongst the members of the community(Al-Sayed and Ahmad 2006). Thus, Spatial data sharing, as transactions in which members of a specific community obtain access from others individuals, organizations or parts to spatial data, its implementation is strongly influenced by inter-organizational sharing (data and knowledge), collaboration is very common. Collaboration in a spatial context has its roots in the participatory planning literature, and involves the inclusion of a wide range of individual perspectives in the decision-making process (Hemmati et al. 2002). Essentially, occurs when people from different organizations produce spatial data or information together through joint effort, resources, and decision making, and share ownership of it. CoP develops implicit ways of working and learning together. In GIS adoption crucial steps to recurrent challenge are commonly shared through conversations and stories among small circles of colleagues and work groups, with members filling in the blanks from their own experience. In this regard, the issue of collaboration and knowledge sharing has significant implications for the successful adoption of GIS. Thus, access to and the sharing of knowledge within and between communities of practice by individuals and groups requires the coordinated management exchange of tacit and explicit knowledge. In this regard, cooperative data sharing among the GIS community members are efficient alternatives that are enabling agencies to maintain data.

3. Research Approach and Methodology This research adopted a case study approach (Yin 2003) to study how knowledge (gained from managing spatial data and practices) is shared among GIS users Mozambique. Case study is preferred in examining contemporary events, when the relevant behaviors cannot be manipulated (Yin 2003). It relies on multiple sources of evidence to add breadth and depth to data collection, to assist in bringing a richness of data together to contribute to the validity of the research (Yin 2003). The strength of this approach is this ability to combine a variety of information sources including documentation, interviews, and artifacts (e.g., technology or tools). Two cases were studied namely: the Geospatial adoption for maternal health management by research group at Medicus Mundi Catalunya in Gaza - Mozambique and the understanding of the practices on spatial data management and sharing between government and non-governmental institutions in Maputo - Mozambique. The study paid special attention to the knowledge sharing between GIS communities. The adopted social network perspective is based on the belief that knowledge sharing takes place through inter-personal interaction. 4. EMPIRICAL FINDINGS This study is based on two case studies performed in Mozambique related to the use of GIS in government and non-government institutions. Specifically it looks on the experience from adopting such technologies for analyzing maternal mortality situation. 4.1. Spatial Data Sharing In Mozambique

A study carried out in selected institutions in Mozambique (presented in Figure 1), in the year of 2009, have confirmed that data collection, and the maintenance of databases, remains the most expensive and time consuming aspect of setting up a major GIS facility. Geospatial data is produced from a wide-ranging group of organizations and entities. Data producers include government and nongovernmental agencies, and individuals. Several methods are used for entering spatial data into a GIS which include: manual digitizing and scanning of analogue maps, image data input and conversion to a GIS, direct data entry including global positioning systems (GPS), and transfer of data from existing digital sources. With the growth of GIS usage in Mozambique, users from each institution often search for spatial data in different places. To acquire some digital sources, users contact the producers directly to gain the necessary data in a compatible format. Most of such data is obtained from Government Agencies such as CENACARTA, INE and CENOE, and other sources. The Worldwide Web is also used by institutions like CENACARTA to provide spatial data. Users access their website and, free of charge and commitment, download the data and use in whatever way they want. The study has also showed that current regulations and procedures within the institutions regarding the adoption of GIS technology are not uniform. For example, one question that was posed to all the interviewers was related to existence of policies on spatial data distribution or sharing. All of them replied saying either, they dont have or dont know about it. It was also clear that the ad-hoc way of sharing data is not linked to specific regulation, or formal procedure. Most of the time, it is linked to the partnerships that exist because most of them are government institutions and also because of social networks that were created among the GIS

professionals in different situations (either while taking courses, for example at faculty or in cross-disciplinary meetings).

Figure 1: Part of GIS Stakeholders in Mozambique

GIS U SER s

C MM

IN E

C EN OE (IN GC )

C EN AC AR TA

DINAPOT (MICOA )

D ATA PR OD U C ER S MIR EMI

D IN AG(MIC OA )

PUBLIC INSTITUTIONS
AR A- SU L

D N OT (MAE ) IIAM (D N TF) IIP INFORM ATION COL L ECTED 1.Gen eral In formation 2 .Curren t GIS Activities 3.Curren t GI Tecn ology In frastructure 4.Data Sharin g & Exchan ge 5.Poten tial Assistan ce (CENACARTA ) 6 .GIS Person n el 7 .Future Plan s

PR IVATE & N ON -GOVER N MEN T IN STITU TION S IN PAC TO U N -H ABITAT FEWS -N ET WH O

WWF

Regarding data sharing the general findings were: Some users do not want to share their practices - including data. The institutions collect and analyze data, then publish the output reports, but leave their practices (data) in proprietary formats. Some do provide their data; however, it misses for quality control instruments. Getting access to spatial data is time consuming activity. Is not easy to know where to fine specific data. Spatial data is not properly archived and are too often archived on isolated hard drives. Thus, initiatives (of creating online repositories) like the one of CENACARTA are an excellent example for bringing data together, to encourage collaboration and sharing. However, the available spatial data lack for metadata. This makes it difficult to qualify if data is of any use. Technology is slowly becoming available to facilitate effective data sharing. However, not many users are used to it and most of them share knowledge base on face-to-face iteration. 4.2. Maternal Health in Mozambique

Maternal Health refers to physical well-being of a woman who is pregnant, and includes prenatal care for women and baby care during childbirth and postpartum services for mother and baby (Arlington 2002). However, motherhood and childhood

are periods of particular vulnerability, requiring special care and assistance[ ]. Being prepared to provide treatment when complications appear is the key to save the life of the mother and newborn (UNFPA 2004). This study is also based on the work done by Medicus Mundi Catalunya in four district health directorates and the provincial health directorates in Gaza (see Figure 2). They support aimed at strengthening the health structures in particular (attention to primary care, training of human resources, infrastructure and equipment). Within this project they identified two (2) priorities, including PMTCT and Safe Motherhood.

Figure 2: Medicus Mundi Maternal Health Research site

Regarding Safe Motherhood it was designed a study protocol with concern about accessibility for pregnant women to health services. The aim was to understand and measure the contribution of factors such as geographic access, resource availability, cultural acceptability, and quality of care to health system coverage. The Medicus Mundi work started by a fieldwork survey and identification of existing health infrastructure and other components for its operation in four districts above-mentioned aiming at creating a database for carrying out of studies with support of a GIS tool. In this work several health units were investigated by the characterization of them in the perspective of use of services by users. Based on the model of three delays, the study indicated that the main determinants of maternal deaths are the one presented in Table 1. Regarding the second delay as presented in the table above the project confirmed what (Granja 2002) have argued that the lack of transport and low quality of antenatal and partum care at peripheral health units are determinants of maternal

mortality. It was also confirmed that the lack of access to and use of essential obstetric care is a crucial factor contributing to maternal mortality (WHO 2007).

Table 1: Causes of Maternal Death in Mozambique

Levels of delay First delay: delay recognition of danger signs and decision to seek care

Second delay: delay in reaching the health facility Third delay: delay in receiving appropriate treatment

Causes Illiteracy or low educational Poverty reflected by lack of piped water, electricity and the unemployment Refusal to take the patient to the clinic Absence or reduced frequency of antenatal Misconceptions about the causes or factors that lead to woman's death Lack of knowledge about the causes of the problem or which led to the death Delay in deciding to go to the clinic. Lack of availability of transport to get to the clinic, including ambulance Long distances translated by long time (several days) Delay in treatment at the facility Delay in receiving appropriate care Inadequate services Inadequate treatment Lack of surgical conditions Lack of staff Absent staff (doctor, nurse and technician surgery) Lack of qualified personnel.

In this project GIS was used as Service Availability Mapping (SAM) tool to perform analysis of data related mostly to the Second delay level of the Three Phases of Delay conceptual framework proposed by (Thaddeus and Maine 1994). The Figure 3 presents a summary of spatial data manipulated within this project, which includes: administrative boundaries (Postos Administrativos), location of health facilities (US/Unidades Sanitarias), rural hospital (Hospital Rural) and referral facility (Sede) for the four districts in case of emergency, distance between one health facility to another, and between one health facility its referral. Its also presented in the map, roads (Estradas) and railway (Linha Ferrea) facilities, the time (Rota das Ambulancias) spent by of ambulances while moving from one health facility to another. The use of GIS tool in this project allowed the easy visualization and consistent monitoring of service availability within and between districts. It was also possible using this tool to monitor and identify the potential inequities in the distribution of health resources. To do so, it was necessary to have spatial data and this was obtained (buying in some cases and getting for free in other) from institutions in Mozambique some presented in the Figure 1 presented earlier. From the data obtained it was possible to notice problems and most of those related to absence of metadata, different map projections, scale, and datum. Part of the spatial data required to perform the needed analysis that was not possible to get from the GIS community members was created by the geographer hired as consultant in the project.

Figure 3: Map showing the time take by the ambulance between health facilities

5. ANALYSIS AND DISCUSSION There is now increasing interest among local institutions in mapping and monitoring their services using GIS tools. The histories presented in the case studies prove this direction. GIS is a specialized case of information systems, in which information is derived from the interpretation of data which are symbolic representation of features (Manguira 1991). Nearly 80 percent of the cost of GIS is in data collection and management (Sugarbaker 1991). The adoption of such tools that connect spatial data to attributes is a large step towards improving service provision efficiency in maternal health field. Study by Medicus Mundi have confirmed what many researchers have been saying that maternal mortality can be reduced if it possible to understand the factors that controls its variables. According to (Thaddeus and Maine 1994), those factors rage from influence of her husband, family members, social norms, educational level, severity of illness, distance, cost and financial opportunities relating to healthcare and experience in relation to health care (Thaddeus and Maine 1994) which are summarized by the three delay model. The study by Medicus Mundi has applied GIS to understand the second delay. By combining different factors in a map

it was possible to create a map (see Figure 3) to be used for the ambulance drivers to decide which routes to use in case of emergency in order to avoid reaching late the referred health facility (the one that provides a service required by a pregnancy woman). Most of the work done by the institutions that makes part of this study is focused only on using GIS tools to manage spatial related problems. This case study has confirmed that in GIS, good decision making is strongly dependent on the collected spatial data. In Mozambique efforts have been articulated by different institutions to collect spatial data. This has been most of the times in isolated manner. Therefore, due to budget constraints, institutions should not afford this. On this regard, obtaining the most current data, then, is a question of resource and a single agency will be unable to provide that on a continued basis. This data limitation can put the GIS users in the midst of a dilemma: not only must they produce information, but also they must do it with available data. The solution should be to ask for spatial data from other members of the community. In this regard, it is clear that there is a need to create an infrastructure where existing information is made available and an understanding of data gaps highlighted to encourage more collection and updates. This infrastructure can be created as a combination of different communities where there is no distinction between government and non-government institutions or individual person. Thus, when end users see that their contributions are shared within the community, they can be motivated to continue providing more information. In order to developing such (knowledge management) infrastructures for long term sustainability it is required that these infrastructures are embedded in the community. Thus, recent works on the knowledge theory arena have highlighted the importance of networks for the exchange and creation of knowledge (Saugene 2010). Such networks include communities of practice, which according to (Wenger 2004) are cornerstones of knowledge management. The CoP concept presented earlier in this paper when applied to the GIS field can provide a robust infrastructure for spatial data collection, access and query, sharing, and updating of knowledge. CoP by integrating multiple forms of knowledge, i.e., knowledge networks; it becomes a suitable approach to be used in developing meaningful solutions to complex problems. As pointed in the maternal mortality case description, the successful adoption of GIS technology for health management is dependent on the available spatial data and the practices which are obtained through collaboration channels. However, those practices are all team-oriented and rely on social interactions. Most of the practices used within the GIS community in Mozambique rely on face-to-face communication this which restricts their use. For many reasons, it is sometimes impossible to have entire GIS community for these meetings. In this regard, reliance on informal knowledge sharing will present challenges. This challenges may be facilitated by negotiation (Obermeyer 1995), a common, super-ordinate goal (Pinto and Onsrud 1995), and clear data ownership (Carter 1992). Hence, distributed teams (networks) and inter-team (inter-networks) knowledge sharing are issues that GIS community must deal with. 6. CONCLUSION The two cases presented in this paper clearly shows that adopting GIS is generally a complex project, compared to the usual system and its successful adoption requires different professionals to work together. Although CENACARTA is

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