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Background: This paper presents learnings from the Re-Imagining Technical Assistance for Maternal, Neonatal, and Child Health and Health Systems Strengthening (RTA) project implemented in the Democratic Republic of the Congo and Nigeria from April 2018 to September 2020 by JSI Research & Training Institute, Inc. and Sonder Collective and managed by the Child Health Task Force. The first of RTA’s two phases involved multiple design research activities, such as human-centered design and co-creation, while the second phase focused on secondary analysis of interviews and reports from the design research. This paper explores the limitations of current technical assistance (TA) approaches and maps opportunities to improve how TA is planned and delivered in the health sector. Methods: We analyzed project reports and 68 interviews with TA funders, providers, and consumers to explore in greater detail their perspectives on TA, its characteristics and drawbacks as well as opportunities for improvement. We used qualitative content analysis techniques for this study. Results: The issues surrounding TA included the focus on donor-driven agendas over country priorities, poor accountability between and within TA actors, inadequate skill transfer from TA providers to government TA consumers, an emphasis on quick fixes and short-term thinking, and inadequate governance mechanisms to oversee and manage TA. Consequently, health systems do not achieve the highest levels of resilience and autonomy. Conclusions: Participants in project workshops and interviews called for a transformation in TA centered on a redistribution of power enabling governments to establish their health agendas in keeping with the issues that are of greatest importance to them, followed by collaboration with donors to develop TA interventions. Recommended improvements to the TA landscape in this paper include nine critical shifts, four domains of change, and 20 new guiding principles.
Data sources. This manuscript draws on four project reports and 68 interviews conducted as part of RTA’s HCD approach, described below. We expand on the analysis approach after providing background on the HCD and co-creation processes that constituted the data collection for this project. Human-centered design and co-creation processes. Sonder and JSI facilitated a series of HCD and co-creation processes with individuals in Nigeria and the DRC who have participated in or received TA 19– 20 . This included interviews and workshops to gain a deep understanding of participants’ experiences with TA, reflect on opportunity areas for addressing the issues associated with existing TA practices, and ideate on potential ways to re-imagine TA. Workshops and participant selection. To ensure that the project was firmly rooted in TA experiences in both countries, individuals representing institutions that funded, provided, or sought TA in each country were invited to form a co-creation team to center their TA experiences and ensure ownership of the ideas that would be generated 19 . RTA held three workshops in Nigeria and four in the DRC 19 . Workshops provided a space for participants to share and reflect on their experiences with TA and ways in which it which could be strengthened. Each co-creation team comprised a dozen people who were purposefully selected to represent the federal, state/provincial, or subnational governments, civil society, non-governmental organization (NGOs), and universities. Co-creation team members received reimbursement for their transportation and all workshops included a complementary lunch, morning refreshments, and afternoon coffee. Team members were not paid for accommodation or meals. Detailed field notes were taken both during and after workshops. Interviews and participant selection. As part of the HCD process, the team also conducted 68 one-on-one interviews with individuals representing TA donors and funders, consumers, and providers. The objective of these interviews was to understand the current challenges and future solutions for TA by different TA actors based on the roles they played in the TA landscape. Interview participants were selected using a combination of purposive, convenience, sampling. We first created a list of potential participants organized by TA actor category and involvement in the DRC and Nigeria health sectors. Participants were then approached face-to-face, by telephone, email, and LinkedIn. Interviews were conducted in participants’ workplaces or conference centers where health-sector meetings were being held in Kinshasa and Abuja. Interviews were conducted using prompts and lasted between 30 and 120 minutes. Interviewers and participants were the only people present during interviews. Detailed notes were taken both during and after interviews. All study materials can be found as extended data 25 . Data processing. After each workshop and interview, project staff transcribed verbatim what participants had said and identified topics to use as prompts and guide discussion during subsequent workshops 19 . These findings were frequently verified with participants to obtain feedback before the next workshop. Data collection ceased once data saturation was achieved. DRC and Nigeria data were analyzed separately, then themes common to both countries were identified. All interviews in the DRC were conducted in French by fluent French speakers. To ensure that the integrity of the conversations and the context were maintained, the interviews were then transcribed and translated into English by a French-speaking researcher who was present during the interview. By the end of the final workshop in each country, participants had prioritized the design principles and concepts that would inform their roadmaps for change. The roadmaps consisted of critical shifts needed to transform the current state of TA into an improved future state. The critical shifts were summarized into four broad domains of change (i.e., strengthen the system as a whole, foster strong governance, build on the existing system, and cultivate trust). Each domain of change was then associated with five design principles that captured the underlying issues identified in the workshops and interviews as well as related recommendations for actions to improve TA. RTA’s findings and the roadmap of critical shifts, domains of change, and design principles were presented during a one-day integration meeting that brought together a wider audience, including TA providers, donors, and national and state/provincial representatives who had not participated in the previous workshops. Sonder and JSI produced individual country case studies, an anthropological report on the DRC, and a summary report on both countries 19– 22 . Consent procedures. Verbal consent was sought from all participants during interviews and workshops. They were assured of confidentiality and that all findings would be anonymized. The RTA project received approval from the MOH in both countries to conduct the workshops and interviews. Ethical approval from an institutional review board was not sought since the study was deemed to carry minimal risk for participants given the topic. Secondary analysis of interviews and project reports. For this manuscript, two researchers re-analyzed 68 interviews (29 in the DRC and 39 in Nigeria), two country case studies 19– 20 , an anthropological report on the DRC 21 , and the summary report on both countries 22 to more deeply explore participants’ perspectives on TA, its characteristics and limitations, and roadmaps for change. We applied qualitative content analysis techniques to examine the interview transcripts and project reports. Interviews. To standardize analysis and synthesis of the interviews, we created a codebook with a list of codes and code definitions to be applied to all data. The codes, developed based on the three key questions listed earlier, were created prior to the analyses of interviews for this paper. The codebook was transferred to a Google Sheet to enable access from various locations since the authors of this manuscript were working remotely. We did not use any software for the analysis. Interviews from each country were analyzed and coded separately in the Google Sheet to ensure that country-specific contextual findings were not overlooked. We copied relevant text from the transcripts to the Google Sheet under the relevant codes. We also drew on quotes from the transcripts to illustrate the major themes and reviewed products and reports to verify our findings. Staff analyzing the data met frequently to discuss the codes, confirm their consistent application, and identify themes specific to each country and common across Nigeria and the DRC. In the event that there was inconsistent application of codes, both researchers met to discuss the text under consideration as well as the code definitions and ensured a standard application of codes. The themes identified in this manuscript were derived from the data. Since participants had reviewed and provided feedback on the project reports and validated findings during workshops, this manuscript was not shared back with them for another round of review. Project reports. All project reports were re-read to extract data based on the codes in the Google Sheet used for the interview data analysis. The intent behind analyzing reports was to complement the findings from the interview analyses by identifying themes that were common to those identified in the interviews as well as themes that offered an alternative explanation.
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