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Background: Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme—a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa—for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance. Methods: Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017–19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts. Results: Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the VAPAR process. Findings were collated into a revised theory of change. Conclusions: The VAPAR learning platform was regarded as a feasible, acceptable and relevant approach to facilitate cooperative learning and community participation in health systems. The evaluation provides support for a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research.
The evaluation drew on existing links in the provincial and national health systems, informed by the health policy and systems research paradigm. Subscribing to enquiry paradigms asserting that reality is multiple, relative and socially constructed, this emerging field brings social science perspectives to bear on key health system and development issues [29, 30]. On this foundation, a pragmatic and mixed-method approach was applied. Prior to the evaluation, the researchers developed the initial programme theory through a process of reflective exchange and drawing on existing literature as well as their experiences and insights from pilot work in 2015–16 [28]. The programme theory of change articulates the complex interplays between context, mechanisms of change and outcomes. Realism applies the concept of mechanism to understand the relationship between context and outcome—to build insights into what it is about programmes and interventions that bring about effects, for whom, to what extent, under what circumstances and why [31]—and was consequently considered as an appropriate evaluation approach for the programme. Realist methodology can be customized to the needs of participatory research assessment and offers an opportunity to advance theoretical understanding of the processes and contexts of implementation that yield impacts, through refinement of the initial programme theory, by means of a context-mechanism-outcome configuration [32]. South Africa is a medium-sized country with a culturally diverse population estimated at 58.8 million [33]. Eight decades of structural discrimination in favour of a minority population group during apartheid formally ended with the nation’s first democratic election in 1994. Health and economic disparities however remain and are further aggravated by slowing local and global economic prospects in recent years, with resulting persistent high poverty, inequality and unemployment [34–36]. The country is furthermore experiencing a rapid epidemiological transition, with a 26.8% probability of death due to noncommunicable disease before the age of 70 years, while the communicable disease burden remains substantial, and an estimated 7.97 million people are living with HIV [33, 37, 38]. In addition, the overall disease burden remains higher in lower socioeconomic groups due to entrenched structural inequalities [39]. This persistent and widening disproportionate burden of avoidable morbidity and mortality is aggravated by poor access to PHC for poor and rural communities [35, 40]. The research was conducted in Mpumalanga, a rural province in the northeast of South Africa. Mpumalanga is one of nine provinces in the country, with a population of almost 4.6 million, 7.8% of the national population [33]. The VAPAR programme is grounded in a collaboration with the provincial health authority and based at the MRC [Medical Research Council]/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), which hosts the Agincourt health and sociodemographic surveillance system (HDSS) [41]. Established in 1992, the Agincourt HDSS is the longest-running HDSS in South Africa, generating longitudinal data on vital events (deaths, births, migrations) for a population of approximately 120,000 individuals from 31 villages [42]. About a third of the population in the HDSS site are migrants from Mozambique, and socioeconomic and health conditions in the area are characterized by limited piped water and basic sanitation, underdeveloped roads, and high unemployment amidst a high HIV/AIDS and rapidly increasing noncommunicable disease burden [42–44]. The VAPAR programme was co-designed with the provincial Directorate for Maternal, Child, Women and Youth Health and Nutrition (MCWYHN), with continued representation of this directorate as co-investigators in this programme. The programme consists of a series of action-learning cycles to progress intersectoral engagement and to confer power to community stakeholders (Fig. 1). The design of the programme allows for continuous engagement with health officials at different levels and from different sections in the health system, as well as other relevant stakeholders. The study involved three data collection phases: individual discussions with VAPAR programme stakeholders over 2 months (April and May 2019); an interactive workshop with provincial Department of Health (DOH) managers (May 2019); and a workshop with national child health experts (May 2019). Findings from the three phases were reviewed, collated and fed into a revised programme theory. The evaluation focused on specific layers of outcomes from the framework of the initial programme theory in order to systematically identify the context-mechanism-outcome configurations that drive these outcomes. These outcomes included research and stakeholder engagement, organization and delivery of services, establishing an evidence base for policy and planning, and improving health behaviours and outcomes . This phase involved individual face-to-face discussions with 10 stakeholders who had participated in the first cycle of the VAPAR programme. Stakeholders represented the different constituencies in the learning platform. Individual participants were identified through maximum variation sampling and recruited telephonically by the researchers, with a date and venue for individual meetings arranged as suitable for each participant. The participants included five officials from government departments and parastatals, as public entities; two representatives from nongovernmental organizations (NGOs); and three representatives of the local communities involved in the VAPAR programme. The purpose of the individual discussions was to capture personal experiences of and reflections on the programme mechanisms of change, contextual construct and early outcomes. Discussions were facilitated by a VAPAR co-investigator familiar to the participants, with background experience as program manager in the public sector. Informal individual discussions were guided by a discussion framework and focused on the four outcome highlighted above. The facilitator made notes of the key discussion points during the discussions, and the discussions were not recorded. Building on the individual discussions, the second phase involved an interactive workshop with nine managers in the provincial DOH, from programmes and directorates relevant to the health challenges identified by the communities during the pilot phase and first cycle of the programme, including PHC, MCWYHN, HIV/AIDS and tuberculosis, and community-based services. An invitation to the workshop was forwarded to the health authority, with an indication of the relevant programmes, and the final attendees were selected by the health authority. The workshop was facilitated by the researchers and guided by a semi-structured agenda, to allow for discussions to be focused but flexible according to participants’ inputs. Findings from the individual stakeholder discussions (described above) were presented to the workshop participants, along with an initial consideration by the researchers on mechanisms to integrate the learning platform into routine health system processes. This was followed by a discussion on the contexts and mechanisms of change and the outcomes, as reflected in the theory of change framework, of the first cycle and insights for the planning of future programme cycles, as well as the levels and mechanisms for integration of the VAPAR programme into the provincial health system. The levels and functions for integration of the VAPAR programme into the provincial health system was captured and displayed electronically during the provincial workshop, allowing for further deliberation and consensus-building. A report of the workshop was shared with participants for validation. In the third phase, we engaged with five child health experts drawn from the Ministerial Committee on Morbidity and Mortality in Children under five (CoMMiC) from four provinces, as health programme and policy specialists relevant to the health-related challenges identified by community and health system stakeholders. Invitations to the workshop were forwarded to the child health experts individually, and the workshop was arranged at a date and venue convenient for the participants. An interactive workshop was facilitated by the researchers and guided by a semi-structured agenda to allow for contributions and discussions by the participants. An overview of the VAPAR programme was presented, with a focus on the verbal autopsy (VA) innovations regarding the causes and circumstances of avoidable mortality in children under 5 years of age, as well as insights from the participatory action research (PAR) process on how these could be addressed collaboratively. Discussions during the workshop focused on health system research processes and the identification of gaps and opportunities to embed such processes into the health system. A report of the workshop was shared with participants for validation. Notes taken by the researchers on the content of and interaction during the individual stakeholder discussions were summarized and a basic descriptive thematic analysis done for each stakeholder constituency (government, NGO and community representatives), exploring the contexts, mechanisms of change and outcomes as described above. The data were further thematically coded and analysed to identify commonalities and divergences between the stakeholder categories. Data sources, including workshop presentations, notes and outputs, as well as internal programme documents (visual data, social media posts, programme briefs and reports) and data were collated and reviewed by the researchers according to the four identified outcomes prioritized in this evaluation. Following data analysis, the researchers reviewed and revised the initial programme theory of change to reflect stakeholder perspectives as lived experiences from health service providers and users.
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