Action research and health system strengthening: The case of the health sector support programme in Mauritania, West Africa

Health Research Policy and Systems, Volume 18, No. 1, Year 2020

Interpretation

Background: Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country’s efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems. Methods: We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process. Results: An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change. Conclusion: Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level. We adopted a single-case study design and defined the ‘case’ as the health system strengthening approach of the AI-PASS programme in Mauritania. We chose two sites, namely the learning districts (“Moughataas d’Apprentissage”) of Dar Naim and Bababé. These districts were selected as AI-PASS sites on the basis of ITM’s experience and presence in Mauritania. There was a deliberate choice for one rural and one urban area in order to support the Ministry of Health in the implementation and adaptation of its national strategies in rural and urban zones. Both districts indeed present the deficits of the weak governance and low performance of the health system. Further details are described in Additional file 2. The study population of our case study included representatives of the communities and civil society of the two districts and the local, regional and central actors in the Ministry of Health of Mauritania. The case study had the following components: (1) a description of the development of the AI-PASS programme; (2) a description and assessment of the LHS analysis that was carried out in each district; (3) a description and assessment of the capacity-building and empowerment activities conducted in these two districts as a result of the situation analysis; and (4) identification and assessment of the effects of the action research approach. The study period was from mid-2016 to March 2019. Mauritania comprises a territory of more than 1 million km2, with about 4.3 million inhabitants and a low population density. For a decade now, internal migration has increased towards the capital, Nouakchott, where one-third of the population lives. Mauritania has substandard healthcare and problems of geographic inaccessibility. The maternal mortality ratio was estimated at 582/100,000 live births and infant mortality was estimated at 72/1000 live births in 2013 [15]. Healthcare is costly; the out-of-pocket expenditure (out of total health expenditure) is relatively high, at 43% [16]. This considerable cost of healthcare affects the vulnerable populations most, leading to catastrophic health expenditure and increased impoverishment. Currently, 42% of the population (59.4% rural, 20.8% urban) lives below the poverty level and 25.9% (40.8% rural, 7.7% urban) lives below the extreme poverty level [17]. Three methods were used to collect qualitative data. We carried out a document review to collect relevant national policy and programme documents, field visit reports, meeting summaries and workshop results. We conducted semi-structured interviews with key informants. To identify key informants, we used purposive and opportunistic sampling techniques. The selection was based on each informant’s current position and participation in programme activities (Table 1). After 12 interviews, data saturation was achieved. Written informed consent was obtained from all participants during the semi-structured interviews. Interviews were recorded when participants consented. Interviews lasted between 30 and 55 min, and they were conducted in French. An interview guide was elaborated (Additional file 1) and adapted iteratively during the process. Characteristics of interviewees MoH Ministry of Health, AI-PASS Institutional support for health sector strengthening We engaged in participatory observations of meetings, workshops and training sessions, in which local actors and representative authorities (at the local, regional and central levels of the Ministry of Health) participated. All participants were informed orally about the study. We collected data for each step of the case study (Table (Table22). Sources of data for analysing the health system strengthening approach of the AI-PASS programme in Mauritania (mid 2016 – March 2019) AI-PASS Institutional support for health sector strengthening The first recorded interviews were transcribed verbatim by the first author (KA). The remaining interviews were transcribed by an independent translator. All were checked for accuracy by the first author. The interviews were then entered into NVivo 12 software for data management and analysis. We used a thematic coding approach to analyse the primary data. Data from the document review, capturing the capacity-building activities and identified changes, were entered into a NVivo 12 project for analysis. Coding and thematic analyses were carried out by the first author (KA) and checked for accuracy by the last author (BC). An initial coding tree was elaborated deductively, based on our hypothesis and the objectives of the study. The coding tree evolved during the analysis. When we categorised the common elements in the interview transcripts and documents (meeting minutes and visit reports), diverse topics and patterns emerged. Recurrent themes included pathways of change, challenges, identified barriers and recommendations. Reflections of workshops and observations of meetings and trainings were systematically collected in a separate Excel file. By analysing the notes taken by the first author and by discussing experiences with the team members of the programme, these data were used for triangulation. We applied for and received ethical approval from the Institutional Review Board of ITM (Ref N° 1280/19). We received study approval from the Ministry of Health of Mauritania (Ref N° 003/2019).

AI Digest

Study Justification:

– Access to qualitative and equitable healthcare is a major challenge in Mauritania.
– Limited knowledge is available on how policies could enhance the performance of the health system and how multi-stakeholder efforts could lead to changes in health policy.
– The study aimed to analyze the ongoing participatory action research and assess the contribution of action research to strengthening health systems.

Study Highlights:

– Continuous capacity-building and empowerment efforts through a participatory approach have enhanced dialogue and ownership among actors at the local health system level.
– The hierarchical structure and low level of decentralization in the Mauritanian health system posed barriers to innovation.
– Sociocultural and organizational constraints also affected the effectiveness of the health system strengthening program.
– An alignment between the flexible iterative approach of action research and the national linear planning process is challenging.
– Effects on policy formulation and implementation were not observed, but certain conditions such as an adequate time frame, engagement of proactive leaders, sustained dialogue, and a pragmatic, flexible approach could facilitate the process of change.

Recommendations:

– Maintain an inclusive and participatory approach to generate engagement and strengthen capacity.
– Continuously evaluate the processes to measure their development and potential impact on policy.
– Address the hierarchical structure and low decentralization in the health system to promote innovation.
– Overcome sociocultural and organizational constraints to improve the effectiveness of the health system strengthening program.
– Ensure an alignment between the flexible iterative approach of action research and the national planning process.

Key Role Players:

– Representatives of the communities and civil society in the two districts (Dar Naim and Bababé)
– Local, regional, and central actors in the Ministry of Health of Mauritania

Cost Items for Planning Recommendations:

– Capacity-building and empowerment activities
– Training sessions for local actors and representative authorities
– Resources for sustained dialogue and engagement
– Evaluation and monitoring processes
– Administrative and logistical support for participatory observations, meetings, workshops, and training sessions

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a single-case study design and includes qualitative data collected through document analysis, interviews, and participatory observations. The study provides insights into the progress made in two districts and identifies key elements for enhancing dialogue and ownership in the local health system. However, the evidence is limited to the specific context of Mauritania and does not provide direct evidence of the effects on policy formulation and implementation. To improve the strength of the evidence, the study could consider including quantitative data and conducting a comparative analysis with other similar health system strengthening programs. Additionally, expanding the study to include more districts or countries would increase the generalizability of the findings.

Abstract

We adopted a single-case study design and defined the ‘case’ as the health system strengthening approach of the AI-PASS programme in Mauritania. We chose two sites, namely the learning districts (“Moughataas d’Apprentissage”) of Dar Naim and Bababé. These districts were selected as AI-PASS sites on the basis of ITM’s experience and presence in Mauritania. There was a deliberate choice for one rural and one urban area in order to support the Ministry of Health in the implementation and adaptation of its national strategies in rural and urban zones. Both districts indeed present the deficits of the weak governance and low performance of the health system. Further details are described in Additional file 2. The study population of our case study included representatives of the communities and civil society of the two districts and the local, regional and central actors in the Ministry of Health of Mauritania. The case study had the following components: (1) a description of the development of the AI-PASS programme; (2) a description and assessment of the LHS analysis that was carried out in each district; (3) a description and assessment of the capacity-building and empowerment activities conducted in these two districts as a result of the situation analysis; and (4) identification and assessment of the effects of the action research approach. The study period was from mid-2016 to March 2019. Mauritania comprises a territory of more than 1 million km2, with about 4.3 million inhabitants and a low population density. For a decade now, internal migration has increased towards the capital, Nouakchott, where one-third of the population lives. Mauritania has substandard healthcare and problems of geographic inaccessibility. The maternal mortality ratio was estimated at 582/100,000 live births and infant mortality was estimated at 72/1000 live births in 2013 [15]. Healthcare is costly; the out-of-pocket expenditure (out of total health expenditure) is relatively high, at 43% [16]. This considerable cost of healthcare affects the vulnerable populations most, leading to catastrophic health expenditure and increased impoverishment. Currently, 42% of the population (59.4% rural, 20.8% urban) lives below the poverty level and 25.9% (40.8% rural, 7.7% urban) lives below the extreme poverty level [17]. Three methods were used to collect qualitative data. We carried out a document review to collect relevant national policy and programme documents, field visit reports, meeting summaries and workshop results. We conducted semi-structured interviews with key informants. To identify key informants, we used purposive and opportunistic sampling techniques. The selection was based on each informant’s current position and participation in programme activities (Table 1). After 12 interviews, data saturation was achieved. Written informed consent was obtained from all participants during the semi-structured interviews. Interviews were recorded when participants consented. Interviews lasted between 30 and 55 min, and they were conducted in French. An interview guide was elaborated (Additional file 1) and adapted iteratively during the process. Characteristics of interviewees MoH Ministry of Health, AI-PASS Institutional support for health sector strengthening We engaged in participatory observations of meetings, workshops and training sessions, in which local actors and representative authorities (at the local, regional and central levels of the Ministry of Health) participated. All participants were informed orally about the study. We collected data for each step of the case study (Table (Table22). Sources of data for analysing the health system strengthening approach of the AI-PASS programme in Mauritania (mid 2016 – March 2019) AI-PASS Institutional support for health sector strengthening The first recorded interviews were transcribed verbatim by the first author (KA). The remaining interviews were transcribed by an independent translator. All were checked for accuracy by the first author. The interviews were then entered into NVivo 12 software for data management and analysis. We used a thematic coding approach to analyse the primary data. Data from the document review, capturing the capacity-building activities and identified changes, were entered into a NVivo 12 project for analysis. Coding and thematic analyses were carried out by the first author (KA) and checked for accuracy by the last author (BC). An initial coding tree was elaborated deductively, based on our hypothesis and the objectives of the study. The coding tree evolved during the analysis. When we categorised the common elements in the interview transcripts and documents (meeting minutes and visit reports), diverse topics and patterns emerged. Recurrent themes included pathways of change, challenges, identified barriers and recommendations. Reflections of workshops and observations of meetings and trainings were systematically collected in a separate Excel file. By analysing the notes taken by the first author and by discussing experiences with the team members of the programme, these data were used for triangulation. We applied for and received ethical approval from the Institutional Review Board of ITM (Ref N° 1280/19). We received study approval from the Ministry of Health of Mauritania (Ref N° 003/2019).

Materials

Innovations

Based on the provided information, it is difficult to determine specific innovations for improving access to maternal health. However, some potential recommendations based on the study’s findings could include:

1. Strengthening capacity-building and empowerment efforts: Continuously investing in training and empowering healthcare providers and community members can enhance their ability to provide quality maternal health services and engage in decision-making processes.

2. Promoting participatory approaches: Encouraging the active involvement of local communities, civil society organizations, and other stakeholders in the planning, implementation, and evaluation of maternal health programs can improve access and ensure that services meet the needs of the population.

3. Addressing sociocultural and organizational barriers: Recognizing and addressing sociocultural norms and organizational challenges that hinder access to maternal health services is crucial. This may involve sensitization campaigns, community dialogues, and policy changes to promote gender equality and women’s rights.

4. Strengthening health system governance and decentralization: Addressing the hierarchical structure of the health system and promoting decentralization can improve decision-making processes, resource allocation, and service delivery at the local level, leading to better access to maternal health services.

5. Enhancing collaboration and coordination: Facilitating effective collaboration and coordination among different stakeholders, including government agencies, NGOs, and international partners, can improve the efficiency and effectiveness of maternal health programs and ensure comprehensive care for women.

It is important to note that these recommendations are based on the study’s findings in Mauritania and may need to be adapted to the specific context and needs of other countries or regions.

AI Innovations Description

The recommendation to improve access to maternal health based on the described case study is to implement participatory action research and health system strengthening approaches. This involves engaging local communities, civil society, and stakeholders at the local, regional, and central levels of the Ministry of Health in Mauritania.

Key elements of this recommendation include:

1. Capacity-building and empowerment: Continuous efforts should be made to build the capacity of healthcare providers and empower local communities to actively participate in decision-making processes related to maternal health.

2. Dialogue and ownership: Enhancing dialogue and fostering ownership among actors at the local health system level is crucial. This can be achieved through participatory approaches that involve all relevant stakeholders in the decision-making process.

3. Overcoming barriers: The hierarchical structure of the Mauritanian health system and its low level of decentralization pose significant barriers to innovation. Efforts should be made to address these barriers and promote a more flexible and inclusive approach to policy formulation and implementation.

4. Time frame and sustained dialogue: An adequate time frame should be allocated for the implementation of action research and health system strengthening initiatives. Sustained dialogue between stakeholders is essential for maintaining momentum and ensuring the long-term success of these initiatives.

5. Pragmatic and flexible approach: A pragmatic and flexible approach should be adopted to adapt to the complex and dynamic nature of health systems. This includes adjusting strategies and interventions based on emerging insights and feedback from stakeholders.

By implementing these recommendations, it is expected that access to maternal health in Mauritania can be improved, leading to a reduction in maternal and infant mortality rates, as well as a decrease in healthcare costs for vulnerable populations. Continuous evaluation is necessary to measure the impact of these processes and their potential effects at the policy level.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening capacity-building and empowerment efforts: Continuously investing in training and empowering healthcare providers and community members can enhance their skills and knowledge, leading to improved access to maternal health services.

2. Promoting participatory approaches: Engaging local communities, civil society organizations, and other stakeholders in decision-making processes can foster ownership and strengthen capacity at the local level, ultimately improving access to maternal health services.

3. Addressing sociocultural and organizational barriers: Recognizing and addressing sociocultural norms and organizational barriers that hinder access to maternal health services is crucial. This may involve sensitization campaigns, cultural competency training for healthcare providers, and addressing gender inequalities.

4. Improving work ethics and environmental support: Creating a supportive work environment and addressing issues related to work ethics can contribute to better access to maternal health services. This may involve improving working conditions, providing incentives, and strengthening supervision and accountability mechanisms.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators that reflect access to maternal health services, such as the number of antenatal care visits, skilled birth attendance, and postnatal care coverage.

2. Baseline data collection: Collect data on the selected indicators before implementing the recommendations. This will serve as a baseline for comparison.

3. Implement recommendations: Implement the recommended interventions, such as capacity-building programs, participatory approaches, and addressing sociocultural and organizational barriers.

4. Monitoring and evaluation: Continuously monitor and evaluate the implementation of the recommendations. This can involve collecting data on the selected indicators at regular intervals.

5. Data analysis: Analyze the collected data to assess the impact of the recommendations on the selected indicators. This can be done using statistical methods to compare the baseline data with the data collected after the implementation of the recommendations.

6. Interpretation and reporting: Interpret the findings of the data analysis and report on the impact of the recommendations on improving access to maternal health services. This can include identifying areas of improvement, lessons learned, and recommendations for further action.

By following this methodology, it is possible to simulate the impact of the recommended interventions on improving access to maternal health and inform future decision-making processes.

Authors & Co-Authors

Statistics:

Citations: 2

Authors: 6

Identifiers:

DOI: 10.1186/s12961-020-0531-1

Research Areas:

Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Mauritania

Study Design:

Case Study, Cross Sectional Study

Study Approach:

Mixed-methods, Qualitative