Collective reflections on the first cycle of a collaborative learning platform to strengthen rural primary healthcare in Mpumalanga, South Africa

Health Research Policy and Systems, Volume 19, No. 1, Year 2021

Interpretação

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.

AI Digest

Study Justification:

The study evaluates the Verbal Autopsy with Participatory Action Research (VAPAR) program, which is a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa. The program aims to strengthen rural primary healthcare systems by generating and acting on research evidence of practical, local relevance. The evaluation provides support for the use of a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research.

Highlights:

– The VAPAR program has shown early outcomes related to effective research and stakeholder engagement, organization and delivery of services, establishment of an evidence base for local policy and planning, and improved health outcomes.
– The program has the potential to support engagement between communities and health authorities for collective planning and implementation of services.
– The evaluation highlights the feasibility, acceptability, and relevance of the VAPAR learning platform in facilitating cooperative learning and community participation in health systems.

Recommendations:

– Integrate VAPAR stakeholders into routine health planning and review activities.
– Involve frontline health officials in the VAPAR process.
– Continue to strengthen research and stakeholder engagement, organization and delivery of services, and the establishment of an evidence base for policy and planning.
– Expand the use of the collaborative learning platform to other areas and contexts.

Key Role Players:

– Government departments and parastatals
– Non-governmental organizations (NGOs)
– Local communities
– Provincial and district Department of Health managers
– National child health experts

Cost Items for Planning Recommendations:

– Training and capacity building for stakeholders
– Communication and dissemination activities
– Data collection and analysis
– Program coordination and management
– Monitoring and evaluation activities
– Stakeholder engagement and participation initiatives
– Infrastructure and technology support for the collaborative learning platform

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed-method evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme in Mpumalanga, South Africa. The evaluation included individual interviews with stakeholders, workshops with provincial and national health officials, and data analysis. The findings suggest positive outcomes related to research and stakeholder engagement, organization and delivery of services, and the establishment of an evidence base for policy and planning. However, the abstract does not provide specific details about the sample size, data collection methods, or statistical analysis. To improve the strength of the evidence, the authors could provide more information on the research design, sample characteristics, and statistical significance of the findings.

Resumo

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.

Materiais

N/A

Inovações

Based on the information provided, it is difficult to determine specific innovations for improving access to maternal health. However, some potential recommendations based on the evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) program in Mpumalanga, South Africa, could include:

1. Integration of the VAPAR program into routine health system processes: This could involve incorporating the program’s collaborative learning platform into existing health planning and review activities, allowing for continuous engagement with health officials at different levels and from different sections in the health system.

2. Strengthening stakeholder engagement: The VAPAR program could further enhance its research and stakeholder engagement efforts to ensure that the voices and priorities of community members, health service providers, and government departments are effectively incorporated into decision-making processes.

3. Establishing an evidence base for local policy and planning: The program could continue to generate research evidence that is of practical and local relevance, focusing on maternal health outcomes and interventions. This evidence could then be used to inform policy and planning decisions at the local level.

4. Improving organization and delivery of services: The VAPAR program could explore ways to improve the organization and delivery of maternal health services in rural areas, taking into account the specific challenges and needs of these communities. This could involve implementing innovative approaches such as mobile clinics, telemedicine, or community health worker programs.

It is important to note that these recommendations are based on the limited information provided and may not fully capture the potential innovations that could be implemented to improve access to maternal health. Further research and consultation with relevant stakeholders would be necessary to develop more specific and tailored recommendations.

AI Innovations Description

Based on the provided description, the recommendation to improve access to maternal health is to further develop and integrate the Verbal Autopsy with Participatory Action Research (VAPAR) program into routine health system processes. This collaborative learning platform, embedded in the local health system in Mpumalanga, South Africa, aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance.

The recommendation includes the following steps:

1. Strengthen stakeholder engagement: Continue to involve government departments, parastatals, non-governmental organizations (NGOs), and local communities in the VAPAR program. This will ensure that diverse perspectives and expertise are considered in the development and implementation of maternal health initiatives.

2. Enhance organization and delivery of services: Use the research evidence generated through the VAPAR program to improve the organization and delivery of maternal health services. This may involve identifying gaps in service provision, implementing innovative approaches, and addressing barriers to access.

3. Establish an evidence base for policy and planning: Build on the research findings from the VAPAR program to inform local policy and planning related to maternal health. This will help ensure that decision-making is evidence-based and tailored to the specific needs of the community.

4. Promote community participation in planning and implementation: Facilitate engagement between communities and health authorities to collectively plan and implement maternal health services. This can be achieved through two-way integration, with VAPAR stakeholders participating in routine health planning and review activities, and frontline health officials being involved in the VAPAR process.

By implementing these recommendations, the VAPAR program can contribute to improving access to maternal health services, addressing health disparities, and promoting community participation in the health system.

AI Innovations Methodology

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

1. Mobile Clinics: Implement mobile clinics that can travel to remote and underserved areas to provide maternal health services. These clinics can offer prenatal care, postnatal care, and family planning services, making it easier for women in rural areas to access essential healthcare.

2. Telemedicine: Utilize telemedicine technologies to provide virtual consultations and support for pregnant women in remote areas. This can help overcome geographical barriers and provide timely advice and guidance to expectant mothers.

3. Community Health Workers: Train and deploy community health workers who can provide basic maternal health services and education within their communities. These workers can conduct home visits, provide health education, and refer women to appropriate healthcare facilities when necessary.

4. Maternal Health Vouchers: Introduce a voucher system that provides financial assistance to pregnant women, especially those from low-income backgrounds, to cover the costs of maternal health services. This can help reduce financial barriers and ensure that all women have access to necessary care.

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

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations. These could include metrics such as the number of women receiving prenatal care, the percentage of women delivering in healthcare facilities, and the maternal mortality rate.

2. Collect baseline data: Gather data on the current state of maternal health access in the target area. This can include information on the number of healthcare facilities, the availability of services, and the utilization rates.

3. Simulate the interventions: Use modeling techniques to simulate the implementation of the recommendations. This can involve estimating the number of mobile clinics needed, the coverage area of telemedicine services, the number of community health workers required, or the projected uptake of maternal health vouchers.

4. Analyze the impact: Use the simulated data to assess the potential impact of the recommendations on the defined indicators. This can involve comparing the projected outcomes with the baseline data to determine the potential improvements in access to maternal health.

5. Refine the interventions: Based on the analysis, refine the recommendations if necessary. This could involve adjusting the number of mobile clinics, expanding the coverage area of telemedicine services, or modifying the voucher system to better meet the needs of the target population.

6. Monitor and evaluate: Implement the recommended interventions and continuously monitor and evaluate their impact. This can involve collecting real-time data on the indicators and making adjustments as needed to ensure the desired outcomes are achieved.

By following this methodology, stakeholders can gain insights into the potential impact of the recommendations on improving access to maternal health and make informed decisions on their implementation.

Autor

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1186/s12961-021-00716-y

Research Areas:

Community Interventions, Disparities, Environmental, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Social Determinants, Technology and Innovations

Study Countries:

Mozambique, Multi-Countries, South Africa

Study Design:

Cohort Study, Cross Sectional Study, Exploratory Study, Grounded Theory, Phenomenological Study

Study Approach:

Qualitative

Participants Gender:

Female

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