A learning platform to address under-five mortality was developed by connecting evidence on rural health priorities with the means for action.
Problems and Purpose
Informed by the health policy and systems research (HPSR) paradigm, a collaborative learning platform was developed in which the Verbal Autopsy with Participatory Action Research (VAPAR) worked as co-researchers with health authorities in Mpumalanga province in rural northeast South Africa. Evidence gaps were identified on under-5 mortality after which they collected quantitative and qualitative data on child deaths.
Their aim was to develop a process generating evidence of practical relevance examining implementation processes among people excluded from access to health systems. The objectives were to develop a collaborative learning platform in which they worked as co-researchers with health authorities, generating evidence on burden of disease and reflecting the priorities and perspectives of community and health systems stakeholders, and eliciting recommendations to address the issues identified.
Background History and Context
Following forty years of apartheid, South Africa introduced visionary health policy committing to the right to health as part of an inclusive, pro-poor primary health care (PHC) approach. Implementation is seriously challenged, however, in an often-dysfunctional health system with scarce resources and a complex burden of avoidable mortality persists. In this scenario, there is an urgent need for evidence on the processes through which policy is implemented for people who are socially excluded from access to health systems.
Organizing, Supporting, and Funding Entities
The research was based at the MRC/Wits Rural Public Health and Health Transitions Research Unit, which hosts the Agincourt Health and Socio-Demographic Surveillance System (HDSS), the longest running HDSS in South Africa.
The partnership was initiated between VAPAR and the Mpumalanga Department of Health (MDoH) through the Stakeholder Engagement Office in Agincourt HDSS, a group with long-term links in different levels and sections of the health system.
Participant Recruitment and Selection
The researchers arranged an initial engagement with the Maternal, Child, Women and Youth Health and Nutrition (MCWYH&N) Directorate of the MDoH on the research, aims and scope, the HPSR approach and proposed a process to work as co-researchers to produce and analyse data of practical relevance.
Methods and Tools Used
The researchers collected quantitative and qualitative data on child deaths in rural villages in the Agincourt HDSS, using:
- Verbal Autopsy
- Participatory Action Research
- Stakeholder Workshops
What Went On: Process, Interaction, and Participation
From the initial engagement, the Mpumalanga Department of Health articulated a lack of timely and robust evidence on contributory circumstances and events occurring outside facilities in under-5 deaths as a priority area on which the Directorate had little information. On this basis, the researchers collected quantitative and qualitative data on child deaths in rural villages in the Agincourt HDSS as follows:
- They applied Verbal Autopsy (VA) to quantify levels, causes and circumstances of deaths to define the size and scope of under-5 deaths.
- They further explored the problems relating to under-5 deaths from community perspectives, through a Participatory Action Research (PAR) process with community stakeholders from the Agincourt HDSS study area, to gain local knowledge on the problem and priorities for action.
- Thereafter, they re-convened provincial DoH stakeholders to analyse and interpret the VA and PAR data and to collaboratively formulate recommendations. This involved two formal workshops, with data collected data in presentations, registers, minutes, observational notes and reflective journal data to develop accounts of interpretations and proposed responses. The analysis was further developed through informal exchanges in person and writing.
Several systems deficiencies were identified as contributory to under-5 deaths: health worker availability and performance; service organisation, infrastructure and emergency response; multiple parallel policy initiatives; and capacity to address social determinants.
Influence, Outcomes, and Effects
Recommendations were developed ranging from immediate low- and no-cost re-organisation of services to those where responses and/or resources from higher levels of the system or outside were required.
While the platform may be a potentially useful approach and closer collaboration and integration appear intuitively useful, more understanding is needed on practicalities of implementation over time, including whether and how research evidence can inform policy, programming and implementation and in terms of ensuring that processes and outcomes are compatible with the goals and values of the institutions involved. On this basis, the researchers secured commitments and support from health systems officials, community stakeholders and funders to sustain and extend the learning platform, and launched the VAPAR programme.
Analysis and Lessons Learned
MDoH stakeholders provided unique interpretations of the VA and PAR data. A series of system wide deficiencies were identified as contributory factors in under-5 deaths and highly context-specific recommendations were developed related to formal and informal spheres of action, influence and change identifying potential leverage points to influence systems performance. It is unlikely that these insights would have been gained with researcher input alone, i.e. without the HPSR-informed approach.
The process was viewed as acceptable and relevant for an overburdened system operating ‘in the dark’ in the absence of local data. Institutional infrastructure for evidence-based decision-making does not exist in many resource-poor health systems.
D'Ambruoso, Lucia, Maria van der Merwe, Oghenebrume Wariri, Peter Byass, Gerhard Goosen, Kathleen Kahn, Sparara Masinga, Victoria Mokoena, Barry Spies, Stephen Tollman, Sophie Witter, Rhian Twine. (2019). "Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa." Health Policy and Planning, 34 (6), p. 418–429.
The original submission of this entry was adapted from D'Ambruoso et al 2019. https//doi: 10.1093/heapol/czz047 under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Please refer to the revision history for a detailed account of subsequent edits and additions made by the Participedia community.
This entry was originally submitted as a method and was converted to a case to meet Participedia's definitional standards.