Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa

Abstract

Following 50 years of apartheid, South Africa introduced visionary health policy committing to the right to health as part of a 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. Our aim was to develop a process generating evidence of practical relevance on implementation processes among people excluded from access to health systems. Informed by health policy and systems research, we developed a collaborative learning platform in which we worked as co-researchers with health authorities in a rural province. This article reports on the process and insights brought by health systems stakeholders. Evidence gaps on under-five mortality were identified with a provincial Directorate after which we collected quantitative and qualitative data. We applied verbal autopsy to quantify levels, causes and circumstances of deaths and participatory action research to gain community perspectives on the problem and priorities for action. We then re-convened health systems stakeholders to analyse and interpret these data through which several systems issues were identified as contributory to under-five deaths: staff availability and performance; service organization and infrastructure; multiple parallel initiatives; and capacity to address social determinants. Recommendations were developed ranging from immediate low- and no-cost re-organization of services to those where responses from higher levels of the system or outside were required. 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 health systems. We developed a process connecting research evidence on rural health priorities with the means for action and enabled new partnerships between communities, authorities and researchers. Further development is planned to understand potential in deliberative processes for rural PHC.

Providers' Definitions of Quality and Barriers to Providing Care: a Qualitative Study in Rural Mpumalanga Province, South Africa

“…Another study from the MRC/Wits-Agincourt Unit identi ed the practice of holding clinics in the mornings leading to ooding the facilities at certain times of day and exacerbating sta ng problems. Those researchers suggested making exible appointments as a no-cost measure to reduce such crowding (17); however, this would require providing additional staff to monitor appointments as well as the materials and space required to support this approach. Another strategy for improvement would be to allocate staff more evenly throughout the week, including weekends, rather than focusing sta ng on Tuesdays-Thursdays as discussed in our research.…”

“…(17) These facilities must now combat deteriorating infrastructure and growing populations. Mpumalanga Department of Health stakeholders have noted that facility maintenance is not within their control, but rather falls under the provincial Department of Public Works, Roads, and Transport (17), thus requiring hard to attain crossdepartmental coordination.…”

“…(8,11) In 2016, a modeling study suggested that of the estimated 97,000 preventable deaths in South Africa, 51,000 (53%) were attributable to poor quality of care, through incorrect management or inability to retain the patient in care, among those utilizing the health system. (16) Research assessing overall health system quality and patient experience has identi ed numerous implementation challenges and de ciencies within the PHC system, including unequal distribution of resources, management and leadership (2,9,17); service delivery issues such as long wait times (2,8,18); and poor hygiene and infection control. (2,19) A number of studies have documented providers' insights into challenges in providing quality care across sub-Saharan Africa.…”

“…(2,19) A number of studies have documented providers' insights into challenges in providing quality care across sub-Saharan Africa. (5,17,(20)(21)(22)(23)(24) Missing from the current literature is an understanding of what providers perceive as quality care, particularly situated within a framework of high quality health systems de ned by the ICRM framework and the Lancet Global Health Commission on High-Quality Health Systems. (11,12) We conducted a qualitative research study within a resource-constrained, rural South African setting to identify what providers de ne as quality care and the barriers they face in providing quality care.…”

Guiding principles for quality, ethical standards and ongoing learning in implementation research: multicountry learnings from participatory action research to strengthen health systems

“…Implementation research frameworks are applied across diverse settings, sectors and disciplines within global health to strengthen the delivery of public health policies and services ( Theobald et al , 2018 ). The increasing demand for real-world, context-specific solutions to implementation problems has led to a growing interest in the co-production of health systems knowledge and learning ( Di Ruggiero and Edwards, 2018 ; D’Ambruoso et al , 2019 ).…”