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The Institute for Global Health and Development

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/9

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Author: search.filters.author.D’Ambruoso, Lucia

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    Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa
    (Public Library of Science, 2024-07-05) Witter, Sophie; van der Merwe, Maria; Twine, Rhian; Mabetha, Denny; Hove, Jennifer; Tollman, Stephen M.; D’Ambruoso, Lucia
    Background: Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient ‘decision space’ to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa. Methods: This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system. Results: Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity. Conclusions: By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability.
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    Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district
    (BioMed Central, 2023-08-18) D’Ambruoso, Lucia; Abruquah, Nana Akua; Mabetha, Denny; van der Merwe, Maria; Goosen, Gerhard; Sigudla, Jerry; Witter, Sophie
    Background: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. Methods: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs’ perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors’ power to affect devolved decision-making. Results: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall ‘tripe-benefit’ from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. Conclusions: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.
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    Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa
    (Public Library of Science, 2023-07-27) Hove, Jennifer; Mabetha, Denny; van der Merwe, Maria; Twine, Rhian; Kahn, Kathleen; Witter, Sophie; D’Ambruoso, Lucia
    Background: Despite international evidence supporting community participation in health for improved health outcomes and more responsive and equitable health systems there is little practical evidence on how to do this. This work sought to understand the process involved in collective implementation of a health-related local action plan developed by multiple stakeholders. Methods: Communities, government departments and non-government stakeholders convened in three iterative phases of a participatory action research (PAR) learning cycle. Stakeholders were involved in problem identification, development, and implementation of a local action plan, reflection on action, and reiteration of the process. Participants engaged in reflective exercises, exploring how factors such as power and interest impacted success or failure. Results: The local action plan was partially successful, with three out of seven action items achieved. High levels of both power and interest were key factors in the achievement of action items. For the achieved items, stakeholders reported that continuous interactions with one another created a shift in both power and interest through ownership of implementation processes. Participants who possessed significant power and influence were able to leverage resources and connections to overcome obstacles and barriers to progress the plan. Lack of financial support, shifting priorities and insufficient buy-in from stakeholders hindered implementation. Conclusion: The process offered new ways of thinking and stakeholders were supported to generate local evidence for action and learning. The process also enabled exploration of how different stakeholders with different levels of power and interest coalesce to design, plan, and act on evidence. Creation of safe spaces was achievable, meanwhile changing stakeholders’ level of power and interest was possible but challenging. This study suggests that when researchers, service providers and communities are connected as legitimate participants in a learning platform with access to information and decision-making, a shift in power and interest may be feasible.
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    Realising radical potential: building community power in primary health care through Participatory Action Research
    (BioMed Central, 2023-05-17) Mabetha, Denny; Ojewola, Temitope; van der Merwe, Maria; Mabika, Reflect; Goosen, Gerhard; Sigudla, Jerry; Hove, Jennifer; Witter, Sophie; D’Ambruoso, Lucia
    Background: While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component. Methods: Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks. Results: Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district. Conclusions: Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.
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    ‘Voice needs teeth to have bite’! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa
    (Public Library of Science, 2022-10-19) D’Ambruoso, Lucia; Mabetha, Denny; Twine, Rhian; van der Merwe, Maria; Hove, Jennifer; Goosen, Gerhard; Sigudla, Jerry; Witter, Sophie; On behalf of the Verbal Autopsy with Participatory Action Research (VAPAR)/Wits/Mpumalanga Department of Health Learning Platform
    There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community ‘voice’ and initiating dialogue with the authorities, giving the voice ‘teeth’. Achieving ‘bite’, however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative
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    Lessons from community participation in primary health care and water resource governance in South Africa: A narrative review
    (Taylor & Francis, 2022-01-07) Hove, Jennifer; D’Ambruoso, Lucia; Kahn, Kathleen; Witter, Sophie; van der Merwe, Maria; Mabetha, Denny; Tembo, Kingsley; Twine, Rhian
    Background In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services.
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    Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa
    (Taylor & Francis, 2021-09-20) Hove, Jennifer; D’Ambruoso, Lucia; Twine, Rhian; Mabetha, Denny; van der Merwe, Maria; Mtungwa, Ishmael; Khoza, Sonto; Kahn, Kathleen; Witter, Sophie
    Background Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water.
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    Collective reflections on the first cycle of a collaborative learning platform to strengthen rural primary healthcare in Mpumalanga, South Africa
    (BMC, 2021-04-19) van der Merwe, Maria; D’Ambruoso, Lucia; Witter, Sophie; Twine, Rhian; Mabetha, Denny; Hove, Jennifer; Byass, Peter; Tollman, Stephen; Kahn, Kathleen
    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.