A mother in Kamuli district smiles with her new baby after using the voucher scheme for transport to a local health facility to access a safer delivery.
There were many methodologically focused sessions during the 2nd Sympsoium on Health Systems Research, including several focusing on more qualitative methods. Future Health Systems participated in one on participatory action research, highlighting their research in Easter Uganda to help improve mothers’ access to safe deliveries. Below are some reflections from the two FHS participants.
HARRIET NAYIGA, SENIOR NURSING OFFICER, KAMULI DISTRICT
What are my responsibilities as part of the District Health Management Team (DHMT) in Kamuli District?
My responsibilities include: the planning, soliciting, receiving and distributing of additional resources for district health needs; monitoring and providing feedback on the implementation of programs; and providing supportive supervision, mentoring and coaching to health providers so as to improve the quality of health care services provided. I have been a senior nursing office for many years and more recently part of the DHMT.
What have I learned from the panel on action research and being at the conference?
It has been an educative experience for me, pushing me to think how best I am learning, doing, improving. Action research has enriched our program as it makes us think broadly, strengthens our planning, makes us prioritize the issues of concern. It has made me think of contingency plans required, to come up with a plan B, in case things change. It has made me consider things not usually talked about, such as what the community is doing today and tomorrow, rather than always depending on technocrats, especially when concerned about sustainability. The conference has been a wide, wide, wide exposure. It has made me think out of the box. I have done a,b,c, now what about d? What can I share with others and contribute?
ASHA GEORGE, ASSISTANT PROFESSOR, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH
What was I presenting at the symposium?
I have been working with Makerere University and Ministry of Health, Uganda over the past year while they have been re-strategising the Safe Deliveries project to ensure more local action, ownership and sustainability. We strengthened our skills in participatory action research and undertook a series of dialogues at national, district and community level in iterative phases with multiple stakeholders including adolescent mothers, male partners, transport workers, local leaders and other district and national officials. We first discussed the current project and identified challenges or issues that had to be addressed to support local action, ownership and sustainability. After identifying the most important challenges, we worked with stakeholders to brainstorm possible strategies to address the challenges and prioritize them in order of feasibility.
What did I learn from the action research panel?
While I was familiar with action research used by those involved in community health, I was very impressed by the number of health systems researchers engaged with action research methodology at the conference and in the panel audience. It was motivating to know that one is not working in isolation.
I realized that we got lost in the challenge of documenting the process (number of meetings, at what stage, with whom) and failed to present how participatory action research is particularly suited for addressing power relations. I perceived our team addressing power by being critically aware of who is involved and what is discussed. Despite the success of the voucher scheme in increasing women’s access to facility services, through this participatory process the following issues were identified as being critical: lack of male engagement in supporting women’s health savings or decision making; low awareness by women of their entitlements; community transport and savings systems still requiring strengthening; and poor quality of care at facilities, including providers being rude, insisting on unofficial payments and making women delivery in positions that ran contrary to their local social norms. Makerere played a critical role in consulting with marginalized groups on their own, before facilitating dialogues that included their participation with other more powerful stakeholders, and ensuring that the issues they raised didn’t get swept under the table. Most striking were my memories of local religious leaders and politicians; as their involvement was not always a one way monologue. Interestingly, the district managers on the panel discussed power in a different way. While I as a researcher was concerned about how power can exclude stakeholders and their concerns or stereotype them in frames that perpetuate their marginalization, the district managers viewed power as a positive force. They felt it was their responsibility to unleash power at every level to support positive change.
It was striking to see the commonalities across the projects presented. That action research helped to change perceptions of district managers reorienting them to more community and public health needs; foster trust relationships; and provide a space to focus, reflect and support more strategic planning in the middle of routines and environments that are more typically characterized by diminished resources, competing demands, overburdened workloads.
Valuable concerns raised by the audience included:
- the duration of time or number of action cycles that needed to be undertaken to see effects
- similarities between action research and quality improvement cycles
- whether action research efforts stay on islands of excellence or whether the skills seep into other areas of practice
- the challenge of generalizing the experience to other contexts
- the challenge of influencing change at levels higher than where the action research initiatives are taking place, especially when higher level officials maybe less process oriented and more demanding for visible, quick results
Most striking for me was realizing the experience it takes to know when to follow the rules or power configurations and when to break them. It was sobering to recognize how challenging it is to present such a rich experience amidst strangers in a foreign land far from the familiar. It takes time to open up, understand and trust one another in order to freely discuss all the questions and issues that arose from the panel and audience interacting. The room was full of ideas, energy, questions, experiences and it seemed rather unfair but entirely understandable and pragmatic decision to stay within the time constraints that bounded the panel. No doubt the discussions sparked and intrigued interests that will go beyond the boundaries of the panel workshop and conference.