Learning health systems: fostering participatory learning and action to equip rural health workers as change agents for maternal and newborn care.

Lead Research Organisation: South African Medical Research Council
Department Name: Health Systems Research Unit


Whilst considerable progress has been made in reducing illness and deaths among mothers and newborn babies globally, sub-Saharan Africa lags behind, especially rural areas. Strengthening health systems in rural districts is essential for the achievement of Sustainable Development Goal (SDG) 3, to reduce global deaths amongst mothers and to end preventable deaths of newborns, due to the challenges of rural health care delivery. Maintaining motivated skilled providers in rural areas is a struggle faced by all countries, but is greater in low and middle income countries due to poor infrastructure, living conditions and road and communication networks. Failure to address the unique difficulties faced by health systems in rural areas will prevent the achievement of the SDGs. The SDGs focus of "leaving no one behind" necessitates consideration of rural health systems which require tailored interventions to optimize health care worker performance and address bottlenecks to care provision. Health system strengthening approaches are recognized as key to unlocking bottlenecks in weak systems. However, there is a lack of clarity about how to effectively implement such interventions.

The provision of high quality respectful care for women and newborns is influenced by factors such as health worker teamwork, leadership, communication, self-efficacy and availability of resources. Where health systems are weak, or under-resourced in terms of human and material resources, skills and confidence may be lacking to provide high quality care, particularly in rural areas, where health workers are often isolated and unsupported. Thus questions remain regarding how best to support and motivate rural health workers (HWs) to achieve high quality and respectful care for mothers and newborns despite weak infrastructure and challenging working conditions. This project will explore these questions using a potentially low-cost, participatory approach in district hospitals and health centres in rural districts. First we will explore and describe experiences of care provision and receipt amongst HWs, their managers and women in rural districts. We will then co-design and implement a participatory learning and action intervention to strengthen teamwork and leadership among rural HWs and to foster a culture of change, and equip HWs with skills to identify and address local challenges and to advocate for additional support needed to provide services from the provincial government. Such participatory and bottom-up approaches can improve sustainability of outcomes as front-line HWs take ownership for identifying challenges and developing solutions. We will undertake research to document the feasibility of applying this approach and determine whether it is successful in fostering an environment for local problem solving, and in turn, improving the quality of care provided to women and newborns.

The project's focus will be rural districts in South Africa, a country with poor maternal and newborn health indicators especially in rural areas. Understanding the impact of the proposed approach holds lessons for other countries also grappling with how to provide high quality care to rural populations under financially constrained conditions, particularly in Africa. South Africa is a very unequal country with parts of the country providing high quality health care, whilst others, mostly deprived rural districts, having health outcomes similar to low income countries. There is considerable poverty in South Africa, especially in rural areas. South Africa however is an ideal country to explore the feasibility and effectiveness of solutions to improve rural district health systems, as only 2% of its health expenditure is from foreign aid, allowing locally generated solutions. Our approach which aims to foster leadership skills, teamwork and problem solving at district level, has the potential to strengthen the health system and improve care for women and newborns.

Technical Summary

Our study aims to create a culture of organizational learning within rural health facilities towards maternal and newborn health (MNH) care quality improvements. We will evaluate an innovative health system strengthening approach in rural KwaZulu-Natal, South Africa (SA) using participatory learning and action (PLA) groups. Evaluation sites are two rural districts, comprising 9 district hospitals and 2 community health centres. Districts were selected on the basis of low population density, long distances between levels of care, poor road infrastructure, lack of health resources, and poor MNH indicators.

We will use implementation research methods to co-design and document intervention implementation via a mixed methods approach. A before-after evaluation design will assess the effect of PLA on organizational learning culture and person-centered MNH care. Pre-implementation, in-depth interviews with health personnel at all levels of participating districts exploring challenges of MNH care provision, and interviews with rural women as recipients of care, will inform the development of the intervention.

Baseline and end-line cross-sectional surveys will measure facilities' performance as learning organisations, and womens' experiences of patient-centred MNH care. Two validated tools, 1) Dimensions of Learning Organisation questionnaire, will measure facilities' performance in terms of team learning, management support, and leadership, and 2) the Person-centred Maternity Care score (PCMC) will measure womens' MNH care experiences and their perceptions of newborn care in terms of dignity and respect, autonomy and supportive care. These will provide quantitative measures of change over the implementation period.
A process evaluation using qualitative case study methodology will rigorously document the intervention implementation. An economic evaluation will determine budgetary implications of replicating this intervention routinely in rural districts in SA.


10 25 50
Description Training for a PhD student in the study team
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact Through support from the research team a woman has been successfully registered to begin PhD studies at the University of the Western Cape in the field of public health. Two members of the research team will be providing supervision for the student.
Title Dimensions of a learning organisation tool 
Description This tool which was adapted by our research team seeks to measure teamwork, leadership and cultures of change within organisations (health facilities). This tool was used to obtain a baseline measure of organisational learning within the 11 health facilities that are participating in our project. 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2022 
Provided To Others? No  
Impact We have just completed a survey using this tool amongst 116 health workers in two districts of KwaZulu-Natal. We are in the process of analysing the data and will then write it up for publication. It hs provided important baseline information regarding functioning of the facilities which is helpful in tailoring our intervention. 
Title Person centered maternity care tool 
Description Person centered maternity care tool was adapted by our team to include questions related to respectful newborn care. The tool measures postnatal women's experiences of care in labour and delivery and care of their newborns. This is the first time the tool has been applied to a large sample of women in South Africa. 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2022 
Provided To Others? No  
Impact The survey tool was used in our baseline amongst a sample of 908 women at 6-10 weeks postpartum. It will provide important information on current levels of respectful care and will provide insights into how to focus our intervention with midwives. The data is currently being analysed and will be written up for peer review publication. 
Description STAR study partnership 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Country United Kingdom 
Sector Academic/University 
PI Contribution The SAMRC is the lead institution on this project and LSHTM is one of two partner institutions. The partnership began with the writing of the proposal in 2020. The SAMRC contributes skills in epidemiology and biostatistics as well as being the lead institution on the grant responsible for all reporting.
Collaborator Contribution LSHTM professors bring expertise in obstetric near-miss and advanced qualitative analysis.
Impact The study is in the preparatory stages with current focus on developing the intervention materials. Baseline surveys have been completed amongst health workers and postnatal women.
Start Year 2020
Description Fedeback meeting with KwaZulu-Natal province department of health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact On Monday 13th February we presented to the head of obstetrics, the head of maternal and child health and the head of neonatal nursing for KwaZulu-Natal province. We presented initial findings from the study baseline surveys and discussed our plans for developing the intervention. This was a very useful meeting as we were able to gather information on existing quality improvement initiatives in the province and gain inputs on intervention focus areas from key policy makers and clinicians in the province.
Year(s) Of Engagement Activity 2023
Description Presentation to Umzinyathi district health department 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact On 14th February we gave a presentation to the Umzinyathi district department of health. We presented initial findings from the baseline surveys and sought feedback on the results and inputs on our proposed intervention. This meeting was well attended by health managers in the district and we received important feedback to guide the intervention focus areas.
Year(s) Of Engagement Activity 2023