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

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.

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.