Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa

Abstract

Background: Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country's efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems. Methods: We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process. Results: An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change. Conclusion: Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.

Conditions for health system resilience in the response to the COVID-19 pandemic in Mauritania

“…The two units of analysis, purposively selected, were the two Moughataas (ie, health districts) of Dar Naim and Bababé. The purposive selection of the two districts was an opportunistic choice, as both were supported by the AI-PASS programme, and after consultation with the members of the AR team and MoH directorates 37. This allowed us to have adequate prior knowledge and facilitated communication and data collection processes.…”

“…Despite the government’s various reforms and its desire to move towards Universal Health Coverage, the health system faces many challenges. Financial and geographical access remains a major problem (GPHC, National Statistical Office, MoH IRM, 2013; National Social Protection Strategy, MoH IRM, 2008), as does the availability of human resources and the quality of healthcare 33. During the period studied, the country experienced two waves of COVID-19 cases, with an average of 129 cases per day in June and 186 cases per day in December 2020.…”

“…The district of Bababé is a rural area in the south-western part of Mauritania, along the natural border of the Senegal River. The population is estimated at 37 494, with a high overall poverty rate 33 38…”

“…One of the objectives is to build the capacity of local players through an action research (AR) approach. Another is to feed national policies ‘from bottom up’ 33. The programme, funded by the European Commission and the French Development Agency for an initial 4-year period (11th FED), was launched in August 2017 and renewed in 2023 (AI-PASS Enabel, 2017).…”

Implementation evaluation of a leadership development intervention for improved family experience in a private paediatric care hospital, Pakistan

“…Utilizing the action learning approach for leadership development similar to the work by Accoe et al (2020) built on empowering frontline staff and capacity-building [ 24 ], an intervention study (the Patient experience Initiative-PExpI) was conducted at the Aga Khan University Hospital (AKUH) [ 25 ]. The findings indicated benefits by demonstrating improved family experience.…”