Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
AI-PASS Programme (Institutional Support for Health Sector Strengthening), Enabel - Belgian Development Agency, Nouakchott, Mauritania.
Health Res Policy Syst. 2020 Feb 19;18(1):25. doi: 10.1186/s12961-020-0531-1.
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.
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.
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.
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.
在毛里塔尼亚，获得高质量且公平的医疗保健服务是一个重大挑战。为了支持该国的努力，建立了一个以参与式行动研究为核心的卫生部门加强方案。加强卫生系统需要采取定制和全面的方法来应对卫生系统固有的复杂性。然而，对于政策如何提高系统绩效以及多利益攸关方的努力如何促成卫生政策的变化，人们知之甚少。我们旨在分析正在进行的参与式行动研究，更具体地说，研究行动研究作为一种嵌入式研究方法能够在多大程度上有助于加强卫生系统。
我们采用了单一案例研究设计，基于两个分析单元，即两个选定的区。通过分析国家和方案文件、进行 12 次半结构化访谈和进行参与式观察收集定性数据。根据他们目前的职位和参与方案的情况选择访谈对象。数据分析旨在解决研究目标，但根据新出现的见解以及通过三角测量和识别整个过程中出现的和/或反复出现的主题进行了演变。
对两个区进展的评估表明，通过参与式方法进行持续的能力建设和赋权努力一直是加强地方卫生系统各级行为体之间对话和所有权的关键要素。然而，毛里塔尼亚卫生系统的强层次结构及其低程度的权力下放是创新的重大障碍。其他限制因素具有社会文化和组织性质。由于环境支持系统薄弱而导致的不良职业道德也发挥了重要作用。虽然旨在使行动研究的灵活迭代方法与普遍的国家线性规划过程保持一致是相当具有挑战性的，但没有观察到对政策制定和实施的影响。足够的时间框架、积极主动的领导者的参与、持续对话的维持以及务实、灵活的方法可以进一步促进变革进程。
我们的研究表明，在满足某些条件的情况下，毛里塔尼亚使用的行动研究方法可以引导地方和国家行为体在卫生系统加强方案中实现变革。包容性、参与性的方法会产生参与的动力，从而能够促进所有权和加强能力。需要不断评估这些进程如何进一步发展，并假设在政策层面可能产生影响。
