Verbal Autopsy with Participatory Action Research (VAPAR): expanding the knowledge base through partnerships for action on health equity

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Health systems can be considered as the products of human relationships: between patients and health workers, managers and policy makers, communities and governments. As a whole, these relationships establish norms of who is eligible for care and what can be expected from the health system. In poor countries where health services are weak and under-funded, care that is unaffordable and unavailable can become socially normal. Communities and health workers have substantial knowledge of these norms and interactions and how health policy is 'brought alive' through them. Their voices are often overlooked in the routine design and delivery of services however. The project will address this situation by institutionalising processes to: (1) strengthen systems to record and report on deaths, their causes and circumstances; (2) enable the voices of people excluded from access to health systems on their needs and priorities for action, and; (3) act on this information with health workers, managers, planners and policy makers. The process will collect data, analyse, plan and act, and demonstrate an ability to bring about change in partnership with those for whom the situations are most directly relevant. Practical research that is understood and 'owned' by end users in an action-oriented process will strengthen relationships between patients, health workers and policy makers to support and sustain positive change. The research builds on development work providing actionable health information for poor and rural groups in South Africa. Rural villages in South Africa represent many settings in the region, with deeply entrenched poverty, inequality, avoidable illness, and weak health systems where many deaths go undocumented and uncounted. The development work has adapted Verbal Autopsy, a method used in many poor countries to establish the causes of death for people who die without a doctor present. The research has introduced a system to record new information in Verbal Autopsy on factors such as transport and hospital admissions. In developing countries these processes can play a critical role in survival, and documenting them provides important information for health service provision.The development work has also tapped into local knowledge on long standing health problems by building partnerships with communities. Using Participatory Action Research, we have developed understandings of the social issues affecting health, and how these affect people's interactions with care. Participatory Action Research provides a route to involve those in the greatest need in health services. This can empower disadvantaged groups to have more of a say in health systems, in turn strengthening people's abilities to protect and promote their health. We have worked with the health authority throughout, considering what the data are telling us, and how changes can be implemented to respond to the issues identified.The project will extend the development work into an ongoing system of collaborative problem solving, taking data to those who organise and provide services, and working at different levels to understand and enable what is required for change. The work will strengthen existing partnerships with communities, policy makers and planners, and develop new relationships with health workers and clinic managers to act on the evidence towards shared goals. The research will embed a partnerships culture to generate and use information on the realities of health workers and patients to improve care, strengthening access to the health system, achieving improved outcomes and fostering equity in health.The work has been done with a research centre in South Africa established for over 20 years. A team of researchers and policy makers from universities and health authorities in developing and developed countries who have shaped health research and policy in Africa for over 25 years have come together to lead the five year programme.