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

卫生系统可被视为人际关系的产物：患者与卫生工作者、管理人员与决策者、社区与政府之间的关系。作为一个整体，这些关系确立了谁有资格获得护理以及可从卫生系统获得什么的规范。在卫生服务薄弱和资金不足的贫穷国家，负担不起和无法获得的保健可以成为社会正常现象。社区和卫生工作者对这些规范和相互作用以及如何通过它们使卫生政策“活跃起来”有了充分的了解。然而，在日常的服务设计和交付中，他们的声音往往被忽视。该项目将通过制度化进程来解决这一问题，以便：(1)加强记录和报告死亡、死亡原因和死亡情况的系统；(2)使被排除在卫生系统之外的人能够就其需求和行动重点发出自己的声音；(3)与卫生工作者、管理人员、规划人员和决策者一起根据这些信息采取行动。该过程将收集数据、分析、计划和行动，并展示与那些与情况最直接相关的人合作带来变革的能力。在面向行动的过程中，由最终用户理解和“拥有”的实际研究将加强患者、卫生工作者和决策者之间的关系，以支持和维持积极的变化。这项研究建立在为南非贫困和农村群体提供可操作的卫生信息的发展工作的基础上。南非的农村代表了该地区的许多环境，存在根深蒂固的贫困、不平等、可避免的疾病和薄弱的卫生系统，许多死亡没有记录和统计。开发工作采用了口头尸检，这是许多贫穷国家用来确定没有医生在场的人死亡原因的一种方法。该研究引入了一种系统，可以在口头尸检中记录交通和住院等因素的新信息。在发展中国家，这些过程可在生存方面发挥关键作用，记录这些过程可为提供卫生服务提供重要信息。发展工作还通过与社区建立伙伴关系，利用了当地关于长期存在的卫生问题的知识。通过参与式行动研究，我们对影响健康的社会问题以及这些问题如何影响人们与护理的互动有了了解。参与性行动研究提供了一条途径，使最需要保健服务的人参与进来。这可以使弱势群体在卫生系统中有更多的发言权，从而加强人们保护和促进自身健康的能力。我们一直在与卫生当局合作，考虑数据告诉我们的内容，以及如何实施变革以应对所确定的问题。该项目将把开发工作扩展为一个协作解决问题的持续系统，将数据提供给组织和提供服务的人，并在不同层次上工作，以了解和实现变革所需的东西。这项工作将加强与社区、决策者和规划者的现有伙伴关系，并与卫生工作者和诊所管理人员建立新的关系，以根据证据采取行动，实现共同目标。这项研究将融入一种伙伴关系文化，以产生和使用关于卫生工作者和患者现实的信息，以改善护理，加强获得卫生系统的机会，取得更好的成果并促进卫生公平。这项工作是与在南非建立了20多年的一个研究中心一起完成的。一个由来自发展中国家和发达国家的大学和卫生当局的研究人员和决策者组成的团队在25年多的时间里影响了非洲的卫生研究和政策，他们聚集在一起领导这个五年规划。

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.