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

虽然全球在减少母亲和新生儿疾病和死亡方面取得了相当大的进展，但撒哈拉以南非洲落后，特别是农村地区。加强农村地区的卫生系统对于实现可持续发展目标3（减少全球母亲死亡率和消除可预防的新生儿死亡）至关重要，因为农村卫生保健服务面临挑战。在农村地区维持有积极性的熟练供应商是所有国家都面临的一个难题，但由于基础设施、生活条件以及道路和通信网络较差，中低收入国家面临的困难更大。不解决农村地区卫生系统面临的独特困难将阻碍可持续发展目标的实现。可持续发展目标的重点是“不让一个人掉队”，因此必须考虑农村卫生系统，这需要有针对性的干预措施，以优化卫生保健工作者的绩效，解决提供护理的瓶颈。加强卫生系统的方法被认为是解决薄弱系统瓶颈的关键。然而，如何有效实施这些干预措施尚不明确。为妇女和新生儿提供高质量的尊重性护理受到保健工作者团队精神、领导能力、沟通、自我效能和资源可用性等因素的影响。在卫生系统薄弱或人力和物力资源不足的地方，可能缺乏提供高质量护理的技能和信心，特别是在农村地区，那里的卫生工作者往往孤立无援。因此，尽管基础设施薄弱，工作条件具有挑战性，但如何最好地支持和激励农村卫生工作者为母亲和新生儿提供高质量和尊重的护理，仍然存在问题。该项目将在农村地区的地区医院和保健中心采用一种潜在的低成本、参与性办法来探讨这些问题。首先，我们将探讨和描述保健工作者，他们的管理人员和妇女在农村地区的护理提供和接收的经验。然后，我们将共同设计和实施参与式学习和行动干预，以加强农村卫生工作者之间的团队合作和领导能力，并促进变革文化，并使卫生工作者具备识别和应对当地挑战的技能，并倡导省政府提供服务所需的额外支持。这种参与性和自下而上的方法可以提高成果的可持续性，因为一线保健工作者可以自主确定挑战和制定解决方案。我们将进行研究，记录应用这种方法的可行性，并确定它是否能够成功地营造解决当地问题的环境，从而提高为妇女和新生儿提供的护理质量。该项目的重点是南非的农村地区，该国孕产妇和新生儿健康指标较差，尤其是在农村地区。了解拟议方法的影响，对于其他国家也是一个经验教训，这些国家也在努力解决如何在财政拮据的条件下为农村人口提供高质量护理的问题，特别是在非洲。南非是一个非常不平等的国家，该国部分地区提供高质量的卫生保健，而其他地区，主要是贫困的农村地区，卫生结果与低收入国家相似。在南非，特别是在农村地区，贫困现象相当严重。然而，南非是探索改善农村地区卫生系统解决方案的可行性和有效性的理想国家，因为其卫生支出中只有2%来自外国援助，允许当地产生解决方案。我们的方法旨在培养地区一级的领导技能、团队精神和解决问题的能力，有可能加强卫生系统，改善对妇女和新生儿的护理。

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.