BLOG: Action Research – developing windows of opportunity to strengthen governance for equitable health systems

Friday, 09 Nov 2012

By Sally Theobald, PERFORM Consortium, Liverpool School of Tropical Medicine, UK

Despite some commentators likening the recent Symposium on Health Systems Research to the International AIDS Conference it remains a forum dominated by the  voices of academics rather than a space where a diverse range of stakeholders come together.

Perhaps as a result of this there was a distinct call at the conference for more representation and participation from both health workers and policy makers in the constitution of Health Systems Global, a new organisation born in Beijing last week. We need multiple voices and perspectives at the table to debate both the theory and practice of strategies to promote universal health coverage.

I attended one panel in Beijing where health workers’ voices and experiences emerged loud and clear. “Governance improvement: The role of action research and reflective practice” was chaired by Lucy Gilson who opened the session by explaining that Action Research is a core part of the panoply of health systems research, providing us with the opportunity to learn from and work with tacit knowledge from managers, providers and communities.

Three different projects were discussed. First, the MANIFEST project in Uganda, which focuses on maternal and new born health. Second was PERFORM, which uses action research to test out strategies to support staff performance in health at district level in Uganda, Tanzania and Ghana. Third was DIAHLS, from Cape Town in South Africa, which explores how the micro practice of governance can be strengthened to support the improvement of primary health care.

For each project we heard the academic perspective (Asha George for MANIFEST, Freddie Ssengooba for PERFORM, and Lucy Gilson for DIAHLS) followed by the perspective of three women health workers and managers who are participating in the action research projects – Soraya Elloker, Sub-District Manager, City of Cape Town, South Africa, Juliana Jocelyn Ama Nimo, District Director of Health Services, Ghana Health Service, Ghana and Harriet Nayiga Muwonge, Senior Nursing Officer, Kamuli District Local Government, Uganda. In the context of the PERFORM project in Ghana, Juliana explained “with the action research… you are identifying your own problems, selecting your own strategies to solve them and being supported in how you apply them. It is also very flexible, you can change things as you need do.”

Whenever I teach Action Research or attend meetings on the topic, the question of generalisability always emerges. How applicable can the research be to other contexts? This came up again in the panel. I found listening to the grounded perspectives of the health worker managers very insightful. Yes – of course – there are always differences in experience and context. But in terms of developing and sustaining space for action to support governance for equitable health systems, there were interesting conceptual parallels.

The engaging discussions revealed shared concepts around how to strengthen the micro practice of health governance and accountability at district level – arguably the glue of a health system – to support the delivery of equitable health care. Common areas discussed  include the importance of learning from and “consulting with” diverse community perspectives, creating collaborative problem solving spaces, using a wide range of information and knowledge, encouraging reflective practice, and bringing new ways of working to challenge and improve hierarchical health systems where gender and power interplay.

We came away from the panel discussion confident that learning from and adapting promising practices from different contexts – those that support local governance, ownership and accountability – is an important step in the journey towards universal health coverage.