Extending verbal autopsy: developing routine field surveillance methods to measure and understand burden of disease in low- and middle-income countries
In November 2019 we organised two interactive workshops: (1) with senior managers in the provincial health department, from key programs and directorates including Primary Health Care; Maternal Child, Women, Youth Health and Nutrition; HIV/AIDS and Tuberculosis; and Community Based Services and (2) with child health experts drawn from the Ministerial Committee on Morbidity and Mortality in Children under 5 (CoMMiC) from four provinces, as health program and policy specialists.
The objectives of the workshops were to: (1) evaluate the first complete action learning cycle of of the VAPAR programme; (2) reflect on the process; gain insights and learning for future cycles; and (3) identify opportunities for integration with health system processes as well as future linkages and collaboration.
The first, provincial workshop with participants holding key management positions in the health system and service delivery at provincial, Ehlanzeni district and Bushbuckridge sub-district levels, was held on 28 May 2019 at Ingwenyama Conferencing and Sports Resort in White River, Mpumalanga and was facilitated by VAPAR researchers. The workshop commenced with an overview of the VAPAR programme, data from the pilot and first action learning cycle. This presentation had an overall focus on process with routine mortality drawn from the MRC/Wits/Agincourt HDSS inclusive of novel additions examining circumstances of mortality, developed in response to evidence gaps articulated by the Mpumalanga Department of Health. Findings were also presented, along with an initial consideration of how the VAPAR process could be integrated into routine health system processes. Presentations were followed by a discussion on the impacts of the first cycle and insights for the planning of future programme cycles; as well as the levels and functions for integration of the VAPAR programme into the provincial health system.
The second interactive workshop with child health experts drawn from the Ministerial Committee on Morbidity and Mortality in Children under 5 (CoMMiC) from four provinces, as health program and policy specialists. The workshop was held on 30 May 2019, at the City Lodge, OR Tambo International Airport, Johannesburg and was facilitated by VAPAR researchers. In this workshop, the VAPAR programme was presented, with an overall focus on process with routine mortality drawn from the MRC/Wits/Agincourt HDSS inclusive of novel additions examining circumstances of mortality, developed in response to evidence gaps articulated by the Mpumalanga Department of Health. While the provincial workshop mainly focused on the first learning action cycle, along with a reflection on the process and identification of opportunities for integration with health system processes, discussions during the national workshop primarily focused on potential future linkages and collaboration.
Overall among provincial, and national stakeholders, VAPAR is regarded as a novel and relevant approach to facilitate community engagement and participation in health systems to address exclusion from access to health systems by connecting service users and providers to generate and act on research evidence of practical, local relevance. From the evaluation, the following recommendations are made:
Traditional leaders and faith-based organisations should be part of the programme, as established and recognised community structures;
Clinical operational managers and community health workers to be included at all stages of cycle 2 of the programme, with a focus on skills exchange;
To ensure action, it is recommended to include local municipal managers during the analyse, plan and act stages of prospective cycles;
It is proposed to convene stakeholders at the end of each VAPAR cycle for collective reflection and learning;
VAPAR representatives to participate in routine district and sub-district planning and reporting processes, including development of the district health plan and quarterly performance reporting;
Alignment/integration of VAPAR programme into existing health structures at critical levels of engagement; primarily at household/community (community health workers, ward-based outreach teams) and sub-district (clinic operational managers, PHC supervisors) level;
Focus on community participation/contemporary priorities - support strengthening management model of PHC facility manager into community, and consider other programmatic priorities such as adolescent and mental health;
Refinement of verbal autopsy with regards to place of death/circumstances of mortality construct; as a unique source of this data;
Continued engagement with CoMMiC, reporting on progress and inform future development / application and feeding up into national learning