Engaging in multi-sectoral collaboration and fostering partnerships: Participatory action research to improve equity and efficiency of health service delivery in Nigeria

Transect Walk with community leaders

By Luret Lar,Ruth Dixon, Laura Dean, Kim Ozano, Sunday Isiyaku, Sally Theobald, Theresa Hoke

Tackling neglected tropical diseases (NTDs) supports achievement of many of the sustainable development goals (SDGs). Their control and elimination reduces poverty (SDG1), leads to good health and well-being (SDG3), which in turn improves access to quality education (SDG4) and through equality (SDG10) driven treatment strategies also promotes gender equality (SDG5). Multi-sectoral programming with water, sanitation and hygiene (WASH), also promotes access to clean water and sanitation (SDG 6). The COUNTDOWN conducted a participatory action research (PAR) cycle that focused on working with actors from across sectors (e.g. education, WASH, civil society organizations, programme implementers at the federal and state level and community members) to enhance equitable engagement of communities with the NTD programme in Nigeria and contribute toward the attainment of the SDGs.  This blog focuses on the benefits of this approach to multi-sectoral planning.

What is participatory action research (PAR)?

PAR is considered a subcategory of action research, which is the methodical collection and analysis of data purposely aimed at identifying problems, taking action and making change based on practical knowledge and experience (Gillis & Jackson, 2002, p.264, Minkler, 2000, p.191). It challenges inequities and power imbalances thus presenting opportunities for empowerment in communities and their health system to instigate social change (Baum et al. 2006, Springett et al. 2016). It ensures an equitable approach to solution findings and ownership of the programme. PAR approaches span many disciplines, such as education, health, community development, adult education, organizational development, agriculture, industry, university-community development, and research with groups of oppressed or marginalized individuals (Greenwood, Whyte & Harkavy, 1993; Selener, 1997; Young, 2006; Maguire, 1987; Varcoe, 2006). Participation is the defining principle throughout the research process.

Given the focus of COUNTDOWN’s research on community engagement strategies and programme planning, PAR which ensures effective use of participatory methods and co-production of solutions with community members was deemed by our partnership to be especially appropriate in Nigeria. The action research approach will not only contribute to conceptualising and developing a clear community engagement plan for implementation to advance NTD programme planning but will also lead to capacity building among planners and implementers. Power imbalances between programme implementers and donors in planning processes are redressed and it allows for ongoing iterative modifications to be made to programme delivery based on the tacit knowledge and understandings of programme implementers with a view to embedding sustainable change. In Nigeria, members of the state NTD team were engaged as co-researchers to facilitate consideration of their priorities in programme development.

PAR conducted to support multi-sectoral NTD programme planning

An earlier situational analysis in Kaduna and Ogun states, identified the need to engage multiple sectors in designing effective NTD programming. We engaged stakeholders from WASH, education, councils, rural and urban organizations and the private sector in the PAR process. The process enabled group reflection on the appropriateness of existing strategies and recommendations for change (Fraun Braun et al. 2006.p854).

Mock training cascade with frontline health facility staff - cropped

(Mock training exercise in Northern Nigeria – February 2018)

Mock training cascades were observed for local level NTD coordinators (LNTDs) by the state NTD team; frontline health facility staff (FLHFs) and teachers (by the trained LNTDs) and community directed distributors; CDDs (by the trained FLHFs) and feedback of such trainings from the trainees. Additional PAR activities (transect walks and community mappings) were conducted with community leaders, younger and older men and women to ensure the voices of communities and vulnerable populations were represented and to support bottom-up planning and solution building. FLHFs, CDDs and teachers gave feedback of the information, education and communication (IEC) materials they used to sensitize community members and children in the communities and these sensitized groups also provided similar feedbacks.

This initial engagement process fostered knowledge exchange between sectors and health system levels and generated an interest in developing a better strategy for community engagement. Preliminary findings from the ongoing PAR cycle show a more innovative and holistic approach to solution-based problem solving. This was real-time, as multiple sectors brought to bear their various experiences in programme implementation to address challenges, gaps and bottlenecks and to leverage and improve on the successes. Without these multiple sectors, such invaluable, collective solutions may be difficult to achieve.

Stakeholders identified relevant community structures that could optimize community engagement.  For example, non-formal Koranic schools for programme sensitization, drinking joints and youth meeting joints were identified as potential structures for mobilisation; and viewing centres/film houses as potential structures for communication, since a lot of youth spend time in these places. Influential members (political office holders and legislators) in the community were identified as potential community members for mass administration of medicines (MAM) and the petrol station as a potential structure for the mechanism to administer medicines, since it was an open area and all community members come there to buy petrol.

Stakeholders also reviewed IEC materials to identify ways to improve health education. One striking discovery was that these materials should be translated to the local language and depict realities the communities face. i.e. most schools do not have functioning toilets and some IECs show the need to have and use toilets, especially in schools. Therefore, it is important for toilets to be provided in schools to depict the messages on the IECs.

We presented results to relevant stakeholders by engaging them during the routine study area planning meetings. Through discussions and presentation of our research findings, the stakeholders developed new action plans for NTD programme delivery which will be implemented in the MAM cycle for 2018. Following this, reflections and revisions will be made ready for the next cycle in 2019. Thus, the planning, action, reflection, action cycle of PAR is continued.

In conclusion, we have found that using innovative participatory research processes meets the needs of the country (Nigeria). We discovered that a PAR approach fosters multi-sectoral collaboration and partnerships smoothing traditional challenges in cross-sector research and allowing for shared programme governance between sectors that enhance progress toward collaborative goals for social development. Engaging health systems actors as co-researchers presents opportunities for capacity strengthening and sustaining the PAR process in future planning cycles.

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