Abstract
Background
Learning platforms can strengthen primary healthcare (PHC) by integrating community knowledge with system decision-making, but evidence on how they work in low-resource settings is limited. This study presents a realist evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) learning platform in rural Mpumalanga, South Africa (2015–25). VAPAR aimed to embed participatory evidence generation and shared learning within routine district processes to support more equitable, community-linked PHC.
Methods
A realist design was used to synthesise data from five action-learning cycles (2017–23), a preceding pilot (2015–16), and an engagement and uptake phase (2023–25). Data included cycle reports, participatory outputs, verbal autopsy (VA) analyses, 22 endline interviews, policy, strategy and planning documents. Using a co-developed theory of change, qualitative data were coded to examine context-mechanism-outcome patterns. Mechanisms were identified and refined through cross-cycle comparison, triangulation, and stakeholder validation.
Results
VAPAR was contextually responsive, adapting to shocks such as COVID-19 and progressively embedding within the district health system. Through regular dialogue, the platform activated generative mechanisms of trust-building, role clarity and recognition, collective sense-making, and strengthened agency, particularly among Community Health Workers (CHWs), whose skills, confidence and legitimacy expanded. These mechanisms operated within an enabling structural context shaped by PHC reforms that strengthened the District Health System and Ward-Based Primary Health Care Outreach Teams, alongside trade-union action for CHW absorption into public service. Institutionalisation followed through Mpumalanga’s revitalised Health Promotion Programme, with adaptation to additional provinces and for outbreak response and emergency obstetric care. Outcomes were interpreted through context-mechanism-outcome patterns, illustrating how participatory learning becomes embedded in decentralised health systems.
Conclusions
Over a decade, VAPAR demonstrated how structured, participatory learning can reshape relationships, strengthen community-linked PHC, and support institutionalisation of routine, evidence-informed practice in decentralised health systems. The findings offer transferable lessons for sustaining learning platforms in resource-constrained settings.
Learning platforms can strengthen primary healthcare (PHC) by integrating community knowledge with system decision-making, but evidence on how they work in low-resource settings is limited. This study presents a realist evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) learning platform in rural Mpumalanga, South Africa (2015–25). VAPAR aimed to embed participatory evidence generation and shared learning within routine district processes to support more equitable, community-linked PHC.
Methods
A realist design was used to synthesise data from five action-learning cycles (2017–23), a preceding pilot (2015–16), and an engagement and uptake phase (2023–25). Data included cycle reports, participatory outputs, verbal autopsy (VA) analyses, 22 endline interviews, policy, strategy and planning documents. Using a co-developed theory of change, qualitative data were coded to examine context-mechanism-outcome patterns. Mechanisms were identified and refined through cross-cycle comparison, triangulation, and stakeholder validation.
Results
VAPAR was contextually responsive, adapting to shocks such as COVID-19 and progressively embedding within the district health system. Through regular dialogue, the platform activated generative mechanisms of trust-building, role clarity and recognition, collective sense-making, and strengthened agency, particularly among Community Health Workers (CHWs), whose skills, confidence and legitimacy expanded. These mechanisms operated within an enabling structural context shaped by PHC reforms that strengthened the District Health System and Ward-Based Primary Health Care Outreach Teams, alongside trade-union action for CHW absorption into public service. Institutionalisation followed through Mpumalanga’s revitalised Health Promotion Programme, with adaptation to additional provinces and for outbreak response and emergency obstetric care. Outcomes were interpreted through context-mechanism-outcome patterns, illustrating how participatory learning becomes embedded in decentralised health systems.
Conclusions
Over a decade, VAPAR demonstrated how structured, participatory learning can reshape relationships, strengthen community-linked PHC, and support institutionalisation of routine, evidence-informed practice in decentralised health systems. The findings offer transferable lessons for sustaining learning platforms in resource-constrained settings.
| Original language | English |
|---|---|
| Article number | 135 |
| Number of pages | 37 |
| Journal | Wellcome Open Res |
| Volume | 10 |
| DOIs | |
| Publication status | Published - 6 Apr 2026 |
Bibliographical note
We would like to thank and acknowledge all participants in VAPAR over its cycles, all interview and workshop participants, and the members of our steering committee, who provided invaluable guidance and review across the years. Portions of the manuscript text were refined using ChatGPT (OpenAI, GPT-5, 2025) for language editing and improving clarity of expression. The tool was not used to generate original scholarly content, data interpretation, analysis, or theoretical argument. All intellectual contributions, interpretations, and conclusions are solely those of the authors. The authors alone remain responsible for the content of this paper. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.Data Availability Statement
Most of the data supporting this article are contained in the article, its tables and supporting references, and the VAPAR website. The transcripts for the final evaluation interviews contain material which could identify individuals, their views and positions and sharing would therefore violate the confidentiality agreement. Applications can be made by email ([email protected]) and would be considered only if transcripts could be heavily redacted to protect identities.Funding
The study was funded by the Joint Health Systems Research Initiative from the Department for International Development/MRC/Welcome Trust/Economic and Social Research Council (MR/P014844/1). The work is nested within the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), supported by the University of the Witwatersrand and Medical Research Council, South Africa. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
| Funders | Funder number |
|---|---|
| Medical Research Council | MR/P014844/1 |
Fingerprint
Dive into the research topics of 'Community and health systems learning: critical realist evaluation of the VAPAR ‘learning platform’ in rural South Africa 2015-25'. Together they form a unique fingerprint.Cite this
- APA
- Standard
- Harvard
- Vancouver
- Author
- BIBTEX
- RIS