Mainstreaming a health systems approach to delivery of maternal health services: transdisciplinary research in Rwanda and South Africa (WOTRO)


The four-year project entitled “Mainstreaming a health systems approach to delivery of maternal health services: Trans-disciplinary research in Rwanda and South Africa” (WOTRO) primarily focuses on gathering knowledge for improving service organisation and delivery for maternal health.

Too many women in low- and middle-income countries (LMICs) still die as a direct result of pregnancy and childbirth, the majority of which are preventable. Most experts believe that strengthening aspects of the health system (as conceptualized in the six WHO building blocks, which include the health workforce; health information systems; leadership and governance; and actual service delivery) is the solution. It is still unclear which building blocks are most important, which interventions within the building blocks offer best value for money, and how interventions in different building blocks influence one another. Another critical but underemphasised aspect for improving maternal health is enabling patients to demand good access to high-quality services.

This project proposes that the key steps needed to improve services in pregnancy include holding maternal health managers accountable for these services and encouraging community participation to thus increase patient demand. In addition, much more is needed to strengthen the skills and team work of public-sector managers to improve these services. The researchers believe that services would be improved through better use of information routinely collected by maternal health services, especially learning from instances of maternal death.


To test this hypothesis, we will thoroughly review the available knowledge on these topics in the academic literature (for all low- and middle-income countries) and in the grey literature (for South Africa, Rwanda and three additional, carefully selected African countries). In Rwanda and South Africa, we will document illustrative cases of successes and failures in maternal health services to identify opportunities for improving the way these services are provided, and to enhance workers’ motivation and leadership. We will study services for treatment of HIV disease in pregnant women and for providing care during emergencies in pregnancy or childbirth.

Through close collaboration with policy leaders and civil society throughout the project, we will take joint actions to improve maternal services. In this way, teams of policy makers and researchers in Rwanda and South Africa will apply knowledge learnt in the project and attempt to markedly improve the way maternal services are organised. In both countries, the major reforms underway and the relative inclusiveness of policy processes mean there are major opportunities to positively influence policy directions and their implementation.


This is a multi-collaborative partnership involving institutions from
• The Netherlands:
- Academic Medical Center, University of Amsterdam & Amsterdam Institute for Global Health and Development (AMC/AIGHD);
- Nijmegen International Center for Health Systems Research and Education, Radboud University, Nijmegen Medical Center, The Netherlands)

• South Africa:
- Gauteng Province, Department of Health;
- School of Public Health, University of the Western Cape;
- Society of Midwives South Africa (SOMSA)

• Kenya:
- Human Rights Watch (HRW)

• Rwanda
- Ministry of Health, Maternal and Child Health, Rwanda
- National University of Rwanda (NUR), Butare, Rwanda
- Projet Ubuzima, Kigali, Rwanda

Capacity Building

The leadership of this innovative project will be significantly southern based, yet enjoying long-standing connections with Dutch partners. This will allow for three-way learning and capacity building, contrasting present approaches to improving maternal health in Rwanda and South Africa with recent experiences in the Netherlands. Capacity building will occur at multiple levels through exchange of skills between senior researchers who will share their expertise in specific areas (e.g. skills in realist reviews reside mainly with UWC, maternal death audits within the Dutch and South African groups, and community organisation and monitoring with Rwanda). Additionally, capacity will be built amongst both research users and junior researchers through involvement in different aspects of the research process and programme.

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