RESEARCH Open Access Engaging Stakeholders: Lessons From .
Ekirapa-Kiracho et al. Health Research Policy and Systems 2017, 15(Suppl 2):106DOI 10.1186/s12961-017-0271-zRESEARCHOpen AccessEngaging stakeholders: lessons from theuse of participatory tools for improvingmaternal and child care health servicesElizabeth Ekirapa-Kiracho1*, Upasona Ghosh2, Rittika Brahmachari2 and Ligia Paina3AbstractBackground: Effective stakeholder engagement in research and implementation is important for improvingthe development and implementation of policies and programmes. A varied number of tools have beenemployed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging withstakeholders – participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based onour experience, we derive lessons about when and how to apply these tools.Methods: This paper was informed by a review of project reports and documents in addition to reflection meetingswith the researchers who applied the tools. These reports were synthesised and used to make thick descriptions of theapplications of the methods while highlighting key lessons.Results: PSNA and PIPA both allowed a deep understanding of how the system actors are interconnected and howthey influence maternal health and maternal healthcare services. The findings from the PSNA provided guidance onhow stakeholders of a health system are interconnected and how they can stimulate more positive interaction betweenthe stakeholders by exposing existing gaps. The PIPA meeting enabled the participants to envision how they couldexpand their networks and resources by mentally thinking about the contributions that they could make to the project.The processes that were considered critical for successful application of the tools and achievement of outcomesincluded training of facilitators, language used during the facilitation, the number of times the tool is applied,length of the tools, pretesting of the tools, and use of quantitative and qualitative methods.Conclusions: Whereas both tools allowed the identification of stakeholders and provided a deeper understanding ofthe type of networks and dynamics within the network, PIPA had a higher potential for promoting collaboration betweenstakeholders, likely due to allowing interaction between them. Additionally, it was implemented within a participatoryaction research project. PIPA also allowed participatory evaluation of the project from the perspective of the community.This paper provides lessons about the use of these participatory tools.Keywords: Participatory, Stakeholders, Network analysis, EngagementBackgroundEffective stakeholder engagement in research and implementation is important for improving the developmentand implementation of policies and programmes [1–4].We define stakeholders as individuals, groups or organisations who have the potential to influence or who maybe influenced by particular actions or aims [3, 5].* Correspondence: ekky@musph.ac.ug1Department of Health Policy, Planning, and Management, MakerereUniversity School of Public Health, New Mulago Hospital Complex, Kampala,UgandaFull list of author information is available at the end of the articleStakeholders are not uniform, but vary in each contextby their available resources, their position and theirinterests. Consequently, reasons for engaging them, andtheir engagement levels with a project, may differ.Arnstein [6] proposed eight levels of stakeholder participation, wherein the first (manipulation) and second level(therapy) allow no participation at all, while the third(informing), fourth (consulting) and fifth (placation)allow forms of tokenism in which stakeholders areinformed of issues and their views are sought (fourthand fifth), but decisions are still made by those who hold The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Ekirapa-Kiracho et al. Health Research Policy and Systems 2017, 15(Suppl 2):106power. Finally, in the sixth (partnership), seventh(delegated control) and eighth (citizen control) levels,shared decision-making and increasing levels of controlare given to the stakeholders.Overall, the process of stakeholder engagement can bemutually beneficial. Stakeholders may choose to engagewith researchers because the research project mightdirectly affect individual stakeholder interests, theengagement process might have financial incentives orbenefits, or the engagement may lead to outcomes oroutputs that benefit the general population [3]. Researchers and project implementers, on the other hand,may have slightly different reasons for engaging stakeholders, including to understand the power, interests,perspectives, values, behaviours and opinions of stakeholders, to understand how change happens in differentcontexts and among different individuals, to build thecapacity of local stakeholders by creating a learningprocess and developing leaders and teams, to create astimulus for change, to promote local ownership, and toassess the effect of a programme [7–11].According to Durham [11], when choosing a methodfor engaging with stakeholders, it is important to consider the aim of the engagement, the resources availableand the expectations of stakeholders. In practice,researchers have employed various tools to engage stakeholders. Provision of information to stakeholders hasoften been done through simple stakeholder workshopsor meetings. Alternatively, consultation of stakeholdersabout their interests, needs, relationships, perceivedbenefits of a project, or about drivers of change has beenperformed through a range of methods that includemost significant change, participatory evaluation, positive deviance approach and beneficiary assessment[2, 4, 7, 8, 10, 12]. For higher levels of engagement, participatory mapping and/or participatory social networkanalysis (PSNA) can be used to facilitate stakeholderinvolvement. Finally, tools such as participatory impactpathways analysis (PIPA) and approaches such as participatory action research are used by researchers to developactive partnerships and stakeholder engagement in projectdecision-making.Participatory approaches are increasingly being advocated for because they give stakeholders a voice and allowthem to table their concerns, as well as improving theidentification of local problems and suggestions of feasiblesolutions and promoting the uptake of local solutions[13–15]. However, participatory approaches differ in theextent to which they involve the community in decisionmaking and hence in the extent to which they empowerthe community to address problems [14]. Approaches thatare simply used to inform the community and stakeholders about what will be done, or that are used to facilitate community involvement in predetermined activitiesPage 18 of 73without shared decision-making are examples of passivecommunity participation that generally tend not to empower the community, while those that allow the community to identify what their problem is and to get involvedin identifying solutions for these problems are examples ofactive community participation. The latter empower thecommunity to deal with not only their current problems,but also their future problems [13–16].The use of many of these methods is still in its infancy,especially in low-income countries [17, 18]. In this paper,we discuss two participatory methods for engaging withstakeholders – PSNA and PIPA, which we have adaptedand used to engage stakeholders as part of our work inthe Future Health Systems (FHS) project in India andUganda, respectively. Based on our experience, we derivelessons about when and how to apply these tools. Ourwork adds to the existing literature that summarisespractical experiences with the use of these tools,highlighting the applicability and limitations of using themethods in different contexts.Overview of the tools and the context in which they wereappliedSocial network analysis (SNA) has been defined as a toolthat allows the mapping and measuring of relationshipsand flows between people, groups, organisations or otherinformation/knowledge processing entities [19, 20]. Furthermore, it provides an opportunity to compare formaland informal information flows. Such information canguide the planning and implementation of new interventions [17].According to Blanchet [17], there are three mainstages in SNA, namely (1) identification and descriptionof the actors, (2) characterising the relationshipsbetween the actors, and (3) analysing the structure andpattern of the network. PSNA follows the three outlinedstages, but also adds the use of participatory approachesthat permit more interaction between the researchersand the participants and allows for feedback of results tostakeholders [21, 22]. These results can then be used toidentify issues that need to be resolved – by so doing itprovides a catalyst for change [21, 23]. However, for thisto happen, there must be a level of trust between theresearchers and the participants so as to allow free discussion [21]. In addition, the participants need to havethe willingness and ability to solve any issues that theyfeel warrant their attention [23].PSNA was applied in the Indian Sundarbans – theworld’s largest mangrove delta – as part of a knowledgeintervention aimed at engaging different stakeholdersthrough knowledge creation, dissemination and effectiveup-take of knowledge regarding child health in the Sundarbans to inform and influence existing health policiesin the region. The Sundarbans region is characterised by
Ekirapa-Kiracho et al. Health Research Policy and Systems 2017, 15(Suppl 2):106poverty, with frequent climatic events, which often lead tomassive destruction of the already poor infrastructure,leaving behind displaced families with insufficient foodand low productivity of the land for cultivation and pondsfor fishing. This situation has led to migration of males insearch of alternative livelihood, creating significant numbers of women-headed households. Furthermore, the childhealth status is poor, with chronic malnutrition and a highburden of communicable diseases [24]. Public health service delivery options are either absent or non-functional.Although non-governmental organisations (NGOs) provide some services, they cover only a limited area. Consequently, the gaps in health service delivery are filled bynumerous Informal Healthcare Providers (IHPs), whopractice modern medicine without any formal training orauthorisation, locally referred to as village doctors orquacks.PIPA is a relatively new planning, monitoring andevaluation tool designed to help the people involved in aproject, programme or organisation work out how theywill achieve their goals and impact [18, 25, 26]. PIPAanalyses project impact through the use of problem treesand network pathways. The problem trees utilise linearlogic that shows how the problems solved by the projecteventually contribute to solving other related problems,achieving the programme goal. On the other hand, thenetwork pathways show how the actions and interrelationships between different actors contribute to creatingan enabling environment to solve the problems identified [18]. PIPA involves five distinct steps that includeconstruction of problem trees, visioning, developing network perspectives, and defining an outcome logic modeland an impact model. PIPA is usually implementedthrough 2- to 3-day workshops. The sessions are conducted through group meetings that comprise 4–6stakeholders with a total of 3–6 groups. The workshopsmay be done at the beginning, middle and end of a project. However, different implementers have used it at different time points in their study. Alternatively, smallerreflection meetings can also be held to monitor progress,for example, every 6 months. These meetings provide anopportunity for learning and hence can provide a springboard for action research. In addition, for follow-upreflection meetings, linking the PIPA meeting to othertechnical or administrative meetings seemed to workbetter [18].Some of the benefits that have been attributed to theuse of PIPA include providing mutual understandingabout intervention logic and the potential for achievingimpact, an opportunity for ex ante impact assessmentand a hypothesis for post ante impact assessment, inaddition to providing a framework and design thatenhances implementation that is aligned to the project/programme plans with room for learning during thePage 19 of 73monitoring and evaluation process. It can also promotecollaboration between different programmes by makingexisting opportunities explicit [18].The PIPA tool was implemented in three rural districtsin Uganda (Kamuli, Kibuku and Pallisa), as part of a project that aimed to increase the number of birthsattended by skilled attendants. These districts have ahigh maternal and neonatal mortality rate comparable tothat of the rest of the country (maternal mortality rateof 438 per 100,000 live births, neonatal mortality rate 27per 1000 live births) [27]. In Uganda, the uptake of costeffective interventions that can reduce this maternal andneonatal mortality has been limited by factors such aspoor maternal and newborn care practices, poor healthcare seeking behaviour, lack of financial means, inadequateinfrastructure, and the existence of few overworked andpoorly motivated health workers [28–31]. The UgandanFHS project, MANIFEST (Maternal and Neonatal Implementation for Equitable Systems), focused on addressingproblems related to inadequate knowledge about maternaland neonatal healthcare (MNH) practices, birth preparedness, poor access to emergency and routine transport, andpoor quality of care at health facilities. Community mobilisation strategies supported locally organised, financedand monitored transport systems. Linkages between thecommunity and the health facility were improved by usingcommunity health workers, who in Uganda are calledVillage Health Teams (VHTs). Quality of care improvements were stimulated using only non-financial incentives, which included training of health workers,mentorship, supportive supervision and recognitionawards. The project was implemented using a participatory action research approach. PIPA was therefore seen asa method that would allow participatory monitoring ofimpact not only through the eyes of the researchers, butalso through those of the community, who were both participants and implementers in this project.MethodsThis paper was informed by a review of project reportsand documents in addition to three reflection meetings.The documents that were reviewed include project proposals that describe how the method was applied, as wellas research team reports summarising the stakeholderengagement activities. Research team members whowere involved in using the methods in India and Ugandaattended the first two meetings (one meeting in eachcountry). The third meeting was used to clarify anyremaining issues. The lead author and a member of theIndia team attended this meeting. The meetings werestructured around why the method was selected, howthe method was applied, training, methods used to collect data, resource requirements, how the method wasadapted and key lessons learnt while applying the
Ekirapa-Kiracho et al. Health Research Policy and Systems 2017, 15(Suppl 2):106Page 20 of 73method [11]. During the meetings, we took notes andalso recorded the discussions. These notes where thenanalysed by two of the authors of this paper to identifykey themes, which have been presented herein. Researchteam reflections on using these tools for stakeholderengagement were synthesised using the conceptualframework presented below. The involvement of an author who was not directly involved in the research project and data collection for PIPA ensured that anobjective perspective was maintained during the writingof the paper.Conceptual frameworkThe framework was developed based on existing literature about the purpose, process and outcomes of stakeholder engagement processes. It highlights the fact thatthe purpose of the engagement determines how the engagement is done, while the process of engagement influences the outcomes of the engagement process [11].Based on this framework, we explore how the purposefor the engagement influenced the choice of tools applied.Furthermore, we explore how the application of PIPA andPSNA influenced the process and outcomes of the engagement (Fig. 1).ResultsIn this section, we summarise results for each of PSNAand PIPA, beginning with the purpose of engagementand why the tools were selected, as well as the processesinvolved in applying the method and outcomes of theengagement.Applying PSNA in the SundarbansPurpose of the engagement and why PSNA was selectedWe engaged the stakeholders in the Sundarbans becausewe wanted to identify the type and nature of linkagesthat exist between the demand (mothers with childrenaged 0-6 years) and supply side (informal healthcare providers), and to understand how the linkages were formedwithin the given social context. The knowledge intervention programme aimed at generating evidence, disseminating it and building the capacity of the stakeholders touse the evidence to take the required actions. Hence, itwas important to identify the crucial actors within theexisting health system and their connection with theother actors who can act as agents of change. Furthermore, the knowledge intervention was implemented in aparticipatory manner to ensure better representation ofthe stakeholders. Therefore, PSNA was selected as it allows an in-depth understanding of the nature and thegenesis of social ties from the stakeholders’ perspectiveand provides an understanding of the dynamics of thenetwork connection of the health system.Fig. 1 Conceptual frameworkProcess of engagementPreparation for the engagementPreparation for the engagement revolved around identifying a suitable location to conduct the activities, purchasingthe necessary resources, identifying the researchers whowould conduct the activity, and identifying and informingrespondents who were to be included. The team decidedthat meetings would be held in the homes and workplacesof the respondents. Permission to hold the meetings inthese venues was therefore sought from the respondentsthemselves through a signed consent form in vernacularlanguage. The researchers were selected from the existingpool of FHS researchers within the India team on the basisof their personal interest in undertaking SNA studies andsocial science background.Resources requiredThe key resources that were required included a venue,researchers to conduct the activity, instruments for datacollection, and stationery such as blank chart paper,colour pens, sticky notes and a recorder. The data collection instrument was comprised of a semi-structured
Ekirapa-Kiracho et al. Health Research Policy and Systems 2017, 15(Suppl 2):106questionnaire to collect respondents’ identification anddemographic data. A guideline for probing during network drawing was also prepared. An audio-recorder wasused to capture respondents’ comments.Training of facilitatorsTwo researchers and one research assistant facilitatedthe research work. The facilitators had prior knowledgeand experience about qualitative research and this facilitated their understanding of the local context andnuances of the application of the participatoryapproaches. The training that was conducted focused onunderstanding the tool
A varied number of tools have been employed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging with stakeholders – participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based on our experience, we derive lessons about when and how to apply these tools.
Engaging P-20W Stakeholders (PPT Presentation). Strategies for engaging P–20 stakeholders were discussed, including who is engaged and why, how stakeholders with varying backgrounds are engaged, roles and responsibilities of stakeholders, and lessons learned from engaging P–20 stakeholders. Engaging Postsecondary Stakeholders
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