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Become a Helping Hand! Although the toolkit emphasizes the need to include representatives from the community and marginalized groups as well from other Ministries, none of the workshops managed to do so due to time and other logistics constraints. At the beginning of each workshop, the participants received information about the participatory methodology within the toolkit and its design, the evaluation of the pilot workshops, and the publication and dissemination of subsequent results and best practices.
The qualitative discussion guide followed the successive workshop steps and asked attendees to share related experiences, ideas, comments, suggestions, and recommendations to help improve the toolkit contents and methodology [ 22 ]. The workshop evaluation was part of planned program monitoring, which was not designed to develop and contribute to generalizable knowledge and therefore did not constitute research and require ethical approval [ 23 ].
Participants were informed that all their feedback would be anonymized, and its management and analysis handled confidentially.
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They were free to participate in the evaluation and were informed that they could withdraw at any time without consequences on their participation in the workshop. The evaluation was deemed to pose no risk to participants who had the opportunity to ask questions and receive clarifying comments before providing their written informed consent to being photographed, filmed, or audio recorded. There was no refusal across settings.
Audio recordings were transcribed, anonymized, and translated if needed from Arabic into English for Yemen. The analyst, who was fluent in English and French, used NVivo 11 to code the transcriptions according to the preset themes of effectiveness, efficiency, and participation while remaining open to emerging themes.
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End-of-workshop evaluations were also analyzed. Tables were used to summarize key facts and figures across the three pilot countries, including recommendations for improvement and lessons learned. These tables allowed iterative comparison across settings to identify common themes and singular perspectives. By following the step-by-step approach outlined in the toolkit, facilitators enabled participants to produce a work plan at the end of each of the pilot workshops, suggesting that the toolkit was effective in reaching its primary objective.
Additionally, results in Yemen suggested that the workshop contributed to raising the importance of SRH, which was perceived to be neglected among decision-makers and health managers and overshadowed by other sectors. Previously, it was all about nutrition and other sectors.
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Reproductive health was totally forgotten. It was a period where reproductive health services were stopped. But we thank them [funders and organizers] for re-activating reproductive health services through their support. Priorities specifically highlighted in the Kasai region included renovating health centers, strengthening the health information system, advocating to the government to harmonize the fees for SRH services, and advocating to donors for additional funding. The capacity development of midwives was a specific concern in Yemen. Participants across settings appeared to welcome the methodology and its efficiency in producing results.
Participants reported the methodology to be practical and simple and underscored the relevance of using the framework of the WHO Health System Building Blocks. Participants appreciated that a two-day workshop could produce specific and achievable planning priorities within a short time. Most participants across settings found that the workshop duration was adequate; none found it too long.
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The methodology was great. It helped us define the priorities we need and how to divide the activities among the six WHO building blocks I would like to say that this methodology is more simplified, practical, and participatory in the sense that it was not a colossal and very complex methodology. Everyone had the opportunity to participate in the exchanges. The added value in this workshop is that we started on reliable bases that reflect the real needs in the field … It was the record time that made the biggest impression on me.
What impressed me the most was the time that was allotted folks. The whole team came together to identify needs and opportunities in record time. Participants found all the successive steps to be useful and complementary. To me, the methodology is great because it involves participation and discussion of different opinions. It also involves the freedom to say and present whatever you want.
It also presents a democratic approach where you can criticize, accept, or reject any point.
We hope that we can present what is discussed and planned here into real action. But another very interesting process was that not everybody talked about the same thing and everybody talked about different points. All the pilot settings were recent or current L3 crises at the time of the workshops. In all three countries, the complexity of the humanitarian situation found and the resulting needs to strengthen the health system after the acute phase of the crisis matched strongly with piloting a planning process that was oriented toward health system strengthening.
In Bangladesh, the process coincided with the Joint Response Plan planning process occurring the following year for the Rohingya humanitarian crisis, illustrating how the workshops should build upon the existing efforts of the SRH coordination groups in each context. In the case of Yemen, continuous cycles of insecurity and the resulting shrinkage of the humanitarian space required for effective response hampered the recovery efforts. Additionally, the Yemen experience spoke for the relevance of the approach when applied to protracted situations.
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Participants in DR Congo found it essential to define by consensus guiding principles for collaborating on the planning before working on the details of the action plan. In Yemen, due to travel constraints, the lead facilitator was not able to go to Aden to conduct the workshop. Therefore, a creative solution emerged in the form of a four-day training of trainers to enable SRH experts and trainers to deliver the workshop. The training of trainers overlapped with the scheduled two-day planning workshop to offer the trainees the immediate opportunity to observe and co-facilitate.
In line with the inclusive approach of the workshop, the facilitator adopted a participatory approach to the training of trainers: participants reflected on and practiced the soft skills required for conducting training, including communication, flexibility, creativity, time management, and leadership. They discussed logistics and potential challenges, such as translation, and co-developed with the main facilitator a practical checklist to assist them with the workshop rollout in Aden.
The checklist covered roles and responsibilities among facilitators and the support team, a task division sheet, a list of documents needed for the summary, a list of required materials and logistics, and a material checklist. The workshop was reportedly successful. In the end, the unexpected logistic constraints equipped Yemen with additional capacity to organize and conduct future planning workshops to transition from MISP to comprehensive SRH services.
Concurrently, the global community acquired a training model and new tools to facilitate a two-day workshop nested within a four-day training of trainers. However, any future implementation should engage community members, including those from often marginalized populations. The pilots yielded several lessons learned, such as enhancing pre-workshop data preparation, equipping all participants with adequate knowledge of the MISP, and defining common principles for collaboration, which allowed for successive improvements of the toolkit. Each of the humanitarian situations had its own specificities, gaps, and opportunities in terms of the health system building blocks and response to the SRH needs of the population.
Priority activities with crosscutting impacts on SRH services and outcomes were high on the agenda, such as ensuring a sustainable supply chain notably for the hard-to-reach Kasai region or siege and blockade-affected Yemen , rebuilding and restoring destroyed and looted health facilities in the Kasai region, and enhancing human resources for health [ 24 ].
The emphasis on common themes, such as strengthening the overall provision of comprehensive SRH services, capacity development of the health workforce, community mobilization, adolescent SRH, and maternal and newborn health services is somehow unsurprising, albeit critical. Trained, motivated, and retained staff form an essential building block of the health system as they enable access to a wide range of information and services [ 7 ].
For instance, in Yemen, new community midwives were trained since to improve coverage and replace those who retired, left to care for their families, quit their job due to prolonged periods of unpaid salaries, or died, among others [ 25 ]. The focus in the work plan to continue supporting the development of such cadres builds of these recent efforts and identified opportunities, and was championed by representatives of the national midwifery association who participated in the workshop.
The MISP objectives focus mostly on the supply side of health services, which must complement activities that generate demand, such as community mobilization and involvement [ 26 ]. Although adolescents and young people form a large, if not the largest, cohort across low-income and middle-income countries — including in crisis-affected communities — they often do not have access to adolescent-responsive SRH services that address their specific needs [ 27 ].
Basic and comprehensive emergency maternal and newborn care is part of the MISP objectives. These services can be challenging to implement with adequate quality, coverage, and effective referrals that must be sustainable during the recovery and redevelopment phases [ 28 ]. Other priorities, such as family planning or gender-based violence, were subsumed under the overall plan to enhance a comprehensive SRH service package or specifically underscored, or both. The collective work plans for comprehensive SRH that participants developed at the end of the workshops are multipurpose.
They could help strengthen the implementation of comprehensive SRH information and services and focus attention on key problem areas. If used to feed into an advocacy and resource-mobilization strategy, they could garner support and funding for programs that feed into the overall reproductive, maternal, newborn, child, and adolescent health program. Initial planning for comprehensive SRH should start at the onset of the acute response, and the participatory process proposed in this toolkit should begin as soon as the MISP clinical services are available and accessible and progress towards reaching Objectives 1 to 5 and other priorities of the MISP are underway.
This participatory process could also take place when agencies begin longer-term planning with new funding cycles and in preparation for humanitarian appeal processes. The integration of comprehensive SRH services into these mechanisms could contribute to avoiding service delays and ensuring their sustainability.
Operations research is needed to examine, whenever possible, the implementation of the toolkit in a real-time transition from an acute response toward recovery and health system strengthening. Researching the implementation of the toolkit in protracted situations is equally important. In both cases, the question remains whether and how a work plan with priority activities developed in a participatory manner would translate into the concrete implementation of these priorities and contribute to health system strengthening efforts.
The bigger question will be whether and how each of the settings will implement the prioritized activities in terms of advocacy, identification of sustainable resources, and eventually expanded access to quality services that the community will utilize. The toolkit preempted the possible challenge of seeing the work plans remaining without follow-up and implementation by participating stakeholders.