How a rural South African learning platform transformed primary healthcare
A decade of the Verbal Autopsy with Participatory Action Research (VAPAR) programme
What is verbal autopsy?
In many rural and low-resource settings, people die without ever seeing a doctor, meaning the cause of death is never formally recorded. Verbal autopsy is a research method that addresses this gap.
Trained researchers interview family members or others who knew the deceased, gathering information about symptoms, events and circumstances leading up to the death. This information is then used to identify the most likely cause of death and build a clearer picture of local health needs.
The VAPAR programme took the approach a step further. Alongside identifying medical causes of death, it collected information on the social and health system factors that may have contributed, such as difficulties accessing transport, delays in receiving care, or barriers within the health system.
This information was combined with community-led research to understand not only why people died, but what could be done to prevent similar deaths in future.
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When those with the greatest understanding are the least heard
Map of Mpumalanga province and clinics where training was scaled. Image credit: Medical Illustration UOA
Map of Mpumalanga province and clinics where training was scaled. Image credit: Medical Illustration UOA
Participatory action research prioritisation exercise, Bushbuckridge sub-district, Mpumalanga Province 2015. Image credit: D’Ambruoso/VAPAR
Participatory action research prioritisation exercise, Bushbuckridge sub-district, Mpumalanga Province 2015. Image credit: D’Ambruoso/VAPAR
When VAPAR launched in 2015, Mpumalanga’s faced the pressures familiar across much of the Global South: high burdens of HIV and TB, rising multimorbidity, and chronic gaps between community realities and facility‑level planning.
Principal Investigator Dr Lucia D'Ambruoso, from the 51cg, explains: “VAPAR began from a recognition that some of the people with the deepest understanding of local health challenges are often the least heard in decisions about services. We also recognised that Community Health Workers (CHWs), central to South Africa’s primary healthcare reforms, were often under‑supported and under‑recognised.
“VAPAR’s early work brought communities, CHWs, and district managers into the same room to examine local mortality patterns and co‑design responses.
“The research programme was designed to bridge this persistent gap in health systems between evidence about community health needs and the decisions made by those responsible for planning and delivering services.”
VAPAR didn’t aim to simply facilitate structured dialogue but also sought to provide evidence and systems to embed the lessons learned into a routine part of district functioning.
The approach combined two sources of knowledge. The first, data, to help identify causes of death and the social and health system circumstances surrounding them and the second, , through which community members share and validate lived experience into collective forms of knowledge, and use this to identify priorities, analyse local problems and work alongside health officials to develop responses.
Rather than producing reports that sit on shelves, VAPAR was designed as an ongoing cycle of evidence, dialogue, action and learning.
Communities, frontline health workers, managers and planners meet regularly to review findings, agree priorities and assess progress. Over time, this created what researchers describe as a health system learning platform: a space where people who would not normally share power or information could work together to build new relationships and work together to solve practical problems.
“The manual, from the department’s perspective, particularly at the sub-district level, inspires a great sense of pride about the realisation of the possibility of building capacity for this cadre of emerging health care workers in South Africa. The manual will go a long in providing a practical and a formal tool to guide Community Health Workers through their day to day work with communities.”
The Invisible Backbone of Primary Healthcare: the Transformation of Community Health Workers
One of the most striking impacts of the platform was the . For years, they had been the invisible backbone of primary healthcare - tasked with enormous responsibility but given little authority or recognition.
“Through VAPAR, CHWs became analysts, planners, and advocates. They learned to interpret verbal autopsy data, map out the root causes of local health problems, and articulate priorities in mixed forums with communities, clinicians and managers. Their confidence grew, and with it, their legitimacy”, Dr D'Ambruoso adds.
“Some CHWs eventually moved into formal government posts. While this shift was also shaped by national labour movements and policy reforms, VAPAR played a crucial role by giving CHWs the visibility, skills, and evidence base that made their contributions undeniable.”
Community Health Workers in Nkangala health district complete the VAPAR Community Health Worker Community Mobilisation training Image credit: Hove/VAPAR 2024
Community Health Workers in Nkangala health district complete the VAPAR Community Health Worker Community Mobilisation training Image credit: Hove/VAPAR 2024
Trust as a structural outcome
Trust is rarely listed as a health system indicator, yet in VAPAR it became one of the most important outcomes.
The platform created a space where communities, CHWs, and district managers could speak openly about problems that had long been sources of tension from , , treatment loss to follow‑up. These conversations clarified roles, surfaced constraints, and built mutual respect.
Over time, trust became a structural feature of the learning system. It shaped how decisions were made, how evidence was interpreted, and how communities engaged with health services. In a province where mistrust had often undermined service delivery, this shift was transformative.
Evidence became a habit, not an event
Before VAPAR, local data - especially community‑generated data - rarely influenced district planning. The platform changed that. Verbal autopsy findings, participatory analyses, and locally produced evidence became routine inputs into district action plans.
This wasn’t just about better data. It was about . District managers began to expect it. CHWs began to rely on it. Communities began to see its value.
Dr D'Ambruoso says: “This is what a learning health system looks like - evidence is not only collected for reports - it is used to shape action.”
Institutionalisation: The hardest step
Many promising initiatives collapse when external funding ends or political winds shift. VAPAR did not. It became embedded in provincial programmes, adapted for health promotion, emergency obstetric care and outbreak response, and scaled across districts.
This was possible because the platform aligned with broader reforms including Public Health Care re‑engineering, district revitalisation, and the rollout of National Health Insurance. VAPAR strengthened the critical relationships and capabilities needed to implement them.
Community stakeholder presenting and appraising visual evidence. Ehlanzeni district 2019 Image credit D’Ambruoso et all 2022
Community stakeholder presenting and appraising visual evidence. Ehlanzeni district 2019 Image credit D’Ambruoso et all 2022
Why this research matters
In a global context where health systems face rising multimorbidity, climate shocks, and widening inequities, the lessons learned through VAPAR matter far beyond Mpumalanga.
Its impact can be seen in four major shifts: a move from top‑down planning to shared problem‑solving; from data scarcity to routine evidence use; from CHW marginalisation to CHW empowerment; and from project‑based interventions to institutionalised learning.
The VAPAR study is more than a research programme – it is a demonstration that even in resource‑constrained settings, health systems can become learning systems which are adaptive, evidence‑driven, and grounded in the lived realities of the people they serve.
A full 10-year evaluation of VAPAR can be viewed in a paper in Wellcome Open Research (