BackgroundThe field of acceptability of health services is emerging and growing in coherence. But there are gaps, including relatively little integration of elements of acceptability. This study attempted to analyse collectively three elements of acceptability namely: patient-provider, patient-service organisation and patient-community interactions.MethodsMixed methods were used to analyse secondary data collected as part of the Researching Equity in Access to Health Care (REACH) study of access to tuberculosis (TB) treatment, antiretroviral therapy (ART) and maternal health (MH) services in South Africa’s public health sector.ResultsProvider acceptability was consistently high across all the three tracer services at 97.6% (ART), 96.6% (TB) and 96.4% (MH). Service acceptability was high only for TB tracer (70.1%). Community acceptability was high for both TB (83.6%) and MH (96.8%) tracers.ConclusionThrough mixed methods, this paper provides a nuanced view of acceptability of health services.

A health system’s ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s. This paper aims to promote high quality research that will generate policy relevant and useful evidence.

BackgroundImproving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.MethodsBetween 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.ResultsWe found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors’ expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.ConclusionRole ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3377-2) contains supplementary material, which is available to authorized users.

We present an interpretive qualitative account of micro-level activities and processes of clinical governance by recently introduced district-based clinical specialist teams (DCSTs) in South Africa. We do this to explore whether and how they are functioning as institutional entrepreneurs (IE) at the local service delivery level. In one health district, between 2013 and 2015, we carried out 59 in-depth interviews with district, sub-district and facility managers, nurses, DCST members and external actors. We also ran one focus group discussion with the DCST and analysed key policies, activities and perceptions of the innovation using an institutional entrepreneurship conceptual lens. Findings show that the DCST is located in a constrained context. Yet, by revealing and bridging gaps in the health system, team members have been able to take on certain IE characteristics, functioning—more or less—as announcers of reforms, articulating a strategic vision and direction for the system, advocating for change, mobilizing resources. In addition, they have helped to reorganize services and shape care practices by re-framing issues and exerting power to influence organizational change. The DCST innovation provides an opportunity to promote institutional entrepreneurship in our context because it influences change and is applicable to other health systems. Yet there are nuanced differences between individual members and the team, and these need better understanding to maximize this contribution to change in this context and other health systems.