From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa

Kinney, Mary; George, Asha; Rhoda, Natasha; Pattinson, Robert Clive; Bergh, Anne‐Marie

doi:10.9745/ghsp-d-22-00213

Cited by 4 publications

(2 citation statements)

References 58 publications

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“…Two neighbouring subdistricts were excluded, as they reported data from regional and tertiary facilities and had much higher mortality rates than other subdistricts. Perinatal mortality is amenable to health service interventions, [17] as compared with infant or under-5 mortality, which are influenced by wider socioeconomic contexts. The PMR is also more easily assessed than in-facility maternal mortality, which was a rare event in the three subdistricts over the period.…”

Section: Special Series On the District Health Systemmentioning

confidence: 99%

Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa

Schneider,

Mukinda,

Cupido

et al. 2023

S Afr Med J

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Background. There is a gap in understanding of potential roles and actions at the subdistrict level to improve quality of care and health outcomes in South Africa (SA). Objectives. To report on the evaluation of a subdistrict health system-strengthening initiative that aimed to reduce maternal, newborn and child mortality, referred to as the ‘3 feet model’ in Waterberg District, Limpopo Province, SA. The model is centred on systems of real-time morbidity/mortality surveillance and co-ordinated responses. It was implemented in three of five Waterberg subdistricts over an 18-month period in 2021 and 2022. Methods. A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined ~100 hours of researcher participant observation, interviews with 14 health system actors, structured reflections by three subdistrict managers and information from the routine District Health Information System. Sources were triangulated and analysed based on a priori hypotheses on mechanisms of action. Results. Following uptake of the model, the perinatal mortality rate (PMR) improved by 28.8%, 11.5% and 28% in the three subdistricts, respectively, while the PMR worsened in two of four neighbouring subdistricts. Plausible factors in implementation successes were the presence of stable and committed hybrid (clinical-managerial) subdistrict leaders and their ability to overcome entrenched silos between a variety of system actors; new collaborative relationships between primary healthcare facilities, hospitals and emergency medical services; the generation and packaging of information in ways that directed responses (‘actionable intelligence’); and support from senior district managers. Conclusion. While not advocating for a cut-and-paste approach to improving quality and outcomes, positive experiences in Waterberg District suggest that the principles and mechanisms of action of the 3 feet model have wider relevance for policy and practice, especially as emphasis shifts towards the subdistrict as a core unit of population health and wellbeing in SA.

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Section: Special Series On the District Health Systemmentioning

confidence: 99%

Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa

Schneider,

Mukinda,

Cupido

et al. 2023

S Afr Med J

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“…Drawing on this emerging global consensus, and building on long standing initiatives to strengthen maternal, newborn, and child health in South Africa’s health system, including District Clinical Specialist Teams 7 and maternal and perinatal death reviews, 8 the Mphatlalatsane Project (hereafter referred to as “the project”) was a South African initiative which aimed to reduce maternal and neonatal mortality by 50% through QI strategies in districts of three provinces (Mpumalanga, Limpopo, and Eastern Cape). 9 This 5-year (2018-2022) initiative was steered by a national partnership of governmental, non-governmental and academic players, and implemented a range of facility-based QI interventions, including PDSA cycles, training, audit, and patient support in the target districts.…”

Section: Introductionmentioning

confidence: 99%

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa

Schneider,

Mianda

2024

Int J Health Policy Manag

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Background: Sustained implementation of facility-level quality improvement (QI) processes, such as plan-do-study-act cycles, requires enabling meso-level environments and supportive macro-level policies and strategies. Although this is well recognised, there is little systematic empirical evidence on roles and capacities, especially at the immediate meso-level of the system, that sustain QI strategies at the frontline. Methods: In this paper we report on qualitative research to characterize the elements of a quality and outcome-oriented meso-level, focused on sub/district health systems (DHSs), conducted within a multi-level initiative to improve maternal-newborn health (MNH) in three provinces of South Africa. Drawing on the embedded experience and tacit knowledge of core project partners, obtained through in-depth interviews (39) and project documentation, we analysed thematically the roles, capacities and systems required at the meso-level for sustained QI, and experiences with strengthening the meso-level. Results: Meso-level QI roles identified included establishing and supporting QI systems and strengthening delivery networks. We propose three elements of system capacity as enabling these meso-level roles: (1) leadership stability and capacity, (2) the presence of formal mechanisms to coordinate service delivery processes at sub-district and district levels (including governance, referral and outreach systems), and (3) responsive district support systems (including quality oriented human resource, information, and emergency medical services [EMS] management), embedded within supportive relational eco-systems and appropriate decision-space. While respondents reported successes with system strengthening, overall, the meso-level was regarded as poorly oriented to and even disabling of quality at the frontline. Conclusion: We argue for a more explicit orientation to quality and outcomes as an essential district and sub-district function (which we refer to as meso-level stewardship), requiring appropriate structures, processes, and capacities.

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Professional nurses’ perceptions regarding the implementation of perinatal Problem Identification Programme in a public hospital in the Bojanala District, Northwest Province

Manjinja,

Malesela,

Mahlangu

2024

International Journal of Africa Nursing Sciences

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From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa

Cited by 4 publications

References 58 publications

Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa

Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa

Professional nurses’ perceptions regarding the implementation of perinatal Problem Identification Programme in a public hospital in the Bojanala District, Northwest Province

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