Managing Local Health System Interdependencies: Referral and Outreach Systems for Maternal and Newborn Health in Three South African Districts

Abstract

In complex health systems, referral and outreach systems (ROS) are formal strategies for connecting and managing interdependencies between facilities in service delivery pathways. Well-functioning maternal and newborn ROS are critical to successful outcomes, and therefore, a good lens through which to examine the management of local interdependencies. We conducted a qualitative study of maternal–newborn ROS, involving interviews with 52 senior, middle, and frontline managers, in three health districts of three different provinces in South Africa. We analyse the differences in functioning of ROS as an interplay of setting (urban, rural), individual facility strengths and weaknesses, the quality of emergency medical services (EMS), and the wider provincial strategic and organisational context. ROS are strengthened by sub-district governance arrangements that recognise and enable connectedness—in particular, between primary health care and district hospital services; by informal, day-to-day communication and collaboration across levels and professions; and by hybrid clinical–managerial players as system brokers and systems thinkers. We also identify leverage points, places where small shifts could have wider system effects, most notably in the design and functioning of EMS, and in addressing small, but significant bottlenecks in supply chains in lower level facilities that negatively impact the system as a whole.

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

“…Despite the considerable local experience of these partners, they are not the views of district and sub-district actors themselves. However, these were obtained in subsequent phases of the Mphatlalatsane Project evaluation and confirmed the findings of this paper, 41 while offering further nuance, including for example on the importance of informal networks and relationships. 14 , 19 Secondly, examining the meso-level through the lens of MNH foregrounds aspects of local health systems, including the management of emergencies, in ways that are different to the quality challenges of care for long term conditions such as HIV or non-communicable diseases.…”