Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building

Lembani, Martina; Pinho, Helen de; Delobelle, Peter; Zarowsky, Christina; Mathole, Thubelihle; Ager, Alastair

doi:10.1186/s12913-018-3726-1

Cited by 22 publications

(37 citation statements)

References 24 publications

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“…As suggested by HCP in this study, unless leadership capacity is built to monitor and supervise processoriented practices, staff trained on the policies and process, and accountability demanded, variations between policy and practice are less likely to be addressed. These are recommendations consistent to that of other authors (10,(35)(36)(37)(38)(39)(40).…”

Section: Discussionsupporting

confidence: 92%

“…In the midst of global efforts to achieve the SDG related to maternal health, identifying improvement opportunities has been of much interest (10,29). This study utilised process mapping developed from the perspective of frontline health workers to examine the functions of an emergency obstetric referral system in a Low-and Middle-Income country.…”

Section: Discussionmentioning

confidence: 99%

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Assessing the functionality of an emergency obstetric referral system among public healthcare facilities in a low resource setting: an application of process mapping approach

Ofosu

Ofori

Ntumy

et al. 2020

Preprint

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Background: Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions, using Ablekuma district in Accra, Ghana as a case study.Methods: The study is an analytical cross-sectional study. Nine (9) in-depth interviews (IDI) were carried out for a three-weeks period in June and July 2019 after informed consent with two (2) Obstetrics & Gynaecology consultants, two (2) Residents, one family physician, and four (4) Midwives managing emergency obstetric referral across different levels of facilities. Data collected included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.Results: Out of the 33 main activities in the referral process within the facilities, 24 (73%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), HCP knowledge and compliance of referral policy and guideline, and financing for referral. Healthcare providers suggested that strengthening communication and coordination, review of referral policy, training of all stakeholders and provision of essential resources would be beneficial.Conclusion: Our findings clearly establish that the emergency obstetric referral system in Ablekuma district, Accra-Ghana is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions likely to ensure that women receive timely and quality care.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Assessing the functionality of an emergency obstetric referral system among public healthcare facilities in a low resource setting: an application of process mapping approach

Ofosu

Ofori

Ntumy

et al. 2020

Preprint

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“…This is seen most clearly in Kilifi and Sedibeng, where challenging processes of decentralisation occurring against a background of resource constraints have generated role confusion and encouraged coping and adaptive strategies with undesirable or unsustainable consequences (see also ref. 6 ). In such settings, resources and organisational stability (organisational hardware) are, clearly, important to health system resilience.…”

Section: Discussionmentioning

confidence: 99%

“…4 Resilience at this level is particularly important given diverse and changing health and social needs, and its interface with other sectors and community systems. 5 Yet very little work has so far considered everyday resilience in district health systems: Lembani et al 6 provide a rare example.…”

Section: Introductionmentioning

confidence: 99%

Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa

et al. 2017

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Recent global crises have brought into sharp relief the absolute necessity of resilient health systems that can recognise and react to societal crises. While such crises focus the global mind, the real work lies, however, in being resilient in the face of routine, multiple challenges. But what are these challenges and what is the work of nurturing everyday resilience in health systems? This paper considers these questions, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach. The paper presents evidence of the instability and daily disruptions managed at the front lines of the district health system. These include patient complaints, unpredictable staff, compliance demands, organisational instability linked to decentralisation processes and frequently changing, and sometimes unclear, policy imperatives. The paper also identifies managerial responses to these challenges and assesses whether or not they indicate everyday resilience, using two conceptual lenses. From this analysis, we suggest that such resilience seems to arise from the leadership offered by multiple managers, through a combination of strategies that become embedded in relationships and managerial routines, drawing on wider organisational capacities and resources. While stable governance structures and adequate resources do influence everyday resilience, they are not enough to sustain it. Instead, it appears important to nurture the power of leaders across every system to reframe challenges, strengthen their routine practices in ways that encourage mindful staff engagement, and develop social networks within and outside organisations. Further research can build on these insights to deepen understanding.

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“…Tinyade Hospital (pseudonym), a poorly performing hospital, and Chisomo Hospital (pseudonym), a better performing hospital. In an earlier study of health systems and maternal health outcomes in this district, leadership had been identified as a key driver of performance in maternal health services ( Lembani et al 2015 ). This study sought to elucidate these preliminary findings in a particular context, and to contribute to the developing body of scholarship and practice aimed at better understanding leadership and how it improves or undermines health services functioning in low- and middle-income countries (LMICs).…”

Section: Introductionmentioning

confidence: 99%

Leadership and the functioning of maternal health services in two rural district hospitals in South Africa

Mathole

Lembani

Jackson

et al. 2018

Health Policy and Planning

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Maternal mortality remains high in Eastern Cape Province, South Africa, despite over 90% of pregnant women utilizing maternal health services. A recent survey showed wide variation in performance among districts in the province. Heterogeneity was also found at the district level, where maternal health outcomes varied considerably among district hospitals. In ongoing research, leadership emerged as one of the key health systems factors affecting the performance of maternal health services at facility level. This article reports on a subsequent case study undertaken to examine leadership practices and the functioning of maternal health services in two resource-limited hospitals with disparate maternal health outcomes. An exploratory mixed-methods case study was undertaken with the two rural district hospitals as the units of analysis. The hospitals were purposively selected based on their maternal health outcomes: one reported good maternal health outcomes (pseudonym: Chisomo) and the other had poor outcomes (pseudonym: Tinyade). Comparative data were collected through a facility survey, non-participant observation of management and perinatal meetings, record reviews and interviews with hospital leadership, staff and patients to elicit information about leadership practices including supervision, communication and teamwork. Descriptive and thematic data analysis was undertaken. The two hospitals had similar infrastructure and equipment. Hospital managers at Chisomo used their innovation and entrepreneurial skills to improve quality of care, and leadership style was described as supportive, friendly, approachable but ‘firm’. They also undertook frequent and supportive supervisory meetings. Each department at Chisomo developed its own action plan and used data to monitor their actions. Good performers were acknowledged in group meetings. Staff in this facility were motivated and patients were happy about the quality of services. The situation was different at Tinyade hospital. Participants described the leadership style of their senior managers as authoritarian. Managers were rarely available in the office and did not hold regular meetings, leading to poor communication across teams and poor coordination to address resource constraints. This demotivated the staff. The differences in leadership style, structures, processes and work culture affected teamwork, managerial supervision and support. The study demonstrates how leadership styles and practices influence maternal health care services in resource limited hospitals. Supportive leadership manifested itself in the form of focused efforts to build teamwork, enhance entrepreneurship and in management systems that are geared to improving maternal care.

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Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building

Cited by 22 publications

References 24 publications

Assessing the functionality of an emergency obstetric referral system among public healthcare facilities in a low resource setting: an application of process mapping approach

Assessing the functionality of an emergency obstetric referral system among public healthcare facilities in a low resource setting: an application of process mapping approach

Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa

Leadership and the functioning of maternal health services in two rural district hospitals in South Africa

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