Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa
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 materna...
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| Format: | Article |
| Language: | English |
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South African Medical Association
2023-11-01
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| Series: | South African Medical Journal |
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| Online Access: | https://samajournals.co.za/index.php/samj/article/view/1558 |
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| author | H Schneider F Mukinda J Cupido J Wessels P Kupa P Leboho N Nkoana N Bosch Y Pillay |
| author_facet | H Schneider F Mukinda J Cupido J Wessels P Kupa P Leboho N Nkoana N Bosch Y Pillay |
| author_sort | H Schneider |
| collection | DOAJ |
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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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| format | Article |
| id | doaj-art-cf9d8ad499934defb3780a42a35cf680 |
| institution | Kabale University |
| issn | 0256-9574 2078-5135 |
| language | English |
| publishDate | 2023-11-01 |
| publisher | South African Medical Association |
| record_format | Article |
| series | South African Medical Journal |
| spelling | doaj-art-cf9d8ad499934defb3780a42a35cf6802025-02-10T12:26:39ZengSouth African Medical AssociationSouth African Medical Journal0256-95742078-51352023-11-011131110.7196/SAMJ.2023.v113i11.1558Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South AfricaH Schneider0F Mukinda1J Cupido2J Wessels3P Kupa4P Leboho5N Nkoana6N Bosch7Y Pillay8School of Public Health and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South AfricaSchool of Public Health and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South AfricaClinton Health Access Initiative, Pretoria, South AfricaClinton Health Access Initiative, Pretoria, South AfricaWaterberg Health District, Limpopo Department of Health, Polokwane, South AfricaWaterberg Health District, Limpopo Department of Health, Polokwane, South AfricaWaterberg Health District, Limpopo Department of Health, Polokwane, South AfricaWaterberg Health District, Limpopo Department of Health, Polokwane, South AfricaClinton Health Access Initiative, Pretoria, South Africa, and Department of Public Health and Health Systems, Stellenbosch University, Cape Town, South Africa 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. https://samajournals.co.za/index.php/samj/article/view/1558District health systemquality improvementoutcomessub-district |
| spellingShingle | H Schneider F Mukinda J Cupido J Wessels P Kupa P Leboho N Nkoana N Bosch Y Pillay Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa South African Medical Journal District health system quality improvement outcomes sub-district |
| title | Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa |
| title_full | Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa |
| title_fullStr | Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa |
| title_full_unstemmed | Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa |
| title_short | Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa |
| title_sort | improving health outcomes and quality at the subdistrict level evaluation of the 3 feet model in waterberg district limpopo province south africa |
| topic | District health system quality improvement outcomes sub-district |
| url | https://samajournals.co.za/index.php/samj/article/view/1558 |
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