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Background: A high maternal mortality ratio persists in South Africa despite developments in emergency obstetric care (EmOC), a known effective intervention against direct causes of maternal deaths. Strengthening the health systems is one of the focus areas identified by the National Committee for Confidential Enquiries into Maternal Deaths in South Africa. District managers as immediate overseers of the frontline health system are uniquely positioned to provide insight into the overall health system processes that influence the delivery of EmOC. Objective: We sought to identify health system enablers and barriers to the delivery EmOC from the perspective of district managers. This would potentially unearth aspects of the health system that require strengthening to better support EmOC and improve maternal outcomes. Methods: Face-to-face audio-recorded key informant interviews were conducted with 19 district managers in charge of the delivery of EmOC in one urban district. Interviews were transcribed and coded. Related codes were inductively grouped into emerging themes. Deductive thematic analysis was then applied to categorise emergent themes into the WHO health system building blocks. Results: Themes included a weaknesses in the organisation of health services; a high vacancy and turnover of senior management; poor clinical accountability from EmOC providers; inadequate resources (including infrastructure, staffing, and funding); and the need to improve district health information system indicators. Conclusion: The functioning of the district health system was weak, affecting the delivery of EmOC. Unless staffing is effectively addressed, the health system is unlikely to reduce maternal mortality to the desired level. Coordination of EmOC services by managers needs to be strengthened to limit fragmentation of care and improve the continuity EmOC. Furthermore, a high turnover of senior leadership affects implementation priorities and continuity in the overall strategic direction of EmOC.
Data collection took place in one urban district of the Gauteng Province. The province has five districts. The district under study is the economic hub of the province with vibrant industrial activity that attracts migrants looking for labour, including low-skilled jobs. It is therefore densely populated, with about 3.2 million people living in approximately 1 975.31 km2 [37]. Informal settlements and poverty are common, challenging the public healthcare system with an increased demand for childbearing services, including EmOC. The MMR of the study district is estimated at 202 per 100 000 live births while the provincial MMR for the province is 148 per 100 000 live births [11], making it a priority district in efforts to reduce the MMR for Gauteng. About 26% of the district population access private health care mostly through private health insurance [38]. This leaves 74% of the population dependent upon public healthcare services funded by the government [38]. Public health care is administered at the district level jointly by the provincial government and the municipality (local government). A qualitative research design was used to explore and describe experiences and perceptions of district managers as they oversee the delivery of EmOC services in the district health system. A total of 19 senior managers were purposively selected from the study district. Inclusion criteria were people in leadership positions that and could make decisions that governed EmOC services. These were senior managers in the district directorate, health facilities (community health centres (CHCs) and hospitals), members of the district clinical specialist team (DCST), as well as the provincial managers that directly governed maternal health services in the district. Seven (36.8%) of the participants were male and 12 (63.2%) were female aged between 45 and 62 years. They were either medical doctors or nurse professionals. Face-to-face key informant interviews were conducted in English with individual participants in the privacy of their offices at times designated by them. Interviews took about an hour on average, depending on interpersonal participant dynamics. Participants were initially asked to relate their experiences of the health system as managers, including perceived failures and successes. The following open-ended question was asked to open the discussion; “Please tell me about your experiences as a manager that also oversees EmOC in the district. What are some of the challenges you experience?” The health system building blocks framework was used to guide probing questions and tease out discussions. The researcher used active listening to encourage participant discussions during interviews. All interviews were conducted in English and recorded. Field notes were also taken by the researcher to document participant non-verbal cues such as body language during interviews. Findings were validated in a feed-back workshop at the district. Thematic content analysis was used to first inductively identify themes and then deductively categorise them into the broader themes of the health system building block framework [1]. Thematic analysis allows flexibility enabling both inductive and deductive coding. The process starts by identifying variables as they emerge from the data [39]. It then progresses to creating broader categorisations and ultimately theory application [39,40]. Audio-tapes were transcribed and typed in MSWord. Phrases and words were coded from the transcripts that gave participant impressions, perceptions, and experiences of the health system. This first step of analysis was done inductively, without reference to researcher preconceived ideas or classifications [41]. From the transcripts, we looked for clues regarding the overall state of the district health system as perceived by managers. We also looked for barriers or bottlenecks encountered during EmOC governance and services delivery, problem-solving or troubleshooting strategies, innovations employed by managers, and identified successes or failures. We grouped related words into emerging themes. Emerged themes were then deductively categorised using the six building blocks of the WHO health systems framework [1]. To assure reliability, an experienced health systems researcher reviewed transcripts and the coded themes to confirm inter-coder agreement [41]. Field notes were also scrutinised thematically and added to themes identified from verbal transcriptions.
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