‘It needs a complete overhaul…’ district manager perspectives on the capacity of the health system to support the delivery of emergency obstetric care in an urban South African district

Global Health Action, Volume 12, No. 1, Year 2019

Interpretation

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.

AI Digest

Study Justification:

– Despite developments in emergency obstetric care (EmOC), South Africa still has a high maternal mortality ratio.
– Strengthening the health system is a focus area identified by the National Committee for Confidential Enquiries into Maternal Deaths.
– District managers, as overseers of the frontline health system, can provide insight into the processes that influence the delivery of EmOC.
– This study aimed to identify health system enablers and barriers to the delivery of EmOC from the perspective of district managers.

Highlights:

– Weaknesses in the organization of health services were identified.
– High vacancy and turnover of senior management were observed.
– Poor clinical accountability from EmOC providers was noted.
– Inadequate resources, including infrastructure, staffing, and funding, were identified.
– Improvement of district health information system indicators was recommended.
– The functioning of the district health system was found to be weak, affecting the delivery of EmOC.
– Staffing needs to be effectively addressed to reduce maternal mortality.
– Coordination of EmOC services by managers needs to be strengthened to improve continuity of care.
– High turnover of senior leadership affects implementation priorities and continuity in the overall strategic direction of EmOC.

Recommendations:

– Address weaknesses in the organization of health services.
– Improve recruitment and retention of senior management.
– Enhance clinical accountability from EmOC providers.
– Allocate adequate resources for infrastructure, staffing, and funding.
– Improve district health information system indicators.
– Strengthen coordination of EmOC services to limit fragmentation of care.
– Address high turnover of senior leadership to ensure continuity in strategic direction.

Key Role Players:

– District managers
– Senior management
– District directorate
– Health facilities (community health centres and hospitals)
– District clinical specialist team (DCST)
– Provincial managers governing maternal health services

Cost Items for Planning Recommendations:

– Recruitment and retention strategies for senior management
– Infrastructure improvements
– Staffing resources
– Funding allocation for EmOC services
– Training and capacity building programs for district managers and EmOC providers
– Implementation of district health information system indicators

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted face-to-face audio-recorded key informant interviews with 19 district managers in charge of the delivery of emergency obstetric care (EmOC) in one urban district. The interviews were transcribed and coded, and related codes were grouped into emerging themes. Thematic analysis was then applied to categorize the emergent themes into the WHO health system building blocks. The findings highlight weaknesses in the organization of health services, high vacancy and turnover of senior management, poor clinical accountability from EmOC providers, inadequate resources, and the need to improve district health information system indicators. The study provides valuable insights into the health system enablers and barriers to the delivery of EmOC from the perspective of district managers. However, the study was conducted in only one urban district, which limits the generalizability of the findings. To improve the strength of the evidence, future research could include a larger sample size and include multiple districts to capture a more comprehensive understanding of the health system factors influencing the delivery of EmOC.

Abstract

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.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could be recommended to improve access to maternal health:

1. Strengthening the organization of health services: Implementing innovative strategies to improve the coordination and management of health services, such as establishing clear protocols and guidelines for EmOC delivery, improving communication and collaboration between different healthcare facilities, and implementing effective referral systems.

2. Addressing staffing challenges: Developing innovative approaches to address the high vacancy and turnover of senior management, such as implementing retention strategies, providing professional development opportunities, and offering incentives to attract and retain skilled healthcare professionals.

3. Enhancing clinical accountability: Introducing innovative methods to improve clinical accountability among EmOC providers, such as implementing quality assurance programs, conducting regular performance evaluations, and providing ongoing training and support to healthcare providers.

4. Improving resources: Exploring innovative solutions to address resource challenges, including infrastructure, staffing, and funding. This could involve seeking partnerships with private sector organizations, leveraging technology to improve resource allocation and management, and advocating for increased funding for maternal health services.

5. Strengthening district health information systems: Implementing innovative approaches to improve the collection, analysis, and use of data related to maternal health. This could involve using digital health technologies to streamline data collection and reporting, implementing real-time monitoring systems, and utilizing data analytics to identify trends and inform decision-making.

6. Addressing social determinants of health: Taking a holistic approach to maternal health by addressing the social determinants that contribute to poor maternal outcomes. This could involve implementing innovative programs that address poverty, improve access to education and employment opportunities, and promote gender equality.

It is important to note that these recommendations are based on the information provided and may need to be adapted to the specific context and needs of the district under study.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health would be to address the weaknesses in the organization of health services, high vacancy and turnover of senior management, poor clinical accountability from emergency obstetric care (EmOC) providers, inadequate resources (including infrastructure, staffing, and funding), and the need to improve district health information system indicators.

To implement this recommendation, the following steps can be taken:

1. Strengthen the organization of health services: This can be done by improving coordination and communication between different healthcare facilities and departments within the district. Clear roles and responsibilities should be defined, and mechanisms for collaboration and information sharing should be established.

2. Address the high vacancy and turnover of senior management: Efforts should be made to attract and retain qualified and experienced senior managers in the district. This can be done through competitive compensation packages, professional development opportunities, and creating a supportive work environment.

3. Improve clinical accountability from EmOC providers: Establish mechanisms for monitoring and evaluating the performance of EmOC providers. This can include regular performance reviews, feedback sessions, and training programs to enhance clinical skills and knowledge.

4. Allocate adequate resources: Advocate for increased funding for maternal health services, including infrastructure development, staffing, and equipment. This can be done through engaging with relevant stakeholders, such as government officials, donors, and non-governmental organizations.

5. Enhance district health information system indicators: Improve the collection, analysis, and reporting of data related to maternal health. This can help identify gaps and areas for improvement, as well as track progress towards reducing maternal mortality.

By implementing these recommendations, the district health system can be strengthened to better support the delivery of emergency obstetric care and improve maternal outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthening the organization of health services: This could involve improving coordination and communication between different healthcare facilities, streamlining referral systems, and ensuring efficient management of resources.

2. Addressing staffing issues: To reduce the high vacancy and turnover of senior management, efforts should be made to attract and retain qualified healthcare professionals. This could include offering competitive salaries, providing professional development opportunities, and creating a supportive work environment.

3. Enhancing clinical accountability: Measures should be implemented to ensure that healthcare providers delivering emergency obstetric care are held accountable for their clinical practices. This could involve regular performance evaluations, ongoing training and education, and the establishment of quality assurance mechanisms.

4. Increasing resources: Adequate resources, including infrastructure, staffing, and funding, are essential for improving access to maternal health. Efforts should be made to secure additional resources and allocate them effectively to areas with the greatest need.

5. Improving district health information system indicators: Enhancing the district health information system can help identify gaps and monitor progress in maternal health. This could involve implementing electronic health records, improving data collection and reporting processes, and using data to inform decision-making.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations. These could include metrics such as maternal mortality ratio, percentage of pregnant women receiving prenatal care, and average distance to the nearest healthcare facility.

2. Collect baseline data: Gather data on the current status of the indicators in the study district. This could involve reviewing existing data sources, conducting surveys or interviews, and analyzing relevant reports.

3. Implement the recommendations: Introduce the recommended interventions and initiatives in the district. This could involve implementing new policies, allocating resources, and training healthcare providers.

4. Monitor and evaluate: Continuously collect data on the selected indicators to assess the impact of the recommendations. This could involve conducting regular surveys, analyzing health records, and monitoring key performance indicators.

5. Analyze the data: Use statistical analysis techniques to compare the baseline data with the post-implementation data. This will help determine the extent to which the recommendations have improved access to maternal health.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any areas that may require further attention or modifications to the interventions.

7. Communicate the findings: Share the results of the simulation with relevant stakeholders, including district managers, policymakers, and healthcare providers. This will help inform decision-making and guide future efforts to improve access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommended interventions on improving access to maternal health in the study district.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1080/16549716.2019.1642644

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Technology and Innovations, Workforce

Study Countries:

South Africa

Study Design:

Cross Sectional Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Qualitative

Participants Gender:

Male & Female