District and sub-district stewardship of quality and health outcomes: roles, systems and strategies
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Sub-district and district health systems – generically referred to as the meso-level – are key to enhancing quality of care and improving health outcomes. Facility (micro) level improvement strategies are less likely to succeed or be sustained if they are not supported and enabled by the meso-level. In this briefing document, we explore district and sub-district stewardship of quality of care and health outcomes, based on insights and experiences of a national initiative referred to as Mphatlalatsane. This initiative seeks to improve maternal and neonatal health in selected districts of three provinces (Mpumalanga, Limpopo and Eastern Cape). As part of the wider evaluation of Mphatlalatsane, we conducted serial interviews with project partners over the course of 2020 and 2021, specifically probing views on the meso-level in relation to maternal and neonatal health (MNH) quality and outcomes. Drawing on these interviews and programme documentation, we seek to characterize both the ‘what’ and ‘the how’ of meso-level stewardship of quality and outcomes, including roles/capabilities, enabling systems and change strategies. We believe the insights generated offer guidance on system functioning that can complement clinical guidelines and standards, and feed into debates on the design of district and sub-district health systems in South Africa. To achieve better quality and health outcomes (whether for MNH or other programmes), the meso-level needs to be able to: drive implementation of provincial and national strategy, while simultaneously advocating for bottom-up service delivery needs; authorise and support innovation by frontline providers, drawing on improvement methodologies; coordinate health programmes and players across levels of the health system; and ensure appropriate accountabilities. These roles imply a high degree of agency and responsiveness on the part of the meso-level, proactively connecting elements of the system, problemsolving, learning, allocating resources and exploiting efficiencies.