School of Public Health and SAMRC Health Services to Systems Unit, University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa.
Mpumalanga Department of Health, No 7 Government Boulevard, Mbombela, South Africa.
Health Policy Plan. 2019 Jul 1;34(6):430-439. doi: 10.1093/heapol/czz060.
There is a gap in understanding of how national commitments to child nutrition are translated into sub-national implementation. This article is a mixed methods case study of a rural South African health district which achieved accelerated declines in morbidity and mortality from severe acute malnutrition (SAM) in young children, following a district health system strengthening (HSS) initiative centred on real-time death reporting, analysis and response. Drawing on routine audit data, the declining trends in under-five admissions and in-hospital mortality for SAM over a 5-year period are presented, comparing the district with two others in the same province. Adapting Gillespie et al.'s typology of 'enabling environments' for Maternal and Child Nutrition, and based on 41 in-depth interviews and a follow-up workshop, the article then presents an analysis of how an enabling local health system environment for maternal-child health was established, creating the conditions for achievement of the SAM outcomes. Embedded in supportive policy and processes at national and provincial levels, the district HSS interventions and the manner in which they were implemented produced three kinds of system-level change: knowledge and use of evidence by providers and managers ('ways of thinking'), leadership, participation and coordination ('ways of governing') and inputs and capacity ('ways of resourcing'). These processes mainstreamed responsibility, deepened accountability and triggered new service delivery and organizational practices and mindsets. The article concludes that it is possible to foster enabling district environments for the prevention and management of acute malnutrition, emphasizing the multilevel and simultaneous nature of system actions, where action on system 'software' complements the 'hardware' of HSS interventions, and where the whole is more than the sum of the parts.
人们对于国家在儿童营养方面的承诺如何转化为国家以下各级的实施情况存在理解上的差距。本文通过混合方法案例研究，探讨了南非一个农村卫生区的情况。该卫生区通过加强地区卫生系统（HSS）举措，实现了严重急性营养不良（SAM）儿童发病率和死亡率的快速下降，该举措的核心是实时报告、分析和应对死亡事件。本文利用常规审计数据，呈现了该地区在五年期间五岁以下儿童住院率和 SAM 院内死亡率的下降趋势，并将该地区与同一省内的另外两个地区进行了比较。本文借鉴了 Gillespie 等人针对母婴营养制定的“有利环境”分类法，并通过 41 次深入访谈和后续研讨会，分析了如何建立有利于母婴健康的有利当地卫生系统环境，为实现 SAM 结果创造了条件。该地区 HSS 干预措施及其实施方式嵌入在国家和省级的支持性政策和流程中，产生了三种系统层面的变化：提供者和管理者对证据的了解和使用（“思维方式”）、领导力、参与和协调（“治理方式”）以及投入和能力（“资源方式”）。这些过程使责任主流化，深化了问责制，并引发了新的服务交付和组织实践和思维方式。本文得出的结论是，有可能促进有利于预防和管理急性营养不良的地区环境，强调系统行动的多层次和同步性质，其中系统“软件”的行动补充了 HSS 干预的“硬件”，整体大于部分的总和。
