School of Public Health and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa.
Clinton Health Access Initiative, Pretoria, South Africa.
S Afr Med J. 2023 Nov 6;113(11):15-21. doi: 10.7196/SAMJ.2023.v113i11.1558.
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).
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.
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.
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.
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.
人们对于在南非（SA）的区县级层面上提高医疗质量和改善健康结果的潜在作用和行动存在理解上的差距。
报告对一项旨在降低孕产妇、新生儿和儿童死亡率的区县级卫生系统强化倡议的评估，该倡议在林波波省沃特堡地区被称为“3 英尺模型”。该模型以实时发病率/死亡率监测和协调应对为中心。该模型于 2021 年至 2022 年期间在沃特堡的 5 个区县级行政区中的 3 个实施了 18 个月。
研究人员、干预合作伙伴和区县级决策者共同进行了前瞻性、过程跟踪评估。数据来源结合了约 100 小时的研究者参与式观察、对 14 名卫生系统行为者的访谈、3 名区县级管理者的结构化反思以及常规地区卫生信息系统的信息。对行动机制的假设进行了三角分析和研究。
在采用该模型后，3 个区县级的围产期死亡率（PMR）分别提高了 28.8%、11.5%和 28%，而在 4 个邻近区县级的 2 个中，PMR 恶化了。实施成功的可能因素是存在稳定和忠诚的混合（临床管理）区县级领导，以及他们克服各种系统行为者之间根深蒂固的隔阂的能力；初级医疗保健机构、医院和紧急医疗服务之间新的合作关系；以指导应对措施的方式生成和包装信息（“可操作情报”）；以及来自地区高级管理人员的支持。
虽然不主张以一刀切的方式来提高质量和结果，但沃特堡地区的积极经验表明，“3 英尺模型”的原则和行动机制具有更广泛的政策和实践相关性，尤其是随着对区县级作为南非人口健康和福祉核心单元的重视程度不断提高。
