Abstract:
BACKGROUND : Despite progress, maternal and neonatal mortality and still births remain high in South Africa.
The South African National Department of Health implemented a quality improvement (QI) programme, called
Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health
facilities, seven per participating province, between 2018 and 2022.
METHODS : We conducted a qualitative process evaluation of the contextual and implementation process factors’
influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection
included three interview rounds with the leaders and members of the QI teams in each facility; intermittent
interviews with the QI advisors; programme documentation review; observation of programme management
meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake
varied across the three provinces and between facilities within provinces.
RESULTS : Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected
QI teams in one province more severely than others, because they received limited pre-pandemic training. Better
uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI
advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more
complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders’ intrinsic motivation to apply QI methodology. We
found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19.
Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using
data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not
the prescribed tools.
CONCLUSIONS : Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced
technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps
cannot be followed.
Description:
DATA AVAILABILITY : All the transcriptions and analysed data can be obtained, on reasonable
request, from the corresponding author.