3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item District-based clinical specialist team's implementation in South Africa: lessons from analyses of institutional role and functioning in a transforming health system(2019) Oboirien, Kafayat OlabimpeRationale Clinical governance is a growing approach or strategy for improving the quality of health care in many health systems, especially those seeking universal health coverage (UHC). This is partly because UHC promotes access to quality health care while minimising the financial and geographical inequities associated with access to health care. South Africa introduced new actors at the local health care delivery level in 2011 – District based Clinical Specialist Teams (DCSTs) to implement clinical governance and improve the quality of care in a system with high maternal and child health morbidity and mortality. The use of multiple organisational level strategies such as risk management, continuous professional development, workforce planning and clinical audits etc. – (i.e. clinical governance) is not new in ensuring quality and holding clinical professionals accountable for the services they provide within the health care system. Yet, DCSTs are new to the district health system (DHS)’s organisational structure and their role is new within an evolving South African quality policy environment. As of early 2019, DCSTs are operational in 49 out of the country’s 52 health districts, as part of a complex decentralising district health system (DHS). Limited decision-making authority, poorly-defined actor roles and inadequate capacity at the district level have generally been obstacles to transferring responsibility down to lower levels in South Africa. Yet, little is known about how DCSTs activities are implemented in practice and whether their institutional role and functioning affect change. vii Aim and methods This doctoral research examines the institutional role and functioning of DCSTs within the context of a decentralising DHS in South Africa between 2013 and 2015. This was achieved through applying a theory of change approach to programme evaluation complemented by a case study design. The study is relevant to how we can understand the dynamics of implementation by constructing and examining the assumptions and processes that drive change. The PhD is nested in an evaluation project, Universal Coverage in Tanzania and South Africa: Monitoring and evaluating progress (UNITAS project) in three health districts. The UNITAS project contributed to the understanding of bottlenecks and unintended consequences in the implementation of a range policy reforms towards UHC. This PhD took forward the UNITAS research focused on DCSTs being one of the reforms seeking to move South Africa towards UHC. Findings There has been a fairly successful recruitment of DCSTs nationally given a 94% rollout. While, activities of teams are fairly similar and informed by emerging national priorities and specific district level processes. However, there are variations in the three study sites by team composition, geographical coverage, as well as number of facilities in each district or those covered by the DCSTs. In addition, differences in institutional settings and organisational arrangements are contextual factors that provided opportunity to draw on existing structures, networks and infrastructure for quality improvement. Further, the understanding and expectations of DCSTs’ role differ by individuals, levels within the DHS (district or sub-district level) and service delivery levels (Hospital vs PHC). This partly led to perceptions of role conflict and a slow adjustment to DCSTs in the three study sites. Yet, despite the observed constrained context, role conflict and adjustments, DCSTs were able to function and lead change while revealing and bridging gaps in maternal and child health service delivery as well as holding health care professionals to account. This was possible through their ability to emerge as institutional entrepreneurs (IEs) by using social and political skills to harness opportunities, leverage resources and strategically (partly) enable change. Further team members have been able to take on certain institutional entrepreneurship characteristics, functioning – more or less – as announcers of reforms, articulating a strategic vision and direction for the system, advocating for change, mobilising resources. In addition, they have helped to reorganise services and shape care practices by re-framing issues and exerting power to influence organisational change. While DCST innovation can foster institutional entrepreneurship, there are nuanced differences between individual members and the team, and these need better understanding to maximise this contribution to change. Conclusions South Africa continues to strive towards instituting a quality improvement policy and system partly through clinical governance. A number of programmes, actors and processes compliments this approach. The introduction of DCSTs to lead the South African clinical governance implementation at a district level through the PHC approach is central to achieving UHC, although learnings are just starting to emerge. Given the understandings, perceptions and experiences of DCSTs in South Africa, with its uniqueness and complexities, providing the enabling environment where institutional entrepreneurship can strive is important for sustaining the DCST innovation.