The whole is more than the sum of the parts: establishing an enabling health system environment for reducing acute child malnutrition in a rural South African district

Abstract

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.

Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa

“…An equilibrium with financial compensation needs to be found, as the latter can crowd out intrinsic motivation. A study of a nutrition programme in a rural district in South Africa highlighted the importance of a supporting environment for capacity-building through three key elements: tangible and comprehensible knowledge transformation and use of evidence ("ways of thinking"), adequate leadership, empowerment and accountability mechanisms ("ways of governing"), and adequate inputs and capacity ("ways of resourcing") [36,37]. Three axes that should be tackled simultaneously and that are, according to our LHS analysis, the main weak factors within the system.…”

Barriers and Facilitators to the Implementation of Large-Scale Nutrition Interventions in Africa: A Scoping Review

“…2015; Sanghvi et al 2013) and low community support for large-scale nutrition projects (Carroll et al 2019;de Villiers et al 2015) created barriers for the implementation process. On the other hand, seven studies cited that developing informal alliances can enable implementation (Schneider et al 2019;Eby et al 2019;Kavle et al 2019a;Carroll et al 2019;Tanumihardjo et al 2017;Blauvelt et al 2018;Nankunda et al 2010). Examples of such informal alliances include involving experts like dieticians, (Schneider et al 2019) or engaging with community leaders that can increase the acceptability of an intervention (Carroll et al 2019).…”

“…Leadership Engagement (Inner Setting) Government support was found to be valuable to implementation by providing policy, guidelines, material resources, and technical expertise to nutrition projects (Schneider et al 2019). Moreover, support from government agencies facilitated meaningful engagement with a range of stakeholders, champions, and community leaders (Sanghvi et al 2013;Blauvelt et al 2018).…”

“…Routine program monitoring was cited in six studies as an enabler for implementation (Schneider et al 2019;Pomeroy-Stevens et al 2016;Sanghvi et al 2013;Eby et al 2019;Menon et al 2013;Baker et al 2013;Guyon et al 2016). To illustrate, program monitoring was achieved through annual review meetings, which provided an excellent platform to raise and address any outstanding program challenges (Eby et al 2019).…”

"Not Just a Journal Club – It’s Where the Magic Happens": Knowledge Mobilization through Co-Production for Health System Development in the Western Cape Province, South Africa

“…A range of publications involve shared authorship among those involved in the JC, 22,27 or draw on ideas discussed in the JC. 23,26,28 Although the macro, societal-level impacts of the JC and linked engagements are inevitably harder to discern, it can be argued that they are likely to flow from the sorts of policy and organizational changes initiated within the WCG:H and CityHealth discussed above. 16 JC thinking is also acknowledged by managers as feeding into the wider processes of co-creating organizational and health service re-design (Figure 1), that will have long-lasting impacts on the provincial health system.…”