Improving health outcomes and quality at the subdistrict level: Evaluation of the '3 feet model' in Waterberg District, Limpopo Province, South Africa

Background. 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). Objectives. 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. Methods. A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined similar to 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. Results. 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. Conclusion. 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.