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. 2018 Nov 29;18(1):912.
doi: 10.1186/s12913-018-3726-1.

Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building

Martina Lembani  1 , Helen de Pinho  2 , Peter Delobelle  3 , Christina Zarowsky  3   4 , Thubelihle Mathole  3 , Alastair Ager  2   5
Affiliations

Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building

Martina Lembani et al. BMC Health Serv Res. .

Abstract

Background: The Eastern Cape Province reports among the poorest health service indicators in South Africa with some of its districts standing out as worst performing as regards maternal health indicators. To understand key drivers and outcomes of this underperformance and to explore whether a participatory analysis could deepen action-oriented understanding among stakeholders, a study was conducted in one of the chronically poorly performing districts.

Methods: The study used a systems analysis approach to understand the drivers and outcomes affecting maternal health in the district in order to identify key leverage points for addressing the situation. The approach included semi-structured interviews with a total of 24 individuals consisting health system managers at various levels, health facility staff and patients. This was followed by a participatory group model building exercise with 23 key stakeholders to analyze system factors and their interrelationships affecting maternal health in the district using rich pictures and interrelationship diagraphs (IRDs) and finally the development of causal loop diagrams (CLDs).

Results: The stakeholders were able to unpack the complex ways in which factors were interrelated in contributing to poor maternal health performance and identified the feedback loops which resulted in the situation being intractable, suggesting strategies for sustainable improvement. Quality of leadership was shown to have a pervasive influence on overall system performance by linking to numerous factors and feedback loops, including staff motivation and capacity building. Staff motivation was linked to quality of care in turn influencing patient attendance and feeding back into staff motivation through its impact on workload. Without attention to workload, patient waiting times and satisfaction, the impact of improved leadership and staff support on staff competence and attitudes would be diminished.

Conclusion: Understanding the complex interrelationships of factors in the health system is key to identifying workable solutions especially in the context of chronic health systems challenges. Systems modelling using group model building methods can be an efficient means of supporting stakeholders to recognize valuable resources within the context of a dysfunctional system to strengthen systems performance.

Keywords: Group model building; Health systems; Maternal health; Quality of care; Systems dynamics Analysis.

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Conflict of interest statement

Ethics approval and consent to participate

Ethics approval was obtained from the Senate Research Committee of the University of the Western Cape and consent forms were used to seek consent from participants. Information sheets were also given to participants to provide information regarding the purpose of the research.

Consent for publication

Not applicable

Competing interests

The authors have declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Interrelationship Diagraph
Fig. 2
Fig. 2
Seed Model
Fig. 3
Fig. 3
Preliminary Causal Loop Diagram representing factors influencing maternal mortality in OR Tambo District developed during group model building
Fig. 4
Fig. 4
Causal loop diagram depicting key pathways of influence on maternal services within OR Tambo District
See this image and copyright information in PMC

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