Health Systems Research: District Innovation, Action and Learning forHealth System Development (DIALHS)

District and sub-district managers in the South African health system are charged with building, strength- ening and managing health systems that implement national policy frameworks. At the same time they need to remain responsive to local needs and contexts, involve multiple actors in decision-making and inspire and motivate staff to be creative in delivering services in  resource-constrained  settings. This  is  a  complex and complicated undertaking, and managers are often hamstrung by the constraints of existing systems while they themselves are not sufficiently well-equipped to navigate between high need, limited resources and inherent system complexity.

The District Innovation, Action and Learning for Health System Development (DIALHS) project – funded by The Atlantic Philanthropies – is engaging with these challenges at the implementation level in the sub-dis- trict of Mitchell’s Plain in Cape Town.  Comprising a partnership between our sister School at the Univer- sity of Cape Town and ourselves, as well as the health departments of the City of Cape Town and the provin- cial government of the Western Cape, the project aims to facilitate a better functioning, more responsive, more effective district health system (DHS). It intends to do this firstly, through better understanding the key restrainers and enablers of health system functioning at local level; and secondly, by jointly developing strat- egies and interventions which respond to the complex and layered nature of the health system.

As  we  are  employing  an  action  learning  approach in this project, we implement all activities through reflective processes which directly engage local health

managers and staff. This involves regular meetings in which we review activities with colleagues within the learning sites, and adapt and revise activities as neces- sary. So in the development stage and in the first year of implementation in 2010, we have worked with local district/sub-district/facility managers to understand and map the multiple layers and facets of sub-district functioning – with a view to identifying entry points for ‘interventions’.

In addition, the research team is playing a supportive role in encouraging practitioners to engage in cycles of planning, implementation/practice, reflection and evaluation, learning and revision. In this way the com- bined DIALHS team (both researchers and health prac- titioners) will work with other local health managers to draw out the wider lessons from this experience. For example identifying the enabling and restraining fac- tors at other levels of the health system will generate lessons and ideas about the systemic changes neces- sary to support the DHS and to improve primary and community care. These could, in turn, positively affect policy implementation and innovation within the DHS – which could provide lessons for the district itself as well as for provincial and national colleagues.

The DIALHS project exemplifies the School’s serious commitment to collaborative work which integrates the many elements required for effective systems functioning, rather than focusing on a single topical issue in isolation. It is also breaking new ground methodologically as the project applies and adapts concepts of reflective practice, case study research and collaborative inquiry to the field of health policy and systems research.

District innovation, action and learning for health systems development
A collaboration between:

City of Cape Town and its Mitchell’s Plein sub structure
Provincial Government of the Western Cape. Metro District Health Services, and its Mitchell’s Plein sub structure

University of Cape Town, School of Public Health

University of the Western Cape, School of Public Health

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