In this article, we review the monitoring and evaluation system that is used to measure the performance of primary healthcare delivered through the district health system and district management teams. We then review some global frameworks, especially linked to the World Health Organization, and look at some of the differences between what is internationally recommended and what we do in South Africa. We end with some recommendations to improve the system.

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 ~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

We report here on the process and findings of a research prioritisation exercise for universal health coverage (UHC) in South Africa, conducted during the course of 2019. As plans to roll out National Health Insurance (NHI) gather momentum and we transition into a pandemic recovery phase, we believe that it is now time to revisit these priorities, while recognising that experiences with the COVID-19 pandemic have revealed new system challenges and strengths and introduced new priorities. The UHC research priority-setting methodology followed a stepwise process of collation of evidence, expert brainstorming and the development of a survey completed by 68 members of the Public Health Association of South Africa. Themes related to leadership and governance were ranked most highly, and with other priorities generated, provide an initial road map of knowledge needs that could guide individual institutions and commissioning by funding bodies. We further reflect on the importance of researcher-decision-maker dialogue and strengthening the contribution of health policy and systems research to policy and practice, especially as new reforms are implemented.

BACKGROUND. North West Province (NWP), South Africa, was an early adopter of the primary healthcare (PHC) ward-based outreach team (WBOT) strategy and has made considerable progress in implementing it. Given the interest in and expectations of greater investment in WBOTs, assessing their impact on and contribution to PHC outputs and health outcomes is becoming increasingly important. OBJECTIVES. To describe the application of a plausibility evaluation design for assessing the contribution of WBOTs to PHC performance in NWP, comparing changes in coverage, utilisation and outcome indicators in facilities with and without WBOTs. METHODS. Routine data from the District Health Information System on both WBOTs and PHC facilities for the period 2011/12 (prior to implementation) to 2014/15 (3 years after implementation began) were extracted. Analysis involved the following three steps: (i) selection of indicators sensitive to community-based action; (ii) data cleaning; and (iii) comparison of the degree of change in median indicator values between 2011/12 and 2014/15 in facilities with and without WBOTs (a difference-in-differences analysis). RESULTS. Changes in indicator values in facilities were grouped into four categories: (i) indicators where there was greater (statistically significant) improvement in facilities with WBOTs (couple year protection rate, measles immunisation coverage in children aged <1 year, incidence of children aged <5 years with severe diarrhoea with dehydration); (ii) indicators that declined or worsened, but less so in facilities with WBOTs at statistically significant levels (antenatal first visits as a percentage of children born in that year, PHC utilisation rate of children aged <5 years); (iii) indicators that improved in all facilities with no significant difference between facilities with and without WBOTs (antenatal attendance before 20 weeks, prophylactic vitamin A coverage to children aged 12 - 59 months); and (iv) indicators that remained unchanged in all facilities (immunisation coverage in children aged <1 year, postnatal mother visits at 6 days, cervical cancer screening coverage in women aged >30 years, PHC utilisation rate of children aged >5 years). CONCLUSION. Notwithstanding the limitations of routine data and the need to approach the findings with caution, this analysis suggests that WBOTs plausibly had some positive effects on the overall performance of the PHC system. We propose a methodology to monitor the performance of WBOTs using routine PHC indicators that programme managers could apply elsewhere.

Scomberomorus cavalla é uma espécie de peixe pelágico amplamente distribuído na costa oeste do Atlântico, e uma diminuição no seu nível de captura tem sido verificada nos E.U.A e Golfo do México, comparada com os níveis alcançados pela espécie no passado. Da mesma forma, em algumas áreas do Brasil, há indícios de sobre-exploração. Entretanto, não existem estudos moleculares que visam o manejo deste importante item. Desta forma, no presente estudo, foram seqüenciados 380 pares de bases nucleotídicas da região da Alça-D do DNA mitocondrial de amostras provenientes de desembarque em Macapá, Bragança e Fortaleza. As análises filogenéticas e populacionais revelaram que há apenas uma população panmítica e baixos níveis de variabilidade genética foram observados. Estes resultados, assim como a observada sobre-exploração de S. cavala, representam dados muito importantes para o estabelecimento do manejo deste estoque a fim de prevenir um colapso ou risco de extinção no futuro.

Scomberomorus cavalla is a pelagic fish species widely distributed on the Atlantic west coast, and a noticeable decrease in its capture level in the USA and Gulf of Mexico is occurring, compared to the levels reached by the species in the past. Likewise, in some areas of Brazil, there has been indication of over-harvesting. However, there are no molecular studies focusing on the management of such an important item. Thus, in the present study, 380 nucleotide base pairs of the mitochondrial DNA D-Loop region of samples from Macapá, Bragança, and Fortaleza were sequenced. Phylogenetic and population analyses revealed that there is only one panmitic population, and low levels of genetic variability were verified. These results, as well as the noticed over-harvesting of S. cavalla, represent very important data to determine the management of such stock in order to prevent a collapse or the risk of future extinction.