As part of a multi-country study, maternal health services were reviewed in one health
district in Gauteng Province, South Africa. Poor record-keeping, inadequate supervision, poor levels
of clinical knowledge and under-utilisation of midwife obstetric units were found. Interventions
identified by local health service personnel to improve maternity care were developed, implemented
and evaluated, included programme-specific (training in prevention of mother-to-child transmission
of HIV and neonatal resuscitation) and system interventions (improving interpersonal relations
and system functioning, use of routine data for monitoring purposes, improving supervision skills).
This resulted in some positive outputs. Health worker knowledge and patient records improved, and
there was some indication that supervision improved. However, system-wide interventions that
could improve programmes were less successful. To build a learning organisation, a new culture
of monitoring and evaluation, including routine self-evaluation, is required as core skills for all
health workers. These data should be used at the point of collection. Changing reporting lines
between programme and district managers may improve co-ordination between different
authorities, and there is a need to enhance the manner in which staff are assessed, appraised,
promoted and rewarded. Professional bodies who oversee training curricula, institutions that offer
training, and institutions that provide funding for training and development need to take on the
challenge of health systems development and avoid promoting programme-specific interventions only.