![]() ![]() We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. In particular, the MRU promoted the formation of non-hierarchical collaborative networks improved coordination between community, PHC and hospital services and shaped collective sense-making in positive ways. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. The MRU was introduced as a decision-making and accountability structure, and constituted of a “triangle” of managers, clinicians and information officers. ![]() This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening.
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