| Summary: | Objective To assess the functioning of maternal, perinatal, neonatal and child death surveillance and response (DSR) mechanisms at a health district level.Design A framework of elements covering analysis of causes of death, and processes of review and response was developed and applied to the smallest unit of coordination (subdistrict) to evaluate DSR functioning. The evaluation design was a descriptive qualitative case study, based on observations of DSR practices and interviews.Setting Rural South African health district (subdistricts and district office).Participants A purposive sample of 45 front-line health managers and providers involved with maternal, perinatal, neonatal and child DSR. The DSR mechanisms reviewed included a system of real-time death reporting (24 hours) and review (48 hours), a nationally mandated confidential enquiry into maternal death and regular facility and subdistrict mortality audit and response processes.Primary outcome measures Functioning of maternal, perinatal, neonatal and child DSR.Results While DSR mechanisms were integrated into the organisational routines of the district, their functioning varied across subdistricts and between forms of DSR. Some forms of DSR, notably those involving maternal deaths, with external reporting and accounting, were more likely to trigger reactive fault-finding and sanctioning than other forms, which were more proactive in supporting evidence-based actions to prevent future deaths. These actions occurred at provider and system level, and to a limited extent, in communities.Conclusions This study provides an empirical example of the everyday practice of DSR mechanisms at a district level. It assesses such practice based on a framework of elements and enabling organisational processes that may be of value in similar settings elsewhere.
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