Table 2. Roles of Meso-Level Actors in Maternal and Neonatal Quality of Care and Outcomes .

Role	Details	Quotes
Mediate between macro and micro levels	Translate policy into implementation	“They are well placed not to be too high up such as national and provincial, but at the same time, they also have direct access to the facilities and hospitals in a way so that they are able to drive from the bottom and from the top to be able to deliver on the healthcare outcomes” (IP).
Enable and drive action	Encourage frontline providers to innovate and implement; prevent disablement	“The people who make decisions, these are district managers and facility CEOs, these are key decision makers and for any improvement work or activity to even begin, these too need to become the sponsors or drivers of that improvement activity” (IP). “At the frontline, there are a lot of people who are working as hard as they can, to do their jobs as they should, but the system itself seems to be disabling rather than enabling” (NDoH). “What happens at facility ends up being paralyzed by the multiple layers above it, all of which appear, to many people at facility level to be placed there precisely to stop them from doing things” (NDoH).
Establish QI systems	Introduce QI projects, develop systems and ensure coverage	“The district clinical specialist introduced a number of quality improvement projects. And they had a system already going, where they were doing some quality improvements with the whole district with … [the] hospital’s drainage area” (IP).
Coordinate and align actors and activities	Alignment and coordination of prorammes (“indicators”) and quality initiatives, addressing fragmentation	“The problem with the district offices and in some places even replicated in subdistrict offices is that we have one manager per indicator, … the management layers have ballooned with people who are responsible for reporting essentially, on a single indicator. And that has fragmented the system” (NDoH). “There was not much coordination, each clinic or district had different quality improvement programs which were not linking to one and other” (IP).
Manage key service delivery and other systems	Referral and outreach and supportive systems, and clinical governance	“The DMT [district management team] is mainly looking at systems but it also has clinical governance [roles], where they look at the real clinical care… The governance structure that they put together now, they, it’s opened the in-reach and the out-reach so you refer to a person, and you can have contact with the person whether a consultant or a specialist prior to actually referring the patient…” (NDoH).

Abbreviations: NDoH, National Department of Health; IP, implementing partners; QI, quality improvement; CEO, chief executive officer.