Can institutional entrepreneurship strengthen clinical governance and quality improvement: a case study of a district-based clinical specialist team in South Africa

We present an interpretive qualitative account of micro-level activities and processes of clinical governance by recently introduced district-based clinical specialist teams (DCSTs) in South Africa. We do this to explore whether and how they are functioning as institutional entrepreneurs (IE) at the local service delivery level. In one health district, between 2013 and 2015, we carried out 59 in-depth interviews with district, sub-district and facility managers, nurses, DCST members and external actors. We also ran one focus group discussion with the DCST and analysed key policies, activities and perceptions of the innovation using an institutional entrepreneurship conceptual lens. Findings show that the DCST is located in a constrained context. Yet, by revealing and bridging gaps in the health system, team members have been able to take on certain IE characteristics, functioning-more or less-as announcers of reforms, articulating a strategic vision and direction for the system, advocating for change, mobilizing resources. In addition, they have helped to reorganize services and shape care practices by re-framing issues and exerting power to influence organizational change. The DCST innovation provides an opportunity to promote institutional entrepreneurship in our context because it influences change and is applicable to other health systems. Yet there are nuanced differences between individual members and the team, and these need better understanding to maximize this contribution to change in this context and other health systems.