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Background: Globally, universal health coverage (UHC) has gained traction as a major health priority. In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment. National Health Insurance (NHI) and primary healthcare (PHC) re-engineering were two vehicles chosen to reach UHC over a 14-year period (2012–2026). The first phase of health system strengthening (HSS) initiatives to improve the quality of health services in the public sector began in 2012. These HSS initiatives are still being carried out by the Department of Health in conjunction with other partners. Methods: A qualitative case study design utilising a theory of change (TOC) approach was employed. Data were collected from key informants (n = 71) during three phases: 2011–2012 (contextual mapping), 2013–2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide, adapted for each phase. All interviews were audio-recorded and transcribed verbatim. An iterative, inductive and deductive data analysis approach was utilised. Transcripts were coded with the aid of MAXQDA 2018. Results: Six broad themes emerged: make PHC work, transform policy development, transform policy implementation, establish public–private partnerships, transform systems and processes and adopt a systems lens. Conclusion: A third great transition seems to be sweeping the globe, changing how health systems are organised. Actors in our study have identified this need also. Health system transformation rather than strengthening, they say, is needed to make UHC a reality. Who is listening?.
A qualitative case study design utilising a theory of change (TOC) approach was employed. A case study design is an empirical inquiry that investigates a phenomenon within its real-life context.12 A TOC explains how change happens.13 Theory of change allowed us to engage with both policymakers and implementers, understanding from their perspective how UHC policies were being implemented. It took into account the assumptions they had, their understanding of policy, beneficiaries and activities they had planned to reach policy goals. Thus, this approach facilitated a deeper and broader understanding of UHC policy implementation experience across levels in the health system. Figure 1 illustrates the TOC approach. Theory of change for the National Health Insurance pilot district. Ten pilot districts were selected as NHI pilot sites by DoH, based on poor performance on key health indicators like high maternal and child mortality rates.14 Universal Coverage in Tanzania and South Africa purposively selected 3 out of the 10 pilot districts. District X was conveniently selected as the only pilot district in the province at the time. Managerial support and willingness to participate in the study also guided the site selection. The district was run by a district health team, headed by a district manager. The district manager was supported by programme managers, PHC supervisors and sub-district managers to provide support to health facilities. The district manager reported to provincial authorities, who in turn reported to national authorities. The study took place over a period of 5 years. This was in a context of high staff turnover. One drawback, however, was that not all actors could be interviewed during all three phases as some had transferred or resigned, and a few had even died. Key informants included provincial actors (policymakers), where the task of operationalising NHI reforms had been assigned,15 and district, sub-district and PHC facility actors (policy implementers). Purposive sampling of actors at provincial and district levels was based on their knowledge of and involvement in NHI activities, their availability for interviews and willingness to participate. From district to PHC facility level, all actors were involved in NHI policy implementation, and the district and sub-district managers further assisted in the purposive selection of these key informants. Senior management, doctors and nurses from 1 district hospital, 2 community health centres and 10 PHC facilities (randomly selected after separating rural and urban facilities to ensure a balanced representation) were involved in the study. No patients were involved because their role in policy implementation is limited. Qualitative data were collected during three phases: 2011–2012 (contextual mapping), 2013–2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide adapted for each phase (Appendix 1). This was an iterative process of data collection and engagement with actors from contextual mapping through rounds 1 and 2. The interviews took place in departmental offices where the actors worked, at times suitable and agreed to by the participants, lasting for 2–3 hours. Two researchers, on every occasion, conducted the interviews in English. All participants were qualified professionals who understood English well. All interviews were audio-recorded. All participants gave informed and signed consent and were free to withdraw from the study at any time. Contextual mapping was carried out before the roll-out of NHI policies (2011–2012). The goal of this phase was to assess the readiness of the district to roll out NHI policies. The first round (2013–2014) interviews involved actors from province to PHC facility level. Interviews were conducted approximately one year after NHI policy roll-out, and the goal of Round 1 interviews was to elicit the experiences of policymakers and implementers one year into policy implementation. The second round was carried out in 2015. The research took place in a context of provincial moratoria on human resource recruitment; hence, there was considerable staff turnover and human resource shortages.15 During this round, a new provincial NHI actor was interviewed. She herself was already on her way out, as she had just resigned. Most of the district actors from the first round were interviewed, excluding one manager who had resigned and a senior one who had no time. The goal of Round 2 was to elicit from actors what they had achieved in terms of NHI policy implementation during this period. We explored with each participant what had transpired since our last visit and what the participant had achieved in terms of the activities they had planned to carry out. If they were successful, we looked for factors that facilitated implementation, and if they failed to carry out the planned activities, we also looked for factors that hindered the implementation. We concluded the second round interviews by asking all participants the following questions. ‘What do you think needs to happen for the current UHC policies to be implemented successfully, and why? Is it with regard to information, power, interactions and motivation, resources or other factors? ‘Who in your opinion are the key structures/people or systems that are in place or need to be put in place to make these UHC interventions work at their best and to become part of routine services?’ Figure 2 presents a summary of key informants and the health system level they worked on. Summary of key informants and the health system level they worked on. The complexity of the policy implementation process has challenged researchers to develop theories and models, although with a limited number of explanatory variables that predict how and under what conditions policies are implemented.16,17 Implementation is far too complex to be accounted for by a single theory;18 at the same time, a theory or model provides a framework for systematically identifying and reporting factors that implementers perceive as affecting implementation.17 We identified contextual interaction theory (CIT),19 as it provides a simple, empirically tested framework for identifying barriers within an implementation network. The basic CIT assumption is that the course and outcome of the policy process depend not only on inputs but more crucially on the characteristics of the actors involved, particularly their motivation, information, power, resources and interactions.20 All other factors that influence the process do so because and insofar as they influence the characteristics of the actors involved. The theory does not deny the value of the multiplicity of possible factors but claims that, theoretically, their influence can be best understood by assessing their impact on the motivation, information, power, resources and interactions of the actors involved.19 Another key assumption of CIT is that factors influencing implementation are interactive. The influence of any factor, whether positive or negative, depends on the particular context, structural and outer.20 Based on the amount of information the actors have regarding policy, their level of motivation, the amount of resources they have to implement and the amount of power they have to mobilise the needed resources, as well as the various interactions among these factors, a policy can be successfully implemented. In this study we analysed how much information, motivation and power and how many resources they had with regard to the UHC policies they were tasked to implement. We also analysed the data inductively. All interview recordings were transcribed into Word documents. A deductive and inductive approach was utilised for data analysis. The CIT framework was used as a starting point for data extraction, allowing for new themes to be developed inductively, following Braun et al.’s approach.21 The analysis followed an iterative process of familiarisation with data, coding, creating and reviewing themes as well defining them whilst avoiding over-condensed data,21 which can lead to loss of content or context.22 Data management and coding were done using MAXQDA 2018 software program. Trustworthiness criteria were used to evaluate the rigour of this study.23 The trustworthiness concepts included dependability, credibility, confirmability and transferability. To ensure dependability, we described the data collection process in detail, and two researchers experienced in qualitative methods kept reflexive individual journals throughout the data collection and analysis. Debriefing after interviews was done daily in the field. The two researchers further analysed the data independently before reaching consensus under the supervision of experienced qualitative researchers. To ensure confirmability, the findings were discussed with supervisors experienced in the field, and their responses were incorporated. To enhance transferability, the participants, context and process of analysis have been described in detail.23 Data source triangulation was achieved using actors from different levels of the health system, and interviews continued until data saturation was reached.24 Overview of key informants, research phase, role and where they worked (health system level). NHI, National Health Insurance; PHC, primary healthcare; UHC, universal health coverage; CEO, chief executive officer. Seventy-one participants involved in UHC policy implementation were interviewed. There was consensus amongst all actors, from provincial to facility level, that the current health system was set up at a different time and that the structures and systems needed transformation. Six main themes emerged from a thematic analysis of the responses given, as presented below. The findings are firstly presented according to the CIT central tenets (information, motivation, power, resources and interactions), followed by presentation of the inductive themes. Both deductive and inductive themes were then categorised into six themes: make PHC work, transform policy development, transform policy implementation, establish public–private partnerships, transform systems and processes and adopt a systems lens. ‘Involve us’: ‘Information’ refers to information about the policy itself as well as knowledge of the policy and who it is supposed to benefit. The understanding of what the NHI was, and what was improved as one went up the health system ladder, at provincial and district levels. At facility level, most of the actors viewed NHI as a novel initiative and were initially excited about it during Round 1, but this excitement could not be felt anymore in the second phase. Lack of resources to transform policy into action was a major stumbling block. The top-down nature of NHI policies further affected their motivation, as some policies were found not relevant by some facilities, and necessary equipment like vaccine fridges were not supplied. Some actors revealed the following: ‘Okay, the first thing is that consultation, I think we must be consulted, number one. Number two, they must see before the policies are finalised how much resources you need to implement this policy. And how much is available. So, considering those first, then they should finalise the policy and start implementation. Just signing policy is not enough to have it implemented and involve stakeholders in every sector, because policies must be relevant for us to implement.’ (Sub-district actor, Round 1) Apart from resources, motivation was revealed as being affected by multiple meetings that often took place without notification. Many actors cited being summoned to the district for meetings, taking them away from work and delaying policy implementation. To combat that, NHI progress meetings on the go or managing by walking about were suggested. Facility actors expected that supervisors would get to know the real issues affecting policy implementation in facilities, first-hand, that way. Seeing broken and leaking toilets might spur supervisors into action as compared to receiving a report. It is the sense of urgency that the implementing actors would like to see. The lack of power to take decisive actions, for example, to hire personnel or get resources, was cited as a huge stumbling block in policy implementation. The provincial actors agreed to a certain extent by saying that decentralisation was the way, but they also had some reservations. District, sub-district and facility actors, on the other hand, unanimously cited the need to transform the system by bringing power to the front line. Facility actors revealed that when they came up with initiatives, their supervisors did not support them. The health system design seems to stifle bottom-up innovation. There is a link between lack of power, top-down directives, bottom-up initiatives that are ignored and motivation. At another level, the tension and ambiguity between provincialisation and the district health system (DHS) could be felt: ‘So, decentralisation, yes of course it’s the way to go. A very critical starting point, but also putting then the systems that ensure that the decentralised functions, the managers are held to account. But also appreciate, what are they contributing to the bigger scheme of things. To decentralise to somebody who just enjoys the powers to be big boss, to be called a boss without using those powers that have been delegated to improve the bigger picture of things in the province. Again, it’s a waste of time and resources.’ (Provincial actor, Round 1) ‘Yes, give us the money. Give us all the powers and let us do the things ourselves.’ (Sub-district actor, Round 1) ‘The other thing that is happening to us is that our anaesthetic component no longer exists on our new structure. The district package of service does not require an anaesthetist because anyone can do local anaesthetic for a Caesar. For that kind of surgery. But because we have an influx of all of these cases, we still have anaesthetists. It is dictated by the public need. Now that needs to be brought into the minds of our principals. I have said that at meetings.’ (Sub-district actor, Round 2) Resource shortages ranging from human, material and equipment to infrastructure were cited as challenges throughout Phase 2. The basics cited as missing included inputs such as drug shortages, processes like communication, motivation and service delivery interface challenges caused by these. Many actors cited being under pressure because of staff shortages, which in turn led to long waiting lines. Some selected facilities got new NHI buildings and were able to implement new policies like streams approach. This demonstrated that when supplied with resources, the actors were motivated to implement policies. Leadership that ensures availability of resources, problem-solving and dealing with the root causes of chronic shortages of supplies could facilitate UHC policy implementation. Some actors suggested stocktaking of resources that is holistic, efficient and encompasses the six health system building blocks before policy implementation begins. When orders are placed, turnaround times are not specified; some actors had not received the orders they had placed before our last visit, 2 years before. These issues – timelines and accountability – seemed to be of utmost importance to the facility actors, and they tie in well with that sense of urgency actors cited as missing. Knowing when identified problems would be resolved, by whom and when could move UHC closer: ‘Going back to the human resources issue, because sometimes your establishment may not have a post for an artisan, you know, or enough posts for a plumber, and yet you are expected to look after a whole big hospital plus the clinics attached to you, and you do not have a post for a plumber? And you get taps and toilets that break, so who is actually going to fix it for you?’ (Sub-district actor, Round 2) Visits to facilities by PHC supervisors are scheduled once a month. All actors cited PHC supervision as inadequate and erratic but gave different reasons for that. At district level, actors cited the shortage of staff (PHC supervisors) and shortage of cars. At facility level, many actors were not aware of why the supervisors did not turn up but expressed how much they longed for such visits. Other facility actors expressed little hope, noting that PHC supervisors cite their own lack of power and that they hardly solve their challenges during such visits. At provincial level, the issue was viewed differently: ‘So, it is critical to get the right managers. Managers that are prepared to take risks. Managers that are prepared to embrace change, and if you still have the district managers who to them business is sitting in offices with air conditioners and comfy chairs, we will not get anywhere.’ (Provincial actor, Round 1) All actors cited the need to have the basics in the health system right, particularly PHC. Primary healthcare is the first level of contact with the health system. The new family and school health teams are meant to redirect focus onto preventive and promotive health, which were neglected the first time PHC was adopted. District actors revealed challenges in retaining school health teams, as many actors saw no clear career prospects. A bottom-up initiative by the district team of buying trailers (small offices) for the family teams was not approved, leaving many discouraged. Many actors mentioned the shortage of cars for outreach as another stumbling block. On a system level, many actors revealed referral system challenges: ‘You see, things will change when the district gets its system right, and I told them this in the district meeting. If they want primary healthcare, you know the district health system has to work … If they get the district health system right, maybe we will improve.’ (Sub-district actor, Round 2) ‘I think the way to improve the health service is to make basics well-functioning: the PHC clinics should be fully functional – most of the clinics are under-staffed, there is no equipment. So, they should provide PHC facilities with staff, equipment and the training, those three things. Look, they are sent on training only to come back to a facility with no equipment, no staff, the clinic being served by one or two nurses … Well, you could make them 24-hour service providers, but then give them sufficient staff. If we improve PHC services, that will reduce the work at the hospital. Most of the clinics are open from 8 to 4 pm. Even that 8 to 4 pm shift is not functioning well due to shortage of staff, equipment and some clinics have no medicine. So, if primary healthcare is improved, then hospital care will also improve, because if our workload is reduced, we then can provide better care here.’ (Sub-district actor, Round 1) According to facility actors, many PHC supervisors seem to focus on ticking the supervision manual checklist, one-size-fits-all approach and fail to see their facilities in context. Challenges vary from one facility to another, with some being in rural settings and others in urban settings. Some facilities have staff shortages that are dire, whilst others lack essential equipment and infrastructure. To function effectively, they want their local needs and priorities to be considered. Actors revealed how they often find themselves between a policy dictate and a lack of resources on the ground to translate that policy into practice. At provincial level (policymaker), the availability of resources was viewed differently than at facility level. According to provincial actors, the earmarked NHI conditional grants had made resources readily available now more than ever. On the other hand, actors at district, sub-district and facility levels cited resource shortages as a major obstacle. National Health Insurance has quality requirements that facilities have to meet if they are to be credited. The conditional grant prescribed to the district what has to be done with the money, leaving no space for facilities to address their own specific facility priorities. Resultantly, some actors reported receiving linens (that they did not need) despite not having basic items like fire extinguishers or sprinklers in case of a fire in the facility. Most of the actors cited not being fully aware of their roles, and some described being handed files with new policies but being neither trained nor orientated on how to prepare for national core standards to date. They suggested: ‘We need change agents and quality champions. Yes, people need to be motivated to internalise these standards, but now when it comes to personal things like that, you need the person or the people to push to get that kind of internalisation. Quality is a way of life, and I think we have got the will. Yes, you need the will, but you need to also find the way, because it is greater than just the papers and the standards.’ (Sub-district actor, Round 2) National Health Insurance has been associated with bringing private sector standards into the public health sector by many South Africans. South Africa has some of the best state-of-the-art private facilities in the world. All actors, from provincial to facility level, cited the private sector as a resource to be tapped into, where actors from the public sector could be seconded to the private sector to learn how to be customer oriented, effective and efficient. Others suggested partnerships like hospital twinning. The utility of these suggestions is yet to be explored. Actors at all levels without exception, from province to facility, pointed to the need of transforming all systems if NHI is to be realised. A provincial actor summed it all up: ‘But the question is, have we done enough in terms of transforming our health systems? Because probably or maybe I expect a manager to have undergone all the mentoring, the support, the coaching, the training, but she comes back and finds I’m still using the same tools but aiming to achieve different results. If I still have the same old same supply chain frameworks and same delegation, same protocols. Back to that same system, same approach? So, government is over-regulated. You have all [this] red [tape] that [is] affecting the whole of South Africa, for example, to recruit a doctor. Other private organisations go to those professional networks. You see a good CV there and invite the person for an interview, set up a panel, but here, I have to do a process 3 months long just to get the adverts out. So, those are the systemic processes that are very difficult to actually work within – major macro challenges.’ (Provincial actor, Round 1) Many actors cited the lack of a functional two-way communication system as a huge stumbling block, with motivational letters hardly responded to. Other actors suggested transforming supply chain systems by including an end user like a nurse in the supply chain department for efficiency purposes. Others clearly pointed out that supply chain processes, dysfunctional as they were, were a complex issue as many levels were involved. The process of maintenance was reported as dire. All actors recommended the transformation of the employee performance motivation and development system (EPMDS), which they cited as useless and a waste of time. Of particular importance seems to be the need for actors to be appreciated for what they are doing despite their current working conditions. The current EPMDS seems not to be doing that: ‘I really don’t know how that is going to happen. To implement NHI successfully, they need to put a whole lot of new systems in place. There are lots of systems that need to be put in place. This hospital is dilapidated. I’ve worked here for so many years; we’ve never been in the state that we are now. Never. It is going to take long to reach NHI, because it’s major structural changes, buildings, etc., new systems have to be put into place.’ (Sub-district actor, Round 2) There are no clear maintenance or service plans for equipment, and many actors revealed that their blood pressure (BP) machines, for example, have never been calibrated, making them prone to giving false readings. A supply chain with clear service and maintenance plans for equipment could not only save costs but also outcomes. As one actor said: ‘So, our (equipment) break at the end so we end up having to buy new ones all the time, and it costs more money. Where we autoclave things? It’s broken, and I mean I spoke to the sister that’s working there. She said it’s broken because she couldn’t find oil to put into that machine, and the whole thing is now broken.’ (Sub-district actor, Round 2) At provincial and district levels, all the actors reported having attended leadership training. Why this was not translating into results on the ground is not clear but could be related to delegations, as the DHS has not yet received full power. Other actors suggested the need for a new generation of leaders not managers – leaders who are motivated, who can think outside the box and so be able to motivate others. The process of how leaders are currently being developed was raised with the actors, suggesting a transformation of the way leaders are developed. The actors also recommended that relevant and context-specific leadership training and quality management should be incorporated in basic nurse and doctor training curricula. The sense of urgency, timelines and accountability again tied in with the leadership issues raised. As one actor said: ‘For everything else to work, the head must be strong, okay. Get the ones at the top to do their work, then all these below will do their work too. That is all.’ (Sub-district actor, Round 2) ‘The district team who wants us to be an NHI pilot site need to get involved from management level. They need to sit and say, these are the issues that are in the clinic. What can we do? We cannot shift the blame from municipality to DoH. It is a problem, and it needs to be sorted out so as to motivate the staff. I think at the moment no one wants to be here.’ (Facility actor, Round 2) The goal of NHI is to achieve UHC. To that end, multiple initiatives are being rolled out. Many actors found these initiatives – though interconnected and inter-related – not coordinated. Programme leaders often concentrated on having their indicators achieved, losing sight of the overall UHC goal. Many actors cited the need to transform the way programmes were operated and viewed, moving from a silo mentality to seeing wholes and the interconnectedness of programmes and activities, all aimed at achieving UHC. Many actors highlighted the need to adopt a systems thinking lens, identifying points of leverage whilst at the same time on the lookout for unintended consequences25 if UHC is to be achieved. Some actors suggested adapting some training programmes for relevance and efficiency, like training the staff manning the obstetric units to get skills in dealing with the essential steps in management of obstetric emergencies. Those people could be absorbed by wards, instead of sitting waiting to transport maternity patients. Emergency medical response system drivers could become physically involved in maternity wards, assisting with deliveries rather than only acting when a patient needs to be moved to a higher level of care. That point has leverage, considering the human resource challenges facilities are facing. As one actor revealed: ‘When we talk about NHI, we are talking about virtual electronic medical records (VEMR), so what is happening here … I do not know, people are so … they are one-sided, you know. When we [are] talking [about] electronic records, they just talk [about] electronic records and forget about Medipost, and when they [are] talking about Medipost they forget about the GP [general practitioner] contracting, you know. And then you find that people concentrate on one thing and forget about everything else. Yet all these things are supposed to go together.’ (Sub-district actor, Round 2) Organisational culture comprises the values that guide the behaviour of members in an organisation. Some organisational culture issues were raised: ‘Then you also have what I would classify as micro challenges. There is the social culture, things that you cannot touch but things that are existing and persisting. In government, it’s business as usual. My job is secure. To get one person fired, no … that does not happen, they just get transferred out. You have to produce bibles of evidence. Different committees around [will] finally [arrive] at saying this person is not productive. So, those are [organisational] cultural decision, and quality tends to be a secondary issue.’ (Provincial actor, Round 1) Apart from being involved in policy formulation, all the actors suggested taking epidemiological transitions into account, seeing the relationships and connections between demand and supply: ‘Okay. This thing happened, and that was before this HIV era. Previously, the clinics were working well. It was nice. They were seeing around about 7, 10, 15 patients, but today you cannot see 15 patients in the clinic. You can never see 10 patients; you see 60 and more, so that further makes you wonder, how can you provide all the particular quality of care that is supposed to be given with the same amount of resources?’ (Facility actor, Round 2) Many actors suggested transforming the way data are collected, used and reported. They felt that reporting should be transformed to become a way of communicating with the higher authorities. One actor revealed the following: ‘You know, because a report does not just sit with us; it goes to national. And it goes to the Office of Health Standards and Compliance, so surely there must be red flagging, saying, what, you always fail because of cleaning. What is happening there? What do we need to do to support you? I would like to see that.’ (Sub-district actor, Round 2) Table 2 provides a summary of emergent themes. Summary of emergent deductive and inductive themes. NHI, National Health Insurance, DHS, district health system; PHC, primary healthcare; UHC, universal health coverage; EMRS, emergency medical response system.
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