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Background: World-wide, there is growing universal health coverage (UHC) enthusiasm. The South African government began piloting policies aimed at achieving UHC in 2012. These UHC policies have been and are being rolled out in the ten selected pilot districts. Our study explored policy implementation experiences of 71 actors involved in UHC policy implementation, in one South African pilot district using the Contextual Interaction Theory (CIT) lens. Method: Our study applied a two-actor deductive theory of implementation, Contextual Interaction Theory (CIT) to analyse 71 key informant interviews from one National Health Insurance (NHI) pilot district in South Africa. The theory uses motivation, information, power, resources and the interaction of these to explain implementation experiences and outcomes. The research question centred on the utility of CIT tenets in explaining the observed implementation experiences of actors and outcomes particularly policy- practice gaps. Results: All CIT central tenets (information, motivation, power, resources and interactions) were alluded to by actors in their policy implementation experiences, a lack or presence of these tenets were explained as either a facilitator or barrier to policy implementation. This theory was found as very useful in explaining policy implementation experiences of both policy makers and facilitators. Conclusion: A central tenet that was present in this context but not fully captured by CIT was leadership. Leadership interactions were revealed as critical for policy implementation, hence we propose the inclusion of leadership interactions to the current CIT central tenets, to become motivation, information, power, resources, leadership and interactions of all these.
The study aimed at tracking NHI policy implementation process through the engagement of policy makers and policy implementers in order to explore, identify and describe why and how policy-practice discrepancies come about in UHC context. Contextual interaction theory was then chosen as an analytic framework for data analysis and we took that as an opportunity to test its utility in a South African UHC context. Ten pilot districts were identified by the Department of Health and selected as National Health Insurance (NHI) pilot sites. The National Department of Health (DoH) selected these sites based on poor performance on key health indicators like high maternal and child mortality rates [3]. UNITAS purposively selected three out the ten selected NHI pilot districts in South Africa. A case study design was used for this research. A case study design is defined as an empirical inquiry that investigates a phenomenon within its real-life context [21]. This study is situated in only one of the three districts, district X (name withheld for anonymity reasons). The case was the district (X), conveniently selected as the only NHI pilot district in that province at the time. Managerial willingness and support to participate in the study also guided site selection. NHI piloting in South Africa started in 2012. Primary health care re-engineering and national health insurance are the two broad reforms selected to reach UHC. These comprise a suite of policies and reforms that were rolled out in selected districts. The first five years focussed on health systems strengthening, particularly, Primary Health Care. The reforms included among others, appointment of district clinical specialist teams, family-based teams, school health teams, management strengthening, referral system strengthening and the establishment of ideal clinics. The overall goal of NHI is to ensure that every South African has access to health care services of high quality, without suffering any financial impoverishment [22, 23]. A qualitative, exploratory case study design was utilized. We tracked policy implementation aimed at achieving Universal Health Coverage in one pilot district in South Africa from 2011–2015. Data was collected during three phases 2011–2012 (Contextual mapping), 2013–2014 (Phase 1) and 2015 (Phase 2). A theory of change (TOC) approach was followed to explore universal health coverage policy implementation experiences. TOC is a theory of how and why initiatives work [24]. Theory of change describes assumptions actors have, explains steps and activities they take to achieve goals and connections between these activities and the policy outcome [24]. Semi-structured in-depth interviews were held with participants using a standard interview guide. See appendix. Participants ranged from provincial, district, sub-district and facility actors involved in policy implementation. No patients were involved since their role in policy implementation is limited. The duration of each interview varied from 2–3 h. Two researchers at every occasion, conducted the interviews in English. All participants were qualified professionals who had no problems understanding or responding in English. Full Ethical approval for the study was granted by the University of KwaZulu-Natal Biomedical Research Ethics Committee; REF BE197/13. Support letters were also provided by the provincial and district offices in our study site. All actors gave written consent and were free to withdraw from study any time [10, 25, 26]. All interviews were audio-recorded. All participants gave informed and signed consent and were free to withdraw from the study at any time. An iterative, inductive and deductive data analysis approach guided by Contextual Interaction theory was utilized. Transcripts were coded with the aid of MAXQDA2018. Trustworthiness criteria were used to evaluate rigour for this study [27]. Trustworthiness concepts included dependability, credibility, confirmability and transferability. To ensure dependability we described data collection process in detail and two researchers experienced in qualitative methods, kept reflexive individual journals through-out 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 an experienced qualitative researcher. To ensure confirmability, findings were discussed with supervisors and co-authors experienced in the field, and their responses were incorporated. To enhance transferability, participants, context and process of analysis have been described in detail [27]. We achieved data saturation [28] and data source triangulation, through interviewing actors from different levels of the health system. Actor description: In a UHC pilot site the following actors are present [20]. We focussed on two actors, policy makers and policy implementers. It is worth mentioning that a multi -actor scenario in health policy evaluation is possible and appropriately suitable in cases of assessing successful policy implementation, involving policy maker, policy implementer, partners and target actors in this case patients. The focus of our study was to understand how and why policy-practice gaps come about, hence our focus is on two actors, policy maker (provincial actors) and policy implementer (district, sub-district and PHC actors) instead. We therefore tested the viability of a two-actor model-policy makers at provincial level and policy implementers (district, subdistrict, facility actors). See Table Table11 below; Study actor description in general National DOH Provincial DOH The focus of our study was to understand policy practice gaps, hence our two actors are policy maker and policy implementer, leaving out linking and target actors as they did not play an active role in UHC policy implementation. See Table Table22 below: Study actor description used in our study National DOH Provincial DOH District Managers and District staff Subdistrict managers and staff PHC facility staff Seventy-one key informants were involved. See description in Table Table33 below; Overview of key informants, research phase, role and where they worked (health system level)
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