Browsing by Department "Health Policy and Systems Division"

Now showing 1 - 20 of 23
  • Thumbnail Image
    Item
    Open Access
    Accountability mechanisms for implementing a health financing option: the case of the basic health care provision fund (BHCPF) in Nigeria
    (BioMed Central, 2018-07-11) Uzochukwu, Benjamin; Onwujekwe, Emmanuel; Mbachu, Chinyere; Okeke, Chinyere; Molyneux, Sassy; Gilson, Lucy
    Background The Nigerian National Health Act proposes a radical shift in health financing in Nigeria through the establishment of a fund – Basic Healthcare Provision Fund, (BHCPF). This Fund is intended to improve the functioning of primary health care in Nigeria. Key stakeholders at national, sub-national and local levels have raised concerns over the management of the BHCPF with respect to the roles of various stakeholders in ensuring accountability for its use, and the readiness of the implementers to manage this fund and achieve its objectives. This study explores the governance and accountability readiness of the different layers of implementation of the Fund; and it contributes to the generation of policy implementation guidelines around governance and accountability for the Fund. Methods National, state and LGA level respondents were interviewed using a semi structured tool. Respondents were purposively selected to reflect the different layers of implementation of primary health care and the levels of accountability. Different accountability layers and key stakeholders expected to implement the BHCPF are the Federal government (Federal Ministry of Health, NPHCDA, NHIS, Federal Ministry of Finance); the State government (State Ministry of Health, SPHCB, State Ministry of Finance, Ministry of Local Government); the Local government (Local Government Health Authorities); Health facilities (Health workers, Health facility committees (HFC) and External actors (Development partners and donors, CSOs, Community members). Results In general, the strategies for accountability encompass planning mechanisms, strong and transparent monitoring and supervision systems, and systematic reporting at different levels of the healthcare system. Non-state actors, particularly communities, must be empowered and engaged as instruments for ensuring external accountability at lower levels of implementation. New accountability strategies such as result-based or performance-based financing could be very valuable. Conclusion The key challenges to accountability identified should be addressed and these included trust, transparency and corruption in the health system, political interference at higher levels of government, poor data management, lack of political commitment from the State in relation to release of funds for health activities, poor motivation, mentorship, monitoring and supervision, weak financial management and accountability systems and weak capacity to implement suggested accountability mechanisms due to political interference with accountability structures.
  • Thumbnail Image
    Item
    Restricted
    ARHAP International Colloquium: Collection of Concept Papers
    (University of Cape Town, 2007) African Religious Health Assets Programme
    ARHAP INTERNATIONAL COLLOQUIUM 2007, Collection of Concept Papers
  • Thumbnail Image
    Item
    Restricted
    ARHAP Tools Workshop Report
    (2004-06) Cochrane, James R; Schmid, Barbara
    The African Religious Health Assets Programme (ARHAP) was proposed in April 2002 and initiated in December of that same year, under the joint leadership of three individuals: Dr Gary Gunderson and Prof Deborah McFarland, both of Emory University (Department of International Health), and Prof James Cochrane of the University of Cape Town (Department of Religious Studies). It is the front edge of a global religious health assets initiative. It was predicated upon a conviction that faith-based organizations, groups and movements, though playing a significant role in the delivery and promotion of health, are generally not well understood or sufficiently visible to public health systems in most societies. The underlying assumption, of course, is that we need a much more “intelligent science” about the role and importance of religious health assets (RHAs) than is currently available (or if available, then only in scattered and fragmented form). This assumption stems from the growing awareness in public health bodies of all kinds, from multilateral bodies such as the UN or the WHO and international NGOs to local governments, that faith-based health activities are a very important part of the effective meeting of ideals such as those embodied in the Millennium Development Goals and their equivalents at less global levels.
  • Thumbnail Image
    Item
    Open Access
    Attitudes and perception of healthcare workers in health facilities with regards to the 'Intention to Use' of the Road to Health Booklet (RtHB)
    (2016) Khumalo, Nanziwe Kelly; Olivier, Jill
    Introduction: That low and middle income countries (LMICs) are plagued with high burdens of disease and limited health resources is well documented in the literature. These two realities necessitate the availability of good quality and reliable information to enable the efficient distribution of recourses and services. Growing recognition of the importance of health information has seen the introduction of numerous health information systems (HIS). The goal of these HIS is to attain preventative and curative treatment for those that need them, in adequate quantities, promptly, reliably and at equitable cost. Amongst the variety of HIS is the Road-to-Health Booklet (RtHB) in South Africa. This is a paper-based, patient-held medical record given to new mothers, intended to monitor all contact children have with the healthcare system. Due to the dearth of local research and increasing need for strong HIS, more research is needed in the implementation of the HIS and its use by healthcare workers (HCWs) in the African context. Methods: The aim of this study is to explore and understand the influence HCWs' attitudes and perceptions have on the implementation of the RtHB within the Khayelitsha Sub-District of Cape Town, South Africa. A qualitative case study was conducted utilising in-depth interviews, naturalistic observations, document review and mind mapping to explore HCWs' attitudes and perceptions on the RtHB. A combination of purposive and snowball sampling was used to identify participants with insights on the RtHB.
  • Thumbnail Image
    Item
    Open Access
    Case Study Focus: Papers and Proceedings
    (University of Cape Town, 2017-03-28) ARHAP International Colloquium
    ARHAP seeks to develop a systematic knowledge base of religious health assets in sub-Saharan Africa; thus to assist in aligning and enhancing the work of both religious health leaders and public policy makers in their collaborative effort to meet the challenge of disease, e.g. HIV/AIDS; and hence to promote sustainable health, especially for those who live in poverty or under marginal conditions.
  • Thumbnail Image
    Item
    Restricted
    The contribution of Religious Entities to Health Sub-Saharan Africa
    (2008-05) Schmid, Barbara; Thomas, Elizabeth; Olivier, Jill; Cochrane, James R
    Background: While most partners in providing health care in sub-Saharan Africa agree that religious entities play an important role in providing health services, there is little comprehensive data about the scope and scale of their contribution, beyond data held by particular religious entities about their own health related work. In addition not much is known, beyond claims and often repeated statements, about the ways in which such health care is different from services provided in the public health system. 2. Aims and Objectives The overall purpose of this study was to provide a description of the contribution of faith based organisations (FBOs), institutions, and networks to the health of vulnerable populations in resource-poor areas of sub-Saharan Africa (SSA); and to identify key areas for investment that would accelerate, scale up and sustain access to effective services, and/or encourage policy and resource advocacy among and in African countries. There were two main parts to the objectives: 1) To give an overview for SSA of the coverage, role, and core health related activities of religious entities, including major networks, vis a vis public and other private sector health services delivery, and their relationship to government and to each other. 2) To give more detailed information for three country case studies in Mali, Uganda and Zambia: a) describing the capacity of faith based organisations to deliver health services and impact on health behaviour; the financial and/or material support they receive and how they are perceived by stakeholders; b) characterizing key faith based networks and describing how they work; c) describing how faith based organisations collaborate with each other and with governments. From these were to be drawn recommendations about key areas for potential investment that would improve population health outcomes. 3. Research overview: The research was conducted under the auspices of the African Religious Health Assets Programme (ARHAP), a research networks focussed on gaining a better understanding of the contribution of religious health assets to public health in Africa. The team of ARHAP researchers, from the University of Cape Town and the Medical Research Council was supported by an international, inter-disciplinary and multi-religious advisory group as well as in-country researchers.
  • No Thumbnail Available
    Item
    Open Access
    Exploring knowledge translation mechanisms in the Western Cape Provincial Health System
    (2018) Edwards Amanda; Olivier, Jill; Zweigenthal, Virginia
    The persistent gap between health research, policy and practice has led to a burgeoning interest in the field of knowledge translation (KT). However, there remains little clarity on what KT mechanisms work in different contexts, particularly in low and middle-income countries. Using mixed methodology this project explores KT mechanisms, barriers, facilitators and outcomes as they function in South Africa’s Western Cape provincial health system. Document review and key informant interviews with health system researchers and provincial health policymakers were synthesised with findings from a random sample of provincial study protocols registered on the National Health Research Database. An evidence-mapping of the literature on KT in African settings complemented this data. Findings indicate variations in the use of health-related research by provincial policymakers and diversity in the mechanisms employed for KT. The important role of organisations, characteristics of available research, relationships and networks play a facilitating role for KT in this context. Resource constraints, system conflicts and politics served as notable barriers. These findings have implications for health researchers and provincial policymakers seeking to “do” KT in the Western Cape health system – including the need for recognition of the important role of context, of the ethical dilemmas within KT processes, and the need for a more systematic approach to KT that includes embedded learning systems.
  • Thumbnail Image
    Item
    Open Access
    Exploring the introduction of a complex intervention in primary health care facilities in the Western Cape: A single site exploratory case study of the C²AIR² club challenge
    (2017) Mphaphuli, Edzani Brenda; Gilson, Lucy
    Context: The Western Cape Province's Department of Health, South Africa, implemented a complex intervention aimed at changing organisational culture across health facilities in the province called the C²AIR² club challenge, in phases, starting from August 2013 and was still ongoing in 2016 at the time of the research. A group of front-line staff from each participating health facility called C²AIR² club champions were capacitated to implement the intervention in their respective facilities. This study aimed to explored the process of introduction, diffusion, adoption and implementation of the C²AIR² club challenge in one of the primary health facilities where the challenge was implemented, using a diffusion of innovation lens. Methods: We examined the process of implementing the C²AIR² club and the contextual and other factors that constrained and enabled this process. Working in one primary health care facility selected as a representative case, we explored the experiences of the champions and other staff members of the C²AIR² club. Our methods included 21 in-depth interviews, informal conversations, document review, and non-participant observation. Results: Innovation-fit, leadership, champions, adopters' characteristics, and contextual issues were the main factors that influenced the spread of the C²AIR² club. Contextual issues particularly those related to resource constraints played a central role in determining the successful spread of the complex organisational culture change intervention. Sufficiently trained champions could successfully spread the intervention without onsite external change consultants' facilitation, however this took time and caution should be taken not to evaluate implementation success too early. Involvement of not only top leadership but of all other multi-levels and multi-disciplines facilitated the spread of the intervention. Conclusions: When introducing an innovation like the C²AIR² club challenge the impact of which is not immediate neither tangible, in an organisation where there are tangible problems such as lack of working space, staff shortages and shortages in working equipment, it is important that efforts are made to address these immediate challenges and where they cannot be addressed that this is openly acknowledged by the implementers and management. If this is not considered, organisational members are likely to acknowledge the innovation as a good initiative but one that they would not actively rally around as it does not speak to their problems.
  • Thumbnail Image
    Item
    Open Access
    Factors influencing institutionalization of health technology assessment in Kenya
    (BioMed Central, 2023-06-22) Mbau, Rahab; Vassall, Anna; Gilson, Lucy; Barasa, Edwine
    Abstract Background There is a global interest in institutionalizing health technology assessment (HTA) as an approach for explicit healthcare priority-setting. Institutionalization of HTA refers to the process of conducting and utilizing HTA as a normative practice for guiding resource allocation decisions within the health system. In this study, we aimed to examine the factors that were influencing institutionalization of HTA in Kenya. Methods We conducted a qualitative case study using document reviews and in-depth interviews with 30 participants involved in the HTA institutionalization process in Kenya. We used a thematic approach to analyze the data. Results We found that institutionalization of HTA in Kenya was being supported by factors such as establishment of organizational structures for HTA; availability of legal frameworks and policies on HTA; increasing availability of awareness creation and capacity-building initiatives for HTA; policymakers’ interests in universal health coverage and optimal allocation of resources; technocrats’ interests in evidence-based processes; presence of international collaboration for HTA; and lastly, involvement of bilateral agencies. On the other hand, institutionalization of HTA was being undermined by limited availability of skilled human resources, financial resources, and information resources for HTA; lack of HTA guidelines and decision-making frameworks; limited HTA awareness among subnational stakeholders; and industries’ interests in safeguarding their revenue. Conclusions Kenya’s Ministry of Health can facilitate institutionalization of HTA by adopting a systemic approach that involves: - (a) introducing long-term capacity-building initiatives to strengthen human and technical capacity for HTA; (b) earmarking national health budgets to ensure adequate financial resources for HTA; (c) introducing a cost database and promoting timely data collection to ensure availability of data for HTA; (d) developing context specific HTA guidelines and decision-making frameworks to facilitate HTA processes; (e) conducting deeper advocacy to strengthen HTA awareness among subnational stakeholders; and (f) managing stakeholders’ interests to minimize opposition to institutionalization of HTA.
  • Thumbnail Image
    Item
    Open Access
    Guidance for evidence-informed policies about health systems: Linking guidance development to policy development
    (Public Library of Science, 2012) Lavis, John N; Røttingen, John-Arne; Bosch-Capblanch, Xavier; Atun, Rifat; El-Jardali, Fadi; Gilson, Lucy; Lewin, Simon; Oliver, Sandy; Ongolo-Zogo, Pierre; Haines, Andy
    In the second paper in a three-part series on health systems guidance, John Lavis and colleagues explore the challenge of linking guidance development and policy development at global and national levels.
  • Thumbnail Image
    Item
    Open Access
    Health policy and systems research and analysis in Nigeria: examining health policymakers’ and researchers’ capacity assets, needs and perspectives in south-east Nigeria
    (BioMed Central, 2016-02-24) Uzochukwu, Benjamin; Mbachu, Chinyere; Onwujekwe, Obinna; Okwuosa, Chinenye; Etiaba, Enyi; Nyström, Monica E; Gilson, Lucy
    Background: Health policy and systems research and analysis (HPSR+A) has been noted as central to health systems strengthening, yet the capacity for HPSR+A is limited in low- and middle-income countries. Building the capacity of African institutions, rather than relying on training provided in northern countries, is a more sustainable way of building the field in the continent. Recognising that there is insufficient information on African capacity to produce and use HPSR+A to inform interventions in capacity development, the Consortium for Health Policy and Systems Analysis in Africa (2011–2015) conducted a study with the aim to assess the capacity needs of its African partner institutions, including Nigeria, for HPSR+A. This paper provides new knowledge on health policy and systems research assets and needs of different stakeholders, and their perspectives on HPSR+A in Nigeria. Methods: This was a cross-sectional study conducted in the Enugu state, south-east Nigeria. It involved reviews and content analysis of relevant documents and interviews with organizations’ academic staff, policymakers and HPSR+A practitioners. The College of Medicine, University of Nigeria, Enugu campus (COMUNEC), was used as the case study and the HPSR+A capacity needs were assessed at the individual, unit and organizational levels. The HPSR+A capacity needs of the policy and research networks were also assessed. Results: For academicians, lack of awareness of the HPSR+A field and funding were identified as barriers to strengthening HPSR+A in Nigeria. Policymakers were not aware of the availability of research findings that could inform the policies they make nor where they could find them; they also appeared unwilling to go through the rigors of reading extensive research reports. Conclusion: There is a growing interest in HPSR+A as well as a demand for its teaching and, indeed, opportunities for building the field through research and teaching abound. However, there is a need to incorporate HPSR+A teaching and research at an early stage in student training. The need for capacity building for HPSR+A and teaching includes capacity building for human resources, provision and availability of academic materials and skills development on HPSR+A as well as for teaching. Suggested development concerns course accreditation, development of short courses, development and inclusion of HPSR+A teaching and research-specific training modules in school curricula for young researchers, training of young researchers and improving competence of existing researchers. Finally, we could leverage on existing administrative and financial governance mechanisms when establishing HPSR+A field building initiatives, including staff and organizational capacity developments and course development in HPSR+A.
  • Thumbnail Image
    Item
    Open Access
    Implementing health system change: What are the lessons from the African Health Initiative?
    (BioMed Central Ltd, 2013) Gilson, Lucy
    The five African Health Initiative Population Health Implementation and Training (PHIT) Partnerships represent a rich and important set of health system strengthening initiatives. All can be called whole system strengthening initiatives in two important respects. First, from a health system perspective, as explicitly discussed, all the PHIT Partnerships are multi-dimensional, seeking to achieve performance improvements by working across the building blocks and levels of the health system. All address resource needs (human, financial, and supplies) in some way. The common focus on strengthening information use in clinical and managerial decision-making, meanwhile, tackles what some regard as the key leverage point for health system improvement [1] and quality of care is another such point [2]. Considering the role of community health workers, moreover, emphasizes that the health system stretches beyond the doors of health facilities, and that health system development requires combined community and facility-based actions. Finally, several initiatives emphasize the importance of strengthening supervision and management coaching and mentoring. Importantly, the different activities within each partnership are intended to work synergistically together.
  • Thumbnail Image
    Item
    Open Access
    Influence of organisational culture on the implementation of health sector reforms in low and middle income countries : a qualitative interpretive review
    (2016) Mbau, Rahab Waithira; Gilson, Lucy
    The qualitative interpretive synthesis carried out for this MPH mini-dissertation reviews existing empirical literature for evidence on organisational culture and its influence on the implementation of health sector reforms in Low and Middle Income Countries. This mini-dissertation is organised into three parts: PART A: This is the review protocol which outlines the introduction, the background and the review questions for both the scoping review (which forms section B) and the qualitative interpretive synthesis ( which forms section C) along with their justifications. It also outlines the methodology for both the scoping review and the qualitative interpretive review. The literature search was carried out in eight electronic databases using key search terms developed from the review questions. Inclusion and exclusion criteria were developed to determine the articles for inclusion into the review. All the search terms, data extraction templates and summary tables used in both reviews are provided in this section. PART B: This is the literature review section which was carried out to map the scope of literature on organisational culture within the health sector in Low and Middle Income Countries in order to support the more detailed analysis in Section C. It begins with a general description of organisational culture and its conceptual frameworks, as well as a description of the tools used in assessing organisational culture that were identified from a broader reading of literature on organisational culture. The reviewer then describes the literature search strategy of the scoping review and maps the retrieved articles based on themes on organisational culture in the health sector. Lastly, the reviewer classifies the different dimensions of organisational culture identified in the reviewed articles using the Competing Values Framework in order to facilitate comparison of organisational culture across the studies. PART C: This is the full qualitative interpretive synthesis presented as a journal ready manuscript. This review begins with an introduction on health sector reforms and organisational culture. This is followed by a description of the methods used to identify the literature, an outline and synthesis of the findings, discussion section and lastly, the conclusion. The findings of this interpretive synthesis indicate the potential influence of various dimensions of organisational culture such as power distance, uncertainty avoidance, in-group and institutional collectivism, mediated through organisational practices, over the implementation of the health sector reforms. It also highlights the dearth of empirical literature around organisational culture and therefore, its results can only be tentative. There is need for health policy makers and health system researchers in Low and Middle Income Countries to conduct further analysis of organisational culture and change within the health system.
  • Thumbnail Image
    Item
    Open Access
    Mapping and tracking the complexity of financial flows through non-state non-profit (faith-based) health providers in Kenya
    (2018) Kingangi, Lucy; Olivier, Jill; Foster, Nicola
    In strengthening health systems, the World Health Report 2000 indicates that health system improvement strategies must also cover private (for-profit and non-profit) health care provision and financing if progress towards Universal Health Coverage is to be achieved. Yet very little is known about the financing of non-profit providers in Africa - especially not faith-based health providers, who have often historically remained elusive in terms of financial transparency. This thesis reports on a multiple case study conducted with two non-profit faith-based health providers in Kenya, namely the Africa Inland Church Kijabe Hospital; and Nyumbani-Children of God Relief Institute in Nairobi (Nyumbani) - and situates these within the broader context of health systems financing and public-private partnership in Kenya. Data was collected from multiples sources including: secondary literature; secondary analysis of existing data (such as the Kenya Health Information System); financial data on projects and annual reports; routine facility and service data; previous research on both organizations; archival data; and supplemented by 6 in-depth interviews with key stakeholders. The study reveals a highly complex funding environment for non-profit (and faith-based) health providers in Kenya, which is a result of historic health system configurations, and current funding policy and focus (such as the influx of HIV-related funding). The HIV program in AIC Kijabe Hospital is solely funded by USAID; while Nyumbani is also funded by USAID (70%), but has other private sources. In both cases, funding from various sources is structured differently with varied financial flows and requirements. Faith-based health providers in Kenya are highly dependent on complex donor-funding arrangements, and lack financial resilience as a result. Donors need to better understand the nuance of engagement with such providers.
  • Thumbnail Image
    Item
    Open Access
    Modelling intermediate care services as part of an integrated care pathway
    (2016) Wilson, Nicola Ann; Gilson, Lucy; Kotze, Kevin
    This study explores the implications of implementing enhanced or redesigned intermediate care initiatives in the Western Cape of South Africa from the 2014/15 financial year onwards. Using a dynamic modelling methodology, we developed an empirical model of an integrated care system to explain the linkages, relationships and interactions among service components and analyse the implications of one of the proposed Healthcare 2030 policy interventions - intermediate care - on hospital admissions, waiting times and length of stay of all patients. We tested and compared a number of alternative intervention points using a simulation model parameterised with service component data from the Department of Health Information Systems. The findings from the study show the inconsistencies between the perceived structure and the available data from the respective service components that describe the resultant behavioural effects on an integrated care system, especially when care pathways cross organisational boundaries. The main managerial learning was around the existence and nature of organisational boundaries that require joint working and sharing of information. We conclude from the simulation results for the alternative scenarios tested that the implementation of enhanced or redesigned intermediate care initiatives can moderate the rate of growth in the demand for hospital services by reducing a percentage of hospital readmissions.
  • Thumbnail Image
    Item
    Open Access
    Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals
    (BioMed Central, 2017-09-15) Erasmus, Ermin; Gilson, Lucy; Govender, Veloshnee; Nkosi, Moremi
    Background: This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies – the Uniform Patient Fee Schedule (UPFS) and Patients’ Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems’ people-centeredness and “software”. Methods: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. Results: Regarding the UPFS, the hospitals’ implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals’ PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people’s values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions: Achieving equity in practice requires managers to take account of “unseen” but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation “hardware” such as putting in place necessary staff and resources, it emphasises “software” implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers’ status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.
  • Thumbnail Image
    Item
    Open Access
    Protocol for a Multi-Level Policy Analysis of Non-Communicable Disease Determinants of Diet and Physical Activity: Implications for Low- and Middle-Income Countries in Africa and the Caribbean
    (2021-12-10) Shung-King, Maylene; Weimann, Amy; McCreedy, Nicole; Tatah, Lambed; Mapa-Tassou, Clarisse; Muzenda, Trish; Govia, Ishtar; Were, Vincent; Oni, Tolu
    Non-communicable diseases (NCDs) are the leading cause of death globally. Despite significant global policy development for addressing NCDs, the extent to which global policies find expression in low-and-middle income countries’ (LMIC) policies, designed to mitigate against NCDs, is unclear. This protocol is part of a portfolio of projects within the Global Diet and Activity Research (GDAR) Network, which aims to support the prevention of NCDs in LMICs, with a specific focus on Kenya, Cameroon, South Africa and Jamaica. This paper outlines the protocol for a study that seeks to explore the current policy environment in relation to the reduction of key factors influencing the growing epidemic of NCDs. The study proposes to examine policies at the global, regional and country level, related to the reduction of sugar and salt intake, and the promotion of physical activity (as one dimension of healthy placemaking). The overall study will comprise several sub-studies conducted at a global, regional and country level in Cameroon, Kenya and South Africa. In combination with evidence generated from other GDAR workstreams, results from the policy analyses will contribute to identifying opportunities for action in the reduction of NCDs in LMICs.
  • Thumbnail Image
    Item
    Open Access
    A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes co-morbidity
    (2016) Matima, Rangarirai; Oni, Tolu; Murphy, Katherine
    Health systems' strengthening is essential in South Africa in an era of the convergence of communicable and non-communicable diseases. Whilst TB is ranked first in all-cause mortality, non-communicable diseases which include cerebrovascular disease and diabetes mellitus follow; with HIV/AIDS in fourth place. In the Western Cape, diabetes mellitus and HIV are the top two causes of death accounting for 6.8% and 5.8% respectively (StatsSA, 2015b). As the burden of non-communicable disease continues to increase significantly due to more South Africans presenting these co-morbid conditions, the complexity of managing these chronic conditions has increased. The reorganisation of primary health services to better cater for patients with multiple chronic conditions has become an imperative in South Africa but still in its infancy. However, how chronic patients with multi-morbidities experience the current services and what their perceived needs are in order to enhance the management of their conditions both at point of healthcare and in their daily lives is not widely understood. Below, is an outline of the three parts presented in this dissertation. Part A is the study protocol, which gives a background of the intersection of communicable and noncommunicable diseases in South Africa, focusing on HIV and type two diabetes (hereafter HIV/T2D) co-morbidity. A qualitative design was employed. In-depth interviews were conducted with ten patients living with HIV/T2D co-morbidity and six health workers who interacted with these patients. Ethical considerations such as potential risks and benefits; confidentiality, autonomy and informed consent are also highlighted in the protocol. Part B is the structured literature review on chronic care in low and middle-income countries (LMICs). Two sub-sections are presented with the first focusing on LMICs excluding South Africa; and the second for South Africa only. Theoretical frameworks, which were applied to managing chronic conditions and empirical studies on HIV/T2D in these LMICs, are reviewed. Reference to the Cumulative Complexity Model (CCM), will also provide an indepth understanding of the prospects of strengthening the primary healthcare system in South Africa to address chronic conditions more effectively. Part C is the journal-ready manuscript of the data collected in the qualitative study. It consists of the background, methods, results, discussion and conclusions. Findings describe patients' experiences of the primary healthcare services and the daily challenges of living with and managing HIV and T2D among a sample of ten patients attending a clinic in Cape Town. Health worker perspectives on managing HIV/T2D co-morbidity are also presented. Both patients and healthworkers also shared strategies on how health interventions could be more responsive to HIV/T2D co-morbidity. Hence, further contributions are made in the knowledge base of strengthening chronic conditions. However, further research with different subsets of patients living with not only HIV/T2D but also other co-morbid or multi-morbid conditions is important for improvements in health policy-making in South Africa.
  • Thumbnail Image
    Item
    Open Access
    The representation and practice of interdisciplinarity in health policy and systems research : a systematic review
    (2016) MacQuilkan, Kim Elizabeth; Olivier, Jill
    The emerging field of Health Policy and Systems Research (HPSR) developed from a variety of disciplines, orientated around the common research agenda of strengthening health systems, which are understood to be both complex and dynamic. The diversity of contributing disciplinary influences is a core feature of HPSR and hence the field is clearly defined as 'interdisciplinary'. However there has been a paucity of research conducted on interdisciplinarity within HPSR, with a lack of clarity on its conceptualization and practice. This study explores the representation of interdisciplinarity, and interdisciplinary practices within HPSR, utilising scoping and systematic review approaches. It is revealed that the term 'interdisciplinarity' (and its variations) have suffered from misuse and confusion. In particular, there is limited practice of an 'integrationist' interdisciplinary perspective and practice within HPSR - despite key HPSR authors supporting the integrationist approach due to its alignment with the HPSR scope of study to address complex health system problems. Over the last ten years, there has been a significantly increased output referenced as part of the HPSR field, however there is a scarcity of interdisciplinary research examples that have intentionally integrated multiple disciplinary influences. This research shows that current HPSR literature mainly reflects a 'generalist' interdisciplinary perspective (which only requires the presence of multiple disciplinary influences) rather than the integrationist perspective (which require intentional integration of influences). As a result, we propose improved approaches to framing, funding, and teaching interdisciplinary HPSR.
  • Thumbnail Image
    Item
    Open Access
    Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings
    (BioMed Central Ltd, 2013) Cleary, Susan; Molyneux, Sassy; Gilson, Lucy
    BACKGROUND: District level health system governance is recognised as an important but challenging element of health system development in low and middle-income countries. Accountability is a more recent focus in health system debates. Accountability mechanisms are governance tools that seek to regulate answerability between the health system and the community (external accountability) and/or between different levels of the health system (bureaucratic accountability). External accountability has attracted significant attention in recent years, but bureaucratic accountability mechanisms, and the interactions between the two forms of accountability, have been relatively neglected. This is an important gap given that webs of accountability relationships exist within every health system. There is a need to strike a balance between achieving accountability upwards within the health system (for example through information reporting arrangements) while at the same time allowing for the local level innovation that could improve quality of care and patient responsiveness. METHODS: Using a descriptive literature review, this paper examines the factors that influence the functioning of accountability mechanisms and relationships within the district health system, and draws out the implications for responsiveness to patients and communities. We also seek to understand the practices that might strengthen accountability in ways that improve responsiveness - of the health system to citizens' needs and rights, and of providers to patients. RESULTS: The review highlights the ways in which bureaucratic accountability mechanisms often constrain the functioning of external accountability mechanisms. For example, meeting the expectations of relatively powerful managers further up the system may crowd out efforts to respond to citizens and patients. Organisational cultures characterized by supervision and management systems focused on compliance to centrally defined outputs and targets can constrain front line managers and providers from responding to patient and population priorities. CONCLUSION: Findings suggest that it is important to limit the potential negative impacts on responsiveness of new bureaucratic accountability mechanisms, and identify how these or other interventions might leverage the shifts in organizational culture necessary to encourage innovation and patient-centered care.