Browsing by Subject "Health Systems"

Now showing 1 - 20 of 43
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    A mixed method media analysis of the representation of the South African National Health Insurance Policy in the mainstream media from 2011 to 2019
    (2021) Bust, Lynn Hazel; Olivier, Jill; Whyle, Eleanor
    Media is a crucial factor in shaping public opinion and setting policy agendas. There is limited research on the role of media in health policy processes in low- and middle-income countries. This study profiles South Africa as a case example, currently in the process of implementing a major health policy reform, National Health Insurance (NHI). A descriptive, mixed methods study was conducted in five phases. Evidence was gathered through a scoping review of secondary literature; discourse analysis of global policy documents on universal health coverage and South African NHI policy documents; and a content and discourse analysis of South African print and online media texts focused on NHI. Representations in the media were analysed and dominant discourses that might influence the policy process were identified. Dominant discourses in SA media were identified relating to ‘health as a global public good', biopolitics, and corruption. Media representations focused on political contestation and the impact of NHI on elite actors. Representations in the media did not acknowledge the lived reality of most of the South African population. The discourses identified might influence the policy process by reinforcing socially dominant discourses and power structures, and hindering public participation. This might reinforce current inequalities in the health system, with negative repercussions for access to health care. This study highlights the need to understand mainstream media as part of a people centred health system, particularly in the context of universal health coverage reforms such as NHI. This would require the formation of collaborative and sustainable networks of policy actors, including actors within media, to develop strategies to counter-act harmful representations in the media that might reinforce inequalities and prevent successful implementation of NHI. Strategies should also investigate how to leverage media within health policy processes to decrease inequalities and increase access to health care. Research should be undertaken to explore media in other diverse formats and languages, and in other contexts, particularly low- and middle-income countries, to further understand media's role in health policy processes.
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    A new methodology for assessing health policy and systems research and analysis capacity in African universities
    (2014-10-08) Lê, Gillian; Mirzoev, Tolib; Orgill, Marsha; Erasmus, Ermin; Lehmann, Uta; Okeyo, Stephen; Goudge, Jane; Maluka, Stephen; Uzochukwu, Benjamin; Aikins, Moses; de Savigny, Don; Tomson, Goran; Gilson, Lucy
    Abstract Background The importance of health policy and systems research and analysis (HPSR + A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR + A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. Methods The Consortium for Health Policy and Systems Analysis in Africa 2011–2015 designed and implemented a new framework for capacity assessment for HPSR + A within universities. The methodology is reported in detail. Results Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR + A that focus solely on universities – we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR + A, the unit of assessment can be a challenge, because HPSR + A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. Conclusions From our experience, we propose that future systematic assessments of HPSR + A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR + A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening.
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    The aims of the primary health care reforms in Finland between 1993-2015: a systematic review
    (2018) Malinen, Sanna; Olivier, Jill
    Aims: Empirical research has proven that a strong primary health care (PHC) system produces better health outcomes and therefore, PHC is an important part of a country's health system. This systematic review focuses on the intended aims and targets of PHC reforms conducted in Finland from 1993 onwards. It describes the challenges that the Finnish PHC system has faced, comparing the objectives and the problem with other similar countries, providing lessons from the Finnish experiences for other countries. Methods: A Campbell-styled systematic review was conducted. Databases including Ebsco, Pubmed/MEDLINE, Scopus, Google Scholar and a Finnish health science database Medic were searched. The keywords and MeSH Terms for the review included terms relating to 'health systems', 'primary care', 'reform', and 'Finland' (see Appendix B). English terms were used when using Medline, Scopus and EBSCO, and both Finnish and English terms were used when using Medic. Reference lists of included papers were also searched. Data was extracted and analysed by utilising thematic analysis. Results: 13 relevant papers were found that dealt with PHC policies or reforms implemented in Finland between 1993 and 2015. The aims of the reforms were classified under five themes, which were developed based on a prior scoping review and then tested during data extraction. The themes were: efficient governance and financing, adequate and equitable access, improved quality, increased patient choice and cooperation and integration of services. Conclusions: A number of policies and reforms have been implemented which have directly or indirectly aimed to strengthen the Finnish PHC system. Some policies have intended to strengthen PHC overall while others have focused on only one aspect or challenge. There has recently been a strong tendency to re-centralise health services, and the importance of patient choice and service integration have become increasingly important. Integration and cooperation of different service providers is one of the newest solutions when finding ways to strengthen weak PHC systems. This study shows that in policy success context matters. PHC strengthening needs to be high on the political agenda, and enough resources are needed. This study showed that there have been few durable or sustainable solutions, and further research is needed especially from the overall health systems perspective.
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    Assessing palliative care policies in Africa: Implication for paediatric palliative care
    (2020) Ngowi, Epiphania; Shung King, Maylene; Meiring, Michelle
    Around the world, there are millions of children who need palliative care from the moment they are diagnosed with life-threatening and life-limiting illnesses, yet very few children have access to palliative care services. In many African countries, where palliative care is still new, many children with chronic illnesses continue to experience needless pain and suffering. The World Health Assembly Resolution 67.19 made a clear call for governments around the world to implement palliative care policies. Such policies should support the “comprehensive strengthening of health systems to integrate evidence-based, costeffective and equitable palliative care services in the continuum of care, across all levels of care”. However, despite these frequent calls, no specific policies target the provision of paediatric palliative care in Africa. This dissertation consists of three parts. Part A is the study protocol, which consists of the introduction and the study methodology. The study is qualitative in nature and it adopted the Walt and Gilson framework for extraction of data and analysis of palliative care policies in Africa. The study used publicly available policy documents, which were identified and obtained from government websites, international agencies' websites and through communication with palliative care experts. An excel spreadsheet was used to extract data, which was analysed thematically. Part B is a literature review of available published and unpublished work pertaining to paediatric palliative care in Africa. It provides the historical background of palliative care and defines palliative care and paediatric palliative care as well as exploring the general literature on paediatric palliative care, and the evidence on the existence of palliative care policies in Africa. Part C is a journal manuscript. It follows the structure and guidelines of the journal of the Health Policy and Planning. The manuscript begins with introduction and the study methods. Further, the study used publicly available policy documents on palliative care in Africa published from 2002 until 2018. An appropriate conceptual framework was chosen, and the results of the policy analysis are provided and followed by the discussion section and conclusions. The study findings indicate that few palliative care policies exist in Africa, and children's palliative care needs are not adequately included and addressed. The findings further show that there was no single policy targeting paediatric palliative care, and children were included among the larger population. As such, palliative care needs were not sufficiently addressed. Only three policies (South Africa, Zimbabwe, and Malawi) clearly address paediatric palliative care needs. The study, therefore, argues that for children with life threatening and life-limiting conditions to be free from pain, African governments need to formulate specific policies that will guide the provision of paediatric palliative care. This study is likely contribute to policy making processes, acts as a reference document for academics and students and provides an advocacy tool for activists, nongovernmental organizations (NGOs), and civil society organizations (CSOs) working on children's welfare and human rights issues more broadly. Further, the findings of the study may contribute to formulating specific palliative care policies for children, particularly in African countries that lack such policies.
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    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.
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    Auditing healthcare facilities against the National Core Standards for occupational health and safety and infection prevention and control: compliance, reliability and impact
    (2016) Cloete, Brynt Lindsay; Ehrlich, Rodney; Yassi, annalee
    Auditing in health care has been recommended by many national organisations to improve patient safety and quality of care, despite inconclusive evidence to support its effectiveness. In South Africa, the National Core Standards for health establishments in South Africa (NCS) was published in 2011. The NCS recognises that staff are vital to ensuring that the health system delivers quality health care and therefore require protection against the risk of injury, infection and other occupational hazards, consistent with the South African Occupational Health and Safety act of 1993. The aim of this study was to determine: (a) the compliance of public sector primary healthcare (PHC) facilities with the NCS for occupational health and safety (OHS) and infection prevention and control (IPC), (b) the impact of the audits three years after baseline audits, at follow up self-assessment audits and (c) the reliability of self-assessment audits when compared to external audit results. This dissertation is divided in three parts. Part A is the study protocol which received ethics approval in March 2015. Part B is a structured literature review covering standards for health care, the impact and effectiveness of accreditation/certification/auditing in health care, interrater reliability and factors associated with OHS/IPC compliance. Previous studies have failed to address whether evaluating occupational health and safety or infection prevention and control standards using accreditation/certification in a primary healthcare, low and middle income setting is effective or reliable. Part C is the journal ready manuscript presenting the results of the study in the form of a manuscript for an article for a named peer reviewed journal. This was a cross-sectional study of NCS OHS/IPC audit data, with a longitudinal component, of a sample of public sector PHC facilities in the Western Cape province of South Africa between 2011 and 2015. Baseline PHC facility compliance with OHS/IPC measures was low. There was no significant improvement in compliance after three years. Poor inter-rater reliability indicates a large degree of measurement error. Practical implications of these results are the need to improve reliability of assessments and a process to convert low compliance scores into implemented improvement actions.
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    Barriers to healthcare access by undocumented migrants in low-and middle-income countries: A qualitative systematic review
    (2023) Adnan, Salman Amirah; Olivier, Jill
    Undocumented migrants experience many barriers to accessing health systems around the globe. Although these barriers are well documented in the context of migration from low- and middle- to high-income countries, less attention has been paid to irregular migration within low- and middle-income countries (LMICs). This study reviewed and synthesized the available literature on barriers to accessing health systems among undocumented migrants in LMICs. Thirty-one studies published either on English, Portuguese or Spanish and published between 2013 and 2022 were included. As a growing body of evidence demonstrates, undocumented migrants are among the most vulnerable populations with access to health care services impacted by high costs, legal barriers, document requirements and unclear policy messages. By applying a health policy and systems research lens, this review found that these barriers are interrelated and further complicated by individual and institutional discrimination, xenophobia, and perceptions that undocumented migrants are less deserving and compete for local resources, among others. Delayed care and limited primary healthcare access with critical health consequences were described in all such cases. The review suggests that barriers to healthcare access require intersectoral action that needs to be guided by embedded, comprehensive evaluations to generate the knowledge that is necessary to inform effective policy-responses and implementation.
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    Community participation and the right to health for people with disability: a qualitative study into Health Committees' understanding and practise of their governance role in relation to disability
    (2015) Abrahams, Theodore William John; Haricharan, Hanne Jensen; London, Leslie
    BACKGROUND: People with disabilities encounter major barriers that prevent them realising their right to health in South Africa. Health committees are legislated structures for community participation in health at a local level. This study investigated how health committee members understand and practise their role in community participation and how this advances the right to health for persons with disability. METHODS: A qualitative study was conducted with three health committees in the Cape Town Metropole in the Western Cape province of South Africa purposively selected for the study. Three facility managers and eight health committee members took part in focus group discussions and semi-structured interviews, supplemented by participant observations of committee meetings. Additionally, semi-structured interviews were conducted with 2 disability activists. These methods were used to gain a rich understanding of health committees’ roles and practises in relation to persons with disabilities. Thematic analysis was used to analyse the data. RESULTS: The main research findings were: (i) health committees did not prioritise disability on their respective agendas; (ii) persons with disabilities were not adequately represented on health committees; (iii) health committees exhibited poor understanding of disability barriers relating to health; (iv) lack of egalitarian values led to persons with disabilities not trusting the health committee, and distrust amongst health committee members; lastly (v) health committees augment health facility operations instead of fulfilling their governance and oversight function. These factors may have contributed to health committees not helping to advance the right to health for persons with disabilities. CONCLUSIONS: Health committees should include mandated representation of persons with disabilities, whilst addressing marginalisation directed toward persons with disabilities on committees. Training of health committees, as well as networking with disabled organisations, could help improve their limited understanding of disability. Health committees should consider addressing disability a human rights issue, which critically involves community mobilisation, raising awareness around issues of disability and promoting agency amongst persons with disabilities to claim their rights.
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    The current situation of children's nursing training in South Africa
    (2017) Chukwu, Uchenna Nneka; Shung King, Maylene; Sieberhagen, Stephanie
    The high rate of Infant and child mortality, much of which is preventable, especially in developing countries, continues to be a global public health concern. Improving the numbers and competencies of child nurse professionals is vital for health system strengthening. Child nurses are important group of health professionals who are responsible for delivering effective health care services to infants and children at all levels of the health system, yet their training situation is being under-investigated. It is documented in various literatures that the high rate of under-five morbidity and mortality in South Africa can be prevented by strengthening the training needs of child nurses, in order to ensure that their competencies adequately align with the priority health needs of children who present at the health facilities. This dissertation is organized into three parts. Part A is the research protocol which outlines the background and the study methodology. Mixed methods comprising qualitative and quantitative methods is adopted for the study. Documentary review and self-administered structured questionnaire is used for the data collection. The questionnaire is designed by applying the basic principles that informs a good questionnaire design. Purposive sampling method is used for sampling the nursing institutions and research participants for inclusion into the study. Defined inclusion and exclusion criteria are used to identify and select the Nursing Education Institutions and key informants suitable for the study. The nursing institutions that are accredited with the South African Nursing Council and conducts child health nursing is an inclusion criterion for the study. In addition, key informants who are nursing educators with expertise knowledge in children's nursing are identified as an inclusion criterion for the study. Documentary review is used to extract secondary data that identifies the South African policy and legislative framework for general nursing and children nursing in particular. Documents will include appropriate policy and strategy documents. The workshop minutes of a sentinel Nurse Educator Forum that took place at Groote Schuur hospital in December of 2016 will be included as an important secondary data source. In addition, primary data collection will be done using a self-administered structured questionnaire where key informants will address a combination of qualitative and quantitative questions. The self-administered questionnaire is used to thoroughly investigate the current situation of children's nursing training in South Africa, with the aim of identifying the numbers trained annually for a five-year period and the curriculum foci of children nursing training across the nursing institutions that host children nursing programs in South Africa. Part B is the literature review which examines the preventable causes of under-five mortality in South Africa and the need to train up suitable, well qualified and competent Child Nurse Professionals needed to improve the health of infants and children in South Africa. Part C is the journal article manuscript which begins with the background and the study methods, followed by the results, discussion and conclusion. The result indicates that a total of five relevant policy and strategy documents were identified for the documentary review. Of the five documents, three documents suggest strategies for improving the nursing education and training programmes in South Africa. The strategies include increasing the supply of the nurse specialists, transforming all nursing colleges to Higher Education Institutions and improving the curriculum guidelines of the nursing programme, in order to ensure that the competencies taught to the nurses aligns with the health care needs of the communities. The two other documents posit the primary roles of the nursing professionals, which is to provide effective care and respect the rights of the health care users. The findings from the documentary review recommends that the nursing education in SA can be strengthened by identifying all nursing colleges as Higher Education Institutions, reviewing curricula and producing more numbers of competent nurses in South Africa. For the primary data collection, out of the seven accredited nursing institutions which conducts children nursing training in South Africa, five respondents from five institutions completed and forwarded their questionnaires. The completed questionnaires provided details on the profile of children's nursing training, including the annual numbers of children nurse trainees and graduates over a five-year period and details of their curriculum components. The results showed that a total of 637 children nurses were enrolled from 2012-2016. Of the 637, 587 graduated successfully which indicates that the number of child nurse trainees and those who successfully graduated over a five -year period across five nursing institutions were very impressive, although the number of child nurses produced annually are still few to address the child health needs in South Africa. In addition, the findings from the questionnaire reveals that the curriculum of children's nursing training across the five institutions are similar and contains topics that are capable of equipping the child nurses with the relevant skills necessary for improving the health of infants and children. However, they exist some variations in the degree the courses are covered by the institutions, as well as variations in the way the courses are conveyed to the nurse learners. For example, some topics where covered to a high degree by some institutions, while some where not covered at all, or where covered to some extent via classroom and clinical placement and assessments. This suggests that the curricula of child nursing in South Africa requires standardization and frequent reviewing to ensure it coincides with the child health needs in South Africa. The dissertation is likely to increase the knowledge of the current training situation of children's nursing in South Africa, and also identify gaps for future research. In addition, the dissertation also provides a better understanding of the curriculum foci of children's nursing training in South Africa and can help inform the human resource training plans for child health nursing in the country.
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    Exploring experiences of HIV counsellors towards the HIV counselling and testing policy in Zambia’s public urban health centers
    (2014) Shawa, Remmy Malama; Stern, Erin; Gilson, Lucy
    Includes abstract. Includes bibliographical references.
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    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.
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    Exploring the complex policy formulation process of the draft Control of Marketing of Alcoholic Beverages Bill in South Africa
    (2017) Bertscher, Adam; Orgill, Marsha; London, Leslie
    International literature suggests that corporate influence is evident when governments attempt to regulate products implicated in non-communicable disease, such as tobacco, asbestos, pollution, and foods, such as trans-fat, salt and sugar. These lifestyle diseases are aptly referred to as 'industrial epidemic', since industries profit from the public's continued consumption of such products. Of these 'industrial epidemics', alcohol is a major contributor to the health burden in South Africa. In the year 2000, 7.1% of all deaths and 7% of total disability-adjusted life years have been ascribed to alcohol-related harm in the country. The tangible and intangible costs of alcohol-related harm amount to 10-12% of South Africa's 2009 Gross Domestic Product. Literature suggests that limiting alcohol use could prevent the incidence of violence, injury, risky sexual behaviours, several forms of cancer, and neuropsychiatric and physical diseases. The World Health Organisation (WHO) released two documents, The Global strategy to reduce the harmful use of alcohol (2010b) and The Global Status Report on Non-communicable Diseases (2010a), detailing the negative effects of alcohol consumption for societies. Both documents recommend that decreasing alcohol consumption through banning of alcohol advertising would have significant public health benefits, although an integrated strategy is necessary to mitigate alcohol abuse including taxation, increasing prices, limiting places of sales and increasing education on the topic. In response, the South African government proposed a draft regulation aimed at restricting alcohol advertising as an evidence-based upstream intervention. The draft Control of Marketing of Alcoholic Beverages Bill is in the process of undergoing impact assessments to determine the impact this regulation may have on South African society. Literature suggests that industry employs various political strategies to avoid such regulation. However, little is known about the strategies the alcohol industry potentially uses to influence policy development in South Africa. There is a lack of knowledge on the current strategies used by the alcohol industry to influence policy; the draft Control of Marketing of Alcoholic Beverage Bill is a case in point. This study sought to explore the complex policy formulation process in South Africa, using the draft Control of Marketing of Alcoholic Beverages Bill as a tracer case and focused on the alcohol industry, as a central actor, to understand how it - together with other actors - may influence this process. A qualitative case study approach was used, which included stakeholder mapping, 10 in-depth interviews and review of approximately 240 documents. This study makes use of two conceptual frameworks. The first framework, Berlan et al. (2014) is used to understand policy formulation as a process with multiple facets. The second framework, Roberts et al. (2004), provides four typologies of political strategies that health reformers/advocates/lobbyists employ to influence the policy process. A thematic analysis was used to analyse the data. Key themes identified were: (1) Competing and shared values - different stakeholders promote conflicting ideals for policymaking; (2) Inter-department jostling - different government departments seek to protect their own interests, hindering policy development; (3) Stakeholder consultation in democratic policymaking – policy formulation requires consultation even with those opposed to regulation; (4) Battle for evidence – industry sought to assemble evidence to use as 'ammunition' in opposition to the ban. It was concluded that networks of actors with financial interest use diverse strategies to influence policy formulation processes to contest proposed regulation. Using the policy formulation process of the draft Control of Marketing of Alcoholic Beverages Bill as a tracer case, this research is a critical enquiry into how the for-profit industry affects public health interests in South Africa; such a critical enquiry could also be applied to other non-communicable diseases. Research suggests that industries have more difficulty in pushing their agenda when policymakers are well informed, are aware of the evidence-based practice and are not motivated by economic arguments alone. There is also a lack of research that focuses on health policy analysis in low and middle-income countries, and there is a lack of research focusing on the policy formulation process in particular. Therefore, this research aims to fill a gap in addressing a lack of research on health policy analysis in the context of a middleincome country. The implications of the study are that measures to insulate policy development are needed to prevent industry influence potentially undermining public health goals, such as: government to moderate certain consultations with industry; industry to declare conflict of interest; guidelines for bureaucrats and policymakers to advise on whose evidence to consider; and guidelines for bureaucrats and policymakers to assess quality of evidence.
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    Exploring the influence of intersecting social identities on the leadership experience of female managers in the South African health system
    (University of Cape Town, 2020) Reddy, Mishka; Gilson, Lucy; Shung-King, Maylene
    In the transition from the Millennium Development Goals to the Sustainable Development Goals, the importance of an integrated health system in which all health activities interact - including the multiple actors within the system - has gained greater recognition. In light of these transitions, the World Health Organisation and the Alliance for Health Policy and System Research called for a participatory leadership model, which engages with multiple health system actors in and out of the health system. It is a leadership model, which seeks to be inclusive of diverse and currently underrepresented stakeholders such as women. This leadership model is aligned with the gender equality movement in health leadership, which has rightfully gained global prominence over the last decade. However, it would be an oversimplification to assume all women in leadership positions have had to overcome similar obstacles. Treating women as a homogenous group tends to leave people out given the evidence that social identities culminate to produce unique experiences and therefore challenge feminist notions of the homogeneity of women. Drawing on data from a primary study on gender and leadership in South Africa, this study sought to explore the influence of gender, as it intersects with race and professional cadre, on the experiences of female health managers in the South African health system. The primary study noted that black females felt as though they were "left behind" throughout their leadership journey. This secondary analysis was undertaken using Bilge's intersectionality approach. It is a two-step qualitative analysis approach, which uses an understanding of intersectionality to extract data related to social identity and intersecting social identities. The analysis assessed 1) how gender, race and professional cadre discretely inform each participant's account and 2) how gender intersects with other social identities to create unique barriers for different women. It explored how intersecting identities might leave certain people behind - and how then to conduct health policy and systems research that can produce qualitative data necessary for creating formalised initiatives that address potential barriers. While recognising the enormous potential of participatory leadership, this study focused on the experiences of formally designated health managers who were able to reflect on their journey towards their current position and explain the barriers in this journey, related to their entangled social identities.
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    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.
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    Factors that affect uptake of community-based health insurance in low- and middle- income countries: a systematic review
    (2014) Adebayo, Esther; Wiysonge, Charles; Ataguba, John
    Includes abstract. Includes bibliographical references.
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    Factors that influence patient empowerment in inpatient chronic care: Early implementation experience with a diabetes care intervention in South Africa
    (2018) Abrahams, Nina; Gilson, Lucy; Levitt, Naomi
    The burden of non-communicable diseases is growing rapidly globally and especially in low and middle-income countries. However, health systems around the world are not appropriately prepared for this increase in need for chronic care. Research suggests that health models that emphasise self-management and empowering patients to care actively for their disease are integral in non-communicable disease treatment as patients live with their disease well beyond contact with health services. Adherence and health-seeking behaviour literature suggest multiple factors within the lives of patients and within health systems that enhance or constrain patient empowerment interventions. However, in depth understanding of these factors are lacking in the South African context and especially in the inpatient setting as most research focuses on the role of primary care. This research used interviews with stakeholders in an upcoming inpatient diabetes intervention as a lens to qualitatively explore empowerment factors in further detail within the South African inpatient context. The study highlights multiple barriers to patient empowerment, namely the low socio-economic contexts of many South Africans who then struggle to access appropriate healthcare information and services and often have financial and emotional priorities that take precedence over their chronic illness. In addition, health services are bound by a shortage of resources and staff and ineffective communication systems which affects health professionals’ ability to implement patient empowerment strategies. It also highlights the unique barriers found in inpatient care as the hospital emphasises short-term acute treatment – losing potential engagement time with patients. The study suggests that patient and provider contexts make encouraging patient engagement in long term chronic care difficult. However, knowledge of these factors can be harnessed to improve chronic care interventions in low- and middle-income countries.
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    Gender analysis: Sub-Saharan African nurses' migration experiences - a systematic review
    (2017) Mavodza, Constancia; Shung King, Maylene; Govender, Veloshnee
    Alleviating the global shortage of health workers, particularly nurses, is critical for health systems and health worker performance. Nurses are mostly women and make up the majority of the health workforce. Several factors have been identified as key players in the shortage crisis and migration is one of these factors. Nurses' migration from Sub Saharan Africa (SSA) increases the nurse shortage in the region and further constraints the already struggling health systems. Migration literature has dominantly focused on macro push-pull, brain drain and ethics theories of migration with limited exploration of relationships, interaction, norms, beliefs and values shaping migration trajectories and decisions. Despite the potential role of gender as an influential component of migration trajectories, there has been little research done to investigate gender in the context of migration of SSA nurses. This review aims to identify, describe, and summarize SSA nurses' migration experiences by assessing the influence of gender on these experiences. The dissertation is organized into 3 parts. Part A is a systematic review protocol that describes the background, justification and methodology of the review. A scoping exercise is conducted to to familiarize with the literature. This is followed by a qualitative systematic approach is utilised and the literature in eight databases is searched using key words and terms derived from an initial scoping exercise and the review questions. Suitable articles are defined and selected using a set inclusion and exclusion criteria. The suitable articles are then appraised and a thematic analysis using a gender focal lens is applied to them. Part B is a literature review of existing primary and theoretical research on health worker shortages; migration and gender analysis in health worker migration and shortages. It provides a background for the systematic review by defining migration, gender and gender analysis as well as presenting the scope on health worker and nurse shortages. The literature review encompasses the scoping exercise and concludes on the relevance of a gender-focused research on nurse migration. Part C. is the full systematic review presented as an article for Human Resources for Health Journal. Articles published on Sub-Saharan African (SSA) nurses' migration experiences between 2005 and 2016 are presented, subjected to a gender analysis to illuminate the results. The discussion and conclusion then follow. The results indicate that there is a paucity of empirical work on nurse migration experiences that is explicitly gender-focused. Gender analysis that is situated in social contexts and identifiers revealed that SSA nurses continuously renegotiate and reconfigure gender roles in child care as they move from one social context to another. Moreover migrating SSA nurse face challenges and limitations at macro, meso and micro levels of the system- that are linked to their identities as either professionals, African migrants and/or women. Therefore, the review underscores the importance of the relationships between gender and local/individual nuances and global/national determinants of migration. However, these studies are limited in their explicit gender and social focus and how it contextually affects health worker performance and quality care provision. More empirical studies are needed to investigate gender influences for migrating male nurses; nurses who remain; and by different geographical & cultural region – to allow comparison across different groups of nurses and determine conceptual generalizations for doing gender research. This dissertation will likely increase understanding of the role of gender in migration decision-making and experiences for SSA nurses across different professional, migrant and woman identities. This understanding has impacts on nurse motivation, capacity and capability as well quality care provision. Additionally, the dissertation provides a better understanding for incorporating gender analysis in health systems research, and also identifies avenues for future research.
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    Health system's barriers hindering implementation of public-private partnership policy in the health sector at district level: A case study of partnership for improved reproductive and child health services provision in Bagamoyo district, Tanzania
    (2015) Kamugumya, Denice Cyprian; Olivier, Jill
    The role of the private sector in improving health systems performance in lower to middle income countries is increasingly gaining more recognition. Public-private partnership (PPP) has been suggested as a tool, to assist governments fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level - which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP. In 2009 a formal PPP policy was introduced in Tanzania, which directs the appropriate allocation of resources, and describes risk and rewards that can be achieved by building on the expertise of each partner. The Health Sector Strategic Plan III (2009-2015) further emphasises the need for service level agreements (SLAs), which are seen as an important indicator of improved PPP. This case study that draws on the decision-space framework, was conducted in the Bagamoyo district of Tanzania, and employed in-depth interviews, document reviews, and observations methods. The study findings reveal several forms of informal partnerships between the local government and non-state actors. The lack of SLAs for facilities that receive subsides from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. This is evidenced by non-state actors who pursue their own interests, diverting from public social goals. Furthermore, findings highlight weak capacity of governing bodies to exercise oversights and sanctions, which is acerbated by weak accountability linkages and power differences. Moreover, restricted flexibility in spending is seen to deter prompt actions to address evolving population needs, given limited local fiscal space. It is concluded that effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Disempowered Council Health Services Board in relation to engaging non-state actors is shown to impede PPP initiatives that are conceptualized at local and national levels. This study highlights a need to consider initiatives that would foster new social contracts with non-state actors at the local level and in return build a people-centred district health system. This study is intended to improve knowledge on health systems policy interventions, strengthen future policy implementation at the sub-national level, and strengthen the district health systems as a result of PPP in a country with similar contextual elements.
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    Health systems determinants of delivery and uptake of maternal vaccines in low and middle-income countries: A qualitative systematic review
    (2022) Davies, Bronte; Olivier, Jill; Amponsah-Dacosta, Edina
    Maternal vaccination has been widely recognised as a key component of the comprehensive package of antenatal care aimed at improving maternal and child health. Low- and middle-income countries (LMICs) are currently falling short of maternal and neonatal mortality targets, with gaps in quality health coverage and a high burden of vaccine-preventable diseases that affect both maternal and child health (MCH). There is a variety and increase of grey and published literature in recent years from LMICs on maternal vaccination programmes and their importance in addressing these gaps in MCH. However, there is a gap in the available literature for research on the role of health systems in the functioning of maternal vaccination programmes, particularly in LMICs. Based on available evidence, understanding health systems determinants of maternal vaccine uptake and delivery requires qualitative insight to inform maternal vaccine programming. A qualitative systematic review was conducted in two phases: a rapid scoping review exploring maternal vaccination and health systems was followed by a systematic review to identify health systems determinants of maternal vaccine delivery and uptake in LMICs. The systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines. Six electronic databases were searched for primary research from LMICs published in English between 2009 and 2021. A qualitative approach to data extraction and evidence synthesis was guided by conceptual health systems framing developed through the scoping review. Thematic analysis identified key descriptive and analytical themes to explore the health systems barriers and enablers of maternal vaccine delivery and uptake in LMICs. Of the 1 242 records identified through database searches, 47 studies were included in the systematic review from 28 LMICs. The majority of included studies were from the South America region (28/47) and included pregnant women as the primary population study group (38/47). Included literature explored mainly Influenza (25/47) and Tetanus toxoid (18/47) maternal vaccine uptake and delivery. Health systems enablers of maternal vaccine uptake included high level of maternal trust in healthcare providers and policy-makers. Barriers to uptake include out-of-pocket spending for vaccination services. Poor communication of policy and guidelines between policy-makers and public/private healthcare providers was identified as a barrier to vaccine delivery, in addition to reliance on external donor funding for vaccine programme implementation and reliance on paper-based antenatal and vaccination records. Urban residence and shorter travelling times to facilities enabled vaccine uptake during pregnancy, while influence of family and influential community members serves as a barrier to vaccine uptake. Limited healthcare worker capacity and subsequent decreased time spent educating patients is a barrier to both vaccine uptake and delivery for pregnant women. Health systems determinants of maternal vaccine delivery and uptake identified and explored in this review study highlight the need for improved communication of vaccine policy guidelines and safety between healthcare providers, policy-makers, pregnant women and the broader community. Monitoring and reporting systems for vaccine delivery in MCH need to be strengthened to inform service delivery policies. This review study provides a health systems approach to maternal vaccination and contributes to the increasing body of work in MCH that can inform future introduction of new maternal vaccines in LMICs.
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    Health systems factors that impact on access to maternal services for women with disabilities in sub-Saharan Africa: a systematic review
    (2015) Mheta, Doreen; Shung King, Maylene
    Maternal mortality is an enormous global challenge that is most prevalent in sub-Saharan Africa (SSA). Its prevalence in the SSA region has been attributed to inadequate access to maternal services (MHS) amongst the poor and rural women. In an attempt to improve access to maternal services, women with disabilities (WWDs) have generally been neglected. Little is known about the health systems factors that facilitate or hinder access to MHS for WWDs. However, available studies for women in general in SSA, examining health systems determinants of access to MHS, utilise the silo approach thereby providing fragmented and ineffective solutions to maternal mortality. Globally, taking a comprehensive health systems approach to understand the full range and interconnectedness of health factors is now recognised as crucial in understanding and planning complex health problems such as access to MHS. This paper presents findings from a qualitative systematic review of empirical studies providing evidence on the health systems factors that impact on access to MHS for WWDs in SSA. This dissertation comprises three sections, namely Part A, Part B and Part C. Part A reviews the Protocol; it presents the background and the qualitative systematic review methodology that is utilised in this study. A systematic search of five data bases is outlined and inclusion and exclusion criteria set out to select the suitable tool. A data extraction tool is designed to summarise the studies in a common format and to facilitate synthesis and coherent presentation of data. Part B is the review of existing empirical literature on access to MHS for both women in general SSA and for WWDs globally. Theoretical frameworks of access to health care services and health systems frameworks are also presented in this section. Furthermore, Part B provides the background on why access to MHS for WWDs is important. This section explores how health systems approach can be adopted to reveal the factors that impact on access to MHS; it links the complex systems framework to the availability, accessibility, acceptability and quality framework. Part C is a complete systematic review journal manuscript. The background of the study and methodology are described. This section also includes the findings from the systematic review of original journal articles published in English from 2000 to 2014 that report empirical findings on health systems factors that impact on access to MHS WWDs in SSA.