How and why are different forms of evidence used in policy-making in the South African health sector? A case study of the National Core Standards and the Prevention Of Mother-To-Child Transmission (PMTCT) of HIV policies

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PURPOSE The South African public health sector lacks a formal, documented, and nationallyadopted system through which evidence is infused into policy-making processes. It is, therefore, unclear what evidence informs policy formulation and why and how this evidence is used. The main goal of this study was to examine why and how different types of evidence are used in policy-making in the South African public health sector and what factors determine whether or not these different evidence forms are used. METHODOLOGY This study used qualitative research methods. This was an insider-led or embedded research study led by a senior government official. It adopted a broad definition of evidence, embracing not only research but also a wider range of routine evidence. In phase 1 of the study, the overall process of health policy formulation was reviewed, and in phase 2, two specific policy process cases were examined in depth. These were the Prevention of Mother-to-Child Transmission policy and programme (2002) and the National Core Standards policy (2011). A total of 30 in-depth interviews were conducted, with both senior executive managers in the public health sector and local Health Policy and Systems researchers. In addition, a range of documentary evidence and relevant literature was examined. Phase 1 of this study, which was mainly descriptive, used thematic content analysis to analyse the interview and documentary data collected. Phase 2 included a more analytic approach, to support explanatory analysis, and so framework analysis was applied – combining inductive analysis with a more deductive approach drawing from relevant theoretical concepts and ideas. FINDINGS Findings from Phase 1 of this study generate an understanding of the key steps in the formal policy-making process in the South African health sector. This is an internal process which is driven by the National Health Council (NHC) and the Technical Advisory Committee of the NHC, and is somewhat closed to stakeholders outside government. This study also shows that policy-makers in South Africa draw on a wide range of sources of evidence, including informal evidence, rather than relying only on research evidence. Findings from Phase 2 of the study reveal that powerful political actors play a central and influential role in health policy development, and influence the use of evidence. These actors apply issue-framing as a strategy to influence this process, although its influence is transient. In the context of a democratic South Africa, where the Constitution prescribes a separation of powers between organs of state, the study also illustrates the power of stakeholders outside government, such as the judiciary, whose judgements ushered in the PMTCT policy, and civil society. Findings from both Phases of the study show that different sources and forms of evidence were used in the development of the two policy process cases. Finally, this study reveals the contestations that occur between spheres of government, sparked by differences over the use of evidence and national policies perceived by provinces as ‘unfunded mandates'.