Towards Universal Health Coverage (UHC) policy roll-out experience in South Africa : how and why policy-practice gaps come about in a UHC context

All countries world-wide are striving towards Universal Health Coverage (UHC). South Africa embarked on this bold and new direction, piloting National Health Insurance (NHI) in 2011. Two vehicles and strategic interventions selected to reach UHC are Primary Health Care (PHC) re-engineering and NHI. The goal of UHC is to ensure that everyone has access to appropriate, efficient and quality health services without the risk of impoverishment or financial catastrophe.
The aim of this thesis was to contribute to a better understanding of policy implementation in a UHC context in one pilot district in South Africa. In order to explain how the policy-practice gap comes about, actor experiences were sought. Utilizing Contextual Interaction Theory (CIT) as a framework for analysis, this thesis sought a more in-depth understanding on 1) What bottlenecks and challenges actors experienced in their current role as a UHC policy maker/ implementer? (Information, motivation, power, resources, interactions and others) 2) how and why policy-practice gaps come about from actors` policy implementation experience and 3) What needs to be done to reach UHC? The study was embedded in a broader project, Universal Coverage in Tanzania and South Africa (UNITAS). A qualitative case study design utilizing a theory of change approach was adopted and data was collected during three phases between 2011 and 2015. Our findings revealed a discrepancy between challenges health workers had on the ground and health systems strengthening initiatives that were being implemented. This is in part due to the non-involvement of front-line staff in policy making. To that end we developed and proposed a Health Systems Strengthening (HSS) Framework to aid the process of identifying needed HSS initiatives in a PHC context that is nurse led.
Findings also revealed five groups of factors bringing about policy-practice gaps; (i) Primary factors stemming from a direct lack of a critical component for policy implementation, tangible or intangible (resources, information, motivation, power), (ii) Secondary factors stemming from a lack of efficient processes or systems (budget processes, limited financial delegations, top down directives, communication channels, supply chain processes, ineffective supervision and performance management systems), (iii) Tertiary factors stemming from human factors (perception and cognition) and calculated human responses to a lack of primary, secondary and or extraneous factors, as coping mechanisms (ideal reporting and audit driven compliance with core standards), (iv) Extraneous factors stemming from beyond the health system (national vocational training leading to national shortage of plumbers) and (v) an overall lack of systems thinking.
Noteworthy among factors fuelling policy-practice gaps are human factors, perception and responses of actors in the system to a lack of resources, processes and systems, through among others, ideal reporting and audit driven compliance with core standards, bringing about an additional layer of unintended consequences, further widening that gap.
Actors identified that current systems e.g. supply chain and supervision are obsolete as they were designed during a different time period demographically, epidemiologically and technologically. Actors are recommending health systems transformation rather than health system strengthening, meaning going back to the drawing board to design systems based on today’s challenges and scenarios. The current lack of progress and stagnation in the health system has been blamed on leadership gaps in all sectors. More research is needed to explore leadership development approaches that produce results on the ground. The findings also revealed that policy implementers do engage with policy upon receipt. They then do a policy-context audit after which they arrive at a decision and act either through policy adaptation, partial implementation to full implementation.
In conclusion, this thesis shares some implementation experiences worth taking into consideration when implementing UHC policies. The first one is the role of leadership in implementation; hence we propose adding leadership to the CIT central tenets to become Information, Motivation, Power, Resources, Interactions and Leadership. Leadership was alluded to repeatedly by actors as a critical ingredient. We propose utilizing a systems approach to addressing health system challenges. Factors fuelling policy-practice gaps are multi-faceted and interrelated so much so that dealing with these systemically will go a long way in making UHC a reality.