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BACKGROUND: Global economic recession coupled with internal inefficiencies and corruption has led to a period of austerity in the South African healthcare system. This paper examines the strategies used by management in response to austerity in the three public hospitals and their effect on organisational functioning. METHODS: We used a comparative qualitative case study approach, collecting data using a combination of in-depth interviews with managers, and focus group discussion and interviews with shop stewards and staff. RESULTS: Austerity, imposed by the introduction of a provincial cost containment committee, has led to a reduction in staff, benefits, shortages of equipment and delayed procurement and recruitment processes. Managers in the first hospital maintained training on labour relations for staff and managers, they jointly planned how to cope with reduced staff and initiated a new forum for HR and finance staff. These strategies improved the way actors engaged, enabling them to resolve problems. Good communication ensured that staff understood what was within the hospitals control and what was not. A second hospital relied on absorptive strategies, such as asking staff to do more with less. The result was resistance, and greater use of sick leave. Some staff gave their own money to help feed patients but were angry at management for putting them in this difficult position. Leadership in the third hospital did not manage actors well either; help from the Government's Expanded Public Works Programme was rejected by the unions, managers did not attend meetings as they felt their contributions were not listened to. Poor communication meant that the managers and staff did not understand what was within the hospital's control and what was not; a misunderstanding led to a physical fight between managers. CONCLUSION: Organisational resilience in the face of austerity requires leaders to manage different stakeholders well. Hospital managers who promote democratic or participatory leadership and management, ...

BACKGROUND: Many low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa. METHODS: We conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives. RESULTS: The nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs' activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities' focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures. CONCLUSIONS: A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can ...

Despite international recognition of health promotion (HP) as a cost-effective way to improve population health, it is not highly regarded nor is it sufficiently institutionalized in many health systems. This diminishes its ability to deliver on its public health promises. This paper examined the role of organizational structure and human agency within the South African health system (drawing on Giddens's structuration theory) in determining the extent of, and barriers to, the institutionalization of HP. We conducted a qualitative case study using a combination of in-depth interviews (n = 37), key informant interviews (n = 8) and one-day workshops (n = 5) with Department of Health (DoH) staff (HP and non-HP personnel) from national, provincial and district levels as well as external HP stakeholders. Within the South African health system, there are dedicated HP staffs, with no specified professional competencies or a coherent hierarchy of job titles. Allocated HP resources were frequently shifted to other programmes. This resulted in a disconnect between national and provincial levels, which impeded communication and opportunity to develop a shared vision and coherent programme. We found some examples of successful HP organization and implementation practices, such as the tobacco control legislation. Overall, HP staff had limited agency and were often unable to articulate the vision for HP. Uncertainty about the role of HP has led to powerlessness, and feelings of resentment have generated demotivation and moral distress. HP voices were seldom heard and were repressed by dominant curative-focused structures. If leaders of HP continue to be embedded in such an institution, there is little chance of driving an effective HP agenda. Therefore, there is a need to engage policy-makers to integrate HP into the health system fabric. Establishment of an independent HP foundation could be one mechanism to drive multi-sectoral collaboration, contribute to evidence-based HP research and further develop health in all ...

AbstractThe value of the social sciences is increasingly recognised in health services and clinical research, contributing to an increasing number of multi‐disciplinary, multi‐method studies. Such studies offer numerous advantages, but also pose particular challenges, including different approaches to or foci in research ethics across disciplines. Drawing on two similar studies conducted in coastal Kenya and in rural South Africa, we share the ethical challenges we faced in relation to several key principles, the responses we adopted, and the new dilemmas that resulted from our actions. Given that multi‐disciplinary, multi‐method studies are often reviewed by committees with greater familiarity with biomedical than social science research, we conclude by drawing on our experiences, and the wider literature and guidelines around conducting social science research, to make suggestions of additional considerations for social science elements of multi‐disciplinary research. We also emphasise that in practice it is the social relationships that are established between researchers and field‐teams, and between field‐teams and community members, that are critical to fulfilling the moral (as opposed to the legal) aspects of ethics guidelines. These essential elements of ethical practice, and of producing quality data, are not easily tested and checked by ethics committees. Rather they are linked to the insight and integrity of the principle investigators and their research teams. Copyright © 2009 John Wiley & Sons, Ltd.

AbstractIllness is a major risk to people's livelihoods in resource‐poor settings, particularly where there are rising levels of chronic illness. Measures that improve access to treatment are increasingly seen as a vital form of social protection for vulnerable households, and central to the achievement of the Millennium Development Goals. International attention is also focussed on cash transfers as a strand of social protection, and on the potential complementarities between free health care and cash transfers in assisting vulnerable people to cope with illness‐related shocks. South Africa provides an interesting setting to examine how households are accessing social protection measures because the government has removed some user fees, implemented hospital‐level exemptions and extended cash transfers including the non‐contributory pension and child support grant. This paper presents findings from household research in rural South Africa. Qualitative and quantitative methods were used to assess the links between illness‐related costs and impoverishment over time, the protection effects of free health services, cash transfers and social networks, and the factors influencing access to these three forms of social protection. Different degrees of success in drawing on these resources affected capacity to cope with illnesses and made a considerable difference to whether households sustained their livelihoods, struggled or declined. Cash transfers combined well with free health care to build resilience among some households. However, households without access to at least two strands of the social protection net were impoverished by the direct and indirect costs of long‐term illnesses. The implications for policies on improving the uptake and coverage of social protection measures are discussed. Copyright © 2009 John Wiley & Sons, Ltd.

Background: Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC. Methods: Using a cross-sectional survey across four of South Africa's nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status. Results: A quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits. Conclusions: By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country's financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC.

BackgroundIn 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues.ObjectivesThis study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment.MethodsMulti-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression.ResultsNotwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs.ConclusionBarriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.

Interaction through online social networks potentially results in the contestation of prevailing ideas about health and health care, and to mass protest where health is put at risk or health care provision is wanting. Through a review of the academic literature and case studies of four social networking health sites (PatientsLikeMe, Mumsnet, Treatment Action Campaign, and My Pro Ana), we establish the extent to which this phenomenon is documented, seek evidence of the prevalence and character of health‐related networks, and explore their structure, function, participants, and impact, seeking to understand how they came into being and how they sustain themselves. Results indicate mass protest is not arising from these established health‐related networking platforms. There is evidence of changes in policy following campaigning activity prompted by experiences shared through social networking such as improved National Health Service care for miscarriage (a Mumsnet campaign). Platform owners and managers have considerable power to shape these campaigns. Social networking is also influencing health policy indirectly through increasing awareness and so demand for health care. Transient social networking about health on platforms such as Twitter were not included as case studies but may be where the most radical or destabilizing influence on health care policy might arise.

Background: South Africa has a high and rising prevalence of hypertension. Many affected individuals are not using medication, and few have controlled blood pressure. Until recently, primary care clinics focused on maternal and child health and management of acute conditions, but new government initiatives have shifted the focus to chronic diseases, including HIV/AIDS and hypertension. Methods/Design: The Nkateko trial will test the effectiveness of clinic-based lay health workers (LHWs) in supporting hypertension management. It is a pragmatic, cluster randomised controlled trial based in the Agincourt subdistrict of northeast South Africa, and it is underpinned by long-term health and demographic surveillance. Eight primary care facilities, with their catchment communities, are randomised to usual care or the addition of LHWs focused on chronic care. All clinics (intervention and control) will be provided with a clerk to collect information on clinic attendees and will match them to preexisting surveillance records. Intervention clinics will have LHWs working alongside nursing staff and focusing on health care for people with chronic conditions, particularly hypertension. The LHWs will be supported by an implementation manager, who will work with clinic staff to develop the most effective role for the LHWs. Control clinics will continue to provide usual care. The primary outcome will be the change between two population surveys conducted before and after the intervention in the proportion of the population with uncontrolled hypertension and a risk profile indicating at least moderate risk of cardiovascular disease. A process evaluation will be based on a realist approach using patient exit interviews, clinic observations and interviews with health professionals, LHWs and patients to document the intervention and its implementation. Discussion: There are challenges in the design of this trial. Assessing change through population surveys may reduce measurable effects; however, we feel this is appropriate because we aim to attract those who currently do not use clinics, and we hope to improve care for clinic users. Clinics were randomised at an open meeting because we were concerned that a remote process of randomisation would not be trusted by the community. We are constantly working to achieve an effective balance between the intervention and process evaluations.

Background: The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. Methods: Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. Results: There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focusing on fiscal measures, regulation and legislation.Conclusions: The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The ...

BACKGROUND: The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. METHODS: Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. RESULTS: There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation. CONCLUSIONS: The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.

15 p. ; Background The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. Methods Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. Results There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation. Conclusions The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.