"It is like an umbrella covering you, yet it does not protect you from the rain": a mixed methods study of insurance affordability, coverage, and financial protection in rural western Kenya.

Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage, affordability and financial risk protection provided by health insurance, especially for rural informal households, is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya.Methods We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 focus group discussions (FGDs) with community stakeholders in rural western Kenya. Health insurance status was self-reported and households were categorized into insured and uninsured. Using survey data, we calculated the affordability of health insurance (unaffordability was defined as the monthly premium being > 5% of total household expenditures), out of pocket expenditures (OOP) on healthcare and its impact on impoverishment, and incidence of catastrophic health expenditures (CHE). Logistic regression was used to assess household characteristics associated with CHE.Results Only 12% of households reported having health insurance and was unaffordable for the majority of households, both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP, with both insured and uninsured households reporting high OOP spending and similar levels of impoverishment due to OOP. Overall, 12% of households experienced CHE, with uninsured households more likely to experience CHE. Participants expressed concerns about value of health insurance given its cost, availability and quality of services, and financial protection relative to other social and economic household needs. Households resulted to borrowing, fundraising, taking short term loans and selling family assets to meet healthcare costs.Conclusion Health insurance coverage was low among rural informal sector households in western Kenya, with health insurance premiums being unaffordable to most households. Even among insured households, we found high levels of OOP and CHE. Our results suggest that significant reforms of NHIF and health system are required to provide adequate health services and financial risk protection for rural informal households in Kenya.

The effect of a roving nurse mentor on household coverage and quality of care provided by community health worker teams in South Africa: a longitudinal study with a before, after and 6 months post design.

OBJECTIVE: Community health workers (CHW) are undertaking more complex tasks as part of the move towards universal health coverage in many low- and middle-income settings. They are expected to provide promotive and preventative care, make referrals to the local clinic, and follow up on non-attendees for a range of health conditions. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle due to inadequate supervision, low levels of CHW literacy, and the marginalized status of CHW in the health system. In this paper, we assess the effect of a roving nurse mentor on the coverage and quality of care of the CHW service in two vulnerable communities in South Africa. PARTICIPANTS: CHW, their supervisors, household members. INTERVENTION: Roving professional nurse mentor to build skills of supervisors and CHW teams. METHODS: Three household surveys to assess household coverage of the CHW service (baseline, end of the intervention, and 6 months after end of intervention); structured observations of CHW working in households to assess quality of care. RESULTS: The intervention led to a sustained 50% increase in the number of households visited by a CHW in the last year. While the proportion of appropriate health messages given to household members by CHW remained constant at approximately 50%, CHW performed a greater range of more complex tasks. They were more likely to visit new households to assess health needs and register the household in the programme, to provide care to pregnant women, children and people who had withdrawn from care. CHW were more likely to discuss with clients the barriers they were facing in accessing care and take notes during a visit. CONCLUSION: A nurse mentor can have a significant effect both on the quantity and quality of CHW work, allowing them to achieve their potential despite their marginalised status in the health system and their limited prior educational achievement. Supportive supervision is important in enabling the benefit of having a health cadre embedded in marginalised communities to be realised.

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa.

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 contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs' formal employment by the Department of Health.

Health promotion capacity and institutional systems: an assessment of the South African Department of Health.

Health promotion (HP) capacity of staff and institutions is critical for health-promoting programmes to address social determinants of health and effectively contribute to disease prevention. HP capacity mapping initiatives are the first step to identify gaps to guide capacity strengthening and inform resource allocation. In low-and-middle-income countries, there is limited evidence on HP capacity. We assessed collective and institutional capacity to prioritize, plan, deliver, monitor and evaluate HP within the South African Department of Health (DoH). A concurrent mixed methods study that drew on data collected using a participatory HP capacity assessment tool. We held five 1-day workshops (one national, two provincial and two districts) with DoH staff (n = 28). Participants completed self-assessments of collective capacity across three areas: technical, coordinating and systems capacity using a four-point Likert scale. HP capacity scores were analysed and presented as means with standard deviations (SDs). Thematic analysis of verbatim transcripts of audio-recorded group discussions that provided rationale and evidence for scores were conducted using deductive and inductive codes. At all levels, groups revealed that capacity to develop long-term, sustainable HP interventions was limited. We found limited collaboration between national and provincial HP levels. There was limited monitoring of HP indicators in the health information system. Coordination of HP efforts across different sectors was largely absent. Lack of capacity in budgeting emerged as a major challenge, with few resources available to conduct HP activities at any level. Overall, the capacity mean score was 2.08/4.00 (SD = 0.83). There is need to overcome institutional barriers, and strengthen capacity for HP implementation, support and evaluation within the South African DoH.

Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis.

BACKGROUND: Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation. OBJECTIVES: To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification. SELECTION CRITERIA: We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country. DATA COLLECTION AND ANALYSIS: We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings. MAIN RESULTS: Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges. AUTHORS' CONCLUSIONS: Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.

Implementing without guidelines, learning at the coalface: a case study of health promoters in an era of community health workers in South Africa.

BACKGROUND: Internationally, there has been renewed focus on primary healthcare (PHC). PHC revitalisation is one of the mechanisms to emphasise health promotion and prevention. However, it is not always clear who should lead health promotion activities. In some countries, health promotion practitioners provide health promotion; in others, community health workers (CHWs) are responsible. South Africa, like other countries, has embarked on reforms to strengthen PHC, including a nationwide CHW programme - resulting in an unclear role for pre-existing health promoters. This paper examined the tension between these two cadres in two South African provinces in an era of primary health reform. METHODOLOGY: We used a qualitative case study approach. Participants were recruited from the national, provincial, district and facility levels of the health system. Thirty-seven face-to-face in-depth interviews were conducted with 16 health promotion managers, 12 health promoters and 13 facility managers during a 3-month period (November 2017 to February 2018). Interviews were audio-recorded and transcribed verbatim. Both inductive and deductive thematic content analysis approaches were used, supported by MAXQDA software. RESULTS: Two South African policy documents, one on PHC reform and the other on health promotion, were introduced and implemented without clear guidelines on how health promoter job descriptions should be altered in the context of CHWs. The introduction of CHWs triggered anxiety and uncertainty among some health promoters. However, despite considerable role overlap and the absence of formal re-orientation processes to re-align their roles, some health promoters have carved out a role for themselves, supporting CHWs (for example, providing up-to-date health information, jointly discussing how to assist with health problems in the community, providing advice and household-visit support). CONCLUSIONS: This paper adds to recent literature on the current wave of PHC reforms. It describes how health promoters are 'working it out' on the ground, when the policy or process do not provide adequate guidance or structure. Lessons learnt on how these two cadres could work together are important, especially given the shortage of human resources for health in low- and middle-income settings. This is a missed opportunity, researchers and policy-makers need to think more about how to feed experience/tacit knowledge up the system.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation.

BACKGROUND: In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. METHODS: A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. RESULTS: Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. CONCLUSIONS: Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Process evaluation in the field: global learnings from seven implementation research hypertension projects in low-and middle-income countries.

BACKGROUND: Process evaluation is increasingly recognized as an important component of effective implementation research and yet, there has been surprisingly little work to understand what constitutes best practice. Researchers use different methodologies describing causal pathways and understanding barriers and facilitators to implementation of interventions in diverse contexts and settings. We report on challenges and lessons learned from undertaking process evaluation of seven hypertension intervention trials funded through the Global Alliance of Chronic Diseases (GACD). METHODS: Preliminary data collected from the GACD hypertension teams in 2015 were used to inform a template for data collection. Case study themes included: (1) description of the intervention, (2) objectives of the process evaluation, (3) methods including theoretical basis, (4) main findings of the study and the process evaluation, (5) implications for the project, policy and research practice and (6) lessons for future process evaluations. The information was summarized and reported descriptively and narratively and key lessons were identified. RESULTS: The case studies were from low- and middle-income countries and Indigenous communities in Canada. They were implementation research projects with intervention arm. Six theoretical approaches were used but most comprised of mixed-methods approaches. Each of the process evaluations generated findings on whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation. The most important learning was that although process evaluation is time consuming, it enhances understanding of factors affecting implementation of complex interventions. The research highlighted the need to initiate process evaluations early on in the project, to help guide design of the intervention; and the importance of effective communication between researchers responsible for trial implementation, process evaluation and outcome evaluation. CONCLUSION: This research demonstrates the important role of process evaluation in understanding implementation process of complex interventions. This can help to highlight a broad range of system requirements such as new policies and capacity building to support implementation. Process evaluation is crucial in understanding contextual factors that may impact intervention implementation which is important in considering whether or not the intervention can be translated to other contexts.

Performance management in times of change: experiences of implementing a performance assessment system in a district in South Africa.

BACKGROUND: Health systems globally are under pressure to ensure value for money, and the people working within the system determine the extent and nature of health services provided. A performance assessment (PA); an important component of a performance management system (PMS) is deemed important at improving the performance of human resources for health. An effective PA motivates and improves staff engagement in their work. The aim of this paper is to describe the experiences of implementing a PA practice at a district in South Africa. It highlights factors that undermine the intention of the process and reflects on factors that can enable implementation to improve the staff performance for an effective and efficient district health service. METHODS: Data was collected through in-depth interviews, observations and reflective engagements with managers at a district in one of the Provinces in South Africa. The study examined the managers' experiences of implementing the PA at the district level. RESULTS: Findings illuminate that a range of factors influence the implementation of the PA system. Most of it is attributed to context and organizational culture including management and leadership capacity. The dominance of autocratic approaches influence management and supervision of front-line managers. Management and leadership capacity is constrained by factors such as insufficient management skills due to lack of training. The established practice of recruiting from local communities facilitates patronage - compromising supervisor-subordinate relationships. In addition, organizational constraints and the constant policy changes and demands have compromised the implementation of the overall Performance Management and Development System (PMDS) - indirectly affecting the assessment component. CONCLUSION: To strengthen district health services, there should be improvement of processes that enhance the performance of the health system. Implementation of the PA system relies on the extent of management skills at the local level. There is a need to develop managers who have the ability to manage in a transforming and complex environment. This means developing both hard skills such as planning, co-ordination and monitoring and soft skills where one is able to focus on relationships and communication, therefore allowing collaborative and shared management as opposed to authoritarian approaches.

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme.

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.

Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system.

BACKGROUND: Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role. METHODS: Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts. RESULTS: We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery. CONCLUSION: Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.

The place of private care governance in the South African health care system.

BACKGROUND: South Africa essentially has two health care systems-the public and private ones. While much is known about how the public system operates, little work has been conducted on the private sector, perhaps not surprisingly in a profit-oriented, proprietary system. But it is a massive system with its own agenda, interests, and organizations. In this paper, we address the place of private care governance issues, one seen by government as maldistributed, costly, and controlled by few groups and the medical search for profit. METHODS: Using qualitative in-depth interviews, 10 top executive managers of the hospital were asked about its functionality in terms of patient care, profitability, and the practice of governance. Data were analyzed based on themes using NVivo 10 software. RESULTS: The study demonstrates that private hospital functionality finds meaning in board structure, composition and functions, purposeful governance practices as evidenced in well-designed management structures and roles, systematizing governance through the planning of activities, and devising appropriate strategies to deal with both internal and external pressures in the health care environment. CONCLUSION: The study findings establish that shareholders and managers goals converge resulting in the institutionalization and consolidating of relational governance practices in the hospital. Yet other stakeholders appeared to be sidelined.

Multisectoral (in)action: towards effective mainstreaming of HIV in public sector departments in South Africa.

Whilst progress has been made, evidence of effective approaches to improve action on addressing the social and structural drivers of the HIV epidemic remains a priority, to meet the 2030 sustainable development agenda, and to achieve key HIV targets, including the 90-90-90 target and the Treatment as Prevention (TasP) intervention. With a focus on the public sector in South Africa, we critically reflect on the HIV mainstreaming approach, assessing its ability to augment multisectoral action on the response to HIV. We reflect on progress made in mainstreaming HIV in non-health sector departments, exploring factors that have enabled and hindered the process. We also highlight limitations in the adopted approach to mainstreaming HIV in non-health sector departments in South Africa; which currently promotes working in silos and does not encourage collaboration and partnerships. We propose a three-step approach to effective mainstreaming of HIV that will augment multisectoral action. The approach also contributes towards realising the sustainable development agenda of "leaving no one behind" and achieving the national and global targets on HIV that are embedded in collaborative efforts.

Community health workers, recipients' experiences and constraints to care in South Africa - a pathway to trust.

Community health workers (CHWs) affiliated with community-based organisations are central to the implementation of primary health care in district health services in South Africa. Here, we explore factors that affect the provision of and access to care in two provinces - Gauteng and Eastern Cape. Drawing on narratives of care recipients and the CHWs who support them, we illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust. In the study we report here, householders in Gauteng Province had poor access to health care and other services, complicating the impoverished circumstances of their everyday lives. The limited resources available to CHWs hindered their ability to meet householders' needs and for householders to benefit from existing services. CHWs in the Eastern Cape were better able to address the needs of poor householders because of the organisational support available to them. Based on an ethos of integrated and holistic care, this enabled the CHWs to address the recipients' context-related needs, and health and medical needs, while building greater levels of trust with their clients.

Adverse or acceptable: negotiating access to a post-apartheid health care contract.

BACKGROUND: As in many fragile and post-conflict countries, South Africa's social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting. METHODS: Using in-depth interviews with 45 patients and 67 providers, and field observations from twelve health facilities in one rural and two urban sub-districts, we explore access narratives of those seeking and delivering - negotiating - maternal health, tuberculosis and antiretroviral services in South Africa. RESULTS: Although South Africa's right to access to health care is constitutionally guaranteed, in practice, a post-apartheid health care contract is not automatically or unconditionally inclusive. Access barriers, including poverty, an under-resourced, hierarchical health system, the nature of illness and treatment, and negative attitudes and actions, create conditions for insecure or adverse incorporation into this contract, or even exclusion (sometimes temporary) from health care services. Such barriers are exacerbated by differences in the expectations that patients and providers have of each other and the contract, leading to differing, potentially conflicting, identities of inclusion and exclusion: defaulting versus suffering patients, uncaring versus overstretched providers. Conversely, caring, respectful communication, individual acts of kindness, and institutional flexibility and leadership may mitigate key access barriers and limit threats to the contract, fostering more positive forms of inclusion and facilitating easier access to health care. CONCLUSIONS: Building health in fragile and post-conflict societies requires the negotiation of a new social contract. Surfacing and engaging with differences in patient and provider expectations of this contract may contribute to more acceptable, accessible health care services. Additionally, the health system is well positioned to highlight and connect the political economy, institutions and social relationships that create and sustain identities of exclusion and inclusion - (re)politicise suffering - and co-ordinate and lead intersectoral action for overcoming affordability and availability barriers to inclusive and equitable health care services.

A new methodology for assessing health policy and systems research and analysis capacity in African universities.

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.

Mobilisation towards formal employment in the healthcare system: A qualitative study of community health workers in South Africa.

In low and middle-income countries, community health workers (CHWs) play a critical role in delivering primary healthcare (PHC) services. However, they often receive low stipends, function without resources and have little bargaining power with which to demand better working conditions. Using a qualitative case study methodology, we studied CHWs' conditions of employment, their struggle for recognition as health workers, and their activities to establish labour representation in South Africa. Seven CHW teams located in semi-urban and rural areas of Gauteng and Mpumalanga Provinces were studied. We conducted 43 in-depth interviews, 10 focus groups and 6 observations to gather data from CHWs and their representatives, supervisors and PHC facility staff. The data was analysed using thematic analysis method. In the rural and semi-urban sites, the CHWs were poorly resourced and received meagre remuneration, their employment outsourced, without employment benefits and protection. As a result of these challenges, the CHWs in the semi-urban sites established a task team to represent them. They held meetings and caused disruptions in the health facilities. After numerous unsuccessful attempts to negotiate for improved conditions of employment, the CHWs joined a labour union in order to participate in the local Bargaining Council. Though they were not successful in getting the government to provide permanent employment, the union negotiated an increase in their stipend. After the study ended, during the height of COVID-19 in 2020, when the need for motivated and effective CHWs became more apparent to decision makers, the semi-urban-based teams received permanent employment with a better remuneration. The task team and their protests raised awareness of the plight of the CHWs, and joining a formal union enabled them to negotiate a modest salary increase. However, it was the emergency created by the world-wide COVID-19 pandemic that forced decision-makers to acknowledge their reliance on this community-based cadre.

Managing under austerity: a qualitative study of management-union relations during attempts to cut labour costs in three South African public hospitals.

PURPOSE: In this paper, the authors examine the strategies used to reduce labour costs in three public hospitals in South Africa, which were effective and why. In the democratic era, after the revelations of large-scale corruption, the authors ask whether their case studies provide lessons for how public service institutions might re-make themselves, under circumstances of austerity. DESIGN/METHODOLOGY/APPROACH: A comparative qualitative case study approach, collecting data using a combination of interviews with managers, focus group discussions and interviews with shop stewards and staff was used. FINDINGS: Management in two hospitals relied on their financial power, divisions between unions and employees' loyalty. They lacked the insight to manage different actors, and their efforts to outsource services and draw on the Extended Public Works Program failed. They failed to support staff when working beyond their scope of practice, reducing employees' willingness to take on extra responsibilities. In the remaining hospital, while previous management had been removed due to protests by the unions, the new CEO provided stability and union-management relations were collaborative. Her legitimate power enabled unions and management to agree on appropriate cost cutting strategies. ORIGINALITY/VALUE: Finding an appropriate balance between the new reality of reduced financial resources and the needs of staff and patients, requires competent unions and management, transparency and trust to develop legitimate power; managing in an authoritarian manner, without legitimate power, reduces organisational capacity. Ensuring a fair and orderly process to replace ineffective management is key, while South Africa grows cohorts of competent managers and builds managerial experience.

Do Integrated Community Psychiatry Services in Primary Health Care Settings Improve Continuity of Care? A Mixed-methods Study of Health Care Users' Experiences in South Africa.

Background: A community psychiatry service is provided from selected primary health care (PHC) clinics in Gauteng, South Africa. This study described the demographic and clinical characteristics of health care users (HCUs), and explored HCUs' experiences of these services in order to shed light on the challenges of integrating psychiatric services into PHC. Methods: A mixed-methods study was conducted at two PHC clinics, where 384 clinical records were reviewed and 23 HCUs were interviewed. In Clinic-1, community psychiatry services were co-located, while in Clinic-2, these services were physically integrated into the PHC clinic. Results: HCUs from both clinics were generally female (55%), had not completed secondary level education (65%), and were unemployed (80%). Both clinics struggled with medication stock-outs and had the same number of community psychiatry health care providers. Compared to the co-located clinic, the physically integrated clinic had insufficient consultation rooms (compromising confidentiality), higher caseloads (910 compared to 580), more HCUs with psychotic disorders (61% compared to 44%) and a history of missed medication (58% compared to 40%). In both clinics, overall care coordination was limited, although some nurses coordinated care for HCUs. While organisational integration approaches improved the proximity of mental health services, there were challenges in continuity of care within and across health care sites. Conclusion: Coordination and continuity of care were constrained in both clinics, regardless of the organisational integration approaches used. As low- and middle-income countries work towards integrating mental health care into PHC, the implementation of organisational integration approaches should consider physical space, caseload, HCU need, and the inclusion of dedicated providers to coordinate care.

Citizen engagement in national health insurance in rural western Kenya.

Effective citizen engagement is crucial for the success of social health insurance, yet little is known about the mechanisms used to involve citizens in low- and middle-income countries. This paper explores citizen engagement efforts by the National Health Insurance Fund (NHIF) and their impact on health insurance coverage within rural informal worker households in western Kenya. Our study employed a mixed methods design, including a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), six focus group discussions with community stakeholders and key informant interviews (n = 11) with policymakers. The findings reveal that NHIF is widely recognized, but knowledge of its services, feedback mechanisms and accountability systems is limited. NHIF enrolment among respondents is low (11%). The majority (63%) are aware of NHIF, but only 32% know about the benefit package. There was higher awareness of the benefit package (60%) among those with NHIF compared to those without (28%). Satisfaction with the NHIF benefit package was expressed by only 48% of the insured. Nearly all respondents (93%) are unaware of mechanisms to provide feedback or raise complaints with NHIF. Of those who are aware, the majority (57%) mention visiting NHIF offices for assistance. Most respondents (97%) lack awareness of NHIF's performance reporting mechanisms and express a desire to learn. Negative media reports about NHIF's performance erode trust, contributing to low enrolment and member attrition. Our study underscores the urgency of prioritizing citizen engagement to address low enrolment and attrition rates. We recommend evaluating current citizen engagement procedures to enhance citizen accountability and incorporate their voices. Equally important is the need to build the capacity of health facility staff handling NHIF clients in providing information and addressing complaints. Transparency and information accessibility, including the sharing of performance reports, will foster trust in the insurer. Lastly, standardizing messaging and translations for diverse audiences, particularly rural informal workers, is crucial.