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

Telemedicine and Online Platforms as an Opportunity to Optimise Qualitative Data Collection, Explore and Understand Disease Pathways in a Novel Pandemic Like COVID-19

This article explores digital technology used in the health sector today. There are several ways digital technology is being used for quantitative study aims during the current COVID-19 Pandemic e.g. online symptom checkers. The knowledge gap in COVID-19 as in all novel conditions, consist of both quantitative and qualitative attributes. Digital tool use is prevalent during the COVID-19 Pandemic but most of the data being collected is quantitative in nature. We therefore recommend taking advantage of this telemedicine era and explore optimisation of qualitative data collection, for the purpose of gaining a better understanding of the phenomenon

The challenges experienced by non governmental organisations with regard to the roll-out of antiretroviral drugs in KwaZulu-Natal

The purpose of this study is to explore and describe the challenges experienced by non-governmental organisations with regards to the roll-out of ART, with an aim to facilitate strategy development to overcome the challenges and enhance the success of ART rollout by the NGOs. A qualitative, exploratory and descriptive study was conducted. Data collection was done using in-depth semi-structured interviews. Three groups of respondents participated in the study; programme coordinators who directed and supervised ART programmes; doctors who were responsible for prescribing, monitoring and dealing with ART complications; and registered nurses who were responsible for monitoring, referring and providing nursing care to patients on ART. The findings revealed five broad areas of challenges namely; challenges related to sustainability, challenges related to adherence, challenges related to health systems, challenges related to stigma and challenges related to behavior. Of interest were the surge of whoonga and the infiltration of ART roll-out by crime and violence.Health StudiesM.A. (Public Health

Poverty Is Not Poverty: The Reality on the Ground Including the Rural-Urban Divide and How We Can Turn the Tide on NCDs

Cardiovascular diseases (CVDs) tend to occur in younger sub-Saharan African (SSA) populations, about 20 years earlier as compared to high income countries (HIC). Weak health systems and infrastructure, scarce cardiac professionals, skewed budget away from non-communicable diseases (NCD), high treatment costs and reduced access to health care. On top of that, hypertension diagnosis, treatment and control are low, less than 40%, less than 35% and 10-20% respectively. SSA has 23% of the worlds rheumatic disease, while 80% of CVD deaths occur in low to middle income countries. Poverty is not poverty. The rural–urban divide is one reality that has to be acknowledged among others, particularly in Africa. Being poor, while owning land and having the possibility to grow crops and rear livestock, goats and chickens, is different from being an unemployed young man or young woman, renting one room, in a crowded township with dilapidated infrastructure, intermittent or untreated water and surrounded by leaking sewers. Understanding the dynamics in different contexts is important for us to identify and address the different challenges affecting health in general, and heart health of people in these contexts in particular. For example, the detection, treatment and control rates of hypertension are higher in semi-urban as compared to rural areas. Detection rates for both men and women are suboptimal particularly in rural areas. Diet, sedentary life, loneliness and stress, insecure environments rather and unsafe places to walk are issues more common in urban settings. The conditions in which people are born, live, grow and work affect their health. The rural conditions are very different from the urban ones. The quality of air, access and types of food, stress levels, isolation, loneliness and fear not to mention violence, vary. All these factors affect heart health in one way or the other. Addressing heart health issues therefore ought to be context specific. The burdens might be treble or more for some -economically, environmentally (climate change, political instability), socially and historically-apartheid and colonialism

A Utility Framework for COVID-19 Online Forward Triage Tools: A Swiss Telehealth Case Study.

The SARS-CoV-2 pandemic caused a surge in online tools commonly known as symptom checkers. The purpose of these symptom checkers was mostly to reduce the health system burden by providing worried people with testing criteria, where to test and how to self-care. Technical, usability and organizational challenges with regard to online forward triage tools have also been reported. Very few of these online forward triage tools have been evaluated. Evidence for decision frameworks may be of particular value in a pandemic setting where time frames are restricted, uncertainties are ubiquitous and the evidence base is changing rapidly. The objective was to develop a framework to evaluate the utility of COVID-19 online forward triage tools. The development of the online forward triage tool utility framework was conducted in three phases. The process was guided by the socio-ecological framework for adherence that states that patient (individual), societal and broader structural factors affect adherence to the tool. In a further step, pragmatic incorporation of themes on the utility of online forward triage tools that emerged from our study as well as from the literature was performed. Seven criteria emerged; tool accessibility, reliability as an information source, medical decision-making aid, allaying fear and anxiety, health system burden reduction, onward forward transmission reduction and systems thinking (usefulness in capacity building, planning and resource allocation, e.g., tests and personal protective equipment). This framework is intended to be a starting point and a generic tool that can be adapted to other online forward triage tools beyond COVID-19. A COVID-19 online forward triage tool meeting all seven criteria can be regarded as fit for purpose. How useful an OFTT is depends on its context and purpose

Relations as patterns: bridging the gap between OBO and OWL.

BACKGROUND: Most biomedical ontologies are represented in the OBO Flatfile Format, which is an easy-to-use graph-based ontology language. The semantics of the OBO Flatfile Format 1.2 enforces a strict predetermined interpretation of relationship statements between classes. It does not allow flexible specifications that provide better approximations of the intuitive understanding of the considered relations. If relations cannot be accurately expressed then ontologies built upon them may contain false assertions and hence lead to false inferences. Ontologies in the OBO Foundry must formalize the semantics of relations according to the OBO Relationship Ontology (RO). Therefore, being able to accurately express the intended meaning of relations is of crucial importance. Since the Web Ontology Language (OWL) is an expressive language with a formal semantics, it is suitable to de ne the meaning of relations accurately. RESULTS: We developed a method to provide definition patterns for relations between classes using OWL and describe a novel implementation of the RO based on this method. We implemented our extension in software that converts ontologies in the OBO Flatfile Format to OWL, and also provide a prototype to extract relational patterns from OWL ontologies using automated reasoning. The conversion software is freely available at http://bioonto.de/obo2owl, and can be accessed via a web interface. CONCLUSIONS: Explicitly defining relations permits their use in reasoning software and leads to a more flexible and powerful way of representing biomedical ontologies. Using the extended langua0067e and semantics avoids several mistakes commonly made in formalizing biomedical ontologies, and can be used to automatically detect inconsistencies. The use of our method enables the use of graph-based ontologies in OWL, and makes complex OWL ontologies accessible in a graph-based form. Thereby, our method provides the means to gradually move the representation of biomedical ontologies into formal knowledge representation languages that incorporates an explicit semantics. Our method facilitates the use of OWL-based software in the back-end while ontology curators may continue to develop ontologies with an OBO-style front-end