Challenges facing the implementation of community and home-based early childhood development programmes for vulnerable children aged 0-4 years in the Western Cape and Eastern Cape, South Africa

This thesis examined the challenges facing the public sector implementation of community and home based early childhood development (ECD) programmes for vulnerable children aged 0-4 years in the Western Cape and Eastern Cape, South Africa. A qualitative case-study approach was used. The unit of analysis was the Department of Social Development (DoSD) as they are the public sector funders of non-profit organizations (NPOs) who deliver these services. The thesis included a literature review, a policy document review, and the collection and analysis of six interviews with officials involved in implementation of the National Integrated Plan for Early Childhood Development 2005–2010 (NIP for ECD). The data was organised using organizational coding and conceptually ordered displays, and analysed using the 5-C protocol of implementation as the overarching conceptual framework. The findings of the study showed that the main challenges facing the DoSD in the implementation of community and home-based ECD are: (1) Human resources that are stretched to capacity at the provincial and district level, primarily social workers who are unable to manage current services; (2) inadequate line item funding to scale up the provision of services in order to fulfill the mandate of the NIP for ECD (2005); (3) a shortage of NPOs to scale up services, current service providers already suffer with their own capacity constraints; (4) a lack of norms and standards for funding community and home-based ECD; (5) the social sector currently prioritizes centre-based ECD (in terms of funding and training) over community and home-based ECD. Another critical shortcoming is a lack of information regarding provision of services and a lack of South African evidence based research to assist implementers in making rationing decisions at the provincial level. Officials at the DoSD however display commitment to, and recognize the need to, support community and home-based ECD. The officials are however limited in doing so due to capacity constraints

Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province

BACKGROUND: Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes. METHODS: Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province. RESULTS: Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of ‘community dialogues’ and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation. CONCLUSIONS: These features resonate with the deliberative, multi-level and context sensitive approaches described as the “simple rules” of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further information.Web of Scienc

School health in South Africa : reflections on the past and prospects for the future

This in-depth report examines the South African school health service, and considers its design and intentions against international models. Across countries of all income levels, the dual role of school health in contributing to both the health and education status of children has been recognised. The paper provides an overview of school health services and the integrated school health policy (ISHP) in particular: its evolution and current implementation progress. The review emphasises need for close collaboration between health and education, regardless of which department leads. It also highlights challenges with modes of delivery, resource constraints, and inter- and intra-sectoral relationships

Health policy and systems research: needs, challenges and opportunities in South Africa – a university perspective

The last two decades have seen growing international recognition of the need to strengthen health systems in order to deliver already available, cost-effective health interventions. This chapter describes the parallel global growth of the field of Health Policy and Systems Research (HPSR) and outlines what this field of research is and what it is not. The chapter also clarifies how HPSR can contribute to strengthening health systems. The particular relevance of HPSR in SA is discussed, given the range of health system transformation initiatives in place. Drawing both on an HPSR capacity assessment conducted in three universities and discussions with a wider group of researchers and health system managers, the chapter also considers the existing assets for and challenges facing the development of the field in South Africa. It closes with suggested strategies and priorities for developing and building capacity in this field nationally.CHEPSAAWeb of Scienc

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district.

BACKGROUND: As part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system. METHODS: We conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs. RESULTS: The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting. CONCLUSION: District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces

Political Prioritisation for Performance-Based Financing at the County Level in Kenya: 2015 to 2018

Background: Performance based financing was introduced to Kilifi county in Kenya in 2015. This study investigates how and why political and bureaucratic actors at the local level in Kilifi county influenced the extent to which PBF was politically prioritised at the sub-national level. Methods: The study employed a single-case study design. The Shiffman and Smith political priority setting framework with adaptations proposed by Walt and Gilson was applied. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings. Results: In the period 2015-2018, the political prioritisation of PBF at the county level in Kilifi was influenced by contextual features including the devolution of power to sub-national actors and rigid public financial management structures. It was further influenced by interpretations of the idea of ‘pay-for-performance’, its framing as ‘additional funding’, as well as contestation between actors at the sub national level about key PBF design features. Ultimately PBF ceased at the end of 2018 after donor funding stopped. Conclusion: Health reformers must be cognisant of the power and interests of national and sub national actors in all phases of the policy process, including both bureaucratic and political actors in health and non-health sectors. This is particularly important in devolved public governance contexts where reforms require sustained attention and budgetary commitment at the sub national level. There is also need for early involvement of critical actors to develop shared understandings of the ideas on which interventions are premised, as well as problems and solutions

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa.

BACKGROUND: In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others. METHODS: A multiple case study design comprising three cases was conducted. Data collection in 2012 - early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts. RESULTS: Managers valued the national Minister of Health's role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved. CONCLUSION: Those driving reform processes from 'the top' must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion

Conceptualising quality early childhood education:Learning from young children in Brazil and South Africa through creative and play-based methods

Early childhood has increasingly been acknowledged as a vital time for all children. Inclusive and quality education is part of the United Nations Sustainable Development Goals, with the further specification that all children have access to quality pre-primary education. As early childhood education (ECE) has expanded worldwide, so have concerns about the quality of ECE provision, including whether its pedagogy is culturally meaningful and contextually appropriate. While these issues are much debated in themselves, often missing is a key stakeholder group for such discussions: young children. Young children have critical insights and perspectives of key importance for ensuring quality ECE. This article addresses how quality ECE can be conceptualised, through reflections on creative and play-based methods with young children, used in a cross-national project titled Safe Inclusive Participative Pedagogy. The article draws on community case studies undertake by two of the country teams in Brazil and South Africa. In contexts where children's participation is not necessarily familiar in ECE settings nor understood by key stakeholders, the fieldwork shows that children can express their views and experiences through using creative and play-based methods. We argue that these methods can become part of a critical pedagogy through ECE settings, where ECE practitioners, children and other key stakeholders engage in ongoing, challenging and transformative dialogue. In turn, critical pedagogy has the potential to strengthen local practices, challenge top-down approach, and foster quality safe, inclusive, participative early years education.</p

Assessment of capacity for health policy and systems research and analysis in seven African universities: results from the CHEPSAA project

The importance of health policy and systems research and analysis (HPSR+A) is widely recognized. Universities are central to strengthening and sustaining the HPSR+A capacity as they teach the next generation of decision-makers and health professionals. However, little is known about the capacity of universities, specifically, to develop the field. In this article, we report results of capacity self- assessments by seven universities within five African countries, conducted through the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA). The capacity assessments focused on both capacity ‘assets’ and ‘needs’, and covered the wider context, as well as organizational and individual capacity levels. Six thematic areas of capacity were examined: leadership and governance, organizations’ resources, scope of HPSR+A teaching and research, communication, networking and getting research into policy and practice (GRIPP), demand for HPRS+A and resource environment. The self-assessments by each university used combinations of document reviews, semi-structured interviews and staff surveys, followed by comparative analysis. A framework approach, guided by the six thematic areas, was used to analyse data. We found that HPSR+A is an international priority, and an existing activity in Africa, though still neglected field with challenges including its reliance on unpredictable international funding. All universities have capacity assets, such as ongoing HPSR+A teaching and research. There are, however, varying levels of assets (such as differences in staff numbers, group sizes and amount of HPSR+A teaching and research), which, combined with different capacity needs at all three levels (such as individual training, improvement in systems for quality assurance and fostering demand for HPSR+A work), can shape a future agenda for HPSR+A capacity strengthening. Capacity assets and needs at different levels appear related. Possible integrated strategies for strengthening universities’ capacity include: refining HPSR+A vision, mainstreaming the subject into under- and post-graduate teaching, developing emerging leaders and aligning HPSR+A capacity strengthening within the wider organizational development.Web of Scienc