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Research Overview

The Centre for Health Policy (CHP) is one of only a few health policy research units in South Africa and in Africa. We actively seek to contribute to excellence in health policy and systems research . With over 20 years of research experience, our primary research focus is to support the development of the South African health system. We conduct independently-funded research projects and commissioned research for the South African government and other South African organisations.

Current Research Projects Include

Examining the policy context and implementation of community health worker programmes in South Africa: Implications for Universal Health Coverage reforms: Although South Africa is in the process of health system reforms towards universal health coverage, the policy position regarding the role of community health workers (CHWs) as part of this process remains unclear. Moreover, although they make up one third of the health workforce in the country, they remain outside of the public service and in unstable employment. This study aims explore the policy context and implementation of the national CHW programme, particularly focusing on the governance model of the CHW programme and CHWs’ relationships with health professionals as part of their integration into the health care system. The findings will generate knowledge on the strengths and weaknesses of implementation of the programme and on the implications of these aspects for Universal Health Coverage reforms. This three year study is funded by the South African Medical Research Council’s Self-Initiated Research grant. The research leader is Dr Nonhlanhla Nxumalo: +27 11 717 3432; Email: nonhlanhla.nxumalo@wits.ac.za

SARChI Chair on Health Policy and Systems Research (Universal Health Coverage) : South Africa's health system is sub-optimal compared to other countries with similar levels of health expenditure. CHP has a chair for Health Policy and Systems Research whose programme focuses on universal health coverage (UHC). The chair is Professor Frances Griffiths. Please contact either Jane Goudge (email: jane.goudge@gmail.com) or Frances Griffiths Email: f.e.griffiths@warwick.ac.uk

Strategic Purchasing in Healthcare

Several millions of people experience financial hardship after accessing medical care through out-of-pocket payments and catastrophic health spending in low-middle-income settings. As a result, a renewed campaign to implement policy reforms will offer some financial protection in healthcare utilisation. Despite the many research findings in less developed geopolitical regions, there is still inadequate attention to effectively prioritising, building consensus, and balancing policy and health politics towards universal health coverage (UHC). The growing concerns garnered multidisciplinary researchers from the UK, US, East, Western and South Africa to seek to understand the issues therein. Strategic purchasing (SP) in healthcare has been a timely approach, tool, and guiding principle towards achieving universal health coverage. Indeed, low-middle-income countries have multiple challenges relating to 1) government stewardship; 2) information management systems; 3) health benefits package design; 4) patient empowerment and provider accountability arrangements; 5) provider payment methods; 6) political economy; and 7) the management and alignment of tensions between these elements. These dimensions have more significant implications on functional healthcare delivery machinery and financing pathways mainly to ensure quality, affordable and efficient healthcare delivery.

Strategic initiatives in this direction were the work of RESYST (Resilient and Responsive Health Systems) consortium in Kenya, Nigeria, Thailand, Vietnam. The study revealed critical factors influencing system functionality. Following this, we have adopted the Sanderson et al. theoretical framework [see Sanderson, J., Lonsdale, C., & Mannion, R. (2019). What’s needed to develop strategic purchasing in healthcare? Policy lessons from a realist review] to understand the varied geopolitical and contextual factors hinging on health system performance improvement and provider payment mechanisms. Based on these reforms, the current project on “Strategic purchasing in healthcare” aims to systematically review and synthesise the evidence from middle-income countries (MICs) for enhanced health policy decisions. We aim to proffer lessons for efficient, quality, improved financial protection, and equitable distribution of health services in MICs. We also aim to highlight strategic purchasing mechanisms in ten countries as case studies - Ghana, Kenya, Iran, Vietnam, Philippines, Mexico, Thailand, Nigeria, China and Indonesia. The Research leader is Joshua Sumankuuro. Tel: 050 007 2754; Email: joshsumankuuro@gmail.com

SOPRIMA (Soweto Primary Care Study)

The private sector provides a large proportion of health services in many low- and middle-income countries (LMICs), particularly for primary health care (PHC), even for poor patients. But the role of the private sector in expanding universal health coverage (UHC) in LMICs remains contentious. Understanding the role and impact of private sector provision is especially important in South Africa as policy proposals for achieving UHC promote the contracting of private providers to expand access to quality PHC for uninsured patients. There are concerns about the current performance of private PHC providers, and the functioning of the PHC market, with little empirical evidence to inform current debates.

The aim of this study is to undertake a detailed empirical investigation of the market for public and private primary care services. It will focus on the determinants of provider performance on the one hand, and demand for private services from uninsured cash-paying patients on the other. The study will be conducted in Soweto, Johannesburg, and it will include five components. Firstly, we will undertake a detailed description of the local PHC market through a census, mapping and interviews of all providers, an analysis of market concentration, and investigation of the strategies which private providers use to compete for patients. Secondly, using standardised patients (SPs), we will compare the performance of private and public providers in terms of accessibility to services, technical quality of care and cost of treatment recommended. Thirdly, we will establish the relationship between competition and performance outcomes, testing if greater competition leads to better outcomes. Fourthly, using linked data on provider performance and cost, we will investigate if accessibility, quality and cost are important determinants of the demand for services by uninsured patients. Finally, in a small randomised pilot, we will test study how populations would react to the introduction of subsidised access to private services, and explore if information about quality influences demand.

The study will provide important information on whether the private PHC market can contribute to better health system access, quality and efficiency. The results are relevant to many LMICs trying to expand UHC within mixed health care systems. This study is funded by the UK Health System Research Initiative (HSRI). The research leader is Dr Duane Blaauw: +11 717 3422 Email: duane.blaauw@wits.ac.za


IMAGENE is an acronym derived from the aim of the study, namely Investigating the empirical relationship among health facility MAnagement and GovernancE , Nursing practice Environment, health workforce outcomes and quality of care. IMAGENE focuses on primary health care (PHC) facilities and aims to investigate the three-way relationship among (1) health facility management and governance; (2) health workforce outcomes, specifically nurses’ job satisfaction and intention to leave; and (3) quality of care, specifically patient perceptions of the responsiveness of the health system, and quality of care provided to individuals with diabetes and hypertension. We will conduct a range of statistical analyses, such as structural equation modelling (SEM), and regression analyses to investigate these relationships.

This study involves facility managers and frontline nurses working in clinics in Gauteng, Limpopo, Mpumalanga and North West provinces. We hope that the study will generate evidence that will contribute to solutions to address nursing challenges and to improve quality of patient care at PHC facilities. To date, the study has made satisfactory progress. A number of research instruments has been developed for the different components of the study and these include: (1) a PHC facility manager questionnaire; (2) a frontline nurses’ questionnaire; (3) a questionnaire measuring patient’s experiences of the health system responsiveness; and (4) a record audit tool to measure the health care provided to people with diabetes and hypertension. The complexity of the study necessitated a number of consultative meetings: firstly, with biostatisticians to ensure that the structural equation modelling would be done correctly; secondly with health systems researchers to examine the assumptions and relationships among the various components; thirdly with the health facility managers to ensure that the instrument measures relevant and appropriate aspects.

The study is funded through the NRF Thuthuka Grant (Post-PhD track) and the University Research Council (URC). The research leader is Dr Prudence Ditlopo. Tel: +27 11 717 3433; Email: prudence.ditlopo1@wits.ac.za

Recent Research Projects Include

Batlhokomedi (Carers) study: South Africa is currently shifting from multiple NGO-led, donor-funded CHW programmes to a national government programme, and is intending to scale up teams of CHWs to provide comprehensive, integrated, community-based care. In this study, CHP will develop an evidence-informed CHW service model based on the key elements of the South African CHW policy, local circumstances and constraints with particular reference to affordability, and an understanding of the literature on barriers and facilitators. It will implement and evaluate this model (before and after design) in two pilot sites in the Sedibeng Health District. The findings of the study will provide practical lessons for implementing a CHW programme at scale in South Africa and similar settings in other low and middle income countries.

This study is funded by the UK Medical Research Council. The research leader is Prof. Jane Goudge. Tel: +27 11 717 3425; jane.goudge@gmail.com

Siyaqinisa (We strengthen together) Learning Site: CHP is involved in a three year study known as the ‘Siyaqinisa’ (We strengthen together) District Learning site to support the Sedibeng District Management with an Organisational Development process involving researchers and colleagues to strengthen leadership capacity to improve staff engagement and team effectiveness. The research leader is Dr Nonhlanhla Nxumalo: +27 11 3432; Email: nonhlanhla.nxumalo@wits.ac.za

The Nkateko Study : CHP is undertaking a cluster randomised controlled trial on treating hypertensionin rural South Africa to test the effectiveness of a new clinic-based lay health worker. This project aims to supplement government initiatives and enhance integrated chronic care. This three year trial is a collaboration of the School of Public Health and University of Warwick (UK) with financial support from MRC (UK).The research leader is Prof Jane Goudge. Tel: +27 11 717 3425; jane.goudge@gmail.com

Resilient and Responsive Health Systems : This international consortium aims to encourage policy and management changes that enhance the resilience and responsiveness of health systems in low and middle income countries to promote health and health equity and reduce poverty. Dr Prudence Ditlopo is the focal point person for this project. Tel: +27 11 717 3433; Fax: +27 11 717 3429;
Email: prudence.ditlopo@wits.ac.za

Mainstreaming a health systems approach to delivery of maternal health services : This trans-disciplinary research project in Rwanda and South Africa focuses primarily on gathering practical knowledge for improving service organisation and delivery for maternal health. The research leader is Dr Duane Blaauw. Tel: +27 11 717 3422; Fax: +27 11 717 3429;
Email: duane.blaauw@wits.ac.za

Past Research Projects Include

Universal Health Care Coverage in Tanzania and South Africa : South Africa is introducing National Health Insurance through proposed mandatory contributions by formal health care sectors. Tanzania is integrating existing health insurance schemes for formal and informal sector workers under a single insurer. This research aims to support these reforms intended to achieve universal coverage by monitoring and evaluating the policy processes.

The Consortium for Health Policy and Systems Analysis in Africa : The development of sustained African health policy and systems research capacity requires the consolidation and strengthening of relevant research and educational programmes as well as the development of stronger engagement between the policy and research communities. This consortium addressed these issues in 2011-2015.

Consortium for Research on Equitable Health Systems : CHP worked with institutions in India, Thailand, Kenya, Tanzania, Nigeria and the United Kingdom to increase what we know about how to strengthen health systems policies and interventions ways which preferentially benefit the poorest. This five-year collaborative project was funded by DFID.

Diagonal Interventions to Fast Forward Enhanced Reproductive health : This project worked on improving sexual and reproductive health services by defining packages of SRH services and models for delivery that meet the needs of all women and impact positively on their health.

The Multilateral Association for Studying health inequalities and enhancing north-south and south-south CO-operaTion strived to create links between three world regions (Europe, Africa and Latin America) for addressing maternal and child health and health inequalities in low- and middle-income countries.

Research on the State of Nursing : This research project explored the state of nursing policies, practice and management in South Africa. It was a four-year research programme funded by the Atlantic Philanthropies to develop and strengthen the research evidence for improved nursing policy development and practice.

Researching Access to Health Care :

Improving and securing access to good quality health care is a central and cross-cutting preoccupation of CHP's work.

Strategies for Health Insurance for Equity in Less Developed Countries :

This was a collaborative project with the Health Economics Unit at the University of Cape Town underway with European Union funding in South Africa, Ghana (Ghana Health Research Unit) and Tanzania (Ifakara Health Research and Development Centre) and includes European collaborators (London School of Hygiene and Tropical Medicine; Karolinska Institute, Sweden; and Royal Tropical Institute, Netherlands).

General enquiries: Contact Jane Goudge, Email:jane.goudge@gmail.com

Research Themes

Alcohol and Health

Health Workforce

HIV and Health Systems

Maternal and Early Child Support Grant

Socially Excluded Populations