Universal Health Coverage

Notwithstanding the progress in the post-apartheid period, the performance of the South African health system has been poor given the country’s level of health expenditure; inequitable access to care and poor health outcomes are persistent problems.

Universal health coverage (UHC; quality care for all irrespective of ability to pay) is a major goal in the post-2015 international agenda. To achieve UHC in South Africa, it is necessary to strengthen the health system’s use of existing resources. Financing, human resources, and governance, within the district health system, constitute the main focus of the original programme, with the addition of access to care as an ‘outcome’. The programme aims to provide new knowledge on how best to strengthen the performance of the South African health system. In line with the SARChI objectives and the WITS 2020 vision to be research intensive university, the programme trains masters, PhD and post-doctoral fellows to the future’s research leaders.

The government has implemented significant reforms to revitalise primary health care and strengthen the district health system. Our research between 2014-2018 documented the progress of these reforms, and showed that the health system, despite these reforms, is under considerable stress. Below we briefly describe our findings from this period, as they form the basis for the next 5 years including the interim period.

Under finance, we documented the challenges that have led to poor public financial management. District officials struggle to estimate the costs of planned activities. The ‘promised' budget envelope is repeatedly cut. The result is a lack of monitoring expenditure, and ‘ownership’ by district officials. Insufficient time to use unspent funds further demotivates staff. Poor IT connectivity and staff incapacity compounds these problems.

Under human resources, we examined the coverage and quality of care provided by the community health worker (CHW) progamme. We found CHW are providing a limited service, with a low coverage of households. Inadequate investment, supervision, training means the potential of the programme is not being achieved.

We examined the potential of lay health workers (LHW) to support integrated chronic disease care, and whether, in particular, they could improve the poor outcomes of hypertension management. While the LHW improved care processes, health outcomes were compromised by unreliable BP machines and insufficient monitoring of outcomes by managers. We documented a rapid increase in the number of patients attending clinics, due to HIV and the non-communicable disease epidemic, placing considerable pressure on an already over stretched system.

We examined the contribution of the new district-based specialist teams to clinical governance. A mixed picture emerged of the teams reshaping clinical practice; the interconnectedness of quality improvement with other systemic processes (recruitment, procurement of equipment) influenced the (in)effectiveness of this new cadre.

Under governance, we examined the day-to-day practices of accountability between staff and their managers and highlighted the unintended consequences of overly bureaucratic accountability, and the importance of supportive employee-manager relationships to facilitate agency and problem-solving.

Under access, we examined how the under-resourced, hierarchical health system generates barriers that prevent patients accessing care. Frontline health workers are ‘street level bureaucrats’ who decide how policy is implemented; their behaviour perpetuates a culture of disempowerment – ongoing structural violence – for citizens. Respectful, empathetic practices are vital to improving access, and the restoration of justice and health.

Building on the first five years, we will continue our work on finance, human resources, governance and access. Our new activities are to: a) assess the feasibility and effectiveness of an electronic patient record system to improve monitoring of patient outcomes; b) to examine the feasibility of collaboration between specialists and PHC to improve access and the quality of care; and c) synthesise evidence on factors influencing strategic purchasing in middle income countries

Prof Frances Griffiths was appointed as the SARCHi chair in early 2020, replacing Prof John Eyles

Please contact either Prof Jane Goudge (jane.goudge@gmail.com), or Prof Frances Griffiths (f.e.griffiths@warwick.ac.uk)