Background

Research attention continues to grow around the goal of universal health care coverage. How best to improve risk pooling and ensure that the most socially disadvantaged receive priority in having their health care costs met are questions yet to be answered, particularly within the African context where very few countries have achieved universal health systems.

South Africa is introducing National Health Insurance (NHI) which includes the proposal that formal sector workers will make mandatory contributions which will be pooled with allocations from general tax revenue. Tanzania is integrating existing health insurance schemes for formal and informal sector workers under the management of a single insurer. 

Objectives

Translating such health financing reforms into intended changes ‘on the ground’ requires a well functioning monitoring and evaluation system which provides data that allow policies to be improved over time, and consequently strengthen their potential to achieve universal health coverage. This research supports these reforms on universal coverage in South Africa and Tanzania (UNITAS) by monitoring and evaluating the policy processes, and communicating findings regularly to policy makers and health care implementers. 

Specifically, it seeks to: 
 - track policy formulation and planning for implementation; 
 - monitor the progress of policy implementation at both the national and district levels, identifying
   implementation problems and serving as an ‘early warning system’ for policy makers and implementers;
 - evaluate the impact of interventions aimed at progressing towards the goal of universal coverage; 
 - engage with policy makers and implementers about the research findings throughout the study period; 
 - synthesise the results from the studies in the two countries, and compare these with experiences in other
   countries. 

At a district level, the South African team is engaged in three NHI pilot sites, focusing on the early implementation of policy innovations such as District Clinical Specialist Teams, GP contracting, management strengthening and strengthening of the maternal referral system. Researchers are exploring how these reforms intersect with health worker motivation, patient satisfaction and quality of care delivered. Using a theory of change approach, they are administering a set of structured tools and conducting in-depth qualitative work to better understand these policy processes.

The five-year project started in 2011. Following a successful first round of quantitative and qualitative data collection in 2013/14, in 2015, we embarked on a second round of data collection in the three sites, resulting in a total of 256 in-depth interviews carried out with managers at district, sub-district and facility levels, and frontline nurses, doctors (private and public sector), and data capturers. In 2015, we also carried out a second round of surveys with (i) patients on their experiences of chronic and maternal services (total 5,622 patients) and (ii) nurses about motivation (total 355 nurses), and (iii) assessed quality of care in 41 participating facilities. In March 2016, we held a workshop to share emerging findings with district managers from the three sites and enable a sharing of experiences. Further findings are expected in 2016. 

The South African work is funded by the European Union and the South African Department of Science and Technology. 

Partnerships

Health Economics Unit, South Africa
Centre for Health Policy, South Africa
Africa Centre for Health and Population Studies, South Africa
Ifakara Health Institute, Tanzania
Institute of Development Studies, Tanzania
London School of Hygiene & Tropical Medicine
Institute of Tropical Medicine, Belgium

Capacity Building

The project has a strong capacity development element, offering an opportunity for a PhD student, a series of workshops on qualitative data analysis, and training of field workers and piloting of survey tools. CHP's Chair for Health Policy and Systems Research within the South African Research Chairs Initiative (SARChI), Professor John Eyles, is helping to build capacity within the project. Networking opportunities are an ongoing feature. 

Publications 

Oboirien KO, Goudge J, Harris B, Eyles J, Orgill M, Chimbindi N, Michel J. Conceptualising health teams in decentralised health systems - a case of district-based clinical specialist teams in South Africa. Poster presentation, 3rd Global Health Symposium, Cape Town, October 2014.