Background
Defining implementation
Justification of contextual interaction theory
Description of CIT
Methods
Study aim
Research setting and sampling
The intervention
Study design and data collection
Data analysis
Justification of two actor scenario
Policy Maker Actors | Linking actor | Implementing actors | Target actors |
---|---|---|---|
National DOH Provincial DOH | NGOs providing training | District, subdistrict and PHC staff | Patients and communities |
Study actors
Policy Maker Actors | Implementing actors |
---|---|
National DOH Provincial DOH | District Managers and District staff Subdistrict managers and staff PHC facility staff |
Research participants
Health System Level | Role | Contextual mapping | Round 1 | Round 2 | Total |
---|---|---|---|---|---|
Provincial | Policy maker -making sure NHI policies are carried out | 1 | 1 | 1 |
3
|
District | Policy implementers ranging from district manager, programme managers, district clinical specialist team, Emergency rescue service manager and PHC supervisors with policy implementation responsibilities including the PHC supervision manual | 1 | 5 | 4 |
10
|
Subdistrict | Policy implementers at subdistrict level ranging from CEOs managers, nurses and doctors implementing policies aimed at UHC as well as providing direct patient care | 3 | 12 | 8 |
23
|
PHC facility | Policy implementers including operational managers and staff in PHC facilities implementing policies aimed at UHC as well as providing direct patient care | - | 19 | 16 |
35
|
Total |
5
|
37
|
29
|
71
|
Results
Motivation
But I’ve been here for a long time. Uh it`s just the environment that we’re working in with all these shortages. You can see, it’s frustrating-PHC Manager round 1Yes, the staff morale is gone, and you see the people are leaving so quickly, some people come here, get appointed, and after two months they decide to leave. You see all the doctors that were appointed in January, there is about nine of them, already gone- sub district Manager round 2
Information
I have never heard of obstetric ambulance. It would be great to have them but I have never heard about them or seen them here-PHC Nurse round 2I had not heard of this before, and there wasn’t anything in writing from National, so it was a big jump in faith. But we’ve gotten used to it and we are doing it. We were conservative about it. They said employ fifty and we then ended up with thirty-two, which I think is okay- it’s been quite difficult. We have had to think up things. -District Actor round 2
Power
The budget is not with the district, the budget is with the head office. I have no power over that, but there are things we need that impact negatively on the quality of care. I cannot do anything- District Actor round 1Some of the problems are supposed to be resolved by the district. Our hands are tied. I could solve some of the problems but I have no power, so I have to refer to the district-PHC Manager round 2
Resources
And then supplies, we are running out of supplies. So how are we going to meet NHI standards, we haven’t got the supplies? Like in our clinic for instance, we haven’t even got anti-bacterial soap-sub-district Manager round 1We don’t even have a defibrillator but that is a requirement of the current national core standards. We do not have the basic equipment-PHC Manager round 2Because the resources you need are not available to implement those things. We are talking about NHI for the past two, three years now- you see. But very little implementation, just talking-particularly with the additional resource needed. So, NHI is good for the standard of care but to implement those you need the resources. It says like for the medical ward, you need these number of square metres between beds or this number of beds in a ward. And currently we are far behind from complying with that standard. -sub district Manager round 1
Interactions
I mean they tell us there is an audit. Clean the clinic. We have to clean the clinic despite sending them several reports that we do not have a cleaner. I told them it is not in my job description to wash the walls and make the clinic look nice so National and Province can come here and say the clinic looks beautiful. They must see it for what it is. I will not do that. It is not in my job to clean-PHC Nurse round 2You understand, because next week we’re having an audit. That is why they are now sending us policies in bits and pieces. No, I will just leave it as it is. Why must I cover up? Every time we get audits, our facility covers up for a lot of things to say, we are fine, we are okay. I can tell you, we’re not okay, things are not working-sub district Manager round 2
Core CIT construct | Policy maker | Implementer |
---|---|---|
Information | Fully informed and aware of NHI policies and intended benefits | District and senior staff aware but many frontline actors have little understanding of their roles [10] |
Resources | Some actors had access to budgets | |
Motivation | Some actors were new appointees to drive the NHI policy implementation and were generally motivated | District and subdistrict actors were demotivated by dysfunctional systems particularly supply chain [10, 26]. Facility staff were demotivated due to lack of resources, dysfunctional systems including employee performance and management systems and lack of support from above [10, 26] Facility staff were demotivated due to being caught in between with pressure from both patients and supervisors [10, 26] Facility actors were demotivated due to longstanding problems that do not get resolved [10, 26] |
Power | Some actors had access to budgets and power to appoint personnel Other functions are only advisory in nature e.g., NHI project Manage | |
Interactions | Actors were housed in one building and had regular meetings though many posts vacant | PHC supervision not frequent enough [10, 26] PHC supervisor not able to solve facility challenges [10, 26]. PHC supervision seen as policing and not supportive [10, 29] National core standards failing facility staff for issues beyond their control [10, 26] According to Elmore, authority relationships affect implementation [45] |
Discussion
Adding and highlighting a fourth construct leadership (meaning supervisor supervisee interactions)
The critical role of leadership in implementation
Leadership definition
Contribution to the literature
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Empirical research discloses implementation as a significant impediment to change. Understanding what facilitates or hinders implementation is critical as many countries strive towards universal health coverage: these findings advance our understanding of how to effectively implement UHC policies in a context similar to South Africa
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Policy implementation is a complex process. A theoretical framework is a lens through which policy implementation can be understood. The literature is awash with many implementation theories. Understanding implementation theories that capture implementation experiences of actors in a particular context aids in reducing policy-practice gaps. Our study has demonstrated the utility of CIT in UHC policy implementation context-South Africa
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Contextual Interaction Theory was developed in a water governance and policy implementation context. To the best of our knowledge, this is one of the first studies that applied CIT in a UHC policy implementation context, assessing its utility and identifying any short-comings. We identified leadership as a critical factor, actors repeatedly alluded to as affecting implementation. This factor however is not explicitly identified as a central tenet in CIT, hence our proposal to include this and improve the utility of CIT in contexts like South Africa. Adding leadership to these central tenets is our proposal to make CIT useful in contexts similar to South Africa. We propose the central tenets to become motivation, information, power, resources, leadership and interactions of all these.
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Contexts matter a lot in implementation. Theoretical frameworks are important road maps in policy implementation and analysis. CIT is a simple but very useful theory and framework that condenses reality into less detailed but informative elements (information, motivation, power, resources, interactions of these). Our contribution to literature is an adapted CIT theory that fully captures policy implementation experiences of actors in a UHC context.