Jane Doherty

Approaches to developing the capacity of health policy analysis institutes: a comparative case study.

ObjectivesTo review and assess (i) the factors that facilitate the development of sustainable health policy analysis institutes in low and middle income countries and (ii) the nature of external support for capacity development provided to such institutes.MethodsComparative case studies of six health policy analysis institutes (3 from Asia and 3 from Africa) were conducted. In each region an NGO institute, an institute linked to government and a university based institute were included. Data collection comprised document review, semi-structured interviews with stakeholders and discussion of preliminary findings with institute staff.FindingsThe findings are organized around four key themes: (i) Financial resources: three of the institutes had received substantial external grants at start-up, however two of these institutes subsequently collapsed. At all but one institute, reliance upon short term, donor funding, created high administrative costs and unpredictability. (ii) Human resources: the retention of skilled human resources was perceived to be key to institute success but was problematic at all but one institute. In particular staff often moved to better paid positions elsewhere once having acquired necessary skills and experience, leaving remaining senior staff with heavy workloads. (iii) Governance and management: board structures and roles varied according to the nature of institute ownership. Boards made important contributions to organizational capacity through promoting continuity, independence and fund raising. Routine management systems were typically perceived to be strong. (iv) Networks: linkages to policy makers helped promote policy influences. External networks with other research organizations, particularly where these were longer term institutional collaborations helped promote capacity.ConclusionsThe development of strong in-country analytical and research capacity to guide health policy development is critical, yet many health policy analysis institutes remain very fragile. A combination of more strategic planning, active recruitment and retention strategies, and longer term, flexible funding, for example through endowments, needs to be promoted. Specific recommendations to funders and institutes are provided.

Developing a new mid-level health worker: lessons from South Africa’s experience with clinical associates

BACKGROUND Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers - known as clinical associates - in small numbers in 2008. OBJECTIVE We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker. METHODS We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed. RESULTS Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards. CONCLUSIONS This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives.Background : Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers – known as clinical associates – in small numbers in 2008. Objective : We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker. Methods : We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed. Results : Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards. Conclusions : This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives.

From conflict to cohesion: Involving stakeholders in policy research

Abstract The transitional period in South Africa, coupled with the general societal context of uncertainly, poses several challenges to policy researchers. While policies which address the inequities of apartheid are urgently needed, the time and resources available for policy formulation are limited. These policies often have to accommodate the views of a range of stakeholders who, at best, have had little prior contact with one another or, at worst, are openly hostile. This article describes our experience as health policy researchers in employing research techniques to partially address these problems. The article makes use of examples from several large studies which were conducted over the past 5 years. All of the studies evaluated primary health care services in disadvantaged communities and were unusual in the extent to which they involved community representatives and health authorities at local, regional and national levels in the formulation of recommendations. The first section of the article describes the process we follow in achieving participation, the second highlights the advantages of this approach and the last section describes the difficulties associated with the approach. We conclude by emphasizing the facilitatory role which may be played by independent researchers in times of transition.

Research in support of health systems transformation in South Africa: the experience of the Centre for Health Policy.

We describe the role and experience of the Centre for Health Policy (CHP), a university-based research unit established in 1987, in influencing and supporting health systems transformation in South Africa over two decades. During 2010, we analyzed relevant documents and conducted interviews with 25 key informants. CHPs research has contributed directly to health policy development and implementation while also changing the way government understood or approached policy issues. Key success factors for policy influence are: research quality and trustworthiness, strategic alliances and networking, and capacity building. CHPs challenges include identifying new funding sources and sustaining a high public profile. The lessons for other countries are to: conduct good quality, relevant research based on strong ethical values; build and maintain open and honest relationships with government; recognize and adapt to changes in the policy environment; develop capacity as part of a continuous programme; and seek core funding that ensures research independence and public accountability.

Cost-effectiveness analysis for priority-setting in South Africa--what are the possibilities?

Priority-setting in the health system is necessary because resources are constrained. The role of cost-effectiveness analysis in supporting decision-making around health care priorities in South Africa is explored by referring to South African studies that have provided clinical and policy guidance at the levels of the patient, the service and the population. Cost-effectiveness evidence is positioned in relation to other concerns such as equity and the overall performance of the health system.

Regulating the for-profit private health sector: lessons from East and Southern Africa.

International evidence shows that, if poorly regulated, the private health sector may lead to distortions in the type, quantity, distribution, quality and price of health services, as well as anti-competitive behaviour. This article provides an overview of legislation governing the for-profit private health sector in East and Southern Africa. It identifies major implementation problems and suggests strategies Ministries of Health could adopt to regulate the private sector more effectively and in line with key public health objectives. This qualitative study was based on a document review of existing legislation in the region, and seven semi-structured interviews with individuals selected purposively on the basis of their experience in policymaking and legislation. Legislation was categorized according to its objectives and the level at which it operates. A thematic content analysis was conducted on interview transcripts. Most legislation focuses on controlling the entry of health professionals and organizations into the market. Most countries have not developed adequate legislation around behaviour following entry. Generally the type and quality of services provided by private practitioners and facilities are not well-regulated or monitored. Even where there is specific health insurance regulation, provisions seldom address open enrolment, community rating and comprehensive benefit packages (except in South Africa). There is minimal control of prices. Several countries are updating and improving legislation although, in most cases, this is without the benefit of an overarching policy on the private sector, or reference to wider public health objectives. Policymakers in the East and Southern African region need to embark on a programme of action to strengthen regulatory frameworks and instruments in relation to private health care provision and insurance. They should not underestimate the power of the private health sector to undermine efforts for increased regulation. Consequently they should conduct careful stakeholder analyses and build alliances to help drive through reform.

Strengthening rural health placements for medical students: Lessons for South Africa from international experience

BACKGROUND This article derives lessons from international experience of innovative rural health placements for medical students. It provides pointers for strengthening South African undergraduate rural health programmes in support of the governments rural health, primary healthcare and National Health Insurance strategies. METHODS The article draws on a review of the literature on 39 training programmes around the world, and the experiential knowledge of 28 local and international experts consulted through a structured workshop. RESULTS There is a range of models for rural health placements: some offer only limited exposure to rural settings, while others offer immersion experiences to students. Factors facilitating successful rural health placements include faculty champions who drive rural programmes and persuade faculties to embrace a rural mission, preferential selection of students with a rural background, positioning rural placements within a broader rural curriculum, creating rural training centres, the active nurturing of rural service staff, assigning students to mentors, the involvement of communities, and adapting rural programmes to the local context. Common obstacles include difficulties with student selection, negative social attitudes towards rural health, shortages of teaching staff, a sense of isolation experienced by rural students and staff, and difficulties with programme evaluation. CONCLUSIONS Faculties seeking to expand rural placements should locate their vision within new health system developments, start off small and create voluntary rural tracks, apply preferential admission for rural students, set up a rural training centre, find practical ways of working with communities, and evaluate the educational and clinical achievements of rural health placements.

Achievements and challenges in developing health leadership in South Africa: the experience of the Oliver Tambo Fellowship Programme 2008–2014

Abstract The Oliver Tambo Fellowship Programme is convened by the School of Public Health and Family Medicine, University of Cape Town, South Africa. It is a health leadership training programme with a post-graduate Diploma at its core, supplemented by management seminars, mentorship and alumni networking. An external evaluation was conducted in 2015 for the period since 2008. This rapid, descriptive study made use of mixed methods—including a document review of existing Programme material (management reports, anonymized alumni’s implementation project reports, exit interviews, field interviews and e-mailed questionnaires), a brief e-mailed questionnaire, and 18 semi-structured telephonic interviews conducted by the evaluator with Programme alumni, convenors and senior government line managers. Data were analysed according to indicators and associated criteria developed by the evaluator on the basis of the Programme’s objectives, international experience, the nature of the South African health system and the particular philosophy of the Programme. The evaluation found that the Diploma offered a unique contribution. This is because it sought less to convey new technical knowledge, than to empower and galvanize students to become change agents in the complex settings of their workplaces. Reflective practice was an important part of this process. Alumni were able to point to a number of positive changes in their management practice and motivation, translating these into improved performance by their teams and more effective health services. Alumni also helped to build the capacity of their own and other staff, sharing the knowledge and skills they had gained through the Programme, and leading by example. However, the Programme found it difficult to arrange adequate mentorship or peer support for alumni once they returned to their workplaces, pointing to the need for human resource development units in government to become more active in supporting alumni and holding them accountable for improving practice.

Strengthening expertise for health technology assessment and priority-setting in Africa

ABSTRACT Background: Achieving sustainable universal health coverage depends partly on fair priority-setting processes that ensure countries spend scarce resources wisely. While general health economics capacity-strengthening initiatives exist in Africa, less attention has been paid to developing the capacity of individuals, institutions and networks to apply economic evaluation in support of health technology assessment and effective priority-setting. Objective: On the basis of international lessons, to identify how research organisations and partnerships could contribute to capacity strengthening for health technology assessment and priority-setting in Africa. Methods: A rapid scan was conducted of international formal and grey literature and lessons extracted from the deliberations of two international and regional workshops relating to capacity-building for health technology assessment. ‘Capacity’ was defined in broad terms, including a conducive political environment, strong public institutional capacity to drive priority-setting, effective networking between experts, strong research organisations and skilled researchers. Results: Effective priority-setting requires more than high quality economic research. Researchers have to engage with an array of stakeholders, network closely other research organisations, build partnerships with different levels of government and train the future generation of researchers and policy-makers. In low- and middle-income countries where there are seldom government units or agencies dedicated to health technology assessment, they also have to support the development of an effective priority-setting process that is sensitive to societal and government needs and priorities. Conclusions: Research organisations have an important role to play in contributing to the development of health technology assessment and priority-setting capacity. In Africa, where there are resource and capacity challenges, effective partnerships between local and international researchers, and with key government stakeholders, can leverage existing skills and knowledge to generate a critical mass of individuals and institutions. These would help to meet the priority-setting needs of African countries and contribute to sustainable universal health coverage.

FeesMustFall and the campaign for universal health coverage.

This editorial reflects on how #FeesMustFall highlighted the political and social upheaval that results from extreme income inequity and inequitable access, problems that beset the health sector as well. It presents data showing how per capita health expenditure declined for a decade after 1994, despite the burgeoning HIV/AIDS epidemic, a blow from which the health system is still trying to recover. The underlying reason for this was a macroeconomic policy that placed constraints on taxation and goverment expenditure on social services. The article shows how South Africa (SA)s tax-to-GDP ratio is much lower than other middle-income countries, and argues that raising this limit is essential for development. Spending on health and education should be seen as an investment in the SA economy. The Department of Health needs to argue this case in Cabinet and demonstrate the effectiveness of health spending through efficient service delivery and fighting corruption.