A multi-dimensional framework for implementing health system reform in South Africa

Abstract

Health systems are pivotal to ensure that individuals have access to affordable, equitable, quality and sustainable healthcare services. South Africa is reforming its health system to achieve Universal Health Coverage (UHC) to improve population healthcare access while ensuring financial risk protection. Despite policies to realise UHC, there are leadership and governance weaknesses across the health system, and poor quality healthcare. There are also reports of inadequate stakeholder engagements about the envisaged health reform. The goal of the study was to conceptualise a multi-dimensional framework for implementing health system reform in South Africa. A case study research strategy was used to explore and describe the complexities within the health system by analysing, multi-dimensionally, the role of leadership and governance in health system reform; how leadership may influence service delivery and determine the service delivery challenges in South African healthcare facilities; and the role of stakeholders and their influence in the health reform process. The participants consisted of stakeholders within the health system, namely, National Department of Health, regulators, medical schemes, medical scheme administrator, healthcare facilities, funder association, labour unions, and an independent medical practitioner. The sample comprised of 26 participants. Face-to-face interviews were conducted with the selected participants. The findings revealed that there are several governance challenges in both the public and private sectors, and boards have been non-existent at various levels of the public sector. Poor service delivery is due to limited government funding, ailing infrastructure and lack of Information and Communications Technology (ICT) systems to support work processes. Stakeholders, mainly in the private sector, believed that they were not engaged about the health reform process. The process has been politically driven and ordinary citizens were not engaged from the start. The dimensions of theories (leadership and governance; service delivery; and stakeholders) and the study findings, informed by the analysed multi-dimensionality of the phenomenon, have been integrated to develop a conceptual framework on how health system reform may be implemented. The conceptual framework is a tool to bridge the identified gaps in literature, and to guide policymakers to implement health system reform effectively.