UWCScholar :: Browsing by Author "Schneider, Helen"

Browsing by Author "Schneider, Helen"

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Addressing social determinants of health in South Africa: the journey continues
(Health Systems Trust (HST), 2017) Scott, Vera; Schaay, Nikki; Schneider, Helen; Sanders, David
With the recent change from the Millennium Development Goals to the 17 new Sustainable Development Goals, the focus of the global development agenda is expanding: there is attention on a broader set of social determinants and, importantly, a specific sensitivity to equity, which could have a substantial effect on health. Addressing social determinants is a cornerstone in the National Department of Health’s Primary Health Care Re-engineering Strategy, and an approach that is embedded in the country’s National Development Plan. However, the translation of this policy commitment to programmatic action at different levels in the health system and in partnership with other sectors remains elusive.
Addressing the social determinants of health: A case study from the Mitanin (Community Health Worker) programme in India
(London School of Hygiene and Tropical Medicine, 2014) Nandi, Sulakshana; Schneider, Helen
The Mitanin Programme, a government community health worker (CHW) programme, was started in Chhattisgarh State of India in 2002. The CHWs (Mitanins) have consistently adopted roles that go beyond health programme- specific interventions to embrace community mobilization and action on local priorities. The aim of this research was to document how and why the Mitanins have been able to act on the social determinants of health, describing the catalysts and processes involved and the enabling programmatic and organiza- tional factors. A qualitative comparative case study of successful action by Mitanin was conducted in two ‘blocks’, purposefully selected as positive exemplars in two districts of Chhattisgarh. One case focused on malnutrition and the other on gender-based violence. Data collection involved 17 in-depth interviews and 10 group interviews with the full range of stakeholders in both blocks, including community members and programme team. Thematic analysis was done using a broad conceptual framework that was further refined. Action on social determinants involved raising awareness on rights, mobilizing women’s collectives, revitalizing local political structures and social action targeting both the community and government service providers. Through these processes, the Mitanins developed identities as agents of change and advocates for the community, both with respect to local cultural and gender norms and in ensuring accountability of service providers. The factors underpinning successful action on social determinants were identified as the significance of the original intent and vision of the programme, and how this was carried through into all aspects of programme design, the role of the Mitanins and their identification with village women, ongoing training and support, and the relative autonomy of the programme. Although the results are not narrowly generalizable and do not necessarily represent the situation of the Mitanin Programme as a whole, the explanatory framework may provide general lessons for programmes in similar contexts.
Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa
(BioMed Central, 2012) Leon, Natalie; Schneider, Helen; Daviaud, Emmanuelle
Background: Mobile phone technology has demonstrated the potential to improve health service delivery, but there is little guidance to inform decisions about acquiring and implementing mHealth technology at scale in health systems. Using the case of community-based health services (CBS) in South Africa, we apply a framework to appraise the opportunities and challenges to effective implementation of mHealth at scale in health systems. Methods: A qualitative study reviewed the benefits and challenges of mHealth in community-based services in South Africa, through a combination of key informant interviews, site visits to local projects and document reviews. Using a framework adapted from three approaches to reviewing sustainable information and communication technology (ICT), the lessons from local experience and elsewhere formed the basis of a wider consideration of scale up challenges in South Africa. Results: Four key system dimensions were identified and assessed: government stewardship and the organisational, technological and financial systems. In South Africa, the opportunities for successful implementation of mHealth include the high prevalence of mobile phones, a supportive policy environment for eHealth, successful use of mHealth for CBS in a number of projects and a well-developed ICT industry. However there are weaknesses in other key health systems areas such as organisational culture and capacity for using health information for management, and the poor availability and use of ICT in primary health care. The technological challenges include the complexity of ensuring interoperability and integration of information systems and securing privacy of information. Finally, there are the challenges of sustainable financing required for large scale use of mobile phone technology in resource limited settings. Conclusion: Against a background of a health system with a weak ICT environment and limited implementation capacity, it remains uncertain that the potential benefits of mHealth for CBS would be retained with immediate large-scale implementation. Applying a health systems framework facilitated a systematic appraisal of potential challenges to scaling up mHealth for CBS in South Africa and may be useful for policy and practice decision-making in other low- and middle-income settings.
Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index
(Taylor & Francis, 2018) Nandi, Sulakshana; Schneider, Helen; Garg, Samir
Background: Countries are increasingly adopting health insurance schemes for achieving Universal Health Coverage. India’s state-funded health insurance scheme covers hospital care provided by ‘empanelled’ private and public hospitals. Objective: This paper assesses geographical equity in availability of hospital services under the universal health insurance scheme in Chhattisgarh state. Methods: The study makes use of district data from the insurance scheme and government surveys. Selected socio-economic indicators are combined to form a composite vulnerability index, which is used to rank and group the state’s 27 districts into tertiles, named as highest, middle and lowest vulnerability districts (HVDs, MVDs, LVDs). Indicators of hospital service availability under the scheme – insurance coverage, number of empanelled private/public hospitals, numbers and amounts of claims – are compared across districts and tertiles. Two measures of inequality, difference and ratio, are used to compare availability between tertiles. Results: The study finds that there is a geographical pattern to vulnerability in Chhattisgarh state. Vulnerability increases with distance from the state’s centre towards the periphery. The highest vulnerability districts have the highest insurance coverage, but the lowest availability of empanelled hospitals (3.4 hospitals per 100,000 enrolled in HVDs, vs 8.2/100,000 enrolled in LVDs). While public sector hospitals are distributed equally, the distribution of private hospitals across tertiles is highly unequal, with higher availability in LVDs. The number of claims (per 100,000 enrolled) in the HVDs is 3.5-times less than that in the LVDs. The claim amounts show a similar pattern. Conclusions: Although insurance coverage is higher in the more vulnerable districts, availability of hospital services is inversely proportional to vulnerability and, therefore, the need for these services. Equitable enrolment in health insurance schemes does not automatically translate into equitable access to healthcare, which is also dependent on availability and specific dynamics of service provision under the scheme.
Book Review: Textbook of Global Health by A-E. Birn, Y. Pillay and T.H. Holtz
(Health and Medical Publishing Group, 2017) Schneider, Helen
Coinciding with a renewed focus on health needs and disease in the global south, the Millennium Development Goal era saw the emergence and widespread use of the term ‘global health’. The term has been associated with greatly increased funding flows and the mobilisation of a panoply of individual and institutional actors under the banner of global health. But what exactly does ‘global health’ mean?
The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa
(BioMed Central, 2015) Schneider, Helen; Schaay, Nikki; Dudley, Lilian; Goliath, Charlyn; Qukula, Tobeka
Similar to other countries in the region, South Africa is currently reorienting a loosely structured and highly diverse community care system that evolved around HIV and TB, into a formalized, comprehensive and integrated primary health care outreach programme, based on community health workers (CHWs). While the difficulties of establishing national CHW programmes are well described, the reshaping of disease specific and care oriented community services, based outside the formal health system, poses particular challenges. This paper is an in-depth case study of the challenges of implementing reforms to community based services (CBS) in one province of South Africa. A multi-method situation appraisal of CBS in the Western Cape Province was conducted over eight months in close collaboration with provincial stakeholders. The appraisal mapped the roles and service delivery, human resource, financing and governance arrangements of an extensive non-governmental organisation (NGO) contracted and CHW based service delivery infrastructure that emerged over 15–20 years in this province. It also gathered the perspectives of a wide range of actors – including communities, users, NGOs, PHC providers and managers - on the current state and future visions of CBS. While there was wide support for new approaches to CBS, there are a number of challenges to achieving this. Although largely government funded, the community based delivery platform remains marginal to the formal public primary health care (PHC) and district health systems. CHW roles evolved from a system of home based care and are limited in scope. There is a high turnover of cadres, and support systems (supervision, monitoring, financing, training), coordination between CHWs, NGOs and PHC facilities, and sub-district capacity for planning and management of CBS are all poorly developed. Reorienting community based services that have their origins in care responses to HIV and TB presents an inter-related set of resource mobilisation, system design and governance challenges. These include not only formalising community based teams themselves, but also the forging of new roles, relationships and mind-sets within the primary health care system, and creating greater capacity for contracting and engaging a plural set of actors - government, NGO and community - at district and sub-district level.
Changes in paediatric HIV-related hospital admissions and mortality in Soweto, South Africa, 1996-2011: light at the end of the tunnel?
(Lippincott Williams & Wilkins, 2012) Meyers, Tammy; Dramowski, Angela; Schneider, Helen; Gardiner, Nicolene; Kuhn, Louise; Moore, David
Background: With widespread availability of pediatric antiretro- viral therapy and improved access to prevention of mother-to-child transmission (PMTCT), it is important to monitor the impact on pediatric HIV-related hospital admissions and in-hospital mortality in South Africa. Methods: Over a 15-year period, 4 independent surveillance studies were conducted in the pediatric wards at Chris Hani Baragwanath Hospital in Soweto, South Africa (1996, 2005, 2007, and late 2010 to early 2011). Trends in HIV prevalence and HIV-related mortality were evaluated. Results: HIV prevalence was similar during the first 3 periods: 26.2% (1996), 31.7% (2005), and 29.5% (2007) P > 0.10, but was lower in 2010-2011 (19.3%; P = 0.0005). Median age of the children admitted with HIV increased in the latter periods from 9.13 (interquartile range 3.6-28.8) months to 10.0 (3.0-44.5) months (P > 0.10) and 18.0 (6.2-69.8) months (P = 0.048). Median admis¬sion weight-for-age z-scores were similar (< -3 SD) for the latter 3 periods. Admission CD4 percentage increased from 0.0% (0.0-9.4) in 2005 to 15.0% (8.2-22.8) in 2007 (P < 0.0001) and was 18.7% (9.6-24.7) in 2010-2011 (P > 0.10). Mortality among all vs. HIV- infected admissions was 63 of 565 (11.2%) and 43 of 179 (24.0%) in 2005, 91 of 1510 (6.0%) and 53 of 440 (12.0%) in 2007, and 18 of 429 (4.2%) and 9 of 73 (12.3%) in 2010-2011. Conclusions: HIV prevalence and mortality among pediatric admissions is decreasing. This is likely a result of improved PMTCT and wider antiretroviral therapy coverage. Continued effort to improve PMTCT coverage and identify and treat younger and older HIV-infected children is required to further reduce HIV-related morbidity and mortality.
Community care workers, poor referral networks and consumption of personal resources in rural South Africa
(Public Library of Science, 2014) Sips, Ilona; Mazanderani, Ahmad Haeri; Schneider, Helen; Greef, Minrie; Barten, Francoise; Moshabela, Mosa
Although home-based care (HBC) programs are widely implemented throughout Africa, their success depends on the existence of an enabling environment, including a referral system and supply of essential commodities. The objective of this study was to explore the current state of client referral patterns and practices by community care workers (CCWs), in an evolving environment of one rural South African sub-district. Using a participant triangulation approach, in-depth qualitative interviews were conducted with 17 CCWs, 32 HBC clients and 32 primary caregivers (PCGs). An open-ended interview guide was used for data collection. Participants were selected from comprehensive lists of CCWs and their clients, using a diversified criterion-based sampling method. Three independent researchers coded three sets of data – CCWs, Clients and PCGs, for referral patterns and practices of CCWs. Referrals from clinics and hospitals to HBC occurred infrequently, as only eight (25%) of the 32 clients interviewed were formally referred. Community care workers showed high levels of commitment and personal investment in supporting their clients to use the formal health care system. They went to the extent of using their own personal resources. Seven CCWs used their own money to ensure client access to clinics, and eight gave their own food to ensure treatment adherence. Community care workers are essential in linking clients to clinics and hospitals and to promote the appropriate use of medical services, although this effort frequently necessitated consumption of their own personal resources. Therefore, risk protection strategies are urgently needed so as to ensure sustainability of the current work performed by HBC organizations and the CCW volunteers.
Comparing a paper based monitoring and evaluation system to a mHealth system to support the national community health worker programme, South Africa: an evaluation
(BioMed Central, 2014) Neupane, Sunisha; Odendaal, Willem; Friedman, Irwin; Jassat, Waasila; Schneider, Helen; Doherty, Tanya
BACKGROUND: In an attempt to address a complex disease burden, including improving progress towards MDGs 4 and 5, South Africa recently introduced a re-engineered Primary Health Care (PHC) strategy, which has led to the development of a national community health worker (CHW) programme. The present study explored the development of a cell phone-based and paper-based monitoring and evaluation (M&E) system to support the work of the CHWs. METHODS: One sub-district in the North West province was identified for the evaluation. One outreach team comprising ten CHWs maintained both the paper forms and mHealth system to record household data on community-based services. A comparative analysis was done to calculate the correspondence between the paper and phone records. A focus group discussion was conducted with the CHWs. Clinical referrals, data accuracy and supervised visits were compared and analysed for the paper and phone systems. RESULTS: Compared to the mHealth system where data accuracy was assured, 40% of the CHWs showed a consistently high level (>90% correspondence) of data transfer accuracy on paper. Overall, there was an improvement over time, and by the fifth month, all CHWs achieved a correspondence of 90% or above between phone and paper data. The most common error that occurred was summing the total number of visits and/or activities across the five household activity indicators. Few supervised home visits were recorded in either system and there was no evidence of the team leader following up on the automatic notifications received on their cell phones. CONCLUSIONS: The evaluation emphasizes the need for regular supervision for both systems and rigorous and ongoing assessments of data quality for the paper system. Formalization of a mHealth M&E system for PHC outreach teams delivering community based services could offer greater accuracy of M&E and enhance supervision systems for CHWs.
The decentralised drug-resistant TB programme in South Africa: From policy to implementation
(University of the Western Cape, 2022) Jassat, Waasila; Schneider, Helen
South Africa is one of the high burden countries for drug-resistant tuberculosis (DR-TB) globally. A policy supporting decentralised DR-TB treatment provision was introduced in 2011 but to date implementation has been suboptimal with variable coverage and quality. This thesis opens the ‘black box’ explaining sub-national policy implementation of DR-TB decentralisation in two provinces of South Africa, Western Cape and KwaZulu-Natal. The thesis is grounded in the field of policy analysis and adopts the methodological approach of a qualitative multiple case study, comparing 15 embedded district and subdistrict cases in the two provinces, through data collected in 94 in-depth interviews, document reviews, and observations. Applying Walt and Gilson’s Policy Analysis Triangle framework, the case studies of DR-TB in the two provinces revealed how aspects of actors’ engagement with the policy instrument, influenced by organisational dynamics and the wider context, resulted in varying effectiveness of policy implementation.
Developing a district level supportive supervision framework for community health workers through co-production in South Africa
(BMC, 2021) Assegaai, Tumelo; Schneider, Helen; Scott, Vera
One of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. Evidence on effective approaches to CHW supervision is limited and intervention research has up to now focused primarily on outcomes and less on intervention development processes. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a coproduced district level supportive supervision framework for Ward Based Outreach Teams in a South African district.: Drawing on a conceptual framework of domains of co-production, the paper reflects on the implications of the research process adopted for participants, generation of research knowledge and recommendations for practice, as well as lessons for research on the supervision of CHWs.
Development of an integrated model of care for use by community health workers working with chronic non-communicable diseases in Khayelitsha, South Africa
(University of the Western Cape, 2018) Tsolekile, Lungiswa Primrose; Puoane, Thandi; Schneider, Helen; Levitt, Naomi
Non-communicable diseases (NCD) continue to be a public health concern globally and contribute to the burden of disease. The formal health system in developing countries lacks the capacity to deal with these NCD as it is overburdened by communicable diseases. Thus, community health workers (CHWs) have been suggested as a solution for alleviating the burden for primary health facilities, by extending NCD care to the community. This thesis aims to develop an integrated model of care for CHWs working with patients with non-communicable diseases by describing and exploring current CHW roles, knowledge and practices in relation to community-based NCD care. The specific objectives for this study included 1) the exploration of the NCD roles of generalist CHWs in the context of a limited resource urban setting; 2) determining the NCD-related knowledge of CHWs, and factors influencing this in a limited resource urban setting and 3) a comparison of actual and envisaged roles in the management and prevention of NCD using the integrated chronic diseases management model (ICDM) as a benchmark, and propose key competencies and systems support for NCD functions of CHWs in South Africa Mixed methods were used to achieve the objectives of this study. First, a qualitative enquiry was conducted using observations to respond to the first objective. A quantitative cross-sectional design was then used to achieve the second objective, and a questionnaire was used to interview CHWs. A comparison of findings from both the quantitative and qualitative studies with policy guidelines was undertaken to address the third objective.
Development of non-profit organisations providing health and social services in rural South Africa: a three year longitudinal study
(PLOS, 2013) Moshabela, Mosa; Gitomer, Shira; Qhibi, Bongi; Schneider, Helen
INTRODUCTION: In an effort to increase understanding of formation of the community and home-based care economy in south Africa, we investigated the origin and development of non-profit organisations (NPOs) providing home-and community-based care for health and social services in a remote rural area of South Africa. METHODS: Over a three-yer period (2010-12), we identified and tracked all NPOs providing health care and social services in Bushbuckridge sub-district through the use of local government records, snowballing techniques, and attendance at NPO networking meetings - recording both existing and new NPOS, NPO founders and managers were interviewed in face--to-face in-depth interview, and their organisational records were reviewed. RESULTS: Forty-seven NPOs were formed prior to teh study period, and 14 during the sutyd period - six in 2010, six in 2011 and two in 2012, while four ceased operation, representing a 22%growth in the number of NPOs during the study period. Histories of NPOs showed a steady rise in the NPO formation over a 20 year period, from one (1991-1995) to 12 (1996-2000), 16 (2001 - 2005) and 24 (2006-2010) new organisations formed in each period. Furthermore, the histories of formation revealed three predominant milestones - loose association, formal formation and finally registration. CONCLUSION: We observed rapid growth of the NPO sector providing community-based health and social services. Women dominated the rural NPO sector, which is being seen as creating occupation and employment opportunities. The implications of this growth in the NPO sector providing community-based health and social services needs to be further explored and suggests the need for greater coordination and possibly regulation.
Development of the health system in the Western Cape: experiences since 1994
(Health Systems Trust (HST), 2017) Gilson, Lucy; David Pienaar, Tracey; Brady, Leanne; Hawkridge, Anthony; Naled, Tracey; Vallabhjee, Krish; Schneider, Helen
Provincial governments in South Africa have a critical responsibility in terms of population health, yet few provincial-level analyses of health-system development have been undertaken. This chapter reports on research being conducted in the Western Cape to understand the province’s particular experience of health-system transformation since 1994, set against wider national experience. The research is being undertaken collaboratively by the authors of this chapter, a team of Western Cape provincial health managers and researchers. The chapter is structured to reflect the Western Cape’s 22-year experience. The situation that faced the province in 1994 is outlined briefly, followed by a description of key features of the three health strategies that have driven provincial health-system development over time. An assessment is then presented of the overall nature and patterns of Western Cape health-system change, and the achievements and limitations of this transformation are considered. The chapter concludes with some early lessons from this experience, and relevant, international experience is considered.
District and sub-district stewardship of quality and health outcomes: roles, systems and strategies
(University of the Western Cape, 2022) Schneider, Helen; Mianda, Solange
Sub-district and district health systems – generically referred to as the meso-level – are key to enhancing quality of care and improving health outcomes. Facility (micro) level improvement strategies are less likely to succeed or be sustained if they are not supported and enabled by the meso-level. In this briefing document, we explore district and sub-district stewardship of quality of care and health outcomes, based on insights and experiences of a national initiative referred to as Mphatlalatsane. This initiative seeks to improve maternal and neonatal health in selected districts of three provinces (Mpumalanga, Limpopo and Eastern Cape). As part of the wider evaluation of Mphatlalatsane, we conducted serial interviews with project partners over the course of 2020 and 2021, specifically probing views on the meso-level in relation to maternal and neonatal health (MNH) quality and outcomes. Drawing on these interviews and programme documentation, we seek to characterize both the ‘what’ and ‘the how’ of meso-level stewardship of quality and outcomes, including roles/capabilities, enabling systems and change strategies. We believe the insights generated offer guidance on system functioning that can complement clinical guidelines and standards, and feed into debates on the design of district and sub-district health systems in South Africa. To achieve better quality and health outcomes (whether for MNH or other programmes), the meso-level needs to be able to: drive implementation of provincial and national strategy, while simultaneously advocating for bottom-up service delivery needs; authorise and support innovation by frontline providers, drawing on improvement methodologies; coordinate health programmes and players across levels of the health system; and ensure appropriate accountabilities. These roles imply a high degree of agency and responsiveness on the part of the meso-level, proactively connecting elements of the system, problemsolving, learning, allocating resources and exploiting efficiencies.
District governance and improved maternal, neonatal and child health in South Africa: Pathways of change
(Health systems and reform, 2020) Schneider, Helen; George, Asha; Mukinda, Fidele; Tabana, Hanani
District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was intro- duced as a decision-making and accountability structure, and constituted of a “triangle” of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leader- ship skills.
Enhancing the use of burden of disease information for health sector decision making
(University of the Western Cape, 2019) Neethling, Ian; Schneider, Helen; Bradshaw, Debbie
Equity, access and utilisation in the state-funded universal insurance scheme (RSBY/MSBY) in Chhattisgarh State, India: What are the implications for Universal Health Coverage?
(University of the Western Cape, 2019) Nandi, Sulakshana; Schneider, Helen
Universal Health Coverage (UHC) has provided the impetus for the introduction of publicly-funded health insurance (PFHI) schemes, involving the private sector, especially in low-and middle-income countries with mixed health systems. Although equity is considered as being core to UHC, the implication of UHC interventions for equity in access (availability, affordability and acceptability) beyond financial protection is inadequately researched. India introduced a national PFHI scheme (Rashtriya Swasthya Bima Yojana) in 2007 which has since then been expanded considerably through the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme. However, contestation remains as to whether PFHI schemes are the most appropriate interventions for UHC in India. Evidence so far provides cause for concern regarding their impact on financial protection and health equity. With PFHI schemes burgeoning globally, there is an urgent need for a holistic understanding of the pathways of impact of these schemes, including their roles in promoting equity of access and achievement of UHC objectives. The state-funded universal health insurance scheme (RSBY/MSBY) in Chhattisgarh State provided the opportunity to explore these pathways of impact, especially on vulnerable communities, as the State has a universal health insurance scheme. This PhD aims to study equity, access and utilisation in the state-funded universal insurance scheme in Chhattisgarh State of India, in the context of Universal Health Coverage. It is presented as a thesis by publications.
Exploring politics and contestation in the policy process: The case of Zambia’s contested community health strategy
(Kerman University of Medical Sciences, 2021) Zulu, Joseph M.; Chavula, Maligzani P.; Schneider, Helen
There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia’s 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.
Expressions of actor power in implementation: A qualitative case study of a health service intervention in South Africa
(Research Square, 2021) Schneider, Helen; Mukinda, Fidele; Tabana, Hanani
Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa.A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’.

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