Original Research

What we need is health system transformation and not health system strengthening for universal health coverage to work: Perspectives from a National Health Insurance pilot site in South Africa

Janet Michel, Brigit Obrist, Till Bärnighausen, Fabrizio Tediosi, Di McIntryre, David Evans, Marcel Tanner
South African Family Practice | Vol 62, No 1 : Part 3| a5079 | DOI: https://doi.org/10.4102/safp.v62i1.5079 | © 2020 Janet Michel, Brigit Obrist, Till Bärnighausen, Fabrizio Tediosi, Di McIntyre, David Evans, Marcel Tanner | This work is licensed under CC Attribution 4.0
Submitted: 12 December 2019 | Published: 03 September 2020

About the author(s)

Janet Michel, Swiss Tropical and Public Health Institute, Basel, Switzerland; and, Department of Epidemiology and Public Health, Faculty of Science, University of Basel, Basel, Switzerland
Brigit Obrist, Swiss Tropical and Public Health Institute, Basel, Switzerland; and, Department of Social Sciences, Faculty of Humanities and Social Sciences, University of Basel, Basel, Switzerland
Till Bärnighausen, Department of Global Health, Harvard T.H. Chan School of Public Health, Boston, United States; and, Institute of Public Health, University of Heidelberg, Heidelberg, Germany
Fabrizio Tediosi, Swiss Tropical and Public Health Institute, Basel, Switzerland; and, Department of Epidemiology and Public Health, Faculty of Science, University of Basel, Basel, Switzerland
Di McIntryre, Health Economics Unit, University of Cape Town, Cape Town, South Africa
David Evans, World Bank, Washington, D.C., United States
Marcel Tanner, Swiss Tropical and Public Health Institute, Basel, Switzerland; and, Department of Epidemiology and Public Health, Faculty of Science, University of Basel, Basel, Switzerland


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Abstract

Background: Globally, universal health coverage (UHC) has gained traction as a major health priority. In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment. National Health Insurance (NHI) and primary healthcare (PHC) re-engineering were two vehicles chosen to reach UHC over a 14-year period (2012–2026). The first phase of health system strengthening (HSS) initiatives to improve the quality of health services in the public sector began in 2012. These HSS initiatives are still being carried out by the Department of Health in conjunction with other partners.

Methods: A qualitative case study design utilising a theory of change (TOC) approach was employed. Data were collected from key informants (n = 71) during three phases: 2011–2012 (contextual mapping), 2013–2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide, adapted for each phase. All interviews were audio-recorded and transcribed verbatim. An iterative, inductive and deductive data analysis approach was utilised. Transcripts were coded with the aid of MAXQDA 2018.

Results: Six broad themes emerged: make PHC work, transform policy development, transform policy implementation, establish public–private partnerships, transform systems and processes and adopt a systems lens.

Conclusion: A third great transition seems to be sweeping the globe, changing how health systems are organised. Actors in our study have identified this need also. Health system transformation rather than strengthening, they say, is needed to make UHC a reality. Who is listening?


Keywords

universal health coverage; health systems in transition; health systems no longer fit for purpose; health systems transformation versus health systems strengthening; policy implementation

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