How and why policy-practice gaps come about: a South African Universal Health Coverage context

• DOI: 10.29392/joghr.3.e2019069
• Publication Date: 2020-03-16T03:43:28Z
• Authors: Janet Michel; Natsayi Chimbindi; Nthabiseng Mohlak...; Marsha Orgill; Till Bärnighausen; Brigit Obrist; Fabrizio Tediosi; David Evans; Di McIntryre; Hans T Bressers; Marcel Tanner
• Keywords: South Africa; 03 medical and health sciences; 0302 clinical medicine; SDG 3 - Good Health and Well-being; Universal health coverage; Global health; Public aspects of medicine; RA1-1270; 16. Peace & justice; 3. Good health

# Background South Africa, like many other countries is currently piloting National Health Insurance (NHI) reforms aimed at achieving Universal Coverage (UHC). Existing health policy implementation experience has demonstrated that new policies have sometimes generated unexpected and negative outcomes without necessarily explaining how these came about. Policies are not always implemented as envisioned, hence the importance of understanding nature implementation. Methods Qualitative data were collected during three phases: 2011-2012 (contextual mapping), 2013-2014 (phase 1) 2015 2). In-depth face-to-face interviews held with key informants (n=71) using a theory change interview guide, adapted for each phase. Key ranged from provincial actors (policy makers) district, subdistrict primary care (PHC) facility implementers). All audio-recorded transcribed. An iterative, inductive deductive analysis approach was utilized. Transcripts coded aid MAXQDA2018 (VERBI software GmbH, Germany). Results Five groups factors bringing about policy-practice gaps identified. (i) Primary stemming direct lack critical component implementation, tangible or intangible (resources, information, motivation, power); (ii) secondary efficient processes systems (budget processes, limited financial delegations, top down directives, communication channels, supply chain ineffective supervision performance management systems); (iii) tertiary human (perception cognition) calculated responses to primary, extraneous factors, coping mechanisms (ideal reporting audit driven compliance core standards); (iv) beyond system (national vocational training leading national shortage plumbers); (v) an overall thinking. Conclusions Africa needs be applauded adopting UHC. Noteworthy among fueling perception in resources, systems, through others, ideal standards, additional layer unintended consequences, further widening gap. Utilizing address challenges identified, could go long way making UHC reality.