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Background New forms of leadership are required to bring about the fundamental health system changes demanded by primary health care (PHC). Using theory about complex adaptive systems and policy implementation, this paper considers how actors' sensemaking and the exercise of discretionary power currently combine to challenge PHC re-orientation in the South African health system; and provides examples of leadership practices that promote sensemaking and power use in support of PHC. Methods The paper draws on observational, interview, and reflective data collected as part of the District Innovation and Action Learning for Health Systems Development (DIALHS) project being implemented in Cape Town, South Africa. Undertaken collaboratively between health managers and researchers, the project is implemented through cycles of action-learning, including systematic reflection and synthesis. It includes a particular focus on how local health managers can better support front line facility managers in strengthening PHC. Results The results illuminate how the collective understandings of staff working at the primary level - of their working environment and changes within it - act as a barrier to centrally-led initiatives to strengthen PHC. Staff often fail to take ownership of such initiatives and experience them as disempowering. Local area managers, located between the centre and the service frontline, have a vital role to play in providing a leadership of sensemaking to mediate these challenges. Founded on personal values, such leadership entails, for example, efforts to nurture PHC-aligned values and mind-sets among staff; build relationships and support the development of shared meanings about change; instil a culture of collective inquiry and mutual accountability; and role-model management practices, including using language to signal meaning. Conclusions PHC will only become a lived reality within the South African health system when frontline staff are able to make sense of policy intentions and incorporate them into their everyday routines and practices. This requires a leadership of sensemaking that enables front line staff to exercise their collective discretionary power in strengthening PHC. We hope this theoretically-framed analysis of one set of experiences stimulates wider thinking about the leadership needed to sustain primary health care in other settings. [ABSTRACT FROM AUTHOR]

Background: Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.Methods: Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.Results: We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.Conclusion: Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines. [ABSTRACT FROM AUTHOR]

Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal.Methods: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method.Results: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team.Conclusions: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues. [ABSTRACT FROM AUTHOR]

Background Access to health care is a particular concern given the important role of poor access in perpetuating poverty and inequality. South Africa's apartheid history leaves large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Methods Using newly available health care utilization data from the first nationally representative panel survey in South Africa, together with administrative geographic data from the Department of Health, we use graphical and multivariate regression analysis to investigate the role of distance to the nearest facility on the likelihood of having a health consultation or an attended birth. Results Ninety percent of South Africans live within 7 km of the nearest public clinic, and two-thirds live less than 2 km away. However, 14% of Black African adults live more than 5 km from the nearest facility, compared to only 4% of Whites, and they are 16 percentage points less likely to report a recent health consultation (p < 0.01) and 47 percentage points less likely to use private facilities (p < 0.01). Respondents in the poorest income quintiles live 0.5 to 0.75 km further from the nearest health facility (p < 0.01). Racial differentials in the likelihood of having a health consultation or an attended birth persist even after controlling for confounders. Conclusions Our results have two policy implications: minimizing the distance that poor South Africans must travel to obtain health care and improving the quality of care provided in poorer areas will reduce inequality. Much has been done to redress disparities in South Africa since the end of apartheid but progress is still needed to achieve equity in health care access. [ABSTRACT FROM AUTHOR]

Background: Women with a prior gestational diabetes have an increased lifetime risk of developing type 2 diabetes. Although post-partum follow-up for GDM women is essential to prevent progression to type 2 diabetes, it is poorly attended. The need for health systems interventions to support postpartum follow-up for GDM women is evident, but there is little knowledge of actual current practice. The aim of this study was to explore current policies and clinical practices relating to antenatal and post-natal care for women with GDM in South Africa, as well as health sector stakeholders' perspectives on the barriers to -- and opportunities for -- delivering an integrated mother - baby health service that extends beyond the first week post-partum, to the infant's first year of life.Methods: Following a document review of policy and clinical practice guidelines, in-depth interviews were conducted with 11 key informants who were key policy makers, health service managers and clinicians working in the public health services in South Africa's two major cities (Johannesburg and Cape Town). Data were analysed using qualitative content analysis procedures.Results: The document review and interviews established that it is policy that health services adhere to international guidelines for GDM diagnosis and management, in addition to locally developed guidelines and protocols for clinical practice. All key informants confirmed that lack of postpartum follow-up for GDM women is a significant problem. Health systems barriers include fragmentation of care and the absence of standardised postnatal care for post-GDM women. Key informants also raised patient - related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for GDM women. All participants supported integrated primary health services but cautioned against overloading health workers.Conclusion: Although there is alignment between international guidelines, local policy and reported clinical practice in the management of GDM, there is a gap in continuation of care in the postpartum period. Health systems interventions that support and facilitate active follow-up for women with prior GDM are needed if high rates of progression to type 2 diabetes are to be avoided. [ABSTRACT FROM AUTHOR]