Strengthening the health system for a people-centred community orientation in South Africa. A formative study.

Health systems in sub-Saharan Africa are typically fragile, reactive and organized around responding to specific diseases. This makes them ill-equipped to deal with multiple co-existing conditions such as tuberculosis, HIV and non-communicable diseases as well as emerging health shocks, such as COVID-19. The need to build resilient and responsive quality health systems is paramount. To this end, people-centred oriented systems which focus on health promotion and prevention interventions and empowering people to take responsibility for their health and that of their communities have been identified as the way forward for sub-Saharan Africa. This need is amplified in the context of COVID-19 which requires people to change their behavior to prevent the spread of the virus. This requires strengthening of the community sub-system (historically a neglected component of the health system) including households, civic groups, community structures and other sectors to play an active rather than passive role in the health care system.
While the SA Dept of Health has engaged in policy reforms to strengthen the system to have a more people-centred community orientation, there are gaps in knowledge about how best to practically achieve these reforms. To narrow this gap, the applicants have partnered with the KwaZulu-Natal (KZN) provincial Department of Health (DoH), to investigate how best to implement these reforms. To this end, we will conduct a formative investigation of the barriers, needs and opportunities for strengthening of the pillars of the health system to be enabling of a people-centred community orientation. This information will be used to inform the co-development (with the KZN DoH and other sectors) of conceptual models of how the pillars of the health system could be strengthened to be more enabling of a people-centred community orientation. Testing and refining of these conceptual models will form the basis of a full stage proposal.

Health systems in sub-Saharan Africa are typically fragile, reactive and vertically organised - being ill-equipped to deal with multiple co-existing health problems, such as malaria, tuberculosis, HIV and non-communicable diseases; as well as emerging shocks such as COVID-19. The Lancet Commission on the future of health in sub-Saharan Africa identified health systems reforms towards people-centred systems as necessary for achieving longer and healthier lives in this region. People-centredness focuses on prevention and health promotion - empowering people to be more in control of their health and that of their communities. Strengthening of the community sub-system - a historically neglected component of the health system, comprising households, civic groups, community structures and other sectors - is central to strengthening a people-centred health system. While there is political will on the part of the South African Department of Health to make a shift towards a people-centred community-oriented health system, visible in policies promoting re-engineering of primary health care (PHC) in particular; there is a knowledge gap on how to implement these reforms operationally.
To provide academic direction to closing this knowledge gap, the applicants have partnered with the KwaZulu-Natal provincial Department of Health and NGOs to provide strategic academic direction to achieve these reforms operationally. Through this foundation grant, we will conduct a formative investigation of the barriers, needs and opportunities for strengthening of the pillars of the health system as conceptualized by the Lancet Commission of Quality Health systems. Guided by Realist Evaluation (RE), this formative work will inform the co-development of Initial Programme Theories (IPT) which will provide logical conceptual models for strengthening of these key pillars, including multisectoral approaches.Testing and refining these models will form the scope of work for a full-stage proposal.