Whole System Change in South Africa: Understanding the experience of health system transformation in the Western Cape province (WholeSyst-SA)

Twenty years after the ending of apartheid the time is ripe to evaluate South African experience of health system transformation. Much was promised and many changes have been introduced - but how much has been achieved, especially for the most vulnerable and previously disadvantaged groups? What factors have enabled or constrained change across the public health system, nationally recognised as the leading edge of efforts to improve the health and well-being of vulnerable groups? What lessons does past experience hold for continuing efforts to improve health care and health? What issues need to be tracked over time to generate the evidence needed to support future policy and managerial decision-making?

This proposed grant intends to address these questions. It is jointly submitted by a team of public health system policy-makers/managers and researchers based in the Western Cape (WC) province. As South Africa is a quasi-federal state, the WC provincial government has the constitutional responsibility for ensuring an effective health system for its population. It also has a reputation for having been relatively effective in sustaining implementation of such change over the last 20 years. Examining the particular experience of one province, in comparison with wider national experience, will allow in-depth investigation of South African health system transformation. The project will consider not only what changes have been implemented, with what achievements and challenges, but also what set of political, leadership, organisational and other factors have supported or limited the implementation of change. From this analysis it will seek to identify the pathways to change underpinning health system development in the province. The project team's combination of experience and expertise will support this in-depth investigation.

Better understanding of what the province has achieved and how, set against the national context, will offer insights of relevance across the country, as well as internationally. It will also, more specifically, contribute to generating the evidence base needed to support future policy and management decision-making, by supporting provincial health system monitoring and evaluation activities and identifying related, larger scale research needs.

Over the last twenty years South Africa has implemented a broad array of changes within its health system in order to improve its ability to offer good quality health care at reasonable cost to vulnerable population groups. Whilst there is national recognition that performance improvements have fallen short of expectations, the Western Cape province is reputed to have performed relatively well. The proposed exploratory and formative research will examine this province's experience since 1994, comparing it with wider national experience and considering the lessons for future monitoring and evaluation of health system development, including related research needs. The project's objectives will be addressed through a sequenced set of data collection activities, comprising review of existing policy documents and research reports, elite interviews with policy-makers, and analysis of routinely collected health system data for the Western Cape and other provinces. The Western Cape experience will be set against wider national experience, including specific comparison with two other provinces which will be purposefully selected to allow reflection on insights generated by initial analysis of the Western Cape experience. The project will be guided and supported by a steering committee comprised of policy-makers, managers and researchers, who will together tease out wider lessons - including those concerning future provincial monitoring and evaluation activities. The project, therefore, is itself an example of the embedded research identified as important for health policy and systems research.

This research will have positive social impact by contributing to health system performance improvements that preferentially benefit previously dis-advantaged and vulnerable population groups in South Africa. By better understanding the whole system change necessary to enable such performance improvements the project will offer lessons and guidance for policy-makers and managers across South Africa, and in other countries. By supporting the development of WC provincial monitoring and evaluation activities focussed on future health system change efforts, the project will also support the generation of evidence to inform managerial decision-making and sustain whole system change over time. Improved decision-making will, in turn, assist the South African provincial and national health departments to establish a person-centred health system - and perhaps more quickly and efficiently than without such evidence. The WC monitoring and evaluation experience will also generate lessons of relevance to other provinces.

Additional South African beneficiaries of the research - who will mediate its impact on the ultimate beneficiaries - are the health system managers seeking to sustain health system transformation in the Western Cape and other provinces. The involvement of senior Western Cape provincial health department officials in the project team is a clear indication of demand for this research and of their intention to use the study's findings. The planned use of the study's finding to support future provincial monitoring and evaluation activities is in response to an explicit request to academic partners from the provincial health department, and will support the sustained influence of the findings in future decision-making. Nationally, there is also a demand for evidence on how to strengthen the health system, as shown by the priorities identified in the 2011 National Health Research Summit (Mayosi et al. 2011) and the national department of health's support for eleven pilot sites in which to test and learn from new health system strengthening approaches. The 2011 National Evaluation Policy Framework, moreover, demonstrates a strong government-wide interest in policy evaluation work (The Presidency, 2011).

The benefits of the research will, finally, extend outside South Africa. The study will generate insights about what whole system change entails and how to support it. These insights will not be transferable to other settings as instrumental 'policy lessons', but can act to stimulate managers in other settings to consider, for example, the broad array of health system changes needed to support sustained performance improvements benefiting vulnerable populations and the political and organisational strategies that might sustain such changes. Adapting insights from South Africa to their own contexts is a critical managerial act of lesson-drawing (Rose 1993). The international relevance of such insights lies, moreover, in the recognition that health systems are able to influence the distribution of health across population groups (CSDH 2008), but weak health systems hinder the deliver of health services and waste resources (Fernandes et al. 2014; WHO 2007).