Institutionalization of health promotion in the South African health system
Introduction: Despite global recognition of health promotion (HP) as a cost-effective way to improve population health, it is not highly regarded nor is it sufficiently institutionalized in many health systems, particularly in low and middle-income countries (LMICs). This diminishes its ability to deliver on public health promises, reducing the need for curative health care. In this regard, capacity of HP staff, as well as the institutions responsible for HP programming, is critical if the full potential of HP in the health system is to be reached. Given that, HP concepts are fundamental to the internationally renewed commitment on primary health care (PHC), it is worthwhile investigating how the role of HP is being ensured as part of the health system and not just subsumed into PHC. Ongoing efforts to strengthen health systems with the view to universal health coverage (UHC) should include measures to improve HP performance. Understanding how HP is institutionalized, within the Department of Health (DoH) at multiple levels (national, provincial and local/district), could inform efforts to strengthen functioning and integration within health systems, thus addressing implementation gaps. The aim of this doctoral (PhD) research was to investigate HP capacity, organization and implementation. The thesis focuses on how HP is institutionalized within the South African health system. Methods: A case study approach was implemented using concurrent mixed methods [QUAL (quan)]. The methodological approach was applied to allow for a systems perspective on the “what” and the “how” of HP institutionalization in the South African DoH. Purposive sampling was used to select DoH settings and participants (both HP and non-HP staff) for the study, from national, two out of nine provinces that had the highest number of HP staff, one district within each province, and two sub-districts within each selected district and 12 PHC-facilities in the selected sub-districts. Snowball sampling was used to recruit external HP stakeholders. Data was collected over a three-month period (November 2017 - February 2018) using a combination of data collection methods. Firstly, qualitative in-depth interviews (n=37) with HP managers, health promoters (HPPs), and facility-managers. Secondly, key informant interviews (n=8) with academia, research and non-governmental organization participants. Thirdly, one-day workshops (n=5) with DoH and HP managers, which used a quantitative capacity assessment tool and elicited in-depth discussions. Lastly, document reviews of the national HP policy and strategy (2015-2019), PHC revitalization implementation guidelines, as well as HP provincial and district level plans were completed. Qualitative data were analyzed using deductive and inductive content analysis using the aid of MAXQDA software. Descriptive statistics were used to analyze quantitative data using STATA 13 software. Mean capacity scores within and across different domains were calculated with standard deviations. Findings: The study demonstrates limited collective capacity to prioritize, plan, deliver, monitor and evaluate HP activities among HP practitioners within the DoH, alongside inadequate institutional capacity to support an effective health promotive agenda, manifesting as systemic barriers against the organization and implementation of HP programming. Fundamental structural factors that impede integration of HP into the fabric of the South African health system include a robust curative-focused approach. This confines the strategic vision for HP within the DoH, further compounded by a limited understanding of the HP concept. There is lack of credibility in the HP programme among those in positions of power at the DoH, which result in insufficient financial investment in HP activities. Programmes with greater resources such as HIV run parallel HP activities. As a result, HP practitioners and their leadership experience feelings of moral distress and an identity crisis within the health system. There is limited collective capacity among HP staff, resulting from inadequate training in HP and the lack of professional classification. As a result, the HP workforce generally feels powerless to change perceptions of low status ascribed to the field and the numerous challenges it faces. Additionally, data suggests inadequate vision and leadership to consider stakeholder coordination and multi-sectoral collaboration as part of the HP role, particularly at national DoH. Despite these results, the analyses show that health promoters have a critical role to play in PHC revitalization, such as provision of support and supervision to CHWs and other community-based initiatives. However, there is no mechanism for HP lessons from the field to be fed into the system to strengthen institutionalization of HP. Conclusions: My PhD provides empirical evidence for the need to re-orient the structure of the South African health system to integrate HP, from the strategic level to the coalface. Given the current status quo, HP is unlikely to bring about any large-scale reductions in the high need for health care among the population, or win the scramble over resources with curative services. Leadership responsible for budget allocations make a limited budget available for HP at any level. The mechanisms for feedback from HP staff implementing activities on the ground are lacking. These factors among others would need to be addressed in order to strengthen institutionalization. Thus, HP will remain a Cinderella service as it is today, with limited meaningful commitment. In order to strengthen HP, strategic oversight from an entity such as an independent or semi-autonomous HP Foundation that will support the HP agenda through prioritization, coordinate funding and contribute to evidence based health public policy, research, advocacy, multi-sectoral planning is required in South Africa.
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, 2020