Bringing them on board: putting health policy into practice in South Africa

The successful implementation of health policy requires the backing of health care practitioners, managers, and patients. In South Africa, the introduction of free health care, although supported in principal by nurses and health facility managers, faced resistance as workloads increased and staff felt excluded from a centrally prescribed policy.

Proponents of a 'street-level bureaucracy' approach to policy implementation acknowledge the day-to-day methods to cope with pressures that are adopted by frontline health care providers in the face of high demand for their services.  It is these mechanisms, they argue, that effectively become public policy, rather than the decisions taken by central government. However, few studies have examined the influence of frontline staff on the implementation of changes in policy.  

This study, by researchers at the University of Witwatersrand, examines the influence of nurses and clinic coordinators on the implementation of one health policy reform in South Africa: the introduction of free health care. The study aims to understand a group of nurses' experiences during the implementation of the policy.  It gives particular attention to the personal and professional consequences of the policy for the nurses, the factors that influenced their responses to the policy, and what they see as the barriers to effective policy implementation.

Findings from the study include:

• The majority of nurses believed the policy to be good for patients, but also reported that it had increased their own workload, and that this had negative effects for themselves on both personal and professional levels.
• A large majority of nurses believed that patients abused the free health care system, and that many were ‘not genuine patients’.
• Two issues were cited as central problems for delivery of free care: limited availability of resources such as drugs and other clinic supplies, and poor planning and communication.
• The majority of nurses felt isolated, overlooked and excluded from the policy process.
• Frustrations over the lack of consultation were compounded by perceptions of poor working conditions and low salaries, resulting in feelings of being undervalued and disempowered.
• Two out of the three clinic coordinators interviewed reported feeling as disempowered in the process of implementation, and as unrecognised, as their nursing staff.

Nurses were expected to implement a policy, about which they had been neither informed nor consulted, regardless of its impact on their daily practice. The categorising and blaming of patients by nurses indicates how the latter's views and values influence their response to the policy itself. It represents a means of coping in an often frustrating working environment. Such behaviour influences the implementation of the policy: for the least powerful patients, the benefits of removing financial barriers to treatment may have been counterbalanced by worsening provider attitudes. The researchers recommend that:

• communication, consultation, and the generation of a shared understanding of policy goals between providers, patients and policy-makers, is crucial to prevent distortion of policies during implementation
• the role of facility managers should be strengthened and the important role of nurses and clinic teams during policy implementation must be recognised
• planning and management must be improved in ways that demonstrate respect and trust for nurses.

Whilst improvement in central-level planning and management are important, they are not sufficient for the effective implementation of policy.  The legitimacy of a new policy must also be recognised by the nurses or other frontline staff responsible for its implementation. 

Source(s):
"We are bitter but we are satisfied": nurses as street-level bureaucrats in South Africa', Social Science and Medicine 59: 1251-1261, by L. Walker and L. Gilson, 2004
HINARI subscribers can access the full-text article here. Full document.

Funded by: European Union; USAID Partnerships for Health Reform project; South African Medical Research Council

id21 Research Highlight: 10 May 2005

Further Information:
Liz Walker
Wits Institute for Social and Economic Research
PO Wits 2050
South Africa

Tel: +27 11 717 4226
Fax: +27 11 717 4235
Contact the contributor: walkere@wiser.wits.ac.za

University of the Witwatersrand, South Africa

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'Political support is crucial for health polciy reforms in South Africa'

'A more just society: health spending in South Africa'

'The colour of money - healthcare financing in post-apartheid South Africa'

'Health-wealth unhappiness: healthcare inequalities in South Africa'

'Improving the quality of primary health care: public and private provision'

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