The role of emergent champions in policy implementation for decentralised drug-resistant tuberculosis care in South Africa

Abstract

ObjectiveChampions are recognised as important to driving organisational change in healthcare quality improvement initiatives in high-income settings. In low-income and middle-income countries with a high disease burden and constrained human resources, their role is highly relevant yet understudied. Within a broader study on policy implementation for decentralised drug-resistant tuberculosis care in South Africa, we characterised the role, strategies and organisational context of emergent policy champions.DesignInterviews with 34 healthcare workers in three South African provinces identified the presence of individuals who had a strong influence on driving policy implementation forward. Additional interviews were conducted with 13 participants who were either identified as champions in phase II or were healthcare workers in facilities in which the champions operated. Thematic analyses using a socio-ecological framework further explored their strategies and the factors enabling or obstructing their agency.ResultsAll champions occupied senior managerial posts and were accorded legitimacy and authority by their communities. ‘Disease-centred’ champions had a high level of clinical expertise and placed emphasis on clinical governance and clinical outcomes, while ‘patient-centred’ champions promoted pathways of care that would optimise patients’ recovery while minimising disruption in other spheres of their lives. Both types of champions displayed high levels of resourcefulness and flexibility to adapt strategies to the resource-constrained organisational context.ConclusionPolicymakers can learn from champions’ experiences regarding barriers and enablers to implementation to adapt policy. Research is needed to understand what factors can promote the sustainability of champion-led policy implementation, and to explore best management practices to support their initiatives.

Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study

“…Since HIV care in South Africa is highly decentralised, HIV status did not appear to affect the degree of decentralisation for people with MDR/RR-TB, even for people living with HIV who had low CD4 values. The dot model, where services are provided closest to the community is likely to be most family centred, but may be less ideal where home social circumstances are difficult, or where people with MDR/RR-TB require highly specialised care 58. In the latter circumstances, models, such as triangle, which are intrinsically more flexible, and responsive to changing patient needs, while containing a mix of care expertise, levels and disciplines may be more appropriate.…”

Strengthening accountability for TB policy implementation in South Africa: perspectives from policymakers, civil society and communities

“…This lack of frontline champions, compared to HIV and drug-resistant TB policy development in South Africa, meant that there are not su cient examples where components of the TB Recovery Plan were adapted to local contexts and implemented successfully. (11,12) A stronger bottom-up approach should include input from frontline health workers on resourcing requirements and build coalitions at local level to advocate for policy implementation.…”

“…Le Roux and Kielmann described the implementation of this policy through focussing on the role of policy champions as a key resource for policy implementation, particularly at service delivery level, where they can help overcome resistance to implementation. (11,12) Community-led responses and civil society engagement can make important contributions to ensure policies are responsive to the needs of people affected by TB, and could also form part of bottom-up implementation strategies. Yet, the perspectives of civil society organisations (CSOs) and TB affected communities on accountability for TB policy implementation, and how they may contribute to bottom-up implementation, is not well articulated in the academic literature.…”

Strengthening accountability for TB policy implementation in South Africa: perspectives from policymakers, civil society and communities

“…Lessons from HIV and drug resistant TB policy implementation include having CSOs as champions that advocate for local implementation and that engage communities in new policies being released. (11,12,14) An example is the treatment literacy campaigns for people living with HIV that the Treatment Action Campaign ran, which stimulated demand and emphasised the critical implications of policy implementation for people living with HIV. (14)To ensure a strong bottom-up approach for the TB Recovery Plan, input from frontline health workers on resourcing requirements and other implementation barriers should be included, alongside community collaborations at local level to advocate for policy implementation.…”

“…Le Roux and Kielmann described the implementation of this policy through focussing on the role of policy champions as a key resource for policy implementation, particularly at service delivery level, where they can help overcome resistance to implementation. (11,12) Community-led responses and civil society engagement can make important contributions to ensure policies are responsive to the needs of people affected by TB and could also form part of bottom-up implementation strategies. Yet, the perspectives of civil society organisations (CSOs) and TB affected communities on accountability for TB policy implementation, and how they may contribute to bottom-up implementation, are not well articulated in the academic literature.…”