‘We had to manage what we had on hand, in whatever way we could’: adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa

Abstract

In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors’ capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of ‘hardware’, i.e. resources and skills to deliver an intervention, a notable absence of systems ‘hardware’ meant that systems ‘software’, i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. ‘Software readiness’ was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems ‘readiness’ assessments would include definition and evaluation of HCW ‘software’ and adaptive capacities in the face of systems hardware gaps.

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.…”

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

“…We did not set out to specifically examine the role of champions in decentralised DR-TB care, although the role of key individuals at both policy and programme levels became clear to the research team following analysis of our data early on in the project. 17 Accordingly, our paper has adopted an inductive, realist approach by focusing on one key theme emerging in our study of decentralised care models. We draw on a relatively small but in-depth set of interviews conducted in a context that the research team became very familiar with over the course of the 4 years.…”

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

“…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.…”