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

Bibliographic Data

ID15127245
AuthorsKarina Kielmann (0000-0001-5519-1658, Queen Margaret University, corresponding author), Lindy Dickson-Hall (University of Cape Town), Waasila Jassat (0000-0003-4279-3056, University of the Western Cape), Sacha Le Roux (University of Cape Town), Mosa Moshabela (0000-0002-9438-7095, Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa), Helen Cox (0000-0001-8949-9335, University of Cape Town), Anne D Grant (0000-0002-2437-5195, Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa), Marian Loveday (0000-0001-9205-9314, Health Systems Research Unit, South African Medical Research Council), Jeremy Hill (0000-0002-3749-6519, University of Cape Town), Mark P Nicol (0000-0002-1366-4805, University of Cape Town), Koleka Mlisana (0000-0002-8436-3268, University of KwaZulu-Natal), John Black (0000-0002-9602-8416, Livingstone Hospital)
Year2021
Volume36
Issue3
Pages249-259
Publication date2021-04-21
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueHealth Policy and Planning (JOURNAL)
Journal identifiersISSN: 0268-1080 • E-ISSN: 1460-2237
PublisherOxford University Press (PUBLISHER • GB)
DOI10.1093/heapol/czaa147
PMID33582787
OpenAlexW3112685559
LanguageEN
Citations received5
References cited35

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

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