Assessing Health Policy Implementation in South Africa: Case Study of HIV Universal Test and Treat

Abstract

Successful policy implementation is dependent upon implementation planning at all stages of the policy process. Addressing implementation barriers at the subnational level is fundamental to achieving the Republic of South Africa’s national health targets, such as UNAIDS’ 90-90-90 targets. Semi-structured interviews were conducted with 55 staff across four purposefully selected provinces and districts in South Africa to explore facilitators of and barriers to implementing national health policy. The interviews further assessed barriers to implementing South Africa’s Universal Test and Treat (UTT) Strategy for HIV Positive Patients and Differentiated Care for Stable Patients policy. Thematic analysis of the coded interviews identified ten key factors affecting policy implementation at the subnational level; four factors relating to the decentralized policy context and six factors relating to the elements of effective policy implementation. Specific to UTT, participants expressed challenges in interpreting policy details and providing quality care in the face of staff shortages and an increased uptake of HIV testing services. Strengthening elements of effective policy implementation to attain national health goals demands commitment and motivation at all levels, from national leaders to frontline implementers. To address the key factors affecting policy implementation in the decentralized context, six strategies are proposed: maximize integration of health policies across programs; model implementation timelines and resources during policy development; strengthen consultations with subnational governments and frontline implementers during all stages of the policy process; develop standardized processes to improve access to policy documents; strengthen training systems for policies; and establish feedback loops to address implementation barriers as they arise.