Whole System Change in South Africa: Understanding the experience of health system transformation in the Western Cape province (WholeSyst-SA)

Twenty years after the ending of apartheid the time is ripe to evaluate South African experience of health system transformation. Much was promised and many changes have been introduced - but how much has been achieved, especially for the most vulnerable and previously disadvantaged groups? What factors have enabled or constrained change across the public health system, nationally recognised as the leading edge of efforts to improve the health and well-being of vulnerable groups? What lessons does past experience hold for continuing efforts to improve health care and health? What issues need to be tracked over time to generate the evidence needed to support future policy and managerial decision-making? This proposed grant intends to address these questions. It is jointly submitted by a team of public health system policy-makers/managers and researchers based in the Western Cape (WC) province. As South Africa is a quasi-federal state, the WC provincial government has the constitutional responsibility for ensuring an effective health system for its population. It also has a reputation for having been relatively effective in sustaining implementation of such change over the last 20 years. Examining the particular experience of one province, in comparison with wider national experience, will allow in-depth investigation of South African health system transformation. The project will consider not only what changes have been implemented, with what achievements and challenges, but also what set of political, leadership, organisational and other factors have supported or limited the implementation of change. From this analysis it will seek to identify the pathways to change underpinning health system development in the province. The project team's combination of experience and expertise will support this in-depth investigation. Better understanding of what the province has achieved and how, set against the national context, will offer insights of relevance across the country, as well as internationally. It will also, more specifically, contribute to generating the evidence base needed to support future policy and management decision-making, by supporting provincial health system monitoring and evaluation activities and identifying related, larger scale research needs.