How and why policy-practice gaps come about: A South African Universal Health Coverage context

Janet Michel, Natsayi Chimbindi, Nthabiseng Mohlakoana, Marsha Orgill, Till Winfried Bärnighausen, Brigit Obrist, Fabrizio Tediosi, David Evans, Di McIntryre, Hans T.A. Bressers, Marcel Tanner

Research output: Contribution to journalArticleAcademicpeer-review

14 Downloads (Pure)


South Africa, like many other countries is currently piloting National Health Insurance (NHI) reforms aimed at achieving Universal Health Coverage (UHC). Existing health policy implementation experience has demonstrated that new policies have sometimes generated unexpected and negative outcomes without necessarily explaining how these came about. Policies are not always implemented as envisioned, hence the importance of understanding the nature of policy implementation.
Qualitative data were collected during three phases: 2011-2012 (contextual mapping), 2013-2014 (phase 1) and 2015 (phase 2). In-depth face-to-face interviews were held with key informants (n=71) using a theory of change interview guide, adapted for each phase. Key informants ranged from provincial actors (policy makers) district, subdistrict and primary health care (PHC) facility actors (policy implementers). All interviews were audio-recorded and transcribed. An iterative, inductive and deductive data analysis approach was utilized. Transcripts were coded with the aid of MAXQDA2018 (VERBI software GmbH, Germany).
Five groups of factors bringing about policy-practice gaps were identified. (i) Primary factors stemming from a direct lack of a critical component for policy implementation, tangible or intangible (resources, information, motivation, power); (ii) secondary factors stemming from a lack of efficient processes or systems (budget processes, limited financial delegations, top down directives, communication channels, supply chain processes, ineffective supervision and performance management systems); (iii) tertiary factors stemming from human factors (perception and cognition) and calculated human responses to a lack of primary, secondary and or extraneous factors, as coping mechanisms (ideal reporting and audit driven compliance with core standards); (iv) extraneous factors stemming from beyond the health system (national vocational training leading to national shortage of plumbers); and (v) an overall lack of systems thinking.
South Africa needs to be applauded for adopting UHC. Noteworthy among factors fueling policy-practice gaps are human factors, perception and responses of actors in the system to a lack of resources, processes and systems, through among others, ideal reporting and audit driven compliance with core standards, bringing about an additional layer of unintended consequences, further widening that gap. Utilizing a systems approach to address challenges identified, could go a long way in making UHC a reality.
Original languageEnglish
Article numbere2019069
Pages (from-to)1-32
Number of pages32
JournalJournal of global health reports
Publication statusPublished - 2019


  • South Africa
  • Universal health coverage
  • Global health

Fingerprint Dive into the research topics of 'How and why policy-practice gaps come about: A South African Universal Health Coverage context'. Together they form a unique fingerprint.

Cite this