Philosophiae Doctor - PhD / South Africa has not responded well to recommendations in national evaluation reports to address human resource challenges associated with the implementation of nutrition programmes and improved service delivery. Twenty-four years have passed since the dawning of democracy and the nutrition situation within the population has actually deteriorated, with persistently high levels of stunting in young children and the growing prevalence of overweight and obesity in all age groups. These conditions not only rob people of their potential, but they carry a high cost for the state and society as a whole. This study aimed to develop a comprehensive and empirically sound nutrition workforce development planning framework for the public health sector so that it is better equipped to address the nutrition-related burden of disease in South Africa. The study explored the provision of nutrition services in South Africa, focusing on the nutrition-specific work components of health personnel ‒ doctors, nurses, dietitians, nutritionists, health promoters and community health workers working at the primary health care level in the public health sector. Evidence-based workforce information was collected through a mixed methodology comprising: literature reviews, document reviews, analysis of scopes of practice, job descriptions, competencies, workforce surveys, key informant interviews and consensus assessments through the application of the Delphi technique. Permission was obtained to adapt and use questionnaires from an Australian workforce study. Ethical approval, permission to conduct the study and informed consent were obtained prior to the commencement of the interviews. Data was then analysed using descriptive statistics, content and thematic analysis and triangulation of all findings, followed by consensus assessments to describe the nutrition workforce and delineate the roles and functions thereof. The comprehensive planning framework that was developed was applied to the Western Cape province.

PROBLEM: As part of Indonesia’s strategy to achieve the goal of Universal Health Coverage (UHC), large investments have been made to increase health access for the poor. These have resulted in the implementation of various public health insurance (PHI) schemes, including Jamkesmas, the largest health insurance program in Indonesia in 2012, targeted towards the poor and near-poor. In the backdrop of Indonesia’s aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. With the implementation of various pro-poor PHI programs in Indonesia, there is limited understanding of how these programs impact maternal health services among poor women. METHODS: This study used a mixed-methods design. The quantitative component entailed secondary analysis of the Indonesian Demographic and Health Survey (IDHS) from 2007 and 2012 on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). Qualitative interviews (n=55) were conducted from May-Aug 2015 in the province of Jakarta and Banten among community representatives and key stakeholders to describe the successes and challenges of health insurance membership and maternal health services among the poor. RESULTS: Controlling for all independent variables, poor women with Jamkesmas were 21% (OR=1.21 [1.05–1.39]) more likely to have HFD and 20% (OR=1.20 [1.03–1.39]) more likely to have SBD compared to poor women without health insurance. Qualitative interviews provide some explanation to the modest effect of Jamkesmas health insurance on HFD and SBD seen in the quantitative analysis, including: the preference for pregnant women to deliver in their parents’ village; the use of traditional birth attendants; lack of proper documentation for health insurance registration, distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation. CONCLUSION: Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings indicate that pro-poor PHI schemes may be able to reduce financial barriers to care. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.

Philosophiae Doctor - PhD / This study is a philosophical analysis of the National Health Insurance (NHI) policy and legislation, including the related NHI Fund, with a view to assessing its prospects in realising Universal Health Coverage (UHC). The NHI system is about ensuring universal access to quality healthcare for all. The rationale is to provide free healthcare for all at the point of care/service. This legislation has the potential to transform, on the one hand, the relationship between the public and private healthcare sectors and, on the other, the nature of public funding for healthcare. Part of the challenge with the NHI system is that it seeks to provide healthcare for all, but by seeking to integrate the private sector it runs the risk of commercializing healthcare. The study is philosophical in that it holds that ideas have consequences (and conversely actions have presuppositions with certain meanings). In part, it aims to show that an implementing mechanism of the NHI system as presently envisaged has socio-political and economic implications with fundamental contradictions within it; for it seeks to incorporate the private healthcare sector in offering free public healthcare services. This introduces a tension for private healthcare services operate with a neoliberal outlook and methodology which is at odds with a public approach that is based on a socialist outlook. The analysis may make explicit conceptual and ideological tensions that will have practical consequences for healthcare. Much of the commentary on the NHI system have focused on the practical consequences for healthcare; my intervention is to explore and critically assess the various philosophical assumptions that lie behind these practical concerns. Some of these practical consequences are related to the possibility that healthcare is likely to become commercialized and the public healthcare sector will remain in a crisis. This study argues for the provision of access to high quality healthcare facilities for all members of the South African population. Healthcare must be provided free at the point of care through UHC legislation or by the setting up of the NHI Fund as financing mechanism. The study provides reason for the decommercialization of healthcare services completely – that is for eliminating private healthcare from contracting with the NHI Fund. Essentially, it argues for the claim that healthcare should not be traded in the market system as a commodity and that the NHI system in its current incarnation seeks to do precisely that. I further argue that in theory and in practice the neoliberal and socialist assumptions underlying the NHI system in its present formulation do not fit together. On the contrary, rather than a two-tiered system incorporating the private and public healthcare sectors, the dissertation argues for a different way of conceptualizing the NHI system that privileges the latter.

Magister Legum - LLM / In South Africa, there are two health systems through which health services are delivered,1 namely private and public. These two systems were inherited from the apartheid regime.2 With South Africa’s political change from a system of parliamentary sovereignty to a constitutionally supreme system in 1996, huge changes were bound to come including changes to the health sector.3 This meant the overhauling of health legislation, as the right of access to health care services became guaranteed in the Constitution of the Republic of South Africa, 1996.4 In 1997, the White Paper on the Transformation of the Health System (White Paper on Health)5 was introduced with the aim of developing a national health system.6 There has been a lot of progress made in reforming the health sector, however there are still many cracks that the national government aims to remedy through the realisation of universal health coverage (UHC).

Health financing policies implemented by nations around the world vary based on who receives coverage and what health system resources are covered. Although, many health systems are attempting to move towards Universal Health Coverage, part of their populations continue to incur out-of-pocket payments for using all or some health services. Some health systems restrict health insurance for certain migrant populations, providing coverage for emergency care only, or none at all. Other health systems fail to provide coverage for prescription drugs, leaving those without the ability to pay out-of-pocket for medications behind. The lack of financial protections against catastrophic or impoverishing healthcare expenditures for these patients may deter them from seeking the care they need or increase the risk of severe financial hardships. This dissertation addresses these migrant and drug coverage gaps by examining the impacts of health financing policies and how these can be changed to move health systems towards Universal Health Coverage. First, this dissertation examines restrictions to refugee health policy in Canada by conducting an interpretive policy analysis to reveal how political actors strategically use causal stories to enact policy change. Second, quantitative studies assessing the effects of health insurance on migrants’ health-related outcomes are systematically reviewed. Third, this dissertation explores a provincial health system without universal prescription drug coverage to establish associations between health services use, prescription drug coverage and immigrant category. Finally, given migrants experience health outcome and health services utilization disparities, an exploratory analysis of factors that impede or assist migrants’ access to prescription drugs is conducted to uncover how these factors influence their health. While each study is distinct, together, these chapters build on each other using mixed methodological approaches to identify ways that address health financing policy gaps to reduce health inequities, build inclusive and cost-effective health systems and strengthen global health security. / Dissertation / Doctor of Philosophy (PhD)

La loi du 27 juillet 1999 portant création de la couverture maladie universelle est intervenue dans le cadre d'une politique générale de lutte contre l'exclusion. Afin d'améliorer l'accès aux soins d'un nombre croissant de personnes pauvres, les socialistes ont élaboré un dispositif comportant deux volets. Le premier volet visait la généralisation de l'assurance maladie, en permettant l'affiliation au régime général sur un critère subsidiaire de résidence. Le second volet avait pour ambition d'offrir une couverture santé complémentaire, aux millions de personnes qui n'en bénéficiaient pas. Cette prestation étant soumise au respect d'une condition de résidence et d'une condition de ressources. L'ensemble du dispositif instauré par la loi CMU s'est substitué à l'aide médicale départementale et à l'assurance personnelle. L'ampleur des inégalités de santé, touchant en premier lieu les individus les plus pauvres et les plus isolés de la société, a conduit au bon accueil général de la loi CMU. Cependant, bien que considérée comme une grande loi de santé publique, certaines mesures ont été le théâtre de débats et d'oppositions, tant sur la scène politique que dans la société. Cela a été le cas concernant l'effet de seuil induit par l'instauration d'un plafond de ressources, le risque de déresponsabilisation des bénéficiaires ayant accès gratuitement au dispositif, les règles de financement essentiellement basées sur des taxes et contributions publiques, le choix d'une gestion partenariale entre sécurité sociale et partenaires privés, ou encore concernant la réticence d'une minorité de professionnels de santé à l'égard du dispositif. / The law of the bearing July 27th, 1999 creation of the universal health coverage intervened within the framework of a general policy of fight against exclusion. In order to improve the access to the care of a growing number of poor people, the Socialists worked out a device comprising two facets. The first facet aimed at the generalization of the health insurance, by allowing the affiliation the general scheme on a subsidiary criterion of residence. The second facet had as an ambition to offer a complementary coverage health, to the million people who did not profit from it. This service being subjected to the respect of a condition of residence and a condition of resources. The whole of the device founded by law CMU replaced for the departmental medical assistance and the personal insurance. The extent of the inequalities of health, concerning initially the poorest individuals and most isolated from the society, led to general warm welcome of law CMU. However, although regarded as a great law of public health, certain measurements were the theatre of debates and oppositions, as well on the political scene as in the society. That in particular was the case concerning the effect of threshold induced by the introduction of a ceiling of resources, the risk of deresponsabilisation of the recipients having access free to the device, rules of financing primarily based on public taxes and contributions, the choice of a partnership management between social security and private partners with in particular the organizations of complementary health, or concerning the reserve of a minority of health professionals with regard to the device leading to refusal of care.

In 2013, Peru initiated a reform process under the premise of recognizing the nature of health as a right that must be protected by the state. This reform aimed to improve health conditions through the elimination or reduction of restrictions preventing the full exercise of this right, and the consequent approach aimed to protect both individual and public health and rights within a framework characterized by strengthened stewardship and governance, which would allow system conduction and effective responses to risks and emergencies. The reform led to an increase in population health insurance coverage from 64% to 73%, with universalization occurring through the SIS affiliation of every newborn with no other protection mechanism. Health financing increased by 75% from 2011, and the SIS budget tripled from 570 to 1,700 million soles. From 2012 to May 2016, 168 health facilities have become operational, 51 establishments are nearing completion, and 265 new projects are currently under technical file and work continuity with an implemented investment of more than 7 billion soles. Additionally, this reform led to the approval of the Ministry of Health intervention for health emergencies and strengthened the health authority of the ministry to implement responses in case of risks or service discontinuity resulting from a lack of regional or local government compliance with public health functions. / In 2013, Peru initiated a reform process under the premise of recognizing the nature of health as a right that must be protected by the state. This reform aimed to improve health conditions through the elimination or reduction of restrictions preventing the full exercise of this right, and the consequent approach aimed to protect both individual and public health and rights within a framework characterized by strengthened stewardship and governance, which would allow system conduction and effective responses to risks and emergencies. The reform led to an increase in population health insurance coverage from 64% to 73%, with universalization occurring through the SIS affiliation of every newborn with no other protection mechanism. Health financing increased by 75% from 2011, and the SIS budget tripled from 570 to 1,700 million soles. From 2012 to May 2016, 168 health facilities have become operational, 51 establishments are nearing completion, and 265 new projects are currently under technical file and work continuity with an implemented investment of more than 7 billion soles. Additionally, this reform led to the approval of the Ministry of Health intervention for health emergencies and strengthened the health authority of the ministry to implement responses in case of risks or service discontinuity resulting from a lack of regional or local government compliance with public health functions.

The South African government intends to overhaul the entire public health system by introducing the National Health Insurance (NHI) system. The implementation of the NHI has created concerns amongst the majority of South African citizens who have a poor image of the quality of services provided by the public sector. One of the major questions that this study attempted to address was whether one of the largest clinics in Soweto could deliver quality healthcare in terms of the proposed NHI system. The study conducted is quantitative in nature and two-pronged. The first part of the study involved a survey conducted amongst staff members at the Soweto clinic to determine their awareness of the National HeaIth Insurance (NHI) and their knowledge of the National Core Standards (NCS). The second part of the study used an assessment questionnaire to determine compliance of the Soweto clinic to the six ministerial priority areas. The results of the survey conducted among the Soweto clinic’s staff members in all staff categories, showed that there is general awareness amongst staff members of National HeaIth Insurance and they have some knowledge of the NCS; however, more education on NHI and NCS is needed for staff working in specialised or isolated departments who are unaware of NHI and have no knowledge of the NCS. The Soweto clinic showed some advancement with regard to the vital measures compliance scores compared to those of the rest of the Gauteng province in the three priority areas. The Soweto clinic has, however, failed to comply under the other four ministerial priority areas, with ratings of less than 80%. This study has shown a disconnect between knowledge of the NCS and the NCS’s implementation by staff members, as staff members have failed to implement or comply with four of the ministerial priority areas, with sub-standard ratings of less than 80%. The Non-NHI clinic is still very far from ensuring the provision of basic quality health service for its clients and it is, thus, not ready to implement NHI. Recommendations from the study: - Managers must drive the quality improvement agenda for their facilities. - Awareness campaigns and more knowledge on NHI and quality improvement (NCS) must be communicated to all staff categories in the health establishments to ensure a deeper understanding of these concepts. - Workshops must be conducted for all staff members in the Soweto clinic, to support the creation of a culture of excellence, with emphasis in providing quality care to clients. Similar future studies need to be conducted on a large scale such as in the whole of Gauteng to determine staff at health establishments’ knowledge of the quality NCS. / MBA, North-West University, Potchefstroom Campus, 2015

The South African government intends to overhaul the entire public health system by introducing the National Health Insurance (NHI) system. The implementation of the NHI has created concerns amongst the majority of South African citizens who have a poor image of the quality of services provided by the public sector. One of the major questions that this study attempted to address was whether one of the largest clinics in Soweto could deliver quality healthcare in terms of the proposed NHI system. The study conducted is quantitative in nature and two-pronged. The first part of the study involved a survey conducted amongst staff members at the Soweto clinic to determine their awareness of the National HeaIth Insurance (NHI) and their knowledge of the National Core Standards (NCS). The second part of the study used an assessment questionnaire to determine compliance of the Soweto clinic to the six ministerial priority areas. The results of the survey conducted among the Soweto clinic’s staff members in all staff categories, showed that there is general awareness amongst staff members of National HeaIth Insurance and they have some knowledge of the NCS; however, more education on NHI and NCS is needed for staff working in specialised or isolated departments who are unaware of NHI and have no knowledge of the NCS. The Soweto clinic showed some advancement with regard to the vital measures compliance scores compared to those of the rest of the Gauteng province in the three priority areas. The Soweto clinic has, however, failed to comply under the other four ministerial priority areas, with ratings of less than 80%. This study has shown a disconnect between knowledge of the NCS and the NCS’s implementation by staff members, as staff members have failed to implement or comply with four of the ministerial priority areas, with sub-standard ratings of less than 80%. The Non-NHI clinic is still very far from ensuring the provision of basic quality health service for its clients and it is, thus, not ready to implement NHI. Recommendations from the study: - Managers must drive the quality improvement agenda for their facilities. - Awareness campaigns and more knowledge on NHI and quality improvement (NCS) must be communicated to all staff categories in the health establishments to ensure a deeper understanding of these concepts. - Workshops must be conducted for all staff members in the Soweto clinic, to support the creation of a culture of excellence, with emphasis in providing quality care to clients. Similar future studies need to be conducted on a large scale such as in the whole of Gauteng to determine staff at health establishments’ knowledge of the quality NCS. / MBA, North-West University, Potchefstroom Campus, 2015

La Couverture Santé Universelle (CSU) vise permettre à chaque individu d’utiliser les services de santé dont il a besoin sans risque de ruine financière ou d’appauvrissement. Bien que le concept de CSU offre un cadre directeur important pour une nation, tous les pays, quel que soit leur niveau de revenu, sont aux prises avec la réalisation ou le maintien de la couverture universelle. Dans ce contexte, générer des preuves sur les expériences des pays et partager les leçons sur les principales contraintes et les choix stratégiques utilisés pour surmonter les barrières techniques serait susceptible de permettre aux pays à revenus faibles ou intermédiaires d’aller de l'avant et de progresser plus rapidement vers la CSU. La thèse propose une analyse comparative de plusieurs instruments politiques, utilisés par cinq cas pays (Niger, Vietnam, Bangladesh, Gabon, France), pour étendre la couverture sanitaire et la protection financière. L’analyse montre que les interventions simples, comme la suppression des frais des utilisateurs (Niger) ou de l'assurance santé à base communautaire (Bangladesh), peuvent accroître l'utilisation des services pour les groupes les plus défavorisés, mais font face à de fortes limitations dans l’atteinte de plus grandes ambitions. Des réformes plus articulées ont démontré des gains importants dans le développement de la couverture santé, mais font également face à des défis pour trouver l'espace budgétaire suffisant (Gabon) et améliorer l’efficience et l'équité du système (Vietnam). Enfin, la thèse analyse les effets de différentes réformes utilisées pour maintenir les gains de la CSU dans des systèmes de santé mûrs, tel que la France. Dans l'ensemble, la thèse a démontré que le menu des réformes vers la couverture universelle est vaste, complexe et perpétuel mais que certains chemins peuvent conduire au succès. / Universal Health Coverage (UHC) is to ensure that everyone can use the health services they need without risk of financial ruin or impoverishment. While the UHC concept offers a powerful framework for a nation, all countries, irrespective of their income level, are struggling with achieving or sustaining universal coverage. In this context, generating evidence about countries’ experiences and sharing lessons on key constraints and strategic choices used to overcome technical barriers would likely enable low-and-middle countries to move forward and make faster progress toward UHC. The thesis provides a comparative analysis of policy instruments used by five selected country cases (Niger, Vietnam,Bangladesh, Gabon and France), to expand health coverage and financial coverage. Analysis shows that single interventions, like user fee removal (Niger) or community-based insurance (Bangladesh), can increase service utilization for the most disadvantaged groups but face strong limitations toward greater ambitions. More articulated reforms have demonstrated significant gains in expanding health coverage but also face challenges in finding the adequate fiscal space (Gabon) and in strengthening system’s efficiency and equity (Vietnam). Finally, the thesis analyzed the effects of different reforms used to sustain gains of UHC in mature health systems, like France. Overall, the thesis demonstrated that the reform agenda for universal coverage is large, complex and perpetual but that certain pathways can ensure success.