Millions of people need palliative care worldwide for symptoms associated with life-threatening illnesses, yet few receive it. This is particularly true in low-and-middle income countries, meaning that most are left without support and pain relief at the end of their life. Access to palliative care is now being understood as a human right and the ethical responsibility of health systems. This has resulted in increased international focus and a call to integrate palliative care into health systems to promote access, and inversely to strengthen health systems. Yet how to do this in low-and-middle income countries is unclear. This study used scoping and systematic review methods to provide synthesised evidence on the approaches and interventions being used to integrate palliative care into African health systems, as well as describe lessons that can be learnt from these efforts. 40 articles were identified in the systematic review that described 51 different interventions that integrated palliative care into part of the health system in one or more African countries. The integration of palliative care services was rarely linked to health systems strengthening and concepts associated with integration were used inconsistently, if used at all. Core themes emerged on facilitators and barriers to the integration of palliative care into health systems. Facilitators included the use of a system-wide approach, the creation of sustainable partnerships, and making the patient central to integration interventions. The health system also needs to be able to support integration. This requires the presence of necessary policies and resources for palliative care, together with sufficient health workers who are trained and motivated to provide palliative care. Findings provide contextual evidence to guide implementors and decision makers seeking to integrate palliative care into health systems in Africa, as well as other low and-middle income countries.

Includes abstract. Includes bibliographical references.

The qualitative interpretive synthesis carried out for this MPH mini-dissertation reviews existing empirical literature for evidence on organisational culture and its influence on the implementation of health sector reforms in Low and Middle Income Countries. This mini-dissertation is organised into three parts: PART A: This is the review protocol which outlines the introduction, the background and the review questions for both the scoping review (which forms section B) and the qualitative interpretive synthesis ( which forms section C) along with their justifications. It also outlines the methodology for both the scoping review and the qualitative interpretive review. The literature search was carried out in eight electronic databases using key search terms developed from the review questions. Inclusion and exclusion criteria were developed to determine the articles for inclusion into the review. All the search terms, data extraction templates and summary tables used in both reviews are provided in this section. PART B: This is the literature review section which was carried out to map the scope of literature on organisational culture within the health sector in Low and Middle Income Countries in order to support the more detailed analysis in Section C. It begins with a general description of organisational culture and its conceptual frameworks, as well as a description of the tools used in assessing organisational culture that were identified from a broader reading of literature on organisational culture. The reviewer then describes the literature search strategy of the scoping review and maps the retrieved articles based on themes on organisational culture in the health sector. Lastly, the reviewer classifies the different dimensions of organisational culture identified in the reviewed articles using the Competing Values Framework in order to facilitate comparison of organisational culture across the studies. PART C: This is the full qualitative interpretive synthesis presented as a journal ready manuscript. This review begins with an introduction on health sector reforms and organisational culture. This is followed by a description of the methods used to identify the literature, an outline and synthesis of the findings, discussion section and lastly, the conclusion. The findings of this interpretive synthesis indicate the potential influence of various dimensions of organisational culture such as power distance, uncertainty avoidance, in-group and institutional collectivism, mediated through organisational practices, over the implementation of the health sector reforms. It also highlights the dearth of empirical literature around organisational culture and therefore, its results can only be tentative. There is need for health policy makers and health system researchers in Low and Middle Income Countries to conduct further analysis of organisational culture and change within the health system.

Objectives: In South Africa, and globally, community participation has become a key feature in the health system. In order for meaningful participation to occur within the health system several mechanisms have been identified as critical and this includes formation of health committees (HCs) at health facility level. Previous research indicates that health committees are imperative in both actualizing community participation and realisation of right to health. However, few studies have been undertaken to understand the impact training health committees has on community participation and right to health. This study sought to evaluate the impact training clinic health committees in community participation, health and human rights has on participation and right to health. The training been evaluated was led by Learning Network on Health and Human Rights and targeted four clinics in Cape Town Metropole of Western Cape, South Africa. The Learning Network is a grouping of five civil society organisations (CSOs) in Western Cape, South Africa at four universities which was launched in 2008 after the recognition of a gap in documented knowledge that CSOs had on health and human rights. The study explored health committees' changes in knowledge, perceived competencies, documented member's understanding of roles and HCs sustainability as well as the trainings impact on relationship between HCs and health service providers. Methods: The study was a multiple case study with multiple qualitative methods for data collection. Narrative data was collected through twelve in-depth interviews with health committee members, one facility manager, two focus group discussions and three physical observations across four health facilities. Health facilities were purposively selected from a list of health facilities trained by the Learning Network in 2014. Inclusion criteria also included English speaking health facilities and those in close proximity to each other. 2 Results: The study revealed that training HCs contributed to improved competencies, awareness and knowledge of community participation and the right to health. After the training, HC members were perceived to be more aware and responsive to their roles and responsibilities at the health facility. It was also noted that the training aided improved HCs perspectives on sustainability and roles, improved interpersonal skills and self-esteem. Conversely, the study revealed that despite the training improving participation and right to health, power imbalances between HC members and facility staff/managers who hold authority has a bearing on when and how participation occurs. Conclusion: The study demonstrates that training health committees contributed to improving the levels of community participation such as planning, consultation and advise [Arnstein, Rifkin and Loewenson] in the realisation of right to health. It is recommended for wider community participation that trainings of such magnitude are conducted together with facility managers/staff.

The high rate of Infant and child mortality, much of which is preventable, especially in developing countries, continues to be a global public health concern. Improving the numbers and competencies of child nurse professionals is vital for health system strengthening. Child nurses are important group of health professionals who are responsible for delivering effective health care services to infants and children at all levels of the health system, yet their training situation is being under-investigated. It is documented in various literatures that the high rate of under-five morbidity and mortality in South Africa can be prevented by strengthening the training needs of child nurses, in order to ensure that their competencies adequately align with the priority health needs of children who present at the health facilities. This dissertation is organized into three parts. Part A is the research protocol which outlines the background and the study methodology. Mixed methods comprising qualitative and quantitative methods is adopted for the study. Documentary review and self-administered structured questionnaire is used for the data collection. The questionnaire is designed by applying the basic principles that informs a good questionnaire design. Purposive sampling method is used for sampling the nursing institutions and research participants for inclusion into the study. Defined inclusion and exclusion criteria are used to identify and select the Nursing Education Institutions and key informants suitable for the study. The nursing institutions that are accredited with the South African Nursing Council and conducts child health nursing is an inclusion criterion for the study. In addition, key informants who are nursing educators with expertise knowledge in children's nursing are identified as an inclusion criterion for the study. Documentary review is used to extract secondary data that identifies the South African policy and legislative framework for general nursing and children nursing in particular. Documents will include appropriate policy and strategy documents. The workshop minutes of a sentinel Nurse Educator Forum that took place at Groote Schuur hospital in December of 2016 will be included as an important secondary data source. In addition, primary data collection will be done using a self-administered structured questionnaire where key informants will address a combination of qualitative and quantitative questions. The self-administered questionnaire is used to thoroughly investigate the current situation of children's nursing training in South Africa, with the aim of identifying the numbers trained annually for a five-year period and the curriculum foci of children nursing training across the nursing institutions that host children nursing programs in South Africa. Part B is the literature review which examines the preventable causes of under-five mortality in South Africa and the need to train up suitable, well qualified and competent Child Nurse Professionals needed to improve the health of infants and children in South Africa. Part C is the journal article manuscript which begins with the background and the study methods, followed by the results, discussion and conclusion. The result indicates that a total of five relevant policy and strategy documents were identified for the documentary review. Of the five documents, three documents suggest strategies for improving the nursing education and training programmes in South Africa. The strategies include increasing the supply of the nurse specialists, transforming all nursing colleges to Higher Education Institutions and improving the curriculum guidelines of the nursing programme, in order to ensure that the competencies taught to the nurses aligns with the health care needs of the communities. The two other documents posit the primary roles of the nursing professionals, which is to provide effective care and respect the rights of the health care users. The findings from the documentary review recommends that the nursing education in SA can be strengthened by identifying all nursing colleges as Higher Education Institutions, reviewing curricula and producing more numbers of competent nurses in South Africa. For the primary data collection, out of the seven accredited nursing institutions which conducts children nursing training in South Africa, five respondents from five institutions completed and forwarded their questionnaires. The completed questionnaires provided details on the profile of children's nursing training, including the annual numbers of children nurse trainees and graduates over a five-year period and details of their curriculum components. The results showed that a total of 637 children nurses were enrolled from 2012-2016. Of the 637, 587 graduated successfully which indicates that the number of child nurse trainees and those who successfully graduated over a five -year period across five nursing institutions were very impressive, although the number of child nurses produced annually are still few to address the child health needs in South Africa. In addition, the findings from the questionnaire reveals that the curriculum of children's nursing training across the five institutions are similar and contains topics that are capable of equipping the child nurses with the relevant skills necessary for improving the health of infants and children. However, they exist some variations in the degree the courses are covered by the institutions, as well as variations in the way the courses are conveyed to the nurse learners. For example, some topics where covered to a high degree by some institutions, while some where not covered at all, or where covered to some extent via classroom and clinical placement and assessments. This suggests that the curricula of child nursing in South Africa requires standardization and frequent reviewing to ensure it coincides with the child health needs in South Africa. The dissertation is likely to increase the knowledge of the current training situation of children's nursing in South Africa, and also identify gaps for future research. In addition, the dissertation also provides a better understanding of the curriculum foci of children's nursing training in South Africa and can help inform the human resource training plans for child health nursing in the country.

Background: Health policy analysis (HPA) is a central component of health systems research (HSR) and contributes significantly to the understanding of health systems reforms including their successes and failures. In most HPA studies, document reviews feature as one of the widely used data collecting methods, especially in retrospective policy analyses. Literature indicates that a substantial number of HPA studies conducted in low and middle-income countries (LMICs) are informed by interactive data collection methods such as interviews, focus group discussions (FGDs), and observations as well as non-interactive methods such as document reviews. While efforts have been made to look into the methodologies that inform health policy analyses for LMICs in the recent years, there is a dearth in knowledge specific to document reviews and how they fit into the framework for doing health policy analysis. This paper provides findings from a qualitative systematic review of peer reviewed policy analysis studies indicating the role of document reviews; why it is employed and how this methodology is positioned and motivated for in the LMICs. Methods: Nine electronic databases were explored in search of articles with adequate information relating to the use of document reviews in HPA studies conducted in LMICs. All 28 articles included in this review were conducted in LMICs between the years 2008-2016. Articles were in English with free full text accessibility. Data extraction focused on the aims of the HPA, and the methodology and results sections in order to identify why and how document reviews were employed in HPA. Results: Twenty-eight articles from LMICs that met the inclusion criteria and examined against a quality appraisal tool were included for thematic synthesis and analysis. Reasons as to why and how health policy analysts use document reviews was directly linked to accessibility and clarity of the document and the perceived contribution of a document to the HPA process. The more accessible the documents are, the more they are likely to be used in a policy analysis. Inductively, the author also considered ‘personal contact with policy makers’ in the identification of documents as another facilitator of document use in health policy analysis studies. Besides access, it is essential that the documents are clear and do not contain conflicting information so that at all phases, intentions of the policy and outcomes are clear to the document user. Apart from validating information obtained from other data collection methods, documents have also been noted to act as advocacy instruments in the health policymaking arena. However, the results have failed to explain as to why policy analysts using document reviews fail to fully describe, quantify or properly display the data obtained from documents used. Conclusion: To the best of the author’s knowledge, this is the first systematic review that has looked into a specific data collection method adapted by many health policy analysts in the LMICs. HPA researchers will always draw on documents. This review has provided a structured way of thinking of documents and document reviews as a data collection method in HPA studies. It elaborates which documents are suitable, for what purposes and how to think of document quality and utility. It is evident from this review that document reviews are a laudable, scientifically sound methodology and that it has a significant role of contributing to the conclusions made about particular policies in evaluating their processes and gauging their current state within a given timeframe. HPA researchers should not underestimate the extent of skill required to adequately analyse documents and draw conclusions from these analyses. Documents are helpful to the policy analysis process and policy analysts should equip themselves accordingly for this kind of methodology and when they do embark on documentary reviews.

The emerging field of Health Policy and Systems Research (HPSR) developed from a variety of disciplines, orientated around the common research agenda of strengthening health systems, which are understood to be both complex and dynamic. The diversity of contributing disciplinary influences is a core feature of HPSR and hence the field is clearly defined as 'interdisciplinary'. However there has been a paucity of research conducted on interdisciplinarity within HPSR, with a lack of clarity on its conceptualization and practice. This study explores the representation of interdisciplinarity, and interdisciplinary practices within HPSR, utilising scoping and systematic review approaches. It is revealed that the term 'interdisciplinarity' (and its variations) have suffered from misuse and confusion. In particular, there is limited practice of an 'integrationist' interdisciplinary perspective and practice within HPSR - despite key HPSR authors supporting the integrationist approach due to its alignment with the HPSR scope of study to address complex health system problems. Over the last ten years, there has been a significantly increased output referenced as part of the HPSR field, however there is a scarcity of interdisciplinary research examples that have intentionally integrated multiple disciplinary influences. This research shows that current HPSR literature mainly reflects a 'generalist' interdisciplinary perspective (which only requires the presence of multiple disciplinary influences) rather than the integrationist perspective (which require intentional integration of influences). As a result, we propose improved approaches to framing, funding, and teaching interdisciplinary HPSR.

This study explores the implications of implementing enhanced or redesigned intermediate care initiatives in the Western Cape of South Africa from the 2014/15 financial year onwards. Using a dynamic modelling methodology, we developed an empirical model of an integrated care system to explain the linkages, relationships and interactions among service components and analyse the implications of one of the proposed Healthcare 2030 policy interventions - intermediate care - on hospital admissions, waiting times and length of stay of all patients. We tested and compared a number of alternative intervention points using a simulation model parameterised with service component data from the Department of Health Information Systems. The findings from the study show the inconsistencies between the perceived structure and the available data from the respective service components that describe the resultant behavioural effects on an integrated care system, especially when care pathways cross organisational boundaries. The main managerial learning was around the existence and nature of organisational boundaries that require joint working and sharing of information. We conclude from the simulation results for the alternative scenarios tested that the implementation of enhanced or redesigned intermediate care initiatives can moderate the rate of growth in the demand for hospital services by reducing a percentage of hospital readmissions.

International literature suggests that corporate influence is evident when governments attempt to regulate products implicated in non-communicable disease, such as tobacco, asbestos, pollution, and foods, such as trans-fat, salt and sugar. These lifestyle diseases are aptly referred to as 'industrial epidemic', since industries profit from the public's continued consumption of such products. Of these 'industrial epidemics', alcohol is a major contributor to the health burden in South Africa. In the year 2000, 7.1% of all deaths and 7% of total disability-adjusted life years have been ascribed to alcohol-related harm in the country. The tangible and intangible costs of alcohol-related harm amount to 10-12% of South Africa's 2009 Gross Domestic Product. Literature suggests that limiting alcohol use could prevent the incidence of violence, injury, risky sexual behaviours, several forms of cancer, and neuropsychiatric and physical diseases. The World Health Organisation (WHO) released two documents, The Global strategy to reduce the harmful use of alcohol (2010b) and The Global Status Report on Non-communicable Diseases (2010a), detailing the negative effects of alcohol consumption for societies. Both documents recommend that decreasing alcohol consumption through banning of alcohol advertising would have significant public health benefits, although an integrated strategy is necessary to mitigate alcohol abuse including taxation, increasing prices, limiting places of sales and increasing education on the topic. In response, the South African government proposed a draft regulation aimed at restricting alcohol advertising as an evidence-based upstream intervention. The draft Control of Marketing of Alcoholic Beverages Bill is in the process of undergoing impact assessments to determine the impact this regulation may have on South African society. Literature suggests that industry employs various political strategies to avoid such regulation. However, little is known about the strategies the alcohol industry potentially uses to influence policy development in South Africa. There is a lack of knowledge on the current strategies used by the alcohol industry to influence policy; the draft Control of Marketing of Alcoholic Beverage Bill is a case in point. This study sought to explore the complex policy formulation process in South Africa, using the draft Control of Marketing of Alcoholic Beverages Bill as a tracer case and focused on the alcohol industry, as a central actor, to understand how it - together with other actors - may influence this process. A qualitative case study approach was used, which included stakeholder mapping, 10 in-depth interviews and review of approximately 240 documents. This study makes use of two conceptual frameworks. The first framework, Berlan et al. (2014) is used to understand policy formulation as a process with multiple facets. The second framework, Roberts et al. (2004), provides four typologies of political strategies that health reformers/advocates/lobbyists employ to influence the policy process. A thematic analysis was used to analyse the data. Key themes identified were: (1) Competing and shared values - different stakeholders promote conflicting ideals for policymaking; (2) Inter-department jostling - different government departments seek to protect their own interests, hindering policy development; (3) Stakeholder consultation in democratic policymaking – policy formulation requires consultation even with those opposed to regulation; (4) Battle for evidence – industry sought to assemble evidence to use as 'ammunition' in opposition to the ban. It was concluded that networks of actors with financial interest use diverse strategies to influence policy formulation processes to contest proposed regulation. Using the policy formulation process of the draft Control of Marketing of Alcoholic Beverages Bill as a tracer case, this research is a critical enquiry into how the for-profit industry affects public health interests in South Africa; such a critical enquiry could also be applied to other non-communicable diseases. Research suggests that industries have more difficulty in pushing their agenda when policymakers are well informed, are aware of the evidence-based practice and are not motivated by economic arguments alone. There is also a lack of research that focuses on health policy analysis in low and middle-income countries, and there is a lack of research focusing on the policy formulation process in particular. Therefore, this research aims to fill a gap in addressing a lack of research on health policy analysis in the context of a middleincome country. The implications of the study are that measures to insulate policy development are needed to prevent industry influence potentially undermining public health goals, such as: government to moderate certain consultations with industry; industry to declare conflict of interest; guidelines for bureaucrats and policymakers to advise on whose evidence to consider; and guidelines for bureaucrats and policymakers to assess quality of evidence.

The burden of non-communicable diseases is growing rapidly globally and especially in low and middle-income countries. However, health systems around the world are not appropriately prepared for this increase in need for chronic care. Research suggests that health models that emphasise self-management and empowering patients to care actively for their disease are integral in non-communicable disease treatment as patients live with their disease well beyond contact with health services. Adherence and health-seeking behaviour literature suggest multiple factors within the lives of patients and within health systems that enhance or constrain patient empowerment interventions. However, in depth understanding of these factors are lacking in the South African context and especially in the inpatient setting as most research focuses on the role of primary care. This research used interviews with stakeholders in an upcoming inpatient diabetes intervention as a lens to qualitatively explore empowerment factors in further detail within the South African inpatient context. The study highlights multiple barriers to patient empowerment, namely the low socio-economic contexts of many South Africans who then struggle to access appropriate healthcare information and services and often have financial and emotional priorities that take precedence over their chronic illness. In addition, health services are bound by a shortage of resources and staff and ineffective communication systems which affects health professionals’ ability to implement patient empowerment strategies. It also highlights the unique barriers found in inpatient care as the hospital emphasises short-term acute treatment – losing potential engagement time with patients. The study suggests that patient and provider contexts make encouraging patient engagement in long term chronic care difficult. However, knowledge of these factors can be harnessed to improve chronic care interventions in low- and middle-income countries.