Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

Philosophiae Doctor - PhD / Health system in Sub-Saharan in Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Wide-ranging capacity development interventions exist to address these limitations. however, failure to take into account complexity into planning and implementation in the practice and research of these capacity development intervention predominate , hindering understanding and learning, and resulting in poor implementation or lack of sustainability of the capacity gains.

The scope of pharmacy practice in global health has expanded over the past decade creating additional education and training opportunities for students, residents and pharmacists. There has also been a shift from short-term educational and clinical experiences to more sustainable bidirectional partnerships between high-income countries (HICs) and low- to middle-income countries (LMICs). As more institutional and individual partnerships between HICs and LMICs begin to form, it is clear that there is a lack of guidance for pharmacists on how to build meaningful, sustainable, and mutually beneficial programs. The aim of this paper is to provide guidance for pharmacists in HICs to make informed decisions on global health partnerships and identify opportunities for engagement in LMICs that yield mutually beneficial collaborations. This paper uses the foundations of global health principles to identify five pillars of global health engagement when developing partnerships: (a) sustainability, (b) shared leadership, (c) mutually beneficial partnerships, (d) local needs-based care and (e) host-driven experiential and didactic education. Finally, this paper highlights ways pharmacists can use the pillars as a framework to engage and support health care systems, collaborate with academic institutions, conduct research, and interface with governments to improve health policy.

Strong health systems are needed to implement clinical and public health interventions. Global evidence-informed health systems guidance, such as that created by the World Health Organization (WHO), has been used to help strengthen health systems. However, global guidance needs to be contextualized or adapted to fit the realities of a particular setting. A workbook for contextualizing health systems guidance was developed to accompany WHO guidance on optimizing health worker roles to increase access to and use of key interventions for improving maternal and newborn health. This dissertation investigates the development and use of the workbook, using qualitative research methods, to help in the planning of future knowledge translation tools, to provide insights for practice and research, and to improve the workbook. First, a single case study explores the development of the workbook, which helped uncover the key features of the process, barriers that arose, and facilitators that helped overcome some of these barriers (chapter 2). Second, a single embedded case study examined the use of the workbook in two real-life settings, Peru and Uganda (chapter 3). Third, a critical interpretive synthesis of the literature was used to better define contextualization and to find what and how contextual factors could be used by policymakers to adapt guidance to their setting (chapter 4). Together, the three studies presented in this dissertation offer substantive, methodological and disciplinary contributions to the field of health systems and policy through a comprehensive examination of the workbook. It presents recommendations for improving the workbook from the perspectives of global guidance developers, users at the national level, and the broader literature on guidance and guideline development, contextualization and implementation. It also supports the continued use of workbooks, or other tools, to contextualize guidance in an effort to strengthen health systems, especially in low- and middle-income countries. / Dissertation / Doctor of Philosophy (PhD) / Strong health systems are needed in order for the right mix of clinical care and public health interventions to get to those who need them. The World Health Organization writes guidance at the global level to help countries strengthen their health systems. This guidance can be used to develop health guidance or policy for the national or subnational (e.g., provincial, state) level, but it first needs to be contextualized or adapted to that particular jurisdiction. It is important to consider what the problem is and what causes it, policy options to help deal with the problem, implementation considerations, as well as factors related to both the health system and the political system that can affect whether or not the intervention will be implemented. A workbook was developed to help contextualize guidance. This dissertation explores the process of developing and evaluating its use to help in the planning of future tools, to provide insights for practice and research, and to improve the workbook.

Background: Although immunisation services are provided free at all public health facilities in South Africa, immunisation coverage remains variable and disease outbreaks still occur. The coverage rate in the Overberg district is recorded as 75.8%, below the national target of 90% (Western Cape Government Provincial Treasury 2013:2). The researcher wanted to understand what the barriers to accessing immunisation services were and how this might relate to other primary health care services. Methods: The researcher visited 22 households and interviewed nine mothers who had brought their children to Zwelihle Clinic to be immunised and nine community health workers servicing the Zwelihle community in the Overberg district, Western Cape Province. Findings: A key finding is that the data does not reflect the actual situation – children in the community either are immunised at other facilities or have left the catchment area, hence strong relationships between the facility and the community and an electronic patient tracking system become important. Findings impacting access to services include the attitude of administrative staff, waiting times and the impact of migratory communities. Recommendations are made to improve the quality of data, provide training to administrative staff, improve patient education, reduce waiting times and improve the relationship between the clinic and the community in order to better track patient migration / Health Studies / M.A. (Public Health)

<b>Background:</b> External Quality Assessment assesses the quality of the structures, processes and outcomes of health facilities using pre-determined standards. South Africa is introducing a national policy on External Quality Assessment, operationalised by a newly established External Quality Assessment agency: the Office of Health Standards Compliance. This thesis seeks to answer three research questions: What is the relationship between External Quality Assessment and patient outcomes (specifically Healthcare Associated Infections) at the specialist-care facility level in South Africa? What are the facilitators of and barriers to health facility performance (i.e. attainment of compliance with standards) in External Quality Assessment at the district hospital level in South Africa? What has been the experience of External Quality Assessment by frontline healthcare workers at the district hospital level in South Africa? <b>Methods:</b> Three systematic literature reviews are conducted that attempt to identify the existing evidence base for the above-mentioned research questions in the international literature. A convergent parallel mixed methods design is used to answer the research questions, comprising an Interrupted Time Series Analysis and a multiple embedded case study of two pairs of health facilities that had undergone External Quality Assessment by the Office of Health Standards Compliance. The Interrupted Time Series Analysis assesses whether an effectiveness relationship can be demonstrated between External Quality Assessment and the Healthcare Associated Infection Methicillin-resistant Staphylococcus Aureus (MRSA) in eight South African specialist-care hospitals using monthly MRSA data from 2004 to 2014. MRSA is used in this thesis as the proxy patient outcome indicator. In order to answer research questions two and three, I participated in a district hospital External Quality Assessment as a participant observer as well as conducted fifteen in-depth interviews with healthcare workers from two pairs of district hospitals and thirteen in-depth interviews with Office of Health Standards Compliance inspectors. These findings are triangulated with health facility External Quality Assessment reports. <b>Results:</b> No conclusive evidence is found of a relationship between implementation of External Quality Assessment and changes in MRSA. The major theoretical lenses drawn from in the analysis of the qualitative findings are systems thinking theory and regulatory theory. The qualitative research suggests that facilitators of performance in External Quality Assessment in South Africa include strong directional leadership within health facilities, a collaborative organisational culture, a whole systems approach, staff development, incentives, a robust information system and a supportive External Quality Assessment agency. The research also identifies poor alignment of External Quality Assessment standards, under-developed and limited human resources, inadequate decision-making space afforded to district hospital leadership, limited financial resources, the use of penalties and negative staff perceptions of External Quality Assessment as barriers to health facility performance in External Quality Assessment. In unpacking the experiences of South African healthcare workers of External Quality Assessment, this research finds that the work of the Office of Health Standards Compliance is valued by healthcare workers as a potential educational opportunity and is useful in providing the health system with a means to compare health facilities using a standardised tool. The implementation of the Office of Health Standards Compliance's External Quality Assessments requires significant improvement and, in their current form, they have potential unintended negative consequences on healthcare worker motivation as well as potentially, inadvertently encouraging the gaming of External Quality Assessment. <b>Conclusion:</b> The Office of Health Standards Compliance is being set up in such a way that once fully established it will be the primary regulator of quality of care in the South African health system. This thesis attempts to identify some of the strengths and weaknesses of this largely under-researched health system intervention and to contribute to strengthening its implementation.

Background: Although immunisation services are provided free at all public health facilities in South Africa, immunisation coverage remains variable and disease outbreaks still occur. The coverage rate in the Overberg district is recorded as 75.8%, below the national target of 90% (Western Cape Government Provincial Treasury 2013:2). The researcher wanted to understand what the barriers to accessing immunisation services were and how this might relate to other primary health care services. Methods: The researcher visited 22 households and interviewed nine mothers who had brought their children to Zwelihle Clinic to be immunised and nine community health workers servicing the Zwelihle community in the Overberg district, Western Cape Province. Findings: A key finding is that the data does not reflect the actual situation – children in the community either are immunised at other facilities or have left the catchment area, hence strong relationships between the facility and the community and an electronic patient tracking system become important. Findings impacting access to services include the attitude of administrative staff, waiting times and the impact of migratory communities. Recommendations are made to improve the quality of data, provide training to administrative staff, improve patient education, reduce waiting times and improve the relationship between the clinic and the community in order to better track patient migration / Health Studies / M.A. (Public Health)

The purpose of the research was to assess the availability of public health services in response to humanitarian crises in Gambella, Ethiopia. This informed the development of a public health service protocol for humanitarian emergency responses in Ethiopia. The objectives of the study were explored and identify current humanitarian health emergency needs and responses, describe the availability of public health services required for humanitarian emergency responses, study and critically analyse different humanitarian responses in respect of health care services and related protocols in other countries, develop a context-specific and needs-based protocol for humanitarian emergency responses in Gambella, Ethiopia, clarify the policy and programme implications of such a protocol. A mixed-method research design was used to conduct the study. Data were collected from 32 health facilities to assess the availability of required resources and public health services. A checklist and in-depth interview guide were used to collect the data. The quantitative data were analysed using simple descriptive statistics using frequency distribution tables and graphs. Thematic analysis was employed to analyse the qualitative data. The study revealed a lack of resources which threatened the availability of public health services in humanitarian emergencies. The ever-increasing number of refugees overstretched the limited resources, leading to stockouts of medicines, other health commodities and equipment. The absence of emergency preparedness, poor coordination of services, coupled with a lack of integration of services exacerbated public health service delivery. The study findings informed the development of a public health service protocol for humanitarian responses in Ethiopia. The study further recommended further research on other factors that might affect humanitarian responses and coordination. / Health Studies / Ph. D. (Public Health)