Barriers and facilitators for strengthening of the community sub-system for people-centred health care in uMgungundlovu, KwaZulu-Natal, South Africa

Health systems in sub-Saharan Africa are typically fragile, reactive and organized around responding to specific diseases. This makes them ill-equipped to deal with multiple co-existing conditions such as tuberculosis, HIV and non-communicable diseases as well as emerging health shocks, such as COVID-19. The need to build resilient and responsive quality health systems is paramount. To this end, people-centred oriented systems which focus on health promotion and prevention interventions and empowering people to take responsibility for their health and that of their communities have been identified as the way forward for sub-Saharan Africa. This need is amplified in the context of COVID-19 which requires people to change their behavior to prevent the spread of the virus. This requires strengthening of the community sub- system (historically a neglected component of the health system) including households, civic groups, community structures and other sectors to play an active rather than passive role in the health care system.While the SA Dept of Health has engaged in policy reforms to strengthen the system to have a more people-centred community orientation, there are gaps in knowledge about how best to practically achieve these reforms. To narrow this gap, the applicants have partnered with the KwaZulu-Natal (KZN) provincial Department of Health (DoH), to investigate how best to implement these reforms. To this end, we will conduct a formative investigation of the barriers, needs and opportunities for strengthening of the pillars of the health system to be enabling of a people-centred community orientation. This information will be used to inform the co-development (with the KZN DoH and other sectors) of conceptual models of how the pillars of the health system could be strengthened to be more enabling of a people-centred community orientation. Testing and refining of these conceptual models will form the basis of a full stage proposal.South Africa has embarked on major health systems reforms to re-engineer the primary health care system towards a people-centred approach. The applicants have partnered with the KwaZulu-Natal Department of Health and Office of the Premier (responsible for coordinating inter-sectoral action) in a Primary Health Care Transformation Committee (PHCTC), to provide academic direction to this endeavour in the province of KwaZulu-Natal. Guided by realist evaluation (RE), this foundation grant application will conduct formative research to explore mechanisms for strengthening of the key pillars of the health system to support the development of a people-centred community orientation. At its core, realist evaluation (RE) involves constructing an initial programme theory, testing the theory using appropriate mixed methods and refining the initial theory to create a middle-range theory that can be applied to different contexts. The latter will form the scope of work for a full stage proposal. The objectives for this foundation grant are to:i) Examine barriers, needs and opportunities for strengthening the key health system pillars (including multisectoral engagement) for a people-centred community orientation.ii) Co-design Initial Programme Theories (IPTs) for strengthening the key pillars of the health system for a people-centred community orientation.<br>