First Referral Hospitals (FRHs), also known as district hospitals, play a pivotal role in both national and sub-national health systems, serving as referral hubs for smaller primary health care facilities and ensuring the delivery of essential hospital care services. Despite their recognised importance, FRHs face persistent challenges, including health workforce shortages, variation in staff skill mix, high turnover and resource constraints. These challenges are growing with increasing demands for expanded services, often driven by advances in diagnostics, therapies, health professional specialities and technologies. The AFRHiCARE study will explore longitudinally how FRHs can deploy and support healthcare workers effectively and integrate technologies to address evolving service demands. The study centres on the roles, practices and professional quality of life of different cadres of health professionals, patient experiences, and the impact of governance, leadership and management practices on health care quality and staff. We will pay special attention to how new technologies impact service delivery and reshape workforce roles and responsibilities and explore the influence of gender, location, and climate-related events. The AFRHiCARE study aims to investigate these themes in sentinel FRHs in Kenya, South Africa and Uganda, combining a longitudinal study design and mixed-methods with multiple and comparative case studies. Our overall research question is: “How can healthcare workers and technologies best be deployed and supported to provide high-quality care to all as essential hospital care evolves?” Findings will provide lessons for the design and strengthening of FRH services across sub-Saharan Africa, with relevance for other low and middle-income countries.

BACKGROUND:The Covid-19 pandemic highlighted the need for public health professionals to be embedded in country health systems. The Master of Public Health (MPH), offered widely, is accepted as the entry degree for public health practice in low- and middle-Income countries (LMICs). The aim of the study was to address the knowledge gaps on the career trajectories of MPH graduates from South African universities. METHODS:A research team from the eight South African universities that graduated MPH students between 2012 and 2016 obtained lists of alumni and invited them to participate in an on-line survey. The self-administered questionnaire elicited the demographic characteristics of MPH graduates, their educational and work background, the impact of the MPH on their subsequent work and their perspectives on the roles of MPH graduates. RESULTS:The overall 37% response rate varied by institution. Respondents were mid-career professionals, in their mid-30s with on average, nine years work life. A sizeable proportion came from sub-Saharan Africa and they returned to their home or a neighbouring country to work. Most had been managers or patient-facing health professionals, and the MPH was the route to shift into public health roles. After MPH completion, 91% were employed in government (40%), non-governmental organisations (32%) or academic/research institutions (21%) in technical, managerial or academic roles. The MPH was a stepping stone for career advancement, and 55% of study participants changed their employers post qualification. They envisaged that MPH graduates could assume leadership positions and effectively contribute across both technical and managerial domains, including during public health emergencies. CONCLUSION:The MPH degree was pivotal to graduates taking on public health roles in their home countries. In view of public health workforce shortages, the study findings contribute to planning for a competent cadre to tackle pressing public health problems and their social determinants and support robust health systems development in Africa.

BackgroundPhD programs typically emphasize scientific competencies but may insufficiently prepare graduates to lead complex global health challenges. Persistent inequities, weak governance and emerging threats to global peace demand leaders who can critically assess systems, respond to local needs, and foster equitable, sustainable change. Such leadership requires reflexivity, humility, and collaborative learning. This study explores how PhD graduates across world regions perceive transformational leadership competencies and compares competencies developed during PhD training with those relevant in their current workplace.Methodology/findingsUsing an expert-validated survey based on a previously published competency framework and Delphi-derived behavioral descriptors (CROSS-guided; internationally piloted), we surveyed 618 graduates from Swiss TPH, CARTA, SSPH+, and CAPHRI; 71 graduates from 27 countries responded (response rate 11.5%). Median age was 45 years (IQR 41–51), 49% were women; median time since graduation was 6 years (IQR 3–9.5). One third completed their PhD in Africa and two thirds in Europe. Most worked in education (53.5%) or health care (10%), with others in NGOs, government, or international organizations. Competencies were rated highly relevant in the workplace (means 5.58–6.23, 1–7 scale). However, mean ratings (5.29–5.97) suggest that PhD training contributed less to competency development than the level relevant in the current workplace. Graduates from low- and middle-income countries reported better alignment between training and workplace relevance than those from high-income countries. Remaining in one location during the PhD was associated with higher perceived development. There was no evidence for gender effects.Conclusions/significanceTransformational leadership competencies are highly valued in the workplace but not consistently developed through PhD training, particularly in high-income countries. Programs with formally structured leadership-related educational components and dedicated pedagogical approaches were associated with higher levels of self-reported competency development. These findings should be interpreted cautiously given the low response rate and reliance on self-reported data. Future research is needed to determine curricular elements that contribute to leadership competency development. A transformational leadership lens may provide a useful framework for strengthening doctoral education in global health while incorporating lessons from low-income settings.

IntroductionMultiple job holding (MJH), the phenomenon of working in more than one paid job simultaneously, affects the achievement of universal health coverage. The dearth of research on MJH among dentists, especially in Africa, forms the backdrop to this study. This study aimed to explore the perspectives of key policy actors on MJH among dentists in Nairobi, Kenya.MethodsThis qualitative study combined semi-structured interviews with key informants and in-depth interviews with dentists who are engaged in MJH. The key informants were selected purposively from the Kenyan government, the regulator, representative organizations of dentists, and oral health researchers and/or experts in human resources for health. The dentists were selected from the government, the private sector, and faith-based organizations, using snowball sampling. The interviews focused on knowledge and/or experiences of MJH, reasons for, and the consequences of MJH. The interviews were analyzed using thematic analysis.ResultsThirty interviews were conducted, comprising 20 key informants, and 10 dentists. MJH among dentists is seen as a normative practice, facilitated by a profession characterized by high rewards and few or no adverse consequences from absenteeism. Although additional income is the primary motivation for MJH, low job satisfaction, the lack of continuing professional development, perverse incentives, and a dysfunctional and resource-constrained public health sector exacerbate MJH. The lack of regulation compounds the practice, while a strong private health sector provides opportunities for multiple sources of income, affecting the provision of oral health services negatively in the public sector.ConclusionMJH among dentists in Nairobi, Kenya is common because of high rewards and few or no adverse consequences from absenteeism. The high reported occurrence of MJH requires a multi-pronged approach that combines individual, system, and structural interventions. Such an approach should also consider the drivers of MJH, and ensure collaboration among policymakers, dentists, and health service managers to develop strategies to mitigate the potential negative consequences of MJH for patients, the health workforce, and oral healthcare delivery in Nairobi.

Background. The remunerative work outside of the public service (RWOPS) policy enables public sector health professionals to engage in multiple job holding (MJH) in South Africa (SA) under specified conditions, but remains controversial. Empirical evidence on health professionals’ perspectives on the RWOPS policy stipulations is lacking. Objective. To examine the perspectives of public sector medical doctors (MDs), professional nurses (PNs) and rehabilitation therapists (RTs) on the RWOPS policy. Methods. In 2022, public sector MDs, PNs and RTs were surveyed in 14 Gauteng and 15 Mpumalanga province public sector hospitals. In addition to demographic and employment data, the self-administered questionnaire collected information on whether the health professionals had obtained permission for additional jobs, their opinions on RWOPS approval requirements and restrictions and the likelihood that they would leave the public sector if RWOPS was denied. Data analysis was performed using Stata 17. The factors influencing health professionals’ perspectives on different aspects of the RWOPS policy were analysed using penalised logistic regression. Results. A total of 1 397 health professionals completed the survey, for a response rate of 84.3%. Most MDs (61.1%) and RTs (60.5%) supported mandatory RWOPS approval, compared with 41.5% of PNs. Overall, 52.6% of MDs, PNs and RTs engaged in MJH also agreed with mandatory approval. Among those who engaged in MJH, the majority of MDs (84.7%) and RTs (87.4%) had RWOPS permission, compared with only 19.2% of PNs. MDs (odds ratio (OR) 9.9, p<0.001) and RTs (OR 30.9, p<0.001) were significantly more likely to obtain RWOPS approval than PNs. MDs (OR 2.2, p<0.001), RTs (OR 1.5, p=0.027), males (OR 1.4, p=0.039) and RWOPS participants (OR 2.8, p=0.030) were more likely to consider leaving if RWOPS was denied. Conclusion. Our findings highlight significant variation in obtaining MJH permission among health professionals. The diverse perspectives underscore the need for targeted communication and stakeholder engagement to clarify policy and improve compliance.

INTRODUCTION:Regulating multiple job holding (MJH) among health professionals is challenging for many health systems. The effectiveness of different MJH policy reforms depends on the behavioural responses of different groups of health professionals but little is known about their preferences and likely reactions. AIM:Investigate the preferences of public sector medical doctors, professional nurses, and rehabilitation therapists for different MJH regulations in two South African provinces. MATERIALS AND METHODS:We developed a novel discrete choice experiment (DCE) to evaluate the preferences of health professionals for jobs with varying MJH policy interventions. The DCE attributes included restrictive regulations (banning MJH) versus reward-oriented policies (increased public sector salaries, expanded overtime, improved clinical practice environment, and better hospital management). We produced an unlabelled DCE using an efficient design and administered it to a representative sample of health professionals. Generalized multinomial logit models were used for analysis. We also investigated group heterogeneity, calculated marginal willingness to pay and estimated uptake for different policies. RESULTS:1387 participants completed the DCE. The doctors, nurses and rehabilitation therapists were strongly opposed to banning MJH, requiring salary increases of 45.7%, 20.0% and 42.8%, respectively, to accept an MJH ban. Increased public sector salaries significantly increased public sector retention. However, non-financial interventions were also influential. Doctors, nurses, and rehabilitation therapists were willing to forgo 57.9%, 54.8%, and 38.9% of their salaries, respectively, for an improved clinical practice environment. Competent hospital management was also important. There was some preference heterogeneity. Nurses had significantly different preferences for certain attributes compared to the other two groups, and professionals currently engaged in MJH were significantly more opposed to banning MJH. CONCLUSION:This study provides new information on health professional preferences for different MJH regulations. It confirms the importance of non-financial policy interventions in addressing MJH and the need to tailor MJH policy design.

Introduction:Integrating public health functions into national health systems is essential to enhance population health. The Master of Public Health (MPH) degree is an important foundation for public health practice in low-and middle-income countries such as South Africa. However, insufficient evidence on individual motivations for undertaking the MPH and the perceptions of graduates on the utility of the degree at work and in society and its contribution to their leadership skills informed this study. Methods:A consortium of academics from eight South African universities developed a self-administered questionnaire to measure inter alia the socio-demographic characteristics, motivations, career paths, perceptions of the utility of the degree, and its contribution to their professional and personal development. The study population comprised the 2012-2016 cohort of MPH graduates from eight universities. Following informed consent, eligible graduates completed an online survey via REDCap. The data were analyzed using Stata. Results:A total of 221 graduates completed the survey. The mean age of respondents was 35 years, and the majority were from South Africa (53.2%) or other African countries (43.2%). The majority (91.1%) completed the MPH to improve their skills or to promote their personal development for senior management and leadership roles. Approximately 75% used identified leadership skills at work, but only half these skills were obtained from the MPH. Over 80% of respondents positively impacted on their workplace and in society, using skills mostly derived from the MPH in all domains. Discussion:This cohort of MPH graduates exercised leadership in different settings, but many stated that these skills were not obtained from the MPH programs. The COVID-19 pandemic underscored the need for public health leaders skilled in communication, collaboration, and crisis management, amidst considerations of social justice and equity. Hence, leadership skills need to be intentionally included in MPH programs in South Africa.

Worldwide, nurses have been at the frontline of the Covid-19 pandemic response and central to its effectiveness. They faced numerous ethical dilemmas which in turn resulted in considerable moral distress. However, there are knowledge gaps on the experiences of critical care nurses in South Africa during the pandemic. Explore the experiences, specifically the ethical dilemmas and moral distress, of critical care nurses working in South African hospitals. Gilligan’s ethic of care theory informed this exploratory, qualitative descriptive study with nurses who had experience of taking care of individuals with Covid-19 and working in intensive (critical) care units in the Gauteng province of South Africa. We recruited eligible nurses through a combination of social media adverts, snowballing, and referral from professional associations or trade unions. Following voluntary informed consent, we conducted in-depth interviews with nurses using an interview guide that focused on personal and professional experiences during the pandemic, ethical dilemmas, relationships with other colleagues and/or management, and the availability of support systems. Data was analysed thematically. The participants comprised 21 nurses, 16 females and 5 males with a mean age of 38 years. The majority were professional nurses (20/21 = 95

Background There is substantial evidence on the associations between a positive nurse practice environment and improved nurse and patient outcomes, as well as the factors that mediate these associations, in high-income countries and in hospital settings. The knowledge gaps in African and primary health care settings motivated this empirical study. Objective The objective of this study was to examine the impact of the dimensions of the nurse practice environment, specifically human resource management, foundations for nursing care, and participation in clinic affairs, on job outcomes and standards of care. Design A cross-sectional study was conducted between November 2021 and June 2022. Setting 180 primary health care clinics in two South African provinces of Gauteng and North West. Participants 665 nurses of all categories. Methods A causal model was developed with pathways between the nurse practice environment dimensions and the outcomes of job satisfaction, intention to leave, and standards of care. A set of standardised instruments was used to measure the study variables. Using structural equation modelling, workload and professional support were tested as potential mediators between the nurse practice environment and the outcome variables. Results The nurses scored the domain of foundations for nursing care 71.2 out of 100 on average, indicating high agreement, while the mean scores for nurses’ participation in clinic affairs and human resources management were lower at 68.0 and 61.7 respectively. Although nurses expressed moderate satisfaction with professional support (67.7), they were less satisfied with their workload (52.2). The mean score of overall job satisfaction was moderate (58.9), with 53.8% of the nurses reporting that they intended leaving the clinic where they were working. Thirty-six percent intended leaving the nursing profession, indicating low intention to stay. The final mediation model was judged to fit the data adequately based on goodness-of-fit indices, confirming that workload and professional support had a mediating role between the nurse practice environment dimensions of interest and both nurses’ job outcomes and standards of care. Conclusions We have highlighted the value of supportive practice environments, effective workload management, and enhanced professional support in improving nurses’ job outcomes and satisfaction with standards of care. Improving nurses’ practice environments at primary health care level may have a wide-ranging impact on the performance of the health system. Therefore, primary health care facility managers should ensure that workload is distributed equitably, professional support for nurses is enhanced, and the overall work environment is improved.

Although large, specialised hospitals are influential and resource-intensive parts of health systems, first referral hospitals (FRHs), often known as district hospitals, are neglected in the current discourse on universal health coverage (UHC) in low-income and middle-income countries, where they should enhance primary health care (PHC).1 FRHs are influenced by the tensions that are inherent in their position at the interface between PHC and more specialist care, and the perceived trade-offs between access, effectiveness, and efficiency (figure).

Background Notwithstanding the global goal of inclusive universal health coverage, and the notion of migrant-sensitive health systems, limited healthcare access or the exclusion of migrants from national health systems persists. South Africa has a rights-based constitution, but there is an inability or a failure of the health system to recognise and address the health needs of migrants. Objective To explore the intersection of the environment of healthcare provision for migrants and the everyday practices and behaviours of health workers and patients in the Gauteng province of South Africa. Methods The conceptual frameworks of health system responsiveness and social exclusion informed this institutional ethnographic study at 13 healthcare facilities in Gauteng province. We developed an observation guide to explore the intersection of culture and environment and its influence on healthcare provision to patients, especially migrants. Following ethics approval, we observed the facilities for 234 person-days. We used thematic analysis to analyse the data. Results Busy, frantic or nervous spaces, and contestations between patients and health workers, and among health workers formed part of the social and cultural environment of healthcare provision. The presence of migrant patients during busy periods served as a detonator for rude or discriminatory remarks, exacerbated by staff shortages and language barriers. Simultaneously, migrants exercised their agency by rebutting or confronting rude health workers. We also observed encouraging examples of kindness, caring and professionalism of health workers. Conclusion The study has implications for achieving a migrant-sensitive health system in South Africa.

Background Multiple job holding (MJH), the phenomenon of working in more than one paid job simultaneously, affects the achievement of universal health coverage. The dearth of research on MJH among dentists, especially in Africa, forms the backdrop to this study. Objective This study aimed to explore the perspectives of key policy actors on MJH among dentists in Nairobi, Kenya. Methods This qualitative study combined semi-structured interviews with key informants and in-depth interviews with dentists who are engaged in MJH. The key informants were selected purposively from the Kenyan government, the regulator, representative organizations of dentists, and oral health researchers and/or experts in human resources for health. The dentists were selected from the government, the private sector, and faith-based organizations, using snowball sampling. The interviews focused on knowledge and/or experiences of MJH, reasons for, and the consequences of MJH. The interviews were analyzed using thematic analysis. Results 30 interviews were conducted, comprising 20 key informants, and 10 dentists. MJH among dentists is seen as a normative practice, facilitated by a profession characterized by high rewards and few or no adverse consequences from absenteeism. Although additional income is the primary motivation for MJH, low job satisfaction, the lack of continuing professional development, perverse incentives, and a dysfunctional and resource-constrained public health sector exacerbate MJH. The lack of regulation compounds the practice, while a strong private health sector provides opportunities for multiple sources of income, that negatively affects the provision of oral health services in the public sector. Conclusion MJH among dentists requires a multi-pronged approach that combines individual, system, and structural interventions.

IntroductionThe knowledge gaps on the experiences of early career health professionals during the COVID-19 pandemic informed this study, which examined their vaccination status, personal and workplace experiences in South Africa.MethodsWits longitudinalStudy toDetermine theOperation of the labourMarket among its health professional graduates (WiSDOM), a prospective longitudinal cohort study established in 2017, consists of eight health professional groups of clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists and physiotherapists. As a part of annual follow-up surveys, we examined the personal and workplace experiences and the vaccination status of cohort members during the COVID-19 pandemic years: 2020 until 2022. We measured workplace experiences using a Likert scale that ranged from 1 (strongly disagree) to 7 (strongly agree). We constructed a composite index of positive workplace COVID-19 support using a principal component analysis.We compared differences among the professional groups using proportions for categorical variables and means for numerical variables. We used multiple linear regression to investigate factors associated with the workplace COVID-19 support score and Firth’s penalised logistic regression for COVID-19 infection and vaccination.ResultsIn 2022, the mean age of the 363 cohort members was 28.9 (± 2.1), and the majority were female (74.2%). In 2020, 22.6% of the cohort reported COVID-19 infections but this increased to 45.3% by 2021. The composite index shows that doctors and nurses reported the lowest COVID-19 workplace support, while oral hygienists and dentists reported the most support. Although 89.5% of cohort members reported full COVID-19 vaccination status, 9.4% indicated non-intention to get vaccinated. The regression analysis showed that doctors (p<0.001) and women (p<0.05) reported significantly lower workplace COVID-19 support scores. Those working in hospitals had 17.1% higher COVID-19 infections (p<0.01). The lack of a COVID-19 supportive workplace resulted in 15.7% higher infections among early career health professionals (p<0.01).ConclusionThe study findings underscore the need for positive practice environments for early career health professionals in South Africa.

Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures. This was a mixed-methods, cross-sectional study in GP’s five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members’ perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively. Only three districts had constituted DHCs. The survey response rate was 73

Given South Africa's colonial and apartheid past, postgraduate supervisors are encouraged to explore decolonial and socially just ways of supervision. I draw on Freire's adult education theory and Hackman's tools of social justice education to reflect on transformative supervision workshops held at a South African university School of Public Health. Combining formal and informal evaluation, postgraduate students reported that the workshops facilitated collegiality and supportive relationships; contributed to their personal and professional empowerment; and enhanced individual and peer accountability. The participatory workshops have facilitated the decentring of power from the supervisor. Postgraduate students have realised their own power and that of the collective to inspire, assist or effect change. The workshops have embraced decolonial pedagogy by demonstrating that postgraduate supervision can be done in a collegial and empowering group setting, valorising different forms of knowledge, encouraging diverse approaches to self-reflection, and highlighting the power of mutual and multi-directional learning.

Background The dearth of empirical research on transformative health professions education informed this study to examine the factors that influence the perspectives of the cohort of health professionals in the WiSDOM study on the learning environment, transformation, and social accountability at a South African university. Methods WiSDOM, a prospective longitudinal cohort study, consists of eight health professional groups: clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists, and physiotherapists. At study inception in 2017, participants completed a self-administered questionnaire that included four domains of selection criteria (6 items); the learning environment (5 items); redress and transformation (8 items); and social accountability (5 items). In the analysis, we, rescaled the original Likert scoring of 1 (strongly disagree) to 7 (strongly agree) to a new scale ranging from 0-10. We calculated the mean scores for each item and across items for the four domains, with low scores (0.00-1.99) classified as poor and high scores (8.00-10.00) as excellent. We used multiple linear regression analysis to compare the mean scores, while adjusting for different socio-demographiccharacteristics. Results The mean age of the 501 eligible participants was 24.1 years; the majority female (72.9%), 45.3% self-identified as Black African; and 12.2% were born in a rural area. The domains of selection criteria and redress and transformation obtained mean scores of 5.4 and 5.3 out of 10 respectively, while social accountability and the learning environment obtained mean scores of 6.1 and 7.4 out of 10 respectively. Self-identified race influenced the overall mean scores of selection criteria, redress and transformation, and social accountability (p < 0.001). Rural birth influenced the perceptions on selection criteria, redress and transformation (p < 0.01). Conclusion The results suggest the need to create inclusive learning environments that foreground redress, transformation, and social accountability, while advancing the discourse on decolonised health sciences education.

Background Health workforce cohort studies are uncommon in low-and middle-income countries (LMICs), especially those in sub-Saharan Africa. Objective Describe the methodology and lessons learned from establishing and maintaining the WiSDOM (Wits longitudinal Study to Determine the Operation of the labour Market among its health professional graduates) health professional cohort study in South Africa. Methods WiSDOM is a prospective longitudinal cohort study that commenced in 2017. The cohort focuses on the eight professional groups of clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists and physiotherapists. Annual, electronic follow-up surveys have been conducted in 2018, 2019 and 2020 with informed consent. Key steps in establishing the WiSDOM cohort include consultation, communication and marketing, stakeholder feedback, resources and infrastructure. Retention strategies consist of an electronic database, detailed cohort contact information, cohort engagement, communication and feedback, short survey tools, and appropriate incentives. Results We obtained an overall response rate of 89.5% at baseline in 2017, 79.6% in 2018, 68.3% in 2019 and 72.8% in 2020. The largest decline in response rates is for medical doctors: 66.0% response rate in 2018, 53.2% in 2019 and 58.2% in 2020. However, for each of the three follow-up surveys, we have obtained response rates in excess of 80% for clinical associates, dentists, nurses, oral hygienists, pharmacists and physiotherapists. Since baseline, the outright refusals have remained very low at 4.7%. The multiple logistic regression analysis showed that self-identified race was the only significant socio-demographic difference between medical doctor respondents and non-respondents. Black African doctors and Indian doctors were 2.0 and 2.6 times more likely respectively to respond than White doctors (p < 0.05). Conclusion Other LMICs can learn from WiSDOM's lessons of establishing and maintaining a health professional cohort that aims to generate new knowledge for health system transformation.

BackgroundWithin the context of universal health coverage (UHC), South Africa has embarked on a series of health sector reforms. The implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme is a major UHC reform. Cooperative governance is enshrined in South Africa's Constitution, with health a concurrent competency of national and provincial government. Hence, effective inter-governmental relations (IGR) are essential for the ICRM programme implementation.AimThe aim of the study was to measure the cohesion of IGR, specifically consultation, support and information sharing, across national, provincial and local government health departments in the ICRM programme implementation.Materials and methodsUsing Provan and Milward's theory on network effectiveness, this study was a whole network design social network analysis (SNA). The study was conducted in two districts in Gauteng (GP) and Mpumalanga (MP) provinces of South Africa. Following informed consent, we used both an interview schedule and a network matrix to collect the social network data from health policy actors in national, provincial and local government. We used UCINET version 6.619 to analyse the SNA data for the overall network cohesion and cohesion within and between the government spheres.ResultsThe social network analysis revealed non-cohesive relationships between the different spheres of government. In both provinces, there was poor consultation in the ICRM programme implementation, illustrated by the low densities of seeking advice (GP = 15.6%; MP = 24.4%) and providing advice (GP = 14.1%; MP = 25.1%). The most cohesive relationships existed within the National Department of Health (density = 66.7%), suggesting that national policy actors sought advice from one another, rather than from the provincial health departments. A density of 2.1% in GP, and 12.5% in MP illustrated the latter.ConclusionThe non-cohesive relationships amongst policy actors across government spheres should be addressed in order to realise the benefits of cooperative governance in implementing the ICRM programme.

Background Gauteng province, with 26.3% of South Africa’s population, is the commercial and industrial powerhouse of the country. During the first epidemic wave in 2020, Gauteng accounted for 32.0% of South Africa’s reported COVID-19 cases. Aim The aim of this study was to describe the health system response to the COVID-19 pandemic during the first epidemic wave in Gauteng province and to explore the perspectives of key informants on the provincial response. Material and methods Using an adapted Pandemic Emergency Response Conceptual Framework, this was a qualitative case study design consisting of 36 key informant interviews and a document analysis. We used thematic analysis to identify themes and sub-themes from the qualitative data. Results Our case study found that Gauteng developed an innovative, multi-sectoral and comprehensive provincial COVID-19 response that aimed to address the dual challenge of saving lives and the economy. However, the interviews revealed multiple perspectives, experiences, contestations and contradictions in the pandemic response. The COVID-19 pandemic exposed and amplified the fragilities of existing systems, reflected in the corruption on personal protective equipment, poor data quality and inappropriate decisions on self-standing field hospitals. Rooted in a chronic under-investment and insufficient focus on the health workforce, the response failed to take into account or deal with their fears, and to incorporate strategies for psychosocial support, and safe working environments. The single-minded focus on COVID-19 exacerbated these fragilities, resulting in a de facto health system lockdown and reported collateral damage. The key informants identified missed opportunities to invest in primary health care, partner with communities and to include the private health sector in the pandemic response. Conclusion Gauteng province should build on the innovations of the multi-sectoral response to the COVID-19 pandemic, while addressing the contested areas and health system fragilities.