Understanding doctors and nurses resistance to implementing the Universal Test and Treat Policy Pronouncement in South Africa.

Abstract

South Africa is one of the African countries affected by the HIV pandemic. It is a signatory to the UNAIDS initiative to eradicate AIDS by 2030. Consequently, the Universal Test and Treat (UTT) Policy Pronouncement was established to help the country achieve the UNAIDS 2020 targets. However, despite this supportive policy environment, South Africa has not met the UNAIDS 2020 targets. To achieve the UNAIDS 2030 targets, reasons behind the lack of performance must be understood and mitigated. Studies previously conducted cite health system deficiencies, central policy making and low staff morale as barriers to policy implementation. This study focuses on policies, with the understanding that policy formulation processes should have pre-empted contextual limitations, such as health system failures and low staff morale. This study investigates how the selected policy pathways serve as a barrier to policy implementation. The study’s scope is limited to the interface between policy implementers and policy formulation process. The purpose of the study is to determine whether there was any ambiguity in motivation among HIV clinicians when implementing the UTT Policy. To achieve the study’s objective, mixed research methods were employed in a phased approach. In the first phase, 100 HIV clinicians working in public health facilities across the country were randomly selected to participate in a survey, and 21 clinicians responded. Findings in the quantitative first phase informed the second phase, where qualitative methods were employed to gain a deeper understanding of meanings associated with ambiguity of motivation to implement the UTT policy and how this affected the efficacy of implementing the UTT policy. Six of the survey respondents were selected to participate in the semi-structured, in-depth interviews. The study revealed that most clinicians understood and agreed with the ideals of the policy. However, they felt that the policy did not take their skills, experiences, and concerns into account for its effective implementation. This was attributed to how the policy was introduced, which provided little room for alignment with other policies and institutional practices. The discontent was mostly highlighted by staff members with longer service history. The policy development process created ambiguity in the motivation to implement the policy, as it was driven by top-level policymakers with inadequate input from the lower levels of the health care system. A bottom-up consultation process would have prevented the delays and challenges experienced, thereby supporting effective policy implementation.