Piercing the veil on the functioning and effectiveness of district health system governance structures: Perspectives from a South African province

Abstract Background Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the National Health Insurance policy, which underscores the importance of primary health care, delivered through the district health system (DHS). In light of this, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province, and the perceptions of members on the functioning and effectiveness of these structures. Methods The study was done in all five districts in Gauteng. The population of interest was members of existing governance structures. Members completed an electronic-self- administered questionnaire (SAQ), which collected perceptions on the functioning and effectiveness of the governance structures, using a seven-point Likert scale. STATA® 13 was used to analyze the survey data. In-depth interviews with the chairpersons of the DHCs and the District Health Council Technical Committees complemented the survey. Interviews were analyzed using thematic content analysis. Results Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD=0.7) and 4.8. (SD=0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, exacerbated by political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. Conclusion In light of South Africa’s move toward NHI, strengthening the governance of the DHS is imperative. The governance gaps identified need to be addressed to ensure the successful implementation of UHC reforms.