A model for organisational readiness and implementation of the proposed National Health Insurance Bill: The case of the North West Provincial Department of Health T Motswakae orcid.org/0000-0003-0038-680X Dissertation accepted in fulfilment of the requirements for the degree Master of Arts in Public Management and Governance at the North-West University Supervisor: Prof M Diedericks Graduation: June 2023 Student number: 26624400 DECLARATION I, Thato Motswakae, hereby declare that the dissertation: “A model for organisational readiness and implementation of the proposed National Health Insurance Bill: The case of the North West Provincial Department of Health” submitted in fulfilment of the requirements of the degree Master of Arts in Public Management and Governance at the North-West University, Potchefstroom Campus is my own work and has not previously been submitted by me to any University. I further declare that all material and sources used in this study has been duly acknowledged by means of complete in-text source references. I understand that the copies of this dissertation submitted for examination will remain the property of the North-West University. Signature: Thato Motswakae Date: 30 November 2022 i ACKNOWLEDGEMENTS Proverbs 3:4-5: Trust in the Lord with all your heart and lean not on your own understanding, in all your ways acknowledge him, and he will make your paths straight. Thank you, God, for granting me the strength and wisdom to finish this incredible journey. Your grace indeed found me! A special thank you to my supervisor, Prof Melvin Diedericks. Thank you so much for believing in me that I would finish this project, though in times it seemed so impossible. Thank you for your endless support, guidance, and constructive feedback. I honestly couldn’t have asked for any other supervisor to undertake this incredible journey with. Thank you, Prof! To the North-West University and the National Research Foundation, thank you for the financial assistance to undertake this study. To the North West Province Department of Health and all those who participated in this study, thank you very much for your contribution and willingness to assist where possible. To my parents, Elias and Goitsimang Motswakae, whom from a very young age have instilled the value of education to me; thank you for always believing in me. Thank you for your prayers and the endless support you have shown me from the beginning of this project. To my younger siblings, thank you for being my motivation, throughout this project. Your faith in me as your sister has kept me going. To my older sister, Ponatshego Motswakae, thank you so much for your support and words of encouragement when the road seemed so dark. I appreciate you. To my special friend, Boineelo Kai, thank you very much for your willingness to always listen to my thoughts regarding this project. You are truly appreciated. ii ABSTRACT The challenges facing the health system of South Africa and the imbalances occurring between the public and private health system has led the government to introduce radical health care changes in the form of the National Health Insurance Bill, to achieve Universal Health Coverage. Adequate research has shown that the challenges facing the health system of South Africa are also hampering the effective and efficient organisational functioning of the North West Provincial Department of Health. Thus, the primary objective of this study has been to investigate whether the North West Provincial Department of Health is ready to implement the proposed National Health Insurance Bill (NHI) once it becomes legislation. To achieve the above primary objective, four research questions and objectives were formulated that aimed to investigate organisational theories and readiness, best practices and principles associated with effective implementation of public policies, legislative and statutory frameworks, and an empirical data-collection investigation. The results of this study were achieved by means of a qualitative method within a case study design. The instruments and data collection methods comprised of semi-structured interviews, a questionnaire, and document analysis, to increase the validity of semi-structured interviews and a data-collection questionnaire. The research sample comprised of knowledgeable individuals employed by the North West Province Department of Health, including line managers in public clinics and -hospitals. The results from respondents were analysed using a thematic information and data analysis. The findings of the study indicated that the North West Provincial Department of Health is not yet ready to implement the proposed National Health Insurance Bill once it becomes legislation due to significant challenges such as a lack of health professionals, insufficient budgeting, poor infrastructure and inadequate medical equipment. The study presented a model for organisational readiness and -implementation as significant contribution in order to assist the Department with implementation of the proposed National Health Insurance Bill once it becomes legislation. The model has both a structural- and psychological perspective taking into consideration the challenges faced by the institution. Addressing organisational challenges is one step closer in achieving organisational readiness which is underscored by components such as clarity, collaboration, capabilities, and organisational culture. Key words: Public policy, health, organisational readiness, implementation, NHI iii TABLE OF CONTENTS DECLARATION ......................................................................................................................... I ACKNOWLEDGEMENTS ......................................................................................................... II ABSTRACT .......................................................................................................................... III LIST OF TABLES .................................................................................................................... XI LIST OF FIGURES .................................................................................................................. XII LIST OF GRAPHS ................................................................................................................. XIII LIST OF PIE CHARTS ........................................................................................................... XIV ANNEXURES ........................................................................................................................ XVI LIST OF ABBREVIATIONS AND ACRONYMS .................................................................... XVII CHAPTER 1: ORIENTATION AND PROBLEM STATEMENT .................................................. 1 1.1 INTRODUCTION ................................................................................................ 1 1.2 ORIENTATION ................................................................................................... 1 1.3 PROBLEM STATEMENT ................................................................................... 6 1.4 RESEARCH QUESTIONS ................................................................................ 12 1.5 RESEARCH OBJECTIVES ............................................................................... 13 1.5.1 The primary objective ....................................................................................... 13 1.5.2 The secondary objectives ................................................................................. 13 iv 1.6 CENTRAL THEORETICAL STATEMENTS (CTS) ............................................ 13 1.7 THEORETICAL FRAMEWORK OF THE STUDY ............................................. 14 1.7.1 The theory of Social Justice for public health .................................................... 14 1.7.2 Organisational theory ........................................................................................ 15 1.7.2.1 Descriptive theory ............................................................................................. 16 1.7.2.2 Normative theory .............................................................................................. 16 1.8 RESEARCH METHODOLOGY ......................................................................... 17 1.8.1 Research approach .......................................................................................... 17 1.8.2 Research design ............................................................................................... 18 1.8.3 Literature review ............................................................................................... 19 1.8.4 Empirical investigation ...................................................................................... 20 1.8.4.1 Population and sampling .................................................................................. 21 1.8.4.2 Instrumentation and data collection method ...................................................... 23 1.8.5 Data analysis .................................................................................................... 26 1.9 LIMITATIONS AND DELIMITATIONS OF THE STUDY .................................... 26 1.10 ETHICAL CONSIDERATIONS ......................................................................... 27 1.11 SIGNIFICANCE OF THE STUDY ..................................................................... 28 1.12 FEEDBACK TO RESPONDENTS AND DISSEMINATION OF RESEARCH FINDINGS ........................................................................................................ 28 1.13 CHAPTER LAYOUT OF THE STUDY .............................................................. 28 1.14 CHAPTER CONCLUSION ................................................................................ 30 CHAPTER 2: ORGANISATIONAL THEORY AND ORGANISATIONAL READINESS ........... 31 v 2.1 INTRODUCTION .............................................................................................. 31 2.2 ORGANISATIONAL THEORY .......................................................................... 31 2.2.1 Conceptualising organisational theory .............................................................. 32 2.2.2 Objectives of organisational theory ................................................................... 33 2.2.3 Approaches of organisational theory ................................................................. 34 2.2.3.1 The classical theory .......................................................................................... 35 2.2.3.2 Neo-classical theory ......................................................................................... 37 2.2.3.3 Contingency theory ........................................................................................... 40 2.2.3.4 Decision-making theory .................................................................................... 42 2.2.3.5 The systems theory .......................................................................................... 43 2.3 ORGANISATIONAL READINESS .................................................................... 44 2.3.1 Conceptualising organisational readiness ......................................................... 45 2.3.2 Importance of organisational readiness ............................................................ 48 2.3.3 Approaches of organisational readiness ........................................................... 50 2.3.3.1 Possible assessment tools for organisational readiness ................................... 51 2.4 MODEL(S) ........................................................................................................ 59 2.4.1 Conceptualising a model(s) .............................................................................. 60 2.4.2 Model for organisational readiness ................................................................... 61 2.5 CHAPTER CONCLUSION ................................................................................ 64 CHAPTER 3: PUBLIC POLICY IMPLEMENTATION, BEST PRACTICES AND PRINCIPLES ......................................................................................................................... 65 3.1 INTRODUCTION .............................................................................................. 65 vi 3.2 CONCEPTUALISING PUBLIC POLICY AND THE IMPLEMENTATION PHASE ............................................................................................................. 65 3.2.1 Conceptualising public policy implementation ................................................... 69 3.2.1.1 The public policy implementation process ......................................................... 72 3.3 THEORETICAL FRAMEWORK OF PUBLIC POLICY IMPLEMENTATION ...... 73 3.3.1 Public policy implementation approaches ......................................................... 74 3.3.1.1 Top-down implementation approach ................................................................. 74 3.3.1.2 Bottom-up implementation approach ............................................................... 75 3.3.1.3 Hybrid approach to implementation ................................................................. 77 3.4 CONCEPTUAL FRAMEWORK OF PUBLIC POLICY IMPLEMENTATION ....... 79 3.4.1 Principles of public policy implementation ......................................................... 79 3.4.2 Tasks involved in public policy implementation ................................................. 80 3.4.3 Features for effective public policy implementation ........................................... 81 3.4.4 Central questions associated with the implementation of a given public policy ................................................................................................................ 83 3.5 BEST PRACTICES OF PUBLIC POLICY IMPLEMENTATION ......................... 84 3.5.1 Discussion of best practices ............................................................................. 85 3.5.2 Lessons learned from implementation of the National Health Insurance System in Ghana .............................................................................................. 90 3.5.3 Lessons learned from Thailand towards UHC ................................................... 92 3.5.4 Lessons learned from Turkey towards health transformation ............................ 93 3.5.5 The United Kingdom health system in brief ....................................................... 94 3.6 THEORETICAL FOUNDATION OF THE THEORY OF SOCIAL JUSTICE ....... 95 vii 3.6.1 Model case of the theory of social justice .......................................................... 98 3.7 CHAPTER CONCLUSION .............................................................................. 100 CHAPTER 4 : STATUTORY AND REGULATORY FRAMEWORK GOVERNING THE HEALTH SECTOR OF SOUTH AFRICA .............................................................................. 102 4.1 INTRODUCTION ............................................................................................ 102 4.2 TRANSFORMATION OF THE SOUTH AFRICAN HEALTH SYSTEM ............ 102 4.2.1 The South African health system in brief ......................................................... 103 4.3 CONTEXTUALISING THE NHI AND THE PROPOSED NHI BILL [B11- 2019] PHASE ................................................................................................. 105 4.4 STATUTORY AND REGULATORY FRAMEWORK OF THE HEALTH SYSTEM OF SOUTH AFRICA ....................................................................... 109 4.4.1 Statutory framework........................................................................................ 110 4.4.1.1 Health Profession Act 56 of 1974.................................................................... 110 4.4.1.2 Constitution of the Republic of South Africa, 1996 .......................................... 111 4.4.1.3 National Health Act 61 of 2003 ....................................................................... 113 4.4.1.4 Nursing Act 33 of 2005 ................................................................................... 115 4.4.2 Regulatory framework ..................................................................................... 116 4.4.2.1 White Paper for the transformation of the health system in South Africa ......... 116 4.4.2.2 National Development Plan (NDP): Vision for 2030 (2011) ............................. 118 4.4.2.3 Medium-Term Strategic Framework 2019 - 2024 ............................................ 119 4.5 CHAPTER CONCLUSION .............................................................................. 120 viii CHAPTER 5: A MODEL FOR ORGANISATIONAL READINESS AND IMPLEMENTATION OF THE PROPOSED NHI BILL WITHIN THE NORTH WEST PROVINCIAL DEPARTMENT OF HEALTH: EMPIRICAL FINDINGS .................................. 122 5.1 INTRODUCTION ............................................................................................ 122 5.2 RESEARCH METHODOLOGY ....................................................................... 122 5.3 EMPIRICAL FINDINGS AND DATA ANALYSIS ............................................. 125 5.4 PRESENTING DATA FROM SENIOR MANAGERS ....................................... 126 5.4.1 Biographical information of senior managers .................................................. 126 5.4.1.1 Gender ........................................................................................................... 127 5.4.1.2 Age ................................................................................................................. 127 5.4.1.3 Highest qualification........................................................................................ 128 5.4.1.4 Job position .................................................................................................... 129 5.4.1.5 Years of experience in the North West Provincial Department of Health ......... 130 5.4.2 Responses from the Likert-scale questionnaire .............................................. 130 5.4.3 Results from semi-structured interviews ......................................................... 143 5.5 PRESENTING DATA FROM HEALTH PROFESSIONALS ............................. 163 5.5.1 Biographical information of health professionals ............................................. 163 5.5.1.1 Gender ........................................................................................................... 164 5.5.1.2 Age ................................................................................................................. 164 5.5.1.3 Highest qualification........................................................................................ 165 5.5.1.4 Job position .................................................................................................... 166 5.5.1.5 Years of experience ........................................................................................ 166 5.5.2 Results from semi-structured interviews ........................................................ 167 ix 5.6 DOCUMENT ANALYSIS OF THE NORTH WEST PROVINCIAL DEPARTMENT OF HEALTH .......................................................................... 179 5.6.1 A brief discussion of the reviewed documents .............................................. 179 5.6.1.1 Challenges .................................................................................................... 179 5.6.1.2 Progress towards the National Health Insurance ........................................... 181 5.7 CHAPTER CONCLUSION ............................................................................. 182 CHAPTER 6: FINDINGS, CONCLUSIONS AND RECOMMENDATIONS ............................ 184 6.1 INTRODUCTION ............................................................................................ 184 6.2 SUMMARY AND PRIMARY FINDINGS OF THE STUDY ............................... 184 6.3 RECOMMENDATIONS BY WAY OF A MODEL TO ENHANCE ORGANISATIONAL READINESS .................................................................. 188 6.3.1 Discussion of a model for organisational readiness ........................................ 190 6.4 RECOMMENDATIONS .................................................................................. 193 6.5 RECOMMENDATIONS FOR FUTURE RESEARCH ...................................... 195 6.6 CHAPTER CONCLUSION .............................................................................. 195 REFERENCE LIST ............................................................................................................... 197 x LIST OF TABLES Table 1: Summary of the population and sample 23 Table 2: Summary of the classical and neo-classical approaches 39 Table 3: Differences between structural and psychological view 53 Table 4: Readiness constructs within organisations 53 Table 5: Readiness scorecard of organisations 58 Table 6: Public policy implementation process 73 Table 7: Summary of top-down and bottom-up implementation approaches 77 Table 8: Population and sampling size for questionnaire 124 Table 9: Population and sampling size for semi-structured interviews 125 Table 10: Likert-scale 131 xi LIST OF FIGURES Figure 1: Challenges facing the South African Public Health System 10 Figure 2: Readiness assessment of organisations 56 Figure 3: A proposed model for organisational readiness 62 Figure 4: Model case of the theory of social justice 99 Figure 5: Development of the NHI Bill [B11-2019] 107 Figure 6: A model for organisational readiness and implementation of the proposed NHI Bill [B11-2019] 189 xii LIST OF GRAPHS Graph 1: Highest qualification 128 Graph 2: Job position 129 Graph 3: Sufficient knowledge about organisational readiness 141 within the department Graph 4: Readiness assessment/model 142 Graph 5: Frequent communication 143 xiii LIST OF PIE CHARTS Pie chart 1: Gender 127 Pie chart 2: Age 127 Pie chart 3: Years of experience within the North West Provincial Department of Health 130 Pie chart 4: Knowledge about organisational readiness and public policy implementation 132 Pie chart 5: Interrelation of organisational readiness and public policy implementation 133 Pie chart 6: Importance of organisational leaders in establishing organisational readiness 134 Pie chart 7: Significance of organisational readiness in public policy implementation 135 Pie chart 8: Definition of organisational readiness 136 Pie chart 9: Public policies and their implementation 137 Pie chart 10: Key elements for successful public policy implementation 138 Pie chart 11: Effective public policy 139 Pie chart 12: Top-down and bottom-up public policy implementation 140 Pie chart 13: Gender 164 Pie chart 14: Age 164 Pie chart 15: Highest qualification 165 Pie chart 16: Job position 166 xiv Pie chart 17: Years of experience within the North West Provincial Department of Health 166 xv ANNEXURES ANNEXURE A: Interview and questionnaire schedule with senior managers 230 ANNEXURE B: Interview and questionnaire schedule with health professionals 239 ANNEXURE C: Permission letter to the North West Province Department of Health 245 ANNEXURE D: Permission letter from the North West Province Department of Health 248 ANNEXURE E: Language editor’s certificate 250 xvi LIST OF ABBREVIATIONS AND ACRONYMS ANC- African National Congress CTS- Central Theoretical Statements CUPs- Contracting Units for Primary Care Services DHET- National Department of Higher Education and Training ESCOM - Electricity Supply Commission EHR- Electronic Health Record HPCSA- Health Professions Council of South Africa HIV- Human Immunodeficiency Virus MTSF- Medium-Term Strategic Framework NDP- National Development Plan NHIS- National Health Insurance System NHS- National Health Service NHI- National Health Insurance PHC- Public Health Care SAA- South African Airways SANC- South African Nursing Council TB- Tuberculosis UHC- Universal Health Coverage UK- United Kingdom xvii CHAPTER 1: ORIENTATION AND PROBLEM STATEMENT 1.1 INTRODUCTION The research title of the study, “A model for organisational readiness and implementation of the proposed National Health Insurance Bill: The case of the North West Provincial Department of Health” is introduced in this chapter. The chapter starts out with the study's orientation, then progresses to the problem statement, research questions, and objectives, including the central theoretical statements. The research methodology employed in this study is discussed in detail. Furthermore, the study's limitations, ethical considerations, and significance are outlined. 1.2 ORIENTATION Organisational readiness in public healthcare settings is a significant factor in fruitful implementation of new public policies. However, research on the subject is delayed by the shortfall of a concise, reliable, and accurate measure (Shea, Jacobs, Esserman, Bruce & Weiner, 2014:1). The inability to implement public policies has become a complicated issue in many organisations around the world as well as in South Africa (Eliah, 2020:1). Eliah (2020:1) states that the criticism for public policy implementation failure has been placed on the absence of measuring readiness to implement in numerous public institutions. Ochurub, Bussin and Goosen (2012:3) and Eliah (2020:1), explain that public policy implementation fails because of the absence of readiness from members of the organisation including the absence of connectedness among policy and practice, with respect to government (Ochurub et al., 2012:3; Eliah, 2020:1). According to Weeks, Roberts, Chonko and Jones (2004:9-10) organisational readiness to implement policy has a significant influence in the accomplishment of public policies, thus it is essential to measure readiness before implementation (Eliah, 2020:1). Researchers such as Weiner (2009:5), argue that greater organisational readiness prompts successful implementation. To contextualise this, the Socio-cognitive Theory proposes that when public organisational readiness for change is high, organisational members are bound to start change, apply greater effort in support of change, and display more prominent persistence, despite obstacles or difficulties during implementation (Shea et al., 2014:2). In addition, Leslie, West, Twine, Masilela, Steward, Kahn and Lippman (2020:2), explain that higher readiness to change should bring greater effort in implementing the change, which overall encourages successful implementation. Organisational readiness is viewed as a critical forerunner to effective implementation of complicated changes in healthcare settings (Weiner, 2009:2). Leslie et al. (2020:1), contend that 1 endeavours that aim to improve health services and do not address the background and implementation capacity of the public health system in most cases fail. Weiner (2009:6) further argues that organisational readiness for successful implementation in healthcare delivery requires mutual and integrated behaviour change by numerous members of the institution. In addition, public health system challenges, including deficient capacity and variable leadership and management has been described as key obstacles to successful implementation (Leslie et al., 2020:1). Furthermore, Malakoane, Heunis, Chikobvu, Kigozi and Kruger (2020:3) state that the South African health system is a two-tier system that comprises of a public and private health system, of which the less disadvantaged depends on the under-resourced public health system, while those who can afford quality health services make use of the private health system (Gordon, Booysen & Mbonigaba, 2020:1). Gordon et al. (2020:1) believe that socio-economic disparities in access to public health care services remain a top public policy priority. In South Africa, the socioeconomically disadvantaged are more likely to have poor health and the occurrence of several concomitant diseases and are less likely to seek inpatient care (Gordon et al., 2020:1). In a research study done also by Gordon et al. (2020:8), it is evident that health inequalities remain to hamper the public health system of South Africa. This incorporates affordability and capacity to pay for health services in the private health system, inaccessibility of transport to get to health institutions, insufficient suppliers for medications or equipment and patients being treated poorly by health professionals in the public health system. To further elaborate on this, the public health system including the North West Provincial Department of Health is regularly portrayed by issues, such as long waiting hours, rushed arrangements, old and unclean facilities, destitute disease prevention, composed safety and security of both staff and patients including low quality public health care when contrasted with the private health system (Omotoso & Koch, 2018:2; Malakoane et al., 2020:2). Young (2016:15) states that South Africa faces various difficulties in conveying high public quality health services to most of its population. To be specific, the majority of the population cannot afford the private health system and should get entry to the public health system in usually a crowded and understaffed public health system, adding to increasingly slow responsive services (National Department of Health, 2019:11). In addition to the challenges faced within the public health system, South Africa is tormented by four challenging health conditions, namely: Human Immunodeficiency Virus (HIV) and Tuberculosis (TB), Maternal, infant and child mortality, non- communicable diseases and lastly, injury and violence (Young, 2016:15). The North West Province, for example, has the fourth highest HIV prevalence in South Africa, with an estimated 2 prevalence of 20.3 percent among adults aged 15 to 49 (Mooney, Campbell, Ratlhagana, Grignon, Mazibuko, Agnew, Gilmore, Barnhart, Puren, Shade, Liegler & Lippman, 2018:2369). For many years, the North West Province's public health system has been in crisis; and of particular concern is the province's recurrent and widespread stock-out crisis, which results in patients being sent home from hospitals empty-handed or with inadequate supply of crucial medicines (Molelekwa, 2021). In addition, the North West Province's health facilities are underdeveloped and have poor infrastructure. Lefafa (2020) further explains that patients normally run out of beds in certain hospitals around the Province which leads to overcrowding (Lefafa, 2020). Furthermore, Hunter (2020) alluded that the North West Provincial Department of Health is generally managed badly. To elaborate on this, the province has not appointed anyone in senior positions in almost four years, and those who have been appointed did not have appropriate skills. The North West Province State of Health Report (2021:11) explains that positions at the local and provincial government spheres are currently vacant or replaced on an interim basis which make service delivery and treatment provision activities difficult to complete. In addition, Felix (2021) outlines that The North West Provincial Department of Health has reported governance and capacity issues within the department. To be specific, Makinana (2021) alludes that in April 2018, the national government placed the government of the North West Province under administration, because of instability at all spheres of government, particularly in the Department of Health. The above-mentioned challenges in the South African public health care system including the North West Provincial Department of Health have led the government to consider different options such as introducing the National Health Insurance (hereafter referred to as NHI). The objective of the NHI is to provide universal access to quality health care for every South African as stated in Section 27 of the Constitution of South Africa, 1996. In terms of Section 27 of the Constitution of South Africa (1996) it perceives healthcare as a vital human right. Furthermore, it states that "everybody has the right to have access to health care services” and that the state must take reasonable administrative and other measures, inside its accessible resources, to accomplish the progressive acknowledgment of these rights and no one may be denied emergency medical treatment” (Republic of South Africa, 1996:16-17). The proposed NHI would be implemented in three stages and is scheduled to be fully operational by 2026 (The South African College of Applied Psychology, 2019). The proposed NHI is currently in its second stage, which runs from 2017 to 2022 and focuses on ensuring that the NHI fund is fully operational and has the necessary management and governance mechanisms in place so that service purchases and population registration can begin. This necessitates the introduction 3 of the National Health Insurance Bill [B 11 – 2019] (Gerber, 2019). Blecher, Daven, Harrison, Fanoe, Ngwaru, Matsebula and Khanna (2019:30) state that the proposed NHI Bill [B 11 – 2019] was announced and approved by cabinet in July 2019 and has been presented to parliament’s Health Portfolio Committee, which is a vital advance towards creating a lawful system of the National Health Insurance (BusinessTech, 2021). A Bill, according to the Republic of South Africa (2020a:5), is a draft version of a law or legislation. It is a piece of a proposed legislation that is being examined by a legislature. Therefore, the law- making process starts with a discussion paper known as a Green Paper. This is written by the Ministry or Department (such as the Department of Health) in charge of the subject to demonstrate how it is thinking about a particular policy. It is then made public so that anyone who is concerned can comment or offer suggestions. After the Green Paper, there is a White Paper, which is a much more detailed discussion paper and a broad declaration of government policy. The relevant department or task team appointed by the Minister of a certain department drafts this. Furthermore, the Republic of South Africa (2020a:5) explains that a bill is created from a White Paper. It is possible that interested individuals' comments will be asked once more. The policy paper will then be returned to the Ministry for further review and a final decision once the relevant legislative committees make any necessary adjustments or recommendations (Republic of South Africa, 2020a:5). Therefore, Blecher et al. (2019:30), argue that the proposed NHI Bill [B 11-2019] is an exceptionally foreseen change and is probably going to be the most significant rearrangement of the South African health system, ever attempted. As alluded from the above, the South African health system is two-tiered, that comprises of the public and private health system (Malakoane et al., 2020:2). Blecher et al. (2019:30) explain that the proposed NHI Bill [B11-2019] intends to connect the current two-tiered health system, whereby most of the citizens that depend on a public health system are tormented by the absence of access and quality of care; and a broadly affluent minority access health services in a better resourced private health system (Blecher et al., 2019:30). Currently, The Health Patient Registration System has been implemented in Public Health Care (PHC) facilities and hospitals in South Africa, resulting in the development of a patient register (Republic of South Africa, 2020b). The Health Patient Registration System is an arranged, electronic framework that is used to register any patient that goes to a health facility, and which records every patient's demographic data and health background (Republic of South Africa, 2016a:2). It is also utilised as a plan for the arrangement of healthcare facilities and services, as 4 well as to help tracking the usage of health services (Wolmarans, Solomon, Tannie, Venter, Parsons, Chetty & Dombo, 2014:36). Furthermore, during the State of the Nation Address, ,2021, President Cyril Ramaphosa emphasised that in apprehension of the proposed NHI Bill [B 11- 2019], South Africa has registered more than forty-four million people at more than three thousand clinics in the electronic Health Patient Registration System and are as of now executing this structure in different hospitals (Republic of South Africa, 2021). The coronavirus has shown the significance of the proposed NHI Bill [B11-2019]. It has taught the South African Government new lessons about staffing, health and safety, and health services, all of which would aid in the execution of the proposed National Health Insurance Bill [B11 – 2019] (Republic of South Africa, 2020c). The Republic of South Africa (2020c) states that the proposed NHI Bill [B11 – 2019] has proved to be the key to ensuring that all South Africans have free and equal access to health. The Republic of South Africa (2020c) further explains that the benefits such as reduced long waiting hours and adequate health professionals that could have been provided if the proposed NHI Bill [B 11- 2019] had been in effect during the coronavirus pandemic have also been discovered through research. Furthermore, the proposed NHI Bill [B11-2019] is not implemented to stop private healthcare, yet it will help make quality health services more available to everyone (Young, 2016:18). South Africans would be able to keep their existing medical scheme memberships, but they would not be able to opt out of contributing to the NHI fund (The South African College of Applied Psychology, 2019). The endeavours of the proposed NHI Bill [B11-2019] include decreased waiting times, since that is one of the issues with South Africa's current functioning of the public health system (Young, 2016:18). Head (2019) argues that once the NHI is fully operational, it would present itself as another state- owned entity in South Africa. Arnold (2020) concurs with Head (2019) that given the proof of ceaseless disappointment in the running of state-owned enterprises, for example, the Electricity Supply Commission (Escom) and the South African Airways (SAA), pessimism proliferate about the state's ability to set out on another enormous state-led endeavour, such as the NHI. Head (2019), further states that if the government of South Africa pursues to execute the proposed NHI Bill [B11-2019], it would prompt health professionals to leave the country. Young (2016:19) also explains that numerous health professionals in South Africa have serious uncertainties about the NHI; these health professionals emphasised that the South African’s health system is too complicated to even consider fixing it within fourteen years, especially since there have been no significant changes in the initial four years of implementation (Young, 2016:19). In addition, The 5 South African College of Applied Psychology (2019) states that researchers argue that the proposed NHI Bill [B 11 – 2019] will be unaffordable in South Africa. However, such an objection ignores the fact that South Africa still spends a disproportionate amount of money on healthcare. In research conducted by Pienaar (2016:120) among pharmacists about their perception of the proposed NHI Bill [B 11 – 2019], the respondents emphasised that it is definitely not an applicable answer to improve the lacking public health system of South Africa, since there are still significant challenges that need to be addressed facing the public health system as outlined above. However, the health system is conflicted by whether the issues that the current health system is facing can be solved without the implementation of the proposed NHI Bill [B 11 – 2019]. Additionally, the respondents perceived that the NHI will not improve the state of the South African health system and if it is not executed in an appropriate way, it will conceivably place the health system under more strain, which could result into more health care inequalities (Pienaar, 2016:121). Therefore, it is against this background that this study focusses on developing a model for organisational readiness for the implementation of the proposed NHI Bill [B11-2019] in the North West Provincial Department of Health. Currently, the proposed NHI Bill [B 11 – 2019] went through a parliamentary process that included a public participation phase, which occurred from 2019 to 2020 in all nine provinces of South Africa with a minimum of three public hearings per province (Karrim, 2019; Parliament of the Republic of South Africa, 2020a). From the discussion above, it is evident that the health system of South Africa, including the North West Provincial Department of Health, poses significant challenges. Implementation of for example the proposed NHI Bill [B 11-2019] would consequently be more challenging, because of the stigma that is already associated with the Bill. The Bill, however, aims to conceive a unified healthcare system by making health services more economical and available for the South African population (Michel, Tediosi, Egger, Barnighausen, McIntyre, Tanner & Evans, 2020:4). 1.3 PROBLEM STATEMENT Leaders in public healthcare systems remain tormented by the difficulties of implementing changes in care practices and service delivery (Maphumulo & Bhengu, 2019:4-5). The logic for this is that healthcare organisations are complicated, unified frameworks of specialised experts working within a structure making use of formal techniques, measurement frameworks and significant informal techniques (Holt, Helfrich, Hall & Weiner, 2010:50). Changes in these settings enclose a wide arrangement of future interventions and some include receiving clinical practices 6 while others include more major changes in a way to provide health services. According to Holt et al. (2010:50), it is important that public healthcare leaders understand what organisational readiness entails, and in doing so, it may improve their capacity to implement planned changes. Khan, Timmings, Moore, Marquez, Pyka, Gheihman and Straus (2014:1) explain that evaluating organisational readiness for change is the earliest approach of implementation, yet estimating it tends to be a perplexing and overwhelming task. In the recent years, public healthcare systems have put a lot of significance on measures that motivate and improve change within public institutions, and that can conclusively prompt better implementation outcomes (Nilsen, Seing, Ericsson, Birken & Schildmeijer, 2020:2). It is significant that public institutions measure and establish readiness for change and this technique can be completed in the initial stages of implementation. Khan et al. (2014:2) contend that determining a public institution’s level of readiness at the earliest phases of implementation for example, the exploration and planning stages can prompt better outcomes of implementation. Furthermore, assessments have been placed that indicates that half of ineffective implementation attempts are because of public leaders overestimating their institutions’ level of readiness (Khan et al., 2014:2). Africa including South Africa have significant challenges in implementing public policies that are aimed at sustainable development; the reason for this is the failure to measure readiness within public institutions (Naidu, 2008:36; Ajulor, 2018:1498). Public policy implementation has been identified as one of the largest serious issues facing developing countries (Ajulor, 2018:1500; Ahmed & Dantata, 2016:60). Since 1994, the post- apartheid government and the national government sphere Department of Health in South Africa have executed different kinds of public policies that had an influence on the delivery of services such as public health in general and health professionals (Brauns, 2016:67). These public policies were continuously accepted by different hospitals from the National office, Provincial Departments and municipalities but were not executed due to various difficulties (Baloyi, 2011:4). Challenges of public policy implementation are associated with inadequate planning, impractical goal setting, political inconsistency, inadequate estimation of the target group to contribute top policy implementation and insufficient knowledge of where the policy would be implemented (Ajulor, 2018:1511). It should be highlighted that if adequate planning and procedures are not followed, implementation and organisational readiness will not be successful. Dialoke and Veronica (2017:22:24) contend that implementation in developing countries is the motivation behind why public policies fail, which means that the aims of the policy are influenced by powerful strengths of legislative issues and administrations in collaboration with citizens (Dialoke & Veronica, 2017:22-24). 7 Hudson, Hunter and Peckham (2019:2), contend that there are four broad contributors to public policy failure: • “Overly optimistic expectations. • Implementation is dispersed. • Inadequate collaborative policymaking. • Vagaries of political cycle”. From the aforementioned, most public policies fail because the objectives set are impossible and cannot be put into practice, execution is too broad, lacking correspondence from public policymakers and conflicting political cycle (Hudson et al., 2019:2). In order to evade policy failure, public policy making begins with defining objectives that are feasible which can set a clear direction to the government and public policy implementers on what to focus on. However, if the policy objectives are unreasonable, the policy will ultimately fail at the implementation stage (Ajulor, 2018:1507). Public policy implementation also fails in developing countries, like South Africa, due to corruption playing a major role, for example, Rheeder (2021:84) explains that corruption in South Africa's public and private healthcare systems is a significant problem. The author continues by pointing out that there is an increase in corruption, which is supported by the fact that from 2003 to 2013, there were more qualified audits performed on health departments. To be more specific, only for the years 2009 to 2013, 24 billion is estimated to be an irregular spending for all provinces of South Africa combined (Rheeder, 2021:84). Therefore, corruption and corrupt officials may interfere with the implementation and workings of the proposed NHI Bill [B 11 – 2019]. With that being said without complete transparency throughout the implementation and running of the NHI, corruption will continue to play a major role (Makinde, 2005:66; Amado et al., 2012:6). Corruption, for example, is a contributing factor in the North West Provincial department of Health’s poor service performance (Lefafa, 2020). Corrupt officials have been suspending provincial workers who try to avoid corruption, delaying progress even more (Lefafa, 2020). Apart from corruption, there is a fundamental criticism that the implementation of the proposed NHI Bill [B11-2019] will be constrained by the poor administrative and managerial capacity of the state and poor collaboration between the national, provincial and district levels, of which questions of “capabilities” rise (Passchier, 2017:836). Currently, the proposed NHI Bill [B 11 – 2019] faces a burden of challenges between the roles and responsibilities of policy implementers for which clarity in this regard need to be established to ensure the effectiveness of the proposed NHI Bill [B 11-2019] implementation (Passchier, 2017:837). 8 Furthermore, South Africa has an estimated population of 59, 809,804, most of whom access health services through government-run public clinics and hospitals (Maphumulo & Bhengu, 2019:5; Worldometer, 2021). Approximately eighty three percent of South Africans rely on the public health system for their health services needs and just 17% of South Africans belong to medical aid schemes and are taken care of by the private health system (Ngobeni, Breitenbach & Aye, 2020:1-2; Maphumulo & Bhengu, 2019:5). Maphumulo and Bhengu (2019:5) contend that there are still issues in delivering high-quality health-care services, particularly in the public health system, where patients' expectations are not always reached. The South African public health system is constrained by too many citizens among the population with a high burden of diseases as alluded in the orientation of this study. This necessitates serious interventions such as the proposed NHI Bill [B 11 – 2019] to establish quality health services for everyone. It can also be argued that there are significant imbalances between the private and public health systems. Such imbalances are a contributing factor to shortages of medical health professionals in the public health system. These imbalances occurring in the South African health system are also applicable to the North West Provincial department of Health and have resulted into deaths of patients that could have been avoided had they received medical assistance in time. In addition, as in section 1.2, the North West Provincial Department of Health is portrayed by issues such as medicine stock outs, emergency medical services, governance and finances, human resources and suspensions (Low, 2020). Significant challenges are facing the South African public health system, as summarised in the figure below by Maphumulelo and Bhengu (2019:2-3): 9 Prolonged Poor hygiene & Adverse events waiting times poor infection control Shortage of health professionals Shortage of Poor recording Increased resources keeping litigation Figure 1: Challenges facing the South African Public Health System Source: Researcher’s own drawing The North West Province is one of the provinces in South Africa with a dysfunctional and weak public healthcare system (Rispel, Blaauw, Ditlopo & White, 2018:18). Each challenge has an influence on patients receiving quality healthcare services which is caused by weak leadership skills within the public health system of South Africa. Each challenge has an influence on the others; health professionals are at the centre of South Africa's health system, especially the public health system. In the North West Provincial Department of Health, for example, Schneider and Nxumelo (2017:7) state that there is a shortage of health professionals. Furthermore, the North West Province State of Health Report (2021:14) outlines that longer waiting times and the spread of infections among sick and dying patients occur when there is a shortage of health professionals. The Report (2021:16) further explains that the average time spent waiting in a public healthcare facility is 5 hours. Such challenges lead to adverse events and increased litigation of health professionals which influence the quality of health services within the public health system. Mahlathi and Dlamini (2015:2) contend that the arrangement of health services is generally dependent on the adequacy of the health workforce, regarding numbers, the nature of 10 abilities that they have, how and where they are conveyed and how they are managed. It can further be argued that poor record keeping, and shortage of resources also have an impact on patients receiving health services in time. These challenges might also have an influence on the North West Provincial Department of Health’s readiness to implement the proposed NHI Bill [B 11 – 2019] successfully once it becomes legislation. This study is therefore undertaken to assess whether this is indeed the case. Some of the root causes for the identified challenges facing the public health system include weak governance structures, inadequate management capacity and administrative systems (Republic of South Africa, 2018:29). The North West Provincial Department of Health, for example, lacks adequate management capability and human resources (Lefafa, 2020). Schneider and Nxumelo (2017:9) states that leadership and governance play a relatively understudied and underappreciated role in the North West Provincial Department of Health's public health system. The governance capacity of many leaders and managers in public health facilities including the North West Provincial Department of Health often lack appropriate management, knowledge, skills and competencies, and therefore it is significant that proper leadership is established before the implementation of the proposed NHI Bill [B 11 – 2019] (Republic of South Africa, 2018:36). For many years, the public health system in the North West Province has been in a condition of crisis (The North West Province State of Health Report, 2021:5). The department is confronted with significant challenges that affect the entire health sector, including the following: • Disease burden is quadrupled. • Healthcare of high quality. • Financial and human resource distribution. • Exorbitant health-care costs. North West Provincial Government (2018:13) explains that budgetary constraints, misuse of resources, particularly wasteful and useless expenditure, and a severe scarcity of health professionals have all exacerbated the issues faced by the North West Provincial Department of Health. In addition, it has been reported that a serious shortage of human resources exists in the North West Province, undermining the province's ability to provide high-quality healthcare services (The North West Province State of Health Report, 2021:14). Furthermore, the North West Province’s public health system problem is exacerbated by significant understaffing and a shortage of healthcare professionals, requiring patients to wait in enormous long queues for many hours to receive the services they require (The North West Province State of Health Report, 2021:5). According to the Report (2021:6), the issue of medicine stock-outs and shortages has been brought up with provincial duty bearers on several occasions, 11 but the situation persists. In order to meet contemporary challenges facing the South African health system, particularly the North West Provincial Department of Health, effective and efficient public policy implementation and organisational readiness would require sound managerial and administrative capabilities (Ajulor, 2018:1500). This study therefore investigated the research problem sketched above; and in addition, it developed a model for organisational readiness and implementation of the proposed NHI Bill [B 11-2019] once it becomes legislation in the North West Provincial Department of Health. 1.4 RESEARCH QUESTIONS The following primary research question derives from the orientation and problem statement: How can the North West Provincial Department of Health improve its state of readiness to implement the proposed NHI Bill [B 11- 2019] successfully once it becomes legislation? The following secondary research questions were generated as a result: • What are organisational theories that could improve the functioning of a public health system with particular reference to the North West Provincial Department of Health? • What are the theories, best practices and principles associated with the effective implementation of public policies (specific reference given to the proposed NHI Bill) in government? • How is the current health system of South Africa functioning with particular reference to the North West Province? • How ready/prepared is the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once it becomes legislation? • What are alternative options for the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] effectively once it becomes legislation? From the aforementioned research questions, the responses of respondents (chapter 5) would assist the North West Provincial Department of Health in identifying gaps and barriers in the proposed NHI Bill's implementation, which could improve the institution’s organisational readiness. The study aimed to accomplish the above by means of thorough theoretical chapters that would include organisational theories and readiness, public policy implementation, statutory and regulatory framework, and an empirical investigation. 12 1.5 RESEARCH OBJECTIVES The research objectives of this study are categorised into primary and secondary objectives in order to answer the problem statement: 1.5.1 The primary objective The primary objective of this study has been to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation. 1.5.2 The secondary objectives To achieve the aforementioned primary objective, a literature review comprising of organisational theory and organisational readiness, public policy implementation, existing statutory and regulatory framework governing the health system of South Africa, particular reference given to the North West Province and empirical investigation was carried out in order to provide sound recommendations. Therefore, the secondary objectives of this study are the following: • Analyse organisational theories that could benefit the more effective and efficient functioning of a public health system with particular reference to the North West Provincial department of Health. • Investigate what the implementation of a government public policy entails with particular reference to the North West Provincial Department of Health. • Analyse the current functioning of the South African health system with particular reference to the North West Province. • Determine the organisational readiness/preparedness of the North West Provincial Department of Health for implementation of the proposed NHI Bill [B 11-2019] once it becomes legislation. • Propose recommendations by way of a model that would enhance the organisational readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. 1.6 CENTRAL THEORETICAL STATEMENTS (CTS) Considering the problem statement, research questions and research objectives of this study; the Central Theoretical Statements of this study include the following: 13 CTS 1: There is a growing alertness that public policies do not fail on their own advantages; rather their progression depend on the process of implementation (Hudson et al., 2019:1). For the purpose of this study, this means that with the end goal for public policies to be fruitful; effective implementation is needed; for example, the success of the proposed National Health Insurance Bill [B 11-2019] can only be accomplished if the North West Provincial Department of Health follows legitimate processes and standards of public policy implementation. CTS 2: According to Halpern, Mweiumo, Suau-Sanchez, Budd and Brathen (2021:3), organisational readiness has a powerful direct impact on innovation. For the purpose of this study, this means that if an institution is not completely ready to implement change, this can have an influence on innovation. For example, if the North West Provincial Department of Health still has significant challenges and are not addressed before hand, these challenges may have a negative impact on the success of the proposed National Health Insurance Bill [B 11-2019]. CTS 3: The current issues encountered by the public health care system in South Africa are immense, yet many of these difficulties may disappear if the execution of the proposed NHI Bill [B 11-2019] becomes fruitful (Amado et al., 2012:8). This means that the challenges faced within the public health system of South Africa (including the North West Provincial Department of Health) are extremely large and need serious intervention to change the situation in this sector. Thus, the central theoretical argument of this study has been that interventions to ensure quality health care services for all citizens are vital and the current imbalances between the private and public health systems could be detrimental in the long run for South Africa. 1.7 THEORETICAL FRAMEWORK OF THE STUDY Theories influencing this study are outlined below: 1.7.1 The theory of Social Justice for public health Social Justice is a key factor in public health strategy, which has been described as the field’s fundamental value (Gostin & Powers, 2006:1053). This implies that the theory of social justice plays a significant role in ensuring that public health is prioritised. Gostin and Powers (2006:1053) define social justice as fairness and reasonableness particularly on how people are treated and how decisions are taken. This means that social justice is concerned with equality in terms of how individuals are treated by the state, particular reference given to the North West Provincial Department of Health and how decisions taken influence them. In addition, social justice is the fair and equitable allocation of goods and services in society to all people, regardless of colour, age, gender, ability status, sexual background, or spiritual background. This means that no one, 14 regardless of their background, should be excluded from government distributions such as the benefits of the proposed NHI Bill [B 11-2019] (Makateng, 2022:457). Powers and Faden (2006:82) state that the theory of social justice is an essential moral justification of public health. The ethical foundation for public health thus rests on general commitments in helpfulness to promote good health. Social justice therefore guarantees that everyone has access to fundamental elements of well-being of which quality healthcare is one. Thus, realising health is a particular objective of social justice; ensuring that everyone is treated fairly and with respect. For the purpose of this study, the argument is that there are significant challenges facing the public health system of the North West Provincial Department of Health and that there are inequalities occurring between the public and private health systems of South Africa. Thus, serious interventions are needed to ensure that equality is established within the health system of South Africa, particular reference given to the North West Provincial Department of Health to meet the principles of social justice. 1.7.2 Organisational theory Organisational theory is defined as a collection of connected concepts, principles, and hypotheses about organisations that explains the components of organisations and how they interact (Mwambi, 2020:3). Organisational theory can also be a set of general principles regarding the organisation (Starbuck, 2003:143). Additionally, Mwambi (2020:3) contends that organisational theory strives to achieve the following three fundamental goals: • Establish a foundation for understanding public organisations. • Lay the foundation for successful collaboration in public organisations. • For taking part in or starting initiatives to adapt and modify public organisations to new conditions. Organisational theory influences this study since it comprises of a set of related concepts and principles for public institutions. The researcher made use of such concepts and principles to make an informed analysis on whether the North West Provincial Department of Health indeed follows them. In addition, organisational theory influences this study since it promotes components of public organisations and how they interact in general. Therefore, organisational theory would guide the researcher on how such components and principles are used in public institutions, particular reference given to the North West Provincial Department of Health. The following section outlines two significant theories under organisational theory. 15 1.7.2.1 Descriptive theory A descriptive theory tries to characterise the nature of the relationship between the organisation’s various subsystems and its environment. It gives an understanding of how organisations should work, which leads to better management techniques (Weimer, 2020:7). A descriptive theory aims to anticipate what will happen, or at least understand what has happened in specific circumstances. For the purpose of this study, this theory influences the North West Provincial Department of Health by means of investigating what would happen after the implementation of the proposed NHI Bill [B 11-2019] (Weimer, 2020:7). Furthermore, descriptive theories concentrate on disciplinary attention to a phenomenon and provide tests to validate or deny their associated hypotheses, guided empirical choices and providing instruments for integrating new empirical findings into useful knowledge. In this regard, the researcher investigated by means of empirical investigation the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019]. In general, descriptive theories are theories of choice (Dillion, 1998:1). 1.7.2.2 Normative theory A normative theory establishes how things should be or what can be done in response to the conditions outlined by descriptive theory. For the purposes of this study, the researcher would provide recommendations from the findings of the empirical investigation about the North West Provincial Department of Health (Mwambi, 2020:4). It would instruct managers on what they should do and would assist them in improving various parts in their organisations to achieve organisational efficiency and effectiveness. Therefore, recommendations provided would assist the general state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] (Mwambi, 2020:4). Normative theory of public administration can also assist in creating agendas for empirical research and provide recommendations to practitioners (Weimer, 2020:9). In addition, normative theory identifies how problems should be solved or what values should be considered when making judgements. For the purpose of this study, this theory assisted the researcher on how challenges identified from empirical investigation could be improved and which principles could be considered by the North West Provincial Department of Health to enhance the state of readiness to implement the proposed NHI Bill [B 11-2019] successfully once it becomes legislation. Furthermore, normative theory directs public administration experts to relevant research and helps fill in gaps in current descriptive theories (Weimer, 2020:10). 16 From the aforementioned, descriptive theory illustrates how public organisations are managed, whereas normative theories explain how they should be managed (Meirvorich, 2015:7). In addition, normative theory explains how effective decisions should be made, whereas descriptive theory shows how decisions are produced in practice (Meirvorich, 2015:7-8). For the purpose of this study, Onichakwe (2016:176), argues that in order to promote effective governance, public managers must be able to forecast consequences and should employ any applicable descriptive theory to do so. On the contrary, public administrators should be required to study normative theory in order to make decisions that would improve society and their organisational effectiveness (Weimer, 2020:7-8). The above theories would be discussed in detail in the theoretical chapters of this study making use of primary sources. 1.8 RESEARCH METHODOLOGY Research methodology is the direction by which the researcher would undertake the study. It is also the route through which researchers motivate the existence of the research problem and supportive research goals to present the findings in a consistent and truthful manner (Sileyew, 2019:1). Additionally, research methodology may include looking at a research project curiously, critically, and systematically to increase in-depth knowledge of its importance, adequacy, and effectiveness (Kumar, 2014:2). Sahu (2013:3) argues that research methodology assists a researcher to complete research work positively, to extract not just unfamiliar truth of the research and to comprehend the society and its demand (Sahu, 2013:3). This study has been both theoretical and empirical in nature; to explain and describe different concepts and processes of public policy implementation and organisational readiness. Empirical research included semi-structured interviews and questionnaires with the one head of department, seven senior managers, two-line managers in public clinics and hospitals and twelve health professionals of the North West Provincial Department of Health to understand the department’s level of readiness. To increase the validity of semi-structured interviews and questionnaires, a document analysis was utilised. In addition, challenges were also identified that the Province is currently facing in terms of its health system. The research approach and design of this dissertation is subsequently discussed. 1.8.1 Research approach This study made use of a qualitative research approach. Qualitative research approach is the study of the nature of phenomena, including the various forms of expression and the environment 17 in which they can be seen. It frequently contains information in the form of words rather than numbers (Busetto, Wick & Gumbinger, 2020:1). According to Kumar (2014:14), a qualitative research approach follows an open, adaptable, and unstructured way to deal with enquiry; that intends to investigate diversity instead of quantifying. Qualitative research emphasises the description and narration of emotions and approaches instead of their estimation (Kumar, 2014:14). Additionally, qualitative research is more concerned with qualitative anomaly; it is related with experiences like reasons of human behaviours and targets finding the reasons of motivations and feelings of the public (Sahu, 2013:6). Struwig and Stead (2013:10) contend that qualitative research concerns itself partially with approaches like phenomenology and ethnography and includes strategies such as participant perception, authentic source investigation, interviews, focus groups, case studies and literature review to gather qualitative data. It should also be noted that, in social research, qualitative methods administer rich sources of data which in most cases propose new lines of enquiry as the research subject equip the researcher with unforeseen perspectives on the research questions (Gaskell, 2000:349). A qualitative research approach was followed in this study because it is most suitable, flexible and focuses on human behaviour. The purpose of this research approach has been that it would assist in developing a model for the North West Provincial Department of Health as indicated by the research objectives. A thorough literature review about organisational readiness, public policy implementation including an empirical investigation was undertaken. The study aspires to assist senior managers and health professionals within the North West Provincial Department of Health to understand the concepts organisational readiness and public policy implementation including establishing the readiness of the Department before the actual implementation of the proposed NHI Bill [B 11-2019] once it becomes legislation. Furthermore, a qualitative research approach assisted the researcher to make an informed conclusion about the state of readiness of the North West Provincial Department of Health. An in-depth understanding of the challenges facing senior managers and health professionals within the public institution, has also been better to understand. The following sections will outline components of a qualitative research approach that was used in this study. 1.8.2 Research design A research design is the guide that a researcher adopts to follow during their research adventure to find answers to their research questions as accurately, impartially, precisely, and economically as possible (Kumar, 2014:122). This study made use of both exploratory and descriptive research 18 designs. According to Sahu (2013:10-11), exploratory research is the type of research in which the researcher has no clue about the conceivable result of the research. For the purpose of this study, the researcher had no clue on what the challenges are that the one head of department, seven senior managers, two-line managers and twelve health professionals of the North West Provincial Department of Health are facing. The researcher therefore investigated this phenomenon by means of semi-structured interviews, a questionnaire and document analysis. Additionally, Struwig and Stead (2013:6), argue that exploratory research design is used when the researcher needs to form an idea and build up a research question; this would involve an intensive investigation of existing data regarding the matter and determine how the subject will be promoted (Sarantakos, 2013:124). For the purpose of this study, the researcher made use of a literature review to clarify how organisational readiness and implementation of the proposed NHI Bill [B11-2019] would be facilitated. Furthermore, a descriptive research design defines a phenomenon, issue, circumstance, and a programme or presents data about a specific issue and describes the approach towards the issue and focus on the how and what questions (Kumar,2014:122). In this regard, this study established how and what could be done to enhance organisational readiness within the North West Provincial Department of Health for implementation of the proposed NHI Bill [B 11-2019] once it become legislation. Therefore, to make an assessment, the researcher made use of defining and describing pertinent ideas and processes in the literature review regarding organisational readiness and public policy implementation. For this purpose, the researcher interviewed senior managers and health professionals about their understanding relating to organisational readiness and public policy implementation. The exploratory and descriptive research design chosen for this study therefore assisted the researcher in developing a model for the North West Provincial Department of Health for organisational readiness and implementation of the proposed NHI Bill [B11-2019] once legislated. 1.8.3 Literature review A literature review is a significant component of a research study, as it clarifies the theoretical, descriptive, and observational work the researcher is examining (Struwig & Stead, 2013:30). The literature review investigates previously conducted research on a similar subject and encourages the researcher to authorise the connections between what the researcher is proposing to explore and what has already been studied (Struwig & Stead, 2013:30). According to Pienaar (2016:23), a literature review is normally performed to build up a perception of the body of knowledge; authorise validity, demonstrate the direction of previous research and show how the current study associates with it, comprehend and review what is perceived in a particular area; and gain 19 information from others in order to add new ideas. Additionally, Kumar (2014:48) argues that a literature review is a significant part when a researcher is conducting research, which has an impact in all aspects of the study. For the purpose of this study, a literature review was utilised in order to gain knowledge on what has been investigated previously in relation to organisational theory, organisational readiness and public policy implementation and to add new information discovered. Therefore, through the literature, the literature review of this study focused on theoretical foundations of organisational theories, organisational readiness as well as principles and processes associated with effective public policy implementation with specific reference to the North West Provincial Department of Health to implement the proposed NHI Bill [B 11- 2019] once legislated. In addition, the theoretical foundation of this study focused on theories, models of public policy implementation and organisational readiness. To gather information, the researcher made use of the following tools to make sure that adequate information is gathered: • Catalogue of books: Ferdinand Postma Library • Catalogues of dissertations and theses of South African Universities • eBooks • EBSCOhost Online Research Database • Google scholar • Official government reports • Scholarly journal articles • Internet publications relating to the National Health Insurance in South Africa 1.8.4 Empirical investigation According to D’Souza (1982:669), empirical research is a fundamental component of the scientific technique, which links reasoning with observation, and disclosure with justification for acquiring scientific knowledge. Empirical research also represents the different techniques of acquiring, analysing, and introducing information in the context of justification (D'Souza, 1982:669). It should be noted that empirical research methods evolve from the use of observation and experience to a research question as opposed to being grounded on theory alone (Gaskell, 2000:349). Empirical methods are utilised to yield objectives and persistent findings (Dan, 2017:1). Dan (2017:1) argues that this methodology is positivistic because the social world is perceived as governed by laws or law-like rules that make it predictable. As indicated in section 1.8.1, this study made use of a qualitative research approach. This approach is descriptive in trying to understand the subject at matter by means of theoretical 20 chapters, semi-structured interviews and a questionnaire comprising a case study with the identified respondents within the North West Provincial Department of Health as outlined in section 1.8. The use of a case study assisted in determining the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019]. It is conceivable to classify qualitative research as empirical to the degree that researchers provide adequate information that permits the multiplication of their findings (Dan, 2017:1). Therefore, the researcher made use of document analysis to multiply the findings from the semi-structured interviews and a questionnaire. The subsection below discusses the methods that this study used to collect data. 1.8.4.1 Population and sampling It is necessary to introduce the study's population before commencing to discuss the sampling techniques used (Makauki, 2017:18). All potential respondents who can contribute information on the subject under research are referred to as the population (De Beer, 2019:27). In this study, respondents were divided into two divisions namely: the senior managers of the North West Provincial Department of Health and health professionals across the Province. This division assisted the researcher in making adequate investigation concerning the state of readiness of the North West Provincial Department of Health. According to Baran and Jones (2016:108), sampling plays a significant part in any research study and accurate examination should be placed on who to incorporate as members as a component of the design. Sampling can be described as the demonstration, cycle, or procedures of choosing a suitable sample or a delegate part of a population to determine the characteristics of the entire population (Mugo, 2002:1). Therefore, the researcher selected a sample from the population of the North West Provincial Department of Health; since it was not feasible to include the whole population. Suri (2011:63) argues that knowledgeable choices about sampling are significant to improving the nature of the research synthesis. This study made use of a non-probability sampling method because non-probability sampling addresses a group of sampling approaches that assists researchers to choose units from a population that they are keen on investigating (Baran & Jones, 2016:120). Additionally, Taherdoost (2016:22) explains that non-probability sampling is frequently connected with case study research design and qualitative research. Concerning the latter, this study focused only on the case study of the North West Provincial Department of Health. This study made use of expert sampling also known as judgemental sampling as it is most appropriate to accomplish the research objectives of this study. Expert/judgement sampling is utilised when a research study needs to get information from people that have specific expertise 21 needed during the exploratory phase of qualitative research (Baran & Jones, 2016:120). Etikan and Bala (2017:215) contend that the motivation behind why researchers utilise expert/judgement sampling is because it has a superior method of constructing the perspectives of individuals that are specialists in a definite area and gives researchers confirmation to make theoretical, detailed, and sensible speculations from the sample that is being utilised (Baran & Jones, 2016:120). Therefore, the head of department of Health was identified as the most relevant person that monitors all activities within the department and could provide sufficient information about challenges faced within the department. Senior managers were also selected as important respondents since they possess knowledge and expertise in relation to finances, human resources, and information technologies within the department. Data gathered from these respondents assisted the researcher in making an informed conclusion about the challenges faced within the department and in general contribute to determining the state of readiness within the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once legislated. Additionally, health professionals were selected, as alluded in section 1.3 of this dissertation that there is a shortage of health professionals within the province. Utilising health professionals as research respondents provided sufficient knowledge about the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] successfully after it would become legislation. In the last instance, line managers in public hospitals and clinics were selected since they are directly involved with the day-to-day operations of public hospitals and clinics within the province. Their specific inclusion and selection in this study is based upon the fact that these respondents are knowledgeable within their occupations and could assist in understanding the challenges faced by the North West Provincial Department of Health. The table below provides a summary of the population employed within the North West Provincial Department of Health as well as an outline of the sample. The total population that could contribute to the study is fifteen thousand nine hundred and forty (15 940). However, the questionnaires would only be distributed to twenty-two (22) respondents identified by means of expert/judgement sampling for purposes of acquiring information about effective functioning of the North West Provincial Department of Health. The data collected from both the questionnaire and semi-structured interviews were utilised in order to achieve/fulfil the study’s research objectives. Table 1: Summary of the population and sample 22 Participants Population Total number that was included in the sample Head of Department 1 1 Senior Managers: 1. Human Resources Management 5 3 2. Financial Management 5 2 3. Information Technology Management 1 1 4. Line managers of public hospitals and 8 3 clinics Health professionals across the North West 15 920 12 Province Total 15 940 22 Sources for the above table: De Beer, 2019:28; North West Department of Health, 2020:48-49; Ngobeni, Breitenbach & Aye, 2020:3 Omona (2013:169) states that considering sampling in qualitative research is significant and assist qualitative researchers to select sample size and sample designs that are most appropriate for their research. Hence, the researcher made use of sampling in this study in order to make an informed conclusion of the state of readiness of the North West Provincial Department of Health in rolling out the NHI system. 1.8.4.2 Instrumentation and data collection method Kumar (2014:1717) explains that multiple types of data collection methods (both primary and secondary data) may be employed in a single study. Due to this study being qualitative in nature, it incorporated both primary and secondary data. Primary data refers to information acquired directly from the researcher and could be surveys, observations, questionnaires, and interviews (Ajayi, 2017:3). Secondary data is information that has already been obtained or gathered by a third party who is not affiliated with the research project but collected the data for a different reason and at a different time in the past (Ajayi, 2017:4). Therefore, to increase the validity and reliability of the information obtained in the literature review of this study, the study made use of semi-structured interviews, a data collection questionnaire, and document analysis. The rationale behind this data collection method has been to make an informed conclusion of the state of readiness of the North West Provincial Department of Health in implementation of the proposed NHI Bill [B11-2019]. 23 1.8.4.2.1 Semi-structured interviews Researchers should note that preparation is significant when conducting structured interviews; researchers should have an idea what type of questions to ask and understand the meaning of the questions in the overall research study (Wholey, Hatry & Newcomer, 2015:366). Furthermore, when researchers are conducting research, they should take an easy approach that is convenient, unbiased, and professional (Wholey et al., 2015:366). Alsaawi (2014:151) states that structured interviews limit the accessibility of in-depth information. However, the benefits are that it is adaptable and allows respondents to expand on their answers (Alsaawi, 2014:151). Semi-structured interviews were utilised in this study by means of interviewing the identified research respondents across the province. The research questionnaire and interview schedule were developed beforehand. Open-ended questions were used. The purpose of open-ended questions is to allow respondents to respond in their own words and express their own opinions (Albudaiwi, 2017:2). The inclusion of open-ended questions therefore allowed respondents to express their thoughts on the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once legislated. The semi-structured interviews with senior managers and health professionals assisted in understanding the perceptions of senior managers and health professionals in relation to the functioning of the North West Provincial Department of Health, the proposed NHI Bill [B 11-2019], organisational readiness and public policy implementation. Also, this method of data collection assisted the researcher to identify the gaps and challenges facing senior managers and health professionals in providing quality health care to all citizens within the province. This method of data collection in general assisted in developing a model for organisational readiness and implementation of the proposed NHI Bill [B11-2019] once legislated within the North West Provincial Department of Health. 1.8.4.2.2 Questionnaires According to Walliman (2011:190), a questionnaire is a written list of questions with responses recorded by respondents. Kumar (2014:178) states that it is critical that the questions within a questionnaire are straightforward and easy to understand. For purposes of this study, biographical information of respondents and a five-point Likert-scale were utilised. This scale provided a variety of options in relation to organisational readiness and public policy implementation that the respondents could choose from. In a case where senior managers and health professionals were unavailable for a meeting due to their busy schedules, the self- administered questionnaire was distributed to the respondents via email. An example of the questionnaire that was distributed among respondents is included in this study as Annexure A and B. The questionnaire comprises of closed-ended questions. Closed-ended questions are less 24 cognitively demanding because they simply require a single key or mouse press to respond (Connor Desai & Reimers, 2019:1426). Sono (2018:28) explains that since each question has a few possible answers to choose from, questionnaires take less time for the participants to complete. Questionnaires, like semi-structured interviews, are used to gain an understanding of the study objectives. As a result, a self-administered questionnaire was disseminated among senior managers and relevant health professionals in the North West Provincial Department of Health who are employed on different levels of the work hierarchy. The researcher obtained the respondents' understanding in relation to organisational readiness and public policy implementation using the self-administered questionnaire. In general, the self-administered questionnaire aided in establishing the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] once legislated. This subsequently assisted in developing a model for effective public organisation functioning. 1.8.4.2.3 Document analysis Qualitative document analysis is a research technique for thoroughly and consistently interpreting the contents of written documents (Wach, 2013:1). This means that document analysis is a method that is used to analyse and evaluate readily available information obtained, for example available annual reports in relation to the proposed NHI Bill [B11-2019] and challenges faced within the North West Provincial Department of Health. Bowen (2009:27-28), further states that like any other analytical methods in qualitative research, document analysis necessitates that information be analysed and explained in order to extract meaning, acquire understanding and create empirical knowledge. For example, the researcher would analyse and explain information gathered from annual reports of the North West Provincial Department of Health in order to create understanding gathered from the empirical investigation. The rationale for document analysis is that the researcher is required to draw upon numerous (at least two) sources of evidence for example, challenges facing the North West Provincial Department of Health, that is to explore convergence and coordinated effort using distinctive information sources and techniques (Bowen, 2009:27-28). For the purpose of this study, the researcher analysed relevant documents such as the Annual Report 2019/2020, Annual Performance Plan 2020/2021 and Annual Report 2020/21 of the North West Provincial Department of Health. This method of data collection assisted the researcher into determining the state of readiness of the Department to implement the proposed NHI Bill [B 11- 2019] once it becomes legislation and into identifying challenges faced within the Department. 25 The rationale for this was to increase the validity of semi-structured interviews and a questionnaire to make a general informed analysis regarding the research problem. 1.8.5 Data analysis Data analysis is the action of lessening a lot of gathered information to make sense of them (Kawulich, 2004:96). Assessing qualitative data includes immersing oneself in the data to get familiar with it and furthermore searching for patterns and topics, searching for various connection between information that help the researcher with understanding what they have done at that point and then optically establishing the information and recording it (Kawulich, 2004:96). As mentioned in section 1.8.4.2, the researcher collected data for this study through semi-structured interviews, a questionnaire and document analysis. Therefore, without being biased, the data acquired through these instruments were compiled and organised using thematic analysis. Thematic analysis can be described as identifying, analysing, organising, characterising, and reporting themes identified within a data set (Nowell, Norris, White & Moules, 2017:2). The findings from the semi-structured interviews, a questionnaire and document analysis were transcribed, organised, and analysed through themes. The results of a thorough thematic analysis produced reliable and informative results. In general, this aided the researcher in reaching adequate conclusions and assisted in developing and providing a model for organisational readiness and implementation of the proposed NHI Bill [B11-2019] to the North West Provincial Department of Health. 1.9 LIMITATIONS AND DELIMITATIONS OF THE STUDY Every study has limitations on how far the researcher can proceed as some issues may be too complex to investigate, and one cannot go deeper than required to (Hodkinson & Hodkinson, 2001). For example, this study did not include any patients within the North West Provincial Department of Health since it would be complex to verify the validity of information obtained but only included the head of department, senior managers and health professionals across the province. Limitations in this study were also the unwillingness of line managers in public clinics and hospitals to allow health professionals to take part in the study although an approval letter was provided from the provincial department. In this instance, several follow-ups were made to line managers to provide permission to interview health professionals, but no agreement was reached. Thus, this study only made use of health professionals in three public hospitals and two public clinics in the North West Province. This inclusion did not have a negative impact on the 26 results. Another limitation was the negative attitudes of health professionals to be interviewed though the purpose of the study was thoroughly explained to them. In addition, limitations were also the availability and commitment of some senior managers. However, alternatives such as online interviews were scheduled with them. Some senior managers and health professionals were alarmed that the information gathered from semi- structured interviews and the data collection questionnaire may be used against them, but all fears were allayed, and an informed consent was provided to them. Lastly, this study focused on the state of readiness of the North West Provincial Department of Health to implement the proposed National Health Insurance Bill and did not make generalisations because it would be difficult to investigate and discuss the efficient functioning of South African health departments as a whole. 1.10 ETHICAL CONSIDERATIONS Ethics in a research study are extremely significant; as it requires researchers to preserve the dignity of their research subjects and interpret data collected very well (Akaranga & Makau, 2016:2; Arifin, 2018:30). There are ethical issues that the researcher should consider when conducting research, which includes incorrect reporting, including reporting findings in a way to serve the researcher’s own interest is unethical (Kumar, 2014:287). Also, inappropriate use of information that could directly or indirectly offend other people. Kumar (2014:287-289) argues that it is important for the researcher to consider ethical issues in collecting data from primary sources, and additionally to consider ethical issues when collecting data from secondary sources as it is easy using someone’s work as your own. Bless, Higson-Smith and Kagee (2006:140) state that in qualitative research, ethics are more concerned with the researcher’s conduct guaranteeing that it remains in accordance with the set standards as indicated by the discipline thereof. Since this study included an empirical investigation, it was the researcher’s responsibility to seek permission/consent from the gatekeeper of the North West Provincial Department of Health before conducting semi-structured interviews and submit a questionnaire to the head of department, senior managers and health professionals within the Province. The researcher made sure that confidentiality regarding interviewees’ responses was assured. As a result, confidentiality in both semi-structured interviews and the questionnaire also preserved anonymity. The researcher ensured that the respondents provide their consent to take part in the study. The informed consent document clarified the study's purpose and outline of what would be expected from respondents taking part in the study. The study sought ethical clearance from the North- West University’s Basic and Social Sciences Research Ethics Committee. Furthermore, the researcher made sure that the information that is presented in this study is based on truth and no 27 information was exaggerated or misinterpreted. In addition, the risk level of this study was low since the researcher did not ask any confidential information from the interviewees; in fact, interview questions were addressed only at the preparedness and efficient functioning of the North West Provincial Department of Health. 1.11 SIGNIFICANCE OF THE STUDY This study is important for theoretical foundations on public policy implementation issues and organisational readiness gaps. Therefore, it aimed to contribute to the body of knowledge of public policy implementation and organisational theory. This study aimed to identify gaps pertaining to public policy implementation with specific reference to the North West Provincial Department of Health. In addition, it also aims to make an informed analysis on the state of readiness of the North West Provincial Department of Health by means of theoretical chapters and an empirical investigation. Gaps identified concerning public policy implementation, organisational readiness and an empirical investigation assisted the researcher in contributing to the body of knowledge of Public Administration. As solution, a model for organisational readiness would be proposed. Furthermore, this study assisted health management in the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] successfully by means of gaps identified in theoretical chapters which include organisational theory, organisational readiness and public policy implementation and would ultimately improve the efficient and functioning of the Department. Potential beneficiaries of this study include the National Department of Health, the North West Provincial Department of Health, academics and researchers in the field of Public Administration and Management. 1.12 FEEDBACK TO RESPONDENTS AND DISSEMINATION OF RESEARCH FINDINGS The study is not classified. Therefore, the researcher with the assistance of her supervisor, undertake to publish the findings from the study within scientific accredited journals regulated by the Department of Higher Education and Training (DHET). Copies (both hard and soft) of the dissertation would be made available in the libraries of the North-West University. 1.13 CHAPTER LAYOUT OF THE STUDY The chapter layout of this study is as follows: Chapter 1: Orientation and problem statement 28 This chapter provides an introduction and direction of the study. The chapter identifies the problem statement, the importance of the study and how to conduct the study in general. Furthermore, this chapter explains the methodology that the study followed, which consists of the literature review, research design and research approach that were used in this study. Chapter 2: Literature review: Organisational Theory and organisational readiness This chapter reviews literature on organisational theory and organisational readiness. Models and approaches are discussed. In addition, the chapter conceptualises a model(s) and how it can be utilised to enhance organisational readiness for more effective functioning of public policies. Chapter 3: Literature review: Public Policy Implementation, best practices and principles In this chapter, a theoretical framework of public policy implementation was established. Theories, best practices, and principles associated with effective implementation of public policies are elaborated on. The theoretical chapter was undertaken to make an informed analysis of the research problem currently under study. Chapter 4: Statutory and regulatory framework governing the health sector of South Africa This chapter is three-fold. In this chapter the proposed National Health Insurance Bill is contextualised in detail. All relevant legislation and regulation are also explained in detail. This chapter reviews the current statutory and regulatory framework pertaining to the health system in South Africa with reference to the North West Province. Chapter 5: A model for organisational readiness and implementation of the proposed National Health Insurance Bill within the North West Provincial Department of Health: empirical findings This chapter presents the research methodology of this study. Empirical findings conducted with the head of department, senior managers, line managers in public hospitals and health professionals in the North West Provincial Department of Health are also discussed via a thematic approach. Chapter 6: Findings, conclusions, and recommendations This chapter provides a summary of the chapters of the study. This chapter makes an analysis of gaps identified in the previous chapters of the study (literature and empirical findings) and presents a model for organisational readiness for implementation by the North West Provincial Department of Health. Findings and recommendations regarding the way forward are presented. 29 1.14 CHAPTER CONCLUSION This chapter provided an overview of the study. It provided arguments in support of the problem statement. This chapter also provided an overview of the research questions and objectives. The chapter provided justifications for the central theoretical statements and the research methodology employed in this study. In addition, the research approach used in this study was justified. Moreover, the significance of the study was provided. Literature about organisational theory and organisational readiness is presented in the next chapter. This chapter will essentially establish the theoretical foundation for the importance of organisational readiness prior to the implementation of a public policy; the primary focus would be placed on the North West Provincial Department of Health. 30 CHAPTER 2: ORGANISATIONAL THEORY AND ORGANISATIONAL READINESS 2.1 INTRODUCTION In chapter 1 of this dissertation, the problem statement, research questions, research objectives, and significance of the study were identified to provide guidance for the development of a model for the North West Provincial Department of Health. The background of the South African health system including the North West Provincial Department of health and the current stage of the proposed National Health Insurance was explained in detail. In addition, the importance of organisational readiness and public policy implementation was provided. As outlined in chapter 1 (section 1.2), researchers such as Weiner (2009:5) argue that greater organisational readiness prompts successful implementation (Shea et al., 2014:2). As a result, the primary goal of this chapter is to provide a theoretical framework of organisational theories and organisational readiness. This chapter conceptualises organisational theory, since public institutions are structured differently and in such a way that could potentially have an impact on organisational readiness by means of public decision making and processes undertaken. This chapter explains how organisational theory influences organisational readiness before implementing a public policy, specific reference given to the proposed NHI Bill [B 11- 2019] once it becomes legislation. Furthermore, this chapter identifies approaches in relation to organisational theory to make an analysis of the functioning of public institutions. The chapter further conceptualises organisational readiness, outlines the importance of this phenomena and provides possible assessment tools to measure readiness, specific reference given to the North West Provincial Department of Health to implement the proposed NHI Bill [B 11- 2019] once it becomes legislation. Additionally, this chapter provides a readiness assessment for public institutions, particular reference given to the North West Provincial Department of Health. This chapter’s central premise is that it is vital that public institutions such as the North West Provincial department of Health establish organisational readiness before implementing any public policy. In addition, this chapter discusses a proposed model for organisational readiness by Aziz and Yusof (2018:201) which could be used as an illustration model of how organisational readiness could be applied in the North West Provincial Department of Health to implement the proposed NHI Bill [B11- 2019] once it becomes legislation. 2.2 ORGANISATIONAL THEORY Organisational research has always been dominated by organisational theory research, because its field covers the application of research theories and behavioural theories to the work and life levels of individuals, groups, and public organisations (Hundley, 2019: 12). Khorommbi (2019:41) 31 states that since the government and its institutions are operating in a period where thorough reorganisation and modernisation of its duties and procedures is a priority, it is critical to understand what organisational theory in government institutions entails. However, before conceptualising what organisational theory entails, it is important to define what a theory is. Oyedele (2015:7) explains that theories are viewpoints that people use to make sense of their experiences in the world. In other words, a theory means understanding the other side of the world instead of just focusing on one phenomenon. Therefore, a theory can be defined as a systematic grouping of interdependent concepts and principles that provide a framework for, or tie together, a significant body of knowledge (Oyedele, 2015:7). 2.2.1 Conceptualising organisational theory Hatch and Cunliffe (2012:3) argue that the concept of organisational theory is difficult to comprehend, and it is more difficult to explain in the context of Public Administration, although it is widely documented that Public Administration has always been tied to organisational theories (Khorommbi, 2019:41). Llhan (2020:294) alludes that the premise of insights developed on epistemological and methodological underpinnings underpins the conceptualisation of organisational theory. According to an organisational theory for the public sector the content of public policy and decision-making in public institutions cannot be understood without examining the organisation and operational modes of public administration (Christensen, Laegreid & Rovik, 2020:1). Organisational theory can therefore be defined as a collection of scholarly perspectives that aim to explain the complexities of organisational structure and its operation (Oyibo & Gabariel, 2020:46). It is made up of knowledge systems that investigate and explain the structure, function, and operation of organisations, with a focus on organisational group behaviour and individual behaviour (Onday, 2016a:17). In addition, Bhardawaj (2020:1) asserts that organisational theory is the study of an organisation's structure, functioning, and performance, as well as the behaviour of individuals and groups within it. Therefore, it is argued that organisational theory is a complex phenomenon and comprises of different variables that make up an organisation. Birken, Bunger, Powell, Turner, Clary, Klaman, Whitaker, Self, Rostad and Chatham (2017:2) state that organisational theory provides implementation researchers with a plethora of current, highly relevant, and generally untapped explanations for the intricate interplay between organisations and their surroundings. In other words, organisational theory guides implementation researchers on important components of an organisation. It is used to define, explain, and forecast the complex interactions that occur between organisations and their external 32 surroundings (Birken et al., 2017:2). In other words, external environments could also have a direct impact on organisations if not considered. Ferdous (2017:1) contends that the goal of organisational theory is to be sympathetic to the organisation's structure, and therefore envisioned to find out if there is a better approach to organise organisations or if it varies depending on the situation (Ferdous, 2017:1). In addition, Saad and Kaur (2020:2) are of the view that organisational theory examines an organisation's efficiency by examining how it achieves its goals, how its environment impacts its operations, and how it survives in the face of external difficulties, in addition to its structure, goals, and members. Therefore, it could be argued that if organisational theory is carefully studied, it could improve performance. Furthermore, organisational theory encompasses a variety of methods to organisational study and aims to explain organisational mechanisms. It also discusses the underlying ideas and procedures that organisations use to attain their goals and objectives in general (Saad & Kaur, 2020:2-3). Christensen et al. (2020:9) explain that organisational theory bridges the gap between the legal tradition, which focuses on legal categories and the formal body of laws to understand an organisation's mode of operation, and the environment’s deterministic approach, which sees an organisation's mode of operation as primarily reflecting external demands and pressures. Organisational theory also aims to explain how organisations work so that people can better understand and appreciate them (Pham, 2018:1). Therefore, it is argued that if organisations are better understood, productivity is established. Furthermore, Khorommbi (2019:42) contends that studying organisational theory can aid managers; by allowing them to better analyse and comprehend their organisation's operations as well as the actions of their sub-ordinates working inside the organisation's structures. Based on this statement, it is recommended that managers within North West Provincial Department of Health assess its organisation which in general would assist them in addressing their sub-ordinates. From the aforementioned discussion, the conceptualisation of organisational theory is based on the fact that the researcher wants to have a better understanding on how public institutions should function. By understanding this notion, it would assist into knowing which factors managers within public organisations could consider when assessing organisational readiness before the implementation phase of a public policy. It also provides an understanding on processes that should be followed since public institutions are complex and requires thorough understanding. The following sub-section presents the objectives of organisational theory. 2.2.2 Objectives of organisational theory The following are the primary goals of organisational theory outlined by Ray (2020:4): 33 • To provide a broad framework for comprehending and explaining organisational behaviour patterns. • To provide a scientific foundation for managerial actions including the prediction, control, and influence of these behaviours to increase organisational effectiveness. • To assist managers in investigating, analysing, and explaining what is happening within the organisation. • To assist managers in becoming more competent and influential. In addition, organisational theory helps managers understand how and why organisation’s function, as well as how to respond in situations involving organisations. From aforementioned objectives, it is significant that managers within public institutions have knowledge about the objectives of organisational theory. This would assist in identifying unforeseen gaps within the public institution. This would include, having knowledge about what is happening within an organisation, identifying potential barriers and assists managers into managing the organisation in general, since public organisations are complex and consistently change. Thus, it is recommended that managers within the North West Provincial Department of Health have sufficient knowledge about the objectives of organisational theory. In doing so, it could potentially assist into identify unforeseen gaps when assessing organisational readiness before proceeding with the implementation phase of the proposed NHI Bill [B11-2019] once it becomes legislation. The following sub-section presents approaches of organisational theory that are most appropriate for this study. 2.2.3 Approaches of organisational theory Khorommbi (2019:42) states that organisational approaches are applied to understand the internal process of public organisations and to establish the foundation for efficiency so that public organisations can reach its goals. Therefore, this section is significant because public organisations are structured differently and comprises of distinctive processes and procedures. Thus, it is important to identify and explain organisational approaches to have a better understanding of organisations and their functioning. 34 2.2.3.1 The classical theory The classical theory of organisations believes that administration is a common structural idea with universal applicability regardless of the circumstance or context, and that it is susceptible to identical challenges (Ferdous, 2017:1). This implies that administration is central within public organisations and how services are administered could be one of the elements causing potential challenges. Saad and Kaur (2020:1) state that the focus of classical theory is on efficiency and production and that people are motivated by their goals or needs. In other words, if individuals have goals or needs, it prompts their motivation to work hard in exchange for rewards. Therefore, Adebayo (2019:2) suggests that employees within an organisation should be rated and rewarded for their efficiency. This classical theory exposes the organisation to a high level of competition in the workplace because the organisation failed to create a relationship with its employees, which allows for non- cooperative and highly competitive workforce (Adebayo, 2019:2). Nhema (2015:177) explains that the respect for the rule of law, a tight separation of politics and administration, and a meritorious public service acting under the concept of anonymity and political neutrality are all pillars of the classical theory of public administration (Nhema, 2015:174). Furthermore, Nhema (2015:177) suggests that this theory is the foundation for a strong system of accountability that runs through all spheres of government. Classical theorists also sought a clear understanding of an organisation's goal, which is critical to understanding how organisations perform and how their methods of working could be improved (Khorommbi, 2019:44). For example, managers within the North West Provincial Department of Health should have an understanding on the current functioning of the public organisation and identify components that need to be improved. Additionally, identify and explain the end goal that the public organisation wants to achieve in terms of the proposed NHI Bill [B11-2019]. The classical theory places a strong emphasis on scientific methods, administrative approaches, and bureaucratic structure, with a focus on task efficiency (Hussain, Haque & Baloch, 2019:157). This means that this theory focusses on elements that could potentially enhance productivity, for example, such as employees within the North West Provincial Department of Health remaining dedicated and committed despite the challenges faced within the public organisation for better outcomes that could impact organisational readiness to implement the proposed NHI Bill [B11- 2019] once it becomes legislation. According to the classical theory, if an organisation is considered as a machine, its efficiency may be raised by making each member more efficient inside it. For example, Taylor emphasised the division of labour and the importance of completing everyone's tasks (Ray, 2020:7). Therefore, the focus is on performance specialisation and 35 coordination of numerous tasks amongst members of the organisation. In addition, the classical theory largely disregards the human dimensions of an organisation and focusses solely on the formal structure that should exist (Ray, 2020:7). This implies that the main emphasis of this theory, is mainly on how organisations should be structured. Furthermore, Khorommbi (2019:43) states that the classical writers also considered the organisation in terms of its purpose and formal structure, emphasising work planning, organisational technological requirements, management principles, and reasonable and logical behaviour assumptions. Hence, it can be argued that public organisations should have proper planning in terms of how public organisations should be managed for successful outcomes of planned endeavours. In this regard, the North West Provincial Department of Health implementing the proposed NHI Bill [B11- 2019] successfully once it becomes legislation. Onday (2016b:22) states that there are four pillars of classical theory, namely: the division of labour, scalar and functional processes, structure, and span of control. Onday (2016b:22) explains that the division of labour is the most important of the four components that govern how work is distributed among members of an organisation, for example the North West Provincial Department of Health should divide work equally amongst its employees particularly health professionals to avoid overloading them with work which could cause delays in delivering services effectively to the residents of the Province. Ray (2020:5) explains that the scalar and functional processes deal with the organisation's vertical and horizontal growth. In other words, it deals with every aspect within an organisation, without neglecting anything. The logical relationships of functions in an organisational structure are structured to efficiently accomplish the organisation's objectives. Finally, Remenova, Skorkova and Jankelova (2018:155) explain that a manager's span of control refers to the number of subordinates he or she can effectively manage, even though it depends on a variety of conditions and cannot be continuously increased. The classical theory approach is primarily concerned with an individual's identification and prioritisation of specific requirements, motives, or goals that are most conducive to the job and organisational satisfaction (Letele & Massyn, 2018:755). This implies that public institutions such as the North West Provincial Department of Health should outline to individuals working within the public organisation what is allowed and what is not. In addition, Nhema (2015:165) states that public organisations that have been shaped by classical organisational theoretical viewpoints have shown to be extraordinarily stable in a variety of situations around the world. Hence, it is recommended that the North West Provincial Department of Health acknowledges the classical theory for effective functioning of the public organisation. Nhema (2015:165) explains that the theoretical and practical levels of such an approach enables public organisations to adapt to 36 rapidly changing conditions and, as a result to be well equipped to meet the demands of their population. This means that since public organisations constantly requires change and upgrade, this approach assists into adapting in changing situations that normally occur. From the aforementioned discussion, it could be argued that this approach is significant for productivity within organisations. This is justified by the fact that public organisations should have knowledge on how organisations need to operate and function, how organisational rewards and goals motivates employees to work hard, how work should be distributed among subordinates to avoid delays in delivering effective services, how efficiency can boost productivity, and how organisations should be organised in general, all of which could improve organisational readiness to implement a public policy particular reference given to the proposed NHI Bill [B11- 2019] once it becomes legislation. 2.2.3.2 Neo-classical theory Nhema (2015:172) states that that this approach arose because of the classical theory's shortcomings. The neo-classical theory, often known as the human relations theory, focuses on employees' needs and guaranteeing their pleasure and well-being in the organisation. In other words, since the classical theory only focused on how organisations are structured, the neo- classical theory argues that it is important to consider the well-being of employees within an organisation. This approach emphasises democratic leadership over task-oriented leadership (Saad & Kaur, 2020). In other words, this approach focusses on each employee within an organisation undertaking a particular role and not only the management side. According to Saad and Kaur (2020), this approach mainly focusses on providing a healthy and happy workplace to meet the needs of employees, which creates a room for creativity, individual growth, motivation, which could be argued increases productivity of which is the goal of every public organisation. In addition, Pham (2018:1) explains that managers utilising the neo-classical approach can manipulate the work environment to produce positive results. This means that managers have control on how things should function within an organisation. Therefore, it is important that managers consider employees’ well-being to enhance productivity within organisations. Furthermore, for productivity within organisations, this approach focuses on people and employees as individuals (Adebayo, 2019:3). It exposes the organisation at the danger of employees being influenced by personal feelings and opinions rather than facts when making judgments (Adebayo, 2019:4). Therefore, it is vital that managers teach their subordinates the importance of making decisions based on facts rather than on emotions. Hussain et al. 37 (2019:157) contend that the neo-classical theory focuses on individual human needs, their relationship at work, behavioural elements, and incentives for effectiveness. In addition, the neo- classical writers argue that high employee moral increases productivity, which is determined by the amount of attention employees receive from their managers (Malik, 2019:4). Therefore, managers in public organisations such as the North West Provincial Department of Health should consider employee concerns, to avoid potential problems that could generally impact the functioning of the public organisation. Malik (2019:8) explains that the neo-classical theory is founded on complex organisational features. Several assumptions are emphasised, including the following: • Organisations exist to help people achieve their objectives. • Each organisation has an appropriate organisational structure that can be used to achieve its objectives. • Organisations function best when they take an ethical and rational approach. • The greatest way to gain control is to exercise formal authority, and organisational problems are frequently caused by ineffective structures that may be fixed by restructuring and reorganising them. In simple terms, the features explain that fruitful outcomes occur based on how organisations are managed and structured. In addition, the neo-classical theory gives the science of organisation and management a more human touch (Nhema, 2015:172). This implies that human concerns should also be considered within organisations, besides on only focusing on how organisations should be managed. This approach also outlines that collaboration is critical to the organisation's success, and that work standards are primarily attained through a behavioural approach. This means that organisations should ensure that collaboration is established amongst subordinates to enhance productivity that could potentially lead to achievement of anticipated goals (Nhema, 2015:172). From the aforementioned, it may be argued that this approach contributes to establishing efficiency within organisations. In other words, this theory argues that managers should consider the well-being of employees, because if the well-being of employees is neglected, it could potentially have an impact on productivity. Thus, it could be contended that if there is no productivity amongst employees it causes delays in delivering services effectively. Additionally, the neo-classical approach promotes teamwork amongst employees, which could be argued that 38 teamwork plays a significant role in productivity, if mutual understanding and collaboration amongst organisational members is present. 2.2.3.2.1 Summary of the classical and neo-classical approach The neo-classical theory came into place because of the deficiency of the classical theory. It is important to know the differences between these two theories. Below Nhema (2015:172) outlines a summary of classical and neo-classical theory: Table 2: Summary of the classical and neo-classical approaches Points of Distinction Classical Approach Neo-classical Approach Organisational Focus Functions and economic Emotion and human qualities demand of workers of workers Structure of organisation Impersonal and mechanistic Social system Application Autocratic management and Democratic process strict rules Emphasis Discipline and rationality Personal security and social demand Work goal of worker Maximum remuneration and Attainment of organisational reward goal Concept about workers Economic being Social being Content Scientific, administrative, and Hawthorne experiment, bureaucratic management. human relations movement and organisational Relations in organisation Formal Informal Nature of organisation Mechanistic Organismic Source: adapted from Nhema (2015:172) The table above presents a summary and outlines the differences between classical and neo- classical approaches by means of the nature of an organisation, how the organisation is structured, the content of an organisation and the formality of organisations. These two approaches are both important for effective functioning of organisations since the classical approach focusses on the structure of organisations and the neo-classical approach focus on employee well-being. Therefore, it could be argued that the classical approach is more appropriate since it focusses on the structural aspects of an organisation (when readiness needs to be established). However, it does not mean that managers should neglect the neo-classical theory, because the well-being of employees also contributes to productivity as outlined in the discussion above. As a result, managers should identify which approach best fit its organisation. 39 2.2.3.3 Contingency theory The contingency theory asserts that an organisation's decisions are influenced by its internal and external circumstances (Birken et al., 2017:4). The authors state that an organisation's ability to adapt to its external environment has an impact on successful implementation (Birken et al., 2017:4). Therefore, it is recommended that organisations acknowledge external environments as well, instead of only considering internal environments. According to the contingency theory, the best implementation entails adapting to internal (organisational capacity, mission and values, culture) and external (e.g., patients' demands, political environment, geographic locations) settings, as well as changes in those contexts over time (Birken et al., 2017:4). In addition, Mendy (2020:3-4) states that this theory's basic assumption is that external factors such as the environment, technology, resources, and size have a significant impact on an organisation's structure (and consequently its outcomes). The contingency theory thus emphasises that organisations must adopt a structure that is appropriate for the environment in which they operate to succeed (Khorommbi, 2019:49). This theory recognises the holistic nature of the organisation and the fact that performance is influenced by external conditions (Khorommbi, 2019:49). Furthermore, Khorommbi, (2019:49) explains that organisations work in a variety of contexts, one of which is the external environment, and it is critical to examine how such an environment affects an organisation’s activity. In addition, Mmutle (2014:40) asserts that the environment is viewed as the defining force on the organisation in contingency theory, and that the organisation is involved in a process of mutual impact and interaction. The contingency theory explains that for organisations to survive, resources must be accessible to meet organisational goals and values (Mmutle, 2014:44). For example, the North West Provincial Department of Health should ensure that there are adequate resources within the organisation when assessing organisational readiness (capital and staff) before implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. This theory also states that managers should make judgments based on what is happening and modify their management styles and approaches accordingly (Saad & Kaur, 2020). This means that managers should be observant with anything happening within an organisation, in order to identify areas that need improvements where necessary. Moreover, Pham (2018:2) is of the view that productivity is important in this approach because it allows managers to react to changes in the environment. The contingency theory emphasises the role of organisational structures in accomplishing successful organisational change. This approach explains that there is no universal 40 organisational structure that fits all types of organisations. Instead, the fit or misfit between the structure and the contingency, such as size and technology, determines organisational success (Aksom & Firsova, 2021:16). Therefore, Aksom and Firsova (2021:16) summarise the contingency theory as follows: • First, organisations exist and function within larger technical settings that define the expectations that must be met for them to live and succeed. • Second, fit and misfit have an impact on performance: organisations that successfully identify and maintain a fit between their structures and circumstances outperform their peers in terms of performance efficiency. • Third, internal structural changes occur regularly and have a favourable outcome. In some ways, contingency theory portrays change as a straightforward and typically successful endeavour. From the aforementioned summary, it could be argued that organisations should be monitored from every aspect (internally and externally) to identify unforeseen issues, especially when it comes to organisational readiness. According to Lartey (2020:47), the contingency theory suggests that the optimum solution to a problem is determined by a variety of factors including: the environment, goals, technology, and the individuals involved. In other words, when seeking for solutions for identified challenges, organisations should look at different alternatives when solving a particular problem instead of focusing only on one solution. Lartey (2020:47) further states that the optimum course of action is determined by environmental uncertainty and instability, as well as other unforeseen circumstances. It also addresses the open systems view of the organisation as a collection of interconnected pieces that make up a whole, which in turn depends on its surroundings. Therefore, Lartey (2020:47) emphasises that organisations are complex systems that are faced with uncertainty while still being subjected to rational criteria under the contingency theory. Finally, the contingency theory explains that organisations interact with and are influenced by their surroundings. In other words, the contingency theory is based on the systems approach to management, which states that organisations are more effective when they are designed to satisfy the needs of the environment (Mmutle, 2014:40). From the aforementioned discussion, the contingency theory emphasises that organisations should acknowledge both the internal and external environments which could assist in identifying potential challenges before undertaking any governmental intervention. This could also assist into identifying challenges occurring from within the organisation and externally. 41 2.2.3.4 Decision-making theory The decision-making theory explains how public policy decision-making shapes and is shaped by an organisation's institutional surroundings, as well as how public policy decision-making both arises from and contributes to institutional processes and outcomes (Harklau & Yang, 2020:90). Olalekan, Olubunmi, Oladipo and Oluwatoyin (2021:144) emphasise that this approach is the driver that propels an organisation's success. For example, it is important that public organisations such as the North West Provincial Department of Health acknowledges this approach to enhance organisational productivity by means of proper decision-making within the organisation. The decision-making theory states that decision-making is centred on public individuals acting in their individual capacities or in positions of leadership in organisations (Olalekan et al., 2021:144). Furthermore, this approach implies that long-term planning decisions should consider the multi-level system, and that components must function together over time to deliver multidimensional sustainability (Danivska & Appel-Meulenbroek, 2021:32). This means that when organisations plan certain decisions, they should be aligned with future demands. Turpin and Marais (2004:145) state that the rational model, the incrementalistic perspective, the organisational procedure’s view, and the political view are all models of decision-making theory that organisations should examine when assessing organisational readiness. Therefore, Turpin and Marais (2004:145) explain that when it comes to making decisions, the rational model contends that organisations should consider a variety of options. Furthermore, the incrementalistic perspective entails a step-by-step series of incremental acts that maintains the strategy flexibility. The organisational procedure’s view explains that decisions are pre- programmed in current procedures as well as the routinized thinking of the persons involved, which are the outcome of standard operating procedures triggered by organisational subunits. Lastly, the political perspective views decision-making as a personalised bargaining process guided by participants' agendas rather than rational procedures. This approach implies that individuals have different perspectives about the organisation's goals, beliefs, and the value of information (Turpin & Marais, 2004:145). From the aforementioned, it may be argued that decision-making plays a major role in public institutions. To expand on this, when public institutions make a decision on a particular public policy such as the proposed NHI Bill [B11- 2019] once it becomes legislation, it is critical that different alternatives be explored, and managers should choose the option that best suits the objectives of that particular public policy. Doing so could potentially improve organisational readiness and in general contribute to effective implementation of a public policy such as the proposed NHI Bill [B11-2019] once it becomes legislation. 42 2.2.3.5 The systems theory A system is defined as a collection of elements or goals that interact to generate a unified whole. These entities or objects are subsystems, and the system is made up of them all (Greeff, 2010:27). Therefore, organisations are viewed as open systems in a state of dynamic equilibrium, always changing and adapting to their surroundings and circumstances, according to the systems approach (Pham, 2018). In other words, the systems theory is of the view that organisations do not stay the same, however continually changes where necessary. Khorommbi (2019:44) explains that this theory aids organisations in organising and studies organisations as a whole. Mopeloa (2015:23) contends that researchers can use the systems theory to better understand the components and dynamics of systems. This enables them to assess issues and devise well- balanced intervention techniques with the goal of improving the fit between people and their surroundings (Mopeloa, 2015:23). This theory is recognised as one of the key intellectual developments of the twentieth century since it tries to analyse individual entities in their wider and interrelated environment (Greef, 2010:27). Greef (2010:27) explains that this context is referred to as a system when it is combined with its related components, with the whole always equalling the sum of its parts. According to Easton (1957:385), a system does not exist in a vacuum. It is constantly submerged in certain scene or surroundings. In other words, a system's operation will depend in part on how it reacts to its overall social, biological, and physical environment. Moreover, the systems theory, according to Khoza (2015:14), allows individuals to understand the components and dynamics of a system in order to evaluate problems and develop balanced intervention solutions. Khoza (2015:14) goes on to explain that this theory gives an organising conceptual framework for comprehending the occurrences under question. In addition, Zamisa (2019:40) states that this theory is a problem-solving technique that aims to find the optimum solution by expanding the decision maker's information base. In other words, when organisations are trying to solve a particular problem within the organisation, they can use the systems theory to guide the decision- making process. Zamisa (2019:40) argues that the systems approach is helpful in conceptualising the relationship between public policy action and its objectives. It provides policymakers with new conceptions of causation, evaluation, and intervention as a result of it. Therefore, the relevance of interconnectedness between subsystems is emphasised in this approach (Zamisa, 2019:40). In addition, Mapeloa (2015:25) states that an organisation cannot live on its own; it is dependent on a variety of elements in order to be sustainable. This implies that an organisation comprises of different variables for survival. As a result, these variables can be considered interdependent 43 (Mapeloa, 2015:25). On the other hand, Zamisa (2019:41) argues that the systems theory is vital to management since it gives a structure within which to visualise external and internal environmental components as part of a unified whole. In addition, this theory encompasses the multidisciplinary study of systems in general, with the objective of uncovering principles that may be applied to a wide range of systems in diverse disciplines of study (Khoza, 2015:15). From the aforementioned, it could be argued that the systems theory is important for effective functioning of every public organisation, because public institutions are continually changing and requires an approach such as the system’s theory. As indicated above, systems within organisations are made up of complex components such as a collection of elements or goals that interact to generate a unified whole, of which these components might potentially have an impact on how public institutions operate, both internally and externally, all of which could potentially affect an organisation's readiness when implementing a particular public policy if such complexities are not explored and carefully assessed. Therefore, it is recommended that public institutions such as the North West Provincial Department of Health considers the systems theory when solving problems and also monitoring those problems frequently, using this approach. Since this study's focus is on organisational readiness and implementation of the proposed National Health Insurance Bill, it is crucial to discuss it. The following section presents a theoretical foundation about organisational readiness. 2.3 ORGANISATIONAL READINESS Organisational readiness is an understudied topic and can be easily misinterpreted and requires detailed clarification and more empirical research to be carried out (Lim & Antony, 2016:134). Therefore, to build up on the theoretical foundation about organisational readiness for the purposes of this study, the researcher carried out empirical research within the North West Provincial Department of Health as outlined in Chapter 1 of this study. Walker, Brandt, Wandersman, Scaccia, Lamont, Workman, Dias, Diamond, Craig and Fernandez (2020:2) contend that implementation success is linked to organisational readiness as described by several frameworks. The most current conceptualisations highlight the critical role that organisational readiness plays throughout the implementation process (Walker et al., 2020:2). In addition, Lindig et al. (2020:1) is of the view that implementing interventions in the healthcare system is a controversial topic that is frequently mediated by public policies and that the readiness to implement is frequently an impediment. Hence, the readiness of health care organisations has been identified as a critical concern (Lindig et al., 2020:1). 44 Kabukye et al. (2020:2) believe that readiness has four aspects. To begin, organisations should consider the change process, which includes the procedures and tactics used to achieve the change, such as the stakeholder involvement. Second, the changes’ content, or the specific initiative being adopted. Third, the organisation's context, which includes the conditions and environment in which employees work, such as a dynamic, learning organisational culture, as well as financial and human resource capacity. Lastly, individual attributes of the staff that are affected by change, such as their abilities, biases, and prejudices (Kabukye et al., 2020:2). Furthermore, it is important to note that in the past year, research experts argued that fifty percent of all failures to undertake large scale organisational change occurred because leaders did not develop adequate readiness within organisations (Weiner et al., 2008:380). 2.3.1 Conceptualising organisational readiness There are numerous meanings attached depending on the context and situation. Therefore, there is no single definition for organisational readiness (Akunyumu, Fugar, Adinyira & Danku, 2020:5). Social scientists such as Weiner et al. (2020:107) argue that organisational readiness should be viewed as a process rather than a state. This implies that instead of organisations focusing on the state of readiness of an organisation it is recommended that readiness be carried out as a process that could change in time. Vaishnavi and Suresh (2020:8) state that organisational readiness is the first stage of the implementation plan, which will aid in describing and evaluating employee readiness levels. These authors further explain that measuring an organisation's readiness level will aid management in taking the necessary steps to make the organisational change ready. In the larger planning and implementation frameworks for reaching a targeted change outcome, organisational readiness is considered as a critical proponent (Bondzi-Simpson & Ayeh, 2019:1002). Thus, an organisation's commitment and competences, as well as the capacity of its facilities, must be enhanced to implement new public policies (Bondzi-Simpson & Ayeh, 2019: 1002). Sharma, Upadhyaya, Schober and Byrd-Williams (2014:1) state that organisational readiness is a well-established predictor of successful public policy implementation. In other words, the degree to which people of an organisation value change and rate three major variables of implementation capacity favourably, namely: task demands, resource availability, and situational factors, determines organisational readiness. Furthermore, Jakobsen et al. (2020:2686) argue that organisational readiness may be viewed as a critical factor in the implementation process. In addition, Hundley (2019:20) states that organisational readiness is important in organisations since it is dependent on several processes such as leadership 45 behaviour, which leads to organisational commitment. Therefore, high levels of organisational commitment are a reliable asset for organisations undergoing transformation (Hundley, 2019:20). Furthermore, Weiner (2009:2) characterises organisational readiness as a multi-level construct. This implies that organisational readiness involves different components that need to be monitored regularly. To be specific, individuals, groups, units, departments, and organisations could all be characterised as components (Weiner, 2009:2). Shea et al. (2014:2) is of the view that organisational readiness refers to the degree to which people of an organisation are mentally and behaviourally prepared to implement change. In addition, Arthur et al. (2020:2) argue that organisational readiness is an implementation strategy that addresses challenges to the implementation of new public policies by giving tools to encourage acceptance and alternative solutions to help improve implementation efforts. Kabukye et al. (2020:3) define organisational readiness as the psychological and behavioural preparedness of an organisation's staff. That is, how willing (change commitment) and capable (change efficacy) people are to continue keeping the change. Kabukye et al. (2020:3) further explains that Weiner's unified view of readiness at the organisational level is motivated by the premise that healthcare improvements entail collective behaviour change in the form of systems redesign, which entails multiple, simultaneous changes in staffing, workflow, decision making, communication, and reward systems. There are four constructs that are operationalised as components of organisational readiness according to Halpern et al. (2021:4) namely: • Clarity: in other words, components and factors that are not understood by subordinates within an organisation would need clarity. • Collaboration: in other words, all members within an organisation would need to work together to enhance readiness. • Capabilities: Organisations need to identify individuals with capabilities to undertake specific tasks. • Culture: The culture in which organisations operate could potentially have an impact on readiness. Moreover, Roth (2015:125) defines readiness as a state of mind regarding the necessity for an invention as well as the ability to carry it out. Roth (2015:125) explains that readiness can also be defined as a mental attitude toward the approaching shift that is influenced by people's 46 perceptions of financial assistance, a well-defined mission and leadership structure, a cohesive work team or the technical skill level to adopt a particular innovation, while the perception of people is to a certain extent separated from the actual existence of these resources. According to Oostendorp, Durand, Lloyd and Elwyn (2015:2) organisational readiness can be described as a state of being willing and able to act. In addition, Shahrasbi and Pare (2014:1) contend that there are two main conceptualisations of organisational readiness, namely: the structural and psychological perspectives. This implies that organisational readiness can be conceptualised as an organisation's ability to access the structural features that are required for change to occur. In this sense, organisational readiness refers to one or more structural attributes namely: institutional and financial resources, technical resources and capabilities, human resources, knowledge, and skills (Shahrasbi & Pare, 2014:1). Alternatively, Burnett, Benn, Pinto, Parand, Iskander and Vincent (2010:1) state that it is critical to understand organisational readiness and define preconditions for success. Therefore, rather than organisations taking a structural approach, other academics have defined organisational readiness in psychological terms by means of emphasising the attitudes, beliefs, and intentions of organisational members (Shahrasbi & Pare, 2014:2-3). Weiner et al. (2008:381) argue that the term organisational readiness refers to purposeful attempts to transform an organisation from its current condition to a desired future one to improve its effectiveness. For example, there are significant imbalances between the public and private health systems. Therefore, the proposed NHI Bill [B11-2019] aims to address these imbalances occurring and making health services accessible to everyone, which could therefore be considered as transition to improve the effectiveness of the health system of South Africa. In addition, Akunyumu et al. (2020:5) state that the term organisational readiness has been used to describe an organisation’s ability to accept new change prior to its implementation. Burnett et al. (2010:7) alternatively state that there are two fields of implications for organisational readiness. First, it allows organisations to focus their efforts on resolving preparedness factors, which gives organisations more confidence in their capacity to succeed. Second, if policymakers have a better understanding of the conditions that signal an organisation is ready for improvement work, they would be able to set fair expectations for outcomes (Burnett et al., 2010:7). Additionally, Lalic and Marjanovic (2011:102) define organisational readiness as the degree to which an organisation has optimised essential traits necessary for successful implementation. This refers to an organisation assessing important aspects for fruitful implementation. Lalic and Marjanovic (2011:102) further explain that it is critical for long-term success to assess readiness 47 in a methodical manner. This means that it is important that organisations assess organisational readiness following different methods and steps. Lindig et al. (2020:2) further define organisational readiness as a degree to which individuals of an organisation are willing to participate in a change process, which is defined by the view that change is necessary, and that the organisation can change if effort is placed. Therefore, several studies have highlighted the role of good attitudes and beliefs among individuals as precursors of organisational readiness (Vax, Farkas, Russinova, Mueser & Drainoni, 2021:6). In a nutshell, organisational readiness can be defined as a state of preparedness that an organisation achieves prior to beginning an activity. Therefore, positive outcomes, such as the successful implementation of new public policies, are frequently associated with such a condition (Halpern et al., 2021:3). For positive outcomes, Roos and Nilsson (2020:3) state that each change endeavour in health care organisations necessitates multiple and simultaneous adjustments in workflow, decision-making, communication, and performance management. From the aforementioned, it could be argued that organisational readiness is a complex concept to conceptualise. However, every organisation may conceptualise this concept based on situational factors within the organisation. The researcher has therefore, conceptualised organisational readiness based on different scholars’ perspective to provide a broader understanding of the concept. The following section presents the importance of organisational readiness. 2.3.2 Importance of organisational readiness The importance of organisational readiness derived from the fact that it has been discovered that most implementation failures are attributable to a lack of readiness knowledge in many organisations (Anjariny, Zeki & Abubakar 2015:176). The authors explain that it is significantly more difficult to get an organisation ready for implementation, hence the importance of organisational readiness. Oomariyah, Mursida, Gonti and Wahyuni (2020:111) also explain that the importance of organisational readiness comes from the fact that better readiness leads to better implementation. Oomariyah et al. (2020:111-112) further explain that members of an organisation are more likely to initiate change (for example, change rules, processes, or new activities), put forth more effort in supporting change, and endure in the face of obstacles or setbacks during implementation (Oomariyah et al., 2020:111-112). Moir (2018:2) argues that individuals inside an organisation should, in theory, be devoted and confident in their abilities to change practices collectively. This is regarded as crucial for the successful implementation inside 48 an organisation (Moir, 2018:2). Therefore, for organisational change to take hold and succeed, organisations and the people who work in them must be prepared (Smith, 2005:408). Smith (2005:411) is of the view that if individual and organisational readiness is insufficient, there is a significant probability of failure. It is vital to assess the current level of readiness inside an organisation, as failing to do so may result in ineffective change development (Yiga, 2015:23). Douglas, Muturi, Doulglas and Ochieng (2017:668) explain that identifying whether an organisation is ready for implementation is one of the most important variables in predicting whether implementation will be successful. Furthermore, organisational readiness predicts public policy implementation success across multiple variables. However, the elements that influence implementation readiness are poorly understood (Sharma et al., 2014:1). Sharma et al. (2014:1) state that organisational readiness is important since public policy success is contingent on optimal implementation, which is influenced by organisational readiness in general. This is to improve management practices that organisations employ to counter any resistance to new initiatives within their workforces (Ochurub et al., 2012:2). In addition, Ochrurub et al. (2012:3) allude that before implementing new systems, it is important that managers assess their organisation's readiness for change. If management fails to do so it may lead to wasteful spending. Therefore, it is significant that management has a clear vision of the results to avoid future failure (Ochurub et al., 2012:3). Recent systematic studies have revealed substantial obstacles in the field of readiness for change, such as differences in operationalising readiness for change and navigating a vast volume of published readiness for change measures to discover the "correct" one. In the healthcare industry, 60 to 80 percent of change strategies fail to be executed (Khan et al., 2014:2). Even though there is evidence that readiness is important, many organisational leaders do not appropriately assess readiness for change prior to implementation (Khan et al., 2014:2). Studies and other observers such as Weiner (2008:280) have also noted that when organisational leaders do not engage in a process of establishing organisational readiness, but instead overestimate the degree of preparedness within the organisation and its people, a predictable variety of negative outcomes occur namely: the change attempt either has false starts from which it may or may not recover, stalled as resistance increases, or fails entirely (Blackman, O’Flynn & Ugyel, 2013:3; Weiner, 2008:380). In addition, Roth (2015:45) argues that organisational readiness aids in identifying change-ready units and initiating change activities within these units. Roth (2015:45) therefore explains that organisational readiness aids in determining an organisation's ability to adapt to change before it is implemented. In addition, Lalic and Marjanovic 49 (2011:112) state that strong leadership, good governance, and a creative approach to the adoption of new public policies are typical characteristics of an organisation with strong organisational readiness, hence the importance of this concept. According to Capacity Building Centre for States (2018:1) organisational readiness is important because it guides the implementation phase by assisting in the identification of a clearly researched problem and the proposal of an intervention to address a problem's root causes. It also assists in recognising change barriers that may exist at the level of individual providers and employees, as well as in the organisational and social environment of care delivery, in order to successfully implement changes (Christl, Harris, Jayasinghe, Proudfoot, Taggart & Tan, 2010:3). In addition, Vax et al. (2021:2) explain that organisational readiness is important because of elements such as organisational environment and resources, commitment, and self-efficacy to execute the change influences organisational readiness for implementation. As a result, if such aspects are assessed in a timely manner, an organisation's level of readiness could be improved (Vax et al., 2021:2). The following sub-section outlines different approaches for organisational readiness. 2.3.3 Approaches of organisational readiness Karim, Mohammad, Abdullah and Razi (2011:1) explain that before beginning the real implementation, it has been emphasised that organisational readiness must be examined. As a result, a proper procedure necessitates some structural and logistical capabilities (Karim et al., 2011:1). Weiner et al. (2020:107) state that when assessing readiness in study or in practice, it is important to remember that time is bracketed, and readiness is viewed as a state with different levels (Weiner et al., 2020:107). Therefore, Weiner et al. (2020:107) argue that it is critical that organisations should not lose sight of readiness's common-sense definition as a state of readiness for future action. In addition, Roth (2015:43) states that to successfully guide the implementation phase, it is recommended that the first step be to assess the state of readiness. Furthermore, organisational readiness assessments have a long history of being created as significant implementation support tools (Miake-Lye, Delevan, Ganz, Mittman & Finley, 2020:12). However, it is uncertain how to adequately operationalise readiness in a variety of contexts (Miake-Lye et al., 2020:12). Several assessment tools have been developed to investigate various aspects of organisational readiness for implementation at both the individual and collective levels. However, it is unclear how readiness might be improved if it is shown to be inadequate for successful implementation (Vax et al., 2021:2). Lim and Antony (2016:138) 50 therefore state that an organisation's readiness assessment can aid in the identification of shortcomings and the development of process improvement initiatives. Walker et al. (2020:1) further explain that currently a complete, valid, reliable, and pragmatic measure of organisational readiness that can be used throughout the implementation phase is urgently needed. Hence, failing to assess organisational readiness may cause managers to spend a significant amount of time dealing with change opposition (Lim & Antony, 2016:134). As a result, a pragmatic assessment of organisational readiness can help to speed up and improve implementation efforts (Walker et al., 2020:1). Oostendorp et al. (2015:2) state that a timely assessment of organisational readiness can aid effective implementation by allowing for a customised implementation plan. However, there is no assessment tool currently used to assess organisational readiness in healthcare institutions (Oostendorp et al., 2015:2). As alluded from the above, there is currently no assessment tool that could be used to assess organisational readiness to enhance the implementation phase. However, the researcher made a compilation of possible assessment tools that could be used in public institutions. The following sub-section identifies and presents these possible assessments. 2.3.3.1 Possible assessment tools for organisational readiness The following discussion presents possible assessment tools organisations could use to assess organisational readiness. 2.3.3.1.1 Structural and psychological perspectives Assessing readiness entails examining elements that influence an organisation's overall ability to implement, as well as those that assist in the preparation of specific interventions and the motivation of individuals involved in the process (Capacity Building Centre for States, 2018:1). Holt et al. (2010:54) allude that organisational readiness is a complex-dimensional construct including structural and psychological factors that occur at both the individual and organisational level. Therefore, an organisation's readiness could be assessed from both a structural and psychological perspective. A structural perspective refers to an organisation's ability to assess structural features such as for example, institutional, and financial resources, technological resources and capabilities, human resources including knowledge and skills. To explain these concepts, Shahrasbi and Pare (2014:9) explain that the term financial readiness refers to the financial and organisational resources needed to implement transformation. These authors further explain that the technical readiness of an organisation relates to its technology, competence, and 51 capability for change implementation (Shahrasbi & Pare, 2014:9). Furthermore, psychological perspective refers to an organisation's ability to assess individual traits inside an organisation. These traits refer to attitudes, beliefs, and intentions of organisational members (Shahrasbi & Pare, 2014:9). Holt et al. (2010:51) explain that psychological factors are frequently framed in terms of a general psychological dimension in healthcare, based on Prochaska and Diclemente's trans theoretical model of change, which proposes that change takes place in five stages, namely: pre-contemplation, contemplation, preparation, action, and maintenance (Holt et al., 2010:51). The stage of pre-contemplation occurs when there is no intention of changing behaviour in the near future (Krebs, Norcross, Nicholson & Prochaska, 2018:1965). In the contemplation stage, Carbajosa, Catala-Minana, Lila, Gracia and Boira (2017:937) state that the individual is aware that a problem exists and is weighing the benefits and disadvantages but does not ignore the need to change. Roman, Caudroit, Hokayem and Bernard (2018:43) explain that preparation is the stage at which individuals alter their behaviour, experiences, and/or surroundings in order to solve challenges. Kim and Lee (2017:990) state that individuals in the action stage have been changing their behaviour for less than 6 months. Lastly, individuals enter the maintenance stage when they maintain the behaviour change for more than 6 months (Kim & Lee, 2017:990). Therefore, Vax et al. (2021:6) state that concentrating on the individuals' psychological barriers in organisations at the pre-contemplation and contemplation stages could enhance the number of engaged participants in the preparation and action stages, resulting in a higher beneficial impact on the change process (Vax et al., 2021:6). Holt et al. (2010:51-52) argue that structural elements exist at both the individual and organisational levels. To be specific, individual characteristics of organisational members, such as training and numbers, are a structural element that will influence collective readiness for change at the individual level. Individuals' readiness is enhanced, for example, when they have the skills to successfully complete the tasks and activities related with the change. Alternatively, Holt et al. (2010:51-52) explain that when assessing readiness, relevant dimensions at the structural and organisational level includes human and material resources, communication channels, and formal policy. As outlined from the above, organisational readiness could be assessed either on the structural or psychological perspective. The table below presents the differences between the structural and the psychological perspective by: Holt et al. (2010:51-52): 52 Table 3: Differences between structural and psychological view Characteristics Structural view Psychological view 1. Philosophical (theoretical) Determinism Behavioural theory of the position organisation. 2. Factors that are thought to Characteristics of the Beliefs and mind-sets of be the primary drivers of organisational structure (e.g., members of the organisation. organisational resources, processes, transformation structure, skills). 3. The notion of Capacity of the organisation The collective cognitive and organisational readiness and acquisition of necessary emotional ability of the reflects structural variables for organisation's members, as change implementation well as their readiness to implement change. 4. The most important Managers and decision- Members of the organisation evaluation factors makers at the highest levels. who are affected or affected by the change. Source: adapted from Holt et al., (2010:51-52). The table above summarises the characteristics used when assessing organisational readiness in terms of the structural and psychological perspective. It could be argued that it is important to assess readiness from both the structural and psychological perspectives, since they both play a major role within public organisations. Therefore, it is recommended that public organisations acknowledge to assess readiness before the implementation phase both from the structural and psychological perspective, since there might be potential factors/gaps influencing organisational readiness from both these perspectives. 2.3.3.1.2 Readiness constructs within organisations Khan et al. (2014:2) contend that there are readiness constructs and related statements for prioritisation when assessing readiness. Below is a table presenting these constructs: Table 4: Readiness constructs within organisations Readiness construct Statements Individual psychological Individual staff members' views, attitudes, and/or perceptions of the intervention should all be assessed. Individual structural Individual staff members' knowledge, skills, and/or ability to deliver the intervention should be assessed. Organisational It is critical to assess how well the organisation's employees psychological collaborate to reach a common goal. 53 Organisational structural It is critical to assess the intervention's human (e.g., personnel, champions, and leaders) and/or material (e.g., information technology, equipment, and funds) resources. Source adapted from Khan et al. (2014:2). Taking the above table into consideration, it could be argued that the table reflects the discussion above (see section 2.3.3.1.1) but with a broader explanation. The table above, summarises readiness constructs within organisations, these constructs include: the individual psychological, individual structural, organisational psychological and organisational structural. Therefore, it could be argued that these constructs are also essential when measuring organisational readiness because potential gaps could be identified in doing so. For example, if an individual within an organisation is not mentally ready for the implementation phase, then less effort would be placed. More importantly, it is significant to assess the organisational structure, by being certain that there are adequate resources as outlined above. In addition, Kabukye et al. (2020:3) state that according to different studies, measuring readiness at the organisational level is more beneficial than testing readiness at the individual level. However, it is important to note that there is no optimal model or measure for all cases. 2.3.3.1.3 Fundamental functions to assess organisational readiness Capacity Building Centre for States (2018:9) outlines that implementation teams or their designated subgroups should perform the following three fundamental functions to assess organisational readiness: • Think about the elements that influence readiness. • Create a readiness assessment strategy. • Conduct the readiness assessment and analyse the results. From the above, it is necessary that organisations acknowledge these three basic functions, as mentioned by Capacity building Centre for States (2018:9), prior to the implementation phase. First, organisations should identify the challenges that may potentially affect the organisation's readiness, then develop a readiness assessment approach that could include looking at critical factors of an organisation (e.g., financial, human resource, and information technology, as outlined in section 2.3.3.1.1 of this study). Lastly, public organisations should compare and analyse the findings. 54 Furthermore, Hanafi, Sing, Abdullah and Ismail (2016:123) are of the opinion that assessing organisational readiness for implementation requires four essential elements as they are highly significant, namely: management, people, process, and technology. In other words, it may be argued that organisations should assess its level of readiness on the management side, since it is one of the critical factors as outlined in the problem statement of this study (see section 1.3), that for effective and efficient public policy implementation and organisational readiness sound managerial capabilities is required (Ajulor, 2018:1500). In addition, organisations should potentially consider the people that might influence organisational readiness. These are people who might not be committed in the implementation process by means attitudes and beliefs (see section 2.3.3.1.1). It could also be argued that organisations should consider processes used within the organisation and identify gaps within those processes to make necessary improvements. Finally, it is important that organisations acknowledge the technological factors as outlined in section (2.3.3.1.1) since technology is known to be a never-ending process (Ogunyemi & Johnston, 2012:12). Lalic and Marjavonic (2011:111) are of the view that since organisational readiness is a multidimensional concept, it must be assessed systematically using the steps below: • Objective assessment of the organisation's strengths and weaknesses. • Building fundamental capabilities with the goal of improving organisational readiness. • Creating and revising a readiness plan on a quarterly basis. Based on the above, it could be argued that it is important that organisations acknowledge the strengths and weaknesses of the organisation by means of making a list of elements that do not need further improvements and identifying all the elements within the organisation that might need further improvements. It may further be argued that these weaknesses need to be identified so that strategies and alternatives could be brought into place to avoid unforeseen negative outcomes. It is also advisable that institutions identify their core skills and capabilities as it might make the process of implementation much easier if required skills are identified beforehand. Lastly, organisations would need to develop a readiness plan. In doing so it might assist to identify gaps and apply necessary improvements. Therefore, Lalic and Marjavonic (2011:111) explain that organisational readiness planning also assists the organisation in overcoming obstacles to success, adapting fast and easily to ongoing changes, and identifying areas for improvement. Finally, the following section presents a general readiness assessment that could be used in institutions, particular reference given to the North West Provincial Department of Health. 55 2.3.3.1.4 Readiness assessment Kabukye et al. (2020:1) state that readiness is a diverse and multilevel abstract construct comprising of individual and organisational characteristics. The authors contend that assessing present tools for readiness is difficult. However, organisations can identify the determinants (obstacles and enablers) that can be used to prioritise implementation locations, guide the selection of implementation strategies to increase the likelihood of successful implementation, and/or be measured over time to assess the effectiveness of implementation strategies by conducting a readiness assessment (Kononowech, Hagedorn, Hall, Helfrich, Lambert-Kerzner, Miller, Sales & Damschroder, 2021: 3). Kabukye et al. (2020:1) explain that developing a readiness assessment can also assist to identify action points or concerns that affect the success of the lifecycle when change management is most adequate. The figure below shows a readiness assessment that organisations can employ depending on their context: NEEDS FIT Figure 2: Readiness assessment of organisations Source: Adapted from Implementation guide toolkit (s.a:1) From the figure above, capacity is critical in determining readiness in the implementation phase. Isaza, Herrera Kit, Lozano Herrera, Mendez and Balanzo (2015:3) explain that the ability of a state to carry out decisions is described as capacity. In other words, organisations can assess their capacity in terms of their strengths and weaknesses, and if weaknesses are discovered, methods to improve an organisation's capacity could be implemented. The social, technological, or systematic ability of a collection of organisations to change 56 and attempt new endeavours is known as readiness (Roth, 2015:25). According to the Oxford Advanced Learner's Dictionary, evidence relates to a notion of fact that is produced by proof (Hornby, 2010:503). In other words, organisations could learn from past experiences as evidence when assessing organisational readiness. Resource refers to adequate staff and enough finances to execute a particular policy (Rutten, Roger, Abu-Omar & Frahsa, 2009:244). In addition, a resource is something that can be employed to assist in the achievement of a goal (Hornby, 2010:1257). Schalm (2013) states that there is no universally agreed-upon concept of organisational fit. Therefore, it is frequently used as a catch-all term by organisational managers to describe why certain behaviours, attitudes, and ways of interacting with others do or do not fit into that organisation's way of doing. For example, this could be adequate skills and sufficient leadership. In addition, the Oxford Advanced Learner's Dictionary defines needs as anything that is required because it is extremely vital and necessary (Hornby, 2010:503). For example, for the purposes of this study it could be argued that the proposed NHI Bill [B11-2019] is vital and necessary for the effective functioning of the South African health system. The end goal or purpose of this study is to develop a model or tool to assess the readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] once it becomes legislation. The above figure is therefore important as it would assist in determining the following: • What is the capacity of the North West Provincial Department of Health at all levels to implement the proposed NHI Bill [B11-2019] once it becomes legislation? • What is the readiness level of policy implementers to implement the proposed NHI Bill [B11-2019] once it becomes legislation? • What are the expected outcomes of the proposed NHI Bill [B11-2019] based on evidence? • Would available resources be adequate to implement the proposed NHI Bill [B11- 2019]? • Do recommendations provided for the proposed NHI Bill [B11-2019] fit within the organisation? • How can the proposed NHI Bill [B11-2019] meet the needs of citizens within the province? 57 Therefore, the following scale may be used to assess an organisation based on capacity, readiness, evidence, resources, fit and needs, particular reference given to the North West Provincial Department of Health. Rating: 1 2 3 4 5 Low med high Source adapted from: Implementation guide toolkit (s.a:2). As indicated above, the scale above can be used to assess whether an institution is ready to implement a particular public policy. The scale measures from 1 until 5 where 1 indicates a low readiness; 2 the midpoint; 3 the medium; 4 is the midpoint and 5 indicates that an institution is ready to implement. The scale may be used to assess an institution based on capacity, readiness, evidence, resources, fit and needs. Below is the readiness scorecard based on the scale above. The readiness scorecard below can be used to assess the institution’s level of readiness. The scorecard is also a 5-point rating scale: 5 indicates that the readiness level of an organisation is high, 3 indicates that the readiness level of an organisation is medium, 1 indicates that the readiness level of an organisation is low and lastly, 2 and 4 can be considered as the midpoints, in other words the readiness level of an organisation is average or in-between. Table 5: Readiness scorecard of organisations. Domains Low Medium High Needs Fit Resource availability Evidence Readiness for replication Capacity to implement TOTAL SCORE Source: adapted from Implementation guide toolkit, (s.a:3). 58 From the table above, organisations or the North West Provincial Department of Health can assess its level of readiness based on the scorecard identified. As indicated, 1 until 5 signifies that an organisation is or is not ready to implement a policy based on a particular dominant (needs, fit, resources availability, evidence, readiness for replication, capacity to implement). The total score is 30, in other words, if an organisation scores a 5 for each dominant it thus indicates that there is full capacity to implement a particular policy. If an organisation scores a 4 (midpoint) for each dominant, it shows that an organisation has a total score of 24, and therefore signifies that an organisation should identify gaps and make improvements on the remaining 6 points for successful implementation. If an organisation scores a 3 for each dominant, it will give a total score of 18, which indicates that major improvements are necessary and therefore adjustments should be made to increase the state of readiness. Furthermore, if an organisation scores a total of 2 (midpoint) for each dominant, it will give a total score of 12 which can be argued that a particular organisation does not meet half (15/30) of the total score and shows that a particular organisation is far from being ready to implement a policy. It would be advisable that an organisation revisits the dominants to see where improvements are needed. Finally, if an organisation scores a 1 for each dominant, it will give a total score of 6; it shows that the readiness level is very low, and it is advisable that a particular organisation identify its strengths and weaknesses to find alternatives or pause the implementation phase in general so that major improvements could be made by identifying gaps from each dominant. It should be noted that each organisation can get a different score and does not have to be the same score as the one’s identified. The following section conceptualises a model and discusses a proposed model for organisational readiness by Aziz and Yusof (2018:201) which could be used as an illustration model of how organisational readiness could be applied in the North West Provincial Department of Health to implement the proposed NHI Bill [B11- 2019] once it becomes legislation. 2.4 MODEL(S) The purpose of this study has been to present a model (or models) that could be utilised in government settings such as the North West Provincial Department of Health to improve public policies, structures, systems, functions, and behaviour (Van der Waldt, 2013:1). Therefore, it is important to conceptualise such a concept. Van der Waldt (2013:1) state that most of the time, researchers create a model to solve a research problem that has been discovered. Elangovan and Rajendran (2015:2-3) contend that many researchers value the use of models in their 59 research, since it is an analysis tool that theorises decision-making by analysing its connection to major research topics and offering a long empirically supported example (Elangovan & Rajendran, 2015:2-3). In addition, Crockett (2017:1) states that implementation researchers are increasingly interested in employing models in their work. Crockett (2017) further explains that others have evolved from the discipline itself, while others have been borrowed from other disciplines (Crockett, 2017:1). 2.4.1 Conceptualising a model(s) Models are more localised versions of theories, with a limited scope and with a more concrete application (Fried, 2020:337). They are frequently applied to a specific feature of a theory, providing a more local explanation, or understanding of a phenomenon (Fried, 2020:337). Admin (2015) states that a model is a tangible, verbal, or graphical representation of a concept or idea. It is created to simplify theoretical concepts and is employed in a variety of sectors today (Admin, 2015). In addition, Nilsen (2015:2) explains that a model is an intentional simplification of a phenomenon or a particular feature of a phenomenon and that it does not have to be 100% accurate approximations of reality (Nilsen, 2015:2). According to Fried (2020:337), a model decomposes processes into relevant parts, attributes of these parts, relationships between the parts, and temporal dynamics of its change to show the mechanisms that might govern the processes that lead to a phenomenon with accuracy. In addition, Nilsen (2015:2) argues that a model does not have to be a perfect representation of reality to be valuable, and that it can be described as a theory with a more narrowly defined scope of explanation, which simply means that models are descriptive. Furthermore, Elangovan and Rajendran (2015:3), explain that a model can also be described as a heuristic device and a pictorial illustration that visually depicts concepts and theories. Modelling becomes a vital aspect of grounded theory since it aids in understanding, prediction, and decision- making (Elangovan & Rajendran, 2015:3). Nurse (2013) states that models are also frequently constructed based on qualitative research, and that they show how the study interprets information and how concepts are related to one another. In addition, a model, according to Goldfarb and Ratner (2008:92), is defined as a set of functions and conditions that provides formal results, such as classes of equilibria inside the model. Crockett (2017) argues that a model describes but does not explain. This means that a model is a term that is frequently used to define or even simplify the process of turning research into practice (Crockett, 2017). Grune-Yanoff (2013:197) also contends that models are 60 representations of data and observations and that they are used to prove or disprove theories (Grune-Yanoff, 2013:197). In addition, Kuhne (2005:3) states that a model is a description or an analogy that is used to assist into visualising something that cannot be seen immediately. Furthermore, Cloete, De Coning, Wissink and Rabie (2018:34), explain that a model is a representation of a more complex reality that has been oversimplified to describe and explain the relationships among variables, and even sometimes to prescribe how something should happen. Cloete et al. (2018:34) further state that models can therefore be used in a neutral, descriptive way, or they can be used in a normative, prescriptive way, expressing a preference for a particular value judgement. Roberts, Russell, Paltiel, Chambers, McEwan and Krahn (2014:10) allude that the appropriate model type is determined by purpose, level of detail and complexity. In addition, models serve as intermediaries between theories and the real world (Fried, 2020:337). The author further argues that models in implementation are commonly used to describe and/or guide the process of translating research into practice (for example, implementation practice) rather than to predict or analyse what factors influence implementation outcomes, for example, implementation research From the aforementioned, it could be contended that models are important since they simplify concepts or provide solutions in terms of the theory that is presented within study/research. As indicated in the problem statement of this study (see section 1.3), the researcher aims to develop a model for the North West Provincial Department of Health for organisational readiness and implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. Therefore, the model would be presented by means of identifying gaps from theoretical chapters of this study, which includes organisational theory and organisational readiness, public policy implementation and empirical investigation within the North West Provincial Department of Health. The following section presents a model that could be utilised to assess factors influencing organisational readiness within the North West Provincial Department of Health. 2.4.2 Model for organisational readiness The model below outlines factors influencing organisational readiness within organisations (Aziz & Yusof, 2018:201): 61 Figure 3: A proposed model for organisational readiness. Figure adapted from: Aziz and Yusof (2018:201) From the above model, it may be argued that each dimension has an influence on organisational readiness in general. From the above, a context is defined as everything that is not part of the quality improvement intervention. For example, the set of qualities and conditions (policies, organisational culture, organisational structure, and previous experience) that surround a certain implementation endeavour (Coles et al., 2017:2). Coles et al. (2017:1) state that understanding and overcoming contextual barriers is critical to implementing effective improvement, yet contextual is still little understood. Furthermore, organisational culture refers to the way things are done in an organisation. Mohsen, Neyazi and Ebtekar (2020:880) state that it is an important factor in the organisation’s success and growth (Mohsen et al., 2020:880). In addition, Mohsen et al. (2020:880) are of the view that the organisational culture is an independent variable that has a positive or negative impact on many other variables in an organisation. Taking the above model into account, learning refers to a process whereby organisations gain knowledge of their past experiences and make an analysis on how improvements could be made for organisational readiness and successful implementation (Cerna, 2013: 7). According to Phillips (2017:15), change valence is an independent variable that refers to how important the 62 proposed change initiative is to the members of the organisation. The stronger the change valence, the more willing an organisation is to change. Trisnawati, Damayanti and Novita (2020:310) explain that change appropriateness is an important aspect of change valence. As a result, if the organisation wants to improve its change readiness, the perceived appropriateness dimension should be prioritised over all other factors (Trisnawati et al.,2020:310). Furthermore, Rani (2019:205) alludes that the implementation method is a strategy for incorporating managerial objectives, methods, and rules into growth projects, financial plans, and procedures. The organisation may quickly fail if such approaches are not properly implemented. Rani (2019:207) further explains that personnel, resources, organisational culture, organisational systems, and organisational structure are all variables that support the implementation method. Nayeemunnisa and Gomathi (2020:413) state that organisational capability is described as an organisation's ability to successfully manage its resources; it entails making strategic decisions and effectively implementing the strategic decision process to accomplish the intended objectives. Martin (2017:83) argues that significant resources are required for successful readiness and policy implementation; otherwise, services would not be supplied. In addition, human resource availability is a critical component that influences the effectiveness of implementation and readiness (Martin, 2017:83). According to Da Silver (2014:312), as indicated on the figure when there is a high task demand, there is also a high mental effort. As alluded previously, each dimension has an influence on organisational readiness. It is significant that organisations identify its contextual factors that might impact organisational readiness. It can also be seen that change valence plays a major role in organisational readiness. Therefore, it could be argued that it is important that organisations acknowledge appropriate factors that might have an influence on a particular change that is implemented within an organisation. Organisations should also take note of additional factors that could influence readiness such as the implementation method, by making sure that regular and effective communication between members that are involved in the implementation phase is established. The model above also explains that it is important that organisations assess its capabilities to set out the change by means of evaluating whether adequate resources are available. All these dimensions generally increase an organisation’s readiness to implement a particular public policy such as the proposed NHI Bill [B 11-2019] once it becomes legislation. To conclude, senior managers of every institution, with special attention paid to the North West Provincial Department of Health, should note that organisational readiness has an impact on public policy implementation. Even though organisational readiness and policy implementation 63 are two distinct ideas, they are linked in some way. Managers, on the other hand, are prone to overlook it. 2.5 CHAPTER CONCLUSION This chapter addressed the first research objective of this dissertation which was to investigate organisational theories that could benefit the more effective and efficient functioning of a public health system, particular reference given to the North West Provincial Department of Health. The chapter started by conceptualising organisational theory. The chapter further identified objectives of organisational theory and explained how organisations could apply them. This chapter also identified approaches of organisational theory namely: the classical theory, the neo-classical theory, the contingency theory, the decision-making theory, and the system’s theory (see section 2.2.3). In addition to this, the chapter provided motivations on why these approaches are significant within organisations and for the purposes of this study. Furthermore, since the study’s focus has been about organisational readiness and implementation of the proposed NHI Bill [B 11-2019] once it becomes legislation, this chapter presented a theoretical foundation about organisational readiness. In addition, this chapter outlined motivations for the significance of organisational readiness (see section 2.3.1 & 2.3.2). The chapter further identified different approaches for assessing organisational readiness (see section 2.3.3). It also provided a readiness assessment that institutions could utilise when assessing organisational readiness, specific reference was made to the North West Provincial Department of Health (see section 2.3.3.1.4). Furthermore, this chapter conceptualised a model(s) and explained how it could be beneficial for the purposes of this study. This chapter also discussed a proposed model for organisational readiness by Aziz and Yusof (2018:201) and explained different dimensions that influence organisational readiness within the model, namely: contextual factors, change valence, implementation method and organisational capabilities (see section 2.4.2). Since it is important to establish organisational readiness before implementing any public policy; the next chapter focuses on the second research objective of this study, which is to investigate what the implementation of a government public policy entails. A detailed literature review regarding public policy implementation, best practices and principles are presented. Specific reference is made to the North West Provincial Department of Health. 64 CHAPTER 3: PUBLIC POLICY IMPLEMENTATION, BEST PRACTICES AND PRINCIPLES 3.1 INTRODUCTION Chapter 2 of this dissertation consulted relevant literature concerning organisational theory and organisational readiness. Emphasis was placed on organisational readiness, the importance of organisational readiness and what public institutions (specific reference given to the North West Provincial Department of Health) need to acknowledge before proceeding to the implementation phase. Discussions relating to organisational readiness, approaches and models were also outlined. As noted in the previous chapter, it is that important institutions assess organisational readiness before the implementation phase of public policies to assist in identifying gaps that might potentially influence positive outcomes. Taking the aforementioned into account, this chapter provides literature about public policy, public policy implementation, best practices and principles of public policy implementation. First, this chapter conceptualises public policy and the implementation phase, including related terms to public policy implementation. It also outlines processes, principles, and best practices of public policy implementation to understand how public policies are implemented after assessing organisational readiness within public institutions. In addition, this chapter discusses the theory of social justice since the theory advocates that inequalities in terms of public health should be prioritised with specific reference made to the North West Provincial Department of Health. The chapter’s main goal is to explore how public policies are implemented. As a result of this knowledge, it would assist the North West Provincial Department of Health to successfully implement the proposed NHI Bill [B11-2019] once it becomes legislation by following legitimate public policy implementation processes. 3.2 CONCEPTUALISING PUBLIC POLICY AND THE IMPLEMENTATION PHASE Kunyenje (2019:19-20) states that the goal of public policy research is to develop solutions to societal issues that require government involvement. Issues in a variety of disciplines or sectors, such as health and education, could be the source of these societal problems. According to Delamaza, 2015:24 in Tebele (2016:2), public policies and their implementation can aid in the improvement of a democracy. Therefore, it is necessary to clarify what public policy is in general, as well as what public policy implementation entails (Delamaza, 2015:24 in Tebele, 2016:2). These concepts are crucial because public policy implementation is a component of public policy. 65 As a result, Tebele (2016:2) explains that public policy implementation is a concept that is encompassed by the phrase public policy. Smith (2018:3), contends that a policy is a deliberate course of action or inactivity taken by an actor or group of actors in response to a problem or issue of concern. This definition asserts that public policy has a distinct set of features. Public policy is defined by Anderson (2006:6) in Barnard (2018:26) as a generally stable, intentional course of action performed by a person or a group of actors in dealing with a topic or issue of importance. It is worth noting that, while public policies do occur (as goal-oriented procedures), they are designed to attain certain goals or deliver specific outcomes (Barnard, 2018:26). A diverse range of stakeholders define and influence public policies at the global, national, and local levels (Balane, Palafox, Palileo-Villanueva, Mckee & Balabanova, 2020:1). For instance, public policies are advanced to respond to the challenges identified and the need for the government to collaborate with other stakeholders (such as, the community, interest groups, and labour unions) to develop effective, efficient, and cost-effective solutions (Mosala, 2016:55). Makoza (2017:8) alludes that public policy refers to the government's intentions for tackling social issues. To expand on this, the policies are written down (or may not be written down) to reflect current government objectives and aspirations, which inform policy actions and practices (Makoza, 2017:8). Furthermore, Kunyenje (2019:19) contends that public policy is a national statement meant to address a public problem in a particular environment. An example for the purposes of this study, the proposed National Health Insurance Bill was a national statement introduced in parliament by the government in 2019 to ensure that everyone receives quality health services in South Africa, since there are significant imbalances between the public and private health system. Cairney (2019:2) argues that public policy is crucial since it has an impact on every part of our lives. For instance, it is impossible to imagine any part of social life that is unrelated to policy. Thus, it is critical to get policy right, or at the very least to explain what goes wrong and what anyone can do about it. Cairney (2019:2) further asserts that what a government chooses to do or not do is referred to as public policy. Such a description may suffice for everyday conversation, but it is clearly insufficient for systematic policy analysis, thus a more precise definition is required to frame our thinking and promote successful communication with one another. Therefore, it could be argued that public policy is defined as the government's actions, intentions, and pronouncements on specific issues, as well as the steps taken (or not taken) to accomplish them and the explanations given for what occurs (or does not occur) (Smith & Larimer, 2018:3). In addition, Howes, Wortley, Potts, Dedekorkut-Howes, Serrao-Neumann, David, Smith and Nunn (2017:2) explain that public policies can be judged on three criteria, namely: effectiveness, efficiency, and appropriateness, and they are more likely to succeed if they achieve social gains. 66 Furthermore, Knill and Tosun (2020:4-5) state that public policy refers to the acts of public actors (usually governments), while societal actors may be active or participate in public decision-making to some level, which is consistent with the underlying concept of governance. Second, Knill and Tosun (2020:4-5) imply that government efforts are focused on specific issues, implying that the scope of operations is limited to one component of the problem. Pulzl and Treib (2017:9) are of the view that public policy is an officially stated objective accompanied by a sanction, which can be either a reward or a punishment. According to Pulzl and Treib (2017:19) a public policy might take the shape of a law, a rule, a legislation, an edict, a regulation, or an order as a course of action (Pulzl & Treib, 2017: 19). In addition, Lenihan, McGuirk and Murphy (2019:12) believe that public policy should be implemented anytime and that a lack of procedures prevents organisations from developing and implementing human resource practices. Furthermore, Anyebe (2018:2) contends that public policy refers to government policies that are established and implemented with the intention of achieving specific objectives. Anyebe (2018:2) motivates that this definition reduces public policy to a straightforward solution. On the one side, Peters (2018:2) argues that public policy is the primary reason for scholars and individuals in any country to be interested about government. Peters (2018:4) continued by stating that public policy is the sum of all government operations, whether carried out directly or through agents, that have an impact on the lives of citizens. Additionally, Cairney (2019:16) asserts that public policy can relate to a statement of intent, an objective, a choice, or a result. It could refer to concerns that policymakers are oblivious to. Cairney (2019:16) states that public policy is also created and affected by a large number of people, some of whom may or may not have formal authority. Yalmanov (2021:558) defines public policy as a set of measures taken to address societal issues through policymaking. In addition, Potucek (2017:7) defines public policy as the sum of all government operations, whether carried out directly or through agents, that have an impact on citizens' lives, and that work on three levels, namely: policy choice, policy outputs, and policy impact. In addition, public policy is characterised as a series of steps that must be completed before a policy's objectives can be realised (De Coning, Cloete & Wissink, 2011:45). Additionally, Ikechukwu and Chukwuemeka (2013:60) allude that public policy directs and determines current and future public decisions, as well as private person or private company institutional acts, decisions, or behaviour, considering a specific social problem. Cairney (2019:17) explains that public policy can be defined in a variety of ways, including as a label for a field of activity (for example, health policy); an expression of intent (for example, we will improve healthcare); specific proposals (for example, manifesto or white paper); government decisions and the formal authorisation of decisions (for example, legislation); a program, or 67 package of legislation, staffing, and funding; and international cooperation. The author states that it is not an event or a single decision, but a process and a series of decisions. Smith (2018:3) also contends that a public policy is not random, but rather purposeful and goal oriented. Authorities in charge of public policy are the ones who make it, patterns of activities made over time make up public policy, demand-driven public policy is a government-directed course of action in response to pressure over a perceived problem. In addition, a policy can be beneficial or negative (Smith, 2018:3). In other words, it can be good or bad depending on the context. Mavrogordato and White (2020:30) are of the view that a thorough understanding of a public policy begins with a basic understanding of the policy parts that must be completed to comply with the law. Therefore, a policy usually presents a vision to attain, as well as goals to satisfy and, in certain cases, the tools to accomplish them (Viennet & Pont, 2017:21). Hence, adequate resources play a significant role in accomplishing successful outcomes. Furthermore, Campos and Reich (2019:226) state that public policy follows a six-stage cycle namely: problems are defined, a causal diagnosis is made, plans are devised, a political choice on reform initiatives is taken, the reforms are implemented, and their impact are assessed. According to Cochran, Meyer, Carr and Cayer (2009:9), public policies can be categorised into four categories, namely: distributive, regulatory, redistributive, and self-regulatory. Distributive policies justify resource allocation to individuals or groups, as well as to crucial infrastructure. To expand on this concept, when coercion is directed at specific persons, a public policy is categorised as distributive and if costs are distributed broadly with controllable benefits; and regulative if costs are distributed broadly with controllable benefits (Kunyenje, 2019:22). In addition, Kuhlmann and Blum (2021:279) are of the view that redistributive policies tell stories about who should or should not receive specific benefits. Therefore, it could be argued that for the purposes of this study, the proposed NHI Bill [B 11-2019] is a redistributive policy, in which health services would be provided to everyone and those who work and generate an income will be required to contribute to the Bill in order for it to be sustained. Cochran et al. (2009:9) emphasise that individuals and groups are bound by regulatory policies. In addition, Cochran et al. (2009:9) explain that self-regulatory policies are like regulatory policies, with the exception that those who are governed have a great deal of power and independence in establishing and enforcing the laws that govern them. Based on the aforementioned and for the purpose of this study, it could be argued that public policy is a statement made by the government to address the imbalances occurring between the public and private health system; while also taking into account the current challenges afflicting South Africa including the North West Provincial Department of Health’s health system as stated 68 in the problem statement of this study (see section 1.3). In doing so, it would aid in achieving the goals and objectives of the proposed NHI Bill [B11-2019] and implementing the proposed NHI Bill [B11-2019] successfully once it becomes legislation. This study is concerned about organisational readiness and implementation of the proposed NHI Bill [B11-2019]. The subsequent sub-section therefore discusses what public policy implementation entails. 3.2.1 Conceptualising public policy implementation The term implementation of a public policy has many different definitions. Vienett and Pont (2017:2) state that the problems of where implementation begins and what role it plays in the policy process are two significant issues in defining public policy implementation. Amir (2020:6), for example, defines public policy implementation as the process by which a policy achieves its goals. Mosehla (2019:26) explains that it also refers to public actions taken against private individuals (or groups) to attain the goals laid out in preceding policy choices. Mosehla (2019:26) asserts that public policy implementation is a complex process that must take into consideration legislative requirements, administrative capabilities, and interest group preferences. In addition, Makoza (2017:18) explains that public policy implementation can be viewed as a system in which policy stakeholders or external variables provide input that can lead to change or transformation. With that being said, socioeconomic conditions, public opinion, and the impact of other policy actions are examples of external variables (Makoza, 2017:18). Public policy implementation starts with a decision regarding which policy to implement, followed by a series of smaller decisions made by implementers as they interpret the policy. As a result, decision-making in implementation differs significantly from policymaking (Fowler, 2019:406). Mosehla (2019:1) alludes that implementation is a broad term for a series of administrative actions that can be studied at the program level. The content or context of a policy should be clear, which includes (1) the interests that are affected (2) forms of benefits, influence the process of executing a policy (3) expected change (4) decision-making location (5) program implementation and resources involved (Amir, 2020:6). Mosehla (2019:71) explains that it also concerns the process of putting into effect or carrying out authoritarian government decisions. Decision-making, restrictions, enforcement of regulations and standards, coordination of actions and processes, and oversight of the implementation agencies' activities are also part of public policy implementation (Makoza, 2017:8). Campos and Reich (2019:225) state that working with and through a variety of organisations to convey policy objectives, assure resource availability, create policy ownership by implementers, manage conflicts and collaboration, and maintain policy 69 changes is all part of the public policy implementation process. According to Howlett (2019:409), implementation is a complicated activity that is influenced by elements such as the nature of the subsystem or network involved in policymaking, particularly in terms of its proclivity to let new actors and new ideas into policy debates. Furthermore, whether the design is conducive to policy implementation determines the direct costs of public policy implementation. In addition, Li, Yang, Wei and Zhang (2019:87-88) argue that the higher the administrative expenditures the government must invest in public policy implementation, the more difficult the policy aim is. For the purposes of this study, implementing a new health policy necessitates more than simply providing instructions for a policy document or creating a set of standard operating procedures (Campos & Reich, 2019:225). Effective health policy implementation necessitates the aggregation of many individual actions, as well as an understanding of how and why the actions in question are consistently reproduced by individual behaviour (Campos & Reich ,2019:225). In addition, Howlett (2019:423) argues that the implementation of public institutions is frequently an expensive, multi-year endeavour, which means that funding for programs and projects is rarely permanent or guaranteed, but rather necessitates ongoing negotiation and discussion within and across the state's political and administrative goals (Howlett, 2019:423). Furthermore, Gong and Janssen (2012:61) explain that implementing new public policies is often costly, takes a long time, and is prone to failure. Hence, the significance of this chapter is to provide a theoretical foundation of public policy implementation, comprising of important elements for the North West Provincial Department of Health to consider when implementing the proposed NHI Bill [B11-2019] once it becomes legislation. Public policy implementation is not always a comprehensible, continuous process; instead, it is often fractured and interrupted, as alluded by Crosby (1996:1405). It refers to the process of putting laws into practice in which a variety of people, organisations, procedures, and strategies collaborate to achieve policy objectives (Gong & Janssen, 2012:61). In addition, Crosby (1996:1406) asserts that public policy implementation is like an assembly process, in that it involves putting together pieces from various sources, some of which may have slightly different goals than those originally intended, and then reshaping those pieces into a mechanism capable of eventually producing the desired results. In addition, Weaver (2009:2) states that public policy implementation is crucial to policy success in policy sectors. In other words, without public policy implementation than public policies would not exist. Furthermore, public policy implementation could refer to the steps and actions involved in putting a policy into force, enforcing it, and administering it (Ikechukwu & Chukwuemeka, 2013:61). DeLean and deLean (2002:47) suggests that implementation is the carrying out of a fundamental 70 policy decision, which is normally enshrined in a statute but can also take the form of key executive orders or judicial decisions. The authors explain that public policy implementation is what happens between the declaration of a government's apparent intention to do something (or not do something) and the final impact in the world of action. In addition, Campos and Reich (2019:225) allude that leaders involved in public policy implementation require persistence, discipline, and rigour in their respective settings, as well as the ability to make difficult decisions about staffing, organisational structure, and stakeholder relationships. It is, however, difficult to achieve this in real time (Campos & Reich, 2019:225). Public policy implementation can also be defined as a participatory process between citizens and street-level bureaucrats. Therefore, it is critical to examine the types of interactions that occur during public policy implementation and to comprehend the various mediation skills that actors possess (Lotta & Marques, 2020:345-351). Mavrogordato and White (2020:8) allude that public policy implementation research focuses on whether the policy is implemented in accordance with the goals and desired outcomes, and whether the public policy implementation complied with the letter of the law, that is, the explicitly documented policy expectations. Furthermore, it has been argued that implementation is difficult when a policy is largely symbolic, that is, when a policy represents something completely different; when it harms the interests of its targets; or when it has multiple conflicting goals (O'Brien & Li, 2017:170). In many ways, public policy implementation is a type of collective action because it necessitates collective decisions and responsibilities from a wide range of actors (Fowler, 2019:406). Amir (2020:5) argues that the most important stage in policy making is implementation because problems that limit the effectiveness of a policy frequently arise during implementation. Therefore, inadequate public policy implementation may result in financial waste, political frustration, disruption of service delivery, and citizen dissatisfaction (Mosehla, 2019:31). Weaver (2009:3) states that failure to anticipate implementation issues when a policy reform is passed may result in a failure to meet programmatic goals, unnecessary costs, and maybe a political reaction against the implementing organisations and policies. As a result, the actual implementation of public policy entails first converting government policy into implementation policy, then administrative policy, and finally monitoring and evaluating the implementation (Mosala, 2016:65). For successful implementation, it is also necessary to evaluate the policy context, policy formation process, policy players, and policy content (Shung-king, 2013:895). In addition, Mosala (2016:65) also believes that public policy implementation is a practical activity including the appropriate course of a legally specified course of action across time, implying that public policy implementation is the responsibility of official institutions. 71 A variety of elements can influence how a policy is implemented, namely: what initiates policy creation, who controls policy decisions, whether policy procedures are administrative or networked, whether policy involves formal or informal institutions, and whether policy decisions are centralised or decentralised (Makoza, 2017:19). Therefore, effective implementation is critical to the successful execution of policies. To ensure effective implementation of public policies, Mosehla (2019:50) states that organisations in each department should pay close attention to the organisational structure while implementing a new or existing policy. Croese, Oloko, Simon and Valencia (2021:8), on the contrary, explain that effective implementation requires collaboration between national and local governments, as well as civil society and private sector actors, with clear guidelines and coordination in place. Furthermore, Siciliano, Moolenaar, Daly and Liou (2017:899) argue that successful policy implementation is more likely when individuals in charge of enacting it value the change and have sufficient resources to do so. In addition, Croese et al. (2021:1) states that effective implementation necessitates a solid framework for multi-stakeholder participation and coordination at all levels of governance, which can be achieved by combining top-down and bottom-up approaches of public policy implementation. In conclusion, researchers, and scholars, according to Williams (2021:349), should engage directly with the intricacies and uncertainties of public policy implementation, which are not effectively reflected by a single construct like capacity at the national, subnational, or even organisational level. Williams (2021:349) states that scholars and researchers can better understand and forecast public policy implementation and establish precise levels for effective implementation by asking specific questions about the likely results of various bureaucracies implementing specific policies in specific situations. As a result, effective policy implementation means implementing a policy in such a way that the policy's aims and objectives are produced, attained, or realised. In essence, the specified and planned development goals and objectives are realised if a policy is effectively implemented. Therefore, it could be argued that policy implementers are advised to properly implement a public policy such as the proposed NHI Bill [B11-2019] once it becomes legislation by clearly stating its goals and objectives and not just overestimating them (Ikechukwu & Chukwuemeka, 2013:63). 3.2.1.1 The public policy implementation process As alluded in the discussion above, public policy implementation is complex and therefore requires proper processes to be followed for successful outcomes. It is believed that many institutions do not follow proper processes of public policy implementation. Hence, the researcher deemed it important to identify essential concepts of public policy implementation and present the process of this phenomenon. 72 Table 6: Public policy implementation process Concepts of public policy Descriptions implementation 1. Valid assumptions It is critical to have a policy in place that sets the vision approach as well as the specifics of how the policy will be implemented to achieve the vision and goals. 2. Clear objectives Implementers are frequently chastised for misinterpreting policy objectives. As a result, policy implementers must have a clear set of objectives. 3. Financial allotment It is critical that institutions have enough money to carry out their policies. 4. Implementer’s capability Policy implementers should have sufficient competencies, such as the essential skills. 5. Extent of decentralisation The decision-making regarding what should be done and how it should be done is included in the scope of decentralisation. Included is the participation process, which determines who should be involved in decision- making. The implementation phase should include participation 6. Political support from government officials, the public, and the constituency group. 7. Situational influences Conditions such as socioeconomics and technical feasibility should be considered. Source: Taing (2019:538). From the table above, it could be argued that the process of public policy implementation is very important to be acknowledged since it guides policy implementers on what to focus on and outlines significant components that should be considered in the implementation phase. 3.3 THEORETICAL FRAMEWORK OF PUBLIC POLICY IMPLEMENTATION Ngwane (2017:1) states that public policy implementation is one of the most crucial elements in the policy life cycle. It is responsible for translating policy objectives into desirable policy outcomes. Ngwane (2017:1) explains that in a democratic society like South Africa, public policy implementation involves participation from all impacted sectors. Since public policy implementation is a crucial element in the policy life cycle, there are important common approaches that policy implementers should consider in the implementation phase. The following sub-section presents those approaches. 73 3.3.1 Public policy implementation approaches Public policy implementation is a confusing, dynamic, multidimensional, multi-actor process that is influenced by the policy's content and circumstances (Cloete et al., 2018:203). To assist on making the process of public policy implementation smoother, Koontz and Newig (2014:1) suggest that an implementation plan be created using either a top-down or bottom-up implementation approach, based on a set of factors that reflect the policy environment. This section presents the top-down and bottom-up implementation approach that could be considered to implement public policies. In addition, the researcher also presents the hybrid implementation approach that is a combination of both the top-down and bottom-up implementation approach. 3.3.1.1 Top-down implementation approach A top-down implementation approach is a process of carrying out what the policy dictates in order to achieve the stated goals and using the means indicated in the policy legislation (Viennet & Pont, 2017:21). This approach starts with an authority decision, recognising the problem's tractability and ability to structure implementation, as well as the non-statutory elements that affect implementation (Seraw & Lu, 2020:114). Croese et al. (2021:9) contend that when it comes to policy direction and rules, a top-down approach is critical. Furthermore, top-down scholars believes that implementation behaviour is centrally controlled, with little or no administrative discretion, whereas bottom-up scholars argues that confusing policies necessitate interpretation, requiring street-level bureaucrats to exercise administrative discretion (Fowler, 2019:405). According to a top-down implementation approach, the most important aspect is a clear definition of the chain of command and ensuring that politics clarifies and controls the flow of each step in the implementation process (Ngwane, 2017:16). Howlett (2019:408) on the one side, argues that the top-down approach ensures that implementation officials can conduct their jobs more efficiently. Top-down approaches to implementation imply that policies are formulated at a higher level and imposed by lower-level implementing agencies (Heidbreder, 2017:1371). Hottenstein (2017:28) explains that top-down approaches are founded on the assumption that policy implementation begins with a government decision. This approach provides insight into how public policies might be implemented, but it has been criticised for assuming that those involved in the process have no personal objectives. Ngwane (2017:16) states that this approach also fails to recognise that policy implementation does not take place in a vacuum; in other words, there are external or environmental factors that may necessitate quick plan revisions. Furthermore, Russell (2015:17) is of the view that when goals and objectives are more defined and policies are created in a 74 thorough manner, a top-down approach is more useful. Kunyenje (2019:33) alludes that the degree of freedom allowed by a rule maker to an implementing actor is emphasised in top-down approaches. In addition, external actors' power is reduced in this approach, which instead recognises the actors who launched the policy proposal as significant actors (Kunyenje, 2019:33). Furthermore, the top-down implementation approach begins with a policy decision and assesses how well its legally mandated goals are met. It represents the viewpoint that authority rests with the top decision-makers, who formulate clear policy objectives and guide the process of putting these objectives into action in a hierarchical manner (Vucic & Vucic, 2020:19-23). According to top-down researchers, statutory qualities, and control at the top of the organisational hierarchy are accountable for policy implementation outcomes, whereas bottom-up scholars emphasise the importance of discretion at the local level in shaping policy design (Yarbrough, 2017:56). Ogunlayi and Britton (2017:1) explain that the top-down approach eliminates duplication of effort by providing central coordination of initiatives, clear accountabilities, timely performance reports, and the resources required to deliver large-scale change. Pulzl and Treib (2017:90) argue that top- down implementation approaches place a premium on decision-makers' abilities to develop clear policy objectives and control the implementation stage. In addition, this approach focuses on the gaps between a policy drafter's intentions and the policy's actual performance (Seraw & Lu, 2020:114). In other words, this approach places an emphasis on gaps identified and whether anticipated objectives are met. 3.3.1.2 Bottom-up implementation approach The bottom-up implementation approach starts with the policy aims and working backwards to identify which implementers and policy structures may have an impact on behaviour change. Rather than believing that policymakers can oversee implementation directly, they should do it through clear lines of authority from the top-down (Koontz & Newig, 2014:419). Bottom-up implementation implies that managers interpret top-down reforms in light of their working conditions, and that they use their own expertise, discretion, and tacit knowledge to put policy into practice (Orgill, Marchal, Shung-King, Sikuza & Gilson, 2020:3). According to the bottom-up perspective, policies are generally entwined in complicated networks rather than simple single- organisation hierarchies (Yarbrough, 2017:63). Vucic and Vucic (2020:24) explain that because one measure does not fit all scenarios, the bottom-up approach recognises that street-level bureaucrats work in situations that require varied responses to different parts of the problem. Additionally, bottom-up critiques see local bureaucrats as the primary actors in policy delivery, and implementation as a series of negotiations amongst networks of implementers (Pulzl & Treib, 2017:90). 75 According to bottom-up theories, discretion is positively related to successful implementation (Thomann, van Engen & Tummers, 2018:585). This approach assumes that discretion will always exist and examine how frontline employees use their degree of freedom (Kunyenje, 2019:33). Ngwane (2017:17) contends that the executive's involvement in policymaking is not negated by the bottom-up implementation approach. It does, however, stress the importance of allowing government servants to provide input that will aid in the proper implementation of policy (Ngwane, 2017:17). Furthermore, the bottom-up implementation approach assumes that individuals or groups identify a society problem, express their aims, plans, actions, contacts, and other elements, and then give it to the public for consideration (Kunyenje, 2019:30). The bottom-up approach emphasises implementers' active engagement and their capacity to adapt or react to policies based on local circumstances. It sees implementation as a collaborative process that involves discussion and dispute (Balane et al., 2020:2). Viennet and Pont (2017:23) concur with Balane et al. (2020:2) that bottom-up approaches regard implementation as a long- term process of interaction and discussion between those wanting to put policy into action and people who are affected by their activities. In addition, Seraw and Lu (2020:115) state that scholars that utilise a bottom-up approach do not focus on a single stage of the policy cycle. Instead, they are interested in the entire process of defining, shaping, implementing, and most likely, redefining policies. The bottom-up implementation approach is of the view that implementation is best studied by starting at the lowest levels of the implementation system and working up to see where performance is more or less successful (Seraw & Lu, 2020:114). Bottom-up approaches to public policy implementation are notable for their normative stance: what matters are the reactions of those on the ground at the end of the line, whose reactions shape the implementation process and the policy itself, rather than how policymakers at the top get their will carried out (Viennet et al., 2017:23). Furthermore, bottom-uppers stated that looking at a policy from the perspective of the target population and street-level officials who directly administered the policy would provide a more accurate knowledge of implementation (Russell, 2015:18). In addition, Hottenstein (2017:28) explains that bottom-up approaches to policy implementation emphasise the involvement of local players in the policy implementation process, emphasising the importance of people who are really implementing the policy. Since the study's focus is on implementing the proposed National Health Insurance Bill in the North West Provincial Department of Health once it becomes a legislation, the view of Orgill, 76 Gilson, Chitha, Michel, Erasmus, Marchal and Harris (2019:2) is important namely that the bottom-up implementation approach to studying health systems recognises that numerous actors are involved in the politics of health system transformation at the coalface. Additionally, bottom- up scholars refute the notion that policy implementation takes place at the top and inside a single, dominating organisation. Bottom-up scholars believe that understanding what happens at lower levels of implementation will better explain outcomes than the top-down proponents' concerns (Yarbrough, 2017:62). Below is a summary of both the top-down and bottom-up implementation approaches from the discussion above. Table 7: Summary of top-down and bottom-up implementation approaches Dominants Top-down approaches Bottom-up approaches Research strategy Top-down: from political Bottom-up: from individual decisions to administrative bureaucrats to administrative execution Goal of analysis Prediction/policy Description/explanation recommendation Model of policy process Stagiest Fusionist Character of implementation Hierarchical guidance Decentralised problem- process solving Underlying model of Elitist Participatory democracy Source: adapted from Pulzl & Treib (2017:94) From the table above, it could be argued that both the top-down and bottom-up implementation approaches are both important when implementing public policies and it is advisable that institutions make use of both the strengths and shortcomings of these approaches for better implementation outcomes. 3.3.1.3 Hybrid approach to implementation Hybrid theories of implementation emerged as scholars developed and analysed the benefits and shortcomings of top-down and bottom-up implementation approaches (Hottenstein, 2017:28). The hybrid approach to policy implementation, also known as the middle-out strategy, combines the top-down and bottom-up approaches with the goal of overcoming the constraints of each approach (Makoza, 2017:222). Both bottom-up and top-down approaches to policy implementation, according to various policy researchers, begin with defining goals, objectives, and directives, then identify and design policies before moving onto the legislative agenda, where 77 decisions are made on whether to implement or reject them (Russell, 2015:18). Croese et al. (2021:9) state that since the hybrid approach combines the shortcomings and strengths of both the bottom-up and top-down approaches; to enable effective multi-level implementation and monitoring of policies, both top-down and bottom-up implementation approaches must be enhanced with institutional, technical, and financial capabilities. Balane et al. (2020:1) also believe that to fully understand policy actors, both top-down and bottom-up approaches to implementation must be considered, as there are disparities in the types of knowledge, interests, and power sources across national, local, and frontline stakeholders. According to Ngwane (2019:3) there is a knowledge gap in that most policy implementation research now focuses on the vertical strategy, that is, top-down and bottom-up policy implementation. This is more about how policymakers (at the top) can affect policy implementation (at the bottom), rather than how those in charge of executing policies (at the bottom) should and can influence policymaking (Ngwane, 2017:8). In addition, both top-down and bottom-up policy analysts see effective communication as a critical component of implementation success (Orgill et al., 2019:3). Cloete et al. (2018:201) are of the view that top-down and bottom-up implementation approaches are essential and provide useful knowledge into the policy implementation process of policies. So, it is critical that policy implementers use both top-down and bottom-up approaches when implementing policies as these approaches illustrate important explanatory strengths and weaknesses. Although each strategy is critical for achieving a specific goal in policy implementation, there is a need to combine the qualities of both approaches to ensure policy implementation success (Cloete et al., 2018:201). Russell (2015:18) explains as well that top- down and bottom-up approaches can be harmonised by focusing on the theoretical importance of ambiguity and conflict for policy implementation. Furthermore, the hybrid approach explains the issue that emerged requiring policy attention, the individuals who aid in policy making process, the procedure of the policy making, the main goals and objectives of the policy, the amount of policy alternatives and how resources would be distributed, the implementation strategies, the outcomes that the policy has produced and the unexpected consequences of the policy (Mengo & Eusebius, 2015: 2). Pulzl and Treib (2017:90) contend that the hybrid theories try to overcome the division between the other two approaches by incorporating elements of top-down and bottom-up approaches. According to Hottenstein (2017:29), the hybrid approach moulds the relevant aspects of both approaches into a middle ground. The approach understands the importance of top-down aspect such as centrally defined 78 policy decision, but also appreciate and value the need to involve lower-levels actors (Hottenstein, 2017:29). As noted previously, this approach focuses on the two approaches’ relative strengths and weaknesses and synthesises them into a balanced implementation theory (Seraw & Lu, 2020:115). Additionally, this approach merit in addressing limitations of top-down and bottom-up implementation approaches but critiques of the implementation approach are that there are necessary conditions and factors that should be in place for the approach to achieve policy objectives. These factors include policy actors having a clear understanding of the policy objectives; the policy actor having necessary skills and competencies for conducting policy programmes and processes; the policy implementation agencies having adequate resources; the favourable operating environment which can support the policy actors and operations of implementation agencies to achieve policy goals (Makoza, 2017:23). This section critically discussed the different approaches to public policy implementation, namely: the top-down, bottom-up and hybrid implementation approaches. 3.4 CONCEPTUAL FRAMEWORK OF PUBLIC POLICY IMPLEMENTATION It is critical to think about how this study's research problem could be improved. The following section highlights different aspects of public policy implementation that could be investigated to avoid potential negative outcomes. The rationale for this section is that policy implementers typically focus on successfully implementing public policies by following public policy processes while overlooking other aspects that could potentially influence successful outcomes if not fully acknowledged. 3.4.1 Principles of public policy implementation The principles of public policy implementation are summarised in this section. Initially, officials must understand the problem and the most essential results. To put it in another way, it is insignificant to hurry into enacting a public policy without first recognising the underlying issue and the policy's intended effects. Ten Ham-Baloyi, Minnie and Van der Walt (2020:1494) state that it is significant to also consider implementation while developing the public policy. In other words, it is critical to consider the policy's actual implementation while developing the policy itself. Ten Ham-Baloyi et al. (2020:1494) explain that organisations should get the right capability, as stated in the study's problem statement and policy implementation process (see sections 1.3 and 3.2.1.1). Capacities to carry out a specific public policy are critical; in other words, adequate skills and leadership aspects are critical. To be specific, according to several research a leader's capacities to educate, good communication skills, being well-trained, and being enthusiastic or determined about altering practice are all essential leadership attributes (Ten Ham-Baloyi et al., 79 2020:1494). Furthermore, Norris, Kidson, Bouchal and Rutter (2014:13) explain that governments just want to put a policy in place without explaining what it is for or what the government wants to accomplish with it. Therefore, governments must provide sufficient information about the policy to the public. For example, for the purposes of this study, the national government and the North West Provincial Department of Health should adequately explain the objectives of the proposed NHI Bill [B11-2019] and the anticipated end results to the public (Norris et al., 2014:13; Mosehla, 2019:30). Mosehla (2019:30) states that policymakers should be aware of the broader context and be prepared to respond to it. As previously said, preparation is critical prior to adopting a policy; consequently, policy implementers should ensure that everything that is needed for the implementation process is on hand (see section 3.2). Ministers also have a crucial role in public policy implementation. For the purposes of this study, it is critical that the North West Provincial Department of Health engages regularly with the Minister of Health while the NHI would be implemented after it has been gazetted and becoming legislation. Furthermore, it is important that policy implementers maintain strong ties with the government and their ministers in order to keep them informed about where change is taking place and how policies are working in practice therefore, throughout the implementation process, it is significant that policy implementers remain focused. This is critical because mistakes are very likely to occur if policy implementers are not focused throughout the implementation period. Finally, policy implementers should make it obvious where and how decisions are made. If policymakers do not understand how decisions are made, it is possible that the decisions they make would have bad consequences (Norris et al., 2014:11-18; Mosehla, 2019:30). From the aforementioned, it could be argued that policy implementers within the North West Provincial Department of Health should acknowledge the principles of public policy implementation as it could potentially contribute to negative results if neglected. These principles provide direction in the implementation phase and could assist in successful outcomes of a particular public policy such as the proposed NHI Bill [B11-2019] once it becomes legislation. 3.4.2 Tasks involved in public policy implementation Tallberg and Zurn (2019:270) state that there are different tasks that should be considered in the public policy implementation phase, namely: policy legitimisation, constituency building, resource allocation, mobilising resources and actions and monitoring the impact of policy change. Policy legitimacy is described as a feature that society ascribes to an actor's identity, interests, or practices, or to an institution's norms, rules, and principles, in which other actors, even subordinate groups, recognise and consent to the traits or actions of one actor (Crilley & 80 Chatterje-Doody, 2021:270). To gain legitimacy, someone, a group, or an organisation must explain that the proposed policy change is vital and necessary, even though it would result in significant costs (Tallberg & Zurn, 2019:586). Constituency building is seen as a collection of people, or political entities, who share similar political beliefs and objectives, or as the people who relate to, or served by, a particular organisation (Lockyear & Cunningham, 2017:3). Constituents are also good stakeholders that can help the policy champion gain traction. Tallberg and Zurn (2019:586) explain that because stakeholders' support for public policy implementation is frequently lacking, a suitable constituency for change should be established. Furthermore, Lemarleni, Ochieng, Gakobo and Mwaura (2017:3) outline that resource allocation keeps organisations running, and allocating these resources can be difficult, but with proper effort, an organisation can acquire the resources it requires. In addition, Kurzawska (2018:1) is of the view that human, technical, and financial resources must be preserved in order to implement a new public policy; this means that all essential resources for a certain policy should be set aside, as this would make the process much smoother. The word resource mobilisation refers to an organisation's efforts to gain new and extra financial, human, and material resources in order to further its mission (Seltzer, 2014:1). The author is however of the view that even if the government has all the necessary resources, there is no guarantee that it will complete the assigned policy change if behaviour does not change. This means that behaviour must change, and actions must be evident to reflect the new policy (Seltzer, 2014:1). Finally, it is critical to understand what impact policy change is having so that actors involved in public policy implementation can address or modify the approach if negative or unacceptable outcomes occur. This means that it is critical that actors involved in public policy implementation take note of the positive and negative impacts of a policy so that they can predict what would influence policy negatively (Schoenefeld, Schulze, Hilden & Jordan, 2019:726). 3.4.3 Features for effective public policy implementation Accessibility and capabilities of staff, correlative activities and supportive responsibilities of participating offices, recognition from the target population, and perseverance of organised exertion are all important features in effective implementation (Rahmat, 2015:11). Rahmat (2015:311) states that effective and successful implementation requires that implementers know what they should do, which implies that if they do not know what they are doing, the policy's objectives may be carried out wrong. Rahmat (2015:311) further alludes that effective implementation should not be taken for granted, nor should it be regarded solely through the lens 81 of obstacles or capabilities. Consequently, for effective implementation to occur, political, epistemological, behavioural, and contextual issues affecting target compliance and agency actions, among others, must be addressed (Howlett, 2019:407). Mosehla (2019:71) explains that key variables that contribute to good public policy implementation include financial and technological resources, as well as the quality of human resources. It is important to note that inadequate resources lead to ineffective implementation attempts and increased stress among the implementing agents (Siciliano et al., 2017:891). In addition, to ensure effective implementation, policymakers should be able to establish performance management mechanisms (Cheah & Ho, 2020:3). Alaerts (2020:11) also believes that for a public policy to be effective, it must be aligned with each set of principles; however, not all principles are mutually inclusive and may require reconciliation, and for a process to be effective, it must begin with a credible model. In addition, Tereza (2019:094) states that there should be clear knowledge of the policy's objectives among the organisations. This means that organisations executing a policy should have a good understanding of what the policy's goals are. The North West Provincial Department of Health, for example, should have sufficient knowledge of the proposed NHI Bill's [B11- 2019] aims and the goals that the organisation wants to achieve once the proposed NHI Bill [B11-2019] becomes law after gazetted and is implemented. Tereza (2019:094) contends that the tasks of a policy should be properly described in the correct order, and that the implementing institution should be aware of these tasks. In other words, organisations should understand which activities are most necessary to handle first when adopting a policy by tackling the most crucial tasks for the policy's success. Lastly, Tereza (2019:094) contends that all stakeholders involved in the implementation process should have great communication and coordination. It could be argued that good communication skills and coordination between different stakeholders increase effective public policy implementation. Balane et al. (2020:1) describe stakeholders as actors with an interest in the subject under consideration, who are affected by the issue, or who have or could have an active or passive influence on the decision-making and implementation process due to their position (Schalk, 2003:43; Tereza, 2019:094; Balane et al., 2020:1). These stakeholders are so critical to the success of a policy, in this regard, efficient communication and coordination are essential to avoid misunderstandings and delays. 82 3.4.4 Central questions associated with the implementation of a given public policy According to Atelhe and Akande (2018:2), these questions include but are not limited to the following: • How well is the implementing organisation carrying out the policy? It could be argued that public organisations such as the North West Provincial Department of Health should be able to determine whether or not a policy such as the proposed NHI bill [B11- 2019] is beneficial for the public organisation. Environmental variables can sometimes have a significant impact on public policy. As a result, before introducing a public policy, an organisation should be able to determine whether the policy is necessary or not. • What is the target group's reaction to a policy's implementation? For the purposes of this study, it could be argued that there are significant imbalances between the public and private health systems, as described in sections 1.2 and 1.3 of this study, with the public health system being the most disadvantaged. The North West Provincial Department of Health therefore, needs to acknowledge the target group’s experiences within the public health system and how the target group is reacting to the implementation of the proposed NHI Bill [B11- 2019] once it becomes legislation. • Does the implementing institution have the necessary resources to carry out the policy effectively? As indicated in section 3.4.2 of this study, resources are important when implementing a public policy; as a result, public institutions should examine whether the institution has the required resources to implement that particular policy. • Is the implementing institution willing and motivated to carry out the policy's instructions? It is vital that public institutions are motivated to put a policy into place. As described in section 2.3.3.1 of this study, individual motives within an institution have a significant impact on organisational readiness before the implementation phase. • Is the society problem sufficiently understood through broad consultation and thorough study, and is the policy being implemented adequate and in the right direction? 83 For the purpose of this study, it could be argued that it is critical to comprehend the proposed NHI Bill [B11-2019], as well as its objectives, and policymakers should revisit the policy on a regular basis, and making changes where needed. • How does the government monitor and supervise the policy's implementation? Monitoring is defined as a constant evaluation of the project's function in relation to implementation timelines and the utilisation of project inputs (Kabonga, 2019:2). Therefore, it could be argued that regularly monitoring a public policy is critical because it allows for the identification of shortcomings and the implementation of essential modifications. From the aforementioned, the principles, tasks, aspects, and essential questions that public institutions should consider before implementing any public policy were identified in this section. The preceding explanation suggests that if the aforementioned factors are not considered, they may potentially have an impact on the policy's success. Furthermore, all the listed criteria emphasise the need of resources in the implementation phase. For this reason, it could be argued that success is not guaranteed without adequate resources. Moreover, good communication, coordination, and target groups may have a significant impact in the implementation phase. 3.5 BEST PRACTICES OF PUBLIC POLICY IMPLEMENTATION In the context of health programs and services, the practical definition of best practices is to know what works in a particular situation and context, without using excessive resources to achieve the desired result. Similar solutions can be developed and used to implement health problems elsewhere in different situations and contexts (World Health Organisation, 2008: 2). Ten Ham- Baloyi et al. (2020:1481) explain that best practices are recent, relevant, and beneficial practices, methods, interventions, processes, or methods based on high-quality evidence. Best practices should be implemented to improve overall health-care quality and to enhance the health-care system as a whole (Ten Ham-Baloyi et al., 2020:1481). As a result, the following discussion highlights best practices learned from other countries such as Ghana, Turkey, Thailand, China, India, Republic of Chile, and United Kingdom that have implemented public policies that lead to Universal Health Coverage (UHC). To increase the comprehensiveness of this section, some noteworthy lessons from Ghana, Thailand, Turkey and United Kingdom are explored. The selection of these countries was informed by the fact that these countries have Universal Health Coverage, which is the end goal South Africa aims to achieve by implementing the proposed NHI Bill [B11-2019] once legislated as alluded by (Pauw,2021:11). Therefore, the best practices and lessons examples presented in this study could provide insights 84 in implementing South Africa's proposed National Health Insurance Bill successfully once legislated, with a special focus on the North West Provincial Department of Health. 3.5.1 Discussion of best practices The South African government believes that implementing the proposed NHI Bill [B11-2019] is the only option to attain Universal Health Coverage (UHC) and equity in the healthcare sector (Pauw, 2021:11). Therefore, to reach this target, it could be argued that there are best practices and lessons that South Africa could follow from different countries that have implemented a similar public policy, the first of which is to establish a Universal Health Coverage that is universal. This means that civil society and marginalised populations must be included in decision-making and health-care coverage, and universality must be embedded into the system (Health systems strengthening, 2019). As a result, considering this lesson, South Africa's intentional exclusion of most migrants from health-care services under the NHI, as well as the marginalisation of health- care users and civil society groups from decision-making processes, must be revised (Health Systems Strengthening, 2019). Second, on an international and domestic level, it is past time to advocate for sexual and reproductive health rights. According to Health System Strengthening (2019), UHC cannot be achieved unless access to such services is recognised as a human right. Therefore, Health System Strengthening (2019) suggests that South Africa should make sure that any NHI benefit package includes clear rights to sexual and reproductive health services. Third, while there is no fool proof governance model to prevent corruption, civil society and public engagement in accountability mechanisms and openness on health-care contracts are critical to preventing and combating corruption. The Health System Strengthening (2019) states that a lot of work needs to be done on the NHI's governance, management, and other accountability mechanisms, as well as ensuring that all relevant information about NHI decisions and contracts is made available (Health systems strengthening, 2019). For example, the National Health Insurance System in Ghana has sufficient funds; but there is corruption, mismanagement, a lack of transparency in funding, claims and payment concerns that should be investigated by the scheme's management (Christmals & Aidam, 2020:1898). In relation to this, the researcher concurs with Christmals and Aidam (2020:1898) that the government of South Africa should deploy electronic claims, verification, and reimbursement systems across the country to reduce corruption and default in facility reimbursement before the implementation of the proposed NHI Bill [B11-2019] (Christmals & Aidam, 2020:1898). Domapielle (2021:7) states that UHC is not a one-size-fits-all process, but rather a significant health-policy undertaking whose success is dependent on three factors: strong and steadfast 85 political support and commitment to UHC's goals, a favourable economic outlook, and the health- care system's ability to meet UHC's equity goals. In this sense, Reich, Harris, Ikegami, Maeda, Cashin, Araujo, Takemi and Evans, (2016:812) state that the adoption of strong UHC public policies in Turkey and Thailand benefitted from strong executive leadership from the ministers of health and the head of the state who worked to create broad popular support (Reich et al., 2016:812). The authors further explain that the implementation of strong UHC public policies in Turkey and Thailand were aided by strong executive leadership from the health ministers and the head of state, who campaigned to win widespread public support (Reich et al., 2016:812). Therefore, South Africa should ensure that a capable and a strong leadership team is established before implementation of the proposed NHI Bill [B11-2019]. Furthermore, Blecher, Pillay and Tangcharoensathien (2020:533) contend that Thailand has gained international praise as one of few middle-income countries that has made significant progress in developing a universal health care system and obtaining good health at a low cost. To elaborate, both hospitals and health centres in Thailand have their own bank accounts, allowing them to keep surplus revenue for operations and additional employee incentives. Thus, decentralised fund holding has given health institutions more flexibility to tackle difficulties; these facilities employ simpler accounting systems and are audited by the auditor general (Blecher et al., 2020:533). This benchmarking could be beneficial for South Africa including the North West Provincial Department of Health to establish similar accounting systems that could assist in curbing corruption before the implementation of the proposed NHI Bill [B11-2019]. Many factors have contributed to Thailand's UHC, as well as the success of public policy implementation, but the most important are political commitment, strong and equitable primary healthcare facilities with dedicated health professionals, technical capacity to generate evidence, and active participation of Civil Society Organisations (CSOs) (Thaiprayoon & Wibulpolprasert, 2017:10-11). Strong political commitment and political leadership, according to Verguet, Hailu, Eregata, Memirie, Johansson and Norheim (2021:385:386), is the most crucial motivator for the formulation and implementation of a public health policy. Therefore, for the purposes of this study, it is critical to have strong political commitment, a dedicated team of health professionals and active civil society participation (particular reference made to South Africa and the North West Provincial Department of Health) at the highest levels of government, transmitted through technical specialists and local decision-makers before implementing the proposed NHI Bill [B11- 2019] (Verguet et al., 2021:386). Tao, Zeng, Dang, Lu, Chuong, Yue, Wen, Zhao, Li and Kominski (2020:1-7) are also of the view that the most critical enabling element for obtaining UHC is continued political commitment. Tao 86 et al. (2020:17) provided an example that China has demonstrated a clear political commitment to make achieving the UHC a more country-led process. Tao et al. (2020:17) state that efforts by many governments at the national level, such as India's 2017 National Health Policy and Rwanda's Vision 2020, demonstrated the importance of political will in driving better healthcare (Tao et al., 2020:1-7). It could therefore be argued that South Africa, including the North West Provincial Department of Health, should establish sufficient political commitment by constantly participating in the activities of the proposed NHI Bill [B11-2019] before implementation to enhance successful outcomes. In Turkey, political leadership, both inside the Ministry of Health and at the highest levels of government, was vital to the success of health reforms (World Health Organisation, 2015:25). Reich et al. (2016:816) state that countries with leaders who demonstrate a political commitment to reform, a thorough awareness of the political economic issues, and a readiness to learn from experience and adopt have a higher chance of going forward. Therefore, South Africa should ensure that it learns from experience of other countries. This confluence of circumstances aids national leaders in their efforts to enact coverage-improving changes that are both inclusive and long-term sustainable (Reich et al., 2016:816). As a result, good coordination across many authorities is required to implement health policies in a more effective and efficient manner (World Health Organisation, 2014:43). There are several elements to consider while creating systems that would enable UHC by 2030. First, understanding the intricacies and cultures of different countries, as well as the fact that healthcare systems cannot work in silos, and the true benefit of public-private collaboration are all important considerations (Board of Healthcare Funders of Southern Africa, 2019). For this reason, it could be argued that a strong collaboration between the public and private health system in South Africa is required for the success of the implementation of the proposed NHI Bill [B11-2019]. This entails that South Africa should start now including the private sector in relation to the activities of the proposed NHI Bill [B11-2019]. Board of Healthcare Funders of Southern Africa (2019) states that when it comes to implementing an effective healthcare system, exchanging trends and data is also recognised as one of the most disregarded factors. Therefore, it could be argued that South Africa should assess the trends occurring within other countries that have implemented a similar public policy so that improvements, lessons, and best practices could be adopted that could potentially assist in implementing the proposed NHI Bill [B11-2019] successfully once legislated. Inadequate healthcare financing, poor leadership, incomplete information, and inaccurate data, as well as a lack of available human resources appropriately trained to conduct technical studies, are important issues in many nations particularly in Africa when it comes to health policies 87 (Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera, Williams & Taylor-Robinson, 2019:401; Verguet et al., 2021:386). Multiple information systems and a lack of alignment not only add to providers' workloads, but also contribute to the underutilisation of data for improved decision-making and program management. As a result, well-designed and managed information systems can substantially simplify UHC scheme administration and hence contribute to the attainment of UHC goals (Atim, Bhushan, Blecher, Gandham, Rajan, Daven & Adeyi, 2021:8). India, for example, is an excellent example of information system design, having a uniform information technology system for all states (Atim et al., 2021:9). In addition, Oleribe et al. (2019:401) propose that one of the most significant solutions to these problems is for African public health policymakers to adopt national recommendations for healthcare system development, based on the World Health Organisation framework, with support from healthcare personnel and, most crucially, governments throughout the region. Kenya, Indonesia, India, and Ghana show that a lack of funding was a major stumbling block with a similar public policy such as the proposed NHI Bill [B11-2019]. Low levels of funding, for example, are the result of both inadequate government taxing mechanisms and a lower budget priority for health (Atim et al., 2021:9). South Africa and the North West Provincial Department of Health should avoid these mistakes and determine if sufficient funds are available and outline how future funds would be generated for the functioning of the Bill. In addition, the government of South Africa should ensure that different measures are in place to ensure that the implementation of the proposed NHI Bill [B11-2019] runs well. The Republic of Chile suggests that South Africa could adopt the NHI in stages and focus on low- hanging fruit in the early stages (Republic of South Africa, 2019a). This means that in the early phases of implementation, South Africa including the North West Provincial Department of Health can focus on the best ways and gradually introduce new and advanced approaches. Based on what Chile has learned, South Africa should focus on a few illnesses in the early stages of the planned National Health Insurance Bill and then expand as the system develops (Republic of South Africa, 2019a). In addition to providing best practice insights, Astrazeneca created one- step centres in China that use smart technologies, such as Artificial Intelligence, to improve early disease identification (Board of Healthcare Funders of Southern Africa, 2019). The researcher acknowledges that it might be costly for South Africa, but since South Africa spends a significant amount on healthcare as outlined in the problem statement of the study, this could be implemented to improve early disease identification. 88 The NHI financing should be managed with transparent financial management free of corruption, which necessitates human resources with good mental and moral behaviour (Adyas, 2021:223). Reich et al. (2016:815) state that when it comes to health human resources, governments such as the government of South Africa must balance their commitment to UHC with their ability to offer health services, which is dependent on the availability of a qualified and motivated health professionals. In this regard, Michel, Mohlakoana, Barnighausen, Tediosi, McIntyre, Bressers, Tanner and Evans (2020:4) argue that actors are driven to adopt a health strategy when resources and capability are available. South Africa might learn from Europe since its services are functional, well-received by its citizens, and delivered using a variety of methods and levels of private participation. In Europe, for example, healthcare is nearly universally financed by the government, either directly through taxes revenue (as in the United Kingdom) or indirectly through legislated, administered, and government-subsidised Social Health Insurance (as in Germany) (Montagu, 2021:2). As a result, more health funding is required, and both public and private sector investment should be explored (Tao et al., 2020:7). As solution, Blecher et al. (2019:39) recommend that South Africa strengthen the NHI process by collaborating more closely with the private sector and recognising them as key stakeholders in the proposed NHI Bill's implementation. Furthermore, Coovadia (2017:3) states that South Africa lacks the financial resources to provide all South Africans with the same level of care as members of the medical system. Therefore, for the purposes of implementing the proposed NHI Bill [B11-2019] successfully, Coovadia (2017:23) suggests that South Africa should consider improving coordination, task-shifting, rolling out mobile health and telehealth programs, pushing care out into communities, and introducing a gatekeeping function. In addition, the Ghanaian experience demonstrates that in order to implement effective health financing systems, countries like South Africa must tailor systems to their socioeconomic, political, and administrative environments (Fusheini, Marroch & Gray, 2017:281). Coovadia (2017:17) argues that building capacity is critical. The author states that when health systems lack adequate infrastructure, no amount of insurance coverage will be able to offer effective care. Therefore, a sufficient number of doctors, nurses, and community health workers with access to reliable supply of medicines and surgical equipment, as well as logistical channels for providing care, are examples of such health system resources (Coovadia, 2017:17). The case of Turkey illustrates that it is critical to create a monitoring and evaluation system that could be used as a management tool to track progress toward operational and strategic plan targets and goals (World Health Organisation, 2015:25). Countries such as Thailand have made 89 accountability a priority by separating the purchaser and provider functions in health care, developing quality standards and strong capacity for strategic goal setting and the assessment of new technologies and pharmaceutical products to be included in benefit packages, and checking interest group pressures by establishing an oversight board with significant civil society participation (Reich et al., 2016:812). 3.5.2 Lessons learned from implementation of the National Health Insurance System in Ghana Apart from best practices presented from the above, South Africa could benefit from Ghana's experience with regards to the implementation of the proposed National Health Insurance Bill [B11-2019]. The implementation of Ghana's National Health Insurance System (NHIS) has been hampered by organisational, budgetary, and administrative issues (Christmals & Aidam, 2020:1894). Therefore, from the above challenges faced within the National Health Insurance System of Ghana, it could be argued that South Africa including the North West Provincial Department of Health should ensure that organisational readiness is established including thorough assessment of budgetary and administrative issues before the implementation of the proposed NHI Bill [B11-2019]. As a result, scholars such as Sodzi-Tettey et al. in Christmals and Aidam (2020:1894) argue that, amongst other things, Ghana and other nations using a similar system built a more modern payment system to save the scheme's survival (Christmals & Aidam, 2020:1894). Health systems must estimate the amount and type of human resources required in the short-, medium-, and long-term to plan and deliver effective health services. In an ideal world, the entire health-care team, including facility teams, should be participating in the policy-making process (Mabunda, Gupta, Chitha, Mtshali, Ugarte, Echegaray, Cuzoo, Loayza, Peralta, Escobedo, Bustos, Mnyaka, Swaartbooi, Williams & Joshi, 2021:2-5). The NHIS favoured the wealthy over the poor, and it was designed to put a greater burden on the poor. According to Christmals and Aidam (2020:1894), since the rich and the poor both pay the same amount to join the system, the rich have access to private-fee-for-service healthcare when NHIS licensed facilities run out of medication and other healthcare supplies. Thus, it could be argued that South Africa should ensure that implementation of the proposed NHI Bill [B11-2019] does not increase imbalances between the poor and the rich. Therefore, Reich et al. (2016:813) is of the view that expanding coverage to poor and vulnerable populations requires a strong government commitment to provide marginalised groups a voice and to overcome interest group politics. For example, Brazil and Thailand are two examples of countries where social movements have joined forces with political leadership to overcome political obstacles and eliminate coverage inequalities (Reich et al., 2016:813). In addition, Adyas (2021:222) states that the NHI organiser 90 in any given country such as South Africa, should implement management and administration in social protection schemes that include some key competencies such as, a good understanding of the insured population, including health technology assessment, evaluation of provider capabilities and negotiation with providers, and lastly contracting, monitoring, and reporting (Adyas, 2021:222). Furthermore, the case of Ghana demonstrates that, to achieve Universal Health Coverage, policymakers in low- and middle-income countries must consider a variety of funding sources in order to address the challenges posed by their economies and labour markets, low taxation capacities, and large informal sectors (Fusheini, Marroch & Gray, 2017:273). The NHIS's long- term viability in Ghana is also a major worry. The scheme's implementation appears to have been rushed. The roles of political actors were emphasised more than the technical expertise supplied by professionals in the field of public health insurance policy (Christmals & Aidam, 2020:1897). According to Christmals and Aidam (2020:1897), Ghana has put forth a lot of effort and money to make the NHIS work, but it has run into problems with coverage, funding, and stakeholder participation and governance. As a result, it could be argued that the South African government establish stakeholder participation, adequate funding, and proper leadership in the implementation of the NHI Bill [B11-2019] prior to its adoption. This would be extremely useful while making decisions relating to the NHI. The smooth operation of the NHIS is hampered by poor machinery, monitoring, and assessment (Christmals & Aidam, 2020:1897). Therefore, it could be argued that regular monitoring and assessment should be established in South Africa even after the proposed NHI Bill [B11-2019] has been implemented, as this would aid in spotting any future difficulties. In the NHIS, an insufficient workforce and weak institutional frameworks, particularly openness, are important challenges faced (Christmals & Aidam, 2020:1897). As indicated in the study’s problem statement, health professionals are at the heart of the South African health systems, and there is still a scarcity of them. As a result, it could be argued that the South African government should learn from the Ghana experience and ensure that appropriate health professionals are established for the proposed NHI Bill [B 11-2019] to function effectively once implemented; this includes complete transparency with the NHI's takings. Feshein, Marroch and Gray (2017:278) state that structures and institutions for accountability and openness should be established during the first implementation of the NHIS. In addition, the technical, capacity, and organisational aspects of implementing National Health Insurance schemes are essential success factors (Fusheini, Marroch & Gray, 2017:273). As previously stated in chapter 2 of this study, South Africa, especially the North West Provincial Department of Health, should ensure that 91 organisational readiness is in place prior to the proposed NHI Bill's implementation. This would contribute with the NHI Bill's implementation being a success. The case of Ghana reveals that while governments endeavour to offer accessible healthcare through various finance channels, there is a major reliance on social solidarity, as the instance of Ghana reveals (Fusheini, Marroch & Gray, 2017:273). To ensure cross-subsidisation and risk equalisation, the public must be willing to participate in National Health Insurance Schemes (Fusheini, Marroch & Gray, 2017:273). As a result, Christmals and Aidam (2020:1899) argue that the South African healthcare system should be redesigned to combat corruption, particularly as the National Health Insurance (NHI) Bill seeks to consolidate healthcare funds to be managed by boards accountable to political authority and the Minister of Health. For purposes of this study, South Africa including the North West Provincial Department of Health could take insights from the implementation of the NHIS in Ghana to avoid making similar mistakes as Ghana when implementing the proposed NHI Bill [B11-2019]. 3.5.3 Lessons learned from Thailand towards UHC Thailand's experience can teach other countries such as South Africa at least three crucial lessons about how to establish their own routes to UHC. To begin, employ the proper strategy: the mountain-moving triangle. Thaiprayoon and Wibulpolprasert, (2017:11-12) explain that the triangle represents the interaction of appropriate knowledge development and management, strong social movements, and political commitment. As a result, the mountain cannot be moved without the involvement of politicians, who have a great impact over resource distribution and use as well as the enactment of legislation (Thaiprayoon & Wibulpolprasert, 2017:11). Second, the tripping point and strategic actors' roles. People in powerful government positions contribute significantly to the development of evidence-based political commitment and social involvement. Long-term investment in health-care infrastructure and personnel. For example, Thailand began major public-sector investments in healthcare infrastructure five decades ago. A range of educational, financial, career development, and motivational measures for health professionals were also developed to ensure an equitable distribution of devoted and skilled health workers to administer these public health institutions around the country. As a result, the geographic distribution of health facilities and staff has been identified as a crucial element influencing the successful implementation of health policies such as the National Health Insurance (Fusheini, Marroch & Gray, 2017:279). Based on the three lessons, South Africa could apply these lessons when implementing the proposed NHI Bill [B11-2019], by ensuring that a tight political commitment, relevant stakeholders, and sufficient health professionals are established locally, provincially, and nationally. 92 3.5.4 Lessons learned from Turkey towards health transformation Turkey made significant gains in terms of health, patient experience, and financial risk reduction with its ten-year Health Transformation Program (Akdag, 2015: 3). Therefore, Akdag (2015:6-7) proposes several guiding principles based on Turkey's transformational experience: • The first step is to obtain public support. A reformer's strategies and implementation should be comprehensive, including all elements of healthcare. Therefore, South Africa should ensure that the proposed NHI Bill [B11-2019] includes all the significant elements of healthcare, and that public support is established. • Second, be firm on the private sector while ensuring that the public sector is strong enough to safeguard low- and middle-income people. As alluded previously, South Africa should ensure that collaboration is established between the private and public health system before implementation of the proposed NHI Bill [B11-2019]. • Third, countries such as South Africa for the purposes of this study should be cautious and concentrated in their efforts to protect their citizens from financial distress. For example, citizens of Turkey are today properly protected, due to a low-cost and efficient system. As a result, countries including South Africa should keep track of patient satisfaction on a regular basis. • Fourth, despite the risk of being criticised, countries should admit and fix their mistakes. If anything does not go as planned during the implementation of a public policy, governments must learn from their failures. For example, should mistakes be experienced in the implementation of the proposed NHI Bill [B11-2019], the government of South Africa should find ways to fix such mistakes, by learning from past experiences and improving from what has gone wrong with new strategies. • Fifth, countries should not be blinded by their achievements. There will always be something that can be improved or adjusted. Therefore, for the purposes of this study, it could be argued that regular monitoring and evaluation of the implementation of the proposed NHI Bill [B11-2019] should be established as there might be gaps that were previously not seen. • Sixth, rather than focusing on inputs, countries should focus on outcomes. To increase the reform's outcome focus, Turkey deployed a variety of feedback channels as well as monitoring and assessment mechanisms. As alluded from the above, the South African government believes that implementing the proposed NHI Bill [B11-2019] is the only option to attain UHC (Pauw, 2021:11). Therefore, Akdag (2015:8) states that these principles are an essential component of a broader approach for 93 achieving UHC. However, it should be noted that transferring Turkey's experience to other regions of the world such as South Africa necessitates careful consideration of the country’s environment. As a result, it could be argued that South Africa, particularly the North West Provincial Department of Health, could implement the proposed NHI Bill [B11-2019] using these guiding principles. The context of South Africa, on the other hand, should be carefully reviewed to ensure that the principles are appropriate for the country. 3.5.5 The United Kingdom health system in brief The National Health Service (NHS) of the United Kingdom (UK) was founded in 1948 and is still the world's most frequently used health-care system. It is largely funded through general taxation (80%), with a payroll tax as a supplement. The treasury oversees the total budget, as well as public money, which accounts for 78 percent of all health spending in the UK. Although every UK resident is eligible to NHS-funded care, numerous prominent private health insurance organisations still cover UK residents (Roland, 2021; Chang et al., 2011:5). According to UK experience, the quality of a system's design must always be distinguished from the quality of its funding (Light, 2003:25). Therefore, the South African proposed NHI Bill [B11-2019] design should align to how the system would be financed. It could be argued that this lesson could also enhance successful implementation. The NHS in the United Kingdom was founded on three principles: free treatment at the point of delivery, comprehensive services available to all, and taxation as a source of revenue (Jha, 2020:2). Therefore, understanding and adhering to basic principles is a vital component for policymakers. The NHSs of UKs guiding principles are that its services are open to everyone, are free at the point of care, and are comprehensive. Jha (2020:2) states that studying the health- care systems of other countries has shown UK that a country rarely adopts a complete finance or delivery model from another country. Jha (2020:2) thus notes that every system is unique and has its own set of values (Jha, 2020:2). Therefore, South Africa should outline its principles based on its environment and that fits the objectives of the proposed NHI Bill [B11-2019] to ensure that each citizen is not excluded from receiving the benefits of the proposed NHI Bill [B11-2019]. Doing so also enhances successful implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. The NHS in the UK places a high priority on providing high-quality care. Quality issues are dealt with in a variety of ways. Chang, Peysakhovich, Wang and Zhu (2011:7) explain that there are a variety of regulatory authorities in operation, for example, that monitor and review the quality of both public and private sector health services. This entails a regular, periodic evaluation of all 94 providers, an investigation of all individual issues brought to the regulatory body's attention, and careful study in order to recommend the best practices (Chang et al., 2011:7). Since the UK is the most widely used health-care system as stated from the above, South Africa could learn from this best practice, while implementing the proposed NHI Bill [B11-2019]. Furthermore, long-standing UHC programs, such as the UKs NHS, have consistently improved national health and economic outcomes in their respective countries. To explain, stakeholders believe that the most important predictor of successful UHC adoption is accountability and delegated management. Therefore, before implementation of the proposed NHI Bill [B11-2019] in South Africa, the government should ensure that accountability measures are set in place and a proper management team to undertake the operations of the proposed NHI Bill [B11-2019] is in place. In addition, the NHS in the UK has emphasised the importance of a "strategic vision" at the district level, as well as the training of local health managers to strengthen their ability to enforce implementation. To put it another way for the purposes of this study, prior implementing the proposed NHI Bill [B11-2019], South Africa should describe its vision for the future of the proposed NHI Bill [B11-2019] and gradually monitor the NHI to reach its vision. To conclude this section, Coovadia (2017:15) states that while each country has its own set of resources and constraints and will need to move to UHC on its own timeline, it is possible to compile a list of lessons learned from recent experiences that could help improve the chances of a successful, decisive, and consensual implementation. It should, however, be noted that a public policy that works in one country may not work in another. Therefore, it has been argued that the ability to learn and adapt on a continuous basis is vital learning and should be at the heart of UHC-related policy procedures (Kiendrebeogo, De Allegri & Meessen, 2020:1). The next section presents a discussion of the theory of social justice. This idea is relevant to this study because it suggests that imbalances in public health should be addressed to benefit the entire population and not just the wealthy or middle class. 3.6 THEORETICAL FOUNDATION OF THE THEORY OF SOCIAL JUSTICE The terms "social" and "justice" are not interchangeable. To begin, Schenker, Linner, Smith, Gerdin, Moen, Philpot, Larsson, Legge and Westlie (2019:130-131) explain that the term "social" refers to something that incorporates communal or collective cohesion. It necessitates the interaction of individuals. In order to promote the "social," one can engage in social activities such as public health, which addresses concerns of social cohesiveness, accomplish something with a social impact, or work for social change, all of which contribute to a greater communal benefit. 95 Second, Schenker et al. (2019:130-131) state that “justice” is concerned with equity and achieving equitable outcomes; while discussing the social, justice considers social categories such as gender, sexuality, socioeconomics, and ethnicity. Therefore, it is fair to assert that conceptualising social justice is both a process and a goal (Philpot, Smith, Gerdin, Larsson, Schenker, Linner, Moen & Westlie, 2021:59). Social justice can be described as the moral imperative to avoid and correct inequitable distributions of societal disadvantage. Dukhanin, Searle, Zwerling, Dowdy, Taylor and Merrit (2018:27) state that it goes beyond fairness in the distribution of policy impacts on other dimensions of well-being when it comes to determining priorities in healthcare and public health. According to Nemetcheck (2019:246), social justice is a type of justice in which society's obligations and benefits are distributed equitably. It encompasses features like equity, equality, and moral rightness, as well as being anchored in human well-being and requiring action. It is also regarded as the moral foundation of public health, and the constant conflict between individual rights and the common good occurs within the context of a wide commitment to ensure that everyone benefits from good health (Mooney-Doyle, Keim-Malpass, Lindley & 2019:1522). Lasker and Simcox (2020:4) contend that social justice is a viewpoint that promotes equality in political, human, social, and economic rights not only at the individual level, but also at the organisational and institutional level. Identifying interconnected patterns of disadvantage that systematically marginalize demographic groups is an important aspect of the mission of social justice (Tol, 2020:4). It recognises that people should be treated fairly and equally, and it justifies medicine and public health as a social good (Rahman, 2020:4). This theory incorporates two moral impulses that are pertinent to public health: (a) the obligation to focus on the health of the most impoverished; and (b) the development of human well-being through advancement (Shafique, Bhattachargya, Anwar & Adams, 2018:63). Furthermore, social justice recognises the capacity principle, which prioritises resources based on medical necessity rather than financial ability (Rahman, 2020:4). People are sometimes unable to afford healthcare, even though it is necessary, resulting in health deprivation. However, Joseph (2020:151), explains that social justice relies on human agency to achieve its goals. People must be involved in advocacy, community, organising, resistance, and social movements. Joseph (2020:151) further states that change will not occur until people take concrete steps to address environmental and structural issues. In addition, Nemetchek (2019:245) alludes that social justice entails full involvement in society and the equitable distribution of rewards and costs among all citizens. 96 According to Quinn, Ghazini and Knight (2019:183), there has been a rise in both evidence and awareness of the negative effects of social injustice on health. Additionally, Mooney-Doyle et al. (2019:1520) suggest that there are two principles that could govern how concepts of justice and fairness could be applied to public institutions, including health care. To begin with, every individual in a society has the same fundamental rights and opportunities. Second, primary good inequality is only permitted if all reasonable citizens have access to the same options for enhanced benefit or burden, and if the inequality improves the lives of the poorest citizens. Therefore, Peter (2001:165) is of the view that the principles of social justice attempt to regulate the terms of social cooperation. Furthermore, Shafique et al. (2018:63) argue that social justice principles should influence how society is organised to allow for equal resource allocation. To ensure equitable distributions, the author explains that Rawls proposed the concept of "initial position," which is a hypothetical circumstance in which people picture themselves in a state of ignorance about their standing in society (based on class, gender, ethnicity, birthplace, socio-economic background, and other characteristics). Additionally, the concepts of social justice apply to the norms, institutions, and social arrangements that ensure that human needs are met on a continuous basis (Mooney-Doyle et al., 2019:1590). To attain universal healthcare, constitutional acknowledgment of social justice and the right to healthcare is required. In this case, for the purposes of this study, it may be argued that South Africa and the North West Provincial Department of Health needs to acknowledge the social justice theory to ensure that the imbalances that are occurring between the public and private health systems are addressed as they could be detrimental in the long run. According to research, healthcare systems do not provide health services in accordance with these principles. Hence, it could be argued that social justice is harmed by a lack of accountability and bad regulatory standards, which have hampered the practice of the right to healthcare (Rahman, 2020:8). Furthermore, Tol (2020:4) indicates that Powers and Faden argue for social justice as the moral basis for public health, rather than the more common considerations of maximising health benefits from limited public health resources. According to Lee (2017:6), Powers and Faden have emphasised the role of social justice in public health ethics, providing a minimum level of opportunity and health for all. Social justice can be considered as a basic ethical principle in public health ethics, and it is anchored in the idea of fairness. In addition, the profession of public health recognises social justice as a responsibility, 97 a set of essential ethical principles, and a moral rationale. It is critical to recognise that promoting and fighting for social justice in the pursuit of better health for all people has been identified as critical to public health (Nemetchek, 2019:246). A public health perspective on justice considers how disease risk is distributed across a population, both directly and indirectly (Mooney-Doyle et al., 2019:1522). Consequently, it may be argued that public health necessitates relationships with the government, professions, and non-governmental organisations, including private and commercial entities (Coggon & Tahzib, 2020:1). It is critical to acknowledge that public health is moral in nature, with a desire to create a better, more equitable society at its core (Coggon & Tahzib 2020:1). In this instance, justice demands that all people be treated equally and fairly (Mooney-Doyle et al., 2019:1525). Mooney-Doyle et al. (2019:1525) state that since inequality causes suffering and deep lack of well-being in marginalised populations. From the aforementioned, it may be argued that the theory of social justice for public health can be said to be coherently defined. Simply expressed, social justice refers to a society's correct or equitable distribution of advantages and burdens. Rahman (2020:4) explains that when people have equitable access to healthcare, social justice is therefore established. Finally, to ensure social justice, the basic institutions of society need to function in compliance with the principles of justice as mentioned above (Shafique et al., 2018:65). For purposes of this study, the North West Provincial Department of Health should utilise the social justice theory to ensure that health services are accessible to all citizens once the proposed NHI Bill [B11-2019] is effectively implemented in becoming legislation. Lastly, it may be concluded that social justice theory must establish guidelines for regulating inequalities in citizens' life chances that come from social starting positions, natural advantages, and historical events (Peter, 2001:165). The following sub-section presents a model case of the theory of social justice. 3.6.1 Model case of the theory of social justice Nemetchek (2019:248-249) states that a model case demonstrates all the defining attributes of social justice in public health as a concept and will assist into bringing understanding and meaning to the concept (Nemetchek, 2019:248-249): 98 Figure 4: Model case of the Theory of Social Justice Source adapted from: Nemetchek (2019:248) It could be argued, based on the figure above, that social justice has always played a significant role in health, ensuring that equity is recognised. From the above figure, an antecedent, according to the Oxford Advanced Learner's Dictionary, is a thing or an event that exists or occurs before another and influences it (Hornby, 2010:52). The antecedents begin with health disparity, which refers to inequities in healthcare delivery and access across different racial, ethnic, and socioeconomic groups (Mandal, 2019:1). According to the Oxford Advanced Learner's Dictionary, oppression is defined as treating a person in a cruel and unfair manner by denying them the same freedom and rights as others. As a result, to recognise social justice and ensure that public health is prioritised; these individuals who are not receiving the same treatment as others ought to be cared for, and it is the government's social responsibility to take the necessary steps (Researcher's own analysis; Hornby, 2010:1033). To provide a clearer picture of the concept’s social justice and public health, Nemetcheck (2019:249) uses the example of a young lady in Uganda whose two-year-old son became unwell and had no money to pay for transportation to take him to a local health centre, causing his illness to worsen. The village chairperson approached her and offered the required funds from the community treasury to transport the child to the local health centre. After the child recovered, the family received a referral letter along with sufficient funding for a follow-up. As a result, this case demonstrates the importance of focusing on public health to influence broader issues that directly or indirectly affect health. This model case displayed both health equality and a caring and cooperative society interaction that resulted in equitable health access, demonstrating social justice (Nemetcheck, 2019:249). Thus, the central argument is that the North West Provincial Department of Health acknowledges the theory of social justice to enhance public health. 99 3.7 CHAPTER CONCLUSION The primary argument of this chapter is that public institutions should acknowledge processes and concepts of public policy implementation to enhance the success of new public policies. This chapter provided an overview of the term public policy since public policy implementation is a concept that is encompassed by the phrase public policy (see section 3.2). It conceptualised public policy implementation to provide knowledge to the reader on what it entails to implement a public policy in general. The chapter also included a description of the public policy implementation process, which is used by many government entities to ensure that proper procedures are followed and that important aspects are not overlooked. Furthermore, this chapter provided a theoretical framework of public policy implementation, which included: public policy implementation approaches namely: the top-down, bottom-up and hybrid approach implementation (see section 3.3.1). The argument was that public institutions should make use of the hybrid approach for implementation since it is a combination of both strengths and weaknesses of the top-down and bottom-up implementation. This chapter also provided a conceptual framework of public policy implementation, which included: the principles of public policy implementation, the tasks involved in public policy implementation, features for effective public policy implementation and central questions associated with public policy implementation (see section 3.4). The argument was that it is important that the researcher finds ways on how the problem of this study could be improved. The central argument was that public institutions tend to overlook other components of public policy implementation and only focus on implementing the policy successfully. Therefore, it is important that public institutions such as the North West Provincial Department of Health acknowledges these components. This chapter also outlined the best practices of public policy implementation to provide insights in implementing public policies such as the proposed NHI Bill [B11-2019] successfully. The rationale for this section is that public institutions tend to have best public policies at hand but implementing them successfully tend to be a challenge. Finally, this chapter provided a theoretical foundation of the theory of social justice. This theory is pertinent to this study because it emphasises the importance of addressing imbalances such as those that are present in South Africa’s public and private health systems. A model case of the theory of social justice was also included in this part to provide a more thorough explanation of this concept. As alluded in the problem statement, this study envisages to present a model to the North West Provincial Department of Health. Chapters 2 and 3 were presented to illustrate the relationship 100 between organisational readiness and public policy implementation. The following chapter presents the statutory and regulatory framework governing the health sector of South Africa with particular reference made to the North West Provincial Department of Health. 101 CHAPTER 4 : STATUTORY AND REGULATORY FRAMEWORK GOVERNING THE HEALTH SECTOR OF SOUTH AFRICA 4.1 INTRODUCTION The relevant literature that public institutions such as the North West Provincial Department of Health must consider before embarking on new policy endeavours was reviewed in Chapters 2 and 3. As stated in Chapter 2 of this dissertation, before the implementation phase, it is critical that public institutions understand what organisational readiness entails and which elements should be assessed beforehand. After reviewing organisational readiness in Chapter 2 of this study, Chapter 3 outlined techniques, theories, and principles connected with effective implementation of public policy. This dissertation reviewed the literature to aid in the development of a model for the North West Provincial Department of Health to successfully implement the proposed NHI Bill [B11-2019] once it becomes legislation. Different concepts were discussed in Chapters 2 and 3 of this dissertation, yet it has been proved that these concepts are somehow interrelated for successful public policy outcomes. This chapter is three-fold. To begin with, this chapter presents the transformation of the South African health system and provides a brief description of the current functioning of the South African health system to motivate the rationale of the development and implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. This chapter further contextualises the proposed National Health Insurance Bill [B11-2019] to provide context for this phenomenon, as it is at the heart of this study. Lastly, this chapter outlines and analyses essential legislation and regulation that regulate the South African health system, with a focus on the North West Provincial Department of Health. 4.2 TRANSFORMATION OF THE SOUTH AFRICAN HEALTH SYSTEM The health system and policies in South Africa have a history of racial segregation and discrimination, with the health system and policies being utilised to buttress white supremacy and capitalist principles. The country became a democracy in 1994, and the African National Congress (ANC), the elected party, adopted a National Health Plan (Pauw, 2021:1). ANC established the National Health Plan for South Africa in 1994, which envisioned an integrated, equitable, and comprehensive health system based on the Primary Health Care (PHC) model. The right to health care was strengthened under the Republic of South Africa's Constitution, 1996. The National Department of Health's White Paper for the Transformation of the health system that was published in 1997, enshrines the vision for a reformed health system into government policy. Furthermore, the National Health Act 61 of 2003 was developed which sets out the legal 102 framework for the policies. The democratic government's health system aims were encapsulated in three documents namely: The Health Sector Strategic Framework (1999 - 2004), Strategic Priorities for the National Health System (2004 - 2009), and the 10 Point Plan (2009 - 2014); all of which were to improve the health system of South Africa (Pauw, 2021:1). Some of these legislation and regulation will be discussed further in this chapter. Since the researcher provided a brief discussion about the transformation of the South African health system since 1994, the following section outlines the current functioning of the South African health system. 4.2.1 The South African health system in brief According to Young (2016:3), the current South African health system is a two-tiered system that is separated along socio-economic lines that comprises both public and private health systems. To further explain, the South African health system is currently divided into four components, each of which is overseen by three different spheres of government. The three parts that relate to the public provision of health services are the national government sphere, which oversees national policy and implementation, the provincial government sphere such as the North West Provincial Department of Health, which has the constitutional mandate for health services and is held concurrently with the national sphere, and the local government sphere consisting of municipalities, which has the mandate for non-clinical health functions such as environmental health and sanitation. The fourth component of the health system is provided by private health service providers and is paid through medical schemes, which are private health insurance plans (van der Heever, 2019:9-10). It is worth noting that the private health system currently serves only 16 percent of the population, which is the socio-economic elite, while the rest, 84 percent rely on the overburdened and badly managed public health system (Pauw, 2021:4). This shows significant inequalities between the two health systems of South Africa. According to Mathew and Mash (2019:2), this has exacerbated the imbalance in South Africa's existing health system; the discrepancy has also rendered the health system unsustainable and costly. The public health system is organised in accordance with the three domains of government (national, provincial, and local), with services mostly funded through allocations from general tax revenue and a tiny percentage derived from local government revenue and user fees (Ataguba & McIntyre, 2018:70). Furthermore, rather than primary health care, the entrance level for receiving health services is usually at an inappropriate level of care (secondary, tertiary, and specialised services). This has played a key role in the high expenses of health care as well as the inefficiency of the health care system (Republic of South Africa, 2015:14). In addition to the imbalances occurring between the 103 public and private health system, the South African health system is currently afflicted by plenty of issues, including inadequate infrastructure, human resource shortages, financing disparities, and bad governance (Sithole, 2015:1-2; de Villiers, 2021:3-4). As a result, the government's perspective, and motive for implementing the NHI include removing barriers and enhancing the above-mentioned factors (Pauw, 2021:4). Ngobeni, Breitenbach, and Netshisaulu (2020:2) explain that the South African government's health system has eight hundred and thirteen (813) hospitals with hundred and thirty-three thousand three hundred and eighty-seven (133,387) beds for acute health care. The public health system represents 49.7 percent or four hundred and four (404) of these hospitals with 69 percent of the total bed allocation. The private health system constitutes four hundred and nine (409) hospitals (50.3 percent) with 31 percent of bed distribution. These numbers clearly highlight imbalances between the private and public hospitals and may additionally allude to a deficiency of the public health infrastructure as these numbers convert into eighty-one thousand hundred and eighty-eight (81,188) individuals per public hospital with an average of two hundred and twenty-eight (228) beds per public facility (Ngobeni et al., 2020:2). As a result, it is argued that the public and private health systems have evolved in tandem, with the public health system serving people with insufficient incomes and the private health system treating those with sufficient incomes via medical schemes (van der Heever, 2019:12). Pauw (2021:1) states that the ANC-led government’s administration has initiated the process of adopting a National Health Insurance Policy (NHI) with the end goal of providing affordable and accessible Universal Health Coverage (UHC) to address current imbalances in healthcare. Besides the imbalances and challenges in the South African health system, it is worth noting that South Africa's health system follows the UHC approach. The UHC pledges to provide human rights-based access to affordable, high-quality preventive, curative, rehabilitative, and palliative health care. Therefore, the proposed NHI Bill [B11-2019] lays out the procedures by which the South African government intends to support the reorganisation of healthcare provision (Kleintjies, Den Hollander, Pillay & Kramers-Olen, 2021:135). The following section contextualises the proposed NHI Bill [B11-2019] since it is at the centre of this study to investigate on whether the North West Provincial Department is ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation. 104 4.3 CONTEXTUALISING THE NHI AND THE PROPOSED NHI BILL [B11-2019] PHASE The NHI aims to make quality health care services more accessible to all South Africans. According to Katurura and Cilliers (2018:1), an Electronic Health Record [EHR] system should be built for South Africa to reach this goal. This system will register and track patients who visit various health care providers. According to Plagerson, Patel, Hochfeld and Ulriken (2019:5), the NHI intends to create a health-care financing system that pools funds to actively acquire and offer access to high quality, affordable personal healthcare for all South Africans, regardless of their socio-economic background. Sithole (2015:1) states that this would be done in the hopes of increasing the use of healthcare services to improve health. As mentioned in section 4.2 of this study, South Africa's health system is divided along socio-economic lines. Therefore, this shows that the objective of the NHI is relevant. Since it attempts to address the imbalances in public healthcare delivery mentioned in section 4.2 of this study by implementing transformative policies aimed at ensuring inclusive public healthcare coverage for South Africa's whole population, with a greater emphasis on health promotion (Sithole, 2015:1). The NHI's guiding principles emphasise equitable access to health care as a socio-economic right, which requires social solidarity to promote risk pooling and cross-subsidisation of the poor by the wealthy, the elderly by the young, and so on. It also emphasises the importance of delivering accessible, efficient, and effective health services, as well as providing appropriate levels of care to satisfy local needs (The Davis Tax Committee, 2017:4). As alluded in section 3.5 of this study, according to Pauw (2021:11), the government of South Africa believes that implementing the NHI is the only option to achieve Universal Health Coverage and equity in the health sector. However, critics of the NHI contend that there is a considerable lot of uncertainty and a lack of common understanding about how the NHI would be implemented and operated, given the scope of the planned transformation. It could therefore be argued that the government of South Africa should provide clarity on how the NHI will function once it is implemented. Furthermore, van der Heever (2019:83) states that, given the existing costing criteria specified in the White Paper, the proposed NHI is unlikely to be sustainable in its current form unless there is ongoing development. The researcher concurs with van der Heever (2019:83) that the government of South Africa needs to continuously make improvements of the NHI. As stated by Michael, Tediosi, Egger, Barnighausen, McIntyre, Tanner and Evans (2020:2), the NHI aims to achieve the following objectives: 105 • Replace the existing fragmented public and private health-financing systems with a single, contemporary universal health financing system that is cost-effective, trusted by citizens, and protects citizens from expensive health care services. • Transition from a voluntary to a mandatory pre-payment system. • Generate more revenue for healthcare. • Strengthen pooling arrangements to better distribute risk and increase cross- subsidisation. • Buy from a variety of public and private suppliers. • Achieve cost-efficiency by utilizing economies of scale and purchasing practices. • Provide high-quality services and to continue to enhance health outcomes. It could be argued that the aims of the NHI are very significant for transformation of the health system of South Africa, considering the fact that there are significant challenges in accessing quality health services in the public health system as outlined in the problem statement of this study (see section 1.3). Furthermore, Michael et al. (2020:1) explain that the NHI's goal is to increase population coverage, improve the quality and quantity of services to which the population is entitled, and provide financial risk protection to individuals and households while lowering the direct costs to which the population is exposed when seeking healthcare. According to Tandwa and Dhai (2020:2), the NHI will achieve these goals through restructuring the structure and financing model of the South African healthcare system over the course of 14 years. In addition, Blecher et al. (2019:30) state that the NHI's core goal is to bridge the gap between the current two-tiered health system, which is hampered by a lack of access to high-quality care in a more well-resourced private sector. As explained in chapter 1 of this study (section 1.2), the NHI is currently in its second phase which is the proposed NHI Bill [B11-2019]. The figure below presents the development of the proposed NHI Bill [B11-2019]: 106 Figure 5: Development of the NHI Bill [B11-2019]. Source: adapted from Pauw (2021:9) The current phase from 2017 to 2022 will set the legal and institutional foundations for the NHI, including the creation of the NHI Fund, Contracting Units for Primary care (CUPs), and multiple ministerial advisory bodies (Blecher et al., 2019:30). The proposed NHI Bill [B11-2019] was developed by the Department of Health in 2018 and presented to Cabinet by former Minister of Health, Zweli Mkhize (Pauw, 2021:6). Phase two is currently underway, and it entails the creation of legislation, specifically the 2019 NHI Bill, as well as the amending of pertinent existing legislation. The third phase entails reallocating resources and creating mandatory payment methods, as approved by Cabinet. Explaining the second phase, in 2019, the NHI Bill [B11-2019] was introduced in parliament, commencing of the legislative process that will enable South Africa to achieve Universal Health Coverage (Gray & Vawda, 2019:3). However, Blecher et al. (2019:30) argue that while little progress has been made, after nearly a decade of policymaking and more than six years of piloting, the reform appears to be moving slowly. In addition, Blecher et al. (2019:30) explain that promoting health and preventing illness is central to the proposed NHI Bill [B11-2019], as well as to South Africa's social and economic growth and development. However, Freeman, Simmonds and Parry (2020:188) argue that a structure should be established to deal with health determinants, including social determinants, as part of the National Health Insurance. 107 According to Murphy and Moosa (2021:2), South Africa has failed to implement structural and financial health changes in the past. Therefore, the NHI Bill [B11-2019] recognises these shortcomings to transform theoretical frameworks into operational strategies and considers the devolution of healthcare governance from provincial health structures to district and sub-district managers to be vital to the NHI's success (Murphy & Moosa, 2021:2). The goals of the NHI, according to the 2019 NHI Bill, are to provide access to quality healthcare for all South Africans, provide financial security for individuals from medical bills, and establish a public fund for all health services. Freeman, Simmonds and Parry (2020:188) explain that the NHI Bill [B11-2019] introduced to parliament, focuses solely on curative and treatment approaches. This means that the Bill focuses primarily on disease and sickness prevention initiatives. It could thus be argued that this plainly demonstrates that other issues plaguing South Africa's health system are not being appropriately addressed. It is crucial to note, however, that the proposed NHI Bill [B11- 2019] provides an opportunity to accelerate the implementation of national policy commitments to improve service access, delivery, and outcomes, including bringing mental health needs into parity (Kleintjies et al., 2021:135). In compliance with the National Health Insurance White Paper and the Constitution of South Africa, 1996, the NHI Bill [B11-2019] aims to ensure equitable access to quality healthcare in South Africa (Republic of South Africa, 2019b:46). In addition, the proposed NHI Bill [B11-2019] recognises the issues of corruption and emphasises the importance of putting in place necessary mechanisms to ensure that it does not persist (Pauw, 2021:8). The researcher therefore motivates that the government should start now by implementing those measures since it would not be feasible implementing them while the NHI Bill [B11-2019] is functioning. The proposed NHI Bill [B11-2019] also allows medical schemes to fund just supplemental coverage for services that the fund does not reimburse. However, Kleintjies et al. (2021:139), argue that the proposed NHI Bill [B11-2019] must utilise the private sector as a strategy for long-term financing to be effective. Even though the public is still concerned about how much tax they will be asked to pay and what medical insurance schemes would look like (Pauw 2021:8). The government should properly outline the contributions towards the NHI. The proposed NHI Bill [B11-2019] repeals the previous legislative framework in the National Health Act and confers control of personal public services with sub district managers within their districts to promote the reorganisation of the health system (Murphy & Moosa, 2021:2). The proposed NHI Bill [B11-2019] outlines several health-policy initiatives, including the creation of a National Health Insurance Fund to advance Universal Health Coverage (Solanki, Cornell, Morar & Brijlal, 2021:812). Murphy and Moosa (2021:3), explain that the Bill proposes for the NHI Fund 108 to finance Contracting Units for Primary Healthcare Services (CUPs) that will serve as either sub- district purchasers, funded by the NHI Fund or as current sub-districts public providers who have contracted with the NHI to deliver personal services. Murphy and Moosa (2021:3) further explain that CUPs are preferred organisational units that consist of an integrated network of district hospitals, clinics or community health centres, and private providers with whom the NHI Fund will directly contract to provide primary health care services in a sub district. The NHI Bill's [B11-2019] basic concept is that devolving governance to sub district managers will combine top-down policy with the wisdom and leadership of sub district managers who deal with the complicated realities of healthcare service delivery (Murphy & Moosa, 2021:2). However, Kleintjies et al. (2021:139) are of the view that the proposed NHI Bill [B11-2019] must consider how its provisions will affect income-generation and employment opportunities in the private sector to alleviate concerns about future employment in South Africa, because practitioners who are not accredited will effectively be unable to work, as the fund will eventually cover most aspects of health care (Kleintjies et al., 2021:139). Solanki et al. (2021:812) suggest that it would be prudent for the Portfolio Committee on Health to address the issues highlighted about the Bill and guarantee greater public support for it, even if this meant delaying its passage. The following section presents the statutory and regulatory framework governing the health system of South Africa particular reference given to the North West Provincial Department of Health. 4.4 STATUTORY AND REGULATORY FRAMEWORK OF THE HEALTH SYSTEM OF SOUTH AFRICA Kadandale, Rajan, and Schemets (2016:500) explain that a statutory, often known as legislation, is a catch all term that refers to the various sorts of laws enacted by a country's legislature or other law-making body. Legislation refers to two forms of legislation, namely: the primary and secondary legislation. The primary legislation refers to laws enacted by the national legislature, whereas secondary legislation refers to laws enacted by the executive or local governments. Furthermore, Kadandale et al. (2016:497) explain that a regulation is the government's promulgation of regulations backed by procedures for monitoring and enforcement (usually assumed to be performed through a specialist public agency). South Africa is still considered a developing country; therefore, it is vital to lay out the statutory and regulatory framework that governs the health system of South Africa, including the North West Provincial Department of Health. The applicable statutory and regulatory framework for the purposes of this study is presented below: 109 • Health Professions Act 56 of 1974 • Constitution of the Republic of South Africa, 1996 • National Health Act 61 of 2003 • Nursing Act 33 of 2005 • White Paper for the transformation of the health system in South Africa • National Development Plan (NDP): Vision for 2030 (2011) • Medium-Term Strategic Framework 2019-2024 4.4.1 Statutory framework The following section presents the statutory framework that is applicable to this dissertation. 4.4.1.1 Health Profession Act 56 of 1974 The South African health system is founded on the Health Professions Act 56 of 1974. Within the South African health setting, it controls the practice of medicine as well as the numerous healthcare professions (Medical Protection, 2021). The primary goal of the Health Professions Act 56 of 1974 is to identify and explain the Health Professions Council of South Africa (HPCSA) including professional boards, to also present regulations in relation to education, training, and registration for and standards that need to be followed by health professions registered under this Act, and to present relevant rules and responsibilities for health professionals and health establishments in relation to this Act. This Act is divided into five chapters. Chapter 1 outlines the statutory framework for the HPCSA and its professional boards, as well as the HPCSA's objectives, functions, and powers, which include co-ordinating the activities of the professional boards established under this Act and acting as an advisory and communicatory body for such professional boards. Chapter 2 provides information about healthcare professional education, training, and registration. No individual or academic establishment, with the exception of a university and universities of technology, may conduct any training for the aim of qualifying anyone for the practice of any occupation to which this Act applies, or for the carrying on of any other activity directed to the mental or physical examination of any person or to the diagnosis, treatment or prevention of any mental or physical defect, illness or deficiency in man, unless such training has been approved by the professional board concerned. Chapter 3 discusses different offenses that affect healthcare providers and unregistered individuals. Therefore, no person shall perform any act believed to be an act relevant to any health profession as may be prescribed under this Act 110 unless he or she is registered in accordance with this Act in respect of such profession, according to this chapter. Furthermore, Chapter 4 describes the professional boards' disciplinary authorities. This chapter specifically states that a professional board has the authority to investigate any complaint, charge, or accusation of unprofessional behaviour against any person registered under this Act, in addition to enforcing any of the penalties set out in section 42 (1), including a warning, reprimand, or reprimand and a warning, withdrawal of his or her name from the record, and a mandatory period of professional service, if the person is found guilty of such behaviour. Chapter 5 concludes with further general and supplementary provisions. This chapter specifically states that a health professional, dentist, or other person registered under this Act may replicate or distribute medicines only with the permission of the Director-General and subject to the conditions of a licence granted under the Medicines and Related Substances Act, 1965. (Act No. 101 of 1965). As noted in the problem statement of this study, section 1.3, health professionals are at the centre of the health system of South Africa and plays a vital role in delivering quality health services to patients. This Act is crucial for the purposes of this study since it sets the criteria for health professionals and all relevant aspects that are considered ethical when working in South Africa as a health professional. As a result, it could be argued that it is significant that the North West Provincial Department of Health recognises this Act as important and beneficial to the Department's efficient and successful operation. 4.4.1.2 Constitution of the Republic of South Africa, 1996 The Constitution of the Republic of South Africa, 1996 (hereinafter referred to as the Constitution) sets the foundation for the country's progressive environmental legislation by ensuring South Africans the right to a safe environment (Diedericks, 2013:128). This means that the South African Constitution guarantees every citizen the right to live in a safe and secure environment without feeling excluded or endangered. The Constitution is critical to the development and implementation of health law and policy, which it regulates in five ways: first, administering the structure of government, controlling the manner in which different parts of government operate, laying out the system for raising and dispensing revenue, guiding the content of all laws and policies, primarily through its bill of rights, and finally, controlling the role of government and non- state actors (for example, private organisations) (Anon, 2017:32). In addition, Dennil, King and Swanepoel (1998:176) note that the most important commitment to every South African's health is that all people are now treated equally before the law, which is the foundation of health care equality. 111 Section 27 (1) (a) of the Constitution states that everyone has the right to health care services, including reproductive health care. However, it is critical to remember and underline that the right to health care is a social right, not an economic one, as is unfortunately the situation in South Africa and around the world (Maimela, 2018:5). The constitutional court states that the state has a fundamental commitment to provide health care to everyone within its resources. Section 27(2) of the Constitution requires the government to take legislative and other measures, within its existing funds, to accomplish the full realisation of the right, which entails taking all reasonable steps to ensure that the right is secured, advanced, and fulfilled, and that universal access to high-quality, comprehensive health care is achieved after a period of time (Republic of South Africa, 1996:17). Even though the right to health care is established in the Constitution, Maimela (2018:5) argues that there are significant imbalances in accessing health care. Imbalances in health resources and barriers to accessing health care services, such as huge distances, expensive travel costs from rural areas, long lines, and disempowered individuals, are mostly responsible for these imbalances (Maimela, 2018:5). Lastly, section 27(3) states that no one may be denied emergency medical treatment. The constitutional court determined that the right not to be denied emergency medical treatment meant that an individual who experiences a disaster that necessitates immediate medical attention should not be denied ambulance or other emergency services that are readily available, nor should they be turned away from a hospital that can provide the basic treatment (Republic of South Africa, 1996:16-17). From the aforementioned, it should be kept in mind that this study is based on investigating the readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Therefore, it is significant to analyse what the Constitution acknowledges in relation to public health. In addition, Diver (1982:404) explains that public managers are public workers, and their actions must be legitimated by the consent of the governed as reflected in the Constitution. The researcher concurs that it is significant that the senior managers of the North West Provincial Department of Health acknowledge the Constitution to ensure that quality health services are provided to residents of the North West as part of their constitutional rights as enshrined in section 27 of the Constitution, in doing so, could potentially improve the organisations state of readiness to implement the proposed NHI Bill [B11-2019] successfully once legislated. 112 4.4.1.3 National Health Act 61 of 2003 On the 19th of April 2005, former South African President Thabo Mbeki signed the National Health Act 61 of 2003, with most of its provisions taking effect on the 2nd of May 2005 (Hall, Ford- Ngomane & Barron, 2005:46). Van Niekerk (2017:32) explains that The National Health Act 61 of 2003 serves as a foundational piece of legislation, which means that it establishes broad legal and operational principles that must be detailed in subsequent legislation (Van Niekerk, 2017:32). The most recent National Health Act 61 of 2003 expands on constitutional rights. It establishes a framework for a structurally unified health system in South Africa, taking into account the obligations imposed on national, provincial, and local government spheres in terms of health services by the Constitution and other laws (Katuu, 2018:135; Republic of South Africa, 2020a:4). Therefore, it could be argued that this Act is significant because it recognises that everyone in South Africa should have access to high-quality health care, this includes the North West Provincial Department of Health. It is important to note that The National Health Act 61 of 2003 is divided into 12 chapters and is mostly implemented through regulations (Van Niekerk, 2017:32). For example, the Act mostly acknowledge previous disadvantages and imbalances in the health system of South Africa. As stated in section 1.6 of this study, interventions to ensure adequate health care services for all citizens are critical, and the present imbalances between the private and public health systems could be detrimental to South Africa in the long run. In addition, section 4 of the National Health Act 61 of 2003 anticipates the development of different categories of people who qualify for free health services from health organisations, while section 5 mandates that any healthcare provider, health worker, or health organisation offer immediate care to anyone who requires it. The present legislative framework for healthcare delivery, as laid forth in the National Health Act 61 of 2003, creates a three-tiered, top-down structure (Murphy & Moosa, 2021:3). In other words, the National Health Council is primarily responsible for policy development and national priorities, although the provincial government is mandated to receive the majority of funding and is responsible for providing healthcare through the district health system. The National Health Act of 2003 describes how health policy is developed in South Africa, how patients are treated, and imposes requirements on those who provide healthcare services (Kirby, 2005). Kirby (2005) explains that the National Health Act 61 of 2003 stipulates the rights and responsibilities of patients, healthcare workers, healthcare providers, and health organisations such as the North West Provincial Department of Health. For example, section 14(1) of the National Health Act 61 of 2003 stipulates that all information concerning a patient, including information relating to his or her health status, treatment, or stay in a health establishment, is 113 confidential (Opperman & Janse van Vuuren, 2018:103). Subsection (2) also states that no one may reveal any information covered by subsection (1) unless the patient consents to it in writing, or unless the revelation is compelled by a court order, or if the information's non-disclosure would pose a major public threat (Opperman & Janse van Vuuren, 2018:108). In its current form, Section 4 (3) of the National Health Act 61 of 2003 stipulates the kind of healthcare services that clinics and community health care must offer. However, it makes no reference to operating hours. As a result, the National Health Amendment Bill intends to change the National Health Act 61 of 2003 to allow public clinics to operate and provide health services 24 hours a day, seven days a week. The researcher concurs with this amendment because individuals can become unwell at any time of the day, necessitating emergency treatment (Parliament of the Republic of South Africa, 2020b). In addition, provisions 6, 7 and 8 of the National Health Act 61 of 2003 provide for consent and engagement in decision-making procedures. Section 7(1) specifies that a health service may not be provided to a user without his or her informed consent. In addition, section 8(1) states that a user has the right to participate in any decision that affects his or her own personal health and treatment (Townsend & Scott, 2019:23). Furthermore, the National Health Act 61 of 2003 establishes a framework for a structured and uniform health system, under which the various components of the South African national health system can work together to improve universal access to high quality care. As a result, this Act is important to this research because it aligns with the proposed NHI Bill's [B11-2019] goals of delivering high quality health care to citizens. The National Health Act 61 of 2003, on the other hand, stipulates that patients must comply with a variety of requirements, including following the rules of a health facility and submitting correct information about their status to a healthcare provider (Kirby, 2005). Furthermore, section 15 of the National Health Act 61 of 2003 states that a healthcare provider may disclose a patient's information to any other person, healthcare provider, or health establishment as necessary for any legitimate purpose in the ordinary course and scope of his or her duties if the disclosure is in the patient's best interest (Opperman & Janse van Vuuren, 2018: 110). According to the Republic of South Africa (2016b:8), the National Health Act 61 of 2003 provides effect to the constitutional right to obtain health care services, as well as the government's obligations in achieving this right. It establishes a unified national health system in order to deliver the greatest possible health care to the Republic's citizens within the constraints of available resources. Furthermore, it should be noted that both public and private health providers are officially covered by the National Health Act 61 of 2003. 114 This Act clearly outlines key issues into providing quality healthcare services to South Africans, including the residents of the North West Province, as seen in the discussion above. As a result, it could be argued that all provisions of this Act should be followed by the North West Provincial Department of Health, since well the key issues outlined in this Act relates to those of the proposed NHI Bill [B11-2019] as discussed in Chapter 1 and section 4.3 of this study. It is thus argued that the North West Provincial Department of Health prioritise such issues as they could enhance the department’s state of readiness to implement the proposed NHI Bill [B11-2019] successfully once legislated. 4.4.1.4 Nursing Act 33 of 2005 Nursing is an integral aspect of the South African's healthcare system, and nurses are known as the heartbeat of the health sector (Singh & Mutharey, 2018:123). Singh and Mutharey (2018:123) explain that nurses concentrate their efforts on the prevention, promotion, maintenance, and restoration of a person's health. Nurses are expected to have extensive knowledge in order to fulfil their tasks and provide comprehensive patient care in a competent, ethical, and legal manner (Singh & Mutharey, 2018:123). Schepmann (2020) states that the Nursing Act 33 of 2005 was enacted to govern the nursing profession and to address issues related to it, such as safeguarding the public from harmful practitioners. Therefore, the goal is competent, high-quality nursing care delivered by trained professionals (Schepmann, 2020). The Nursing Act 33 of 2005 allows nurses to understand the professional council's responsibilities and the pertinent sections that outline the laws or norms that guide and control the profession (Singh & Mutharey, 2018:123). The Nursing Act 33 of 2005's key features include aligning nursing education and training with the National Qualifications Framework (Risks, 2018:7). It makes no provision for nurses' scope of practice to be expanded to include clinical assessment and diagnosis outside of the supervision of a medical practitioner (Lapere, 2018:10). However, where the services of a medical practitioner or pharmacist are unavailable, section 56 (6) of the Nursing Act 33 of 2005 permits the Director-General to authorise the nurse to provide, administer, or prescribe medicine (Hornsveld, 2020:36). In addition, this Act states that as part of a four-year integrated curriculum, a nursing student must work for a minimum of 4000 hours in the clinical setting (Du Toit, 2013: 1). Furthermore, the Nursing Act 33 of 2005 established the South African Nursing Council (SANC), which is an autonomous statutory authority. Duma (2012:14) explains that it is self-sufficient because it is funded by licensing, registration, and accreditation fees paid by nurses and nursing 115 education institutions. The SANC is responsible for promoting and maintaining nursing education standards in the Republic of South Africa (Marepula, 2013:6). The Nursing Act 33 of 2005 gives the SANC the authority to regulate nursing practice in terms of ethics, law, and professionalism (Dolamo, 2018:4118). Mathibe-Neke (2020:52) states that by the foundation of SANC in 1944, South Africa became the first country in the world to attain state registration for nurses, marking a key milestone in the governance and regulation of the nursing profession. In addition, according to McIntosh and Stellenberg (2009:12), quality nursing practice is based on enough knowledge, skills, or competencies, morally and scientifically based comprehensive and holistic patient care, and timely/accurate and complete or comprehensive recordkeeping. This Act is crucial for the purposes of this study since nurses would play a significant role in the successful functioning of the proposed NHI Bill [B11-2019] once it becomes a legislation. It is also worth remembering that nursing practice is built on norms, ethical standards, and professional regulation, all of which are required for competency in making ethical clinical decisions (Mathibe- Neke, 2020:52). Therefore, Mutshatshi, Mothiba, Mamogobo and Mbombi (2018:1) believe that successful nursing practice necessitates precise record-keeping that is complete, timely, and accurate in order to provide quality care. The above section presented the statutory framework that is most relevant for this study. 4.4.2 Regulatory framework The following sub-sections presents the regulatory framework that is applicable to this dissertation. 4.4.2.1 White Paper for the transformation of the health system in South Africa The Department of Public Service and Administration produced the White Paper, which was adopted by other departments including the Department of Health (Malomane, 2020:29). The Ministry of Health released a White Paper on the transformation of the health system. The purpose of the White Paper is to offer to the people of South Africa a set of policy objectives and principles that will underpin the country's Unified National Health System (Department of Health, 1997:1). The White Paper has introduced a number of significant concepts that governed the health sector's human resource planning, production, and management (Mthembu, Mtshali & Frantz, 2014:1807). The first wave of transformational policies and laws saw the creation of an enabling policy and legal framework for a complete overhaul of the health-care system, the creation of an integrated national public health system from 14 fragmented, racially divided health departments, and the 116 removal of racial barriers to health-care access (Rispel, 2016:18). The White Paper for the Transformation of the South African health system was executed to achieve the goal of the South African Constitution. Malomane (2020:2) states that the main objective of the White Paper is to implement enhanced services. This was accomplished by reorganising and changing South Africa's whole health system, including human resources, financial and physical resources, and all communicable diseases (Malomane, 2020:2). Furthermore, the White Paper for the Transformation of South African health system lays the groundwork for achieving Universal Health Coverage in South Africa through the implementation of the National Health Insurance (NHI) and the creation of a unified health system. In response to the poor performance of South Africa's health care system, continuing inequities, and the vulnerability of subgroups, the newly released White Paper on NHI wants to expand on these reforms to increase quality, coverage, and equity (Burger & Christian, 2020:44). The White Paper on NHI, according to the Republic of South Africa (2017:1), recognises that good health is a fundamental value of human social and economic life and is an essential prerequisite for poverty reduction, sustained economic growth, and socio-economic development. Maseko and Harris (2018:22) explain that the NHI White Paper in South Africa aims to achieve more fairness between those who are served by the public and private health system (Maseko & Harris, 2018:22). It is therefore argued that the White Paper in general is important for this study, since its main focus is on establishing equality between the public and private health systems. According to the government's White Paper on the NHI, South Africa's implementation of the NHI is consistent with the constitutional commitment for the state to take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of the right to all for access to health care services, including reproductive health care (Fushein & Eyles, 2016:2). Despite the recent developments, Khoza-Shangase and Mophosho (2018:2) claim that access to health remains unequal, particularly for rural and impoverished black populations, as evidenced by press coverage and scholarly studies, resulting in the White Paper on NHI. As indicated in the central theoretical statements of this study (section 1.6) interventions to ensure quality health care services for all citizens are vital and that the current imbalances between the private and public health systems could be detrimental in the long run for South Africa. As a result of the foregoing, it is argued that the White Paper for the transformation of the South African health system is significant for the purposes of this study since it corresponds with the proposed NHI Bill's aims in providing quality and equal health services to South African citizens. It is further argued that to provide quality health services to the North West Province's citizens once the proposed NHI Bill [B11-2019] becomes legislation, the North West Provincial Department of 117 Health must acknowledge the White Paper for the transformation of the South African health system. 4.4.2.2 National Development Plan (NDP): Vision for 2030 (2011) The National Development Plan (hereafter referred to as the NDP) effectively conveys long-term national growth development aims and goals, giving national endeavours focus and direction (Diedericks, 2013:65). The NDP's principal goal is to decrease inequities like those that exist between the public and private health care systems (Republic of South Africa, 2011:14). Therefore, it is argued that the NDP is important for the purposes of this study, since its goal relates to the central argument of this study, which is to reduce the imbalances occurring between the public and private health systems. Gray and Vawda (2016:10) explain that the NDP has broad objectives, such as giving proper access to quality health care while progressing health and wellbeing, but also specific mandates, such as phasing in the National Health Insurance with a focus on upgrading public health facilities, training more health professionals, and lowering the relative cost of private health care. Therefore, it is argued that these broad objectives are important for the purposes of this study, as they focus in addressing current challenges facing the public health system, which in general assist readiness to implement the proposed NHI Bill [B11- 2019] once it becomes legislation. The NDP recognises the difficulties that the South African health system confronts, such as those that were outlined in the study's problem statement (see section 1.3). The National Health Insurance framework should be implemented in stages, according to Chapter 10 of the NDP, and should be accompanied by a decrease in the relative cost of supplemented private medical treatment, as well as improved human capacity and frameworks in the public health system. The Republic of South Africa (2011:69) explains that bringing additional capacity and expertise to strengthen the health system at the district level, implementing a national health information system to ensure that all parts of the system have the information they need to effectively fulfil their responsibilities, putting in place a human resource strategy with national norms and standards for staffing, linked to a package of care, and determining qualifications for hospital managers are all highlighted in the NDP (Republic of South Africa, 2011b:69). The researcher supports the assertion that in order for the North West Provincial Department of Health to function properly, managers within the department must have the necessary qualifications to carry out their duties. Furthermore, the NDP emphasises the importance of human capacity. This entails that managers, doctors, nurses, and community health workers should be properly trained and managed, as well as generated in sufficient quantities and deployed where they are needed most (Republic of South 118 Africa, 2011:330). Therefore, since the major purpose of this study is to ensure that health professionals are sufficiently trained to carry out their obligations, the emphasis accords with the Health Professions Act 56 of 1974 and the Nursing Act 33 of 2005 as outlined in section 4.4.1.1 and 4.4.1.4 of this study. In addition, the NDP emphasises the need for competent leaders and managers at all levels of the South African health system, from clinic to tertiary hospital (Republic of South Africa, 2011:336). Therefore, it could be argued that competent leaders and managers are significant for effective functioning of the South African health system to ensure that efficient services are provided. From the aforementioned, it is clear that the argument of this study is centred to the NDP, which is access to proper and quality health care services to everyone. Therefore, it is argued that the NDP is a significant strategic policy that needs to be prioritised by the government of South Africa, particularly the North West Provincial Department of Health to ensure that the NDP achieves its targets and goals as mentioned in the discussion above by 2030. 4.4.2.3 Medium-Term Strategic Framework 2019 - 2024 The government's strategic plan is called the Medium-Term Strategic Framework (MTSF). It reflects the governing party's election manifesto commitments, particularly the promise to implement the NDP. The MTSF lays out the steps that the government should follow and the goals that must be met (Republic of South Africa, 2014:4). The MTSF is a five-year building block for achieving the vision and goals of the country's long-term strategy, such as the NDP. Following the NDP's adoption, cabinet decided in 2013 that the 2014 - 2019 MTSF would serve as the NDP's first five-year implementation phase and directed that work on aligning national and provincial departments, municipalities, and public entities' plans with the NDP's vision and goals begin immediately (Republic of South Africa, 2014:4-5). The MTSF's goal is to achieve policy coherence, alignment, and coordination across government plans, as well as budgeting process alignment (Republic of South Africa, 2014:5). As a result, the NDP serves as the foundation for the MTSF 2019 - 2024. The MTSF 2019 - 2024 recognises that improving the health sector's management, financing, and delivery is critical for South Africans. The researcher agrees with the MTSF 2019 - 2024 in improving the health sector, since it is currently faced with significant challenges as outlined in the problem statement of this study, which delay the process of delivering quality health services. Furthermore, the MTSF emphasises that South Africa's health outcomes have improved over the last decade, notably during the MTSF's five-year period of 2014 - 2019. To be specific, key health measures, such as overall life expectancy at birth, men's and women's life expectancy, maternal mortality, and new-born and child mortality, all show this (Republic of South Africa, 2019c:103). The MTSF 2019 - 2024, on 119 the other hand, emphasises that the country's dual and unsustainable health system, which is characterised by high private-sector health-care costs, continues to be a burden (Republic of South Africa, 2019c:71). As a result, the MTSF 2014 - 2019 recommends that the South African health sector provide special attention to disadvantaged populations and individuals with specific needs. Therefore, women, youth, individuals with impairments, and the elderly are all included (Republic of South Africa, 2019c:104). According to the MTSF 2014 - 2019, the government will continue to reform the health sector and focus on strengthening specific health programs, such as the finalisation, promulgation, and implementation of the NHI Bill [B11-2019], as envisioned in the NDP 2030. All South Africans will have access to high-quality health services based on their health requirements rather than their financial ability to pay. The MTSF 2014 - 2019 also emphasises the importance of the health sector finalising and implementing the Human Resources for Health (HRH) Strategy 2030 and Human Resources Plan for 2020/21 - 2024/25 to improve existing capacity to deliver quality healthcare by ensuring adequate numbers of appropriately skilled and competent health workers with the right attitudes towards patients. Furthermore, the MTSF 2014 - 2019 contends that excellent health reflects the government's multi-sectoral commitment to address the socioeconomic determinants of health, not only an effect of providing health care. To put it in another way, the government and other stakeholders should find ways to address concerns other than health that can affect an individual's total health (Republic of South Africa, 2019c:106). From the aforementioned discussion, the MTSF acknowledges that the South African health system is still hampered by significant challenges. Therefore, it is argued that before implementing the proposed NHI Bill [B11-2019] once it becomes a legislation, the government and the North West Provincial Department of Health should address the current challenges faced within the health sector by means of being in alignment with the goals of the MTSF as outlined in the discussion above. 4.5 CHAPTER CONCLUSION As indicated in the introduction of this chapter, this chapter was three-fold. The chapter started by explaining the transformation of the South African health system and examined the current functioning of the health system. This was done to form a basis on motivations for the introduction of the National Health Insurance in South Africa. This chapter further contextualised the NHI and the proposed NHI Bill [B 11-2019] since it is the focus of this study. This chapter's goal was to examine the regulatory and statutory frameworks that control the South African health system, with a focus on the North West Provincial Department of Health. This was done to understand which regulatory and statutory frameworks influence the South African health system. This 120 chapter started by analysing the Health Profession Act 56 of 1974, since health professionals are at the centre of the health system of South Africa as outlined in the problem statement. It is therefore argued that health professionals within the North West Provincial Department of Health acknowledge this Act, to ensure that ethical standards are practiced. Furthermore, this chapter examined the Constitution of the Republic of South Africa, 1996. Emphasis was placed that everyone in South Africa should have the right to access health services. In addition, the National Health Act 61 of 2003 was explained in detail. The Nursing Act 33 of 2005 was also analysed placing emphasis that nurses need to have the necessary skills and qualifications before providing any health services to patients. In addition, different regulatory frameworks were examined in this chapter, namely: The White Paper for the transformation of the health system in South Africa, National Development Plan: Vision for 2030, Medium-Term Strategic Framework 2019-2024. All these regulatory frameworks are significant for this study since they are all emphasising and placing strategies for quality and equal health services, including the improvement of the health system of South Africa which in general has a direct relation to the goals of the National Health Insurance, which is providing quality health services to everyone. The previous chapters have presented a theoretical foundation about organisational readiness, public policy implementation including statutory and regulatory frameworks. Based on the theoretical foundation, the next chapter will present the research methodology of this study. Empirical findings within the North West Provincial Department of Health will be discussed via a thematic approach. 121 CHAPTER 5: A MODEL FOR ORGANISATIONAL READINESS AND IMPLEMENTATION OF THE PROPOSED NHI BILL WITHIN THE NORTH WEST PROVINCIAL DEPARTMENT OF HEALTH: EMPIRICAL FINDINGS 5.1 INTRODUCTION The preceding chapter was three-fold. It highlighted the transformation of the South African health system and provided a summary of the current functioning of the health system to motivate the introduction of the proposed National Health Insurance Bill [B 11-2019] in South Africa. The chapter contextualised the National Health Insurance including the proposed NHI Bill [B 11-2019] since it is the focus of this study. The main goal of chapter 4 was to present the applicable statutory and regulatory frameworks that regulate the South African health system, with particular reference made to the North West Provincial Department of Health. The importance of everyone having access to equal quality healthcare in South Africa was emphasised. This chapter presents the empirical findings of the North West Provincial Department of Health, including the research methodology employed which was discussed in detail in chapter 1 of this dissertation. The primary goal of this chapter is to gain insights from senior managers and health professionals about organisational readiness, public policy implementation, the proposed NHI Bill [B 11-2019] as well as the functioning and challenges facing the North West Provincial Department of Health. Data gathered from semi-structured interviews and the questionnaires are presented in this chapter. A thematic analysis is used to present the information gathered through these instruments of data collection. In addition, to ensure the validity of the information gathered from these data collection instruments, a document analysis is also presented. This ensured the achievement of the primary objective of this study which was to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. 5.2 RESEARCH METHODOLOGY This study is both theoretical and empirical in nature, as described in Chapter 1. This approach aimed to explain and define the various concepts and processes involved in organisational readiness and public policy implementation. Empirical research was conducted following a case study approach within the North West Provincial Department of Health that involved senior managers and health professionals. This was done to get an understanding from the respondents about organisational readiness and public policy implementation including the department’s state 122 of readiness to implement the proposed NHI Bill [B11-2019] once legislated, as well as to learn about the functioning and challenges faced within the North West Provincial Department of Health. Moreover, this study used a qualitative research approach as explained in chapter 1, section 1.8.1. A qualitative research approach was defined as the investigation of the nature of events, including their many manifestations and the context in which they occur. It was explained that qualitative research approach usually uses words rather than numbers to present information (Busetto, Wick & Gumbinger, 2020:1). Therefore, a qualitative research approach has been employed in this study because it was most suitable, flexible and focuses on human behaviour. The purpose of this research approach is that it would assist explaining data gathered from the empirical investigation in detail using words. Moreover, chapter 1, section 1.8.2 explained that the study would be descriptive as well as exploratory, with the goal of determining how and what could be done to improve the state of readiness within the North West Provincial Department of Health to successfully implement the proposed NHI Bill [B 11-2019], once legislated. Therefore, by means of being descriptive, theoretical chapters, chapters 2, 3 and 4 outlined and defined relevant approaches, concepts, and processes in relation to organisational theory and readiness, public policy implementation and statutory including the regulatory framework. Exploratory research design included semi- structured interviews and a questionnaire with senior managers and health professionals within the North West Provincial Department of Health. It was argued in chapter 1, section 1.8.4.1 that the selected respondents might provide sufficient information regarding the North West Provincial Department of Health's state of readiness to implement the proposed NHI Bill [B 11-2019], once legislated. Furthermore, non-probability expert/judgement sampling was used as explained in chapter 1, section 1.8.4.1. It was explained that expert/judgement sampling is utilised when a research study needs to get information from people that have specific expertise needed during the exploratory phase of qualitative research (Baran & Jones, 2016:120). Etikan and Bala (2017:215) contended that the motivation behind why researchers utilise expert/judgement sampling is because it has a superior method of constructing the perspectives of individuals that are specialists in a definite area and gives researchers confirmation to make theoretical, detailed, and sensible speculations from the sample that is being utilised (Baran & Jones, 2016:120). Chapter 1 explained that the rationale for this sampling method was that the identified respondents (senior managers) are experts in their fields and could provide appropriate and sufficient information in establishing the North West Provincial Department's state of readiness in terms of human resources, finances, information technology including public clinics and hospitals. 123 In addition, the inclusion of health professionals was that they are at the centre of the South African health system, including the North West Provincial Department of Health. As argued in chapter 1, section 1.8.4.2 health professionals deal with day-to-day activities within the North West Provincial Department of Health and could provide sufficient information about challenges faced in public clinics and hospitals. Chapter 1, section 1.8.4.1 explained that the respondents are divided into two divisions, namely: senior managers and health professionals. The aim was to get a sample size of 22. Below is an overview of the population and sample size applicable for this study. Table 8: Population and sampling size for questionnaire Respondents Population Sample Head of 1 1 Department Senior managers 18 9 Health 15 920 12 professionals Source adapted: Researchers own drawing In chapter 1, section 1.8.4.1 it was explained that the aim was to get a sample size of 22 for completion of the questionnaire. Sample size included 1 Head of Department and 9 senior managers including 12 health professionals. A hundred percentage response rate was achieved among the Head of Department and senior managers. However, from health professionals only 11 respondents took part in the study, due to their busy schedules within public clinics and hospitals. The overall respondent rate is still very good and indicates a 95,5% response rate from the sample. 124 Table 9: Population and sampling size for semi-structured interviews Respondents Population Sample Head of 1 1 department Senior managers 18 9 Health 15 920 12 professionals Source: Researchers own drawing From the above table, as explained also in chapter 1, section 1.8.4.1 that the aim was also to get a sample size of 22 for semi-structured interviews. This includes 1 Head of Department, 9 senior managers and 12 health professionals. A hundred percentage response rate was achieved among the Head of Department and senior managers. However, only 11 respondents took part in the study from health professionals, due to their busy schedules within public clinics and hospitals. The overall respondent rate is still very good and indicates 95,5% response rate from the sample. 5.3 EMPIRICAL FINDINGS AND DATA ANALYSIS As expounded in chapter 1 of this study, the process of analysing data in qualitative research implies immersing oneself in the data to get familiar with it and furthermore searching for patterns and topics, searching for various connections between information that help the researcher with understanding what they have done at that point then optically establishing the information and recording it (Kawulich, 2004:96). According to Bazeley (2009:6), the main method of data processing and reporting for qualitative researchers is the presentation of key themes accompanied by excerpts from participants' texts. As stated in chapter 1, section 1.8.5, this study used a thematic analysis approach to analyse the information gathered from the research population because the approach's nature is aligned with the study's qualitative research method (Sono, 2018:109). Thematic analysis is described as a process for methodically identifying, organising, and providing insight into patterns of meaning (themes) throughout data sets; by concentrating on the overall significance of a data set (Braun & Clarke, 2012: 57). The authors further explain that thematic analysis enables the researcher to recognise and understand collective or shared meanings and experiences. As a result, the information gathered through semi-structured interviews and a questionnaire within the North West Provincial Department of Health are presented in the subsequent sections. 125 The information is presented by using themes from the questions provided to the respondents. Moreover, to ensure the validity of the data presented from the semi-structured interviews and questionnaire, a document analysis is also presented. Subsequently, this would assist to address the study's primary research question, which is: How can the North West Provincial department of Health improve its state of readiness to implement the proposed NHI Bill [B 11-2019] successfully once it becomes legislation? 5.4 PRESENTING DATA FROM SENIOR MANAGERS In this section, permission was provided from the North West Department of Health and appointments with the respondents were set in advance. As a result, data acquired from the Head of Department and senior managers within the 3 districts of the North West Province, namely, Ngaka Modiri Molema, Dr Kenneth Kaunda and Dr Ruth Segomotsi Mompati within the North West Provincial Department of Health is presented. As indicated in chapter 1, section 1.8.4.1 the Head of Department was identified as the most relevant person that monitors all activities within the public institution and could provide sufficient information about the functioning and challenges faced by and within the North West Provincial Department of Health. Senior managers were selected as important respondents since they possess knowledge and expertise in relation to finances, human resources, information technologies including public clinics and hospitals within the North West Provincial Department of Health. The questions that were asked in the questionnaire with senior managers were grounded under three themes to ensure that consistency was maintained which includes: biographical information, Likert-scale questionnaire about organisational readiness and public policy implementation and expertise in terms of semi- structured interviews. 5.4.1 Biographical information of senior managers Under this theme, the aim was to discover the biographical information of respondents. The information from the biographical information required respondents to identify their gender, age, highest qualification, job position and years of experience within the North West Provincial Department of Health. 126 5.4.1.1 Gender Responses 40% Female 60% Male Pie chart 1: Gender Source: Researcher’s own drawing The results obtained from respondents indicate that the majority of respondents (60%) were males rather than females. The results indicate that more males are in higher positions than females within the North West Provincial Department of Health. Thus, it is deduced that the North West Provincial Department of Health should attend to issues of employment equity among men and women. 5.4.1.2 Age Responses 10% 0% 0% 18-25 26-38 40% 39-45 46-53 50% 54-60 60+ 127 Pie chart 2: Age Source: Researchers own drawing In terms of age variances, most respondents fell within the age group of 46-53 (50%), with a few being between the ages of 39-45 (40%) and only one respondent was between the ages of 54- 60 (10%). Thus, it is deduced that the respondents that participated in this study are old enough to make decisions including to understand the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. 5.4.1.3 Highest qualification Responses 45% 40% 35% 30% 25% 20% 40% 15% 30% 10% 20% 5% 0% 0% 10%0% 0% Graph 1: Highest qualification Source: Researcher’s own drawing All respondents indicated that they have acquired a tertiary qualification, with a majority holding a bachelor’s degree (40%), followed by master’s degree (30%), a small number holding a diploma (20%), and only one respondent fell under the “other” category of which the respondent indicated that they hold a postgraduate diploma. From the above results, it could be deduced that all the respondents have relevant qualifications to render services within the North West Provincial Department of Health and to make decisions in terms of implementing the proposed NHI Bill [B11- 2019] once it becomes legislation. 128 5.4.1.4 Job position Responses Other: 0% Health professional 0% Line manager 20% Senior manager 60% Top management 20% 0% 10% 20% 30% 40% 50% 60% 70% Graph 2: Job position Source: Researcher’s own drawing The majority of respondents (60%) in this theme have indicated that their job position falls under senior managers with a small number of line managers (20%), and two respondents have indicated that they are in the top management (20%). From the results above, it could be deduced that the respondents are knowledgeable about the North West Provincial Department of Health since they were all classified as managers. 129 5.4.1.5 Years of experience in the North West Provincial Department of Health Responses 0% 10% 0% 1-2 years 10% 30% 3-5 years 6-10 years 11-15 years 50% 16-20 years Over 20 years Pie chart 3: Years of experience within the North West Provincial Department of Health Source: Researcher’s own drawing The majority of respondents (50%) in this theme have indicated that they have 16-20 years of experience within the North West Provincial Department of Health, with a few more who have more than 20 years (30%) in the North West Provincial Department of Health and only one respondent (10%) indicated that he/she has 11-15 years of experience within the North West Provincial Department of Health. Relatively, one respondent (10%) has indicated that they have 3-5 years of experience within the North-West Provincial Department of Health. The results indicate that the respondents have been employed for a number of years within the department and could provide adequate and sufficient knowledge about the functioning of the North West Provincial Department of Health. 5.4.2 Responses from the Likert-scale questionnaire Under this theme, the aim was to discover the knowledge of respondents about organisational readiness and public policy implementation. This theme is related to the first and second research objectives of this study and the statements derived from the theoretical foundations of the mentioned objectives. The results should hopefully provide an indication on whether respondents understand the significance of organisational readiness and public policy implementation. This section used a Likert-scale questionnaire. The questionnaire comprised of 12 statements. The 130 statements comprised of 5 options that respondents could choose from. Furthermore, the respondents were requested to indicate the most relatable answer to the statements imposed to them. The following is the scale that was provided to the respondents: Table 10: Likert-scale Likert-scale Strongly Disagree Unsure/not Agree Fully agree disagree sure As explained in chapter 1, section 1.8.4.2.2 of this study, the questionnaire comprised of close- ended questions which are less cognitively demanding and require respondents to choose only one option (Connor Desai & Reimers, 2019:4126). The Likert-scale was used to provide a variety of options in terms of organisational readiness and public policy implementation that respondents could choose from. The inclusion for this was to have a broader understanding whether respondents had knowledge about organisational readiness and public policy implementation before implementing the proposed NHI Bill [B11-2019] within the North West Provincial Department of Health. The answers from respondents would potentially assist into making an informed conclusion of the state of readiness within the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019]. The results acquired from the questionnaire are presented below according to the self-administered questions that derived from the theoretical chapters of this dissertation. Statement 1: I have knowledge about organisational readiness and public policy implementation. The first statement in the Likert-scale was to identify if senior managers have an understanding about organisational readiness and public policy implementation. This was done to ensure that respondents understood that the North West Provincial Department of Health ought to be ready before implementing the proposed NHI Bill [B11-2019]. The majority of respondents (50%) indicated that they agree with the statement, with a few more (30%) who indicated that they fully agree and a small equal number of respondents (10%) of each option disagreed and were unsure/not sure if they have knowledge about organisational readiness and public policy implementation. 131 Pie chart 4: Knowledge about organisational readiness and public policy implementation Responses 0% 10% Strongly disagree 30% 10% Disagree Unsure/not sure Agree Fully agree 50% Source: Researcher’s own drawing From the findings above, it can be deduced that the majority of respondents possessed adequate knowledge about organisational readiness and public policy implementation. Furthermore, this is a positive sign as the respondents would be able to apply their knowledge for successful implementation of the proposed NHI Bill [B11-2019] once it becomes legislation within the North West Provincial Department of Health. Statement 2: Organisational readiness and public policy implementation are distinct concepts, but they are somehow interrelated for successful policy outcomes. The second statement tested whether organisational readiness and public policy implementation are indeed distinct concepts but are somehow interrelated for successful policy outcomes. The understanding of these concepts by the respondents were thus important to evaluate as they would know once the proposed NHI Bill [B11-2019] becomes legislative that organisational readiness and public policy implementation are both important for successful policy outcomes. The results indicate that the majority of respondents (60%) agree to the statement and a small number of respondents (20%) fully agree. Relatively, the same number of respondents (10%) indicated that they disagree and are unsure of the statement. 132 Pie chart 5: Interrelation of organisational readiness and public policy implementation Responses 10% 0% 20% Strongly disagree 10% Disagree Unsure/not sure Agree 60% Fully agree Source: Researcher’s own drawing From the above, the theoretical foundation about organisational readiness have argued that senior managers of every organisation, should note that organisational readiness has an impact on public policy implementation. Even though organisational readiness and policy implementation are two distinct ideas, they are linked in some way (see chapter 2, section 2.4.2). It could thus be deduced that it is a positive indication that the majority of respondents agree and fully agree with the statement because it would encourage senior managers within the North West Provincial Department of Health to consider both approaches and processes of organisational readiness and public policy implementation for successful implementation of the proposed NHI Bill [B 11- 2019] once it becomes legislation. Statement 3: It is important that organisational leaders engage in a process of establishing organisational readiness instead of overestimating the preparedness of the organisation. Chapter 1, section 1.3 has outlined that it is important that public healthcare leaders understand what organisational readiness entails, and in doing so, that it may improve their capacity to implement planned changes (Holt et al., 2010:50). Chapter 1, section 1.3 also argued that half of ineffective implementation attempts are because of public leaders overestimating their organisations level of readiness (Khan et al., 2014:2). Therefore, the statement was imposed to respondents to assess if they agree with the significance of establishing organisational readiness before implementation. The majority of respondents (70%) fully agree with the above statement, with a small number of respondents (30%) who have indicated that they agree. 133 Pie chart 6: Importance of organisational leaders in establishing organisational readiness Responses 0% 0% Strongly disagree 0% 30% Disagree Unsure/not sure Agree 70% Fully agree Source: Researcher’s own drawing From the results, it could be deduced that it is important that leaders establish organisational readiness before implementation and that leaders within the North West Provincial Department of Health should engage regularly about the department’s readiness to implement the proposed NHI Bill [B 11-2019] once legislated. Statement 4: Organisational readiness is significant because it guides the policy implementation phase. Chapter 2, section 2.3.2 explained that organisational readiness is important because it guides the implementation phase by assisting in the identification of a clearly researched problem and the proposal of an intervention to address a problem’s root cause (Capacity Building Centre for States, 2018:1). This statement was imposed to the respondents to evaluate their understanding of the above statement. The majority of respondents (50%) indicated that they fully agree with the statement with almost an equal number of respondents (40%) who indicated that they agree with the statement and only one respondent (10%) indicated that he/she is not sure about the statement. 134 Pie chart 7: Significance of organisational readiness in public policy implementation Responses 0% 0% 10% Strongly disagree Disagree 50% Unsure/not sure 40% Agree Fully agree Source: Researcher’s own drawing From the results above, it could be deduced that this is an excellent indication, because the respondents possessed adequate knowledge that organisational readiness plays a significant role for successful implementation outcomes. Moreover, having sufficient knowledge about this statement could potentially motivate respondents to assess the North West Provincial Department’s state of readiness to implement the proposed NHI Bill [B 11-2019] once legislated. Statement 5: Organisational readiness is defined as a state of preparedness that an organisation achieves prior to beginning an activity. In chapter 2, section 2.3.1, Halpern et al. (2021:3) defined organisational readiness as a state of preparedness that an organisation achieves prior to beginning an activity. Therefore, positive outcomes, such as the successful implementation of new public policies, are frequently associated with such a condition. The purpose of this statement was based upon the assumption that it is important for respondents to understand what organisational readiness entails before assessing it within an organisation such as the North West Provincial Department of Health. Therefore, the majority of respondents (60%) indicated that they agree with the definition of organisational readiness, with a small number of respondents (30%) indicating that they fully agree with the statement and only 1 respondent (10%) indicated that he/she is unsure/not sure about the definition. 135 Pie chart 8: Definition of organisational readiness Responses 0% 10% 0% Strongly disagree 30% Disagree Unsure/not sure 60% Agree Fully agree Source: Researcher’s own drawing From the above results, it could be deduced that respondents within the North West Provincial Department of Health have sufficient knowledge about the definition of organisational readiness. Therefore, it would be easier for the respondents to define the state of readiness within the North West Provincial Department of Health. Statement 6: Public policies and their implementation can aid in the improvement of public services. This statement was derived from chapter 3, section 3.2 of this dissertation. Delamaza, 2015:24 in (Tebele, 2016:2) argued that public policies and their implementation can aid in the improvement of a democracy. The purpose of this statement is based upon the belief that respondents should understand the significance that public policies have on public services. If respondents believe that public policies could assist in the improvement of public services, then a positive attitude is provided during the implementation phase. An overwhelming number of respondents (60%) fully agreed with the statement and a small number of respondents (30%) agreed with the statement, while only one respondent (10%) indicated that he/she is unsure with the statement. 136 Pie chart 9: Public policies and their implementation Responses 0% 0% Strongly disagree 0% 30% Disagree Unsure/not sure Agree 70% Fully agree Source: Researcher’s own drawing The results indicate that respondents within the North West Provincial Department of Health believe that public policies such as the proposed NHI Bill [B11-2019] once it becomes legislative could assist in the improvement of public services offered within the department. Statement 7: Capacity, readiness, the environment, resources, decision-making and communication are key elements for successful public policy implementation. The theoretical foundations of Chapters 2 and 3 of this study outlined key elements in different sections that influence successful public policy implementation. Thus, before embarking with implementing a public policy such as the proposed NHI Bill [B11-2019] once legislated, stakeholders need to assess key elements for successful implementation. An enormous number of respondents (70%) indicated that they fully agree with the statement and only a small number of respondents indicated that they agree (30%). 137 Pie chart 10: Key elements for successful public policy implementation Responses 0% 0% 30% Strongly disagree Disagree Unsure/not sure 0% Agree 70% Fully agree Source: Researcher’s own drawing From the results above, it could be deduced that the identified key elements are significant when assessing organisational readiness and could assist the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] successfully once it becomes legislation. Statement 8: Effective public policy means implementing a policy in such a way that the policy’s aims and objectives are produced, attained, or realised. In chapter 3, section 3.2.1 of this study, Ikechukwu and Chukwuemeka (2013:63) explained that effective policy implementation means implementing a policy in such a way that the policy’s aims and objectives are produced, attained, or realised. In essence, the specified and planned development goals and objectives are realised if a policy is effectively implemented. The purpose of this statement was to investigate whether the respondents understood what effective public policy implementation entails. This would ensure that the proposed NHI Bill’s [B11-2019] aims are attained once it becomes legislation. An equal number of respondents (50%) indicated that they fully agree and agreed with the statement. 138 Pie chart 11: Effective public policy Responses 0% Strongly disagree Disagree 50% 50% Unsure/not sure 0% Agree Fully agree 0% Source: Researcher’s own drawing From the above results, it is clear that respondents agreed that it is important for a public policy to attain or realize its aims and objectives. Statement 9: Public organisations should make use of both the top-down and bottom-up public policy implementation approaches as they provide useful knowledge into the policy implementation process of public policies. Chapter 3, section 3.3.1.3 of this dissertation, Cloete et al. (2018:201) explained that it is critical that policy implementers use both top-down and bottom-up approaches when implementing policies as these approaches illustrate important explanatory strengths and weaknesses. The majority of respondents (50%) indicated that they fully agree with the statement, with a relatively small number of respondents (40%) that indicated that they agree about the statement, and only one respondent (10%) indicated that he/she is not sure concerning the statement. 139 Pie chart 12: Top-down and bottom-up public policy implementation Responses 10% 0% Strongly disagree Disagree 50% Unsure/not sure 0% 40% Agree Fully agree Source: Researcher’s own drawing It could therefore be deduced that respondents possessed adequate knowledge about different methods of public policy implementation which could be helpful to decide on the most suitable form of public policy implementation method for the proposed NHI Bill [B11-2019] once it becomes legislation. Statement 10: It is critical that the North West Provincial Department of Health’s senior managers and health professional have sufficient knowledge about the department’s readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Ochrurub et al. (2012:3), alluded in chapter 2, section 2.3.2 of this dissertation that before implementing new policies, it is important that managers assess their organisations readiness for change. In addition, Lim and Antony (2016:134) argued that failing to assess organisational readiness may cause managers to spend a significant amount of time dealing with change opposition. Hence, the significance of this statement. The results indicate that the majority of respondents (70%) fully agree with the statement, with a small number of respondents (30%) that agreed to the statement. 140 Graph 3: Sufficient knowledge about organisational readiness within the department Results Fully agree 70% Agree 30% Unsure/not sure 0% Disagree 0% Strongly disagree 0% 0% 10% 20% 30% 40% 50% 60% 70% Source: Researcher’s own drawing From the results above, it could be deduced that respondents acknowledged the significance of having sufficient knowledge about the North West Provincial Department’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. It would therefore be beneficial for senior managers and health professionals to have sufficient knowledge about the department’s state of readiness to implement the proposed NHI Bill [B11-2019] once legislated to ensure successful implementation. Statement 11: It is important that the North West Provincial Department of Health develop a readiness assessment/model before implementing the proposed NHI Bill [B11-2019] once it becomes legislation. Chapter 2, section 2.3.3, indicates that organisational readiness assessments have a long history of being created as significant implementation support tools (Miake-Lye et al., 2020:12). The results indicate that an equal number of respondents (both 50%) fully agree and agreed that the North West Provincial Department of Health should develop a readiness assessment/model before implementing the proposed NHI Bill [B11-2019] once it becomes a legislation. 141 Graph 4: Readiness assessment/model Results Fully agree 50% Agree 50% Unsure/not sure 0% Disagree 0% Strongly disagree 0% 0% 10% 20% 30% 40% 50% 60% Source: Researcher’s own drawing From the results from the above, it could be deduced that before implementing the proposed NHI Bill [B11-2019], it is important that a readiness assessment/model is developed within the North West Provincial Department of Health as it could potentially assist with implementing the proposed NHI Bill [B11-2019] successfully once it becomes legislation. This deduction is in line with the ideals of this study. Statement 12: There is frequent communication about the North West Provincial Department of Health’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. The results from this statement reflected divergent views from the respondents. The majority of respondents (40%) indicated that they are unsure/not sure if there is frequent communication about the North West Provincial Department of Health’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation and a relatively small number of respondents (30%) indicated that they agree with the statement, while two respondents (20%) indicated that they disagree and one respondent (10%) indicated that he/she strongly disagree with the statement. 142 Graph 5: Frequent communication Results 45% 40% 35% 30% 25% 20% 40% 15% 30% 10% 20% 5% 10% 0% 0% Strongly Disagree Unsure/not Agree Fully agree disagree sure Source: Researcher’s own drawing Considering that there are divergent views in terms of frequent communication about the North West Provincial Department of Health’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation, it could be deduced that there is a lack of communication within the North West Provincial Department of Health since senior managers are at the top of the work hierarchy and should be well-informed if there is indeed frequent communication about the North West Provincial department of Health’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. This is quite concerning, because without frequent communication about the state of readiness to implement the proposed NHI Bill [B11- 2019] once legislative within the North West Provincial Department of Health, successful implementation cannot be guaranteed. 5.4.3 Results from semi-structured interviews Under this theme, data was acquired from three districts out of the four districts within the North West Provincial Department of Health; this includes Ngaka Modiri Molema District, Dr. Ruth Segomotsi Mompati District and Dr. Kenneth Kaunda District. As explained previously, data was acquired from senior managers in Human Resources, Financial and Information Technology departments. In addition, line managers from public hospitals and public clinics in Dr Ruth Segomotsi Mompati and Dr Kenneth Kaunda were interviewed. Sixteen open-ended questions were used which have allowed respondents to use their own words and express their opinions in relation to the functioning of the North West Provincial Department of Health, challenges faced within the public institution, their views about the proposed NHI Bill [B11-2019] and in general the 143 state of readiness of the North West Provincial Department of Health. The use of open-ended questions also allowed the respondents to provide their views on how the North West Provincial Department of Health could successfully implement the proposed NHI Bill [B 11-2019] once it becomes legislation. The results obtained from senior managers are analysed and presented below. Question 1: Views about the proposed NHI Bill [B11-2019] The question afforded the respondents the opportunity to provide their views about the proposed NHI Bill [B11-2019]. This question is important to determine the level of understanding respondents have in relation to proposed NHI Bill [B11-2019] as their understanding would assist in attaining the objectives of the proposed NHI Bill [B11-2019] once it becomes legislation. The results revealed that the respondents (100%) understood the objective of the proposed NHI Bill [B11-2019] and are quite positive with the Bill. The respondents provided very detailed responses that are worth noting. The majority of respondents (80%) believe that the proposed NHI Bill [B11- 2019] is an important legislative intervention towards implementing Universal Health Coverage and addressing the health imbalances between the public and private health systems which would ensure that health services are available to everyone without being limited to levels of income. Though there were a few respondents (20%) who raised their concerns with regards to the proposed NHI Bill [B11-2019]. Below are some interesting views and concerns provided by respondents about the proposed NHI Bill [B11-2019]: Respondent 1: “My view is that based on the socio-economic position of our people in our country, it is an approach or intervention that is necessary, in order to contribute to restoration of dignity to our people, so I think this Bill once it becomes an Act; will go a long way to contributing to better health statuses of our people”. Respondent 2: Respondent 2 provided a very detailed response with regards to the proposed NHI Bill [B 11-2019]. The respondent indicated that “there are several factors to consider in the Bill. Firstly, if the government is indeed ready to provide services that the private sector is providing, because the Bill suggests that anybody can go to any facility for acquiring health services. Secondly, the respondent further alerted that as much as the government wants to develop public health facilities at an ideal facility level, the question of capacity and budgeting rises; one can ask, “whether all of the public health facilities will be at that level when the Bill is implemented”. In addition, the respondent alluded that the Bill requires a lot of resources and making sure all medicines are available of which for the government to reach the private sector level would be a struggle”. 144 The concerns of reviewer 2 are relevant to this study and it is thus argued that to ensure the functioning of the proposed NHI Bill [B11-2019] once it becomes legislative. The government of South Africa including the North West Provincial Department of Health should ensure that sufficient budgeting\funding and proper capacity is available. Question 2: Improvement As explained by Plagerson et al. (2019:5), in chapter 4, section 4.3, the NHI intends to create a health-care financing system that pools funds to actively acquire and offer access to high quality, affordable personal healthcare for all South Africans, regardless of their socio-economic background. Therefore, this question aimed to establish the opinions of the respondents on whether the NHI would significantly improve health services in South Africa. The results indicate that all the respondents (100%) indeed believed that the NHI would significantly improve health services in South Africa. However, some of the respondents provided very detailed responses that are worth noting. The following comments were made by some of the respondents: Respondent 1: “Yes, should it be implemented health services will be improved. I think what it will do is that it would give the people of South Africa confidence that they get equal treatment across the board regardless of whether you have a medical aid or you don’t”. Respondent 2: “If implemented as proposed or suggested, yes it should. One of the things I know that the NHI is supposed to do for facilities to participate in the NHI, they need to meet certain quality standards, so it is going to push certain public facilities so that they could be able to participate in the NHI”. Respondent 3: “I think this will be dependent on key stakeholders and role players. If all the key players, role players in government, businesses and citizens play a role, I think it can go a long way in improving health services as well as health conditions of the country”. Respondent 4: “Without a doubt it will and at the same time we must consider that for the economy of the country to grow, we need people to work, if we have people who do not work, the economy will not grow. Therefore, NHI will be able to assist us to improve indeed, by ensuring that our people are healthy, and will be able to assist towards the economic growth of the country”. The responses correspond to the objectives of the NHI as outlined in chapter 4, section 4.3 of this study. Therefore, it could be deduced that if the NHI is implemented with all necessary resources it should improve the health services of South Africa and address the current imbalances occurring between the public and private sectors as outlined in chapter 1, sections 1.2 and 1.3 of this study. 145 Question 3: Role and contributions of senior managers. According to the decision-making theory discussed in chapter 2, section 2.2.3.4 of this study, the decision-making theory implies that long-term planning decisions should consider a multi-level system (Danivska & Appel-Meulenbroek, 2021:32). The purpose of this question was to understand the role of respondents within the North West Provincial Department of Health. Also, the rationale for this question was to have an idea to which extent could the respondents be involved in the decision-making processes within the department. The results revealed that each respondent holds a significant position within the North West Provincial Department of Health. Respondents confirmed that they are occupying the following positions within the health sector: Head of Department (10%); chief directors (50%) in Human Resources, Information Technology, and finance. Moreover, a few respondents indicated that they are senior managers and line managers within public clinics and public hospitals within the North West Provincial department of Health (40%). The following are responses from the respondents: Respondent 1: “My role is that of the Head of Department. In terms of the Public Finance Management Act, I am the accounting officer, thus making me accountable for the outcomes that the department is expected to achieve”. Respondent 2: “My role as a chief director of financial services is to ensure that when we do our strategic plans and annual performance plans, we also look at the estimate expense. My role is to liaise with the provincial treasury, the National Department of Health as well as the National Treasury. To ensure that the objectives, indicators, and targets as per the Annual Procurement Plan strategies are funded”. Respondent 3: “I am the chief director for IT in the department. As part of the implementation of the NHI we need Information Communication Technology (ICT) to be a foundational layer to ensure that we can achieve quality health services. One of the things that we will have to put in services in ICT is an effective patient administration and revenue management systems that will assist the department to claim from insurance and issues of electronic management records. Therefore, ICT will play a critical role in implementation of the NHI as part of providing quality health services to the recipients”. Respondent 4: “My role as a chief director of human resource includes several roles, this will include two portfolios. The first role entails human resources planning, organisation development as well as other aspects of human resources information systems. The other portfolio is on human resources management, which is about recruitment, selection, appointment of staff; basically, about filling posts within the department; this portfolio includes benefit administration known as 146 the condition of service and lastly management of performance of employees within the entire department”. Respondent 5: “Now I am managing a district. I am ensuring that there is support from the highest level to the lowest level within the district. To ensure that people can access quality services in public hospitals and clinics with the best equipment and health professionals”. Respondent 6, 7, 8 and 9: These respondents were line and senior managers within public clinics and hospitals ensuring that the community is well taken care of, and that quality services are provided within health facilities. Respondent 9 have indicated that he/she is the line manager in the North West Provincial Department of Health and responsible for managing the construction of new health facilities and upgrades. Respondent 10: “My role within the North West Department of Health is that of a finance manager. One of the responsibilities is to see that once services have been rendered; we process payments. Ensuring that payments are made in each health facility. Therefore, one of the key responsibilities is to pay service providers which ultimately improve healthy living of our people in North West”. As indicated in chapter 1, section 1.8.4.1, it was outlined that this study would make use of expert/judgement sampling. The results obtained from the respondents indeed indicate that they are experts within their field of work. The responses indicate that the respondents are skilled and valuable for purposes of this study and provided valuable information about the North West Provincial Department of Health; which could contribute in reaching adequate conclusions about the state of readiness within the North West Provincial Department of Health. Question 4: Challenges to overcome. The purpose of this question was to investigate challenges that might not have been outlined in the study. The respondents outlined critical challenges within the North West Provincial Department of Health that all arise from the issue of budgeting and finances. The issue of dilapidated infrastructure and a lack of health professionals were also identified by the majority of the respondents (40%). The following are detailed challenges and recommendations that were identified and made by the respondents: Respondent 1: “Currently, the main challenge is around funding, the budget allocation is never enough. The other thing is the misuse of the available funding. As much as we are raising the issue about limited budgeting, we still have incidents of misuse of funding especially with procurement of goods and services”. 147 Respondent 2: “One of the biggest challenges is the issue of funding. The respondent explained that ICT in government is not taken as an issue of priority. The respondent stated that: I do not think the government realise the important role ICT plays in positioning an organisation, to provide a competitive advantage because once we get into NHI, my understanding is that we’ll also be competing with private health facilities for patients. Therefore, the challenge might be funding in terms of the projects that might be proposed for supporting the NHI”. Respondent 3: “The challenge is about having or completing an ideal structure. The Department currently have an organisational structure that is approved but as a department we realised that adequate budgeting for that structure is a challenge. Another challenge is a question of whether we would have the capacity to attract and retain human resources we require. The respondent further explained that critical posts remain vacant for a long time within the department”. Respondent 4: “I hope that we will reduce a lot of red tape in the sense that we should have a more decentralised way of managing. We shouldn’t wait a long time to get things approved from the highest level to come to the lowest level. Managers in public hospitals and public clinics should have full capacity to approve”. Respondent 5: “The first challenge is to overcome the issue of dated or dilapidated infrastructure in our health facility that was built before 1994 that accommodated a smaller population. The population of today and of yesterday is not the same to accommodate everyone. The respondent further explained that the second challenge is to address a shortage of personnel within the public clinic”. Respondent 6: “Some of the challenges to overcome are firstly, resolving backlogs in infrastructure maintenance, ICT and health information related lags, inadequacy in human resources; and staff capacity including attitudes. However, the respondent noted that these challenges will not realistically be wholly resolved, they can be resolved progressively as part of implementing NHI”. The results above motivate the research problem currently under study. The majority of respondents (100%) indicated that they are faced with significant challenges within their departments. It is argued that such challenges could hamper the North West Provincial Department of Health’s readiness to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. Thus, the argument for this question is that implementation of the proposed NHI Bill [B11-2019] cannot be successful if implementation challenges are not resolved within the North West Provincial Department of Health. 148 The following is a follow-up question from the challenges mentioned. Question 5: Follow-up question. The purpose of this question was to provide respondents an opportunity to indicate whether the current challenges faced within their department could be fixed without the implementation of the proposed NHI Bill [B 11-2019]. The majority of respondents (40%) believe that the current challenges faced within their department could be fixed without implementation of the proposed NHI Bill [B11-2019] and a few respondents (20%) indicated that the challenges cannot be fixed without implementation of the proposed NHI Bill [B11-2019]. However, the respondents indicated that they could be fixed during the implementation of the proposed NHI Bill [B11-2019]. Moreover, some of the respondents (40%) argued that it is necessary to solve the current challenges for effective implementation of the proposed NHI Bill [B11-2019]. Though some respondents were a bit unsure in terms of this question and answered it vaguely. The following are some interesting responses from the respondents: Respondent 1: “Yes, to some extent some of the challenges we are facing could be dealt with during the implementation. The respondent further stated that with the implementation of the proposed NHI Bill [B 11-2019], we hope that it will come with additional funding. We are limited when it comes to medical resources and health professionals due to the availability of budgeting”. Respondent 2: The respondent provided a detailed response and explained that “they do not believe that they can be fixed, we will just be able to maintain the status core. The respondent explained that: in my experience in government specifically in the Department of Health, to assist into getting the things we couldn’t get previously, when the government identifies a new policy or programme, it comes with funding. Therefore, I believe that the proposed NHI Bill [B 11-2019] should be able to assist with the challenges we are facing within the Department” Respondent 3: The respondent also provided a very detailed response in relation to this question and explained that; “maybe there are certain challenges that will not necessarily be fixed by the proposed NHI Bill [B11-2019] but it is about the challenges we need to fix to make it easier for the proposed NHI Bill [B 11-2019] to be implemented. The respondent further stated that we can’t say that the proposed NHI Bill [B11-2019] will come with all the solutions. Some of the challenges that are there will have to be fixed in such a way that universal access becomes realizable. Therefore, it is about readiness that must be there before implementation of the proposed NHI Bill [B 11-2019]. There are certain things that can be fixed by the insurance when it is there like accessing public health facilities without having to pay the bare minimum fees and certain challenges must be fixed for preparation of the implementation of the NHI”. 149 Respondent 4: “I do not think that there is a silver bullet, NHI will not come in as a bullet that will fix everything. We need a mixture of strategies to be able to deal with the challenges that we are facing. However, if you look at the proposed NHI Bill [B 11-2019] to a greater extent, most of the challenges will be eradicated.” Respondent 5: “Yes, they can be fixed. If you know your purpose that health comes first. We don’t have to wait for changes. The respondent alluded that whether the proposed NHI Bill [B 11-2019] is going to be implemented or not, we should continue to meet the needs of our community than the rest will come”. Respondent 6: “Yes, indeed. I am of the view that these challenges can be fixed without the implementation of the proposed NHI Bill [B11-2019] and matter of fact is that even if it wasn’t because of the implementation of the proposed NHI Bill [B11-2019] we still needed to see that we fix these challenges because these challenges impede our patients to receive health services. The respondent further stated that though budgeting might be a problem, government need to categorise and prioritise facilities within a particular financial year”. Respondent 7: Currently yes, an ideal hospital realisation model can fix all the problems which could make it easier to implement the proposed NHI Bill [B 11-2019]. Respondent 8: “NHI was not intended to fix these challenges. The respondent explained that with or without implementation of NHI these challenges should be resolved. Notably, the resolution of these challenges will smoothen implementation of NHI”. From the comments above, it could be deduced that respondents do not believe that the proposed NHI Bill [B11-2019] will solve all the challenges faced within the North West Provincial Department of Health; but such challenges need to be solved to make implementation of the proposed NHI Bill [B11-2019] smoother. Thus, it is argued that the government and the North West Provincial Department of Health should come with strategies and alternatives to fix the current challenges faced within the Department to enhance readiness before proceeding to the implementation of the proposed NHI Bill [B 11-2019] once legislative. Question 6: Preparation for implementation of the proposed NHI Bill [B11-2019] once legislative. This question aimed to provide respondents an opportunity to state their views on what would be required to be fully prepared as senior managers for implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. The purpose of this question is that the researcher is of the view that it is significant that respondents provide suggestions on how readiness could be enhanced for implementation of the proposed NHI Bill [B 11-2019] within the North West 150 Provincial Department of Health since they are fully knowledgeable of the gaps within the department. Some respondents (50%) indicated that they need to be involved during the planning process and acquaint themselves with the Bill. The following are some valuable views that the respondents provided: Respondent 1: “As a senior manager, I need to ensure that a clinic in the far rural and clinic in an urban are provided the same services. The North West Provincial Department of Health need to ensure that there is the same number of personnel. The respondent further explained that all health facilities need to reach the same staffing level before implementation of the proposed NHI Bill [B11-2019]”. Respondent 2: The respondent provided a very detailed response and indicated that “one of the things I think needs to be done is the whole senior management team to understand the whole purpose of the NHI. There need to be change management initiatives by experts in the area to bring senior managers on board. Once senior managers understand the overall intention of government, then it becomes easier to get people to rally behind that policy. The respondent explained that two main things are important, which is change management and communication to ensure that we have appropriate skilled personnel”. Respondent 3: “As senior managers, information is important. We need to acquaint ourselves with the Bill and be fully cautious about the implication within our portfolio’s and contribute individually and collectively towards the department getting ready for implementation of the NHI”. Respondent 4: “The first thing that we need is a mind-shift. We need to think differently and manage our health facilities as business entities. We need to see people who are coming to our health facilities as people who are bringing in money and making sure that we remain in business. Therefore, we need sufficient budget, the respondent explained that though budgeting can never be enough we should have a budget to cover for basics. In addition, there should be room for managers at a local level to be able to make decisions to ensure flexibility”. Respondent 5: “Commitment, if each and every manager is committed and coming together; than commitment will automatically lead to teamwork and teamwork will be able to master complex situations to see that we achieve every objective in terms of the proposed NHI Bill [B11-2019]”. Respondent 6: The respondent raised a valid point that “There are national issues such as the NHI fund, national information systems, and procurement systems. At a provincial level it would mean leadership preparedness (which I believe we have) and progressively dealing with the challenges outlined in question number 4 from the above. The respondent further stated that while 151 these challenges should be resolved by the province, they would require national health and treasury support”. The above comments indicate that the respondents are fully knowledgeable on what would be required to be fully prepared as a senior manager within the North West Provincial Department of Health for implementation of the proposed NHI Bill [B11-2019]. Croese et al. (2021:1) stated in chapter 3, section 3.2 of this study that effective implementation necessitates a solid framework for multi-stakeholder participation and coordination at all spheres of governance. Therefore, it could be deduced from the results that collaboration and communication amongst respondents would go a long way in ensuring preparedness amongst senior managers. Question 7: Benefits of the proposed NHI Bill [B11-2019]. The North West Province is known to be one of the rural Provinces in South Africa. This question aimed to investigate if the proposed NHI Bill [B 11-2019] would positively benefit the North West Province and improve the health services within the province. The results indicate that all of the respondents (100%) believe that the proposed NHI Bill [B11-2019] would positively benefit the North West Province in terms of every resident receiving equal and quality health services without financial constraints. The following are some noteworthy comments made by the respondents: Respondent 1: “I think it will be a benefit firstly to the citizens in terms of universal access. All citizens will have access to quality health services. However, the respondent was of the view that the North West Provincial Department of Health first need to be ready in terms of human resources, medical equipment and infrastructure because quality health services are always comprised by the issue of funding”. Respondent 2: “The implementation of the NHI would see that we have a healthy living community in the North West. The respondent explained that if we have a healthy living community; people would be able to contribute enormously in terms of the economic growth, which automatically would assist with several issues such as unemployment”. Respondent 3: “I think the North West Province is the most rural province in the country but with the NHI we will be sure that whatever you get in the big metropolitan cities you will get in the North West”. From some of these comments, it is deduced that the proposed NHI Bill [B11-2019] is an intervention that is necessary for the North West Province and would ensure that the citizens have access to equal quality health services. 152 Question 8: Duties influencing quality of health services. The purpose of this question was to determine how the duties of respondents have an influence on quality of health services offered in the North West Provincial Department of Health since the identified respondents are experts within their fields and would contribute to the success of the implementation of the proposed NHI Bill [B 11-2019] once legislated. The results revealed that each respondent’s duties significantly and directly influence the quality of health services within the North West Provincial Department of Health. The following are some detailed responses from respondents in relation to the question asked: Respondent 1 outlined that “my duties play a very critical role on the quality of health services, depending on what we are implementing. For example, it plays a role in reducing the workload of staff, assisting to streamline certain processes and services. It also assists in issues of electronic reporting, management of queues in healthcare facilities, management of appointments and file recording”. Respondent 2 explained that “my duties as a senior manager and collectively is being responsible for developing, reviewing, monitoring, implementing a departmental strategy. In my duty, if you fail to develop organisational structure that is aligned with departmental strategy, you have already failed the department in delivering quality health services. My role is very critical to health services, I (we) need to make sure that we recruit appropriately qualified staff and make sure we fill those posts in a short time”. Respondent 3: “My duties influence the quality of health services by ensuring that service providers are paid on time, and which automatically contributes enormously to quality services”. Respondent 4: My duties influence the quality of health services by ensuring that facilities and health infrastructures are in conditions that provide best health services and that they are easily accessible by all. Respondent 5: My duties influence the quality of health services by ensuring that strategic plans are made and that the target for services fits the everyday world and incorporating operation plans into key performances. Respondent 6: As an accounting officer I am responsible for ensuring that each manager and employee performs, and that the department generally functions effectively. Therefore, to that extent my influence on quality of services is huge, or at least is expected to be huge. 153 The results from the above revealed that respondents play a significant role in the quality of health services within the North West Provincial Department of Health. Thus, it is argued that it is important that the respondents are fully prepared before implementation of the proposed NHI Bill [B 11-2019] once it becomes legislative. Question 9: Opinions for services to function effectively. The purpose of this question was to give respondents an opportunity to provide their views on what would be required to ensure that services are effectively rendered once the proposed NHI Bill [B11-2019] becomes legislative within the North West Provincial Department of Health. These views could potentially assist during the implementation of the proposed NHI Bill [B11-2019] once it becomes legislative. The respondents provided quite interesting comments in relation to this question. The following are comments and recommendations made by the respondents: Respondent 1: “I think the issue of culture, financial management, state resources management and also adequate of resources in terms of human, financial and skilled personnel would really assist”. Respondent 2 provided a detailed response and indicated that “one of the things we must strengthen in the department is governance and accountability, because governance plays a very important role in terms of decision-making and to monitoring implementation of policy pronouncements and plans. The respondent further alluded that if the North West Provincial Department of Health has strong governance processes in place than it means that everyone would be held accountable, from executive management”. Respondent 3: “My view is that as senior managers it is non-negotiable. We must function effectively with or without the NHI in the provision of services we are expected to render and improve the level of effectiveness. The respondent further explained that it would be maybe the NHI would come with additional expectations and additional requirements but the provision of services changes over time”. Respondent 4 explained that “one of the key things is decentralised form of management. We shouldn’t have prescriptions from above. I want to see clinic managers making decisions. The respondent further explained that key items that needs to be procured needs to be made available. Moreover, we should have an efficient system that ensures flexibility that would ultimately ensure that services are effectively implemented”. 154 Respondent 5: In my opinion primary care should be prioritised, because in primary care we promote health education, and we continue doing our best. Therefore, sufficient information should be provided in primary care. Respondent 6 outlined that “I am of the view that as a senior manager, consultation plays a key role because if we consult, for example the people we are earmarking to be recipients of these services, they need to know, they need to be consulted to know what we are planning. The respondent further argues that planning in silos will not lead to successful implementation. Therefore, we need to consult with key stakeholders to ensure that we do not get backlashes”. Respondent 7, 8 and 9 outlined that it would require the availability of resources in terms of funds and quality staff, workshops, and constant engagements with the community to ensure that they fully understand the Bill. Respondent 10 provided a very detailed response and indicated that “one of the ways to understand the ingredients for a health system to function effectively is to look at it from the perspective of the World Health Organisation building blocks: leadership/governance; health workforce/human resources provisioning; health information systems; health technologies and access to medicines/pharmaceuticals; financial resources; and service delivery improvement. The respondent further argued that these are what health senior managers should ensure the functionality thereof’. From the results above, it is deduced that the views of senior managers are valuable and could potentially assist the Department into effective implementation of the proposed NHI Bill [B11- 2019] once it becomes legislative. Question 10: Adequate resources The rationale for this question was to assess if the implementation of the proposed NHI Bill [B 11- 2019] would be possible within the North West Provincial Department of Health, because chapter 2, in particular section 2.3.1 including chapter 3, section 3.4.2 of this study, have indicated that human and financial resources play a significant role in organisational readiness and public policy implementation. The results from the respondents (100%) indicate that their department/section does not have adequate resources for implementation of the proposed NHI Bill [B 11-2019]. The following are some of the detailed responses from the respondents: Respondent 1: “For now, I will say no, in terms of human resources across the province. Yes, in the provincial office we have tried to fill in several positions that were vacant for a long time and 155 now we are focusing on districts and hospitals. In terms of financial management, we still have room for improvement”. Respondent 2: “No, the IT is underfunded and is under resourced. We are not at a state to say that we are capacitated enough to be able to support the NHI. There is a lot of investment that needs to be done in the IT space”. Respondent 3: “The issue of resources in this Department and generally and specifically in my portfolio is a challenge that has been there for several years”. The respondent further explained that “human resources and financial resources within their section is not necessarily adequate”. Respondent 4: “I do not think that there is anywhere in life where we have sufficient resources. Never, be it in the private sector or not. The only thing that we must do is maximise the resources that we are having. If we can just get the basics, the functioning of the NHI would not be an issue”. Respondent 5: Most health systems across the world are under serious resource constraints. Ours is not different. But the basics are in place: there are far more resource constrained settings across the world, yet they are doing their best. The same must happen with us. From the results, it could be deduced that interventions in terms of adequate human and financial resources are necessary within the North West Provincial Department of Health. The best practices of this study and lessons learned from various countries who implemented a similar policy such as the proposed NHI Bill [B11-2019] (see chapter 3, section 3.5) indicated that countries should ensure that adequate resources, both financial and human resources, are available for effective implementation of any health policy. It is thus argued that adequacy is important and maximising the resources as outlined by respondents 4 and 5 from the above would have a negative impact in the long run for successful functioning of the proposed NHI Bill [B11- 2019]. Question 11: Enough skilled personnel The purpose of this question was to investigate if the North West Provincial Department of Health has enough skilled personnel to carry out the proposed NHI Bill [B 11-2019] once legislated. The rationale for this question is that sufficient skills play a significant role during implementation. An equal number (50%) of respondents believe that there are and aren’t skilled personnel to carry out the proposed NHI Bill [B 11-2019] once it becomes legislated. However, the respondents that indicated that there’s skilled personnel raised the issue of “adequacy”. The following are some noteworthy responses from the respondents who indicated that there are enough skilled personnel to carry out the proposed NHI Bill [B11-2019] once legislated: 156 Respondent 1: “We’ve got two-legged personnel required. We’ve got the administrative personnel as well as the health professionals, so with regards to adequate skilled personnel, yes indeed we appoint skilled people especially for health programmes. The question is: are they enough”? Respondent 2: “I think we do. As a department we have sufficient skills. The only thing is to coordinate the skills and refocus our energy towards a particular direction”. Respondent 3: “My view is that we do have skilled staff now, because we are still able to provide services. However, the adequacy is a challenge which is limited by funding and the availability of those skills”. Respondent 4: “Definitely, we have enough. The only unfortunate part is that some of these skills are not available, posts are there, we have the funds for those posts but in some areas, we are unable to attract those”. Respondent 5 was of the view that the North West Provincial Department of Health do not have enough skilled personnel. The respondent stated that “we need more advanced midwifery, who are able to manage patients when there is an emergency at maternity, not because of experience but because of being both trained and experienced”. The results above are divergent. It is argued that respondents should be able to have knowledge on whether the North West Provincial Department of Health has enough skilled personnel since they hold senior positions within the department. Moreover, the results for this question contradict with Hunter (2020) as alluded on the problem statement that the North West Provincial Department of Health has not appointed anyone in senior positions in almost four years, and those who have been appointed did not have appropriate skills. In addition, as outlined in chapter 1, section 1.3, the North West Province State of Health Report (2021:11) explained that positions at the local and provincial levels are currently vacant or replaced on an interim basis which make service delivery and treatment provision activities difficult to complete, as explained by respondent 4. Therefore, chapter 3, section 3.2.1.1 outlines that policy implementers should have sufficient competencies, such as the essential skills. Chapter 3, section 3.4.1 also specifies that capacities to carry out a specific public policy are critical; in other words, adequate skills and leadership aspects are critical. From the above, respondent 5 has indicated that there are not enough skilled personnel in terms of mid midwifery. Chapter 4, section 4.4.1.4 under the Nursing Act 33 of 2005 placed an emphasis that nurses need to have the necessary skills before providing any health services to patients. Therefore, it could be argued that without sufficient skills of personnel within the North West Provincial Department of Health, successful implementation of the proposed NHI Bill [B11-2019] is not guaranteed. 157 Question 12: Proper infrastructure Chapter 1, section 1.2 outlined that the North West Provincial Department of Health has poor infrastructure (Molelekwa, 2021). This question aimed to investigate if proper infrastructure is available for implementation of the proposed NHI Bill [B11-2019] once legislated. The rationale for this question is that it is significant that proper infrastructure (in terms of medical resources and healthcare facilities) is available to ensure that services are rendered effectively. Chapter 3, section 3.5.1 outlines that building capacity is critical. Coovadia (2017:17) states that when health systems lack adequate infrastructure, no amount of insurance coverage will be able to offer effective care. The lessons learned from Thailand in Chapter 3; section 3.5.3 also indicate that long-term investment in health-care infrastructure is critical. For this question, the majority (70%) of respondents were contradicting themselves with responses in relation to this question, though some (30%) indicated that there is no proper infrastructure within the North West Provincial Department of Health. The following are some of the comments from respondents who have indicated that there is proper infrastructure in terms of healthcare facilities and medical resources: Respondent 1 stated that “it is a mix-bag. We have facilities that are very old and under resourced. We have facilities that are new because they have been built recently. However, most of our infrastructures are very old and not in the right state. If we must implement the NHI, the department will have to do a lot of investment in bringing our facilities to particular standards and overhauling our infrastructure all in all”. Respondent 2: explained that “we do have facilities, some are being built and others are being replaced because they are dilapidated and very old. The challenge comes again with the adequacy of resources in terms of maintenance budget, limitations of budget and resources. The respondent further explained that facilities are there, but they are not adequate”. Therefore, my view is that why build facilities, if we cannot maintain what we have and come up with a plan to build additional infrastructure. The respondent concluded by saying, medical resources and infrastructure is still a challenge within their department”. Respondent 3: “I will say we do; the only challenge is the maintenance of such. The respondent further explains that the Department can build a facility but unable to maintain it to ensure that it remains functioning, probably because of funding”. Respondent 4: “For now, I would say that we are 50% still in the process. Now we have the ideal hospital and clinical assessment. To ensure 100% medical resources and 100% maintenance of infrastructure”. 158 Respondent 5: The respondent has indicated that “the department do not have proper infrastructure in terms of healthcare facilities and medical resources. The respondent further explained that infrastructure is a very serious challenge in the North West Provincial Department of Health. The respondent asserts that there is still a lot to do so that once the NHI is legislated, the Department know that it is ready”. Respondent 6: “Yes, but there are still gaps. Resources shall never be 100% available. The respondent explained that more needs to be done in terms of investment in maintenance”. From the above, the comments indicate that the North West Provincial department of Health does not have proper infrastructure, if there was there wouldn’t be doubts and insecurity from the respondents. It could be argued that either there is proper infrastructure or there is not. Moreover, the issue of maintenance seems to be a challenge as outlined by respondents 2, 3 and 6. Thus, maintenance of infrastructure should be prioritised within the North West Provincial Department of Health to ensure that effective care is provided as alluded by Coovadia (2017:17) outlined from the above and in Chapter 3, section 3.5.1 of this study. Question 13: Comparison of health services in the North West Provincial Department of Health and private sector. The purpose of this question was to investigate the problem currently under study. Chapter 1, sections 1.2 and 1.3 and chapter 4, section 4.2.1 indicate that there are significant imbalances between the private and public sectors, of which approximately 84 percent rely on the overburdened and badly managed public health system and 16% rely on the private health system (Pauw, 2021:4). The majority of respondents (70%) indicated that the quality of health services offered in the North West Provincial Department of Health is not the same as those offered in the private sector because the doctor patient ratio is not the same. The following are some of the comments that the respondents made: Respondent 1: “No, the public health sector is carrying a big number of patients compared to the private sector. Doctor patient ratio is different between the two sectors and the experience of health is not the same”. Respondent 2: “I think it is about the experience of care between the public and private sector. It is about perception and the key to that is about the attitudes of health professionals in the North West Provincial Department of Health. As a department, we do provide quality services but there are challenges that needs to be addressed”. 159 Respondent 3: “The quality for now I would say no. The quality in the public sector is not the same because if it was, I wouldn’t have belonged to a medical aid. The respondent is of the view that NHI will close the gap currently faced between the private and public sector”. Respondent 4 explained that “the services offered in the North West Provincial Department of Health is not the same as the private sector. The respondent explained that the problem with the public service is the bureaucratic system currently being used. The respondent further explained that in the private sector, equipment can be bought when there is a need and within the public sector, you will need to go through all these channels which takes time. Thus, when you compare the two, the private sector will take a lead”. Respondent 5: The respondent has indicated that “the services are the same and even better. The only limitation is a shortage of staff especially specialists and resources. The respondent further explained that the doctor patient ratio is not the same”. Respondent 6: “It differs from hospital to hospital. The respondent stated that some public sector hospitals offer the best health care that can be found anywhere in the world. However, the respondent has indicated that the services offered in the public sector is not the same as those offered in the private sector because the private sector caters only 20% or less of the population. The respondents further alluded that people with medical aids go to private hospitals, and when medical aids are exhausted, they are dumped on the public sector. Therefore, the public sector is often overwhelmed”. Respondent 7: I would say no we are rendering the best as opposed to the private sector. From the above results, it could be deduced that there are significant imbalances between the public sector (North West Provincial Department of Health) and the private sector. Though, respondent 7 indicated that the North West Provincial Department of Health renders the best services. Chapter 1, sections 1.2 and 1.3, indicated that the North West Province’s public health system has been in crisis. Of particular concern is the Province’s recurrent and widespread stock- out crises, which result in patients being sent home from hospitals empty-handed or with inadequate supply of crucial medicines (Molelekwa, 2021). Thus, the question refers to the central argument of this study, as mentioned in chapter 1, section 1.6 that interventions to ensure quality health care services for all citizens are vital and the current imbalances between the private and public health systems could be detrimental in the long run for South Africa. Question 14: Engagement 160 The purpose of this question has been to investigate if respondents are actively engaged about the proposed NHI Bill [B11-2019]. The majority of respondents (90%) indicated that they have had no engagements in relation to the proposed Bill [B 11-2019]. Only two respondents (20%) indicated that they took part in an operation called Operation Phakisa, into ensuring if services are rendered at a fast pace and would lead to an ideal clinic. The respondents however, indicated that no direct engagements about the proposed NHI Bill [B 11-2019] was done. Chapter 2, section 2.4.2 explains that organisations should take note of additional factors that could influence readiness such as making sure that regular and effective communication between members that are involved in the implementation phase is established. Furthermore, chapter 3, section 3.3.1.3 outlines that both top-down and bottom-up policy analysts see effective communication as a critical component of implementation success (Orgill, 2019:3). In addition, chapter 3, section 3.4.3 explains that all stakeholders involved in the implementation process should have great communication and coordination (Tereza ,2019:094). Though the majority of respondents (60%) indicated that they have not had any engagements with regards to the proposed NHI Bill [B11- 2019]. The following are some of the comments respondents made: Respondent 1: “I don’t have any engagement for now. The last time I engaged on the NHI discussion was way back in 2012 when it started, so since then I am sure that there are big changes”. Respondent 2 provided a very detailed explanation regarding their engagement in relation to the proposed NHI Bill [B11-2019]. “I have been fortunate; I had a good relationship with the committee that started the Bill in legislature. I was involved in the public hearings that happened in 2019, we went to different communities, stakeholders, different organisations, and public meetings to explain the NHI. We also went to staff members including health professionals and we even discussed it amongst ourselves as managers. Therefore, my engagement with the Bill have been robust in the sense that us as a district have been the pilot side for the North West. The current challenge now is maintenance to engage further about the Bill”. The results revealed that there is no communication and coordination with regards to the proposed NHI Bill [B 11-2019] amongst respondents. As outlined in chapter 4 under the statutory framework, section 4.4.1.2, Diver (1982:404) explains that public managers are public workers, and their actions must be legitimated by the consent of the governed as reflected in the Constitution. Therefore, it is important that managers engage about the proposed NHI Bill [B11- 2019] to ensure that readiness is established within the department. As alluded in chapter 3, section 3.5.5, the National Health Service, is the most frequently used health system in the United Kingdom and has emphasised the importance of a strategic vision at the district level, as well as 161 the training of local health managers to strengthen their ability to enforce implementation. Thus, it is argued that respondents from the North West Provincial Department of Health engage more about the proposed NHI Bill [B11-2019] and formulate a strategic vision to establish organisational readiness before the implementation of the proposed NHI Bill [B 11-2019] once it becomes legislation. Question 15: A model for organisational readiness The purpose of this question was to investigate if a model for organisational readiness could assist the North West Provincial Department of Health to implement the proposed NHI Bill [B11- 2019] successfully once legislated. This question has reached data saturation. All of the respondents (100%) indicated that a model for organisational readiness would go a long way and would definitely assist the North West Provincial Department of Health to successfully implement the proposed NHI Bill [B11-2019] once it becomes legislation. Some interesting comments have also derived from the respondents. For example, respondent 1 indicated that it should be able to assist, models are usually generated to assist real life situations depending on how that model would have been informed, and if it is a model that is informed by real data. Respondent 2 also made some interesting comments and indicated that “a model would assist with the issue of readiness and linking it with change management. The respondent further argued that it is important that the North West Provincial Department of Health make a conscious decision that organisational readiness is important and should understand what it is and how to go about it, by linking it to change management. The respondent also added that the North West Provincial Department of Health has not been prioritising the issue of organisational readiness, the respondent further argued that with such a model, it might assist a long way into getting ready for implementation of the proposed NHI Bill [B 11-2019]”. The results from the respondents indicate the significant value of a model for organisational readiness within the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] successfully once legislated. It is therefore argued that research objective number 5 of this study is relevant which is to propose recommendations by way of a model that would enhance the organisational readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. Question 16: Additional comments about the proposed NHI Bill [B11-2019]. The purpose of this question was to give the respondents an opportunity to alert/flag anything in relation to the proposed NHI Bill [B 11-2019]. Some of respondents (40%) indicated that they 162 have nothing to alert or flag and those that had something to alert were concerned about the issue of proper budgeting and funding to finance the proposed NHI Bill [B 11-2019]. The respondents indicated that funding should always be available to keep the proposed NHI Bill [B11-2019] sustained. As outlined, in chapter 3, section 3.5.1, in terms of best practices, Kenya, Indonesia, India, and Ghana showed that a lack of funding was a major stumbling block with a similar public policy such as the proposed NHI Bill [B11-2019] (Atim et al., 2021:9). Therefore, it could be deduced that the government of South Africa should ensure that the North West Provincial Department of Health has sufficient funding to finance the proposed NHI Bill [B11-2019] to avoid stumbling blocks once the Bill is implemented. As outlined in chapter 1, section 1.8.4.1, respondents were divided into two divisions. The above section presented data from senior managers; the following section presents data from health professionals within the North West Provincial Department of Health. 5.5 PRESENTING DATA FROM HEALTH PROFESSIONALS In this section, data acquired from health professionals in three public hospitals and two public clinics from the two districts of the North West Province, namely, Dr. Kenneth Kaunda and Dr. Ruth Segomotsi Mompati is presented. Appointments with respondents were scheduled in advance. Chapter 1, section 1.3 of this dissertation indicates that health professionals are at the centre of the health system of South Africa, including the North West Provincial Department of Health. It was also outlined in chapter 1 of this dissertation that there is a shortage of health professionals within the North West Provincial Department of Health. Therefore, utilising health professionals as research respondents would provide sufficient knowledge about the state of readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] successfully after it would become legislation. The questions that were asked in the questionnaire and semi-structured interviews with health professionals were grounded under two themes: Biographical information and personal experience in terms of semi-structured interviews. 5.5.1 Biographical information of health professionals In this theme, the aim was to discover biographical information of health professionals within the North West Provincial Department of Health. The information from the biographical information required respondents to identify their gender, age, highest qualification, job position and years of experience within the North-West Provincial Department of Health. The following sections outline the biographical information of the respondents. 163 5.5.1.1 Gender Responses 45% Male 55% Female Pie chart 13: Gender Source: Researcher’s own drawing The results obtained show that the majority of respondents who took part in the study are females (55%), with only 45% of males who took part in the study. Although the majority of respondents were females, this did not have a negative impact on the results of the study. 5.5.1.2 Age Responses 0% 18-25 9% 28% 26-38 27% 39-45 46-53 9% 27% 54-60 60+ Pie chart 14: Age 164 Source: Researcher’s own drawing In terms of age variances, 28% fell under the category 26-38, an equal number (27%) of respondents fell under the category 39-45 and 54-60, only one respondent (9%) fell under the category of 46-53 and only one respondent fell under the category 60+ (9%). The results are interesting and reflect that respondents are old enough to provide blended responses in terms of the functioning of public clinics and hospitals. 5.5.1.3 Highest qualification Responses 18% High school 0% Diploma 0% 37% Bachelor’s degree 18% Honour’s degree Master’s degree 9% 18% PhD Other: Pie chart 15: Highest qualification Source: Researcher’s own drawing In relation to the highest qualifications, the majority of respondents indicated that they hold professional diploma qualification (37%), followed by an equal number of a bachelor’s degree and master’s degree (18%), only one health professional indicated that he/she has an honours degree (9%) and two health professionals indicated other (18%), but did not disclose which other qualification they have. The results indicate that the respondents are educated and trained well to perform their duties within the North West Provincial Department of Health as outlined in chapter 4, section 4.4.1.1 under the Health Profession Act 56 of 1974. 165 5.5.1.4 Job position Responses 0% 0% Top management Senior manager 0% 0% Line manager Health professional Other: 100% Pie chart 16: Job position Source: Researcher’s own drawing All of the respondents (100%) indicated that their job position is health professionals within the North West Provincial Department of Health, this comprised of registered nurses and medical doctors. Further details of their roles would be described later in this study. 5.5.1.5 Years of experience Responses 1-2 years 3-5 years Over 20 years 0% 9% 18% 6-10 years 18% 11-15 years 0% 16-20 years 55% 1-2 years 3-5 years 6-10 years 11-15 years 16-20 years Over 20 years Pie chart 17: Years of experience in the North West Provincial Department of Health 166 Source: Researcher’s own drawing The majority of respondents (55%) years of experience within the North West Provincial Department of Health fall under the category 16-20 years of experience, followed by a small number (18%) of individuals who fall under the category over 20 years and between 6-10 years, only one respondent (9%) indicated that he/she falls under the category 3-5 years. None of the respondents indicated that they fall under the category 1-2 years and 11-15 years. It could be deduced from the results that the majority of respondents have many years being employed within the North West Provincial Department of Health and could provide sufficient information about the functioning of public clinics and hospitals. 5.5.2 Results from semi-structured interviews In this theme, data acquired from health professionals is identified, organised, and presented. The main purpose of this theme is that the problem statement (see section 1.3) outlined that health professionals play a significant role in the health system of South Africa including the North West Provincial Department of Health, therefore their contribution would assist into achieving the primary objective of this study. In this theme, a questionnaire with 11 open-ended questions was used. Moreover, the use of open-ended questions would allow the respondents to use their own words and provide their views about the proposed NHI Bill [B11-2019] once it becomes legislation and how it would impact them as health professionals. The use of open-ended questions would also give health professionals an opportunity to provide their views about their daily duties within public hospitals and clinics, including the challenges that they are facing as health professionals. Some of the health professionals did not want to be recorded during the semi-structured interviews and preferred writing down their answers on a paper that was provided to them. Consequently, this theme is significant for achievement of the primary research objective which is to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation? The results obtained from health professionals are analysed and presented below: Question 1: Role and contribution of health professionals The aim of this question was to determine the role of each health professional that took part in the data collection part of the study. From the results, the role of health professionals that took part in this study are professional nurses, assistant nurses, medical officers, medical practitioners 167 and one sub-district family physician. Professional and assistant nurses (64%) indicated that their duty is to provide health care at a primary and secondary health care setting, to assist patients with health-related issues, to render quality health care to patients due to their expectations and provide optimal care to patients. Medical officers and medical practitioners (36%) that took part in the study indicated that their primary role within the North West Provincial Department of Health is to carry out consultations with patients by compiling a detailed medical history of the patient, examine Pulmonary thromboendarterectomy and to administer medical treatment. However, one of the respondents provided a very detailed noteworthy response to this question. The respondent indicated that he/she “is a sub-district family physician, that is responsible for consultative health services and provides advise in clinical cases. The respondent further indicated that they are also responsible for providing one clinical session per week and works with interns to assess if they comply with the Health Professions Council of South Africa (HPCSA) standards. Moreover, the respondent has indicated that they provide overtime in the emergency department within some public hospitals in the North West Provincial Department of Health. The respondent continued by saying they do train for in-service training to assist babies into breathing which is an emergency course for physicians and nursing staff that is part of the whole North West Province training skills. Finally, the respondent indicated that they are the coordinator of the postgraduate programme of the department of family medicine and primary care including emergency medicines”. The results indicate that the respondents play a significant role in the North West Provincial Department of Health to ensure that citizens receives health services. It could thus be deduced that the identified respondents will play a significant role during the functioning of the proposed NHI Bill [B11-2019] within the North West Provincial Department of Health. Question 2: Impact of the proposed NHI Bill [B11-2019] In chapter 1, section 1.2, Head (2019) stated that if the government of South Africa pursue to execute the proposed NHI Bill [B 11-2019], it would prompt health professionals to leave the country. The purpose of the second open-ended question was to investigate if this is indeed the case and to determine if the proposed NHI Bill [B11-2019] would positively or negatively impact the job(s) of health professionals within the North West Provincial Department of Health. Fifty percent of the respondents indicated that the proposed NHI Bill [B11-2019] would not have an impact on their job. This is a positive response from the respondents because if there are negative impacts that health professionals think that the proposed NHI Bill [B11-2019] would bring than some might consider relocating to other countries. The following are some of the comments made by the respondents: 168 Yes, the proposed NHI Bill [B11-2019] will ease the burden of overflowing influx number of patients in respect to our health facility setting. Yes, the proposed NHI Bill [B11-2019] will have a positive impact on my job if we are really equipped. One respondent raised a concern that yes, “the proposed NHI Bill [B11-2019] would have an impact on my job because health professionals within the North West Provincial Department of Health are expecting that the number of patients they consult, or patients that need referrals to tertiary hospital will increase drastically”. Furthermore, another respondent indicated that: Yes, I think that the proposed NHI Bill [B11-2019] would have an impact on my job, in such a way that health services would be improved and make it easier for everyone to have access to well improved structures and facilities; including the availability of resources. Interestingly, one respondent indicated that “I do not know how the proposed NHI Bill [B11-2019] will have an impact on my job”. The respondent further outlined that “to me, it is still patients and all about patients; it would still be my job to provide health services”. This shows a positive attitude from the respondent in terms of providing health services to the patients, regardless of the situation. From the aforementioned and making sense of the results, the responses are quite positive about the proposed NHI Bill [B11-2019] and health professionals do not believe that the Bill would negatively impact their job. The emphasis to the respondents is that the impact it would bring within their job is equal health services amongst citizens. Question 3: Challenges faced by health professionals The problem statement Chapter 1, section 1.3 of this study indicated that the North West Provincial Department of Health is hampered by significant challenges, such as a shortage of health professionals. The purpose of this question was to investigate if this is the case and to have knowledge of challenges that might not have been addressed previously in this study. The majority of respondents (90%) indicated that the main challenge is a shortage of health professionals, shortage of medical equipment and a lack of proper infrastructure. However, one respondent provided an interesting comment to this question. The respondent commented that “I would like to think that our biggest challenge is the dyssynergy between clinical governance and organisational governance, in the sense that organisational governance is not always aware of 169 what we need as clinical governance. The respondent further explained that “I always do not understand the policies within the HR systems, I don’t have much training in that”. The comment made by the respondent is a critical challenge because for a health professional to provide their services effectively within a department or organisation, they need to understand policies of that organisation. Moreover, another respondent has indicated that “the current challenge faced as a health professional in the North West Provincial Department of Health is that the North West do not have a fully fleshed tertiary hospital; whereby all specialists are available and where patients could be referred to. The respondent further explained that as health professionals they still need to see patients in junior hospitals and transfer them to the next level which is the secondary hospital and thereafter a patient would need to be transferred to another province or tertiary advice”. From the above results, it is evident that most of the challenges identified by health professionals are applicable to the problem statement of this study. It is important that the North West Provincial Department of Health addresses these challenges, because without adequate health professionals, sufficient medical equipment and proper infrastructure, quality health care is compromised and leads to demotivated health professionals within the public institution. The theoretical foundations of this study (chapters 2 and 3) also emphasised that adequate resources play a significant role in organisational readiness and successful public policy implementation. As alluded, within the problem statement (see chapter 1, section 1.3), good governance was also identified as a challenge within the North West Provincial Department of Health. It was confirmed by one of the respondents from the aforementioned sentence that clinical and organisational governance is a challenge within the Province. Thus, it is argued that the North West Provincial Department of Health needs to ensure that coordination between clinical and organisational governance is established within the Province. The following question is a follow-up from the above identified challenges. Question 4: Solutions This question provided elucidation/a follow-up to the previous response received above. The respondents were provided an opportunity to outline how they would overcome daily challenges in line with their duties. The respondents came up with several solutions to overcome daily challenges in line with their duties of which could also assist with the implementation of the proposed NHI Bill [B 11-2019]. There was one common comment that the respondents provided which was that having adequate health professionals would assist in overcoming daily challenges in line with their duties. The following are some of the comments made by the respondents: 170 Respondent 1: “I would ensure that renovation for infrastructure is there, purchase new equipment and draft a recruitment plan of scarce skilled health professionals”. Respondent 2: “I would ensure that proper communication is established, be patient in difficult and challenging situations, proper planning and the ability to stay calm under pressure”. Respondent 3: “I would ensure that scarce skills are provided in rural areas”. Furthermore, two respondents (respondent 4 and 5) provided very detailed comments that “the only way is to follow straight policies and procedures that are in place and are being implemented in terms of transferring patients and referring patients out. The respondent further outlined that they would ensure that each section within the public hospital have relevant machines without having to borrow from another section. Respondent 5 outlined that “they would ensure that the available posts are filled in and stick to the plans made into filling in the posts. The respondent further stated that, I would make sure that the Essential Drugs List is followed and that there is no drug shortage; we just need to make sure that the policy that is being set out there is followed, as simple as that. The respondent further stated that the ordering from the provincial level needs to be downgraded. It needs to be down referred to different health facilities so that each department can manage for themselves. The respondent concluded by saying, I would give clinical governance over to clinicians and give organisational governance over to the management”. From the above comments, it could be deduced that the solutions proposed by respondents could assist in the improvement of health services provided within the North West Provincial Department of Health. For example, as indicated by respondent 2, if proper communication is established amongst a health professional and a patient than it ensures the patient into receiving health services efficiently. In addition, from respondent 4’s comment, it is argued that policies are there for a reason, which is to be followed. If they are sufficiently followed and monitored within public hospitals and clinics of the North West Provincial Department of Health than referrals and transferring of patients should not be as difficult as outlined by respondent 4. Question 5: Fears as a health professional The purpose of this question was to investigate if respondents have fears as health professionals with regards to the implementation of the proposed NHI Bill [B11-2019] once legislated and if yes, they should outline their fears. This was done to have an understanding on whether the implementation of the proposed NHI Bill [B11-2019] would instill some fear on them considering the current challenges that they are facing as outlined above (see question 3). The majority of respondents (64%) indicated that they do not have fears with regards to the implementation of 171 the proposed NHI Bill [B11-2019]. The following are direct quotations of respondents who have indicated that they have fears regarding the proposed NHI Bill [B11-2019]: Respondent 1: “Yes, I do have fears because we are currently faced with a severe shortage of health professionals in public institutions, including a shortage of skilled managers for the running of hospitals and subdistrict offices”. Respondent 2: “Yes, I do have fears with regards to the implementation of the proposed NHI Bill [B11-2019] as a health professional, which are fraud and unregistered organisations that will emerge”. Respondent 3: “Yes, budgeting is one of the fears; who is going to pay for the proposed NHI Bill [B 11-2019]”? Respondent 4: “Yes, I do have fears. If the Bill is not unfolded correctly, it might be good on paper but the implementation of it might have a burden on the health system. Therefore, there should be a model that tests the Bill if it would work”. Besides the fears of other respondents, an interesting comment was made by one respondent who indicated that they do not have fears and argued that “obviously if the government says that they are going to implement the proposed NHI Bill [B11-2019], they will implement it with necessary resources”. Though the results revealed that the majority of respondents do not have fears for implementation of the proposed NHI Bill [B11-2019] the few concerns and fears that the respondents outlined are important to note and relevant to this study. As outlined in the problem statement (see section 1.3) and by respondent 2, if the Bill is not correctly implemented, corruption and fraud could play a significant role. The fear respondent 1 outlined about a shortage of health professionals is also relevant because the Bill would not function effectively without adequate health professionals. As alluded in chapter 3, section 3.5.1, one of the many factors that contributed to the success of Thailand’s Universal Health Coverage is motivated and available health professionals (Thaiprayoon & Wibulpolprasert, 2017:10-11). It is therefore argued that the current shortage of health professionals would be detrimental for implementation of the proposed NHI Bill [B11-2019] once legislated; the current health professionals would be overworked/overburdened to provide services efficiently. It was also argued in Chapter 3, section 3.5.2, that the South African government should learn from the Ghana experience and ensure that appropriate health professionals are trained/employed for the proposed NHI Bill [B11-2019] to function effectively once implemented. 172 Moreover, it is important that the government clearly outlines how funding of the proposed NHI Bill [B11-2019] would be acquired as alerted by respondent 3. Lastly, respondent 4’s fears are relevant to the study and the North West Provincial Department of Health should ensure that organisational readiness is prioritised and public policy implementation processes are followed as outlined in the theoretical chapters of this study (see chapters 2 and 3). Question 6: Benefits of the proposed NHI Bill [B11-2019] The purpose of this question was to establish the views of the respondents on how the proposed NHI Bill [B11-2019] would benefit the health sector of South Africa. This was included to assess if health professionals concur with senior managers that the proposed NHI Bill [B11-2019] is a good intervention to solve current imbalances faced within the health sector. From the results, indeed, most of the respondents (100%) indicated that the proposed NHI Bill [B11-2019] would positively benefit the health sector. The respondents indicated that the proposed NHI Bill [B11- 2019] would benefit the health sector by ensuring that all patients access equal quality health services irrespective of their socio-economic status. The following are some of the noteworthy benefits that respondents outlined: Respondent 1: “Health professionals within their department hopes that the services offered within the private sector would be offered within the public sector. The respondent further explained that is how they think it would benefit the health sector by bringing quality health services in the public sector”. Respondent 2: “The proposed NHI Bill [B11-2019] would benefit the health sector in such a way that there would be a fair distribution of health services. The respondent further explained that if there is a fair distribution of equipment, all townships won’t spend a lot of money outside their province for referrals of patients to other provinces”. Respondent 3: “The proposed NHI Bill [B11-2019] would benefit the health sector by making it possible for communities to access health facilities and making it possible to be referred to regional and tertiary institutions in a much better and simpler way”. The results from the above are applicable to the central theoretical statement of this study see chapter 1, section 1.6, which are interventions with which to ensure quality health care services for all citizens is vital and that the current imbalances between the private and public health systems could be detrimental in the long run for South Africa. Thus, it can be argued from the results above that the proposed NHI Bill [B11-2019] is a significant intervention within the health sector of South Africa and would have a positive impact in the health sector, which is ensuring 173 that everyone have access to equal and quality health services as alluded in chapter 4, section 4.3. Question 7: Adequate health professionals. Several arguments have been made in this study that there is a shortage of health professionals within the health system of South Africa as well as in the North West Provincial Department of Health. The purpose of this question was to investigate if there are adequate health professionals within the North West Provincial Department of Health. The majority of respondents (90%) indicated that there is a severe shortage of health professionals within the North West Provincial Department of Health. The respondents outlined that the patient to staff ratio is not correlating and that there is an extreme difference. However, one respondent has provided a detailed comment and indicated that “at the moment, we have enough health professionals because we have intern doctors, we also have community service doctors who are allocated for the year within our sub-district. The respondent further explained that they do have enough doctors on the ground roots level, the problem comes with the system that needs family physicians and stronger middle management. The respondent further stated that they are currently losing registrars, who are strong candidates because there are no posts”. Furthermore, another respondent explained that there are no adequate health professionals for the large number of patients within the North West Provincial Department of Health. The respondent stated that “patients consult with different problems and the structure of health facilities have no health professionals to assist with those problems”. The respondent further argued that this leads to patients spending a long time queuing up, waiting to be assisted. The respondent pointed out that if they had sufficient health professionals, patients wouldn’t be spending hours or the whole day to get assistance. The respondent alluded that it is not because health professionals are pulling their legs, but it is because of the unfavourable ratio of health professionals versus patients. From the results from the above, it could be deduced that the North West Provincial Department of Health is severely challenged with a shortage of health professionals. Though one of the respondents explained that there are intern doctors currently, it is argued that the North West Provincial Department of Health should ensure that it hires these interns on a permanent basis once the intern’s contract ends. This is to ensure that a shortage of health professionals within the province doesn’t worsen. In addition, it is important that the North West Provincial Department of Health make posts available for health professionals within the province, because one respondent asserted that the North West Provincial Department of Health is losing registrars because there are no posts. 174 Question 8: Causes of long waiting times and backlogs Chapter 1, section 1.3 has outlined that the North West Provincial Department of Health is hampered by long waiting times and backlogs of patients. The purpose of this question was to investigate the causes of waiting times and backlogs of patients within the public department. In this question, the researcher got different views from the respondents. The majority of respondents (90%) explained that long waiting times and backlogs are caused by shortage of health professionals that leads to an influx of patients being seen by one health professional and poor filing including a lack of equipment and resources. The following is a very detailed comment provided by one respondent: Respondent 1: “The causes of long waiting times and backlogs is two-fold. According to the ideal clinic system, there is an appointment system, our patients do not always come the day that they are supposed to come, for various reasons such as accessibility and no funds to come to the hospital, sassa payments, which leads to patients not being able to come to health facilities. Therefore, the respondent explained that from the patient’s side is that patients do not honour the appointments made to them and often come late than the time provided to them. The respondent also believes that the long waiting times and backlogs are because posts are not filled in terms of health professionals”. From the results above, the issue of a shortage of health professionals is recurring since the majority of respondents have indicated that backlogs and long waiting times are caused by a shortage of health professionals. This shows that workforce capacity in the form of health professionals is the main challenge compromising quality health services within the North West Provincial Department of Health. Thus, it is argued again that without sufficient health professionals, the implementation and functioning of the proposed NHI Bill [B 11-2019] would not be successful. Question 9: Concerns The purpose of this question was to determine the concerns respondents have in relation to an increased number of patients who would make use of public NHI facilities. The majority of respondents were concerned about the ratio of people that would make use of public health services will not equate to the ratio of health professionals. However, one respondent has explained that they do not have concerns because those people who will be using public NHI facilities will be accessing quality services with appropriate equipment. The following are some of the concerns raised by the respondents: 175 Respondent 1: “there will be long waiting times, patients might be frustrated because of long waiting times and difficulty to obtain appointments for further medical interventions at the regional and tertiary institutions”. Respondent 2: “the concern would be the cross-border consultations. Moreover, the respondent made an example that the North West Province is supposed to provide health services for the people of the North West only. The concern was that: we are going to find people in other provinces making use of North West health facilities. “So, my concern is, would our town/district provide health services to its people”? A direct comment from respondent 3 was that “I do not think that it is a lot of people, because currently 85% is using the public health system and the 15% from the private health system won’t be that much. I think we are sorted; we just need the staff that is planned. However, we can provide the services, the only problems would occur is in the hospitals”. From the results, the concerns that the majority of respondents have in terms of the ratio of people that would make use of public health services, would not equate to the ratio of health professionals is critical; considering the fact that the North West Provincial Department of Health is challenged with a shortage of health professionals. Though respondent 3 has indicated that 15% from the private sector won’t be much, it is argued that the 15% would add more constraints to health professionals. Hence it is important that the government and the North West Provincial Department of Health ensure that more individuals are recruited and trained to become health professionals. Question 10: Quality of health services The purpose of this question was to establish if respondents are satisfied with the current quality of health services offered within the North West Provincial Department of Health or would the implementation of the proposed NHI Bill [B11-2019] substantially improve the current quality of health services offered within the public institution. The majority of the respondents (90%) have indicated that yes, the current quality of health services offered within the North West Provincial Department of Health would substantially be improved by implementation of the proposed NHI Bill [B11-2019]. The following are some of the interesting comments and recommendations made by the respondents: Respondent 1: “Yes, the improvement of filing system and renovation of infrastructure will improve. However, the staff shortage will remain. The respondent recommended that the correct appointment of hospital managers and sub-district managers needs to be improved”. 176 Respondent 2: “Yes, there will be substantial improvements because we will see services, equipment and machines being brought into the North West Province and there won’t be a difference amongst provinces, each province would be provided with fair distribution of services without looking at finances and standards. The respondent further added that the way the government is proposing the Bill, indicates that there won’t be any difference between the public and private sector”. Respondent 3: “yes health services would significantly be improved because the current service that the public sector is providing is substandard, but once NHI is here it would improve”. Respondent 4: “I think so, if once again health professionals are allocated. I believe that currently health professionals are providing quality health care, but the challenge is the shortage of staff that poses pressure on the stuff”. Though the results are positive from the respondents, one respondent argued that at the moment, no, because the current services need to be improved and fixed before implementing the Bill. The researcher concurs with the respondent that the current challenges faced in the North West Provincial Department of Health need to be addressed to avoid creating more challenges when the proposed NHI Bill [B11-2019] becomes legislative and would be implemented. 177 Question 11: Views This question provided respondents an opportunity to outline their views on how the North West Provincial Department of Health could operate more effective and efficiently. The motivation for this question is that health professionals are knowledgeable because they directly deal with day- to-day challenges within public hospitals and public clinics of the North West Provincial Department of Health. The researcher was of the assumption that their views could assist to achieve research objective number 5, namely, propose recommendations by way of a model that would enhance the organisational readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. From the results, the majority of respondents (60%) provided similar views that in order for the North West Provincial Department of Health to function effectively and efficiently the department should train more health professionals, build and improve health facilities and increase medical resources. These are critical views from the respondents as they contribute to citizens receiving quality health services. The following are very noteworthy views provided by respondents that could assist the North West Provincial Department of Health to operate more effective and efficiently: Respondent 1: “The North West Provincial Department of Health should appoint skilled managers, who have background in the medical field and finances, renovate clinics, buy necessary equipment and have a maintenance plan, improve filing methods and assist in continuous trainings”. Respondent 2: “A system like the Donald Gordon would really work. We need to take hands with the private sector, and we need to treat people like Ubuntu. There should be respect from both sides which is the clinical governance and organisational governance”. Respondent 3: The respondent has indicated that “consistent communication is critical”. The respondent argued that the department should involve clinicians in decision-making so that they can know what is happening on the ground. Respondent 4: The respondent has indicated that a fair allocation of ambulances for different health issues will ensure that people would get help fast. The results from the above are quite noteworthy and could potentially provide insights on how the North West Provincial Department of Health could operate efficiently and effectively. It is therefore argued that the different views from respondents could ultimately assist the North West Provincial Department of Health into implementing the proposed NHI Bill [B11-2019] successfully once it becomes legislation. 178 The following section presents a document analysis to increase the validity of semi-structured interviews and a questionnaire and to make a general informed analysis regarding the research problem. 5.6 DOCUMENT ANALYSIS OF THE NORTH WEST PROVINCIAL DEPARTMENT OF HEALTH As explained in chapter 1, qualitative document analysis is a research technique for thoroughly and consistently interpreting the contents of written documents (Wach, 2013:1). Bowen (2009:27- 28) explains that like any other analytical methods in qualitative research, document analysis necessitates that information be analysed and explained to extract meaning, acquire understanding, and create empirical knowledge. Three documents were collected from the North West Department of Health’s website to assist into achieving the primary objective of the study. The next section presents an analysis of these documents namely: The Annual Report 2019/20, The Annual Report 2020/2021, and The Annual Performance Plan 2020/2021. 5.6.1 A brief discussion of the reviewed documents The discussion of the reviewed documents are presented under two themes, namely challenges and progress towards the National Health Insurance within the North West Provincial Department of Health. 5.6.1.1 Challenges The North West Department of Health Annual Report 2019/20 validates the data gathered through semi-structured interviews that was conducted with senior managers and health professionals within the North West Provincial Department of Health and outlines that the department has encountered a number of challenges which included a shortage of medicines and associated supplies, deficiencies in management of health facilities and poor infrastructure (Republic of South Africa, 2019d:13). The Annual Report 2020/21 also states that infrastructure of healthcare facilities is worse than previously thought (Republic of South Africa, 2020d:19). However, to eradicate the outlined challenges, the Department has started with implementation of several measures to mitigate against a shortage of medication. It is argued that even though the Annual Report 2019/20 outlined that the Department has started with implementation of several measures to mitigate against a shortage of medication. The researcher is of the view that the department should clearly state what those measures are; in doing so also contributes into making an informed assessment of the department’s readiness to implement the proposed NHI Bill [B 11- 2019] once it becomes legislation. Moreover, the 2019/20 Annual Report states that the North 179 West Department of Health was placed under administration since 2018, in this regard one of the challenges was governance and consequence management. Thus, in relation to this challenge, it could be highlighted that good governance plays a significant role as outlined by respondent 2, in chapter 5, section 5.4.3, question 9 into enhancing readiness to implement the proposed NHI Bill [B11-2019] (Republic of South Africa, 2019d:12-14). The Annual Report for 2019/20 and Annual Report 2020/21 outline that there are ongoing issues with unequal distribution of healthcare facilities and human capital resources, with a skewed distribution of medical officers, registered nurses, and allied health professionals among health districts (Republic of South Africa, 2019d:52; Republic of South Africa, 2020d:67). This is concerning, because chapter 4, section 4.4.1.1 outlines that health professionals including nurses should be registered with the Health Professions Council of South Africa (HPCSA) to provide services. In addition, from the aforementioned, the researcher argues that readiness to implement the proposed NHI Bill [B11-2019] within the North West Provincial Department of Health cannot be realised without an equitable distribution of health facilities and human capital resource. In this instance, strategic budgeting is important to ensure that equal health facilities are established across the districts of the Province. The Annual Report for 2019/20 outlines that there is still an uneven distribution of health professionals among districts and as outlined by senior and health professionals from semi-structured interviews, this challenge could have a significant impact on the institution’s readiness to implement the proposed NHI Bill [B11-2019] successfully (Republic of South Africa, 2019d:13-52). Moreover, The Annual Performance Plan 2020/21 outlines that there are many obstacles that must be addressed before the ideal condition of healthcare can be achieved. These obstacles include an ever-rising disease load, especially non-communicable diseases, which causes medical facilities to become overcrowded, expensive medical supplies and equipment, and a lack of health professionals (Republic of South Africa, 2020e:42). These obstacles also have a significant contribution to the Department’s readiness to implement the proposed NHI Bill [B11- 2019] successfully. A financial shortage within the North West Provincial Department of Health is also mentioned in the Annual Performance Plan 2020/21, which translates to a situation where the supply of resources cannot keep up with the demand for health services. This challenge was also outlined by senior managers and health professionals during semi-structured interviews as outlined in chapter 5, sections 5.4.3 and 5.5.2 (Republic of South Africa, 2020e:43). The Annual Report 2020/21 states that insufficient capital makes it difficult for the Department to carry out its mandate. This prevents into having a sufficient post structure and hinders its ability to respond as needed in providing quality health care services (Republic of South Africa, 2020d:18). A major stumbling block for readiness to implement the proposed NHI Bill [B 11-2019] 180 would be corruption. It was discovered from the Annual Report 2020/2021 that corruption permeates the Department at all levels, not just the high level (Republic of South Africa, 2020d:18). Thus, it is recommended that the National Government intervene, and strategic systems should be placed to track corruption at all levels within the North West Provincial Department of Health before implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. 5.6.1.2 Progress towards the National Health Insurance Though the three documents have outlined significant challenges facing the department, the Annual Report 2020/21 states that despite the challenges that the Department is currently facing, it has made commendable progress. To further explain, the Annual Report 2020/21 notes that oral collaboration and stakeholder involvement are strongly intertwined. This progress is also contributing to the organisations readiness to implement the proposed NHI Bill [B11–2019] once it becomes legislation. Additionally, the Annual Report 2020/21 states that the department has plans to upgrade its systems once the National Health Insurance (NHI) becomes a reality. However, the researcher believes that the Department should outline these intentions to ensure that all people receive equitable services and the plans to strengthen its systems should involve strong collaboration and alignment between the four districts within the North West Province. Moreover, the Annual Performance Plan 2020/21 outlines that the department is concentrating on enhancing the quality of health services by giving priority to important health services unique to district services within the Province. This demonstrates the importance of promoting universal health throughout the province of which one is of the objectives of the proposed NHI as outlined in chapter 4, section 4.3. Therefore, the Annual Report 2020/21 states that to be able to implement the National Health Insurance, the department aims to gradually increase service access and quality (Republic of South Africa, 2020e:240). In relation to organisational readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation, the Performance Plan 2020/21 states that the Department of Health, under the direction of the political head, conducted community engagements in the four districts of the North West Province in November 2019 to introduce NHI in advance of parliamentary hearings. The Performance Plan 2020/21 further explains that the NHI Summit was held internally in December 2019 to propose the NHI Bill [B 11-2019] and solicit opinion from all types of health professionals (Republic of South Africa, 2020e:42). Additionally, the Department is currently starting the process of setting up a Contracting Unit for Primary Healthcare, which will be preceded by the creation of a geospatial distribution of all healthcare facilities in the North West Province. In the future, patients will be able to use this to locate the health facilities closest to them. Lastly, the Annual Performance Plan 2020/21 explains that this will create a new referral 181 pathway by grouping healthcare facilities within a geographic area, including clinics, CHCs, district hospitals, and private hospitals referring to regional and tertiary hospitals within a specific geographical area (Republic of South Africa, 2020e:42). The document analysis confirmed that the North West Provincial Department of Health is faced with significant challenges. These challenges might prevent the department from implementing the proposed NHI Bill [B11-2019] successfully. The three documents under analysis exclusively describe community involvement and make no mention of senior management’s engagements. The majority of respondents (90%) in section 5.4.3, question 14 during semi-structured interviews, stated that there aren't any engagements presently related to the proposed NHI Bill [B11-2019]. Therefore, it is argued that ongoing engagements of the department’s readiness to put the proposed NHI Bill [B11-2019] into effect are necessary. To conclude, the primary objective of this study was to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. Based on the results obtained through a questionnaire, semi-structured interviews and document analysis, the North West Provincial Department of Health is not yet ready to implement the proposed NHI Bill [B11-2019]. Due to the fact that the department needs to establish organisational readiness by means of effective communication amongst senior managers and health professionals with regards to the proposed NHI Bill [B11-2019] and address significant challenges mentioned by the respondents including a document analysis before implementation of the proposed NHI Bill [B11-2019] once it becomes legislative. 5.7 CHAPTER CONCLUSION This chapter provided an overview of the research methodology discussed in chapter 1. The chapter presented the empirical findings and data analysis. Firstly, the chapter presented data from 10 senior managers which included the biographical information of senior managers, Likert- scale about organisational readiness and public policy implementation including semi-structured interviews. The results from senior managers were organised, presented, and interpreted thoroughly. The findings from semi-structured interviews indicate that senior managers and the North West Provincial Department of Health is facing significant challenges. Hence, organisational readiness needs to be established prior implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. Secondly, the chapter presented empirical findings and data analysis from 11 health professionals, which included the biographical information of them by means of semi-structured 182 interviews. The findings from the semi-structured interviews with the health professionals within public clinics and hospitals revealed that they are hampered by significant challenges such as a shortage of health professionals and medical equipment. These challenges could potentially have an impact to implement the proposed NHI Bill [B11-2019] successfully once it becomes legislation. Thirdly, this chapter presented a document analysis to validate data acquired from semi- structured interviews. Shortage of health professionals, medical equipment, budgeting, skilled personnel and poor infrastructure were critical aspects identified by means of semi-structured interviews and document analysis within the North West Provincial Department of Health. Thus, it is argued that these challenges need to be addressed first before implementation of the proposed NHI Bill [B11-2019]. The previous chapters have presented a theoretical foundation about organisational readiness, public policy implementation, statutory and regulatory frameworks including the empirical findings from the North West Provincial Department of Health. The following chapter provides a summary of the chapters of the study. The chapters make an analysis based on the theoretical foundations including empirical findings and provide recommendations by way of a model for organisational readiness and implementation of the proposed NHI Bill [B11-2019]. 183 CHAPTER 6: FINDINGS, CONCLUSIONS AND RECOMMENDATIONS 6.1 INTRODUCTION This study's main objective was to determine if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B11-2019] after it would be gazetted and becomes legislation. As a result, a theoretical basis about organisational readiness and public policy implementation, as well as an empirical investigation, were carried out to achieve this objective. It was crucial to present the literature review regarding organisational readiness and public policy implementation to gain a better understanding of what these ideas involve and how they relate to one another. The statutory and legislative framework governing the South African health system was also presented in this study, with the emphasis on everyone's right to obtain quality healthcare services. Moreover, an empirical investigation was presented in chapter 5, of which the purpose was to establish the understanding of respondents about organisational readiness and public policy implementation (as discussed in chapters 2 and 3), about the proposed NHI Bill [B11-2019], and the functioning of the North West Provincial Department of Health in general. The findings in chapter 5 revealed that the North West Provincial Department of Health is facing significant challenges and is not ready yet to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Based on this background, the final chapter provides a summary of the chapters and proposes recommendations by way of a model that would enhance the organisational readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11-2019] once it becomes legislation. The findings and recommendations regarding the way forward are also presented. 6.2 SUMMARY AND PRIMARY FINDINGS OF THE STUDY Chapter one provided a detailed orientation and background of the study. The orientation and background focused on organisational readiness and public policy implementation. It argued that organisational readiness prompts successful implementation. The chapter also provided a detailed background of the South African health system. Several challenges hampering the health system of South Africa including in the North West Provincial Department of Health were briefly outlined. The challenges include imbalances between the private and public health systems, a shortage of health professionals, prolonged waiting times, poor hygiene and infection, adverse events, shortage of resources, poor record keeping and inadequate leadership and governance. It was argued that such challenges have led the government of South Africa to consider different 184 options such as introducing radical health care changes in the form of the National Health Insurance. Therefore, the National Health Insurance including its current phase was briefly explained in this chapter. The chapter also argued that it is evident that the health system of South Africa including the North West Provincial Department of Health poses significant challenges. Due to the negative connotations that the proposed NHI Bill [B11-2019] already carries, its implementation would be more difficult. The chapter, however, made the argument that the Bill aims to create a unified healthcare system by increasing the affordability and accessibility of health services for the South African population (Michel, Tediosi, Egger, Barnighausen, McIntyre, Tanner & Evans, 2020:4). The problem statement, goals, and objectives were provided to justify the research topic in light of the aforementioned background. The research methodology used to support the problem statement was also described in the chapter. The study used a case study research design and a qualitative research methodology. The North West Provincial Department of Health's senior managers and health professionals completed a self-administered questionnaire as part of the empirical investigation, which also included semi-structured interviews and document analysis. An expert sampling, often referred to as a judgmental sampling, was used from these data instruments. The chapter also analysed the significance of the study which provided further motivation for the research topic. Chapter two presented a literature review about organisational theory and organisational readiness. The chapter contextualised organisational theory and provided the objectives of the phenomena. It was argued that it is significant that managers within public institutions need to have knowledge about the objectives of organisational theory. This would assist in identifying unforeseen gaps within the public institution. This would include, having knowledge about what is happening within an organisation, identifying potential barriers and assist managers into managing the organisation in general, since public institutions are complex and consistently change. The literature review investigated approaches of organisational theory, which included: the classical theory, neo-classical theory, contingency theory, decision-making theory, and the systems theory. It was argued that organisational approaches are applied to understand the internal process of public organisations and to establish the foundation for efficiency so that public organisations can reach its goals (Khorommbi, 2019:42). The chapter further provided a theoretical foundation about organisational readiness. The importance of organisational readiness, approaches and possible assessment tools were provided. It was argued that organisational readiness is important because elements such as organisational environment and resources, commitment, and self-efficacy to execute the change 185 influence organisational readiness for implementation. As a result, if such aspects are assessed in a timely manner, an organisation's level of readiness could be improved (Vax et al., 2021:2). Moreover, it was argued that before beginning the real implementation, organisational readiness should be examined by means of structural and psychological perspectives. A readiness assessment tool was provided. It was asserted that by conducting a readiness assessment, organisations could identify the determinants (obstacles and enablers) that could be used to prioritise implementation locations, direct the choice of implementation strategies to increase the likelihood of successful implementation, and/or be measured over time to assess the effectiveness of implementation strategies (Kononowech et al., 2021:3). A model that could be utilised to assess factors influencing organisational readiness within the North West Provincial Department of Health by Aziz and Yusof (2018:201) was also presented. The central argument of this chapter was that senior managers of every organisation, with special attention paid to the North West Provincial Department of Health, should note that organisational readiness has an impact on public policy implementation. Despite being two separate concepts, organisational readiness and policy implementation are somehow related. On the other hand, managers tend to disregard it. Chapter three was aimed at accomplishing research objective number 2. A literature review about public policy implementation, best practices and principles was presented. In this chapter, the defining concepts of public policy and public policy implementation were discussed in length. The literature review presented the process of public policy implementation and public policy implementation approaches which included: top-down implementation, bottom-up implementation, and hybrid implementation approach. It was argued that the hybrid approach combines the shortcomings and strengths of both the bottom-up and top-down approaches; to enable effective multi-level implementation and monitoring of policies, and that both top-down and bottom-up implementation approaches must be enhanced with institutional, technical, and financial capabilities (Croese et al., 2021:9). Furthermore, a conceptual framework of public policy implementation was presented and included principles, tasks, features, and central questions associated with the implementation of a given public policy. It was argued that successful implementation is not guaranteed without adequate resources, good communication and coordination. As part of the theoretical foundation of public policy implementation, best practices learned from other countries such as Ghana, Turkey, Thailand, China, India, Republic of Chile and United 186 Kingdom that have implemented public policies leading to Universal Health Coverage (UHC) were discussed in detail. It was argued that while each country has its own set of resources and constraints and will need to move to UHC on its own timeline, it is possible to compile a list of lessons learned from recent experiences that could help improve the chances of a successful, decisive, and consensual implementation (Coovadia, 2017:15). Moreover, in this chapter, the theory of social justice was identified as the leading theory that informed the study. Chapter four outlined the statutory and regulatory framework governing the health sector of South Africa. To achieve research objective number 3, an analysis of the statutory and regulatory framework was presented. The purpose of this chapter was to identify the statutory and regulatory framework governing health in South Africa, including the North West Provincial Department of Health. In addition, the chapter presented the transformation of the South African health system, the National Health Insurance and the proposed NHI Bill [B11-2019] was also thoroughly explained in this chapter. Chapter five presented the empirical findings from senior managers and health professionals. The findings from the document analysis, self-administered questionnaire, and semi-structured interviews were analysed and presented using thematic analysis. This chapter's goal was to gather information about the respondents' understanding in relation to organisational readiness, public policy implementation, the proposed NHI Bill [B11-2019], challenges facing the North West Provincial Department of Health, as well as opinions on how the department operates. The main findings from the data collection methods indicated the following: • The overall results about organisational readiness and public policy implementation from the questionnaire revealed that the respondents possessed sufficient knowledge about organisational readiness and public policy implementation and deemed organisational readiness significant for successful public policy implementation. • The results revealed that the respondents understand the objective of the proposed NHI Bill [B11-2019] and believe that the proposed NHI Bill [B11-2019] is an important legislative intervention towards implementing Universal Health Coverage and addressing the health imbalances between the public and private health systems which would ensure that health services are available to everyone without being limited to levels of income. • The results from the questionnaire and semi-structured interviews revealed divergent views about the North West Provincial Department of Health’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation; it was therefore deduced that no sufficient communication is made often enough concerning the Bill. 187 • The overall results about engagement with regards to the proposed NHI Bill [B11-2019], revealed that there is no engagement about it amongst senior managers. • The results from semi-structured interviews, including a document analysis, revealed that the North West Provincial Department of Health is hampered with significant challenges such as a shortage of health professionals, deficiencies in management of health facilities and poor infrastructure, inadequate funding, ever-rising disease overload and a shortage of medical equipment. The conclusion made in this chapter was that the North West Provincial Department of Health is not yet ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Chapter 6 is the final chapter of the study. This chapter summarises all the chapters of the study. The aim of this chapter is to achieve research objective number 5 which is to propose recommendations by way of a model that would enhance the organisational readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Therefore, this chapter presents and explain a model for organisational readiness and implementation of the proposed NHI Bill [B 11-2019] within the North West Provincial Department of Health. Lastly, the chapter provides recommendations regarding the way forward on how the North West Provincial Department of Health could successfully implement the proposed NHI Bill [B11-2019] once it becomes legislation. 6.3 RECOMMENDATIONS BY WAY OF A MODEL TO ENHANCE ORGANISATIONAL READINESS The goal of this section is to offer recommendations by way of a model presented below in figure 6 that would improve the North West Provincial Department of Health's organisational readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. The literature review of this study (chapters 2 and 3), including the empirical findings in chapter 5, led to the discovery of the information provided regarding the model. To elaborate, chapters 2 and 3 of this dissertation, presented literature regarding organisational readiness and public policy implementation. Chapter 5 presents data from senior managers and health professionals and significant challenges were identified that need to be addressed to establish organisational readiness within the North West Provincial Department of Health. Therefore, utilising existing knowledge gathered from these chapters and data from empirical investigation assisted with the development of the model. The model presented below explains where organisational readiness begins, and highlights key elements, components, and key determinants of organisational readiness that should be prioritised by the North West Provincial Department of Health to 188 establish organisational readiness for successful implementation of the proposed NHI Bill [B11- 2019]. Figure 6: A model for organisational readiness and implementation of the proposed NHI Bill [B11-2019]. Source: Researcher’s own drawing. 189 6.3.1 Discussion of a model for organisational readiness The model details that the first step to obtain organisational readiness is to guide the implementation phase, meaning that the North West Provincial Department of Health needs to thoroughly assess its state of readiness. In this instance, the Department could start assessing its state of readiness by assessing the individual employees, groups, units, and organisational levels as outlined by (Weiner, 2009:2). To further elaborate, the North West Provincial Department of Health could do this by assessing the structural and psychological perspectives as outlined by Shahrasbi and Pare (2014:1). This involves that in terms of the structural perspective for organisational readiness, the North West Provincial Department of Health should have sufficient institutional and financial resources, sufficient technological resources, capabilities, including adequate knowledge and skills for such assessment purposes. Furthermore, as contended by Lalic and Marjavonic (2011:111), the North West Provincial Department of Health could create and revise a readiness plan on a quarterly basis to ensure that the structural perspective is achieved at an identified specified timeline. In terms of the psychological perspective, it is advised that the North West Provincial Department of Health should ensure that it has sufficient knowledge about the beliefs, intentions and attitudes of the members with regard to achieving their state of readiness vital for effective and efficient public policy implementation. This could be achieved by developing and disseminating a survey amongst Departmental members to gather sufficient information on whether employees are positive or negative towards the change that would be occurring if and when the proposed NHI Bill [B11-2019] would be gazetted to become legislation. To ensure that organisational readiness is achieved within the North West Provincial Department of Health, challenges that were identified by senior managers and health professionals during the empirical investigation need to be addressed as a matter of urgency. If left unattended, these challenges could compromise the quality of public health services already perceived not to be very effective and efficient. Therefore, the model suggests a strategic onslaught in how the challenges should be addressed. This would entail ensuring that sufficient institutional resources, such as human and financial resources, are available for the different policy implementation stages. A proper budget as well as budget implementation plan is needed for successful implementation of government polices as would be the case also for the proposed NHI Bill [B11- 2019] once legislated. Appropriate funding should be acquired from the Provincial Government and National Treasury for the purpose of implementing the proposed policy in the National Department of Health once it becomes legislation. Moreover, the North West Provincial Department of Health would need to create a strategic recruitment plan specifying the requisite skills required for implementation of the proposed NHI Bill [B11-2019]. The workforce to assist with implementation of the proposed NHI once legislated should be qualified, competent, 190 knowledgeable, and dedicated personnel. To entice such applicants, recruitment packages should be lucrative and market-related with a focus on employee well-being. A next aspect of the model is the focus on the “Implementer’s capability” as outlined in Table 6 (p.74) of the dissertation. This inter alia involves that senior managers should familiarise themselves with the ideals and objectives of the proposed NHI Bill [B11-2019]; do adequate planning that would include holding frequent meetings to ensure that various viewpoints and ideas about possible ways to implement the proposed NHI Bill [B11-2019] be exchanged. This would be helpful that gaps may be identified, and potential solutions could be investigated. In addition, the role of Information Technology (IT) during the implementation process would include electronic reporting, managing queues in healthcare institutions and managing appointments with patients. Thus, IT should be mobilised and prioritised to play a significant role in the establishment of organisational readiness. Thus, sufficient funds for IT should be readily available to ensure organisational readiness for implementation of this important government policy. Establishing competent leadership is another important aspect. In this case, the model recommends that servant leadership should be practiced in overseeing implementation of the proposed NHI Bill [B 11-2019] once legislated. Lalic and Marjavonic (2011:112) motivate that strong leadership, good governance, and a creative approach to the adoption of new public policies are typical characteristics of a public sector institution with strong organisational readiness. A readiness scorecard is vital for implementing policy as outlined in chapter 2, section 2.3.3.1.4 of this study. The readiness scorecard assesses organisational readiness and contains domains such as low, medium, and high as ratings. In addition, it also makes use of a 5-point Likert rating scale. Interpretation of the rating means that five (5) in a particular recommendation such as adequate institutional resources would indicate that the readiness level of the institution is high, while three (3) would indicate that the readiness level of the institution is medium; one (1) would indicate that the readiness level of a particular recommendation is low. Lastly, two (2) and four (4) could be considered as midpoints, in other words the readiness level of that particular recommendation is average or in-between. Therefore, while assessing the recommendations, the North West Provincial Department of Health should ensure that each recommendation scores a 5. This would indicate that the Department is ready to fully implement the proposed NHI Bill [B11- 2019] once it becomes legislation. Organisational readiness is a multi-level construct as argued by Weiner (2009:2), meaning that it involves different components that need to be monitored regularly. Therefore, the model recommends that the North West Provincial Department of Health monitors the key determinants (resource availability, task demands and situational factors), essential elements (management, 191 processes, technology and commitment) and components (clarity, collaboration, capabilities and culture) of organisational readiness as it would determine if the public institution is fully ready to implement the proposed NHI Bill [B11-2019] successfully once it becomes legislation (Sharma, Upadhyaya, Schober & Byrd-Williams, 2014:1; Hanafi, Sing, Abdullah & Ismail, 2016:123; Halpern, Mweiumo, Suau-Sanchez, Budd & Brathen, 2021:3). Successful implementation of the model is also dependent on role-players involved. Therefore, the model recommends that the North West Provincial Department of Health should ensure that the goals and objectives of the proposed NHI Bill [B11-2019] are clearly understood by its role players and all relevant stakeholders. In this case, it is important to fully comprehend each goal/objective of the proposed NHI Bill [B11-2019]. This means that to guarantee there is a shared understanding of the goals of the proposed NHI Bill [B11-2019], stakeholders and role players should interact often. For strategic implementation, the model recommends that a substantial collaborative effort would be required. To put it in another way, all role players and interested parties should have a similar goal, inspire, and support creative thinking, and set clear expectations for implementation of the proposed NHI Bill [B11-2019] once legislated. To support this, role players and stakeholders should be held accountable if they fail to carry out their responsibilities or participate in the decision-making processes. Therefore, to ensure that everyone who is directly involved and should even participate prior to the implementation, consequence management should be implemented. In this regard, consequence management would imply that the North West Department of Health officials take reasonable steps to effectively, efficiently, economically and sustainably implement the proposed NHI Bill [B11-2019] as legislative measure once it becomes legislation and would be gazetted by the President of the Republic. Strong governance would also be required as part of the strategic implementation of the proposed NHI Bill [B11-2019]. In this case, the North West Provincial Department of Health would need to implement strong accountability and transparency measures. As alluded by Feshein, Marroch and Gray (2017:278) as quoted in chapter 3 of this study, that structures and institutions for accountability and openness should be established during the first implementation stage of a policy such as the proposed NHI Bill [B11-2019]. To elaborate, it is important to communicate fully and promptly about failures, progress, institutional resources, and risks. Additionally, rather than only being preached, policies pertaining to the proposed NHI Bill [B 11-2019] should be put into effect while it is being implemented. Thus, it is stated, successful implementation is ensured by establishing strong governance. Moreover, the literature review (as presented in chapter 3 of this study) suggests that the North West Provincial Department of Health could employ the hybrid 192 approach when implementing the proposed NHI Bill [B 11-2019]. This requires utilising both the top-down and bottom-up implementation approaches. Both weaknesses, strengths and bridging any gaps between the two approaches should be sought to successfully implement the proposed NHI Bill [B 11-2019] once it becomes legislation. The review aspect of the model implies that (as argued in chapters 2 and 3 also), organisational readiness and policy implementation are two distinct ideas, although they are linked in some way. Thus, it is argued that both organisational readiness and policy implementation be prioritised by the North West Provincial Department of Health to ensure the end goal of achieving both organisational readiness and successful implementation of the proposed NHI Bill [B11-2019] once legislated. In conclusion, the proposed model is exclusively for organisational readiness and implementation of the proposed NHI Bill [B 11-2019] based on the literature review and challenges identified during empirical investigation with senior managers and health professionals within the North West Provincial Department of Health. The findings can therefore not be generalised for similar government departments. 6.4 RECOMMENDATIONS From the literature review and different views from respondents during the empirical investigation the following important recommendations could be considered for effective and efficient functioning of health services, including successful implementation of the proposed NHI Bill [B 11-2019] once legislated: • This study recommends that the government of South Africa, including the North West Provincial Department of Health, prioritise IT services for the effective and efficient operation of health services within the said department. The department should introduce an improved system that is interconnected within the four districts of the North West Province to reduce lengthy waiting times of patients. This would be accomplished by making patient information easily accessible online. Although a significantly improved system would be implemented, a recruitment strategy would also be required to guarantee that health professionals with in- demand skills are specifically lured to the rural areas of the Province. Therefore, qualified, competent health professionals would be key in implementing the proposed NHI Bill [B11- 2019] once it becomes legislation. • It has been stated that corruption has considerably contributed to the failure of public policy implementation, as financial resources are diverted to other uses (Rahmat, 2015:310). Corruption might possibly also have an impact on how the proposed NHI Bill [B11-2019] 193 would be implemented after it becomes legislative. A robust strategy for allocating resources fairly amongst the four provincial districts should be developed. Therefore, auditing should be done often. It is also suggested that managers within the four districts should give transparency a high priority. In this instance, strong accountability standards should be implemented. In other words, if there is sufficient evidence to show financial abuse and irregular transactions, transgressors should be held accountable. • The infrastructure of the North West Provincial Department of Health is outdated, as in most government departments. Unfortunately, implementation of the proposed NHI Bill [B11-2019] once legislated would require a well-maintained infrastructure. To address the issue of outdated and dilapidated facilities, the North West Provincial Department of Health should establish procedures for conducting assessments every two months within each district's healthcare facilities. In this sense, district managers ought to be assigned this duty, and the provincial government ought to follow up to assess that it is carried out through monitoring and assessment. In this regard, severe accountability procedures should also be implemented whenever district managers show signs of incompetence. • The North West Provincial Department of Health is challenged and faced with a shortage of medical equipment. The study recommends that public clinics and hospitals, especially from rural areas with a large number of patients, be prioritised with sufficient medical equipment. This entails that medical equipment provided to these rural areas should meet the demands of the population. The study also recommends that senior- including line managers of public clinics and hospitals need to be given the authority to make and take part in public decision making regarding a shortage of medical equipment together with the provincial department, since they are directly involved with public clinics and hospitals and have sufficient knowledge of necessary and high in demand medical equipment. • This study recommends that the North West Provincial Department of Health, should ensure that the ratio of patients that would be using public NHI health facilities corresponds with the number of health professionals to prevent long waiting times and the spread of diseases. This is to ensure that the proposed NHI Bill [B 11-2019] once legislated operates effectively after its gazetting and implementation. This again means that funding and sufficient training is required from the national government of South Africa. The proposed NHI Bill [B 11-2019] needs as many health professionals as possible to function effectively; otherwise, health professionals would relocate, and health circumstances would worsen. In addition, health professionals should also be paid liveable and market related salaries. 194 6.5 RECOMMENDATIONS FOR FUTURE RESEARCH Based on the literature review and empirical investigations of this study, the following are recommended for future research: • Due to the limited scope of a Master’s dissertation, this study did not include all four North West Province districts of the Department of Health, but only three. For future research, the study recommends that all four districts be included and that all relevant health professionals such as physical and occupational therapists and radiologists be included to explore if different challenges would be identified by these respondents. • Organisational theory and organisational readiness were the only aspects covered in chapter 2 of this study. Even though there was enough data, the study recommends that organisational profiling be included in future research to better understand the internal and external factors that influence the operating environment of public sector institutions. • It was discovered that the North West Provincial Department of Health is not yet ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation. In chapter 1, sections 1.2 and 1.3 it was also pointed out that the South African health system faces significant challenges. Future studies should therefore consider investigating government’s organisational readiness to implement the proposed NHI Bill [B11-2019] on a much broader scale. This would assist in ensuring that Universal Health Coverage is achieved by 2030. 6.6 CHAPTER CONCLUSION The chapter aimed to present recommendations by way of a model for organisational readiness and implementation of the proposed NHI Bill [B11-2019] once it becomes legislation. This aim was achieved through a combination of undertaking a literature review as well as an empirical investigation. The model aimed to provide guidance for organisational readiness within the North West Provincial Department of Health by addressing current challenges and outlining key components, elements and determinants of organisational readiness to ensure successful implementation of the proposed NHI Bill [B 11-2019] once it becomes legislation. It is believed that the recommendations outlined to address challenges faced within the North West Provincial Department of Health including elements, components and determinants are core factors that would establish organisational readiness for implementation of the proposed NHI Bill [B11-2019]. The key findings for each chapter were also summarised in this chapter, along with all the chapters that were presented in this dissertation. The overall purpose of this chapter was to provide a demonstration of achievement of the research objectives of this study. The study's 195 general conclusion is that cooperation between the national, provincial, and local spheres of government is necessary for the proposed NHI Bill [B11-2019] to be implemented successfully once it is gazetted and becomes legislation. 196 REFERENCE LIST Adebayo, O.R. 2019. Evaluate the influence of classical and human relations approach in management today. Business and Lifestyle (no volume number): 1-15. 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Private vs public healthcare in South Africa. Michigan: Western Michigan University. (Honours Theses). 228 Zamisa, M.G. 2019. An inquiry into the relationship between diversity management practices and organisational practices in the Department of Military Veterans: A case study. Potchefstroom: North-West University. (Dissertation-Masters). 229 ANNEXURE A: INTERVIEW AND QUESTIONNAIRE SCHEDULE WITH SENIOR MANAGERS North West Department of Health Head of Department, senior managers, and line managers Section A: Consent form to participate in the study The purpose of this study is to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Please take note of the following: • Anonymity of participatory results and confidentiality are guaranteed. • The information provided will be used for research purposes only. • Your participation in this study is voluntary and you have the right to withdraw at any given time. • The interviews will not take more than 35 minutes of your time. I (name and surname) agree to take part in a research study entitled: A model for organisational readiness and implementation of the proposed National Health Insurance: The case of the North West Provincial Department of Health. Participant’s signature Date Researcher’s signature Date Section B: Biographical information for interview schedule and questionnaire Please complete the following information: Please mark with an x 230 1. Gender Male Female 2. Age 18-25 26-38 39-45 46-53 54-60 60+ 3. Highest qualification High school Diploma Bachelor’s degree Honour’s degree Master’s degree PhD Other: Specify other: 231 4. Job position Top management Senior manager Line manager Health professional Other: Specify other: 5. Years of experience in the North West Provincial Department of Health (Please mark with an x) 1-2 years 3-5 years 6-10 11-15 16-20 Over 20 years years years years Section C: Likert-scale Questionnaire. This section focuses on organisational readiness and public policy implementation. Please indicate to what extent you agree with the following statements by marking the appropriate box with an ‘x’ (cross). Statements Likert-Scale 1 2 3 4 5 Strongly Disagree Unsure/ Agree Fully disagree Not agree sure I have knowledge about organisational readiness and public policy implementation. 232 Organisational readiness and public policy implementation are distinct concepts, but they are somehow interrelated for successful policy outcomes. It is important that organisational leaders engage in a process of establishing organisational readiness instead of overestimating the preparedness of the organisation. Organisational readiness is significant because it guides the policy implementation phase. Organisational readiness is defined as a state of preparedness that an organisation achieves prior to beginning an activity. Public policies and their implementation can aid in the improvement of public services. Capacity, readiness, the environment, resources, decision-making and communication are key elements for successful public policy implementation Effective public policy means implementing a policy in such a way that the policy’s aims and objectives are produced, attained, or realised. Public organisations should make use of both the top-down and bottom-up public policy implementation approaches as they provide useful knowledge into the policy implementation process of public policies. It is critical that the North West Provincial Department of Health’s senior managers and health professionals have sufficient knowledge about the department's 233 readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. It is important that the North West Provincial Department of Health develop a readiness assessment/model before implementing the proposed NHI Bill [B11-2019] once it becomes legislation. There is frequent communication about the North West Provincial Department of Health’s state of readiness to implement the proposed NHI Bill [B11-2019] once it becomes legislation. SECTION D: EXPERTISE Semi-structured interview questions for senior managers. 1. What are your views about the proposed NHI Bill [B11-2019]? 2. Would the NHI significantly improve health services in South Africa? 3. Please describe in detail your role within the North West Provincial Department of Health? 234 4. As a senior manager, what are some of the challenges you hope to overcome before the implementation of the proposed NHI Bill [B11-2019] once legislated? 5. Do you think that the current challenges faced within your department can be fixed without the implementation of the proposed NHI Bill [B11-2019], if yes, please indicate how? 6. What do you think it would take as a senior manager to be fully prepared for implementation of the proposed NHI Bill [B11-2019] once legislated? 235 7. How would implementing the proposed NHI Bill [B11-2019] benefit the North West Province? 8. How do your duties as a senior manager within the North West Provincial Department of Health have an influence on the quality of health services? 9. In your opinion, what would be required as a senior manager for the health services to function effectively once the proposed NHI Bill [B11-2019] becomes legislative within the North West Provincial Department of Health? 10. As per your role, does your section/department have adequate resources (both human and financial) for implementation of the proposed NHI Bill [B11-2019] to function effectively once it becomes legislation? 236 11. In your opinion, does the North West Provincial Department of Health have enough skilled personnel to carry out the proposed NHI Bill once legislated? 12. Does the North West Provincial Department of Health have proper infrastructure (healthcare facilities, medical resources etc) for the implementation of the proposed NHI Bill [B11-2019] once legislated? 13. Is the quality of health service offered within the North West Provincial Department of Health similar to that offered in the private sector? If no, please explain. 14. Can you please tell me about your engagement in relation to the proposed NHI Bill [B11- 2019]? 237 15. Could a model for organisational readiness assist the North West Provincial Department of Health to successfully implement the proposed NHI, once it becomes legislated? 16. Anything else about the proposed NHI Bill [B11-2019] that you would like to alert/flag? 238 ANNEXURE B: INTERVIEW AND QUESTIONNAIRE SCHEDULE WITH HEALTH PROFESSIONALS North West Department of Health Health professionals Section A: Consent form to participate in the study The purpose of this study is to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B11-2019] once it becomes legislation. Please take note of the following: • Anonymity of participatory results and confidentiality are guaranteed. • The information provided will be used for research purposes only. • Your participation in this study is voluntary and you have the right to withdraw at any given time. • The interviews will not take more than 35 minutes of your time. I (name and surname) agree to take part in a research study entitled: A model for organisational readiness and implementation of the proposed National Health Insurance: The case of the North West Provincial Department of Health. Participant’s signature Date Researcher’s signature Date 239 Section B: Biographical information for interview schedule and questionnaire Please complete the following information: Please mark with an x 6. Gender Male Female 7. Age 18-25 26-38 39-45 46-53 54-60 60+ 8. Highest qualification High school Diploma Bachelor’s degree Honour’s degree Master’s degree PhD 240 Other: Specify other: 9. Job position Top management Senior manager Line manager Health professional Other: Specify other: 10. Years of experience in the North West Provincial Department of Health (Please mark with an x) 1-2 years 3-5 years 6-10 11-15 16-20 Over 20 years years years years SECTION C: PERSONAL EXPERIENCE Semi-structured interviews with health professionals according to personal experience. 1. Please explain in detail, your role within the North West Provincial Department of Health? 241 2. As a health professional, do you think implementing the proposed NHI Bill [B11-2019] once legislated will have an impact on your job? If yes, please explain. 3. What are current challenges that you are facing as a health professional within the North West Provincial Department of Health? 4. Please explain in detail, how you would overcome daily challenges in line with your duties? 5. Do you have fears as a health professional with regards to the implementation of the proposed NHI Bill [B11-2019] once legislated? If yes, please specify. 242 6. In your opinion, how will the proposed NHI Bill [B11-2019] benefit the health sector? 7. Are there adequate health professionals for the large number of patients within the North West Provincial Department of Health? 8. In your opinion, what causes long waiting times and backlogs of patients within the North West Provincial Department of Health? 9. What are your concerns for the increased number of people who will make use of public NHI facilities within the North West Provincial Department of Health? 243 10. Would the current quality of health services offered within the North West Provincial Department of Health be substantially improved by implementation of the proposed NHI Bill [B11-2019] once it becomes legislation? 11. Anything else that you would like to share on how the North West Provincial Department of Health could operate more effective and efficiently? 244 ANNEXURE C: PERMISSION LETTER TO THE NORTH WEST DEPARTMENT OF HEALTH 1711 Motlhopi street Boitumelong Bloemhof 2660 Cell no: 0735735959 Email: motswakaethato@gmail.com The Gatekeeper/Head of Department 21 August 2020 Mr Obakeng Mongale North West Department of Health Private Bag X2068 Mmabatho 2735 RE: PERMISSION TO CONDUCT RESEARCH WITHIN THE NORTH WEST DEPARTMENT OF HEALTH Dear Sir I, Ms. Thato Motswakae currently a full time Masters student, kindly seek your approval to conduct research within the North West Department of Health. The research is part of the compulsory dissertation fulfilment of the requirements for the degree Master of Arts in Public Management and Governance at the North-West University which I am currently enrolled for. The research title is: A model for organisational readiness and implementation of the proposed National Health Insurance Bill: The case of the North West Provincial Department of Health. The primary objective of this study is to investigate if the North West Provincial Department of Health is ready to implement the proposed NHI Bill [B11- 2019]. The reason for wanting to conduct this research is due to the fact that there are significant inequalities between 245 the private and public health South African systems. This study is therefore undertaken to investigate the readiness of the public health system to implement the proposed NHI Bill [B11-2019]. The objective of the NHI Bill [B11-2019] is to provide universal access to quality health care for all South Africans as enshrined in the Constitution of the Republic of South Africa, 1996. This study envisages to propose recommendations by way of a model that would enhance the organisational readiness of the North West Provincial Department of Health to implement the proposed NHI Bill [B 11- 2019]. To achieve the primary objective of this study, the participants would be the Head of Department, senior managers, line managers of public hospitals and clinics including health professionals across the North West Province. In conducting this study, the following research ethics will be considered: • Incorrect reporting will not be practiced, which includes, reporting findings in a way to serve the researchers own interest. • The researcher will seek consent/permission from the gatekeeper of the North West Provincial Department of Health before conducting interviews with participants. • The researcher will seek ethical clearance from the North-West University’s Human and Social Sciences Research Ethics Committee. • The researcher would also make sure that the information presented in this study is based on truths and no information would be exaggerated or misinterpreted. • The researcher will maintain confidentiality regarding interviewees responses. • The participation in the study will be voluntary. • Research participants will be treated with respect. Permission is hereby requested to please interview the above identified participants for purposes of this research. Completion of the semi-structured interviews and questionnaires would be as brief as possible and anonymity of participatory results and confidentiality are guaranteed. Interviews with identified respondents could last up to 35 minutes. If there are any further enquiries, please contact myself, as researcher at the above-mentioned contact details, or my supervisor, Prof Melvin Diedericks at 018-299 1629 or Melvin.diedericks@nwu.ac.za Kind regards Prof. M Diedericks Miss Thato Motswakae Study supervisor Master’s Researcher 246 I ………………………………………………………….. (Gate Keeper/Head of Department) hereby grant/does not grant permission to Miss T Motswakae to conduct her research using identified senior managers, health professionals, line managers of public hospitals and clinics across the North West Province as a unit of analysis for her Master of Arts in Public Management and Governance Degree study. Signature: ……………………………………………………………. Date: ………………………………………… 247 ANNEXURE D: PERMISSION LETTER FROM THE NORTH WEST DEPARTMENT OF HEALTH 248 249 ANNEXURE E: LANGUAGE EDITOR’S CERTIFICATE 28 November 2022 TO WHOM IT MAY CONCERN This Certificate serves to inform that the draft Dissertation A model for organisational readiness and implementation of the proposed National Health Insurance Bill: The case of the North West Provincial Department of Health was submitted to PAT by Ms T Motswakae, Student No: 26624400 for proofreading, linguistic editing and academic writing treatment. They, through the use of Track Changes in the Review Function on Word, inter alia, identified and indicated typing-, language- and linguistic shortcomings and through comments suggested changes and improvements to be considered and affected to the final Mini-dissertation. Yours faithfully Prof EJ NEALER PAT Contractor SATI registration NO: 1002488 250