Routine governance in Mitchells Plain sub-district in South Africa

MP case


Drawing on the experience of the Mitchells Plain sub-district in Cape Town, South Africa, this case study provides a window onto the routine functioning of a local-level health system and the ways in which middle managers and frontline staff have sought to cope with their challenges and do things differently to improve the health system’s functioning.

This case study highlights:

  • The structural complexity of health systems, as well as the complex, multi-directional relationships that are required for the system to work;
  • The different ways in which a health system can be governed;
  • The full range of skills required of mid-level managers and health facility managers;
  • The values, mind-sets and relationships of different health system actors; and
  • Ways in which managers can strengthen the health system, especially through strategies that are sensitive to power, communication, relationships and values.

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Health system decentralisation in Kenya

Kenya case


This case study focuses on the early stages (2013-2015) of the decentralisation of government functions that occurred after the adoption of Kenya’s 2010 constitution, in particular how these changes affected the local-level health system and service delivery to communities.

The case study is useful for stimulating students’ thinking about:

  • The influence of the broader political system on the health system;
  • The role of time and timing in health system change;
  • The (changing) relationships between actors and the software and hardware of the organisational contexts within which reforms come to life;
  • The sometimes counter-intuitive impacts of reforms; and
  • The impact that changes in one aspect of the broader government or health system can have on other aspects of that same system.

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The marketing of alcoholic drinks in South Africa

alcohol case


Covering the period March 2011 to May 2017, this case study explores the process through which the 2013 draft Control of Marketing of Alcoholic Beverages Bill was formulated.

This case study’s focus on policy formulation makes it quite distinctive, as it is more common for policy change case studies to cover implementation. The case study can be used to support students to analyse the typical steps in policy formulation, as well as the context of policy change and the support or opposition of different actors; the nature of policy content and how it relates to the interests, values and understandings of actors; and strategies that policy proponents and opponents use to influence the outcome of the policy process.

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In brief: Street-level bureaucracy theory

One of the most enduring questions in health policy analysis is why policies are often implemented in unintended ways; why implementation “on the ground” looks different to the intentions of top-level policy makers or the objectives of official policy documents.

Part of the answer lies in the working environments and mind-sets of street-level bureaucrats: front-line workers or policy implementers such as nurses, teachers and police officers.

This guidance note, courtesy of the Health Policy and Systems Division of the University of Cape Town, summarises the theory of street-level bureaucracy. It is intended to be used as a teaching resource, with the aim of introducing students to street-level bureaucracy theory and stimulating them to read further. It can work well with CHEPSAA’s module Health Policy Analysis or any other discussion of the behaviour of front-line health policy implementers.

This summary was developed in the context of work that synthesised the literature on street-level bureaucracy, as well as other aspects of the health policy analysis literature in low- and middle-income countries. This open access work can be accessed here.

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Community Health Funds

This case study encourages students to interrogate the strengths and weaknesses of the voluntary community health fund (CHF) model. Based on the results of a health systems analysis of the performance of the CHF, students are asked to use systems thinking to test how accurately they can anticipate the problems experienced in implementation and then to propose modifications to the CHF model that might mitigate shortcomings or take advantage of synergies elsewhere in the system.

This case study address issues around health care access, quality and equity; the facilitation of stakeholder involvement; politics and power; as well as accountability and trust.

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