"We were caught sleeping": formulation of national policy to decentralise management of drug-resistant tuberculosis in South Africa - a qualitative policy analysis study.

objectiveIn response to growing numbers of people with drug-resistant tuberculosis (DR-TB), South Africa was, in 2011, among the first countries to launch a national policy on the decentralisation of DR-TB management, preceding normative guidance from the World Health Organization. The objective was to understand the process of formulation of the South African policy on DR-TB service decentralisation.

designQualitative policy analysis. We reviewed policy-related documents to create a timeline, then conducted in-depth interviews with key individuals who had influence over or insights into the policy formulation process. We used Kingdon's policy analysis framework to examine the convergence of problem, policy and politics streams in agenda-setting to create the window of opportunity for policy adoption.

settingSouth Africa.

participantsPolicy makers, implementers and researchers in three South African provinces and at national level, and international DR-TB experts.

resultsInternational publicity concerning the extensively drug-resistant TB outbreak in Tugela Ferry positioned DR-TB as a public health crisis. The health system lacked capacity to match hospital bed supply in specialised hospitals to the high number of people with DR-TB. Reports of detention against will, victimisation and stigmatisation, and failure to uphold person-centred approaches, sparked a human rights outcry. Tensions between actors favouring 'control-based' approaches with emphasis on centralisation and control of patient treatment and resources, and those favouring 'access-based' approaches that emphasised decentralised care led to a tipping point in the policy process. Centralised, specialised DR-TB approaches were perceived to protect quality of care, but these compromised person-centred care and human rights, and restricted access to DR-TB treatment. Policy actors used lessons from pilot studies of DR-TB decentralisation and HIV programmes to overcome policy stagnation.

conclusionsPolicy makers should monitor demand and supply of specialised services and support evidence-informed policy change before health system pressures make reform unavoidable.