How might we determine the leverage points within the South Africa Health System where ASELPH could play a significant role in generating positive change?

A Systems Evaluation of the Albertina Sisulu Executive Leadership Programme in Health (ASELPH)


South Africa is working to combat the increasing health inequalities influenced by the uneven distribution of disease burden, including HIV, Tuberculosis, non-communicable diseases, and high maternal and child mortality. The disease burden, coupled with a widening disparity of expenditure between public and private health care, calls for a change. In 2012, the Minister of Health introduced National Health Insurance (NHI) as a way to improve health care for all with particular emphasis on providing quality health services regardless of income level. NHI aims to transform the two-tiered health system – public and private sectors – into a unified health system and move South Africa towards universal health coverage (UHC). With the introduction of NHI came an increased emphasis for leadership across the South Africa Health System; thus, the Albertina Sisulu Executive Leadership Programme in Health (ASELPH) was formed. The ASELPH Programme is a partnership between the University of Fort Hare, University of Pretoria, South Africa Partners, South Africa Department of Health, and the Harvard University School of Public Health. ASELPH seeks to train provincial and district managers to develop the skills needed for successful implementation of NHI and to strengthen the health care transformation process. GKI set out to determine the following three points of interest:

  1. Is the ASELPH Programme effective in teaching the skills required for strong performance within the Health System;
  2. Are the skills taught by ASELPH the most critical skills needed within the Health System; and
  3. What areas within the Health System, if improved, have the potential to unleash the most positive transformation.


Assessing this challenge, the SPACES team provided a quantitative and qualitative systems analysis. Pulling from GKI’s repertoire of systems tools and methods and previous work analyzing healthcare systems, GKI conducted the qualitative portion of the evaluation. The goal of this evaluation was to determine the extent to which the ASELPH Programme could positively impact the South Africa Health System.

GKI began by employing a modified version of the World Health Organization’s (WHO) building blocks for health systems as a framework for analyzing distinct health system functions. The functions analyzed included Human Resources, Supply Chain Management, Service Delivery, Policy, Finance, and Monitoring & Evaluation. These functions guided the direction of background research and the design of the interview protocol. The team conducted 47 interviews with key stakeholders in South Africa across 4 provinces: Gauteng, Eastern Cape, Mpumalanga, and Limpopo. The insights gleaned from the interviews helped inform the creation of a causal loop diagram, a type of system map focused on critical feedback loops. This diagram underscored the skills which require additional emphasis in the South Africa Health System, systemic enablers and barriers, and possible recommendations for how the ASELPH team might play a role in alleviating those barriers. The results presented are intended to serve as a precursory step to an impact evaluation by way of highlighting which areas in the South Africa Health System ASELPH might have the greatest potential for impact.

Results / Outcomes

  • Continued to introduce and apply systems monitoring and evaluation approaches across USAID Missions and Bureaus through the innovative mechanism designed to bring advanced Monitoring, Evaluation, Research and Learning (MERL) methods known as the Strategic Program for Analyzing Complexity and Evaluating Systems (SPACES).
  • Gained key insights through conducting 47 interviews with health system stakeholders, including ASELPH fellows, ASELPH faculty, and non-ASELPH members working across 4 provinces in South Africa.
  • Created a causal loop diagram, based on the insights gathered from the interviews and qualitative coding that identified common themes across health system functions that prevent critical skills from reaching scale among health professionals.
  • Identified 13 groups of recommendations where the ASELPH Programme could play a significant role in generating change within the South Africa Health System.


  • SPACES South Africa Report – Final report outlining findings and recommendations for the ASELPH Programme and the USAID South Africa Mission to consider.