The general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution. This qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson’s health policy analysis triangle and Liu’s conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved. Three models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity. The GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach.

Introduction: In South Africa over the past 20 years, immunisation has saved countless lives as well as prevented illnesses and disabilities. Despite this, vaccine-preventable illnesses remain a danger. The demand for and uptake of immunisation services are shaped by a variety of factors that can either act as barriers or facilitators to immunisation uptake. The aim of this project was to identify the supply and demand barriers and develop local strategies to improve childhood immunisation in four zero-dose districts in South Africa. Materials and Methods: This study used a mixed-method approach. In each of these four districts, 15 in-depth key informant interviews with health workers and local health managers and four focus group discussions (10 participants per focus group discussion) with community members and caregivers were held over a three-month period. Transcribed interviews were thematically analysed using qualitative analysis software (Nvivo^®) into 10 factors as identified as important in influencing immunisation demand and uptake in previous studies. A further four were identified during the data analysis process. Results: Despite the varying role of factors affecting demand and uptake of immunisation services, three consistent findings stand out as major barriers across all districts. The first is interaction with healthcare staff. This clearly highlights the crucial role that the interactions between patients and staff play in shaping perceptions and behaviours related to immunisation services. The second is the overall experience of care at healthcare facilities. This emphasises the role that patient experience of services plays in perceptions and behaviours related to immunisation services. The third is family dynamics. This highlights the important role family dynamics play in shaping individuals’ decisions regarding immunisation uptake as well as the impact it has on the ability of people to access health services. Discussion: The role played by the different factors in the demand and uptake of immunisation services varied across the four districts examined in this study. Each of the districts presents a unique landscape where different factors have varying degrees of importance in affecting the utilisation of immunisation services. In some districts, certain factors are major barriers, clearly hindering the demand and uptake of immunisation services, while in others, these same factors might be a relatively minor barrier. This discrepancy highlights the unique nature of healthcare challenges across the districts and the need for tailored strategy recommendations to address them effectively.

WHO recommends computer-aided detection (CAD) in chest X-ray (CXR) for systematic screening of TB. Increased detection of individuals with high CAD score but without bacteriologically confirmed TB can be expected, requiring guidance on their clinical management. We followed participants of a TB prevalence survey (TBPS) in Zambia and South Africa with a high CAD score but no bacteriologically confirmed TB over a median time of 9 months and assessed their clinical outcomes. At the TBPS participants with TB-suggestive symptoms or a CAD score ≥40 submitted two sputum samples for Xpert-Ultra testing, and, an additional sample was collected the next day for liquid culture and Xpert-ultra testing. Participants with a CAD score ≥70 and no bacteriologically confirmed TB were eligible for follow-up. At follow-up visit participants were asked about TB symptoms and treatment, underwent a repeat CXR with CAD, and those with either TB-suggestive symptoms or a CAD score ≥70 at follow-up submitted a sputum sample for Xpert-Ultra testing. A composite “clinical” outcome was defined based on changes in CAD-score and TB-suggestive symptoms between the TBPS and the follow-up. Of the 254 eligible TBPS participants 162 (65%) completed follow-up. Most of the participants self-reported previous TB (65% 105/162), were from Zambia (79%, 128/162,) and male (70%, 97/162). Overall, 43% (70/162) participants progressed clinically/remained radiologically abnormal and 6% (10/162) developed TB between the TBPS and the follow-up, with an overall TB incidence rate of 7% per year (95% CI: 3.8-13.3). Patients with high CAD score but no bacteriological confirmation may have had a past TB or other pulmonary lesions identified in the CXR, which may need to be investigated. Also, these participants may be at risk of progressing to TB over time and could benefit from a follow-up visit and from repeated assessment of symptoms and CXR.

Background: South Africa’s Referral Policy and Implementation Guidelines aim to ensure continuity of care, manage patient flow, and improve health system efficiency. However, in Mpumalanga province, a growing number of patients bypass Primary Health Care (PHC) clinics and seek hospital services without formal referral. This trend undermines the structured referral pathway and strains healthcare resources. Aim: This study sought to identify the key factors that influence patients to bypass PHC facilities in Mpumalanga province. Setting: The study was conducted across the three districts in Mpumalanga province. Methods: A qualitative exploratory design was employed to better understand the factors influencing patients to bypass PHC clinics from the perspective of healthcare workers (HCWs). Using purposive sampling techniques, key informant interviews were conducted with 20 HCWs from 10 selected hospitals. Thematic analysis of the qualitative data was conducted using an inductive approach, with NVivo® software facilitating systematic coding, theme development and data organisation. Results: Key factors that influenced patients to bypass included a lack of adherence to the referral system, perceptions of poor quality at PHC facilities, long waiting times, negative HCWs’ attitudes and concerns pertaining to stigma and confidentiality. Conclusion: Insights gained from this study contribute to the understanding of factors that lead patients to bypass PHC facilities. Contribution: By understanding the underlying reasons for such bypassing, policymakers and healthcare providers can develop targeted interventions to enhance the quality and utilisation of PHC services. Moreover, addressing these challenges is crucial for achieving equitable healthcare access.

Background/objective: The Immunisation Agenda 2030, led by the World Health Organization, aims to ensure that people of all ages benefit from vaccination. South Africa remains committed to these goals, strengthening childhood immunisation largely through the Expanded Programme on Immunisation. However, despite progress, the number of unvaccinated and partially vaccinated children continues to rise in some urban settings. This study sought to identify barriers to childhood immunisation in selected zero-dose urban communities in Gauteng Province. Methods: A qualitative exploratory–descriptive design was used to examine factors influencing childhood immunisation. Data were collected through seven focus group discussions and fifteen key informant interviews with purposively selected caregivers, community leaders, community health workers and healthcare workers involved in routine immunisation services at public healthcare facilities across the Cities of Johannesburg, Ekurhuleni, and Tshwane. Thematic analysis was conducted using NVivo^® software. Results: The study identified multiple demand-side and supply-side barriers. Demand-side barriers included limited parental knowledge, lack of trust in the government and immunisation services, religious beliefs, migration, and perceptions of caregiver substance use. Supply-side barriers involved distance to the facility, negative healthcare worker attitudes, long queues and waiting times, and frequent vaccine stock-outs. These barriers collectively contributed to missed opportunities and decreased uptake of immunisation services. Conclusions: Childhood immunisation remains a critical and cost-effective public health intervention. The findings demonstrate the complex interplay of individual and system-level factors influencing vaccine demand, uptake and persistent zero-dose status in urban Gauteng communities. Addressing these barriers requires a comprehensive approach that strengthens community trust, improves caregiver vaccine literacy, and ensures accessible, responsive, and respectful immunisation services.

The article reads more as an advocacy piece than a balanced scientific review. Phrases like “apparently,” "fatal flaw," and "festering problems" undermine academic credibility. A more measured tone is required. The authors describe the 2025 fractiona...