Tshabalala, KhanyisileRispel, Laetitia C.2024-07-032024-07-032023-08-31Tshabalala, K. & Rispel, L.C. 2023, 'Piercing the veil on the functioning and effectiveness of district health system governance structures : perspectives from a South African province', Health Research Policy and Systems, vol. 21, no. 89, pp. 1-13. https://DOI.org/10.1186/s12961-023-01044-z.1478-4505 (online)10.1186/s12961-023-01044-zhttp://hdl.handle.net/2263/96782AVAILABILITY OF DATA AND MATERIALS : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.BACKGROUND : Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures. METHODS : This was a mixed-methods, cross-sectional study in GP’s five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members’ perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively. RESULTS : Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. CONCLUSION : In light of South Africa’s move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms. KEY MESSAGES (1) In 2018, only three of the five health districts in the Gauteng Province of South Africa established district health councils, the governance structures for primary health care. (2) The mean score for the perceived functioning of the District Health Council (DHC) was 4.5 out of 7 (SD = 0.7), with the three lowest scoring items being for orientation of DHC members (score 3.8; SD = 2.1), punctuality of meetings (score 4.4 SD = 1.8), and the regular review of DHS performance data (score 4.7 SD = 1.9). (3) The mean score for perceived effectiveness of the DHC was 4.8 out of 7 (SD = 0.7) with the lowest scoring items for tension among members of committees and management (score 3.4 SD = 1.6), the existence of criteria to monitor progress towards goals (score 4.6 SD = 1.7), and accountability to communities (score 4.6 SD = 1.7). (4) The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fuelled by the complexity of governing across two spheres of government, exacerbated by political differences, and contestations over limited resources constrained DHS governance. (5) Both the survey and interviews identified gaps in accountability to communities.en© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License.GovernanceAccountabilityUniversal health coverage (UHC)Gauteng Province, South AfricaDistrict health system (DHS)District health councils (DHC)SDG-03: Good health and well-beingArticle