Service Delivery Constraints Research Articles

Challenges encountered: A Qualitative analysis of professionals’ lived experiences in the field of autism

Autism Spectrum Disorder (ASD) significantly impacts American families, requiring substantial support from professionals in the field. This qualitative study explores the experiences of nine professionals in the ASD field using a phenomenological framework. Four main themes emerged from the analysis: 1) Service Delivery Constraints, 2) Knowledge Limitations, 3) Professional Adaptation, and 4) Future Directions. These findings illuminate the unique challenges professionals face in service delivery and their roles within the autism field. The study provides practical and scholarly insights based on real-life experiences, benefiting professionals, scholars, and families with children with autism.

Sustainable Improvement Alternatives to Animal Health Service Delivery Constraints in the Daffiama-Bussie-Issa District of the Upper West Region of Ghana

Livestock production plays a key role in the livelihoods of rural people, serving as a source of employment, income, food, and security against the uncertainties of crop production. Yet delivering quality, affordable, and sustainable animal health services remains a major constraint in developing countries, including Ghana. This study explores the sustainable improvement alternatives to animal health service delivery constraints in Daffiama-Bussie-Issa District, Ghana. A total of 150 livestock farmers were randomly selected from fifteen communities and interviewed using semi-structured questionnaires. Statistical Product and Service Solutions (SPSS/IBM) version 20.0 was used to compute all descriptive statistical variables. Chi square analysis was done to check for the effect of some variables on others at a significant level of 5%. The study showed that 42.7% of the respondents were between 46-60 years. However, age had no influence on veterinary service patronage (X=8.672, df=3, p=0.34). Sixty-four percent of the respondents had no educational background. Also, education did not influence veterinary service patronage (X=2.357, df=5, p=0.798). Majority (41.3%) of the respondents traveled over 16 km to access animal health service providers. All (100%) of the respondents who had access to veterinary drugs practiced self-medication. The study revealed government animal health service providers as a sustainable animal health delivery channel. Based on these findings, livestock farmers should be encouraged to consult veterinary service providers before administering drugs and vaccines to their livestock.

Effectiveness of Social Health Insurance Program in Nepal: Challenges and Recommendations

The article explores into the concept of health insurance in Nepal as a means of financial protection against unexpected medical expenses. It outlines commitment to providing fundamental health care as a citizen's right and the challenges faced in Nepal to achieving this goal. The study highlights the initiation and expansion of the Social Health Insurance Program, marking to suggestion financial security to individuals and families during illness. Despite progress, economic, social, and institutional barriers hinder many citizens' access to adequate health services. The paper emphasizes the importance of health insurance for low and middle-income families, addressing concerns of economic hardship due to healthcare costs. Challenges in the implementation of the program are discussed, including issues related to organizational systems, service delivery, infrastructure, and budgetary constraints. The need for collaboration between government bodies, quality improvement in healthcare facilities, and better management of health workers is emphasized. The successful implementation of health insurance in Nepal is seen as a pivotal step towards achieving universal health coverage, alleviating financial burdens on citizens, and contributing to national development goals and international commitments.

Ambulance Service in Kathmandu, Nepal: Service Delivery Constraints, Challenges, and Achievements during the COVID-19 Pandemic.

An Emergency Medical Service (EMS) is defined as a complete system that responds to public medical and surgical emergencies with prompt and adequate emergency care. Ambulance services are also classified as EMS in modern medical history. In the Nepalese context, prehospital care is very limited, and the EMS system is still a new concept in Nepal. In a study in the emergency room at Patan Hospital in Kathmandu, only 9.9% of patients came by ambulance, 53.6% by taxi, 11.4% by private car, 13.5% by bus, 5.4% by bicycle, and another 6.2% came with alternative routes. This study aims to investigate the constraints, challenges, and achievements made by ambulances services during the coronavirus disease 2019 (COVID-19) pandemic. The study design was phenomenological and the method was qualitative. In-depth interviews (IDIs) were conducted with six human resources working from the COVID-19 first wave pandemic in the ambulance service of Nepal Ambulance Service (NAS), Kathmandu. Four themes were generated from IDIs: (1) challenges in service delivery; (2) constraints on service delivery; (3) working experiences; and (4) achievements of ambulatory service providers during the COVID-19 pandemic. Under these four themes, 12 sub-themes were constructed. The new nature of disease (COVID-19) in the first wave led to fear and anxiety, which also forced them to think about quitting the job; however, later on with proper training and safety measures, it led to working for COVID-19 patient transfers from home to hospital, as well as hospital to hospital, and proper prehospital care services were provided. The major challenges faced by ambulatory service providers were long working hours, wearing a single personal protective equipment (PPE) for long hours, confusing locations to pick up patients, and both stigma and discrimination. From IDIs, it was concluded that although constraints and challenges arise during a pandemic, from proper guidance and support through NAS, they are able to provide proper prehospital care for the patient. Challenges like fear, heavy workload, PPE, and other material barriers do not hamper in service delivery.

Improving services for chronic non‐communicable diseases in Samoa: an implementation research study using the care cascade framework

ObjectiveSamoa needs to intensify the response to the growing non‐communicable disease burden. This study aimed to assess bottlenecks in the care continuum and identify possible solutions. MethodsThe mixed‐methods study used the cascade framework as an analysis tool and hypertension as a tracer condition for chronic non‐communicable diseases. Household survey data were integrated with medical record data of hypertension patients and results from focus group discussions with patients and healthcare providers. ResultsHypertension prevalence was 38.1% but only 4.7% of hypertensive individuals had controlled blood pressure. There were large gaps in the care continuum especially at screening and referral due to multiple socio‐cultural, economic and service delivery constraints. ConclusionsIn Samoa, care for chronic non‐communicable diseases is not effectively addressing patient needs. This calls for better health communication, demand creation, treatment support, nutritional interventions and health service redesign, with a focus on primary healthcare and effective patient and community engagement. Implications for public healthThe proposed actions can improve the reach, accessibility, quality and effectiveness of Samoa's chronic care services. Health system redesign is necessary to ensure continuity of care and more effective primary prevention. The findings are useful for other countries in the region facing similar challenges.

State led innovations for achieving universal health coverage in a low resource setting Odisha, India: opportunities and challenges

Background: Odisha, a developing state of India, has introduced an innovative scheme known as Biju Swasthya Kalyan Yojana (BSKY), which aims at providing free health care to all the people. This paper examines the scope, key features, challenges and potentiality of BSKY to achieve universal health coverage (UHC) in Odisha.Methods: We reviewed policy documents and conducted qualitative interviews with key state government officials and other stakeholders to understand implement processes and constraints.Results: The scheme intends to provide free health care to all people in public health care institutions and additionally, 71 lakh poor households can avail health care services from the empanelled private hospitals with financial coverage up to 5 lakhs per family and women members up to 10 lakhs annually. This is implemented in assurance mode by merging state-run schemes- Rashtriya Swasthya Bima Yojana (RSBY), Biju Krushak Kalyan Yojana (BKKY) and Odisha State treatment fund (OSTF). The implementing agency is introducing several measures to control unnecessary health care utilisation and cost. Gate keeping mechanism and reserved packages by public hospital are major initiatives in this direction. Further, efforts to settle claims on time and IT related challenges are teething problems of the scheme. The findings further suggest that public expenditure on health stands at 1.3% of GSDP and inadequate human resources and health infrastructure are affecting service delivery.Conclusions: Achieving UHC with such a low public spending on health and different service delivery constraints looks ambitious. Odisha may learn from other countries to implement UHC phase wise.

Retention of radiographers: A qualitative exploration of factors influencing decisions to leave or remain within the NHS

IntroductionIn many countries a widening imbalance exists between radiographer workforce supply and demand. Improving retention is a rapid method of workforce expansion which is gaining importance with policy makers and providers. To better understand the current leaver profile, this study aimed to identify why radiographers leave the NHS early, and what incentives are important in their decision to stay. MethodsA qualitative framework methodology used semi-structured telephone interviews to explore the perspectives of radiography managers, radiographers who have left the NHS, and those considering leaving. Purposive sampling ensured representation across radiography professional groups, geographical and organisational diversity, and stages of career. ResultsThree over-arching themes were identified across all radiographer professional groups (n = 44): 1) Challenging working patterns and the impact on employee health and wellbeing; 2) Lack of flexibility in working terms and conditions; 3) Lack of timely career progression and access to CPD, and the need to feel valued. Radiographers were keen to express how they ‘loved being a radiographer’; small concessions and changes to workplace culture might be the incentive to remain in radiography that some were clearly searching for. Manager participants recognised the need to offer greater flexibility in working patterns but this was challenging within financial and service delivery constraints. ConclusionsWhile some influencing factors varied between radiographer professional groups, the three themes were consistent across participants. Failure to address these concerns will exacerbate the loss of experienced and highly trained staff from the NHS at a time when demand for services continues to rise. Impact on practiceRecommendations are presented related to three primary themes which will be a catalyst for sharing of best practice between radiology and radiotherapy centres.

'So just to go through the options…': patient choice in the telephone delivery of the NHS Improving Access to Psychological Therapies services.

This article considers patient choice in mental healthcare services, specifically the ways that choice is enabled or constrained in patient-practitioner spoken interaction. Using the method of conversation analysis (CA), we examine the language used by practitioners when presenting treatment delivery options to patients entering the NHS Improving Access to Psychological Therapies (IAPT) service. Analysis of 66 recordings of telephone-delivered IAPT assessment sessions revealed three patterns through which choice of treatment delivery mode was presented to patients: presenting a single delivery mode; incrementally presenting alternative delivery modes, in response to patient resistance; and parallel presentation of multiple delivery mode options. We show that a distinction should be made between (i) a choice to accept or reject the offer of a single option and (ii) a choice that is a selection from a range of options. We show that the three patterns identified are ordered in terms of patient-centredness and shared decision-making. Our findings contribute to sociological work on healthcare interactions that has identified variability in, and variable consequences for, the ways that patients and practitioners negotiate choice and shared decision-making. Findings are discussed in relation to tensions between the political ideology of patient choice and practical service delivery constraints.

An Exploratory Study of Speech and Language Therapy Intervention for Children Born With Cleft Palate ± Lip

Children born with a cleft palate ± lip are at risk of developing speech and language difficulties, which may require intervention from a speech and language therapist (SLT). To date, there is no strong evidence to support one approach to intervention over another, neither is it clear which approaches or methods of provision are commonly used. To describe the range of speech and language therapy interventions being used with children born with cleft palate in the United Kingdom up to 5 years of age. To explore the different ways, interventions are being delivered. A prospective study to conduct 9 semi-structured focus groups. Iterative content analysis was completed. Regional Cleft Lip and Palate Centers in the United Kingdom. Sixty-two speech and language therapy professionals from specialist cleft teams and community services. Four main codes were identified: "intervention approaches," "service delivery models," "decision-making and rationale," and "patient-centered care." Participants frequently discussed how they adopt an eclectic style when delivering intervention, the importance of an individualized approach for each child and service delivery constraints, such as a lack of resources. Insight into the multitude of intervention approaches used by SLTs, aspects which influence their decision-making and the variability of service delivery models were gained. Uncertainty regarding which intervention approaches and methods for delivery are most effective provides rationale for future research, to improve the effectiveness of speech and language intervention for children with cleft palate ± lip.

A One Health framework for integrated service delivery in Turkana County, Kenya

Pastoralists in sub-Saharan Africa have limited access to public services due to their mobile lifestyle, economic and political marginalization, and the limited health infrastructure that is common to arid and semi-arid lands (ASALs) where they primarily reside. This often results in poor health outcomes, including increased rates of maternal, neonatal, and under-5 mortality. One Health approaches that integrate human and animal health service delivery can help to improve pastoralists’ health through increased vaccine coverage and improved access to services.Kenya has institutionalized One Health at the national level; however, progress at the subnational level has been limited due to sustainability concerns, competing priorities, and insufficient coordination platforms. To address this gap, this paper presents a One Health framework (OHF) to aid in the implementation of integrated human and animal health policies in Turkana County, which can act as a model for other ASALs. Utilizing a grounded theory design, we conducted semi-structured interviews and focus group discussions with human health, animal health, and pastoralist stakeholders. Inadequate engagement with the public sector was identified as a major limitation by community members. Factors that contributed to this include distance to health facilities and restricted department capacities such as availability of vehicles, personnel, and cold chain maintenance.Our proposed OHF harnesses the existing structure of service delivery in Turkana and establishes an official coordination mechanism to implement One Health activities, through the form of mobile “One Health Huduma Centres”, offering a range of public services. This innovative framework is supported by stakeholders in Turkana and can improve service delivery constraints thereby improving the health of Turkana pastoralists.

Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review

BackgroundStroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.ObjectiveOur objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.MethodsWe performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.ResultsThe criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.ConclusionsWe identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.

Medicolegal responsibilities for the administration of intravenous contrast media by radiographers: Radiologists’ perspectives

Background. Global trends in the delivery of healthcare services have placed tremendous strain on resources, among them human and capital. With this has emerged the need to revisit the job requirements and/or scope of practice of cadres within a profession, to ensure adequate training where needed. The administration of intravenous contrast media (IVCM), a fundamental element of expertise within the radiology field, is an example of such evolution in South Africa (SA). Currently falling within radiologists’ scope of practice, it has become necessary for radiographers to extend their own scope to include this skill, owing to the national shortage of radiologists and subsequent service delivery constraints, as well as the need to close the gap with international trends. Objective. To provide a synopsis of the perspectives of radiologists on the medicolegal responsibilities related to the administration of IVCM by radiographers. Methods. A quantitative, descriptive, cross-sectional research design was conducted, targeting qualified radiologists in KwaZulu-Natal Province (KZN). An online questionnaire was administered through SurveyMonkey that provided information on the medicolegal responsibilities associated with the administration of IVCM. Results. Of a total of 97 qualified radiologists in KZN, a response rate of 48.5% ( n =47) was obtained. The majority of respondents felt that radiographers should be responsible for obtaining informed patient consent (66.0%), and deciding on the site of IVCM administration (72.3%). It was also felt that the radiologists should remain responsible for decisions regarding the type and dose of IVCM (87.2%) and managing the possible complications and adverse reactions due to the administration of IVCM (78.7%). Conclusion. Evidence-based research provides a contextualised approach towards addressing transformation in service delivery and training needs. This study, in demonstrating the importance of appropriate medicolegal responsibilities in the extension of a professional role, forms a basis for informing the future training of radiographers in SA.

Medicolegal responsibilities for the administration of intravenous contrast media by radiographers: Radiologists’ perspectives

Background. Global trends in the delivery of healthcare services have placed tremendous strain on resources, among them human and capital. With this has emerged the need to revisit the job requirements and/or scope of practice of cadres within a profession, to ensure adequate training where needed. The administration of intravenous contrast media (IVCM), a fundamental element of expertise within the radiology field, is an example of such evolution in South Africa (SA). Currently falling within radiologists’ scope of practice, it has become necessary for radiographers to extend their own scope to include this skill, owing to the national shortage of radiologists and subsequent service delivery constraints, as well as the need to close the gap with international trends. Objective. To provide a synopsis of the perspectives of radiologists on the medicolegal responsibilities related to the administration of IVCM by radiographers. Methods. A quantitative, descriptive, cross-sectional research design was conducted, targeting qualified radiologists in KwaZulu-Natal Province (KZN). An online questionnaire was administered through SurveyMonkey that provided information on the medicolegal responsibilities associated with the administration of IVCM. Results. Of a total of 97 qualified radiologists in KZN, a response rate of 48.5% ( n =47) was obtained. The majority of respondents felt that radiographers should be responsible for obtaining informed patient consent (66.0%), and deciding on the site of IVCM administration (72.3%). It was also felt that the radiologists should remain responsible for decisions regarding the type and dose of IVCM (87.2%) and managing the possible complications and adverse reactions due to the administration of IVCM (78.7%). Conclusion. Evidence-based research provides a contextualised approach towards addressing transformation in service delivery and training needs. This study, in demonstrating the importance of appropriate medicolegal responsibilities in the extension of a professional role, forms a basis for informing the future training of radiographers in SA.

Service delivery and intervention intensity for phonology‐based speech sound disorders

When planning evidence-based intervention services for children with phonology-based speech sound disorders (SSD), speech and language therapists (SLTs) need to integrate research evidence regarding service delivery and intervention intensity within their clinical practice. However, relatively little is known about the optimal intensity of phonological interventions and whether SLTs' services align with the research evidence. The aims are twofold. First, to review external evidence (i.e., empirical research evidence external to day-to-day clinical practice) regarding service delivery and intervention intensity for phonological interventions. Second, to investigate SLTs' clinical practice with children with phonology-based SSD in Australia, focusing on service delivery and intensity. By considering these complementary sources of evidence, SLTs and researchers will be better placed to understand the state of the external evidence regarding the delivery of phonological interventions and appreciate the challenges facing SLTs in providing evidence-based services. Two studies are presented. The first is a review of phonological intervention research published between 1979 and 2016. Details regarding service delivery and intervention intensity were extracted from the 199 papers that met inclusion criteria identified through a systematic search. The second study was an online survey of 288 SLTs working in Australia, focused on the service delivery and intensity of intervention provided in clinical practice. There is a gap between the external evidence regarding service delivery and intervention intensity and the internal evidence from clinical practice. Most published intervention research has reported to provide intervention two to three times per week in individual sessions delivered by an SLT in a university clinic, in sessions lasting 30-60 min comprising 100 production trials. SLTs reported providing services at intensities below that found in the literature. Further, they reported workplace, client and clinician factors that influenced the intensity of intervention they were able to provide to children with phonology-based SSD. Insufficient detail in the reporting of intervention intensity within published research coupled with service delivery constraints may affect the implementation of empirical evidence into everyday clinical practice. Research investigating innovative solutions to service delivery challenges is needed to provide SLTs with evidence that is relevant and feasible for clinical practice.

In Brief, Look Sharp: Short Form Assessment in the Geriatric Setting

ObjectiveOlder adults are an increasing proportion of the population globally. They are also an underserved population with respect to psychological services generally, and neuropsychological services specifically, with both cognitive and psychological concerns going undetected and therefore untreated. Strategies to improve detection of cognitive and psychological concerns in this population, as well as means of obtaining data within limited time or service delivery constraints, include the use of relatively brief assessment protocols. This review of such tools aims to assist clinicians in understanding when best to use such approaches with older adults.MethodA review of the extant empirical literature on brief assessment tools for older adults was undertaken, with the aim of enumerating both advantages and drawbacks of the use of such tools.ResultsAlthough short‐form assessments in geriatric settings can indeed be advantageous and appropriate, if used incorrectly, they can potentially hamper accurate diagnosis and treatment. Measures, which hold particular promise with this population span, refer to both cognitive and affective measures, and include instruments designed for specific populations, for example specific cultural groups or disorders.ConclusionOlder adults present across a wide range of settings, often with complex presentations, impaired cognition, and frail health that can challenge both diagnostic and assessment efforts as well as actual health service provision. This review provides data to enable practitioners to sharpen their practice with brief assessments for greatest efficacy in serving geriatric populations. Consideration is also given to possible areas for future clinical and research developments with respect to brief assessment strategies.

Inequities in resources and preparedness for surgical complications of caesarean section in southern Gauteng hospitals

Background. The number of maternal deaths from bleeding during and after caesarean section (BDACS) has increased in South Africa. Health-worker training and health-system strengthening are considered important prerequisites for improving maternal health outcomes. Objectives. To determine preparedness for, and health-system constraints to, safe caesarean section in southern Gauteng hospitals. Methods. This was a cross-sectional study in 15 hospitals. Data were collected by questionnaire from clinical heads of department in each hospital. Results. The 15 hospitals included 5 district hospitals, 7 regional hospitals and 3 central (university academic) hospitals. The number of deliveries per hospital ranged from 893 to 44 256 for 2013 - 2014, with a total of 201 314 births and 70 095 caesarean sections (34.8%). Despite similar numbers of births, there were 20 deaths from BDACS at regional hospitals and 6 at central hospitals ( p =0.008). Service delivery constraints included an unequal staff distribution between central hospitals and lower levels of care, as well as non-availability of essential drugs and a lack of surgical capacity to arrest severe haemorrhage at district and regional hospitals. Conclusion. The findings of this study reflect inequity in maternity services. Compared with central academic hospitals, district and regional hospitals are inadequately prepared for the management of complications from BDACS.

Rapid and scalable isp service delivery through a programmable middlebox

With only access billing no longer ensuring profits, an ISP's growth now relies on rolling out new and differentiated services. However, ISPs currently do not have a well-defined architecture for rapid, cost-effective, and scalable dissemination of new services. We present iSDF, a new SDN-enabled framework that can meet an ISP's service delivery constraints concerning cost, scalability, deployment flexibility, and operational ease. We show that meeting these constraints necessitates an SDN philosophy for a centralized management plane, a decoupled (from data) control plane, and a programmable data plane at customer premises. We present an ISP service delivery framework (iSDF) that provides ISPs a domain-specific API for network function virtualization by leveraging a programmable middlebox built from commodity home-routers. It also includes an application server to disseminate, configure, and update ISP services. We develop and report results for three diverse ISP applications that demonstrate the practicality and flexibility of iSDF, namely distributed VPN (control plane decisions), pay-per-site (rapid deployment), and BitTorrent blocking (data plane processing).

Measuring the quality of allied health services in Australia: is it a case of “the more we learn, the less we know?”

Correspondence: Karen GrimmerSomers University of South Australia, City East Campus, North Tce, Adelaide 5000, Australia Email karen.grimmer-somers@unisa. edu.au Background: Sensitive and reliable measurement of allied health (AH) service quality is in its infancy. This is largely related to the complexity of the AH discipline-mix, the services these disciplines provide, and the locations in which services are provided. AH is variably described, with up to 49 disciplines being listed in the literature. These disciplines often undertake a range of interlinked activities such as assessment and diagnosis, counseling, therapy and rehabilitation, manufacture, education, and service organization. AH disciplines work in a range of roles in a range of public and private sector organizations, and often consult with their patients/ clients a number of times for the management of one condition. They operate under a variety of funding models, and often within service delivery constraints. This evidence-informed analytical review outlines factors which should be considered by allied health leaders, reflecting clinicians, policy-makers, managers, and academics, in regards to making an informed choice of sensitive and reliable measures of AH service quality. Strong, visionary, and collaborative leadership is required to ensure that allied health activities and outcomes are measured and reported effectively and efficiently.

Prevention of Mother to Child Transmission of HIV Program in Tanzania: Service Delivery and Uptake Constraints

Each year more infants are infected with HIV, mostly in sub-Saharan Africa and mostly due to mother-to-child, or “vertical” transmission. Advances in ART made the prevention of mother-to-child transmission (PMTCT) of HIV affordable in sub-Saharan Africa and other resource-constrained settings. However, Implementation of PMTCT programs has been facing many challenges, thus affecting uptake of PMTCT services especially in rural areas. The purpose of this paper is to analyze the health system constraints facing PMTCT service delivery and uptake in Tanzania at Individual, Household, community and National levels using the constraints Analysis Framework and suggest the way forward.

Expanding the Social Security Net in South Africa: Opportunities, Challenges and Constraints.

For a large proportion of the South African population social welfare grants are an important source of income. Rapid increases in government expenditure on social security between 2000 and 2006 has further increased poor households' reliance on welfare grants and has been important in the fight against poverty. Given these apparent successes, many are calling for further expansions in social security provisioning, with the idea of developing conditional cash transfer schemes surfacing in policy circles from time to time. However, as we argue in this paper, various constraints to such expansions of the welfare net exist. Whereas in the past much of the increased expenditure on social security provisioning could be financed out of government revenue overruns, it is likely that further increases will only be possible through a reallocation of government expenditure. Already there is evidence of a substitution taking place within the social budget: expenditure on education and health seems to have declined in favour of increased welfare transfer expenditure. This, we argue,is untenable and may harm the already weak education and health services in South Africa. Conditional grants linked to school attendance and visits to health clinics will only put further pressure on health and education services, as well as the agency responsible for disbursing and monitoring welfare payments in the country. We argue, therefore, that budgetary and service delivery constraints, at the present moment, present a strong argument against any expansion of the social welfare system in the immediate future.