Understanding Doctors’ and Nurses’ Resistance to Implementing South Africa’s Universal Test and Treat (UTT) Policy

BY: .

Mrs Emma Monaheng has worked in the health sector for over 20 years and has long struggled to understand why health outcomes remain poor - especially when South Africa has world-class policies and significant resource allocations.

This desire to uncover the root causes of the problem inspired her to pursue a Master’s in Sociology. More specifically, Monaheng set out to investigate the use of the Universal Test and Treat Policy (UTT) in South Africa. She explained: ‘South Africa’s UTT policy, implemented in September 2016, mandates that all HIV-positive individuals receive antiretroviral therapy (ART) regardless of their CD4 count, aiming to improve HIV care outcomes and reduce transmission.’

The policy was adopted in line with the World Health Organization’s (WHO) recommendation and aims to achieve the UNAIDS 90-90-90 targets to have 90% of people living with HIV know their status, 90% of those diagnosed receiving treatment, and 90% of those on treatment achieving viral suppression.

Monaheng’s research, titled: “Understanding Doctors and Nurses Resistance to Implement the Universal Test and Treat (UTT) Policy Pronouncement in South Africa”, explored how power and politics influenced UTT policy formulation, implementation and outcomes.

She builds on existing research into the poor outcomes of UTT policy, adding a unique perspective by exploring the reasons behind low uptake among HIV clinicians - and their views on the policy process. Her study also contributes to a better understanding of healthcare workers’ attitudes, which are often cited as problematic.

‘My study highlights the problematic power dynamics and imbalances in the top-down approach adopted by global health organisations in shaping our local UTT policy.

‘Unfortunately, the process lacked meaningful consultation with the key players on the front lines of service delivery. This lack of dialogue and understanding of country-specific challenges led to 60% of HIV clinicians being unwilling to implement the policy as prescribed in its initial phase - despite supporting the policy’s intent,’ argued Monaheng.

However, her findings show that their willingness to implement the policy increased significantly when the clinicians’ areas of concern were addressed in subsequent revisions of the UTT policy.

Monaheng said: ‘This has therefore affirmed the role of consultation in ensuring that the policy is contextually relevant, while providing room for areas of resistance to be known and used to strengthen the policy, thus building trust and avoiding unnecessary revisions.’

Her supervisor Professor Sultan Khan said: ‘This study revealed that international policy and implementation are often top-down driven resulting in failure as local conditions and adaptation are not considered. In this instance the UTT policy as pronounced by the UNAIDS did not take the skills, experiences, and concerns into account for its effective implementation.’

Looking ahead, Monaheng has challenged herself to breathe life into her research by publishing both academically and in the mainstream media.

‘The withdrawal of USAID funding is an opportunity for South Africa to find a new way of thinking and responding to our health priorities. I believe my study provides a potential pathway for discussions on our approach to Global Health Partnerships,’ she said.

Her academic journey was supported by Professor Khan, her supervisor, who provided the perfect balance of encouragement and constructive feedback. She thanked him for his persistence, tolerance and unwavering support.

She also acknowledged Ms Sinqobile Mchunu from UKZN ICS, whose patience and joyful spirit transformed moments of frustration into valuable learning experiences.

Born in Limpopo to educator parents, Monaheng has always valued learning - and encouraged it in her own family. She is especially proud of her son, Phetogo Elijah Mabusela, who completed his BA in Politics, Philosophy and Law (PPL) in 2023, and whom she describes as both her greatest nemesis and motivator.

‘Life is unpredictable. I have lost loved ones, faced mental health challenges, and gave birth to a beautiful - but unplanned - baby at 46. Through it all, my faith sustained me.

‘I hope to always remain curious, bold and committed to social justice - someone who chooses the price of freedom over the comfort of security.’

Words: Jennene Naidu

Photograph: Sethu Dlamini