The unintended consequences of health policy processes: a qualitative systematic review of experience with the 2007 Occupation-Specific Dispensation (OSD) strategy in the South African public nursing sector

Abstract Health policies inevitably produce unintended consequences when introduced into a health system. These consequences can be linked to factors occurring before and throughout a policy’s development and implementation. Understanding unintended consequences in relation to these factors can help mitigate its unintended health system impact. Current literature reveals a paucity of information exploring this interaction. Examining the 2007 Occupation-Specific Dispensation (OSD) strategy for nurses in South Africa can help fill this gap. We conducted a health policy analysis exploring the relationship between unintended consequences and the factors which occur in a policy process using a qualitative systematic review and applying a longitudinal lens. We included literature relating to the 2007 OSD in nursing and human resources for health (HRH) from 1994 onwards. In data analysis, we applied the Walt and Gilson (1994) Health Policy Analysis (HPA) Triangle to 1) give an overall description of the OSD policy process in the nursing sector; 2) identify the main unintended health system consequences of the policy for nurses and 3) investigate the relationship between the unintended consequences of the 2007 OSD and its relevant contributing factors occurring before, during and after the OSD’s development and implementation. Three main unintended consequences were identified: nursing demoralization; nursing division and a breakdown in the relationship between nursing managers and frontline staff. Our findings suggest that the relationship between unintended consequences and its relevant contributing factors are rooted in the historical and socio-political realities of the health system. Frontline-level actors can help mitigate potential unintended consequences through sharing their historical and socio-political insight. We therefore urge policymakers to include these actors in policy development and implementation processes. Future research should explore the inclusion of frontline knowledge in policy processes as a method to reduce the potential severity and/or number of unintended consequences experienced.