SA Health Review: HR weaknesses threaten NHI

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“Major gaps and weaknesses in the current human resources-for-health foundation must be addressed to ensure a high-quality health system and the success of the proposed National Health Insurance (NHI) reforms.”

This, notes Pam Saxby for Legalbrief Policy Watch, is according to Chapter 2 of the Health Systems Trust’s latest annual review of South Africa’s health care system. The review calls for closer collaboration with private health care providers in “rolling out” NHI, however, Saxby writes, without enough efficient, effective public health care professionals to run with the ball, private sector input is unlikely to make much difference.

This is especially noting that, as the August 2019 NHI district pilot evaluation report made very clear, “organisational culture” across the state-run facilities targeted was found to limit problem-solving and innovation, leaving ordinary staff members feeling disempowered, undervalued and demotivated. This may well prove to be government’s most persistent challenge going forward and appears not to have been tackled in any significant way.

The Health System Trust’s review blames a variety of factors for prevailing human resource “weaknesses”, including ‘poor and ineffective operational management across all types of health facilities and provincial health departments, with rural provinces worse off than their urban counterparts’.

Other shortcomings range from the “insufficient stewardship of human resource-for-health planning” – and “gaps, and at times failures”, in human resources governance – to inadequate information on human resource supply nationwide (making it difficult to address “historical inequities between urban and rural areas and the public and private health sectors”). Perhaps most worryingly, however, is the “fragmentation, weak co-ordination and sub-optimal governance of health sciences education”.

Against that backdrop, key recommendations include ‘enhancing’ the technical capacity and expertise required if the national Department of Health is to provide ‘strategic leadership and support for the entire health system’; recruiting public servants with ‘the right skills, competencies, ethos and values’; and deploying them equitably in the context of rural and/or underserved areas.

Diane McIntyre at the Health Economics Unit, University of Cape Town writes in a SA Health Review chapter:

The recently released National Health Insurance (NHI) Bill has once again led to heated debate about health system reform. Some media coverage of the Bill demonstrates lack of clarity on the nature of these reforms. However, much of the controversy is attributable to different levels of “buy-in” to the goal of NHI, which is to move towards a universal health system (UHS). South Africa is not alone in pursuing this goal; it is a key element of the health-related Sustainable Development Goals. Underlying the goal of UHS are the principles of: universality (everyone benefits, not just a privileged few); and social solidarity whereby there are both income and risk cross-subsidies in the overall health system. UHS is fundamentally a redistributive policy and as such it is not surprising that it has generated intense debate.

This chapter explains what the key elements of NHI reform are and unpacks how these elements will contribute to achieving a UHS. It also considers some of the key concerns raised in debates around the Bill, particularly the pace of change; affordability and sustainability of the reforms; and governance issues. The NHI Bill can and must be improved. It is 25 years since the first democratic elections, and there must be greater and faster progress in addressing the serious efficiency and equity challenges facing the South African health system. This can only happen if the public conversation focuses on how best to achieve a UHS, backed with clear explanations of how any proposed reforms will achieve this goal.

It is well recognised that there are challenges in both the public and private health sectors and in the maldistribution of resources between the public and private health sectors relative to the population each serves. There is growing recognition that the NHI proposals are about moving to universal health coverage (UHC), which is a key element in the health-related Sustainable Development Goals (SDGs). Substantial progress towards a universal health system (UHS) cannot be achieved by “fiddling around the edges” of a status quo system. Instead, fundamental system-wide changes are required.

Meanwhile, participants in the public hearings on the somewhat contentious NHI Bill, held on the 28th January in Bloemfontein included several concerned about the implications of “endemic corruption within state-run institutions” for NHI.

This is according to a National Assembly Health Committee media statement, which also note fears that “staff shortages” may well be “exacerbated” by the “emigration” of skilled healthcare professionals; and “uncertainty about where funding for the Bill will come from” given “SA’s high unemployment rate and associated small tax revenue base”. Committee statements on last year’s hearings tended to gloss over these issues, observes Pam Saxby for Legalbrief Policy Watch.

The hearings also drew attention to the need for the country’s healthcare system to be “fixed” and “well-functioning” if NHI is to be successful – especially at primary healthcare level. In this regard, reference was made “insufficient” numbers of doctors, nurses and ambulances; long queues at clinics; and infrastructure development and maintenance backlogs. In view of the “critical role” of primary healthcare clinics in facilitating “equity and access” for historically disadvantaged communities, the committee intends inviting Free State Health Department officials to “explain what they have done to address these challenges”.

This notwithstanding, thus far the nationwide programme of public hearings appears to have pointed to widespread in-principle support for the proposed new piece of legislation in the context of government’s commitment to “ensuring universal healthcare coverage”. Begun last October, the programme is expected to have been concluded by mid-February after one more hearing in Free State province followed by hearings in North West province, the Western Cape and Gauteng.

Legalbrief Policy Watch report

SA Health Review

SA Health Review chapter

Legalbrief Policy Watch report

Media statement

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