As delegates met for the second Presidential Health Summit last week, longstanding, unresolved challenges were back on the agenda, but adding to the woes were several new hurdles, not least load shedding and funding for the National Health Insurance (NHI), notes MedicalBrief.
The summit last week set out 10 key areas targeted for intervention to meet government’s objective of advancing the introduction of NHI, but also touched on some unresolved challenges, like corruption, critical staff shortages and the need to boost nurse training through private-public partnerships.
While it’s the second iteration of the summit (the first one was in 2018), the backdrop remains one of multiple systemic crises in healthcare. There also remain unanswered questions about the overall inaction or slow progress from the first summit, writes Ufrieda Ho for Spotlight.
Some long-standing health sector challenges include failing infrastructure and maintenance of hospitals and clinics, staffing shortages at crisis levels, widespread corruption that goes unpunished, political interference and poor governance, mounting medico-legal claims and costs arising from sub-standard treatment and care, and patient experience of clinics and hospitals marked by high levels of dissatisfaction and distrust.
Bhekisisa reports that there are a number of unresolved objectives that had been laid out at the 2018 summit: in fact, the Health Department had missed a whopping 60% of those goals, which include the following:
Pillar 1 problems: Government didn’t create a tracking system to monitor whether there are enough doctors in rural areas. It also didn’t review the health systems governance systems.
Pillar 6 problems. The Health Ombud’s office doesn't have enough money to ensure it’s funded in full for the next five years. Provinces are still battling with payment backlogs, and a plan to improve services at central hospitals by 2022 failed.
Pillar 7 problems:
Plans to beef up accountability systems for the running of the health system (admin, procurement, staffing) didn't happen. The plan was to separate the political from the administrative parts of the health system without totally removing the oversight role of politicians.
Pillar 8 problems: The government failed to establish functioning boards or clinic committees at all 3 880 state facilities by 2022. It also didn’t update training for CHWs and other health workers.
Compounding problems now was the major issue of power outages, and the impact of the government not having in place a stronger strategy to end the rolling blackouts that have worsened to higher stages of load shedding at greater frequencies each year.
‘Health revolution’
However, President Cyril Ramaphosa said the groundwork of this year’s summit would lead to a “health revolution” in realising universal health coverage.
The NHI Bill presented to Parliament in 2019 will be debated in the National Assembly next month, Ramaphosa said, thereafter the National Council of Provinces will consider it.
“We need to implement the pillars of the compact if our health system is to be prepared for NHI; so what we are doing here is really preparing work for the health revolution to take place.”
The 10 pillars of the 2023 Summit were:
1. human resources;
2. access to medicines, vaccines and health products;
3. infrastructure planning;
4. private sector engagement;
5. quality, safety and primary healthcare;
6. public sector financial management;
7. leadership and governance;
8. community engagement;
9. health information systems, and
10. pandemic preparedness.
Pandemic preparedness was the newly added 10th pillar in the 2023 Health Summit agenda, and aligns with African Union healthcare goals, reports Spotlight.
Focus on corruption
Ramaphosa was scathing of corruption in the sector. “All the crooks and the thieves conspire; it is the healthcare sector they wait to plunder and from where they’re going to siphon money … So making funding available should mean we need to use money properly. We need to watch the money with a hawk’s eye, make sure it is properly used – no overcharging, overspending, or incidents of non-spending …because sometimes money is not spent because people are trying to find ways of siphoning it.”
He lauded investigations by the Special Investigating Unit (SIU) and said stronger partnerships with civil society and protection of whistle-blowers were essential to improve oversight and accountability.
The President also homed in on moonlighting healthcare workers who defraud government and taxpayers in illegal payments for hours worked in the public sector, and those who mistreat patients with bad attitudes and unprofessional conduct.
“To develop a motivated, capable, compassionate workforce, we are working with medical schools, nursing colleges, and other healthcare training institutions… government must invest more in training programmes and increase staffing levels … And community healthcare workers should be integrated into the national health issue,” he said.
‘Teething problems’
He said there was a need to expand public awareness of NHI, which he conceded was having “teething problems” but added, “Working together (to find solutions) includes implementing policies that address poverty, education, housing, transportation, and environmental factors.”
Recommendations
The Summit closed with a set of recommendations from the 750 in-person delegates and about 700 online participants over the two days.
They included new nursing qualifications being “ramped up” through greater collaboration between the private and public sectors; recommendations for alternative resolution mechanisms for medico-legal claims to curb rising bills from maltreatment/malpractice cases; better assessment/monitoring tools to measure the functionality of clinics and hospitals; and better reporting systems to regulate and account for remunerative work outside the public service.
Other recommendations included incentives for provinces that manage their health budgets efficiently and a no bail-out policy for those that fail.
Explaining why a second summit report was needed, Ramaphosa’s health adviser Olive Shisana told Bhekisisa the health workforce in South Africa faced a paradoxical challenge.
“On one hand, we have a shortage of healthcare workers, particularly doctors and nurses, and this has resulted in a high patient-to-healthcare worker ratio … On another hand, there is the large number of professionals who are unemployed – thousands of nurses and more than 1 000 doctors.
“The major factor is the inability of the fiscus to absorb and provide all occupational protections to the number of health workers required for the country.”
Health Minister Dr Joe Phaahla also highlighted corruption and mismanagement as pervading drawbacks to the health sector’s goals to achieve a sustainable NHI scheme, a News24 report says.
The challenges facing the country’s health system were vast and varied, but Phaahla said they were topped by the high burden of disease, poor management, and “outright corruption”.
Additionally, Phaahla said, incidents of poor financial management were still occurring, leading to non-delivery of essential goods and services, and despite an anti-corruption forum being launched in the sector in 2019, “its impact is yet to be seen”.
Even with limited resources, many public health facilities could perform better if it were not for inefficiency, neglect of duty and supervision, and “poor economic performance”, he told delegates.
The first summit had put sufficient and appropriate human resource for health as a priority for any improvement of quality. However, said Phaahla: “While there has been positive intervention e.g. the Presidential Stimulus package in 2018/19 and a further cash injection at the height of Covid-19, sustainability has been undermined by continuous budget cuts.”
Regarding infrastructure, he said that via an agreement with National Treasury and Infrastructure SA, it was agreed “that we need to urgently look at an alternative financing model”.
The mode of delivery of infrastructure also needed urgent reform to increase speed and quality, while reducing wastage and high cost. The estimated cost of all infrastructure needs done in 2019 was R70bn for hospitals and R12.6bn for primary health care facilities.
Yet, “while there is an ongoing roll-out of new placement, upgrades and maintenance projects, more is needed”, he said.
On the up side, the Minister observed, despite severe weakness, the public health system had proven resilient even under the most testing pressure of the Covid-19 pandemic.
“While there were days – especially at the peak – when both the public and private health hospitals ran out of high care and ICU beds, the system did not collapse.”
He reminded delegates that the 2018 summit had identified areas needing attention to improve financial management had included supply chain management, but the subsequent PPE issues had exposed serious weakness, leading to reputational damage.
Promoting UHC and achieving sustainable development, he said, would rely on collaboration between governments, civil society organisations, the private sector, and other stakeholders.
Meanwhile, Ramaphosa's special adviser on social policy, Olive Shisana, told the summit there should be no bail-out for provinces that fail to control their budgets.
She said accruals and medico-legal claims put significant pressure on the provincial health budgets, and that there should be incentives for provinces that make progress and control their finances, reports News24.
“For instance, provinces like the Eastern Cape, which make progress with managing down accruals and medico-legal claims, should be rewarded for progress, with additional above-budget allocations and incentivised to continue on this path.”
But those provinces that showed no progress should not be bailed out. “Improvement in service delivery can only be generated through efficiencies and reducing non-essential administration costs.”
She also called for all stakeholders, including unions, to lobby Treasury, which had suggested that the 7.5% salary increase should be funded by reducing headcounts. She said this was unsustainable.
Among the proposed interventions drawn up at the Summit for the next five years are a parallel system for managing non-pharmaceutical products, with similar governance processes to those used for medicines, she added.
Additionally, all South African Health Products Regulatory Authority registered products must have a single exit price for data sharing, transparency, and benchmarking.
2018 presidential-health-summit-report
Speech by Health Minister Dr MJ Phaahla: Presidential Health Summit (Open access)
See more from MedicalBrief archives:
Opposition parties walk out in protest during NHI meeting
Netcare frustrated by bureaucracy restricting nurse training
NHI Bill ‘won’t be a silver bullet’ in saving public healthcare in SA
Nursing council denies preventing private hospitals from training nurses