Dear Mr President, we need to talk about our health system

Upgrades at Pelonomi Hospital show swish and modern new waiting areas and facilities. Now they just need to be staffed properly and be appropriately maintained

Four of South Africa’s top public health systems academics last month sent a letter to President Cyril Ramaphosa as the country grapples with finding solutions for our struggling health services. By Lucy Gilson, Jane Goudge, Uta Lehmann and Helen Schneider.

The four professors, Lucy Gilson from the University of Cape Town, Jane Goudge of the University of the Witwatersrand, Uta Lehmann and Helen Schneider from the University of the Western Cape state upfront their commitment to supporting the development of a health system that promotes health and wider social benefits, and contributes to redressing the inequities in our society.

They believe the 2019 elections provide a window of opportunity to institute actions that could, over the longer term, develop the health system as such a mechanism of societal transformation.

They make important points that should serve as reference for the ongoing and critical needed debates taking place as government considers various pieces of legislation and recommendations to fix our health system.

Collectively, for over 20 years, the professors have been deeply engaged in research to understand what makes our health system tick, what its challenges are and what strategies of positive change may support its development.

As internationally acknowledged, the public sector, as a funder and provider of health care, has a vital role in ensuring that the broader health system offers benefits for all[1].

In the letter the four academics pay tribute to the incredible individuals they have been privileged to work with, people who are working within the South African public health system – serving the population at large, holding true to high professional and ethical standards, making sure health care is offered day in and day out. They state clearly that there are clear pockets of effective care within our health system today.

On the flipside they also state that they have seen the pressures these colleagues are under, resulting from the HIV/AIDS epidemic, the necessary, massive response to it, a complex and changing disease burden, and, more recently, austerity budgets. And they have also seen how these pressures have been made worse by the dysfunctionality of the system of which they are part.

“We are mindful of the key fault-lines facing our health system: the skewed distribution of resources and access between public and private sectors, and the governance crises in provincial health departments. The problems facing the health system have been widely acknowledged.”

The authors identify the recently released NHI Bill as a touchstone for debate about how to tackle these problems. “We are encouraged by the amount of energy that has been galvanized around it, and we fully support the principles of cross-subsidisation and financial risk protection that underpin the Bill. It offers a range of proposals that should stimulate debate about how to strengthen the health system in the interests of the most vulnerable – and it clearly envisages that some of details will be further developed over time.”

However, they have some very real concerns:

“However, we write now to alert you to our real concerns that, first, the provisions of the Bill simply do not address some of the most critical problems facing the public health system.  Second, we are concerned that hasty action now could only exacerbate its existing dysfunctionality. On both grounds, there is then a danger that we will lose sight of the overall goal, namely a comprehensive, integrated and equitable health system.

Global experience certainly suggests that reforms of this scale demand that careful attention is paid to the processes of implementing change[2].  Yet, in South Africa, the process of developing this significant reform agenda has so far neither engaged society at large nor the majority of those who have hands on experience of how the system currently works and are committed to serving society.

We urge you to support actions now that will provide time and space for greater learning about how to manage the process of change moving forward. How we support change in the health system is a necessary component of delivering that change.

Our concerns are twofold:

First, the NHI Bill says very little about some vital aspects of health system development required to serve the interests of the most vulnerable groups in society.

• There is nothing in the Bill about community engagement, although such engagement is internationally recognised as a critical feature of pro-poor health systems[3]^,[4].
• The Bill reflects a bio-medical model of health care, and does not consider the inter-sectoral actions necessary to support health promotion and address the social determinants of health[5].
• Although the Bill touches briefly on patient referral pathways, there is no direction on how to develop a coherent and integrated health system overcoming the multiple organisational silos that already exist; indeed, the new lines of financial accountability alongside existing bureaucratic and health structures seem likely only to fragment the system further. As the World Health Organisation notes, fragmentation ‘undermines the ability of health systems to provide universal, equitable, high-quality and financially sustainable care’[6].
• There is almost nothing in the Bill about human resource planning and management, although this is a central pillar of any well performing organisation – essential in maintaining the motivation of health staff and in building the inter-disciplinary clinical and managerial teams required in a robust health system. Both have direct bearing on the care offered and received.

Second, the Bill’s provisions may well exacerbate current problems and unintentionally undermine the public health system.

These provisions will be implemented within a system that continues to be influenced by apartheid-era bureaucratic norms of control and hierarchy. These norms have been compounded by a top-down approach to change since 1994, primarily bureaucratic and vertical lines of accountability, and weak leadership and management[7]^,[8]. Failures in inter-governmental relations, the politicisation of the civil service and corruption are additional dimensions of dysfunctionality. The prevailing ‘compliance culture’ has prevented the public health system from being responsive to local communities and from creatively responding to routine challenges[9].

We are concerned that without wider measures to tackle this existing environment, the restructuring arrangements proposed by the NHI Bill will only consolidate organisational norms and cultures that contradict the goals of Universal Health Coverage.

More specifically

• the institution of a complex network of contracting relationships may not achieve the performance gains anticipated, and, together with the proposed new governance structures, is likely to exacerbate the existing weaknesses of governance and management capacity at all levels of the health system (facilities, districts, province and national);
• the exercise of powerful financial incentives could crowd out the non-financial incentives that also matter to any organisation’s performance[10] – such as the values that shape the caring behaviours so vital to health systems; wider experience about the impact of financial incentives in health systems offers cautionary lessons[11];
• the Bill clearly envisages a much weaker future role for provincial departments of health, premised on greater centralisation in the NHI Fund, on the one hand, and decentralisation to districts and primary health care contracting units, on the other hand. However, as recent difficulties with contracting private general practitioners from the national level have demonstrated, the solution to poor performance in a complex system is not greater centralisation. The geographical diversity of health needs and size of the public health system are such that the role of provinces cannot be wished away. Rather than seeking to work around provincial departments should we not ask critically  – have we sufficiently used the existing public planning and accountability levers to ensure performance at provincial level? What can we do to strengthen them to play an enabling role in the health system?

Finally, the current public health system crises are clearly one symptom of the broader governance crisis facing the country. The ‘state capture’ project did not only entail corruption, but was also associated with political rather than meritocratic appointments across the health system, with managerial instability, with loss of vision, and with environments of dis-trust. The NHI Bill simply cannot itself address these issues.”

The authors then turn to making a range of concrete proposals:

“We urge that the political and health debate is widened – to address a broader set of issues and to release bottom-up creativity within the health system itself. Strengthening any health system takes a combination of bottom up innovation and top down direction. Even with its challenges, the South African system has a huge reservoir of dedicated health staff and managers with commitment to public service. Their passion and professionalism needs to be harnessed, alongside that of the public at large, to support sustained and long-term health system change in the interests of the most vulnerable groups. We need to shift the narrative around NHI so that it can become the catalyst of energy and action towards that goal.

We suggest four starting points:

• A central focus on the people of the public health system

‘People centred health services’ and ‘people centred health systems’ are international slogans intended to reinforce the message that health systems are, ultimately, human systems. They are slogans entirely in alignment with universal health coverage, as acknowledged in the World Health Organisation’s 2016 Framework on Integrated People Centred Health Services and the 2017 Lancet Commission on the future of health in sub-Saharan Africa.

People-centred health systems focus attention on prevention, primary care, and public health, on the values of respect, dignity, and compassion, and, as the World Health Organisation has argued, recognize ‘the importance of people, processes, systems, power relations, and values in the foundation and pillars of any effort to improve health and wellbeing’[12].

• New thinking about health system governance

International experience clearly shows that governance is a critical leverage point of health system development[13]^,[14].  Strengthening health system governance requires concern not only for structures and legislation, the frameworks of accountability, but also – and vitally – for strengthening the responsible exercise of power by all health system stakeholders. Relationships of trust and accountability have to be established across the system as whole. Values and principles that shape those relationships must be affirmed. The capacities of all health system organisations and actors must be developed[15].

The existing ‘pockets of effective care’ within the South African public health system demonstrate the importance of new forms of governance. Such pockets include numerous instances of well-functioning clinics and hospitals as well as programmatic strengths (such as the widespread access to antiretroviral therapy and vaccines delivered through our primary health care system)[16]. The new forms of governance are illustrated by novel approaches to strengthening district health systems in the Eastern Cape, Limpopo and Mpumalanga, founded on collaborative relationships and reciprocal accountability, with positive health consequences[17]. As a province that has been able to sustain efforts towards an improved and functional public health system over more than 20 years, the Western Cape experience highlights, meanwhile, the importance of stable and purposeful leadership, clear demarcation of, and respect for, the boundaries of political and administrative power, decentralised and distributed leadership, clearly stated values driving health system change and the development of public health expertise and wider learning processes[18].

Whilst there have been health system initiatives since 1994 to address some of the governance processes highlighted here, others have simply been ignored and none have received adequate backing and resources to be effective. Policy requirements for clinic committees and hospital boards have, for example, not been translated into effective community accountability structures[19]. Meanwhile, the more recently proposed National Academy for Health Care Leadership and Management remains just an idea. Yet community engagement and system-wide leadership development are both vital in strengthening health system governance.

Moving forward, energy, technical, political and financial resources must be invested in strengthening the full range of necessary governance processes.

• New thinking about human resource development and management

Without adequate numbers, and equitable distribution, of appropriately trained and motivated staff, health systems cannot serve the most vulnerable groups even if they have funding.

To take effective action to redress existing inequities, the lessons from past human resource initiatives, such as community service and the occupation specific dispensation, as well as international evidence, should be carefully considered to inform a rethinking of human resource development for the health sector. Action must be taken to allow for the better integration of community-based cadres, targeted recruitment of health professional students from under-served areas (something which has been done very successfully in small pockets[20]), and a rethinking of the teaching platform (as envisaged by the National Health Act) to give much more emphasis to primary health care and community-based training[21].  Valuable lessons in this regard can be learned from other middle-income countries such as Brazil and Thailand[22].

In addition, human resource management, presently oriented towards generic civil service rules and personnel administration, needs to be completely reconfigured. Human resource management staff must also be appropriately trained to play a more strategic and enabling role in supporting health care provision.

• New thinking about how to implement health system change

Since 1994, South Africans have criticised themselves for their inability to implement what are generally regarded as good policies. Yet we continue to develop policies and legislation, and debate design details, whilst barely paying attention to the processes of their implementation – leading to unanticipated consequences[23]^,[24]. There is little recognition that new policies are implemented into settings of pre-existing policies and organisational cultures that influence how any new policy is understood and supported, and if and how it takes effect[25].

The lessons of international experience show clearly that organisational and system change cannot be prescribed from the top but must be developed with and through the experience of those within the system[26]. Indeed, the details of policy design often have to be developed during implementation, through processes of learning and engagement with those at the front line of change, such as the public and health staff[27].

The NHI pilot sites, from the first phase of NHI implementation, were intended to serve this purpose. A formal evaluation of their experience is now being conducted, and managers from the sites will have their own insights and experiences to share. However, will there be opportunities for these experiences to inform further implementation or indeed, as has happened previously, will this evaluation be ignored?

In addition, as there are health system challenges that NHI cannot address, how will they be tackled in parallel to the NHI reforms? How can implementation of the NHI proposals avoid undermining the pockets of effective care that do exist? And how can implementing the NHI Bill proposals itself help to develop the organisational capacities needed to sustain health system development?”

The authors then make specific proposals:

“With these four starting points in mind, and given the concerns we have raised, we propose the following as critical steps in public health system reform towards a comprehensive, integrated and equitable universal health system:

• Immediate action to hold to account those politicians and health managers responsible for corruption and mal-administration – sending strong signals across the system;
• The clear separation of political and administrative powers across every level of the public health system;
• An immediate national health consultation process focussed on local level pockets of effective care and aimed both at engaging local level actors in generating ideas for future reforms as well as harvesting ideas about the system-wide actions needed to support local level health system development;
• Dedicated action to strengthen the human resource development and management function across the entire health system – including engagement with the Department of Public Service and Administration;
• Completion of the evaluation of the NHI pilot site evaluation currently under way, and consideration of its results;
• Review of the NHI Bill’s implications for public health system governance, including consideration of the relative roles and responsibilities of the national and provincial departments of health, DHMOs and primary health care contracting units, and paying particular attention to issues of human resource management, clinical supervision and support, and community engagement in decision-making;
• The development of NHI implementation processes aimed at supporting organisational capacity development at DHMO, hospital and primary care levels – possibly through the introduction of district support teams (as a governance and management equivalent to the District Clinical Specialist Teams introduced in the NHI pilot sites);
• A process of trialling aspects of the current NHI Bill proposals (such as the role of PHC contracting units, or payment mechanisms) – to learn through implementation how they might impact on and take effect in the public health system, and so, to further develop the proposals;
• Implementation of a coordinated process of health leadership and management development as a nation-wide and sustained public health system intervention, targeting teams and organisations, not only individual competencies;
• A continuing and sustained nation-wide learning initiative to support the sharing of experience about reform implementation within the health system – considering the lessons of other countries, and engaging with the national department of health, provincial departments of health as well as concerned NGOs and research and education groups;
• Dedicated capacity and resourcing to support these new initiatives;
• Public commitment from the national Department of Health and Presidency for these processes, through supporting and engaging with them.

As academics deeply committed to the development of South Africa’s health system towards the goals enshrined in our constitution, we stand ready to be engaged in these proposed activities.”

Professor Lucy Gilson is the Head of the Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town. Professor Jane Goudge is Director of the Centre for Health Policy, School of Public Health, University of the Witwatersrand. Professor Uta Lehmann is Director of the School of Public Health, University of the Western Cape. Professor Helen Schneider is the SARChI Chair in Health Systems Governance, University of the Western Cape.

[1] Gilson, L., Doherty, J., Loewenson, R., & Francis, V. (2007). Challenging inequity through health systems. Final report of the Knowledge Network on Health Systems. Report for the WHO Commission on the Social Determinants of Health. Johannesburg: Centre for Health Policy, EQUINET, London School of Hygiene and Tropical Medicine.

[2] Balabanova D, McKee M and Mills A (eds) ‘Good health at low cost’ 25 years on. What makes a successful health system? London, London School of Hygiene and Tropical Medicine.

[3] World Health Organisation. (2008). Closing the gap in a generation. Health equity through action on the social determinants of health. Final report of the Commission on the Social Determinants of Health. Geneva: WHO.

[4] World Health Organisation (2016) Framework on Integrated People Centred Health Services. Report by the Secretariat. 69^th World Health Assembly. A69/39, 15^th April 2016

[5] World Health Organisation. (2008). op cit.

[6] World Health Organisation (2016) op cit.

[7] Local Government and Health Consortium. (2004) Decentralising health services in South Africa: Constraints and opportunities – a cross-cutting report. Health Systems Trust: Durban.

[8] Gilson L and Daire J (2011) Leadership and Governance within the South African health system. Chapter 6 in Padarath A and English E (eds) South African Health Review 2011. Durban: Health Systems Trust

[9] Gilson, L., Elloker, S., Olckers, P., & Lehmann, U. (2014). Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care. Health Research Policy and Systems, 12(1), 30.

[10] Frey, B. S., & Jegen, R. (2001). Motivation crowding theory. Journal of Economic Surveys, 15(5), 589-611.

[11] Paul, E., Albert, L., Bisala, B. N. S., Bodson, O., Bonnet, E., Bossyns, P., … & Gyselinck, K. (2018). Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?. BMJ Global Health, 3(1), e000664.

[12] Agyepong, I. A., Sewankambo, N., Binagwaho, A., Coll-Seck, A. M., Corrah, T., Ezeh, A., … & Mayosi, B. (2017). The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. The Lancet, 390(10114), 2803-2859. p.2821

[13] De Savigny, D., & Adam, T. (Eds.). (2009). Systems thinking for health systems strengthening. World Health Organization.

[14] Balabanova, D., Mills, A., Conteh, L., Akkazieva, B., Banteyerga, H., Dash, U., … & Kidanu, A. (2013). Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. The Lancet, 381(9883), 2118-2133.

[15] Agyepong, I. A et al. (2017). op cit. p.2821.

[16] McKenzie A, Schneider H,  Schaay N, Scott V, Sanders D. (2016) Primary Care Systems Profiles & Performance (PRIMASYS): South Africa Case Study. Geneva: Technical Report for the Alliance for Health Policy and Systems Research, World Health Organization.

[17] Schneider H, McKenzie A, Tabana H, Mukinda F, George A. (2017). Evaluation of health system strengthening initiatives for improving the quality and outcomes of maternal, neonatal and child health care in four South African districts. Cape Town: School of Public Health/MRU Health Services to Systems Unit.

[18] Gilson, L., Pienaar, D., Brady, L., Hawkridge, A., Naledi, T., Vallabhjee, K., & Schneider, H. (2017). Development of the health system in the Western Cape: experiences since 1994. South African Health Review, 2017(1), 59-69.

[19] Padarath A, Friedman I. (2008) The status of clinic committees in  primary-level public health sector facilities in South Africa. Durban: Health Systems Trust

[20] Ross, A., MacGregor, G., & Campbell, L. (2015). Review of the Umthombo Youth Development Foundation scholarship scheme, 1999-2013. African journal of primary health care & family medicine, 7(1), 1-6.

[21] van Schalkwyk, S., Blitz, J., Couper, I., De Villiers, M., & Muller, J. (2017). Breaking new ground: lessons learnt from the development of Stellenbosch University’s Rural Clinical School. South African Health Review, Durban: Health Systems Trust pp. 71-75.

[22] Campbell, J., Buchan, J., Cometto, G., David, B., Dussault, G., Fogstad, H., … & Quain, E. E. (2013). Human resources for health and universal health coverage: fostering equity and effective coverage. Bulletin of the World Health Organization, 91, 853-863.

[23] Ditlopo, P., Blaauw, D., Bidwell, P., & Thomas, S. (2011). Analyzing the implementation of the rural allowance in hospitals in North West Province, South Africa. Journal of Public Health Policy, 32(1), S80-S93.

[24] Lehmann, U., & Gilson, L. (2012). Actor interfaces and practices of power in a community health worker programme: a South African study of unintended policy outcomes. Health policy and planning, 28(4), 358-366.

[25] Erasmus, E., Gilson, L., Govender, V., & Nkosi, M. (2017). Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals. International Journal for Equity in Health, 16(1), 164.

[26] Ramalingam B, Jones H, Reba T, Young J. (2008) Exploring the Science of Complexity: Ideas and Implications for Development and Humanitarian Efforts. Working Paper 285. London: Overseas Development Institute

[27] Chapman J. (2004) System failure: Why governments must learn to think differently. London: Demos