Building public health system capacity for NHI: Learning from disease-specific successes for system development

We are reminded on a daily basis of failures in our public health system:  strikes, stock-outs, critical vacancies, vulnerable patients left to die, cancer patients without treatment,  dilapidated and poorly equipped facilities, rampant corruption and wholesale capture of provincial health departments. By Helen Schneider, Uta Lehmann, Lucy Gilson

Yet viewed from different starting points, South Africa’s much maligned public health  system has achieved remarkable successes in tackling particular disease burdens over the last ten years:

• More than 4 million people are receiving anti-retroviral therapy, mostly through nurse-based primary health care, free at the point of use;
• the risk of an HIV infected mother transmitting HIV to her infant declined from a high of 25-30% in the early 2000’s to 1.5% in 2015, through greatly improved detection and management of HIV in pregnancy;
• Progressive realization of new entitlements to a range of maternal, neonatal and child health interventions; and new diagnostic capabilities and drug regimens for tuberculosis.

These measures are largely responsible for the improvements in life expectancy, reductions in maternal and child mortality, and a declining incidence of tuberculosis. They have been implemented through the same national, provincial, district and facility service infrastructure that is also associated with the public sector’s many failings.

As columnists have pointed out since the publication of the NHI Bill, South Africa’s public health system – as both funder and provider – will form the bedrock of a future NHI. Its problems have to be confronted.

What can we thus learn from the disease-specific successes for addressing the wider problems of the public health system? We offer two key lessons, both of which can inform the urgent task of (re)-building the public health system’s capacity and unlocking its latent capabilities:  firstly, an understanding of the processes which led to the programmatic successes described above; and secondly, a recognition that disease-specific responses do not in themselves solve underlying systems problems, which require a different and new kind of focus.

With respect to first lesson, the approaches to HIV and to some extent maternal and child health in South Africa over the last 10 years have been characterized by the following:

• Relatively open systems of national programme leadership that enabled participation and coordinated the actions of clinicians, managers, activists and researchers;
• The development of significant communities of practice, drawing extensively on national expertise, with opportunities to interact in regular conferences, programmatic reviews, and technical committees;
• Service delivery cultures embracing innovation, transparency, information, new scientific evidence and technologies, consensus and learning by doing;
• The development of significant research capacity in universities and statutory research councils;
• The drive to efficiency through measures such as task shifting and strategic purchasing of anti-retrovirals;
• Supportive implementation processes that have engaged directly with frontline providers and the mobilization of local/district level support processes and teams.

Crucially, underpinning these approaches has been scrutiny and holding to account by global health bodies (through the Millennium Development Goals, for instance), as well as a national civil society, able and willing to contest decisions at every turn.

The development of the NHI proposals – from green to white papers, pilot sites and interventions, and the more recent Bills – has followed a very different path. Decision making processes have appeared to many as centralised, opaque and closed. There has been little investment in the development of technical expertise or crucial support systems or well evaluated local experiments. Also absent is a nationally mobilised community of provincial and district managers, practitioners, researchers and civil society players in support of NHI.

The measures outlined in the NHI Bill appear to rest on the assumption that the health system can be fundamentally “re-engineered” from the top through legislative, financial or compliance levers. They ignore the abundant global evidence that health systems function as complex adaptive systems: namely, that they are social and political institutions, are unpredictable, produce unintended consequences, and contain a multiplicity of interacting norms and values.  It is difficult to see how front line health care provision, involving powerful interests and hundreds of thousands of individual, daily transactions, can be controlled, let alone reoriented into completely new and better performance by strings pulled at the top, however necessary or well designed.

Learning from the successes of HIV, MCH and TB programmes, a better starting point would be to recognise that South Africa’s public health system offers numerous instances of positive functioning, has a large number of experienced, public interested and skilled players, and has within it the seeds of renewal.  These are evident in nodes of system innovation and good performance in community-based services, clinics, hospitals, districts and support systems within provincial bureaucracies. Yet these pockets of effectiveness, which could be a source of bottom-up energy in support of system strengthening and NHI remain largely undocumented and uncoordinated. There are few opportunities for genuine national dialogue, and sharing of experiences and learning across institutions, districts and provinces in these areas. Research is also under-developed, and that which has been done, inadequately utilised.

Rather than drawing on the available sources of grounded experience and expertise, wider system change is often reliant on piece-meal (and sometimes contradictory) initiatives from the top, whether on ward based primary health care outreach teams, district health systems, regional and tertiary hospitals, human resource planning and development, information and financial management systems, to name a few.

Changing this situation would require willingness to invest in the functions, building blocks and relationships of health systems with the same degree of leadership, attention and rigour in which HIV and TB were tackled over a decade; and to capitalise on the considerable know-how and know-to already available within the health system, by creating the opportunities for feedback and learning.  We need more consultative processes, reviews, tasks teams and summits which seek to rally, build consensus, chart visions and inform decision-making – not more expensive talk shops to ratify pre-set positions.

One commentator has proposed mirroring the recently completed and excellent Health Market Inquiry with a National Commission of Inquiry into NHI.

In the same way the AIDS social movement led the way on HIV in South Africa, Schools of Public Health, statutory research councils, the Public Health Association of South Africa and civil society organisations need to mobilise under the banner of NHI. Together these could form an important voice in support of a new focus and approach to systems development, and provide the much needed critical mirror on the future development of NHI.

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 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.