Stronger governance is at the heart of addressing the health workforce crisis

Stronger governance is at the heart of addressing the health workforce crisisPHOTO: Joyrene Kramer/Spotlight
Comment & Analysis

The recently leaked 2030 Human Resources for Health (HRH) Strategy delivers a grim assessment on the staffing gaps and inequities facing South Africa’s health workforce and outlines an ambitious set of recommendations to address this. The plan stems from a widely consultative process, bringing together points of view from a number of stakeholders and thematic task teams.

While the extent of consultation that went into this plan is to be commended, this is not the first time that the National Department of Health has drafted a wide-ranging and ambitious plan for health human resources. Indeed, such plans are a necessary component of any attempt to address health workforce issues. Since the first “unofficial” drafting of a national strategic plan in 2001 (also known as the ‘Pick Report’), there have been two further plans released by the department. For the most part, these addressed the same issues to those in this latest plan, and there is little to indicate that the new strategy will go a different route.

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Taking a longitudinal look at the HRH plans released to date, it is clear that issues such as vacancies, chronic staff dissatisfaction and poor labour relations, unconducive work environments, maldistribution between the public and private sectors, poor rural retention and a lack of adequate workforce planning are not new. Instead, these are persistent and recurring motifs in the landscape of human resources for health in South Africa, held firmly in place by deeper problems in the governance of the HRH function in the health system. By its own admission, better governance and leadership are the most critical conditions for successful implementation of the 2030 HRH Strategy.

Pointing to the urgent need for a strengthened HRH governance function are the poor alignment of health professional education with actual health system needs (as highlighted in the 2018 Academy of Science of South Africa report), inadequate health workforce information, and ineffective stewardship of the complex HRH stakeholder environment, involving a range of government sectors, professional regulatory bodies and educational institutions.

Ad hoc and reactive

The dominant approach to HRH over the last two decades has been an ad hoc and reactive one, constantly responding to crises, resulting in piecemeal solutions and intermittent bursts of attention and resources, while the required re-alignments based on long-term planning have received little attention. Monitoring and evaluation exercises have all been undertaken in response to these crises or single-focus issues. An example of this is the 2015 Ministerial Report on maladministration in the Health Professions Council of South Africa, while there has yet to be a comprehensive evaluation of the previous HRH Strategies, or of the impacts of significant wider changes, such as the Occupation Specific Dispensations. Additionally, where evaluations are undertaken, they are rarely followed by decisive policy action.

What underlies these governance failures and the intractable difficulties of building an effective and efficient health workforce in South Africa?

We attribute this in part to the legacy of a fragmented and disease-oriented health system, where funding has been largely defined according to single-focus issues couched in conditional grants. This has meant that the transversal HRH function has long been undermined in both structure and stature. The much needed strategic, technical and political capabilities required to steer the HRH function are missing at both national and provincial levels, in contrast to, say, the HIV/AIDS or maternal-child health programmes.


The imminent implementation of National Health Insurance (NHI) and the call for Universal Health Coverage (UHC) may bring a shift towards a more systems-oriented organisation of resources and priorities and bring private and public players together. However, the HRH strategy development and how this intersects with the ongoing debates and discussions about the NHI Bill and UHC has not been clear. Given how central a strong health workforce will be to the success of NHI and the achievement of UHC, it does not bode well that these two discussions have not been more explicitly linked.

The HRH Strategy provides an extensive, in-depth analysis of the HRH situation in South Africa, but also a sobering assessment of the successes of previous strategies. It outlines all the necessary information and guidance required to address the governance malaise underlying the continuously weak HRH function and performance.

However, the recommendations, goals and objectives of national level strategic plans alone are insufficient to bring about the momentum required to shift this landscape. Such plans need to be backed by political support and appropriate, capacitated institutional structures to see the light of day. If this latest strategy is to survive South Africa’s notorious policy-implementation gap, a starting point must be reinvigorated, well-supported and strategically oriented HRH units across levels of government. This needs to be accompanied by strengthened stakeholder engagement across sectors and regulatory bodies, and much improved information management. It remains unclear where the energy and leadership for such changes will come from.

The COVID-19 pandemic has placed significant strain on the health system, while simultaneously highlighting health workers as essential workers – especially frontline staff such as nurses and community health workers. This recognition should see more resources being put towards the health workforce, while providing the opportunity for revitalising previous efforts to orient the health workforce towards the community and primary health care foundations of the health system. The lasting effects of COVID-19, as well as the plans for NHI and UHC, will sharply intensify the need to do much better with respect to the governance and stewardship of the people function in the health system.

*van Ryneveld is a researcher and Schneider and Lehmann (director) are professors affiliated to the School of Public Health at the University of the Western Cape.