Cape Times  20 July 2009

The National Health Insurance (NHI) – in essence a pooling of public and private resources for healthcare – will potentially increase significantly the funds available for health, and therefore, it is assumed, improve access for all South Africans to a wider range of services. However, unless the NHI can significantly change the undersupply and maldistribution of health workers, and enable the development of better management and competent teams at all levels of the health system, it will have a limited impact in bridging the unconscionable gap between the minority who receive private care and the great majority using the public sector.  It is concerning that nearly all analysis and discussion of this major policy intervention pays scant attention to this crucial dimension of ‘service delivery’. For the NHI to be successful, the current human resource (HR) model for health service delivery needs to change.

Since 1994 South Africa has committed itself to implementing a comprehensive Primary Health Care (PHC) approach, within the framework of a District Health System. PHC is based on the recognition that much illness can be prevented and most can be treated successfully and cheaply in the community or at clinic level.  Yet despite this commitment, and the development of many good policy documents, we still possess an overwhelmingly curative medical model, primarily utilising doctors and nurses. The clinic based services are limited in their ability to reach community level, and often inadequate with regard to prevention, rehabilitation and health promotion through intersectoral action .  Essential community based services, such as home based care of terminally ill, have been outsourced to NGO’s, with few systems to ensure continuity of care, and inadequate compensation for services. Thus, much ill-health goes untreated and many deaths still occur from eminently preventable or treatable conditions. It is a source of embarrassment that South Africa is one of only 9 countries worldwide that are moving away from their Millennium Development Goal target in child survival.

In addition to the above, policy implementation has been further hampered by an increasing burden of disease, especially HIV/AIDS and TB, and inadequate numbers and inequitable distribution of health workers between private and public and rural and urban sectors, and between large specialist hospitals and first-level hospitals and health centres. Appalling working conditions and uncompetitive salaries have prompted the recent doctors’ strike and resulted in many health professionals emigrating or choosing to work in the more lucrative and well funded private health sector.
The most recent figures indicate that 57% of public sector recurrent spending on health is on human resources (HR), making this the most expensive component of our health system.  Although on paper South Africa has a respectable number of doctors and nurses, extreme maldistribution results in ratios that are not dissimilar to those in much poorer countries. For example, there are 34 687 medical practitioners registered of which only 10 653 work in the public sector.  In the Western Cape, 7396 medical practitioners are registered yet only 1418 work in the public sector. Indeed, only 30% of doctors work in the public sector, the remainder serving the minority 16% of the population with private medical insurance and some uninsured who pay out-of-pocket.

SA currently has a total of 178 404 nurses (professional, enrolled and nursing assistants) but it is estimated that only 42% of these work in the public sector.  This is likely an overestimate since a significant number are not working because they are sick; are registered but not employed or are working abroad.  Alarmingly, vacancies in the public sector remain high both because of difficulties in recruitment and freezing of posts due to budget cuts: 34.9% medical practitioner positions and 40.3% of professional nurse positions were vacant in 2008. Furthermore, 40% of registered nurses may retire within the next 10 years. Since 1994, there has been a dramatic decrease in the ratio of nurses to population. In 1998, there was an average of 149 professional nurses/100 000, but by 2007 the ratio had decreased to 110.4/100 000. A study of the HR requirements for PHC in South Africa in six of the poorest districts found only 7% of the required doctors at clinics and community health centres (CHCs). Unless both rapid production and the distribution of HR are prioritised, this will remain a significant impediment to achieving an equitable health system.

Even if the NHI fund becomes a reality, the present model will not address the broader health needs of the majority, since extreme maldistribution of doctors results in large sections of the population being unable to access their services. Moreover, even if the NHI could enrol the services of the 70% of doctors in the private sector, it is highly unlikely sufficient numbers would relocate to rural or peri-urban underserved areas. By contrast, lower level workers such as Community Health Workers (CHWs) and Mid Level Workers (MLWs) are much more likely to remain in such areas and robust research shows they can perform many of the functions of doctors and nurses in managing common and uncomplicated illnesses and injuries. CHWs and MLWs are quicker to train and in dealing with the less complicated cases can ease the workload of doctors and other professionals. However, CHWs should be supported by nurses and be able to refer complicated cases to higher levels. In the short term, the skills gap must be primarily filled by CHWs and MLWs, while simultaneously the production of nurses and doctors must be accelerated and their skills base adapted to low-resource settings and the PHC approach.

Transforming the health system to provide accessible and comprehensive care to all South Africans, will require a system more responsive to the country’s needs with a priority focus on district health and particularly the community and primary levels (clinics and health centres) as well as on determinants of ill-health such as inadequate water, sanitation and food security . This should not be at the expense of improving working conditions, staffing and quality of care in hospitals, but there is accumulating evidence globally of the importance of early access to basic care by providing such services close to where people live. Proposed strategies include ‘task shifting’ of selected activities from professionals to CHWs and MLWs which requires redefining the scope of practice of health workers, revising the training curricula of health professionals, increasing production of health workers (old and new categories), and instituting mechanisms to retain health professionals in the public sector. Government needs to utilise presently active CHWs.  While there are thousands of CHWs, there is no defined scope of practice, standardised training or model of working. Many work on single issue (especially HIV) programmes; there is no career progression; and despite carrying out essential health services, the CHWs (who are most often women from the most disadvantaged communities), are often paid a stipend, or expected to volunteer.
Brazil, a large middle income country, two decades ago manifested similar social indicators and disparities to those seen in South Africa today. Since the early 1990’s, Brazil has developed a Unified Health System (SUS), to provide “all Brazilians with universal, integral and equal access to health promotion, prevention, treatment and rehabilitation.”  Decentralisation of health services with social participation in planning and monitoring are core features of the SUS. Implementation of this policy has required a major and radical HR initiative. Multi-professional teams form the core of the health system delivering PHC services through a Family Health Programme (FHP) in a defined geographical community. Each team consists of at least a doctor, several nurses and assistant nurses, CHWs and sometimes a dentist. The work of the CHWs, supported and guided by a nurse supervisor, is essential as they form the link to the communities. There are approximately 250 000 CHWs employed in urban and rural areas. Also notable is that the government funds state Schools of Public Health whose primary function is to train and re-train large numbers of health personnel for priority programmes.  Brazil’s social progress, particularly in health, is acknowledged as impressive, and clearly holds lessons for South Africa whose social indicators are now much worse than Brazil’s.

In South Africa the skills mix required will depend on catchment area size and level of facility, but ideally all facilities within a district should have access to: CHWs, MLWs, doctors, nurses and a pharmacist. Physiotherapists, occupational therapists, speech therapists; psychologists; dieticians; dentists, social workers and specialists should be available through referral, and MLWs should understudy such professionals at primary level.

There will need to be a major increase in staffing of (especially rural) district hospitals, with doctors trained  as generalists with core skills in medicine, surgery, paediatrics, obstetrics, gynaecology, psychiatry, orthopaedics and anaesthetics as well as basic public health. Doctors would share hospital clinical duties and also supervise priority programmes in the district and provide support to CHCs and peripheral clinics. MLWs could complement doctors’ numbers and skills. Rapid production of more nurses, orientated to practice in low resource environments, is an urgent necessity. Health science faculties and nursing colleges need to expand their teaching platforms to include additional facilities, especially rural health centres and district hospitals. Such reforms will require significant and targeted investment by government and a major review of policies and legislation, including that limiting nurses’ scope of practice.

Retention of health workers in rural areas needs urgent addressing. If trainees are selected from and trained in rural areas, they are more likely to stay.  There needs to be improved management support for rural health professionals. Infrastructure and amenities, including accommodation, need upgrading. Clinical support and governance must be improved and should include rotating specialist visits. Understandably, many rural professionals feel abandoned and unsupported in practising in isolated and low-resource settings. More Provincial and Regional specialists are needed with skills to upgrade district hospital services: this implies a new, and overdue, emphasis in specialist training oriented to rural public sector work.

The proposed NHI offers a new mechanism for bridging the huge and unacceptable funding gap between private and public sectors and potentially an opportunity to ensure more equitably distributed quality health care. However, if it is implemented without addressing the HR crisis or fixing the current public health system, it is unlikely to provide increased access to health services, improved quality of care or improved health outcomes.

David Sanders is Professor of Public Health at the University of the Western Cape. He and Bridget Lloyd are on the national and global coordinating structures of the Peoples Health Movement.