South Africa’s healthcare system: eight steps that would get it on the right track

South Africa’s healthcare system suffers from widespread problems in its governance. A number of indicators point to this dysfunction. These include the large number of managers in acting positions, frequent changes in senior leadership, worse health outcomes than similarly resourced countries, and overall deterioration of morale and trust in the public health system.

These indicators confirm that there are system-wide failures. And that much needs to be done to improve governance of the South African health system.

The findings were made by a panel appointed by the Academy of Science of South Africa. The seven-member panel was made up of a multidisciplinary group of South African public health and health systems researchers, academics and practitioners.

The findings underline that poor governance results from many interrelated factors. And that the country’s complex health system is still influenced by its historical context of colonisation, exclusion, fragmentation and inequity.

That said, there are examples of good service and health workers committed to their jobs and to providing good, even excellent care. These “pockets of excellence” can be found across the country and at all levels in the health system. Drawing from these pockets of excellence, we are able to make recommendations about how to improve South Africa’s health system.

We have sought to make recommendations which are clear, informed by evidence, respond to the governance challenges that have been identified and are feasible to implement. Doing nothing may in the long term prove more costly. It will also, among other things, create greater inequality in health in South Africa.

The panel recommends eight steps – in no particular order – to address key governance issues.

The eight steps needed

1.) Define and communicate a clear public value mission and the mandate for each level of the health service and each governance actor.

The National Department of Health has a critical stewardship role to play for the entire health system. It must engage all governance actors in the public value mission of achieving Universal Health Coverage and communicate and institutionalise its goals throughout the health system. This means engaging all sectors, partners and stakeholders in working towards that vision.

The department must set the terms of engagement, create governance arrangements to improve health outcomes, and improve institutional arrangements for accountability within the public and private sectors. Statutory and external regulatory bodies in the health sector, ombud structures and oversight boards should be prioritised.

Staff performance across the health system should be defined by what needs to be achieved rather than simply activities that staff should do. Incentives should promote behaviours and action that will realise the public service mission.

2.) Update legislation and governance structures to insulate them from vested interests and give them executive rather than merely advisory functions.

Accountability structures need to be made effective through the following:

• Amend conflicts within legislation that weaken or undermine the delegation of governance roles and accountability.
• Implement the recommendations of the Competition Commission’s Health Market Inquiry on private sector regulation. The inquiry found that the South African private healthcare market is characterised by high and rising costs of healthcare and medical scheme cover, significant overutilisation, and an absence of demonstrable associated improvements in health outcomes.
• Institutionalise a public value mission in the goals of all health institutions, levels, and sectors which align with and support a national public value mission for the health system.
• Establish arrangements to ensure the focus on the public value mission. For example, set up more than one supervisory entity in a given setting, including an external regulator, ombud, or independent board.
• Create effective accountability structures to prevent capture from above (politicians or senior managers) and from below (stakeholders’ groups, professional groups, trade unions).
• Boards (for example, of statutory bodies) must be structured to ensure separation of entities responsible for nomination and appointing, and removing members. Removal should require a decision by more than one party.
• To govern, boards (for example, of hospitals) and committees must have appropriate decision-making powers for the structure, rather than being limited to an advisory role.

3.) Delegate authority appropriately to each level and within levels of the health system.

Each actor must have the authority required to carry out and take responsibility for their work. If the right people were in place, it would be possible to delegate without (or with less) risk. Oversight structures at each level that are insulated from vested interests would generate confidence that each level was operating within its mandate and to standard. Examples include boards and community groups that measure health outcomes or processes.

The design of the proposed National Health Insurance potentially poses substantial risks to decentralisation by shifting many health service functions to the national level. Attention should be paid to clarify roles and responsibilities of various players when it comes to the NHI fund.

Lack of trust in the managing of the fund can be dealt with by making it independent of the Department of Health with appropriate independent oversight structures.

4.) Get the right people – ethical people with the appropriate competencies – into leadership and management positions within the health system.

To achieve this, merit (demonstrating competencies appropriate to the post) must be the primary basis for appointment. Processes, including the criteria for appointments, must be transparent and open to public scrutiny.

5.) Surround managers and leaders with functional, fit-for-purpose systems so that they can do their work.

This includes human resources, procurement and health information systems.

Procurement is a function governed by too many, sometimes contradictory rules. Simplification of the rules and greater delegation to facility and district or sub-district managers is required.

Overly complex procurement systems are inhibiting decentralisation, as the complexity of existing rules makes it difficult for decentralised managers. This does not mean that every facility should be issuing its own medicine tenders. But there is no reason why strong sub-district offices or larger facilities should not be ordering supplies off transversal tenders without multiple layers of high-level signoff.

Primary care facilities should be able to get simple maintenance problems fixed without waiting months or years for higher level or Public Works Department approval. This lack of delegated powers together with overly complex rules on budgets and procurement is crippling the effective functioning of many community facilities.

The reforms needed on procurement include:

• delegation of procurement powers to facility managers
• e-procurement systems, electronic catalogues with improved price benchmarking, electronic stock management systems, barcoding, and faster simplified electronic ordering systems
• inclusion of medical supplies and equipment in transversal tenders to achieve economies of scale.

6.) Support managers at every level with the resources, understanding and ability to build teams and attend to the relationships that make complex systems work.

Systems of accountability need to be strengthened. However, they must also allow for innovation and learning from mistakes, supporting mentorship and training.

Resources across the country in both the public and private sectors must be harnessed to improve management capacity. Partnerships with research and academic institutions have demonstrated success in the past. The department of health should consider identifying districts to be supported by relevant university departments to strengthen their management capacity and approach.

7.) Harness the potential of community participation in an authentic way to ensure appropriate, respectful and responsive health services and to monitor health service outcomes and processes.

For community governance structures, clear steps are needed to strengthen clinic committees, hospital boards and other entities.

8.) Act on dereliction of duty and acts of corruption and protect whistle-blowers.

To be effective, governance must be understood to be a distributed function that has to operate at all levels. Role clarification and delegation of authority will promote distributed governance.

The public sector’s human resources system in its current form does not advance accountability, as it does not sufficiently distinguish good from poor performance. Decisions such as promotion, continued employment or incentives must be linked to objective assessment based on performance data. Health managers in particular need clearer alignment between HR performance assessment and consequence management.

Managers need to be empowered to act against dereliction of duty. Insufficient consequence management will encourage corruption and incompetent performance.

Managers who do not act against dereliction of duty must be held to account. Delegation and greater local control over HR processes will make this easier.

Action against corruption also requires intervention beyond the health system along with improved functioning by state investigative and related authorities.

Implementation

These recommendations may not be simple to implement. But failure to grasp these opportunities will render Universal Health Coverage even more unlikely and, instead, lead to the situation in which quality healthcare becomes available to only a minority of South Africans.

The panel believes that these recommendations balance the centralisation-decentralisation tension that is present in all health systems. The recent signing of the National Health Insurance Act emphasises the risks of implementing a national health insurance system within the current context of weak governance in both the private and public sectors.

This is an edited extract from the report, Achieving Good Governance and Management in the South African Health System, published by the Academy of Science of South Africa. Dr Mark Bletcher, chief director, health and social, at National Treasury, was also a member of the panel.

Lilian Dudley, Emeritus Associate Professor Health Systems Research, Stellenbosch University; Catherine Mathews, Chief Specialist Scientist, South African Medical Research Council; Flavia Senkubuge, Deputy Dean: Health Stakeholder Relations in the Faculty of Health Sciences, University of Pretoria; Guinevere Lourens, Research Fellow at Ukwanda Centre for Rural Health, Stellenbosch University; Leslie London, Head of the Division of Public Health Medicine in the School of Public Health and Family Medicine, University of Cape Town, and Sharon Fonn, Professor, School of Public Health, University of Gothenburg Sweden, University of the Witwatersrand

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