decision space for district health management in south …1 | p a g e aselph: decision space for...

1 | P a g e ASELPH: Decision Space for District Health Management in South Africa: 27 September 2014

Decision Space for District Health

Management in South Africa

A Policy Seminar hosted by the

University of Fort Hare

27 September 2014


CONTENTS OF THIS REPORT

1. WELCOME & OVERVIEW OF ASELPH .......................................................................................... 2

2. INITIATIVES IN NHI PILOT DISTRICTS IN THE EASTERN CAPE ..................................................... 3

3. VARIATIONS IN DISTRICT APPLICATION OF GP CONTRACTING .................................................. 5

4. MDG COUNTDOWN: AN APPROACH TO REDUCE MATERNAL AND UNDER-5 MORTALITY ....... 7

6. DECENTRALIZATION CHOICES FOR DISTRICTS: INTERNATIONAL EXPERIENCES ...................... 11

7. THE DISTRICT HEALTH SYSTEM: IN SUPPORT OF QUALITY PRIMARY HEALTH CARE ............... 13

8. LESSONS LEARNED ON IMPLEMENTING THE ALBERTINA SISULU EXECUTIVE FELLOWSHIP ... 18

9. ASELPH APPLIED RESEARCH AND IMPACT ON ACTION LEARNING METHODOLOGY ............... 18

10. PANEL DISCUSSION AND QUESTIONS....................................................................................... 20

11. VOTE OF THANKS AND CLOSURE .............................................................................................. 24

Programme Director: Professor R Thakhathi, University of Fort Hare

1. WELCOME & OVERVIEW OF ASELPH

Dr Mvuyo Tom, Vice Chancellor, University of Fort Hare It is encouraging to see people coming together at this important seminar to discuss the many pertinent issues on health and policy at both national and international levels. Policy seminars are by nature critical spaces for decisions, since policy guides the actions that must be taken by all stakeholders. The opportunity to share ideas, engage with like-minded people, and possibly influence meaningful change is valuable. The topic is an interesting one – the decision space for district health monitoring in South Africa – where it is necessary to fully understand where decisions must be taken and where policy implementation issues may arise. ASELPH is an agency that seeks to address a critical gap that has been identified in the health sector in South Africa, namely executive leadership. Health management is not specifically addressed in most business leadership programmes. It is thus of great value that the Harvard School of Public Health, together with the University of Pretoria, are partners with ASELPH to build capacity, supported by South Africa Partners, the South African Department of Health, and committed donors. The work of ASELPH is underpinned by a commitment to social justice and equity, whether in relation to an individual or to whole populations, and all the work being undertaken has this in mind. In this regard, it is necessary to keep the importance of social and economic determinants of health


at the forefront of policy decision-making. Social determinants apply equally to education. Recent research indicates that even if children from poor backgrounds are provided with equal education opportunities they will still not achieve to the same extent as children from well-off backgrounds, and the inequities in their achievements tend to persist. This is related not only to direct cash resources that wealthier children have available to them, but also the level of family and social support. The situation with health provision appears similar. A good example is that of the Ebola outbreak in West Africa where there are inequities in responses. The health systems in countries with Ebola outbreaks are inadequate. Poor social environments and cultural impacts also influence the spread of disease, especially contagious disease. HIV/AIDS, for example, is easily addressed in the United States, but remains an ongoing challenge in South Africa. It is important, therefore, to keep in mind the context when decisions are made around health services. The implementation of National Health Insurance remains a central issue for South Africa. International experiences are useful. National Health in the United Kingdom has been in place for many decades yet challenges are still experienced. The United States recently implemented national health insurance in the form of “Obamacare”, which had a key influence on politics, as all national health systems will inevitably do. In debating the decision space for district health management in South Africa, the importance of meaningful decentralization will have some influence in how the health care system is implemented, and how health care professionals can ensure that the critical social justice concerns are addressed so as to promote equitable access. The extent of HIV prevalence in South Africa should always be an informing factor in relation to programming. Provinces are affected differently with some provinces experiencing a prevalence rate of over 30%. South Africa has more than 6 million people living with HIV and AIDS, which contributes to the increasing vulnerability of many households and families. The debate will also be usefully informed by information from the South African National HIV Prevalence, Incidence and Behaviour Survey conducted by the Human Sciences Research Council in 2012; important points in relation to the current prevalence rate include:

• There is a decrease in condom use among individuals 15-49 years of age; • Knowledge about HIV is low, with a national average of 26.8%; • There has been an increase in multiple partners among individuals 15-49 years of

age to 23.1% for males and 5.1% for females; • Age disparate sexual relationships for the 15-19 age group has increased to 33.6%

for females and 4.1% for males;

2. INITIATIVES IN NHI PILOT DISTRICTS IN THE EASTERN CAPE

Dr T Mbengashe, Superintendent General, Eastern Cape Province It is important to be fully informed of where and how policy decisions are made and what informs them. National Health Insurance needs to respond to social issues if it is to be relevant to all citizens. Many factors start at population level. In the triangle of demographics and disease profile, the health system is located to address demographic issues. If the health system cannot respond to the population, cannot meet expectations and does not contribute to equity and social justice, then it will not achieve the necessary objectives. This is, however, a long term process.


The first step is to identify the problems accurately and draw on the National Development Plan to envision the future health of the people. What is needed by 2030 is not only improved health outcomes but also greater educational attainment, increased economic opportunities and an inclusive society. The main outcome of the 2030 plan is a better quality of life for all. It is widely accepted that the location where people are born and live strongly determines health outcomes in all aspects of health, as well as influencing longevity. The implementation of NHI intends to transform the society to the extent that there is a better chance of survival for all. Health care must be addressed where people live and in the context of social determinants of health. A good health system must work for everyone and be accessible to everyone. A key outcome is an HIV-free generation. Addressing the challenges of inequitable access to health care must be underpinned by the efficient use of the available resources. The social determinants of health must be kept in mind, linked to health education, economic opportunities and social inclusion. It is also necessary to address the main mortalities. The NHI itself should promote a shift to addressing poverty, lack of economic opportunity and lack of access to equitable services. The health system can be used as a key driver for change. When the NHI picks up momentum and helps to address the drivers of poverty, the government in taking forward the NHI must ensure that everyone has at least some level of risk protection. The NHI as a programme for transformation will be implemented over 14 years. Funding of the NHI will be driven by universal provision. There are presently eleven districts in which pilots are running, including the O R Tambo District in the Eastern Cape. People tend to move to where resources are available so it is important to assess the social profile of each district. This should influence the allocation of resources and contribute to the NHI being able to drive social determinants and promote equity and social cohesion.

As a society and population, the experience is that the health system is skewed in favour of certain populations or communities. There are many clinical services but a large part of the population has limited access and this needs to change. Clinical resources need to be shifted down to communities.


At district and sub-district level these should be active engagement of all stakeholders including all government departments. When making policy decisions, the shared vision must be kept in mind, while not ignoring the social determinants of health. The decisions being taken at present may only see outcomes fifteen years hence. The Department of Health is keen to promote improved educational attainment, better economic opportunities, greater social inclusion and improved survival. The burden of disease has been due to communicable diseases but this is shifting towards non-communicable diseases that are influenced by lifestyle choices. Another important health concern is that of mental health, which is becoming a major concern in South Africa and indeed elsewhere. At both district and sub-district levels there must be active engagement of all stakeholders, including all government departments.

3. VARIATIONS IN DISTRICT APPLICATION OF GP CONTRACTING

Dr Itumeleng Funani, Honorary Senior Lecturer, Centre for Global Health and Research, University of Fort Hare The private sector has in its employ approximately 13 000 general practitioners who are presently not fully utilized. On the other hand, the State health system experiences a serious shortage of qualified general practitioners. The challenge is to find ways to address this misalignment in the interests of the patient. The NHI will provide opportunities to address these concerns, so that health professionals in the private sector are fully utilized to help address the gaps in public health provision. Contracting GPs in to assist in state facilities has not provided a workable solution. Research is presently being undertaken on alternative contracting models for GPs. Policy work needs to commence with research on the ground


There is limited data in South Africa on primary health care services although there is information available on how the system has worked in the United Kingdom. There is some research based in the Western Cape on public health issues. One of the problems in South Africa is that documentation is inadequate and experiences are thus not shared. This is why it is essential that the health systems research is undertaken in conjunction with institutions of higher learning. A growing trend in the United Kingdom is to contract private providers into the state structures and this is working well. An entire practice is contracted in, so that a given number of GPs is always available to local public health facilities. The policy and vision for the NHI are clear. It is important to commence with NHI implementation as soon as possible and learn as it develops. It is not acceptable to spend 8.5% of GDP on health services but get poor outcomes. The experiences in working with part-time GPs, including district surgeons, reveals that there are continued inequities in that the GPs prioritize private paying patients over those in the public facilities. A survey undertaken with patients indicated dissatisfaction with the short consultation time, long waiting time, and limited information given to the patient. The GPs, on the other hand, complained of poor remuneration, lack of provincial support, limited availability of drugs and challenges with nursing capacity. There is serious concern at both political and administrative level to assess the impact on health outcomes and to identify examples of successful implementation before scaling up. However, existing information reveals that state patients often prefer to visit GPs even where there is a cost to the patient personally. There is a great reluctance to spend the day waiting in a queue. This may also relate to potential loss of income that patients incur. Furthermore, if people are in pain and discomfort they are prepared to pay for quicker relief. It is clear that people largely prefer an intervention that is GP-based. Who are the GPs who must be engaged? In general, GPs work a long week, doing both sessions in public hospitals (40% of GPs) as well as trying to maintain a private practice. Many GPs face a high level of competition and cash flow challenges. Drugs are expensive for cash or public patients and this impacts on what GPs prescribe and hence health outcomes. Doctors may open up a practice with only a certificate and the sector is not highly regulated. Even so, patients tend to prefer GPs rather than the local public health facility. A local example is found in Mthata where there are GPs in practice that are closely located to clinics but people leave the clinic and go to the GP where they have to pay for a consultation and the medication. The reasons for this need to be examined.


A useful example to draw on is that of the United Kingdom’s National Health Service, which has a long history of GP contracting. Capacity is required at local level to contract GPs successfully, which is done in different layers of contracting. Group practice is preferred rather than single GP as this ensures constant availability including for emergencies. However, mechanisms to promote quality assurance are of importance. GPs remain an asset to the national health system, including cash patients, and must be better engaged to service communities. There needs to be a balance between private practice and public work and incentives should be both financial and non-financial. A non-financial advantage to GPs who choose to enter the public health system would be access to new practices and broad exposure. GPs also need to be incentivized to stay current with new developments in health care. The Quality Outcomes Framework provides for 60% of income as basic salary and up to 120% as an incentive component where GPs and other health workers undertake training and remain current with best practice. A payment scale is under negotiation and it is hoped that GP contracts will be implemented from October 2014.

4. MDG COUNTDOWN: AN APPROACH TO REDUCE MATERNAL AND UNDER-5 MORTALITY

Dr Joey Cupido, Deputy Director General, PGWC The aim of this project is to identify and support three Districts to achieve MDGs 4 and 5 – reduction of maternal and under-5 mortality rates - and via the project outcomes, to strengthen the entire health system with particular attention given to the role of the DHS. This requires evidence to inform the development of a delivery model for scale-up. Health provision has been overly hospital-centric whereas a stronger district focus was required. Policies are in place and all policies and protocols have been shared and understood. There is strong political commitment to improving the provision of health care for all and the DHS is a key platform. The Treasury and relevant departments have all agreed on annual and five-year planning


cycles based on a rational planning process. There is extensive information on demographics, causes of death and what the health care priorities should be. Strengthening the role of the DHS requires drawing on current performance and identifying challenges and gaps. The implementation plans need to be linked to other plans such as infrastructure and capital expenditure. The NDOH dashboard for 2014 has 25 indicators at District level. Seven neonatal mortality indicators were identified and all Districts must provide plans of how they plan to reduce this. District Health forms the basis for improved delivery and has been clearly defined as being the following:

A District Health System based on Primary Health Care is a more or less self-contained segment of the National Health System.

It comprises first and foremost a well-defined population, living within a clearly delineated administrative and geographical area, whether urban or rural.

It includes all institutions and individuals providing health care in the district, whether government, social security, non-governmental, private or traditional.

A district health system therefore consists of a large variety of inter-related elements that contribute to health in homes, schools, work places and communities, through the health and other related areas.

It includes self-care and all health care workers and facilities, up to and including the hospital at the first referral level and the appropriate laboratory, other diagnostic, and logistic support services.

Its components need to be well co-ordinated by an officer assigned to this function in order to draw together all these elements and institutions into a fully comprehensive range of promotive, preventive, curative and rehabilitative health activities.

The Outcomes Based Approach (OBA) will shift from input processes towards applying interventions that will prevent the negative outcomes. If there are things that work and reduce deaths, these are what must be utilized. First decide on the intervention, then what resources are needed, and then design an action plan. A critical study by Hofmann documented the outcomes of specific actions for saving newborn and maternal lives:

Seven interventions account for 90% of neonatal lives saved. Eleven interventions account for 70% of child lives saved. Six interventions account for 90% of maternal lives saved.

The above information must centrally inform a plan to address the challenges; the plan must be managed by a single person with the required authority. There should be no deviations from the Standard Treatment Guidelines that are based on international best practice. These provide a powerful lever for improving all health care provision in South Africa. These are linked to resources, consumables, infrastructure and support and provide a neutral and equitable measure. Of particular importance is the adequate provision of consumables. Strong accountability via enhanced Monitoring & Evaluation is essential. Specific individuals are responsible for identified levels of care. Monthly meetings are held to monitor, provide feedback on mortality rates and sharing information with relevant DHS facilities. Where any incompetence is


identified there must be immediate training interventions. Extensive structured communication processes are key to the system working.


The DHS Accountability Framework has been developed and has four pillars drawing on collective wisdom and experience: Governance; Services: Critical Support Functions: and Quality.


5. DECENTRALIZATION CHOICES FOR DISTRICTS IN SOUTH AFRICA: LESSONGS FROM INTERNATIONAL EXPERIENCE

Dr Tom Bossert, Harvard University & Dr Ravindra Rannan-Eliya, Institute for Health Policy, Sri Lanka It is important when attempting to restructure and improve health care, that the objectives form the

starting point. In general the intention is that the decentralization policy should achieve better health

system performance; improve health status in a more equitable manner; provide financial risk

protection; and contribute to healthier and happier citizens. This can be done through improved

access to health services; which are of better quality; where scarce resources are used more

efficiently; and outcomes are monitored and shortcomings addressed.

Equally important in such a process is to have intermediate objectives that lead to improvements. In considering decentralization as an approach to achieving these objectives, there are some basic issues that affect performance:

• Decision Space: How much choice about health services functions should District authorities

be able to exercise so as to improve performance of local district health systems?

• Accountability: How are these authorities accountable both to the higher administration and

to the local population?

• Capacities: What competencies do the district authorities have and what do they need to

have?

A key aspect is to build management capacity within the health sector and this is where ASELPH plays a central role. In the process of empowering health management practitioners, it is important to address the extent of choice that health managers may have over the specific functions that will improve the performance of local district health systems, in the following key areas:

• Financing means choices over funds that come into the district or mobilizing local sources of funding. Involvement in budgeting processes is critical. Capital expenditure is a particular challenge.

• Payments relate to the choice of methods of paying private and public institutions

and individual private providers, as well as managing GP contracts and large

tenders. There is also competition for funding from the private sector.

• Human Resources in the public sector are challenging to manage. Who will hire and

fire, promote and motivate and manage incentives?

• Service Provision needs to accommodate diverse needs and demands and

accommodate varied demographic needs while complying with the norms and

standards and priorities of types of services within the health sector.

International experience indicates that certain functions are delivered better when centralized, namely information systems; auditing, which is particularly important in the context of addressing corruption in South Africa; maintaining quality norms and standards; implementing major national priority programmes; economies of scale and bulk purchasing since many health purchases are high-cost items; and merit-based systems of human resources management that will promote equity and the deployment of appropriate skills.


Other important points to take into account when developing DHS processes include:

• Ensuring service delivery flexibility to demonstrate performance enhancement, informed by priorities at district level, since this is where patient needs are met or not;

• Addressing absenteeism and drawing on communities to hold people responsible for good delivery;

• Working at district level with other institutions and developing the necessary capacities to expand effective decision space;

• Providing incentives to improve performance and allocating responsibility for all outcomes; and

• Reducing opportunities for corruption through increased local engagement. There are three governance options available for consideration:

1. De-concentration within the organizational hierarchy which is the approach that has influenced the NHS in the United Kingdom;

2. Devolution to local government, for example in Chile and Sweden where hospitals also devolve to county government, which has the advantage of helping to mobilize additional resources from the local tax base who are the primary users; and

3. A quasi-autonomous public corporation which is separate from local government structures and which has a board of governors that holds staff accountable and provides greater business case flexibility – such as in Hong Kong, Vienna, Singapore, Ghana and New York.

Key international learnings include:

• Whatever option is selected is not the most important decision; rather, how it will be implemented and developing detailed plans is the greater challenge;

• Implementation is key – people must be held accountable for own delivery. • Strong information systems are critical to successful implementation; and • The success of devolution depends on the capacity of local government to implement.

There are two different paradigms:

1. Purchaser-provider separation and NHI purchasing which implies that greater

weight will be given to financial incentives to drive provider performance with

accountability and influence being done at a distance, which requires a strong

reliance on regulation;

2. Vertical integration and/or de-concentration implies a greater weight being given to

improving management of managers and exerting a more co-operative and directive

influence.

These two different paradigms may be contradictory. The design of district authorities has to be done in tandem with that of the NHI. Purchaser-provider separation and direct funding by central government in the United Kingdom resulted in the elimination of middle-level authorities. This is a major shift that must be taken into consideration. The decision space framework will also need to take this into account.


The following are some aspects of the international experiences in relation to health management choices:

• De-concentration requires strong skills to manage the managers. Many hospital and health managers are medical doctors rather than managers and this must be kept in mind.

• In Australia, Hong Kong, Malaysia and Sri Lanka, management skills are provided through ongoing training, in some cases six years of post-graduate training.

• Managers need to have at least equal and preferably higher status than those reporting to them. Health management status must be enhanced.

• When devolving to local government there can be a negative impact on equity provision, such as in Malaysia, where a central agency was needed to ensure the equitable provision of resources.

• Where a quasi-autonomous public corporation is selected, such as in Hong Kong which corporatized all hospitals under one national agency, the key challenges will be to maintain equity of access and cost control. Strong budget caps will be required.

• It is important to ensure that the goal of equity is not undermined; in Hong Kong, for example, which is a good example of autonomous public sector provision, for every dollar raised by the hospital authority a further dollar is provided from public grants.

• Autonomous entities can be difficult to manage well, and this is a common challenge where public sector delivery is not well managed and then reviewed and discarded.

6. SOUTH AFRICA’S DISTRICT HEALTH SYSTEM: IN SUPPORT OF QUALITY PRIMARY HEALTH CARE

Ms Jeanette Hunter, National Deputy Director General, Primary Health Care The current national vision is better health for all in South Africa, without exception. This requires a strong interaction between the sociopolitical environment and the economy. The social determinants that influence health must be addressed and the health system must begin to improve with immediate effect and impact. This starts with quality ante-natal care through every other illness. The broader environment from which patients come cannot be overlooked. Education is central to improving health care outcomes, since educated and informed people are better able to take care of themselves.


South Africa has a significant burden of disease, which includes communicable diseases, maternal deaths, high levels of violence, and non-communicable or lifestyle illnesses, as well as increasing mental health challenges. The influence of social problems in exacerbating the burden of disease cannot be overlooked. Education also plays a critical role, where research indicates that people with higher educational attainment have better health outcomes. The continued inequality in South Africa remains the highest in the world and is a direct influence on poor health outcomes. It is thus key to equalize society and address the provision gaps. The quality of housing, for example, plays a direct role in increasing TB rates. Limited provision of clean water,


lack of adequate nutritious food and high unemployment levels all contribute to the burden of disease as well as greater aggression and social issues. An important aspect of health provision relates to the deployment of GPs into State facilities. It has been noted that conditions in public facilities can be challenging to GPs in private practice as are the lack of equipment and medication. These infrastructure challenges are being addressed and it is expected that around 200 GPs will soon be appropriately deployed. It is important to ensure that all doctors subscribe to the same treatment guidelines. The clinical service provision environment needs to be sufficiently improved before patients are sent to GPs. There are strict parameters to what can be funded by government in terms of health provision. The NHI cannot be expected to fund services that are not equal in quality as this will simply exacerbate current inequities. District Health Systems strengthening thus remains a key component of improved health provision.

It is recognized that local government structures do not at present have the capacity necessary to deliver optimal health care. Public health systems therefore need to work with other stakeholders such as the private sector, traditional healers, non-government organizations, other government departments, and international supporters. The aim of primary health care provision is to keep people healthy in their own location and with ready access to health care when needed. This draws on the six World Health Organization building blocks as well as the Maputo Declaration which is considered more informative as it includes research. All the decisions and planning of the NDOH are based on solid research and evidence. In South Africa, national and provincial departments are equally accountable for health service delivery and districts are required to implement services in accordance with legislation. Where districts cannot deliver, this is linked to provincial health departments not delivering. The recent baseline audit conducted by the Health Systems Trust indicated that 40% of public health facilities are in a poor state and unable to function well. This applies to all nine provinces. Providing greater decision space at the district level has the potential to begin to address such challenges. The HST


study showed that hospitals are functioning better than clinics which influences the consumer demand, where people avoid their local clinic and insist on being treated at a hospital. This is an indication that provinces have not invested sufficiently in the local infrastructure of the 52 health districts. Improved integration between the district health facility and communities should incorporate the important role of community health workers who have been instrumental in improving the presentation of pregnant women for ante-natal care before 20 weeks. District clinical specialist teams have improved referrals upwards from communities. In the Free State, for example, the improved referral system has reduced the maternal mortality rate. The implementation of the NHI requires as a cornerstone the development of the Ideal Clinic. The Office of Health Standards Compliance will function as of April 2014 in an independent capacity as a health ombudsperson and the Ideal Clinic process will provide an internal auditing tool to comply with that Office. Surveys from 2011-2012 identified a number of critical issues in health delivery across the country. It is of great concern to report that in April 2014 a mock inspection showed that not only did those facilities fail to effect the required improvements, but in many cases had fallen even further in quality delivery of health care. The critical question therefore is why primary health care facilities continue to deprive citizens of their right to health care, to the extent that while 60% of PHC function adequately, a significant 40% are failing their people. Key Takeaways:

• Infrastructure and resource provision must be improved. This is acknowledged. However, the lack of professionalism on the part of nursing personnel in particular remains a grave concern.

• Extensive visits around the country have been undertaken and facilities visited on the ground which indicated that in relation to resource provision, including medication, there are few problems at depot level.

• Achievements include no user fees at PHC level for the indigent, increased PHC visits from 68 million to 120 million in the past financial year, strong health promotion programmes, and the largest ARV programme in the world which reaches 2.5 million. Life expectancy has improved.

• Ongoing challenges include the increase in mortality of non-communicable diseases, and the growing challenge of mental health, which is of great concern and will be included in the post-2015 MDG agenda.

• Early detection of diseases should be improved and communities mobilized to take better charge of health outcomes. This will link with the improvement and strengthening of downstream facilities provision.

• A critical aspect of improved delivery is a strong M&E unit at provincial level. • The ideal clinic is an exciting concept that will feed positive results upwards via report cards

to the province which should become the monitoring and evaluation body and strengthen where required, while the district must provide services. This can only be achieved with the provision of optimal decision space for the DHS.

• Keep in mind that there will always be certain elements of health service provision that must remain centralized, such as revenue sources, so as to promote equity.

• National Treasury will need to give permission for health departments to contract outside of GPs such as dental, speech, optometrists, audiologists and psychiatrists. All must have


greater autonomy. However, salaries must be centralized to avoid disparities. This is strongly demonstrated in the international lessons.

• The country is at an exciting juncture in its provision of health care and a common commitment is needed. The current decision structures can be maintained but need to work better.

• The role of the NHI as a fund can be separated from the facilities but provinces must also provide key support to address issues and gaps.

• Monitoring is key. The NDOH itself is policed by the WHO. Everyone must be monitored, both upstream and downstream.

• It cannot be business as usual – there has to be radical change for improved service delivery and health outcomes, including mental health.


7. LESSONS LEARNED ON IMPLEMENTING THE ALBERTINA SISULU EXECUTIVE

FELLOWSHIP

Professor Pinky Seekoe, Head: School of Health Sciences, University of Fort Hare / Overall Manager: ASELPH Programme ASELPH provides a unique partnership with a range of partners, and provides an important opportunity for contributing to the transformation of health systems in South Africa. It aims to strengthen human capacity in health leadership and management. This is a ministerial imperative and requires a high level of commitment The initial needs assessment of the programme where research was undertaken to identify needs on the ground revealed that many high level staff were unable to function as expected and also demonstrated an inability to use their decision space well. Training spend since 1994 has been high but with limited results. A key concern remains the inability to manage performance. Highly targeted management programmes were thus developed and careful selection processes undertaken to identify the candidates with strong potential and ability. In many cases this proved to be challenging since it was discovered that a high number of health management employees did not have appropriate qualifications. The University of Pretoria as a partner was central to identifying the required academic parameters and criteria. The course is run as a multi-pronged diverse technologically advanced intervention and the partnership of Harvard University has been integral in this regard. Mentoring is also a critical aspect and mentors are shared between UP and UFH. The Harvard case methodology approach has been strongly implemented with good outcomes. Action learning methodology is a critical approach that includes community capacity building, while the importance of good research is emphasized. The main challenges to the Programme include the lack of high level candidates, an inability on the part of candidates to properly delegate their responsibilities and focus on their course, the difficulty of high level personnel being released by their departments, and the challenges inherent in ensuring academic rigor and quality at all times. The takeaways include the importance of a unique partnership between the partners which provides an important opportunity to promote networking and collaboration for improved health outcomes; the space to share experiences on the ground; the academic space to draw on international research and case work; and the opportunity to contribute to building the national health system via the NHI.

8. PROGRESS IN ASELPH APPLIED RESEARCH AND IMPACT ON ACTION LEARNING METHODOLOGY

Professor Stephen Hendricks, ASELPH Programme Manager, University of Pretoria A key objective of ASELPH is to promote development scholarship and leadership. Regarding health policy praxis there are always successes and failures that inform the work and the African experience is not unique. However, the responses are unique to the specific context and should be informed by research and case study. Informed research must be relevant, rigorous, empowering, and critical, and add value. Business focuses on return on investment and the public service the return on investment is seen as service delivery. Opportunity cost is a key aspect of assessing return on investment.


Where people are healthy, this must be sustained. Community based health services must provide evidence of their delivery outcomes. This is done to good effect in Cuba and shows the positive influence of a healthy lifestyle. Evidence-based management and leadership are important since people become entrenched in non-productive attitudes that are not evidence-based. New ways of thinking and doing are critical. Good data is essential to making informed decisions. This is a particular deficit in South Africa that is being addressed. There have been useful baseline household surveys done that can be drawn on in the interim. The importance of strong and equitable human resource management and strict monitoring of deliverables is essential. This is the main factor affecting quality of service delivery. It links directly to the extent of decision space that health management is allowed. Hospital quality and costing studies are being undertaken and the outcomes are keenly awaited. For example, both the NDOH and Treasury are keenly interested in this study for service delivery and costing reasons. This will be done in two phases, firstly using cost accounting methods to derive the cost for each major service rendered by hospitals (ideally use the ICD 10 codes) which will be useful for managerial decisions and comparative analysis. Secondly, it will establish standards for the measurement of services and clinical quality of services. This information will be useful for managerial decisions as well as monitoring and evaluation at district and provincial level. Accurate quality and cost information is especially important to NHI implementation. A training and incentive structure for community health workers is required. Training is needed beyond HIV care and the required education content needs to be examined and discussed. The incentivization of community health workers is important. Research is needed on all these various aspects of health care delivery. The knowledge being acquired in academic sessions should be documented and shared and utilized. The public is the shareholder and must be reported back to in essence. Quality of engagement with all stakeholders in the health workplace needs to be strengthened. For example, clinical ward rounds must be emulated and become management rounds used to transfer leadership and management that is linked to M&E so that people learn organically from each other. This will also provide space to share international experiences. Knowledge management in public health practice must be based on applied research findings. Each person can be tracked and their extent of knowledge management assessed. Four areas of applied research will become a platform for information. For example, if the Minister is building a platform for the NHI, what research is needed to strengthen that platform? Concurrent research must inform these processes. ASELPH is in a position to contribute strongly to these four areas.


9. PANEL DISCUSSION AND QUESTIONS

Chaired by Professor L Obi, Deputy Vice Chancellor Academic, University of Fort Hare Delegate Comments and Questions:

1. KwaZulu-Natal: Policies for health systems are good and we are working well with other departments but in attaining the MDGs and in general with other indicators the results are not good. It is a concern that facilities are provided but then destroyed by community members. What is needed is improved social science to educate people about improved health outcomes.

2. KwaZulu-Natal: The cost of private GPs to see state patients is not sustainable or effective for public health but what is the type of alternative public-private partnership that we could engage in because private sector involvement is necessary. The market could be regulated to control cost escalation. We must support the idea of health services as a private market.

3. Eastern Cape: In creating competition between the public and private sectors, how can government stimulate that competition and what international experiences can be drawn on, taking into account the existing culture in public service.

4. Eastern Cape: In the O R Tambo District, thanks to national and provincial intervention, there have been infrastructure improvements and there are an additional 16 structures for GPs to consult. However, the space is only used when GPs are there but is under-utilized the rest of the time. This relates to managing supply and demand.

5. KwaZulu-Natal: One challenge is the limited rural connectivity which is required in preparation for NHI. Banks could be asked to assist as they have established infrastructure and can also assist with funding and payment mechanisms.

6. OR Tambo NHI Pilot Site: There is a concern that separating sub-districts from district hospitals in the context of scarce resources will not work well. The hospital is the central point catering for clinics in each catchment area of that hospital, so that no clinic will lack nurses or materials. This worked well before and was then changed and now it is not working at all.

7. O R Tambo District: PHC re-engineering is useful but the challenge lies in provision of outreach teams to communities as was done previously. Those trained to do outreach work must continue to do that. Team leaders for outreach are needed at the clinics. Furthermore, the strategy for contracting GPs does not explain how they will be monitored in relation to time spent at a facility. The experience has been that GPs get paid but do not provide a service to the facility.

8. University of Fort Hare: The NDOH is commended for supporting ASELPH and ensuring that health managers are here. There are national norms and standards and tools to assist. There is a concern, however, that psychologists and psychiatrists are not mentioned yet the DDG noted the increasing mental health concerns. Many doctors simply prescribe anti-depressants to people who should have psychosocial counselling. Doctors need to be trained further and should also be better regulated.

9. KwaZulu-Natal: The KZN-DOH is keen to support its provincial and district managers and the ASELPH approach is valued, since it includes ongoing mentoring and support. In KZN 3 NHI pilot districts are hosted, where 28 GPs are contracted. There have been challenges but it is important to make GPs feel needed and valued. They require assistance with training and capacity development and sometimes practical support such as the use of vehicles for rural work.

10. A key aspect is to promote partnerships with communities and empower them to take charge of their own health matters. This must be strongly encouraged


11. Research shows that traditional medicine can be successfully used but their role is not stipulated in the NHI plans. It is important to work closely with traditional healers. The specific role of NGOs in health delivery should also be clarified.

12. State obstetrician: There is a concern that clinical supervision in clinics is inadequate. Legislation should also be improved so as to protect both health personnel and patients. There are often poor skills and this leads to greater mortality rates. There is a lack of emergency readiness which should be a core competency for professional nurses who work in a clinic. They need first-hand exposure to emergency situations and should be able to stabilize patients in emergencies.

13. There has been a rise in maternal mortality since sessional GPs came in since they do maternity work but have not had sufficient exposure to the public health challenges. The basic training must be legislated and GPs should only be contracted if they have requisite additional skills.

Response from Dr Bossert:

1. It is usually the case that social science processes are thorough and slow, whereas

governments prefer quick answers. The interest in using social science research to inform delivery is growing so there is a need to work with the available resources but within a reasonable period of time to assign different ways of doing work with communities and interacting with the communities in ways that will generate better models or methods for community health work for government to pursue. Harvard students, for example, are keen to undertake research in communities and assess developmental outcomes and impact.

2. Regarding competition between the public and private sectors, there was a theory that in Colombia which had an inefficient of public sector but with a monopoly on health provision it was not necessary to have competition. However, patients could go to the private sector. In Colombia a national health programme was designed and implemented where the money follows the patient, and the NHI paid either provider. The private sector was more accustomed to competition and was likely to have better quality and more efficient services whereas the public sector lacked experience in competing. Budgets for the public sector were reduced and they were allowed to obtain funding from health insurance companies to meet the demand and were given this competitive advantage for a period of ten years. This did not work and was opposed by unions and the public. The budgets remained in the public sector.

3. In Chile a private university attempted to show that the private sector can do better than the public sector with the same per capita funding and an agreement entered into with government to provide the same kind of services as the public sector with the same per capita funding as the public sector. The model and initiatives in the private sector became the activities of the public sector. It learned from the private sector and became a competitor and there is now little difference between the two sectors, which indicates that it is possible to make such a shift.

4. When communities destroy public property the social sciences tell us that they are frustrated at not being heard. Address issues locally and proactively before they escalate. A key problem with management in South Africa is that it is not sufficiently proactive in addressing challenges.


Response from Dr Rannan-Eliya:

1. In encouraging health care workers to work more closely with communities they need to understand their role better and academic partnerships will promote this, particularly social science studies.

2. Regarding the choice of private services and how to promote competition under some kind of funding arrangement, all things being equal, there is neither a better nor a worse approach. They are organized quite differently in most aspects. In India, for example, both approaches are equally well funded, whether public or private. In other countries, health care facilities compete for the same funding under a single financing mechanism – examples are found in Japan, Germany and most of Europe, South Korea and Taiwan. In most of these systems, it is not possible for the private sector to supplement over and above the public amounts that are being paid. It is hard to predict the outcomes when the scenarios are so different.

3. In the United Kingdom, for example, private capital was used to develop public hospitals under Margaret Thatcher, but the private projects found it hard to compete when similarly priced. In the past five years there has been a push-back because private facilities are more expensive, but may not always be more efficient.

Response from Ms Hunter, Deputy Director General, Primary Health Care

1. Clinics at all levels should arrange Open Days for their communities and share more with them. Community dialogues are key to proactively pre-empting many challenges.

2. It will be a challenge to sustain a practice of paying R200 per patient for GPs. Funding must be found elsewhere. The NHI must be sustained and is grounded in strengthening PHC with comprehensive services.

3. Regarding the role of psychologists, the NHI stipulates comprehensive provision of health care. The Treasury must identify funding sources which are ultimately taxpayers’ monies. The NHI must be affordable, therefore the model with GPs providing services is being used.

4. In seeking to assure the quality of provision and conduct M&E, there will be basic mentoring and training for GPs before working in the public sector that will be compulsory. GPs must comply if they wish to benefit. Timesheets will apply as they do for all health personnel.

5. There has been much concern regarding situations where GPs have been paid by the state for work not done. Therefore a new approach has been taken. There are now 200 GPs working via NDOH and this is challenging in some aspects. NGOs will be contracted in to manage both delivery and clinical quality.

6. Regarding the lack of nursing skills, the playing fields must first be levelled and only then can the NDOH contract GPs to see people in the facilities. It is important to embrace the concept of health as a social commodity.

7. Infrastructure in the OR Tambo District is working well. Quicker structures have become possible with new building technology – these are no longer temporary and are of an acceptable standard. Great strides have been made in this regard. The Minister’s requirement is that all health workers must be comfortable in their work space. Some facilities may be empty at present because of lack of suitable staff but this will change.

8. The Malaysian model of getting results fast in response to long-standing problems provides a useful starting point, and one aspect is the provision of health facilities. The Ideal Clinic is an immediate priority and comprises 195 elements. The challenge then is to scale up the approximately 3 000 health facilities to the requisite levels. One key component is human resources strengthening.


9. It is the prerogative of government at the highest level to decide how to scale up and commit resources to the plan. Clinics cannot themselves address understaffed areas.

10. Some models in the Eastern Cape are not working because there is too much separation between district and sub-district. Some provinces like the North West are even further divided. Some provinces do not have any sub-districts. The district hospital must be a referral node for a number of clinics, some of which may be open only 8-10 hours while other clinics will be open 24 hours. The community health centre is a step higher than the clinic and a 24-hour open time is standard as is the provision of more advanced services. NGOs will manage some services using external funding. The lack of adequate emergency skills must be addressed as must the situation where GPs may have knowledge or practices that are not current.

Response from Professor Obi:

1. It is expected that qualified professional nurses provide emergency assistance in a health facility. This is linked to the regulatory requirements for all nursing personnel. There is work presently being done at NDOH around improving statutory compliance for all health personnel.

2. Rapid response teams in the provinces are headed by senior management – each district has a manager. The reason for this is to support what has been said about lack of capacity and skills and NDOH will support districts to begin to address these concerns.

3. RRT goes to district, identifies challenges, and deals with challenges, whether infrastructure challenges such as poor maintenance, or human resource problems such as vacancies. People with decision-making capacity are thereby supported.

4. The nursing profession has been operating with the same curriculum for many years and is not current with international shifts and health reforms. It needs to respond to the changes so that nurses are capacitated to meet current needs. There are changes underway at NDOH that will include the introduction of clinical mentors. When a nursing student is placed in a hospital this will ensure that the student is exposed to every training and issue that may arise, including specific rural challenges.


5. ASELPH Fellows are requested to select research topics that have relevance for curriculum such as the impact of community service. Key challenges can be identified and explored further with recommendations made. This will be an important contribution.

11. VOTE OF THANKS AND CLOSURE

Professor F Aghdasi, Dean of Science and Agriculture, University of Fort Hare Professor F Aghdasi reflected on the days’ proceedings and expressed the hope that having gained much knowledge, those who were present will renew their focus on “Action Research”. It is also important for this group to meet regularly so as to provide updates about what is happening in the Eastern Cape and indeed elsewhere in the country. Much can be achieved where people work collaboratively. The social determinants of health, as emphasized by Dr Tom, must remain at the forefront of the work, keeping in mind the link between health outcomes education, safety and security, science, human rights and justice. The speakers for the day were acknowledged for their valuable contributions:

Dr Mvuyo Tom

Dr T. Mbengashe

Dr Terrence Carter

Dr Itumeleng Funani

Dr Joey Cupido

Dr Tom Bossert

Dr Ravindra Rannan-Eliya

Mrs Jeanette Hunter

Mrs M. Tiseo

Prof Pinky Seekoe

Professor Stephen Hendricks

Professor L. Obi

Professor F. Aghdasi

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