Three challenges for public health care
While South Africa's public health care system has come a long way since the end of apartheid, three major issues are worrying Professor Laetitia Rispel.
"We have come to tolerate ineptitude and leadership, management and governance failures; we do not have a fully functional district health system (DHS), which is the main vehicle for the delivery of primary health care; and we have not dealt decisively with the health workforce crisis," said Rispel, the Head of the School of Public Health at Wits, at her inaugural lecture.
Her analysis comes from a 21-year journey in the public health sector, where she worked as a health worker at the Groote Schuur and Red Cross Children's Hospitals in the Western Cape.
"I know what it feels like to be at the bottom of the health hierarchy, in a racially segregated and unequal health care system," she said.
She also was at Wits Centre for Health Policy as an emerging researcher and experiencing the euphoria of contributing to health policy and systems changes in a post-apartheid period. Rispel was the Head of the Gauteng Health Department where she was involved in developing and implementing transformative health policies.
Whilst acknowledging the great work done by Minister of Health Aaron Motsoaledi and a number of public health service managers and health professionals, Rispel said there is little focus in the health departments on the "crisis of ineffective management, incompetence and failures of leadership and governance at all levels of the health system, exacerbated by a general lack of accountability."
Along with a number of colleagues, she recently published a paper on corruption in the South African health sector.
"Corruption is difficult to measure, as there are no validated measurement tools or indicators," She said.
Rispel advocates for a functional district health system because she believes that the current districts are not functioning as decentralised authorities as originally intended.
"The head of the provincial department of health remains the accounting officer, and there are marked variations in financial and human resource delegations across provinces.
"The constitutional autonomy of provincial health departments creates the conditions for different interpretations of what constitutes a DHS and what structures and mechanisms are most appropriate to ensure implementation," she said.
Lack of accountability
Rispel said although the country has a five-year national Human Resources for Health Strategic Plan to address the South African health workforce crisis, the plan lacks detail, it largely ignores lower levels of government, and the vast human resource implications of the National Health Insurance (NHI) appear to be underestimated.
"The critical issue of how to get the right skills and the right numbers of health professionals at different levels of the health system is not even dealt with in the plan."
Rispel said the health system is also challenged by a crisis of unprofessional behaviour, poor staff motivation, sub-optimal performance, and unacceptable attitudes of health workers towards patients
"The lack of accountability is illustrated by our research on moonlighting, which found that 10% of nurses took sick leave to do moonlighting when they were not sick."
After identifying some of these issues, Rispel said there is hope for the future.
"We have a strong foundation to build on. South Africa is well resourced and there is tremendous good-will among many people to help to make things work. There is also huge untapped potential among the Academy in universities, many who are keen to contribute to positive change," said Rispel.
She added that the reforms envisaged by the NHI provide exciting opportunities for health system change in South Africa, which are rarely available in most countries.
Rispel was recently awarded the South African Research Chairs Initiative (SARChI) Chair on the Health Workforce four Equity and Quality. She acknowledged that this Chair comes with the "grave responsibility of generating and disseminating new knowledge on the health workforce and using the knowledge to advocate for positive changes within the health system."
As a SARChI Chair on the Health Workforce, she will focus on these four areas:
A comparative analysis of health workforce policies, planning and governance in Brazil, Russia, India, China and South Africa;
- An analysis of the health labour market in South Africa;
- Research on health workforce accountability and performance; and
- Research on health workforce requirements