NATIONAL HEALTH BILL

1. NATIONAL HEALTH BILL Submission at Public Hearings 18/19 August 2003 Prof. David Sanders School of Public Health, University of the Western Cape

2. Focus of submission • Presentation will focus on three key areas, which fall within our particular area of expertise and concern: • Equity in health service delivery • Human Resource Development • Health Information systems

3. 1. Human Resource Development • What is Health Human Resources? • Summary of HRD elements in the Health Bill • The 1997 White Paper on Transforming the Health System • Key issues • Suggestions for changes to Bill

4. What is Health Human Resources? • Before we focus on the Bill and in order to understand better what we argue later, a brief map of what human resources for health entails in terms of elements and functions:

5. Human Resources for Health (HRH) refers to • All personnel working within the health system and towards the health of the country, whether they are Nurses, doctors, dentists, physio-, occupational or speech therapists, pharmacists, community health workers, paramedics, traditional birth attendants, cooks and cleaners, clerks and administrators

6. Importance of HRH Development • Human resources account for ±70% of recurrent expenditure • Health HRD is a primary step in health systems development • Health sector “reform” has entailed a move to decentralised health services which need to implement a Primary Health Care Approach

7. How and where do human resources fit into the health system?

8. Components of Health Systems • ”HARDWARE” • Facilities e.g. Health Centres • Technology / Equipment / Drugs • Transport • Communications • “SOFTWARE” Human Resources for Human Resources Health Communities Other Sectors’ Personnel

9. Human Resources for Health Quantitative Numbers / Distribution Health Personnel Qualitative Competence: Knowledge Skills Attitudes

10. What is HRD? • Defining and developing human resource policy and facilitating implementation in line with health service needs. • Overseeing the education and training of health workers. • Ensuring the supervision, support and development of health personnel.

11. Human Resources Development (HRD) encompasses three major functions regarding the workforce • Planning • Training and skills development • Management and motivation

12. What is HR Planning? HRH Planning ensures that we have: • the correct categories of staff, • in the right numbers, • in the places where they are needed, • at the time when they are needed, • with the appropriate skills to perform required tasks, • at an affordable cost, • in line with identified health service needs. A prerequisite for planning is accurate information.

13. What is HR Development & Training? HRD&T ensures that all present and future staff receive the appropriate initial and continuing education to render effective, efficient and appropriate service.

14. : What is HR Management? HR Management functions include: • Employment • Utilisation, functioning, retention • Support • Development

15. HRD is broad in scope and is the key pillar to any health system. • If the human resource component of the health system is dysfunctional, for whatever reason, the health system cannot function.

16. How do human resources and human resource development feature in the National Health Bill?

17. Summary of Chapter 7 (sections 53 - 57), Human Resource Planning and Academic Health Service Complexes

18. Chapter 7 • Provides for the establishment of a Forum of Statutory Health Professional Councils; • Provides for the establishment of academic health complexes; • Devolves responsibility for policy development to the National Health Council and to the Minister

19. Forum of Statutory Health Professional Councils • Membership: • Chairs and CEOs of statutory health professional councils, eg. SANC; • Community and DoH representatives • Functions: • oversee policies and performance with regard to health professionals; • advise the Minister on issues relating to health professionals

20. Academic Health Complexes: • The MoH will, in consultation with the MoE, establish academic health complexes, defined as “one or more health establishments and one or more educ. institutions working together to educate and train health care personnel and to conduct research in health services”. • The MoH can establish co-ordinating committees as required.

21. The National Health Council • The NHC is given authority to “develop policy and guidelines for, and monitor the provision, distribution, development, management and utilisation of human resources within the national health system”.

22. The Minister • will determine guidelines to enable provincial DoHs and district health councils to implement programmes for distribution of health personnel.

23. The Minister • will regulate with regard to: • availability of education and training resources; • appropriateness of education and training; • creating new categories of health workers; • identifying skills shortages; • prescribing recruitment and retention strategies; • prescribing when staff may be recruited from other countries.

24. Balance • 140 lines in chapter 7 dedicated to Forum of Statutory Health Professional Councils • 8 lines to Academic Health Complexes • 17 lines to all other aspects of HRD Quantity does not indicate substance, but is this balance correct?

25. Furthermore: • Chapters 3, 4 and 11 refer to HRD: • 22 (1) (a) (iv): The NHC must advise the Minister on human resource planning, production, management and development. • 25 (1) (a) The DG must prepare strategic, medium term health and human resources plans annually (…).

26. 27 (2) (h) The head of the provincial department must … plan, manage and develop human resources for the rendering of health services. • 29 (1) (a) (iv) The Provincial Health Council must advise the relevant MEC on human resource planning, production, management and development.

27. 32 (1) (a) The head of the provincial department must prepare strategic, medium term health and human resource plans annually (…). • 95 (1) (e) The Minister (…) may make regulations regarding human resource development.

28. Chapter 5: • A district health system is established, which presupposes decentralisation of functions, but no human resource functions are allocated to districts.

29. Chapter 3 and 4 • National and Provincial Health Councils are set up without any representation from the academic/research community, civil society and communities.

30. Key questions: • Should virtually all direction, all setting of parameters, be postponed and devolved to the National Health Council and the Minister? Or • Should the legislature play more of an active part in determining parameters and direction of the future SA health system through the Bill?

31. We are concerned with the silences in the Bill. • The Bill does not give direction to human resource development in the health sector. • It does not clarify the division of HR functions between different levels of government. • It does not provide for the decentralisation of HR functions to district level. • We will make some suggestions for changes and amendments.

32. Previous government documentation giving direction to the health sector:The Health White Paper,1997 • Six years ago, the DoH produced a document to guide health systems development, the White Paper - Transformation of the Health System. • While this paper may be in need of updating (some aspects have been overtaken by history), its sets useful parameters and provides direction.

33. The White Paper articulates a vision of a future health system in South Africa. In chapter 4, Developing Human Resources for Health, it sets out six principles aimed at guiding health system development.

34. These principles talk to: • The establishment of a national HRD framework; • Achieving equity in HR distribution; • Reorientating training towards PHC and the district health system;Establishing a caring health system;

35. Principles cont. • The decentralisation of management functions and capacity development of managers; • The development of clinical and managerial capacity and institutional capacity to support HRD; • Representivity of the health workforce.

36. Many of the principles and implementation strategies developed in the White Paper could be picked up and adapted to give the Bill substantive direction (without going into policy detail inappropriate for framework legislation).

37. Key issues that need direction in the Bill: • Distribution (brain drain; rural-urban drift; public-private drift) • Production • Function • Organisation

38. Distribution: • The issues: • health personnel very unevenly distributed (80% of doctors working in urban areas); • public sector losing staff to private sector; • health personnel leaving the profession and the country (? 2,114 nurses to UK in 2001?, ? 104 doctors emigrating in first half of 2002?) • UNCTAD (UN Conference on Trade and Development) estimated that for each professional trained outside the country, US$ 184 thousand are saved by developed countries. • SA spends about US$ 61,500 on training per medical student.

39. Production: • The issues: • At present only large tertiary hospitals are designated as academic health complexes; • Co-ordination between DoH and DoE is not functioning (one result: crisis in nursing education) • Neither location nor content of training reflect the new health pyramid -> focus on PHC

40. Example: inadequate training: • “There wasn ’t enough emphasis on patient management in a lower level institution, our training was mostly theoretical ...most patients are filtered out at this lower level therefore the students don ’t see them ...The environment here is very different from both RCH and Pretoria Academic ...some of the antibiotics we were taught to use aren ’t available so we have to look for alternatives ...The Sister is teaching me a lot,I ’m learning more than I ever learnt in my whole training!" • Interview with community service doctor at Sipetu Hospital, Tabankulu, Eastern Cape.

41. Functioning: • The issues: • White Paper has strong focus on capacity development; • There is a growing body of research, which confirms the White Paper’s concern with capacity at clinical and management levels. • Examples from research conducted by UWC SoPH in the Eastern and Western Cape ->

42. Example: Management Capacity 1 • Research looking at functioning of clinic supervisors in the Eastern Cape showed the following: • Most important challenge to clinic supervisors’ performance and ability to fulfil their role is the fact that many governance issues remain unresolved. • Continued fragmentation of services, unfilled posts and unclear lines of accountability have negative impact on working conditions and supervisors’ ability to render effective service.

43. Example: Management Capacity 2: • INP implementation in Cape Town: • governance issues, particularly integration of services, remain unresolved • strong perception among stakeholders that management does not understand the INP, nor appreciate the importance and role of nutrition in health service delivery • INP lacks a human resource plan • capacity building for affected staff is insufficient

44. Example: clinical capacity 1: • Review of the clinical management of severe malnutrition amongst children in rural hospitals revealed: • lack of resources, as well as poor management and the use of outdated, inappropriate treatment practices, resulting in very high case fatality rates

45. Example: clinical capacity 2: • Study conducted by the Centre for Health Policy found: • of a sample of 215 providers in PHC facilities in Gauteng more than half had received some training in HIV/AIDS, 40% had been trained in counseling, but only 10% had received training in the clinical aspects of HIV/AIDS and management

46. Lack of functioning has direct impact on productivity, morale, and ultimately staff’s choice to stay or leave

47. Qualitative look at workloads of nurses in primary care facilities in Cape Town revealed that nurses: • feel unsupported by management; • suffer from ‘transformation fatigue’; • feel ill-equipped to deal with new challenges; • feel overwhelmed and often ready to go.

48. How could the Bill give direction?Some suggestions for changes:

49. Within the HRD chapter (para. 53 - 57):

50. Paragraph 53 • “The NHC must develop and monitor policy and plans which facilitate and advance: • the equitable distribution of human resources; • the provision of appropriately trained staff at all levels of the system to meet the population’s health care needs; • the effective and efficient utilisation and functioning, management and support of human resources within the health system • The establishment of structures at a policy level to facilitate coordination between the DoH and DoE”.