Giving Medical Staff a Voice in Management Is Key to Making the NHI Work

By Glenn Ashton · 22 Aug 2012

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There are two kinds of South Africans. Some, who will read this article - the consumers of printed and online media - and the rest, who most likely will not. The first kind are more likely to be able to access health care on demand. The second probably cannot. How can we get these two worlds to meet?

The National Health Insurance (NHI) programme is a state initiative to improve the constitutional prerogative of egalitarian, universal health care. Although a degree of healthcare is broadly available, most national health services remain stagnant or even retrograde.

Presently there are two major stumbling blocks to achieving universal quality healthcare. One is the dynamic tension between private and public interests in health provision. Second are inefficiencies in the public health system.

Well-resourced private health sector interests are opposed to the NHI initiative in principle. Their objections are generally misplaced and founded more upon profit motives than substantive concerns. The counter is that the private health sector is inefficient, bloated and complacent in its ability to extract constantly increasing profits, year on year.

We do have a semblance of a national health system. All too often it looks like this: you fall ill and drag yourself down to the local clinic. If it is functional you will probably have to queue for several hours, perhaps longer, only to be cursorily examined and sent home with the traditional clinic cure all, Aspirin.

Those who receive chronic medication consistently have to take at least a day off work each month, simply to collect their medicines and have an occasional check-up. While some provinces exhibit a degree of functionality by making chronic medication available on demand, others are utterly dysfunctional. There are numerous well-documented cases of such decay, where facilities are desperately short of medical staff, medicines and managerial skills.

The NHI, as set out in the 2011 green paper, is certainly in accord with the constitutional prerogative. The reality remains that those able to subscribe to private health insurance enjoy a level of healthcare worlds apart from those too poor to do so. Yet even this is often inefficiently managed and overpriced through its alignment with the profit motive.

Ironically most government workers are now able to access private healthcare under the government medical aid known as GEMS. GEMS presently has over 1.7 million members, around 65% of whom are women. Perhaps it is not unsurprising that the introduction of the national health insurance initiative has a certain inertia.

Perhaps there is a lessened sense of urgency from state bureaucrats, administrators and parliamentarians who enjoy health coverage, to push the NHI as hard as it should be pushed. If this sector relied on the public health system there might be far greater incentive for change.

South Africa arguably has its best Minister of Health ever in Aaron Motsoaledi. He has a practical medical background with a sound ethical foundation. Motsoaledi has been central in pursuing the implementation of the NHI and has recently rolled out the first pilot programme in Klerksdorp, North West Province.

The recent release of the National Development Plan (NDP) by the National Planning Commission provides further perspective on the NHI. The NHI is only one amongst several urgent initiatives to address national inequality covered by the NDP. The NDP clearly recognises the scale and challenges of implementing the NHI and suggests that it could take between 15 and 25 years to incrementally roll out this ambitious plan.

The primary health aims of the NDP health plan include increasing national life expectancy to 70 years, reducing infant mortality rates, reducing the national burden of disease and ensuring that the present under 20 generation remains HIV free. In order to achieve these goals the NDP recognises the need for committed leadership across all tiers of the health system.

This latter point remains the greatest single challenge to an integrated national health system. While there are sectors of excellence in the public health system – institutions like the Red Cross paediatric hospital in Cape Town spring to mind – there are equally significant pockets of low performance, morale and discipline.

Properly restructuring the health system will require far more than the routine denial that meets any accusation of poor management practices. Events in the Eastern Cape Department of Health are salutary in this regard. First was the Costa Gazi debacle, when that doctor was taken to court for speaking out against the genocidal policies of the prior minister of health, Manto Tshabalala-Msimang. More recently three senior doctors were intimidated after raising concerns about the failures within the largest regional health facility.

These attacks by political leaders and administrators on active and involved medical personnel are not isolated. Similar actions have been taken against doctors working within the national health system in Kwa-Zulu Natal, Mpumalanga and Gauteng. It is unacceptable that health experts are shut down when they raise fundamental concerns about healthcare management. This problem is not isolated to South Africa. When the national health system was introduced into New Zealand significant friction occurred between administrators and health practitioners in health facilities.

While large medical systems require an administrative bureaucracy this cannot operate in a vacuum, without the inputs of the medical fraternity who make the system operational. The introduction of universal healthcare of a sufficiently high standard can never be achieved if the life and morale is crushed out of the system by heavy-handed bureaucratic intervention.

The management of the National Department of Health must be properly aligned in order to be efficient. Medical staff cannot continue to be blocked from providing meaningful inputs into the management of the health care system. The culture of denial of responsibility and of condoning inefficiency cannot be condoned.

In New Zealand the rift between hospital management and medical staff was healed by enabling representation on hospital and regional management bodies by medical staff. In this way those at the coal face of health care – the nurses, matrons and doctors – can provide inputs and can advise and instruct administrators of operational requirements on the one hand, while keeping an eye on wasteful expenditure on the other.

Management is one of the highest costs in modern public healthcare. Inefficiency and poor management can easily be rectified by involving health care staff. After all doctors are amongst the best and brightest of our school and university graduates, and are highly educated and informed professionals. There is no hope of success in transforming our health sector if health care professionals continue to be isolated by political and administrative heavy-handedness. While the NDP recognises some of these managerial shortcomings, implementation remains important.

This critical detail must be taken onboard to successfully transform our national health care system. Otherwise it will fail as surely as has happened in the Eastern Cape. The healthcare system cannot be captured and held ransom by political cadre deployment and expediency. Health care reform and implementation of the NHI can only be successfully accomplished through the efficient, professional management of a complex and challenging system.

Ashton is a writer and researcher working in civil society. Some of his work can be viewed at Ekogaia - Writing for a Better World. Follow him on Twitter @ekogaia.

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