Abstract
Human resources for health (HRH) are critical to health systems development and functioning but South Africa faces a crisis of production, recruitment, retention and management. In October 2011 the Minister of Health released a five-year national HRH strategy. Although this is an important advance in recognising and describing the HRH crisis, information gaps remain and there is still uncertainty about effective strategies and interventions to address the problems. This paper triangulates information from three sources: a 2009 health systems assessment; an analysis of the 2011 national HRH strategy and the 2011 Green Paper on National Health Insurance against the assessment criteria used in the 2009 assessment; and an analysis of qualitative data obtained from 1200 front-line nurses. The authors argue that addressing the human resource challenges at structural, system and management levels is critical to the success of any future national health insurance system.
1. Introduction
The current health political leadership in South Africa is committed to a substantial overhaul of the entire health system, in order to deal with the complex burden of disease, improve health care access and affordability, and ensure responsiveness to population health needs (DoH, Citation2010). The main policy initiatives to strengthen the South African health system are the re-engineering of primary health care (PHC), the improvement of human resources for health (HRH), the introduction of compulsory accreditation of all health facilities, and the proposed national health insurance (NHI) system (DoH, Citation2010). Within this context, human resources are critical to the development and functioning of health systems, achieving the millennium development goals (MDGs), and scaling up key health interventions for improved health outcomes (Travis et al. Citation2004; MSF, Citation2007; International AIDS Society Citation2008; Van Damme et al., Citation2008; George et al., Citation2009; Bärnighausen et al., Citation2010). Furthermore, health workers' salaries account for a large proportion of overall health care expenditure, making this an important area for attention and intervention (McCoy et al., Citation2008).
In 2010, the total number of health professionals on the payroll of the public health sector in South Africa was 210 511 (DoH, Citation2011a). The dimensions of the HRH crisis in South Africa are well recognised, and include problems of production, recruitment, retention and management (Lehmann, Citation2008; Rispel & Barron, Citation2010; DoH, 2011a). At a policy level, there is some recognition that a holistic and innovative approach to strengthening human resources is critical if the country's health system is to perform better (DoH, 2010, 2011a). In the last decade, significant policy developments to address the HRH crisis have been the release of an overall human resource development strategy in 2006 and a nursing strategy in 2008, training and capacity building initiatives, community service for health professionals, and the implementation of various financial incentives.
shows a high-level timeline of HRH policy developments in South Africa between 1994 and 2011. As the table shows, the period since democracy has been characterised by a plethora of policy initiatives. Despite these initiatives, there have been numerous problems, including delays in finalising some important HRH policies, significant gaps between policy development and implementation, weak overall leadership and governance of HRH with poor coordination among key policy actors, poor staff morale, and a disjuncture between the national policy discourse and the experiences of front-line health care providers (Penn-Kekana et al., Citation2004; Lehmann, Citation2008; DBSA, Citation2008; Rispel & Moorman, Citation2010; Cooke et al., Citation2011; Ditlopo et al., Citation2011).
Table 1: Timeline of key HRH policy developments in South Africa, 1994–2011
In October 2011 the Minister of Health released a revised national HRH strategy for the period 2011/12 to 2016/17 (DoH, 2011a). Although the release of the 2011 HRH strategy represents an important advance in recognising and describing the HRH crisis in South Africa, information gaps remain and there is still considerable uncertainty about effective strategies and interventions to address the HRH problems. This paper argues that a major gap in the proposed health care reforms, specifically the Green Paper on National Health Insurance (DoH, 2011b), is that insufficient attention is paid to HRH. We argue that addressing the human resource (HR) challenges at structural, systemic and management levels is critical to the success of any future NHI system in the country. This is because of the links between adequate numbers, performance and management of HRH on the one hand, and good population health outcomes and health system performance on the other hand (WHO, Citation2006).
2. Methods
This paper triangulates information from three sources: a 2009 health systems assessment (ISTs, Citation2009); analysis of the 2011 national HRH strategy (DoH, 2011a) and the NHI Green Paper (DoH, 2011b) against the assessment criteria used in the 2009 assessment; and analysis of qualitative data obtained from 1200 front-line nurses as part of a large survey on agency nursing and moonlighting in four South African provinces (Rispel et al., Citation2011).
The 2009 health systems assessment was done at the request of the then Minister of Health, Barbara Hogan, because of the projected over-spending in the 2008/09 financial year in most of the provinces (ISTs, Citation2009). At the time, the Minister was concerned that the over-spending could undermine the capacity of the health system to deal with the HIV epidemic and to improve the general health of the population. The Minister requested an in-depth review of the factors behind the overspending. This led to the establishment of the Integrated Support Teams (ISTs) in February 2009, in which the authors led the health systems component (ISTs, Citation2009).
The purpose of this IST review was to provide the Health Ministry with a comprehensive overview of the factors behind the overspending trends, review health service delivery priorities and programmes, and recommend where and how costs could be saved (ISTs, Citation2009).
The IST review was a broad-based, rapid appraisal using the World Health Organization framework on health systems strengthening. This framework focuses on the performance of the health system, by linking system building blocks such as finance and human resources to population health status (WHO, Citation2007). The review focused on the following HR aspects: organisational design and establishment; HR planning; delegation, accountability and responsibility; recruitment; performance management; retention; rewards; training and development; and information systems. All relevant HR documents were reviewed, and in-depth interviews were conducted with some 150 senior managers in the health system: heads of provincial health departments; all chief financial officers; deputy-director generals in the national and provincial health departments; representatives from the national treasury and the department of public service and administration; chief directors responsible for strategic planning; and programme managers for maternal and child health, and for HIV & AIDS, tuberculosis and sexually transmitted infections.
The 2011 national HRH strategy and the NHI Green Paper were examined critically to analyse their relevance to the human resource problems identified in the IST review and to discover how far they offer solutions to the HRH crisis.
The qualitative information was obtained as part of a survey of nurses on the topics of moonlighting and agency nursing in the Eastern Cape, the Free State, Gauteng and the Western Cape (Rispel et al., Citation2011). The survey recruited a total of 3766 nurses in both the public and private health sectors using stratified, random sampling. The survey instrument included one page that allowed for open-ended responses from participants. The authors analysed 1200 of these responses using thematic content analysis. The first step in the analysis was to look at the participants' own words and phrases without preconceived notions or classification. The language used by each participant was then examined in light of the following question: What do the responses tell us about HR progress or challenges from the perspective of front-line health care providers? Information collected from the open-ended question was then grouped into 12 themes (see ). Each set of qualitative comments by front-line nurses was then coded and allocated to one or more of these themes. In the final analysis, the information was triangulated to arrive at the findings reported in this paper.
Table 2: Themes identified from nurses' comments
3. Results
The IST review found that the main HR issues affecting service delivery and costs were organisational structuring and establishments; rewards, specifically the occupation specific dispensation (OSD); performance management; staff recruitment and retention; training and development; and HR information systems (ISTs, 2009).
3.1 Organisational structuring and establishment
Notwithstanding the existence of a plethora of legislation and regulations, the IST review found that HR organisation in the provinces was not structured according to public sector guidelines or aligned with existing service plans or resources. A worrying trend was the growth in management and administrative positions across the various provinces, especially in provincial head offices, relative to the growth in health professional positions. Consequently, departmental strategic plans were not aligned to HR planning and budgeting (ISTs 2009). This lack of alignment was exacerbated by the lack of role clarity among various role-players (national and provincial health departments, public service and administration, national and provincial treasuries); the relative autonomy of provinces with regard to implementation of legislation and national guidelines; ‘silo’ functioning within the various departments; and poor HR information systems (ISTs, 2009).
A contentious issue was the withdrawal of delegations of authority in the majority of provinces due to the projected over-spending in the various health departments. The result was de facto day-to-day management by provincial head offices and widespread feelings of disempowerment and lack of accountability at health facility levels (ISTs, 2009).
3.2 Rewards, including OSD
The OSD is a policy that makes provision for revised salary structures that are unique to each identified occupation in the public sector. The overall goals of OSD in the health sector are to enhance recruitment and retention of those skills and competencies required in health service delivery; provide clear salary and career progression measures based on competence and performance; recognise outstanding performance through remuneration; reward skills and professional competencies; support personal development; and create transparency in salary determination (DPSA, Citation2007).
However, OSD implementation led to numerous reported problems in various provinces, including over-expenditure and industrial action (ISTs, 2009). Interviews with senior managers found that the national and provincial health departments perceived the OSD problems differently. On the one hand, the national Department of Health argued that the problems experienced with OSD were mainly as a result of insufficient funding from national Treasury, lack of skills to implement the roll-out, wrongful application of guidelines by provinces, incorrect staffing numbers, and job titles and grades that varied from province to province. On the other hand, the various provincial departments blamed OSD as a major reason for over-expenditure. However, the IST review found that the implementation of OSD was not the only reason for overspending in the compensation of employees. Growth in staff establishments, overtime, additional allowances and salary increases were all factors contributing to the over-expenditure (ISTs, 2009).
3.3 Performance management
In many of the provinces it was found that management of staff performance was sub-optimal. In one province there was reported political interference in performance management procedures and staff performance scores were pulled back to an average for all staff, coupled to the withholding of bonuses. This contrasted with the situation in another province, where performance agreements were in place for all employees and the process was managed according to HR guidelines with incentives that linked performance targets to service delivery (ISTs, 2009).
3.4 Recruitment and retention
The single most important HR challenge is how to recruit and retain health professionals. The problems facing recruitment and retention in the rural areas include socioeconomic factors such as lack of housing, schools, recreation facilities and transport, and inadequate security. Consequently in rural areas, where the need is greatest, the difficulty of recruiting skilled staff is one of the most significant constraints to improving access to health care (ISTs 2009). The IST review found that the recruitment turnaround times across the various provincial health departments ranged from six to nine months, thus contributing to the problem of recruiting scarce skills (ISTs, 2009).
With regard to retention, the IST review found that OSD had assisted to some degree in retaining nursing staff. However, in rural provinces it continues to be difficult to retain health professionals, and the problem goes beyond health professionals' rewards. The review found that retention was also linked to career development opportunities, training and career mobility and the socioeconomic factors mentioned above (ISTs, 2009).
3.5 Training and development
Although there are various national training and development initiatives, as well as access to training, the IST review found that there was insufficient attention to training and development in all provinces. Moreover, the focus of training programmes is not always linked to improved health service delivery, and budgeted training expenditure was often cut back to save costs. There was also a disjuncture between the various HR policies and insufficient linkages to training institutions with regard to the production of health care professionals (ISTs, 2009).
3.6 HR information systems
The personnel salary system (PERSAL) had limited functionality in the public sector, but the review found that that it was not fully used as a management and planning tool. Inconsistent HR indicators were found in different official documents (ISTs, 2009). This was because the system was not maintained as required, the existing functionality was not fully used or understood, and the capacity and skills to use PERSAL optimally were lacking (ISTs, 2009).
Across all provinces, PERSAL consistently showed large numbers of outdated and unfunded positions and hence planning and reporting using PERSAL was largely an academic exercise, for example in revealing vacancy rates. A new HR information system was being planned at national level, and in 2009 was reportedly 90% complete. It was envisaged that the new system would provide sufficient information for planning and managing the health workforce nationally. However, the total cost of the new system was unknown and it was unclear whether maintenance and long-term sustainability had been taken into account.
In summary, the 2009 IST revealed serious HR structural and system weaknesses (see ). As the table shows, there was considerable national variation in HRH performance against selected indicators and most provincial health departments ranked poorly on almost all of the HR indicators. In eight out of 10 health departments, organisational design and staff establishments were not linked to core health functions or health service delivery or both. Similarly, there was insufficient planning and budgeting for HRH, with unsatisfactory performance in seven out of 10 health departments. This was exacerbated by sub-optimal HR information systems. None of the health departments received a satisfactory rating on recruitment and retention of health professionals, while the management of staff performance and rewards was another cause for concern.
Table 3: Consolidated view of HR indicators reviewed across 10 national and provincial health departments
3.7 Analysing the NHI Green Paper
The Green Paper on NHI, released at the beginning of August 2011, acknowledges the problems of HRH shortages and mal-distribution between the public and private health sectors, but it lacks any detail on HRH (DoH, 2011b). None of the problems identified in the IST review is dealt with, although the Green Paper makes reference to the HRH strategy, which was subsequently released for public comment at the end of August 2011. Notwithstanding the release of a separate HRH strategy soon after the NHI Green Paper, we argue that a major flaw in the Green Paper is the superficial analysis of the HRH implications of many of the NHI proposals. highlights these potential implications.
Table 4: HRH implications of the NHI proposal
As the table shows, the implications are vast. A fundamental re-thinking of all aspects of HRH is required, from production (training) through to organisational structures to support the reforms and the ‘softer’ aspects, such as awareness-raising, and existing health care providers' support for the reform process and their commitment to it. Importantly, the NHI document is silent on the need to improve governance and accountability throughout the health system, particularly in public hospitals and the district health system (Rispel & Fonn, Citation2011). Although there are proposals on the staffing needs of the new PHC re-engineering reforms (Naledi et al., Citation2011), it is important to know how many and what kind of health care providers are needed at district or hospital levels, to complement the PHC reforms. Critical outstanding matters that have not been dealt with in the NHI document are the use and management of existing staff to overcome the chronic problems that beset the public health sector in particular, the most appropriate and affordable staffing model to strengthen PHC, and the links and relationships between the new outreach and community caregivers and existing providers and the relationship of this cadre to the proposed district clinical specialists' teams (Rispel & Fonn, Citation2011).
3.8 Analysing the national HRH strategy
The national HRH strategy is welcomed for its bold admission of existing HRH problems, and for providing a broad road-map for action. The three main themes of the HRH strategy are the supply of health professionals and equity of access; education, training and research; and the working environment of the health workforce (DoH, 2011a). In addition, there are eight strategic priorities that range from leadership and governance to the promotion of access to health professionals in rural and remote areas (DoH, 2011a). shows the extent to which the HRH strategy deals with the problems identified in the IST review.
Table 5: Assessing the HRH strategy against the criteria used in the IST review
At face value, the HRH strategy deals with many of the important problems identified in the IST review. However, the strategy does not take further many of the recommendations contained in the IST review. Greater specificity is required rather than general recommendations.
Each of the eight strategic priorities has at least five objectives and there are more than 100 activities listed for achieving these objectives (DoH, 2011a). Most of the activities are process oriented, for example ‘Establish an electronic database on the health workforce in the public & private sectors’ (DoH, 2011a:88) or ‘Work with the NHI Ministerial Advisory Committee to determine HRH requirements for the NHI service delivery model as the model is formulated’ (2011a:98). The document lacks detail both on many critical aspects, such as the costs of implementation, and on how to move from the current situation to the desired goals. It also does not prioritise activities that have to be undertaken, in tandem with the proposals contained in the NHI Green Paper. The consultation process was also rushed, with only six weeks between the release of the draft strategy and the launch of the final document, so it is unclear how far stakeholders have bought into the recommendations contained in the document.
3.9 Views of front-line nurses
The top five issues that dominated nurses' responses to the open-ended question were salaries, staffing issues (notably shortages), benefits, working conditions or nurses' practice environment, and specific issues related to agency nursing and moonlighting (). This last issue is not surprising, as the survey was designed to measure the prevalence of, and the factors associated with, agency nursing and moonlighting.
Table 6: Front-line nurses' responses to open-ended question a
As can be seen from , almost one in two nurses commented on salaries, while one in four commented on staffing. One in 10 nurses commented on benefits, working conditions, training, management, the sub-optimal performance of the health system or the nature of nursing. Importantly, their unprompted responses reveal the apparent disjuncture between stated, high-level policies and the perceived needs of front-line providers, as the following examples show.
Short staff – we are being overworked and exhausted because of lack of nurses. Our nurses' home is far from the hospital and we don't have transportation. Sometimes, you feel like not coming to work because of the attitude from the community and patients – they belittle us, they treat us as if we are not human beings and we don't have rights. Sometimes, we are working as mortuary attendants, lifting heavy corpses, sometimes we end up also working as porters. We are also at risk of contracting infectious diseases as we don't have isolation rooms to isolate our patients who have infectious diseases. We are being underpaid – OSD was never implemented. Rural allowance was never implemented as was done in other provincial hospitals. If you are working at night you are paid only four hours overtime, with the rest given as time off. What I find also tiring is the ambulance services which take a long time to fetch the patient to a referral hospital, and when there are complications, the referral hospital's personnel will blame you for keeping the patient. (Participant 1491)We are overworked – we have a drastic shortage of staff. We are only six but we must do the work of 14 people who used to work here, and the management expect wonders … if things go wrong you are to blame, but they [management] know if there was enough staff nothing would go wrong in the department. (Participant 3212)
Government should improve our salaries, the OSD payments were not done fairly, and experience was not considered. How can a newly qualified midwife be on the same level with one who has 20 years of experience? Nurses do not have a say in this country, nobody listens to us… instead of long service award ceremonies, how about giving us money rather than the food eaten there? (Participant 2463)Government should place a stronger emphasis on nurses studying further, especially the lower categories of nurses. I haven't seen much action. I constantly find myself listening to nurses say: ‘I have been applying for study leave for the last year, I have not received it. I think l want to leave this place’. People complain about being short staffed all the time. (Participant 2494)
4. Discussion
In 2011, the World Health Assembly reiterated the centrality of HRH for the effective functioning of any health system (WHO, Citation2011). There is now global recognition that health workforce shortages and inefficiencies hamper effective PHC implementation and expansion of health service coverage (WHO, 2011). Despite high levels of global commitment to HRH and reported successes in various countries, problems to be overcome include insufficient investment in HRH, lack of education reforms, lack of incentives, ineffective retention strategies and inability to translate policy into action (WHO et al., Citation2011).
This paper has shown that in 2009 significant HR weaknesses were identified at both structural and systems levels in most provinces in South Africa. These weaknesses ranged from the lack of alignment between organisational design and staff establishments (structural aspects) and health service delivery, to unsatisfactory health professional recruitment and retention (systems) and the sub-optimal management of staff performance and rewards. These identified weaknesses were borne out by the perceptions and views of more than 1000 front-line nurses.
Almost three years after the IST review, similar system weaknesses are listed in the revised five-year HRH strategic plan for the country. It is unclear what has happened with the proposed HR information system, reportedly 90% complete in 2009. The problems of HRH information systems are not unique to South Africa and include technical issues such as data quality, coverage and comparability, as well as data dissemination and use (WHO et al., 2011). In 2011, the Global Health Workforce Alliance found that the least progress had made in the area of HR information systems. However, the development of effective policies and plans that address the country-specific constraints relating to health workers requires strong technical capacity to compile, analyse and use HRH data (WHO et al., 2011).
Although it is encouraging that there is a revised HRH strategy that articulates a broad road-map on HRH (DoH, 2011a), the document lacks details, and is silent on the critical area of re-engineering organisational structures in provincial health departments and on HR delegation. Such re-engineering requires that attention be paid to getting the right skills and the right numbers of health professionals at different levels of facilities. Notwithstanding reference to the NHI in the HRH strategy (and vice versa), the two documents are not aligned. It is of concern that the vast HRH implications of the NHI appear to be underestimated. The successful implementation of the NHI proposals requires organisational design and staff establishments with sufficient numbers of well-trained health professionals to meet the requirements of universal coverage; clear policies on delegation, accountability and responsibility in the health system; an efficient and effective recruitment and retention system; equitable distribution of health professionals; reorientation of health professional training to take account of the future requirements of the NHI; transparent and fair personnel performance management and reward systems; and a good HR information system, able to link production, management and implementation of rewards.
All these issues were highlighted in the 2009 IST review (ISTs, 2009). The NHI Green Paper suggests a major emphasis on decentralisation. But it has been pointed out that ‘capacities that need to be strengthened for effective implementation of decentralization are diverse and involve not only leadership, but also the adequacy of structural, organizational, and human resources’ (Omaswa & Boufford, Citation2010:9). Importantly, the technical aspects of HRH are only one aspect of successful implementation. A successful NHI system also requires competent managers who understand the rationale for health care reforms, and the understanding, commitment and support of front-line health care providers who are enthusiastic about implementation and good communication and change management strategies.
The qualitative information collected from front-line nurses highlights the disjuncture between the issues of immediate concern to nurses (such as staff shortages, salaries, benefits and working conditions) and the various activities listed in the HRH strategy. The strategy does not prioritise the implementation of these activities and does not clearly define the role of provincial health departments that are the main implementers. This raises doubts about whether the health sector as a whole can implement the reforms and make measurable progress.
Despite the plethora of HRH initiatives since democracy (see ) there is a big gap between policies or plans and implementation. Several authors have pointed to the gap between policy and implementation in the public health sector (Rispel & Setswe, Citation2007; Schneider et al., Citation2007; Lawn & Kinney, Citation2009; Rispel & Moorman, Citation2010; Rispel & Kibua, Citation2011; Padarath & English, Citation2012; Van Rensburg, Citation2012). The reasons for the gap are complex, but include sub-optimal leadership and stewardship; underestimation of the complexity of policy implementation; failure to consider the views of the target population or the service providers, or both; and poor management of change (Rispel & Setswe, Citation2007; Schneider et al., Citation2007; Lawn & Kinney, Citation2009; Rispel & Moorman, Citation2010; Rispel & Kibua, Citation2011; Padarath & English, Citation2012; Van Rensburg, Citation2012). Hence it is critical that strategies be developed to ensure implementation of the HRH strategy.
The central argument of this paper, however, is that unless the critical issues of HRH are dealt with, many of the laudable goals of current health care reforms are unlikely to be achieved. This issue has been also been raised by a review of HRH to implement the previous national strategic plan on HIV & AIDS (George et al., Citation2009). The authors found that the absolute shortage of HRH and the mal-distribution of HRH between the public and private health sectors and between rural and urban areas constrain efforts to achieve the NSP (National Strategic Plan on HIV and AIDS) goals (George et al., Citation2009). Similarly, HRH has also been found to be the bottleneck restricting the successful implementation of numerous policies, not just in South Africa, but in several other countries. For example, a study in Côte d'Ivoire, Ethiopia, Mozambique, Thailand and Zambia found that health workforce problems constrain these countries' ability to meet the MDG targets (WHO, Citation2010). Similarly, a 2010 review of the PHC package in South Africa found that there was wide variation in the implementation of the package across the nine provinces. HRH problems were consistently mentioned by all provincial respondents as a factor hampering ‘full’ implementation of the package (Rispel et al., Citation2010).
5. Conclusion
The reforms envisaged by the NHI provide exciting opportunities for health system change in South Africa, rarely available in most countries. However, this paper has shown that there were considerable weaknesses in the performance of the health system against selected HRH indicators in 2009. Neither the 2011 NHI Green Paper nor the revised HRH strategy deals adequately with the well-recognised HRH crisis of production, recruitment, retention and management. HR information systems remain sub-optimal, and there is an apparent disjuncture between stated policies and implementation, and between policy intentions and the perceptions and experiences of front-line health care providers. Several key issues need to be addressed to ensure successful implementation of the NHI. These include ongoing consultation with a range of stakeholders and implementers, accurate costing of implementation requirements, concerted efforts to strengthen implementation at different levels of the health system, addressing health system governance and accountability, and ongoing monitoring and evaluation of the reforms. However, the ultimate success of the NHI will require valuing human resources in the health sector, and immediate and effective action to address the critical human resource challenges facing the South African health care system.
Acknowledgements
The authors wish to thank their colleagues on the IST, Hanno Gouws, Bertie Loots, Gitesh Mistry, Annie Snyman and Konrad van Nieuwenhuizen, for their participation, Annie Snyman for her comments, and Ronelle Burger for her encouragement. The paper is based on a presentation to an ERSA (Economic Research Southern Africa) symposium on Health Reforms held at Stellenbosch University on 1 July 2011. It draws extensively from a technical report entitled ‘Review of health over-spending and macro-assessment of the public health system in South Africa’. The research on front-line nurses was funded by the Atlantic Philanthropies. The IST review was funded by the UK Government's Department for International Development (DfID) Rapid Response Health Fund. The views presented in this paper are those of the authors and do not necessarily represent the decisions, policy or views of the DfID or the other IST team members.
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