Valuing human resources: Key to the success of a national health insurance system

Figures & data

Table 1: Timeline of key HRH policy developments in South Africa, 1994–2011

Time period	Key developments
1994–1999	• Recruitment of first group of Cuban doctors and training of medical doctors in Cuba
	• White Paper on the transformation of the health system, containing recommendations on equitable health professional distribution
	• Commuted overtime for doctors and dentists
	• Public-sector-wide policy on voluntary severance packages
	• Rationalisation and closing of nursing colleges
	• Community service for medical doctors and for allied health professionals
	• National Nursing Summit
2000–2004	• Pick report on Human Resources for Health
	• Policy on the recruitment and employment of foreign health professionals
	• National Health Act No 61 of 2003 developed, but only promulgated in 2005
	• Amendment of legislation governing the training of health professionals
	• Introduction of rural and scarce skills allowances
	• Bilateral agreement with Iran to allow Iranian doctors to work in rural South African health facilities
	• DoH bilateral agreements on nurse migration to prevent active recruitment by high income countries
2005–2010	• New Deputy Director-General appointed for Human Resources in national DoH
	• Human Resources Strategic Framework (2006)
	• Sections of Nursing Amendment Act promulgated but awaiting regulations
	• National Strategic Plan on HIV, AIDS and STIs, 2007–2011, contains explicit recommendations on HRH
	• Policy debates on Community Health Workers (CHWs) and task shifting
	• 2008 National Nursing Strategy
	• Community service for nurses commenced
	• Introduction of occupation specific dispensation (OSD), i.e. salary categories specific to each occupation category in the health sector
	• First group of clinical associates commence training
	• Introduction of nurse-initiated anti-retroviral therapy
	• Primary Health Care re-engineering with explicit guidelines on HRH requirements
	• Improving Human Resources Management, Planning and Development is one of key strategic goals in the DoH 10-point plan
2011 onwards	• National Nursing Summit and Compact
	• Ministerial Task Team on District Clinical Specialist Teams
	• Green Paper on National Health Insurance
	• Revised Human Resources for Health Plan, 2011/12–2016/17
	• Ministerial Task Team on Nurse Education and Training
	• DoH steers a central CHW training programme in all provinces, but KwaZulu-Natal and Western Cape provinces opt out of programme
Sources: DoH (1997, 2006, 2008, 2010, 2011a, 2011b, 2011c); Ditlopo et al. (2011).

Table 2: Themes identified from nurses' comments

Theme	Brief description
Staffing	• Shortages of staff, whether of nurses, doctors or other categories of staff (porters, clerks), frozen posts.
Salaries	• Salaries of nurses, monetary justification/reason for agency nursing or moonlighting, compensation commensurate with skills/training.
Benefits	• Housing subsidy, danger allowance, medical aid, uniform allowance.
Working conditions / practice environment	• Workload, working conditions, long shifts (working hours), working under stress, experience of burnout, lack of recreational facilities, shortage or insufficient choice for nurses, lack of safety.
Training	• Need or opportunities for training of new or existing nursing staff, bursaries, study leave, learning new skills/ skills development.
Management	• Lack of or poor supervision, perceived lack of fairness by management, lack of feedback/communication from management, lack of praise or affirmation for good work done by nurses.
Community or patient aspects	• Comments related to community perceptions of nurses, patient care provision, quality of care, saving lives.
Agency nursing or moonlighting	• Any comments that mention agency, moonlighting, reasons for or against agencies or moonlighting, controls.
Nature of nursing	• Need to appreciate/recognise/value nurses (or nursing), image/marketing of nursing, nursing as a calling, reward nurses for the work they do, migration of nurses, attitudes of nurses, misappropriation of or tension among different categories of nurses.
OSD	• Specific comments on OSD whether about eligibility or perceived unfairness or positive comment about benefits of OSD.
Health system	• Comments related to the need for additional health facilities, upgrading of health facilities, lack of stock, supplies or medicines, faulty or lack of equipment, lack of financial resources, differences between public and private health sectors, health service governance or accountability.
Other	• Feedback on research, family commitments, allegations of racism in workplace, allegations of exploitation or abuse, union negotiations in the private sector, corruption, attitudes of doctors.

Table 3: Consolidated view of HR indicators reviewed across 10 national and provincial health departments

Indicator	Health Department with a rating of 1 (i.e. satisfactory or good performance)	Health Department with a rating of 2 (i.e. sub-optimal performance, requiring attention)	Health Department with rating of 3 (i.e. unsatisfactory or poor performance, with negative impact on health system efficiencies and health service delivery)
Extent to which organisational design and staff establishments are linked to core health functions and/or health service delivery	1/10: Western Cape	1/10: Northern Cape	8/10: Eastern Cape; Free State; Gauteng; KwaZulu-Natal; Limpopo; Mpumalanga; DoH; North West
Evidence of planning and budgeting for HRH	1/10: Western Cape	2/10: Gauteng; Northern Cape	7/10: Eastern Cape; Free State; KwaZulu-Natal; Limpopo; Mpumalanga; DoH; North West
Integration of and coordination across various HR functions	0/10	2/10: Gauteng; Western Cape	8/10: Eastern Cape; Free State; KwaZulu-Natal; Limpopo; Mpumalanga; DoH; Northern Cape; North West
Implementation of delegation, with clear accountability and responsibility	2/10: DoH; Western Cape	–	8/10: Eastern Cape; Free State; Gauteng; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape; North West
Efficient recruitment systems and mechanisms	–	2/10: DoH; Western Cape	8/10: Eastern Cape; Free State; Gauteng; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape; North West
Extent to which staff performance management is in place	1/10: Western Cape	3/10: Free State; Gauteng; DoH	6/10: Eastern Cape; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape; North West
Clear measures to address retention of health professionals	–	3/10: Gauteng; DoH; Western Cape	7/10: Eastern Cape; Free State; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape; North West
Management of rewards, including OSD	–	2/10: DoH; Western Cape	8/10: Eastern Cape; Free State; Gauteng; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape; North West
Training and development	1/10: DoH	3/10: Gauteng; North West; Western Cape	6/10: Eastern Cape; Free State; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape
HR information systems	–	4/10: Free State; Gauteng; DoH; Western Cape	6/10: Eastern Cape; KwaZulu-Natal; Limpopo; Mpumalanga; Northern Cape; North West
Source: Adapted from ISTs (2009); DoH = national Department of Health.

Table 4: HRH implications of the NHI proposal

Key element of NHI proposal	HRH implications
Membership of the NHI will be compulsory for all South Africans and permanent residents, but individuals may choose to continue with voluntary private medical scheme membership	• Requires careful HR planning to ensure sufficient numbers of well-trained health professionals to meet requirements of universal coverage
	• Good HR information system, linked and integrated with the NHI and financial management systems
All employed individuals earning above a certain income level will make a payroll-linked mandatory contribution to the NHI	• Nil
	• It is assumed that this aspect will be administered outside the health system
Each citizen and permanent resident will be issued with an NHI card which will be the same for the entire population	• Good HR information system, linked and integrated with the NHI and financial management systems
Every South African and permanent resident, regardless of employment or socioeconomic status, is guaranteed a comprehensive health care package that will include disease prevention, health promotion, treatment of diseases where prevention has failed, and rehabilitative services at all levels of care (from clinic level through to central hospitals)	• Organisational design and staff establishments must be linked to NHI requirements
	• Sufficient numbers of well-trained health professionals to meet requirements of universal coverage
	• Clear policies on delegation, accountability and responsibility
	• Efficient recruitment and retention system
	• Equitable distribution of health professionals
	• Health professional training to take account of new requirements of the NHI
	• Transparent and fair personnel performance management and reward systems
	• Good HR information system, able to link production, management and implementation of rewards
	• Competent managers who understand reforms, and who are able to implement them
	• Front-line staff understanding and supportive of reforms to ensure goals of reforms are met
School-going children will also have access to comprehensive school health services	• Finalisation of regulations on education and training of nurses
	• Rapid scale-up of training of school health nurses
	• Leadership and management of the district health system
Population sub-groups with greatest health needs will be prioritised	• Sufficient numbers of well-trained health professionals to meet requirements of universal coverage
	• Clarity on role of community health workers and relationships to nurses and doctors
	• Clear policies on delegation, accountability and responsibility
	• Efficient recruitment and retention system
	• Equitable distribution of health professionals
Citizens will be encouraged to use the PHC facilities, including accredited private providers, and will have access to a district clinical specialist team consisting of medical and nursing specialists who will be ‘an integral and permanent feature of health care delivery in South Africa’	• Sufficient numbers of well-trained health professionals to meet requirements of PHC re-engineering
	• Efficient recruitment and retention systems
	• Equitable distribution of health professionals
	• Health professional training to take account of PHC re-engineering
	• Good leadership and stewardship at all levels of the health system
	• Competent managers at all levels of the health system
	• Transparent and fair personnel performance management and reward systems
	• Good HR information system, able to link production, management and implementation of rewards
	• Health worker commitment to proposed reforms
	• Clear guidelines on roles and responsibilities of different categories of health care providers
For citizens and permanent residents, the comprehensive health care package will be free care at the point of contact, except under certain conditions such as cosmetic surgery or not following agreed protocols	• As above
All health establishments (public and private) that render health services to the population will have to meet core quality, service, management systems and performance standards	• As above
	Source: DoH (2011b).

Table 5: Assessing the HRH strategy against the criteria used in the IST review

IST criteria	HRH strategy
Extent to which organisational design and staff establishments are linked to core health functions and/or health service delivery	• Staff establishments would need to take account of PHC re-engineering
Evidence of planning and budgeting for HRH	• Emphasis on importance of planning, including need for HR and service information
	• One of the strategic priorities is to establish a Centre for Health Workforce Intelligence which will provide health workforce information and ensure oversight of health workforce planning across the health care system
	• Envisages the DoH playing a leadership role in workforce planning, providing information, direction and oversight for HRH, enabling provincial planning and ensuring capacity and alignment with national priorities and outcomes
Integration and coordination across various HR functions	• Recognises the importance of integration of service, workforce and financial planning
Implementation of delegation, with clear accountability and responsibility	• No mention of delegation
	• Recognises the importance of accountability in the health system
Efficient recruitment systems	• Efficient recruitment contained in the mission statement
	• Recognises the importance of regulatory, financial and organisational structures that will support development, recruitment, retention and equitable deployment of the health workforce
	• Proposes training of all managers in recruitment
	• Entire sub-section on recruitment of foreign health professionals
	• Proposes National Recruitment and Retention Unit to ensure and oversee recruitment, retention and equitable distribution of professionals for the health sector
Extent to which staff performance management is in place	• Recognises poor implementation of performance management
	• Good performance management of the health workforce seen as essential to improving efficiency, productivity and quality of care
	• Key objective is to implement a performance management framework in the public health sector
Clear measures to address retention of health professionals	• Recognises importance of retention and lists it as strategic priority together with recruitment
	• Calculates a retention gap for health professional graduates. Proposes transformation of the recruitment and retention process for the public sector
	• Proposes National Recruitment and Retention Unit
	• Proposes audit to gauge perceptions and problems, as well as turnover and retention survey
	• Separate strategic priority on access to health professionals in rural and remote areas
Management of rewards, including OSD	• Does not deal with an overall reward system
	• Proposes to review the OSD and ensure that the recommendations enhance retention and attraction of health professionals, especially in rural areas
Training and development	• Education, training and research is one of three themes in the strategy
	• Deals extensively with pre-service training, as well as links between training needs, costs, services and sites/locations
	• The development of a DoH Institute of Leadership and Management in Health Care is proposed
	• Recognises the need for training and coaching to up-skill relevant personnel in their roles and responsibilities
HR information systems	• Recognises importance of improved data and financial information for health professionals in the public sector
	• Reiterates that information for planning and managing the health workforce is not available
	• Discusses problems of the use of, and maintenance of PERSAL
	• Proposes database and improvement in HR information system as a medium-term strategy
	• Proposes DoH Centre for Health Workforce Intelligence

Table 6: Front-line nurses' responses to open-ended question ^a

Theme	Frequency	Percentage
Salaries	570	47.5
Agency nursing or moonlighting	503	41.9
Staffing	293	24.4
Benefits	195	16.3
Working conditions / practice environment	177	14.8
Training	144	12
Nature of nursing	137	11.4
Health system	132	11
Management	130	10.8
Other	94	7.8
Community or patient aspects	77	6.4
OSD	41	3.4
Total number of responses analysed	1 200	–
^aThese categories are not mutually exclusive, i.e. one nurse's comment could fall into more than one category.

DoH (Department of Health), 1997. White Paper on the Transformation of the Health System in South Africa. Government Printer, Pretoria.

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DoH (Department of Health), 2006. National Human Resource Plan. Government Printer, Pretoria.

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DoH (Department of Health), 2008. Nursing strategy for South Africa 2008. Government Printer, Pretoria.

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DoH (Department of Health) . 2011c . Nursing Compact: National Nursing Summit , Pretoria : DoH .

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