The Colleges of Medicine of South Africa (CMSA) notes with concern ongoing media reports of service delivery failures and quality of care issues at public sector health facilities in South Africa. These are a reflection of the numerous challenges faced by South Africa’s health system. Patients and health workers on the frontline (including our members) bear the brunt of these system-wide challenges. There is an urgent and critical need in South Africa to strengthen all of the health system ‘building blocks’ viz. (1) leadership and governance, (2) health system financing, (3) health workforce, (4) health information systems, (5) medical products and technologies, and (6) service delivery. As the CMSA’s purpose is to “promote the highest degree of skill and efficiency in medical and dental practice and to cultivate the highest ethical standards and professional conduct … not for pecuniary profit, but for the betterment of humanity”, the CMSA believes it has an important role in advocating for, and supporting positive change to South Africa’s health system.
The CMSA recently established a Health Policy Subcommittee whose mandate includes reviewing and recommending endorsement of public health, health systems, and health policy-related statements of other organisations. Noting the importance of health systems governance as a ‘building block’ and the implications of poor governance on all other components of the health system, the Health Policy Subcommittee has reviewed the Academy of Science of South Africa (ASSAf) consensus study report ‘Achieving Good Governance and Management in the South African Health System’ published in June this year. The ASSAf report was based on a comprehensive review of existing evidence as well as consultative meetings with key informants and experts from across the health system. The authors of the report note that there are “failures of governance at multiple levels within the South African health system” that “contribute to inefficiency, wastage and poor quality of care; constrain the ability of the health system to respond to needs; and undermine the collective efforts of health workers and communities to achieve better health for all”.
The ASSAf report describes a number of health governance, leadership, and management challenges which have contributed to current state of South Africa’s health system. These include:
- Deficiencies in leadership and management competencies: The report notes that a large proportion of health managers lack essential competencies. In many instances, this is linked to questionable practices in selection and appointment of candidates.
- Leadership instability: High turnover of senior managers has impacted continuity and created instability. Gauteng Department of Health is cited as an example having had 10 heads of department in a decade.
- Inadequate use of health information: Information systems are geared towards reporting to central levels while collection and use of data to facilitate decision-making at lower levels is largely ignored.
- Lack of accountability: Data on health outcomes and health systems performance which would be critical for accountability of health managers is not being produced. Findings of the Office of Health Standards Compliance and Auditor General are not being used to hold managers accountable.
- Corruption: The lack of action to deal with corruption when detected within the health system and charge alleged perpetrators is a major governance failure. The report notes that a “lack of consequences for corruption created an environment of impunity within the health system”. The lack of adequate protection for whistle-blowers is a serious concern.
CMSA would like to urge government to implement a number of specific recommendations mentioned in the ASSAf report as soon as possible viz.
- Ensuring transparent criteria and processes for management appointments and an increased focus on competency-based selection
- Offering more competency-based training to managers through partnerships with academic institutions
- Shifting to measuring performance of managers based on outcomes achieved rather than just activities that should be carried out
- Generating and increasing access to data on health systems performance and health outcomes including implementation of the National Health Information System of South Africa
- Resourcing the Office of Health Standards Compliance and the Auditor General to comprehensively assess performance against delegated functions
- Identifying underperforming districts that could be supported by the relevant academic departments at universities to build management capacity
- Re-instituting national learning conferences for health managers to share experiences across districts and learn from each other
- Ensuring human resources decision-making for health managers (e.g. promotion) is based on objective assessment using performance data
- Empowering managers to act against incompetent performance and corruption
- Providing legal support and adequate protection for whistle-blowers
CMSA (based on the recommendation of its Health Policy Subcommittee) endorses the steps outlined by the ASSAf panel to strengthen health systems governance and management in South Africa and calls on the relevant government entities to address the country’s health governance and management
challenges as a matter of urgency. The Health Policy Subcommittee will liaise with the authors of the ASSAf report to identify any areas in which it can support the implementation of recommendations.
As a membership organisation with approximately 11 000 members representing every medical and dental speciality in South Africa across the public, private, and academic sectors, CMSA looks forward to engaging with government and other stakeholders through its Health Policy Subcommittee to find solutions to South Africa’s pressing health system challenges.
Issued by:
Prof. Johan Fagan, President: CMSA
Dr Saiendhra Moodley, Chair: CMSA Health Policy Subcommittee
