Summary Bulletin 3 - DHS-LG Discussion List

30 JUNE 2001

1.Shortage of African people in health professions in SA

The debates in the recent weeks focused on the recruitment, selection, training and placement of health professionals in South Africa. Concerns were expressed that the composition of health professions in this country does not reflect the demographic profile of the country. There was a reminder that one of the goals of the National Health Plan for South Africa (1993) which stated that: All health education institutions must ensure that the composition of their student bodies reflect society in terms of gender, race and geographic distribution. This will require the application of affirmative action principles in the short to medium term in order to redress present imbalances has not been achieved. Recent studies were conducted by Lehmann and Sanders (1999), looking at the production of doctors in South Africa, and by Van Rensburg and Van Rensburg (1999), examining the distribution of human resources in the private and public health sector. These studies provide empirical evidence that although progress has been made; an equitable racial distribution of medical students and health professionals continues to be elusive.

Compared to urban areas, rural areas of South Africa continue to be the hardest hit by the inadequate supply of health professionals. This trend is not likely to be addressed in future as there are still fewer students from rural areas who are pursuing careers in the health sciences, medical or other health professions. Only a small number of those candidates from rural areas who ultimately qualify as health professionals return to these areas to uplift the quality of life of the communities.

2. Suggestions for addressing the inequity

2.1. Building the capacity of rural schools

It has been suggested that the quality of education in rural schools should be enhanced to enable these schools to produce matriculants with the potential to succeed in tertiary institutions. This can be achieved by:

• Department of Health and the Department of Education to set upon a distance learning/mentorship programme for rural teachers linked to hospitals. Visits by local schools to health facilities (clinics & hospitals) where teachers and learners can ask questions to be encouraged, to enhance knowledge and trigger an interest in the health profession.
• Giving senior medical or health science students an option of working in a rural hospital and mentoring learners interested in health sciences
• Health science students to be encouraged to do volunteer work in rural health facilities under the supervision of the facility manager
• Historically White Universities (HWU) to develop exchange programmes in which rural teachers are given an opportunity to further their studies and urban based teachers spend a period of time in rural areas to relieve the rural teachers.

2.2 Selection Criteria for Candidates wishing to pursue careers in the Health professions

Community members through their elected representative should participate in the selection process. The criteria to be looked at include:

• Affirmative action principles
• Willingness to commit to service in the district on a year-for-year basis
• Commitment to delivering PHC services for a specified period
• Academic capacity (potential to succeed): Bursaries for bridging programmes to be awarded for capable and motivated youth from disadvantaged areas
• Commitment to doing community service work during holidays
• Understanding that inadequate academic performance (despite all support provided e.g., bridging programmes) could result in loss of bursary/scholarship
• Monitoring systems to trace the outcomes and location of all students

2.3. Funding as a lever to ensure change

• Government subsidies should not be sent directly to training institutions as they provide inequitably distributed services
• Government subsidy for academic institutions to be redirected to Provincial Health Departments, which will decide on the criteria for allocating these funds, based on the health needs of the provinces. Medical Schools to respond to these needs
• Provincial health departments with bursaries for health professions to advertise unashamedly for African and Coloured students in local news papers
• Bursaries from Historically White Universities (HWUs) to be routed to reputable rural hospitals which have a good staff-community relationships
• District management teams to be allocated grants for medical bursaries

2.4. Content of training programmes and curricula

• Addressing inequities in the recruitment, training and distribution of health professionals, should extend to a critical analysis of the curricula of training institutions. These curricula and other training programmes should be geared towards addressing the health needs of the majority of South Africa.
• Training should not be high tech, first world oriented, addressing diseases of affluence, than of poverty.

2.5. Role of legislation

• Government to enact legislation to compel academic institutions to develop policies to enhance the intake of Black (especially rural African) candidates to accelerate the move towards becoming reflective of the demographics of the country

2.6. Autonomy of academic institutions

Academic institutions might construe legislation as government interference in their affairs, which undermines their autonomy and academic freedom.

This could result in protracted legal battles between the government and these institutions

2.7. Incentive Schemes to attract health professionals to rural areas

• Creating awareness among health science and medical students of health needs of the majority of South Africans, for instance, by assisting them to do home visits to assess health needs and give health education.
• Fast tracking rural health professionals for continuing/postgraduate training. Health workers who are based in rural areas to be eligible earlier for postgraduate education

2.8. Innovative Local Solutions

Innovative case histories of communities, their leaders, NGOs and local hospitals that have taken it upon themselves to produce health professionals to serve their communities exist. They generate resources to support the training of local students, participate in the selection of these candidates, and monitor their performance and ultimately their placement once they have qualified. Moving cases were shared from Ingwavuma, Mosvold Hospital, and the Northern Province. This clearly demonstrates successes generated by the resolve of communities and other community-based organisations to produce more human resources for health to address their local health needs. The sustainability of some of these local educational initiatives without committed external support is not guaranteed. But is it this responsibility of communities? Of hospitals? Of NGOs? The foregoing discussions illustrate that different stakeholders, together with their national and provincial governments, have a crucial role to play.

3. Provincial Health Authorities (PHAs)

At its meeting held on the 13^th February 2001, the Health MINMEC took several decisions regarding the implementation of the District Health Systems and the Role of Local Government in Health Service Delivery. Among other decisions, MIMMEC agreed that:

• The MEC for Health shall establish a Provincial Health Authority (PHA) in each province by the 30^th June 2001.
• The functions of the PHA shall be to advise the MEC for Health on health matters
• The PHA shall comprise the MEC for Health and the Councilors responsible for Health in a District or Metropolitan Council
• The MEC shall chair the PHA

MINMEC further agreed that:

• The Head of the Provincial Department of Health shall establish a Provincial Health Advisory Committee (PHAC) in each province by the 30^th June 2001.
• The functions of the PHAC shall be to coordinate the planning and delivery of health services and to advise the PHA on health matters
• The PHA shall comprise the Head of Health of the Provincial department of Health, the District Council and Metropolitan Council
• The Provincial Head of Health shall chair this committee

What the provinces have done:

Four provinces, Gauteng, North West, Northern Province and the Free State have launched the PHA and/or PHAC.

Gauteng Province

• The MEC for Health launched the Interim PHA on the 17th May 1999 and several meetings were held leading up to the LG elections in December 2000.
• The MEC then launched the PHA on the 31st January 2001. PHA consists of MEC, Executive Councilors for Health of the 3 metros and 3 District Councils. PHA has already met (on 08/05/2001) and will meet again on 17/07/2001
• The PHAC has been established by the Health HoD and has already met on the 16/03/2001
• Joint tasks teams have been established on: Audit and Information; District Service Plan with components of services, facilities, staff and finance; Legal Framework and Labour Relations; Capacity Building and Support; Communication to incorporate joint work done and to develop a Framework for the Development of PHC to LG. The teams met in June 2001.

North West Province

• PHA to be launched on the 10^th July 2001. Suggested composition is: MEC, Health District Councilors, 2 Representatives of the House Traditional Leaders and 5 Executive Mayoral Health Councilors (executive mayors to be ex-officio).
• Technical team to be headed by the DDG will be formed to advise and support the PHA.
• Meetings have already been held with Provincial governance structures and
• Councilors to brief them about the DoH’s plan for evolution.

Northern Province

• Consultation between the Provincial Department of Health and Welfare and the Northern Province Local Government Association took place on the 17^th and 18^th February 2001.
• The Provincial Health and Welfare Advisory Committee (PHWAC) was launched by the MEC on he 23^rd March 2001. MEC for LG was fully involved in the process
• PHWAC meetings are scheduled for July, September, November 2001 and January 2002
• Two presentations made by Provincial DoHW to councilors and officers of the Capricorn District Municipality

Free State

• MEC (Health) supported by the Premier briefed local government councillors on the DHS in April 2001
• PHA being implemented in terms of the Free State Health Act, no 8 of 1999. It will be composed of the MEC (health) and the councillor in charge of health from each of the 5 DCs
• 5 DHAs will be established
• FSDOH will be hosting a provincial DHS conference in 6 weeks to market the DHS (this will be an annual event used to track progress in DHS implementation)

Bulletin complied by ISDS and HealthLink as part of Health Systems Trust.
For any further information, contact Thulani Masilela

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