NUMB AND NUMBERLESS

The department of health has delayed the release of key reports - into the deaths of more than 20 babies at a Durban hospital, on HIV statistics, and on a strategic plan to deal with shortages of human resources at public health facilities. The national HIV prevention plan expires this year, but there has been no evaluation of HIV prevention. The recent drafting of a black economic empowerment charter for the health sector suggests a lack of consultation by the department on key policy issues. Academics and the private sector alike are concerned that the department is using the broader socioeconomic objectives of health-care access to entrench its power and control. And despite generous health-care spending (11% of the national budget), the World Health Organization ranks SA 175th out of 191 countries in terms of health-care efficiency.

What are the key problems and how might they be tackled? Topping the list is human resources. About half of the 83 500 posts in the public health service are vacant, according to Persal, government's personnel administration system. Like other developing nations, SA is in a tug-of-war with wealthy nations, which need more doctors and nurses to care for their ageing populations and can pay to get them. In addition, World Trade Organization rules force countries to remove regulatory barriers so that those with a medical passport can more easily work elsewhere. The health department's website lists seven key vacancies, among them the heads of communicable diseases HIV & Aids and sexually transmitted infections employment relations standards compliance and health economics. And though the new National Health Act requires more levels of management throughout the health system, there is a lack of skilled management staff. This week the department was expected to release in parliament a report on a comprehensive human resources strategy completed in March - after the DA invoked the Promotion of Access to Information Act.

Another problem with this report is that there was inadequate consultation, says DA health spokesman Dianne Kohler Barnard. No nursing organizations were consulted in the process of drawing it up, though the problems are mostly felt at nursing level. Health department spokesman Sibani Mngadi says a number of nursing colleges that were closed after 1994 are likely to be reopened, private GPs could be contracted to work in public facilities, and allowances that reward health professionals for scarce skills and for working in rural areas will help to improve the situation.In the Northern Cape, for example, we've been able to attract doctors back to remote rural areas because their salaries are competitive with the private sector, says Mngadi. Skilled workers can earn up to 40% more for working in far-flung areas.

The Health Systems Trust (HST), a non-governmental organization, believes health systems are likely to improve only once there is better deployment and orientation of health workers towards major health problems and when tasks and resources are in better balance at primary care level. Until recently, HR departments of health systems have been under-resourced, reflecting the lack of attention given to this component, says the HST's Ashnie Padarath. Without a blueprint to guide HR development, the treasury's R4,6bn grant to provinces to train and develop health professionals over the next three years will merely stem the bleeding. Next on the department's list is improving the relationship between the public and private sectors. The minister, Manto Tshabalala-Msimang, has a poor record of consulting private players - as suggested by her recent court battle with pharmacists over controversial medicine pricing regulations.

Most players agree with the guiding principles of the legislation - to make health care more affordable - but feel a lack of consultation means policies are badly planned and lead to unintended consequences in the health-care system. Mngadi says the private sector plays a critical role in creating greater access to health care, and the department's focus is on setting up a social health insurance system to make medical aid available to more people. But government has yet to capitalise on the potential of public-private initiatives (PPIs). The department has developed its own guidelines for PPIs, different from the national treasury's public-private partnerships (PPPs). These differing documents have the potential to lead to conflict, writes Dr Shane Dorfman, CEO of Linkwood Clinic, in a paper based on MBA research. Many of the provincial health departments embarked on initiatives that conformed to national treasury rather than national department of health guidelines. The third challenge for the department is to ensure that its legislation and regulations are translated into instruments that fix problems on the ground. Werksmans director Neil Kirby says that though the National Health Act was promulgated last year, there is little evidence that it is likely to redress inequities in the health-care system. It's a limping piece of legislation, with only three-quarters of it actually implemented, says Kirby.

It is aspirational and introduces administrative and bureaucratic hurdles without getting to the nitty-gritty of the problems. Kirby says a better approach might have been to set targets - for example, that every person have access to a clinic, doctor or nurse, within a 50 km radius. Poor data collection may partly explain the department's failure to set proper targets. Mngadi admits this is one of the department's biggest weaknesses. However, he says, there are pilot projects under way to capture a range of patient information in two provinces, and the department plans to use its Aids programmes as a way to capture other essential patient data. The aim is to develop a full profile of each patient, Mngadi says. Figures on those infected with HIV/Aids differ by millions between Statistics SA, the department's antenatal prevalence surveys and the Actuarial Society. Moreover, there is limited public information on the progress of the state's antiretroviral plan and the minister admitted last year that she could not be sure how many people were receiving treatment. Fourth on the list of the challenges facing the department now to accelerate the registration of medicines and clinical trials.

Mngadi says the department is awaiting guidance from cabinet on how the Medicines Control Council (MCC) should be structured. We need to make sure that the MCC assists SA in improving access to medicines and making sure its decisions consider issues of public interest, he says. However, there are concerns that the department will meddle in the process of approving medicines. Good clinical practice means that the clinical audit must be done by people who are not involved in the roll-out process, says one insider. The MCC's role is simply to decide on the safety and efficacy of new medicines. The MCC is in disarray, taking years to approve new medicines, many of them considered essential.

What's clear is that the minister needs to work with other departments and players who are willing to help. This is not a road she can walk alone.

(Source: Financial mail, July 22, 2005)