This document is made as a consolidated representation of the position of the People’s Health Movement of South Africa on the issues and priorities within the Human Resources for Health (HRH) environment. Investment in and reorientation of HRH can and should form a key focus in a shift towards a system that embodies the broad principles of the Primary Health Care approach. It is this overarching strategy that should inform all HRH reform.
The key areas of recommendation included within this document are:
- A commitment towards building an empowered and expanded Community Health Worker (CHW) workforce that is integrated within the larger health system
- Greater investment in health personnel and in their education
- Reorientation of health professions education
- Commitment to the establishment of an integrated Mid-Level Health Workforce within all fields of healthcare
- The upskilling of competent and capacitated managers at all levels of the health system
- Building self-reliance and investment in South African institutions as centres of policy and consulting expertise
Human resources are the most important and expensive of the health system ‘building blocks’, accounting for approximately 70% of recurrent health expenditure. South Africa’s draft HRH Strategy states that ‘South Africa’s performance in terms of health outcomes when compared with peer countries is extremely poor, with much higher infant and maternal mortality. This reflects on poor productivity, poor design and poor management of resources and not only necessarily on the number of available professionals in the health sector.’ It also notes that ‘South Africa has a nurse-based health care system with 80% of health professionals comprising nurses’, but that ‘South Africa has considerably less doctors per 10,000, pharmacists and oral health practitioners per population than the other comparing (sic) countries.’
However, these averages mask disparities in the distribution of health personnel between public and private sectors, health centres/clinics and hospitals, and rural and urban locations. Such disparities are driven by differences in service conditions between the public and private sectors and by poor preparation, deficient infrastructure and inadequate incentives for practice in low-resource and rural environments.
These quantitative and distributional deficits are compounded by qualitative deficiencies: several studies have noted a significant skills gap amongst practitioners, both nursing and medical, in relation to those required for district, especially rural, practice. This is a result of inter aliaa continuing strong orientation in health professions education to hospital-based, specialist and urban practice.
Community Health Workers (CHWs) and Volunteers:
Community-based health care: more Community Health Workers who are allowed to do more
A core component of the ‘Re-engineering Primary Health Care’ strategy is the proposal to place much greater emphasis on population-based health and outcomes, which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities.
The case for the creation of a large cohort of community health workers is an economic and developmental one as much as it is based on a commitment to the principles of Primary Health Care.
There is both evidence and experience to support these linked components of community-based care. CHWs can successfully undertake a range of interventions in maternal, newborn and child health (MNCH). While in recent years in South Africa CHWs’ activities have often been restricted to a few actions, especially in relation to HIV and AIDS care and prevention, there is a growing number of examples of countries where CHWs perform a wide range of tasks, including in MNCH care.
Research and experience from a growing number of countries show rapid improvements in child health when good household coverage is attained through the use of community-level workers who are supported by clinics and health centres and are equipped with basic skills to identify, prevent and treat common conditions.(1)
The number of tasks a CHW can reasonably perform depends upon the ratio of CHWs to households, the duration and quality of their training, and the extent and quality of their supervision.(2) In Thailand and Rwanda a high CHW-to-household ratio ensures that all households, including the poorest with the most vulnerable children, are visited regularly and health problems are detected early. Such a high ratio of CHWs to households has been attained by having both full-time and part-time CHWs with ratios of 1:10 to 1:20. In Thailand, for example, high coverage is achieved by instituting a ‘two-tier’ system where there is one full-time CHW for every 300-500 households, and who then supervises 10 part-time CHWs who have more limited training. (3)
If South Africa were to adopt such an approach this would require a total of at least 700,000 community-based workers, the majority of them part-time. In addition to rendering health care more accessible and equitable, this system will create jobs, and indirectly improve health by reducing the prevalence and depth of poverty.
CHWs in several countries have proven effective in treating childhood pneumonia with antibiotics.(4) Yet CHWs in South Africa are prohibited from treating pneumonia and the plans to re-engineer primary health care continue to limit their role in treatment. In 2010, 29 of 44 UNICEF country ofﬁces in sub-Saharan Africa report government community case management implementation, including treatment of pneumonia with antibiotics. (6)
If this community-based model is to succeed, the power of conservative professional councils needs to be moderated to allow widening of the scope of practice for nurses and CHWs and to enable CHWs to administer antibiotics for specific childhood diseases.
In South Africa pneumonia accounts (conservatively) for 6% of all under-5 deaths (in 2009 Stats SA reported that respiratory infections accounted for 11.7% of infant deaths). This notwithstanding, the ‘Re-engineering’ document proposes a very restricted role for CHWs in treating common diseases, including pneumonia. Policies permitting community-level workers to use antibiotics to treat pneumonia have been controversial because of concerns by health professionals that antibiotics might be misused or over-used. In Nepal and in Ethiopia, monitoring the quality of care provided by community workers in treating pneumonia has affirmed that the quality of care has remained high. (5)
Supportive national policies should allow CHWs to administer antibiotics for specific childhood diseases along with strengthened regulatory and quality controls for the distribution and appropriate use of antibiotics.
Community Health Workers and Community Health Volunteers
In Ethiopia, Mali and Niger the second- or higher tier consists of the more formal CHW cadre promoted by governments and donors since around the early 2000s. They are formally recruited, with at least primary level schooling, are salaried and operate mostly often out of fixed health posts situated in communities (e.g. in Niger and Ethiopia) or out of their homes (e.g. in Mali). This cadre has garnered more attention in terms of evaluation. In all three of these countries, there is a first-tier of exclusively volunteer CHWs whose role is less well understood. They operate semi-formally within communities, at village and household level without necessarily requiring formal education and with limited training. These volunteers, called Relais Communautaire (or Relais) in Niger and Mali and Health Development Army in Ethiopia, practice health and nutrition promotion and disease prevention at community level as well as referral to first-level (CHW and clinic) facilities, and as we noted previously, further evidence should be sought on the respective roles and mechanics of the two CHW cadres (9).
Scope and location of practice
A major focus for CHWs in the Alma Ata Declaration was community involvement in prevention and promotion, but since the HIV crisis, and in response to the challenge of the health Millennium Development Goals, the shift has been towards using CHWs to increase access to treatment.(10) CHWs were previously recruited (often drawing from a volunteer cadre operating at village level), provided with basic health training to deliver various services including health promotion, immunization, family planning, support for breastfeeding and improved infant and young child feeding practices, hygiene, disease control and curative care. With the increased momentum towards child survival in sub-Saharan Africa, this tier of CHWs has become increasingly focussed on community treatment of malaria, pneumonia and diarrhoea as well as acute malnutrition. There is also now a push to include essential newborn care and some maternal health interventions. Donor partners have provided funds for training on integrated community case management (iCCM), medicines, equipment and tools for supportive supervision, alongside strengthening of the supply chain and monitoring and evaluation systems. The discourse has been one of ‘task-shifting’ within primary health care, from the clinic level (and formal clinicians) to the health post or community level. (11)
Community Health Volunteers to Increase Coverage and density
The volunteer cadres have a strong focus on health promotion and disease prevention, through raising community awareness, doing promoting social mobilization, sparking community dialogue and demonstrating key practices including the promotion of and distribution of long-lasting insecticidal nets, nutrition support activities, promotion of proper hygiene and supporting immunisation outreach campaigns.(7-8, 12-15). Their roles are often defined as promotion of essential or key family practices. They work closely with both the CHWs at the health post and the clinicians at the health centre in their catchment area. For example, they may accompany the CHWs on home-visits, do home-visits on behalf of the CHWs or do health promotion talks at the health facility. They also identify sick and malnourished children, motivating parents to seek health care at the health facility and provide community-based oral rehydration therapy and nutritional support for malnourished children. (12, 14, 16).
The Relais in Niger and Mali and the Health Development Army in Ethiopia come from and live in the community, they form the link between the community and the health service, they participate in village health committee structures and their role is well appreciated in communities.(15, 16). In Ethiopia, the Health Development Army encourages ‘model’ families and they deliver the Community-based Nutrition Program; with tasks such as monthly weighing of children under two, counselling of mothers, home visits to follow up growth faltering or sick children and referral of sick or malnourished children to the health post (which can lead to life-saving therapeutic feeding).(7) The Health Development Army forms part of the government’s social protection programme. (8) In Niger and Mali, donor organizations have encouraged the development of this cadre through providing them with training in Key Family Practices and in delivering the Community-Led Total Sanitation programme. (12-13) In Ethiopia, it is mostly women who form the Health Development Army, whilst in Mali the Relais are mostly male. In Niger, the volunteers are often respected and influential elders, older men and women; some women are also traditional birth attendants.
Many volunteers struggle to balance their voluntary health role with their own economic livelihood activities. Incentives that are enjoyed by some include stipends for attending training and for participation in immunisation campaigns. The free health care policy in Niger is seen as a driver for improved geographic access to service delivery points, including new efforts to formalize the Relais cadre. Niger is planning to standardise the roles and tasks of the Relais, possibly including curative care, and providing them with training and incentives (such as resources for income generation). Given that training costs represent a large additional expense for implementing iCCM (whether salaried or volunteers), the financial implications of such training are daunting and need to be considered. (7)
Until recently, there were no official country-level numbers of volunteer CHWs, but indications are that the ratio of volunteer CHWs to the population is much higher than the ratio of formal CHWs to the population.(7, 12) In Niger most CHWs are supported by at least one Relais with more Relais at village level. A 2013 census of Cases de Santé (health posts) and Centres de Santé Intégrés (integrated health centres or clinics) in Niger confirmed that for the 1997 health posts surveyed, there was almost double the number of Relais to CHWs and 5 to 6 Relais for each of the integrated health centres.(17) In Mali the Relais are responsible for approximately 50 households each.
Widening Scope of Practice for Nurses and CHWs
With recent shifts in the focus of health policy over the past period with increasing emphasis on PHC most of the statutory health councils have continued to issue subordinate legislation related to the regulation of scope of practice, registration and qualifications for specific professions. This notwithstanding, there remain legislative obstacles to CHWs as key members of WBOTs prescribing treatment for common childhood illnesses such as pneumonia which remains a top cause of death of young children outside health facilities, despite robust research evidence supporting this practice and one which has been adopted in 30 African countries. The lack of updated regulatory instruments from the South African Nursing Council is of concern. There is an urgent need to update the Regulations to accompany section 56(6) of the Act (33 of 2005), and thus extend prescribing privileges to include Schedule 5 and 6 medicines.
Investing in Health Professionals and Reorienting Education
Overall funding of Health Education Institutions (HEIs) has effectively declined over the past decade, with government grant allocations falling behind inflation and growth of student numbers. Available resources are currently insufficient to support eligible students, including in the health sciences. Much of the funding for health professions education comes through the Health Professions Training and Development Grant (HPTDG) and the smaller Clinical Training Grant (CTG) allocated to provinces by the National DoH. While the DoH and DHET have independently commissioned reviews of these grants and the DoH’s National Conditional Grant Task Team and HPTDG review report was tabled with the National Health Council in August 2013 its recommendations have still not been implemented.
Brazil’s health system, and especially it’s Family Health Programme (FHP), has inspired some of South Africa’s key new policies, in particular, ‘Re-engineering Primary Health Care’. It is instructive to review briefly how the main features of the HRD policies adopted in Brazil were aligned with and supported the implementation of the FHP. Brazil has more than 2.5 million workers formally employed in the health sector, with an emphasis on Health Workforce (HWF) for the primary and community levels of care; this number represents about 1.3% of the country’s population. This is a far greater concentration than in South Africa which has under 300 000 health workers in the public sector for a user population of approximately 44 million, constituting only 0.7% of the population ie approximately half Brazil’s percentage. Brazil’s numbers have been achieved by significant investment in the training of nurses and technicians, the upskilling of public health and auxiliary personnel (to promote problem-solving and reflective thinking), and curricular reform in undergraduate programmes.
For example, the large number of managers in Brazil’s FHP have been prepared for their roles and receive continuing education through several networks: the first one constituted by Technical Schools; secondly, enrolling State Schools of Public health in more than a dozen states; and thirdly, establishing a voluntary network of academic institutions in a federal funded network called Open University. This continuing education is provided through a combination of residential and distance learning, the latter utilising state-of-the-art materials and technology by the Open University and its nodes. More recently, an online teaching platform has been developed for doctors recruited to work in the FHP. This platform is administered by the National Ministry of Health, and tutors for the generalist doctors have been provided by the university Schools of Medicine, Nursing, Dentistry and Public Health, which have accredited the teaching modules and award qualifications.
In South Africa however there has been a stagnation in production of doctors and, until recently, a decline in the production of nurses. Training in Public Health, a core component of PHC, is minimally supported by government funding, with most South African Schools of Public Health relying heavily on external donor and research funding to support most of their small contingent of teaching staff. Moreover, most tutors in nursing schools have not themselves been adequately oriented to the demands of the new health policies.
Workable examples of innovative health personnel training exist predominantly in various university units and certain NGOs – these models balance appropriate and practical clinical training with public health competencies and form part of both undergraduate, graduate, and continuing education training. However, there is no clear national policy to ensure coordination and scalability.
Strengthening Quality of Care
Weak Competence to Implement Comprehensive PHC
Nurses, mid-level and community health workers
Such qualitative deficiencies have become particularly evident with the current introduction of new policies to strengthen the public health sector in advance of full implementation of the National Health Insurance scheme (NHI). The initiative on ‘Re-engineering Primary Health Care’ demands that at least the core of the primary health care (PHC) outreach team, which consists of a professional nurse, staff nurse and a team of community health workers, require substantially enhanced skills to carry out and support primary health care, given that the majority of nurses have received little substantive training in the application of PHC to practice, especially in low-resource environments.
An expanded Mid-Level Workforce has been demonstrated to have positive impacts on health equity and access to care within a number of sub-Saharan countries. In light of dramatic shortages of specialist clinicians and overburdened health systems on the African continent, a focus on building and integrating a mid-level health workforce should be a national priority. Examples such as clinical associates, surgical associates, medical and surgical technicians and physician assistants. While established in some forms in the South African health system there is no concerted NDoH support for a formalised and expanded mid-level workforce, as demonstrated by recent protests from the Professional Association of Clinical Associates of South Africa against the failure of the public health service to employ many recent graduates.
It is important to push for an expanded Mid-Level Workforce as a key priority of the South African HRH policy going forward. This, we must note, should not be limited to the medical or surgical technician fields but should include areas of rehabilitation science and dietetics. The disparities in the distribution of healthcare service providers between public and private sectors are deepened by the massive urban-rural divide. In addition to expanding the capacity and number of the health workforce in general, a strong mid-level workforce can serve to bridge the urban-rural care divide for many of these priority healthcare services and allow the country to move away from an urban hospicentric model.
Doctors and specialist support teams
Additionally, medical doctors located at regional and district hospitals are now required to play supervisory as well as clinical roles, and hence also need to possess skills in monitoring, managing and supporting primary health care. According to the Re-engineering Primary Health care document, ’family physicians as part of the district specialist support team in line with national policy and guidelines, should take the primary responsibility for developing a district specific strategy, implementation plan for clinical governance and provide technical support and capacity development for the implementation of clinical governance tools, systems and processes for clinical service quality in the district health system that includes the community-based services, primary health care facility services and district hospital services. Family physicians should also take overall responsibility for the monitoring and evaluation of clinical service quality for the entire district.
There remains a significant shortage of qualified medical doctors employed by the public sector and continued pressure upon medical schools to produce more graduates to fill this deficit, however, this mechanism is not a sustainable nor comprehensive solution to HRH understaffing and an overburdened health system – especially without concerted government financial commitments to ensure the mandatory filling of all currently vacant clinical posts. Task-shifting must be considered therefore as an adjunct, if not primary focus of any attempt to bridge the clinical shortages within the South African setting.
Education and Training Imperatives
The above requirements demand a rapid expansion and reorientation of both medical and nurse training. The policy decisions to increase the intake of medical schools and reopen and expand nurse training colleges are welcome steps in the right direction, although their graduates will only be available to staff the service in 5 to 7 years hence. In light of the above qualitative deficits, revitalising these institutions must be accompanied by curriculum review and reform. In the case of nursing this process should include advisers external to the current nurse training bodies (Nursing Council and Sector Education and Training Authorities), with experience of or exposure to countries that have successfully implemented a comprehensive, district-based approach. This is necessary because experience over the past two decades strongly suggests that the professional councils, and particularly the Nursing Council, have, through commission or omission, been unsupportive of any significant changes in the orientation of health professions curricula.
In the short to medium term, however, the primary challenge is to strengthen amongst personnel already in practice the competences required to implement PHC and to effectively manage the health system, especially at district level and below.
Implementation of policies based on PHC requires, in addition to basic clinical skills (therapeutic and rehabilitative), competence in promotive and preventive actions. Health promotion and disease prevention comprise the core activities of public or population health. Thus, doctors and nurses (or at least the professional nurse leading the outreach team) will need, in addition to skills in primary clinical care, to be substantially competent Public Health ie in addressing health issues at a population level. Indeed, in several countries, community nurses (professional nurses with public health training) leadthe implementation and management of district health programmes.
Several research studies and audits over the past two decades have indicated deficiencies in clinical skills required to practise competently at district level and below. It has been acknowledged that many – perhaps the majority – of practitioners working at district level and below are poorly equipped to manage common conditions in low-resource environments. Recognition of such deficits by the training institutions has been slow, with curriculum change in health professions pre-service training programmes being minimal or piecemeal in the majority of institutions, and barely discernible in postgraduate training. In this regard, the role of the statutory professional councils, which remain the accrediting bodies – despite recommendations made by the National Commission on Higher Education (NCHE) that this situation be reviewed – merits critical evaluation. The NCHE recommended that the accreditation of educational programmes be performed not by the licensing bodies (the professional councils) but by an association of teaching institutions, as presently occurs in North America.
A major challenge to improving quality of health services is poor supervision of PHC services despite much training and the availability of a national “Supervisory Manual”. Monthly supportive supervision from a suitably trained supervisor to drive continuous quality improvement is proposed, but infrequently achieved in most districts, and, when conducted, often inadequate.
Similarly, systems of clinical governance entailing support from regional and district hospitals are non- existent or weak in most provinces. One exception is the use of the Perinatal Problem Identification Programme (PPIP) in about half of all deliveries in public facilities; however, such tools are rarely employed for other programmes.
Management and Leadership
Additionally, public health competence, especially in the areas of management and leadership, has been noted to be weak and to require substantial strengthening if functioning of the health system is to be improved. A 2008 national survey of District Management Teams (DMTs) found that in most provinces management structures were in transition, delegations for human and financial resources were inconsistent, and that courses available to managers were not systematically aligned towards their needs. Moreover, the dominant culture in the health sector discourages innovation and implementation of new approaches, with directives from provincial level often undermining initiative. Similarly, at sub district level management strengthening is urgently required. Such weak management at district and sub-district levels and poor understanding of PHC results in unresponsiveness to community needs; a failure to prioritise primary health care issues; and a fragmentation of activities into vertical, disease-specific interventions and campaigns as well as poor integration of different levels of care – household, community, and facility.
The roles that must be played by managers are different at different levels of the health system. Managers working at district level need a different set of public health competences from those traditionally ascribed to managers at the policy level. For example, in the area of health economics and financing the manager at the policy level needs to know about elasticity of demand and amortization of assets, while a district manager needs skills to draw up a financial plan. This recognition that distinct competencies are required for different roles has major implications for health professions education, and, given the current policy changes, underlines the imperative of providing access to public health and management skills to a wide range of health professionals, including medical doctors.
Competences Required by Practitioners and Managers in Decentralized Systems
The development of comprehensive programmes, integrated into decentralized district systems, requires both significant skills in primary clinical care as well as strengthened management capacity of health personnel. It requires reorienting district level health personnel to managing all aspects of health service implementation, and working with other sectors’ professionals and facilitating community participation to address the local social determinants of ill-health. Managers will also need to be trained to use monitoring and surveillance data for action. Lastly, the introduction of the National Health Insurance will require a huge injection of skills building to manage the purchaser-provider split in health care financing, and to oversee, and monitor contracts at all levels of the system – particularly at primary care level.
Managerial and administrative services are an essential part of the demands placed upon the health workforce. Managerial competence is not built into current clinical training and yet in many sectors of the health system clinical personnel are relied upon for a broad range of managerial tasks. It is vital that competent management is available at all levels of the system. Therefore, there should be a focus on providing adequate management training and administrative support to those serving in managerial positions. An example of this principal within the context of the NHI is that of Contracting Units for Primary Health Care at the local level which will never be able to effect identification of suitable providers or monitor contracts appropriately unless they are upskilled to do so.
A significant burden upon clinical time, specifically that of highly trained or specialised clinical personnel, is caused by administrative and bureaucratic requirements. This is an inefficient use of resources in light of critical staff shortages in many medical and rehabilitation services. A concurrent focus on the development of efficient knowledge management systems and on the establishment of a well trained and distributed administrative cohort is essential to maximize the capacity of specialised services.
Building Self-Reliance in Policy and Consulting
The National Department of Health is far too dependent on external consultants for its plans and does not look nor invest internally in South African institutions who could provide such support for much less cost than spent on international consultants. Building a reliance upon localised expertise and strengthening centres of policy excellence within local institutions would contribute to strengthening of the HRH system within South Africa.
Local South African institutions, academic, civil society or otherwise, as well as local institutional expertise should be the first port of call for processes of consulting, critical review, and monitoring and evaluation tied to any major national health interventions. A dependence on international contracting and consultants is not only expensive but discourages the development of local capacity, disregards pre-existing South African expertise and fosters brain-drain within the health sector at the leadership level.
Social determinants of Health
The Re-engineering Primary Health care policy states that: ‘It is well recognised that many of the factors that impact on health are outside of the health sector. Much of the work of community-based service teams can be linked to improving social determinants at the community level in addition to an expanded clinical role.
It is, however, not clear which health personnel have the competence to lead this work at the district and ward level. This could, in theory, be the role of environmental health officers, yet the numbers and distribution, as well as current training and activities of these personnel suggests that they are too few and not well-equipped to lead such work in disadvantaged communities.
Recommendations to Bridge Competence Challenges
Therefore, given these listed challenges, a set of recommendations is made in response to the challenge of health education and training specifically in addition to those discussed in the document above. These include:
- It is clear that, if current policies are to be implemented, there needs to be a massive and focussed investment in health personnel training where government incentivises the production of appropriate and appropriately trained personnel in sufficient numbers and within a negotiated, but short, time frame. Aspects of task-shifting and the upskilling of a mid-level and community level health workforce across a broader scope of practice are key areas of focus.
- Accordingly, the NDOH should undertake or commission a process to: identify and systematise the ‘competence gap’ for each level of care, focussing initially on the DHS; define which categories of personnel would need to acquire or enhance these competences; identify a set of educational institutions/organisations to supply such training and electronic platforms through which it can be delivered on a large scale; and enter into contracts with the identified organisations to systematically address the competence gap.
- Simultaneously, the NDOH will need to critically evaluate the role of the statutory professional councils in accrediting educational and training programmes to ensure that they are facilitating progressive reform rather than continuing to ensure the reproduction of a cadre of health personnel who are trained primarily to provide a hospital-based, specialist-oriented system of care. A specific focus should be on building statutory and professional capacity of cohorts of mid-level workers and formalising the integration of CHWs and volunteers into the public healthcare workforce.
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