The unlawful state of healthcare

The chronic shortage of trained medical personnel means long queues in clinics and hospitals. (Oupa Nkosi, M&G)

The chronic shortage of trained medical personnel means long queues in clinics and hospitals. (Oupa Nkosi, M&G)

 Health systems are a complex ecosystem. They require physical infrastructure, medical technologies, medicines, information systems. But access to, and the functionality of, each part depends absolutely on the presence of sufficient numbers of appropriately trained healthworkers.

The backbone of a public healthcare system, which is more low-tech than tertiary care but no less life saving, is its personnel.
Its success depends on the qualitative interactions of staff in the system with patients and the population of each district. This requires the calculation of appropriate ratios of doctors, nurses and community healthworkers linked to community clinics, their equitable geographical distribution and efficient systems for managing and monitoring them.

In 1994 a process to quantify the country’s unmet needs for different categories of healthworkers, a plan to train them and then to locate them equitably across the country, as well as costing and budgeting for this plan, should have been the starting point for health system transformation – immediately.

Numbers matter. But experts in health provision also stress the need for policy-makers to appreciate that “healthcare is a human system, and that reforms have to address themselves centrally to the personnel staffing the service” (South African Health Review 2002). This requires planning to improve the living and working conditions faced by black healthworkers.

Social justice for users of health systems depends on respect for those who work in them, and healthworkers’ trust in the system. This entails a reciprocal social contract with the state, a commitment to advancing their fundamental rights.

Twenty years have passed since the National Health Plan (NHP) was published. Sadly, during that time an extensive and depressing academic literature records the missed opportunities for health transformation.

Instead of charting the rise of a primary care system and the renewal and equitable distribution of a health workforce, the literature records its demise. Failure to act on the volume of academic and research articles pointing out the human resource challenge, and particularly the looming shortages of doctors and nurses, creates political culpability for the suffering now being experienced by health system users and providers.

The national department of health is planning and beginning to implement a national health insurance (NHI) system. The department

recognises, however, that “the biggest threat to NHI is the unequal distribution of health professionals between the private and public sector, and between urban and rural areas”.

It promises that the “NHI Fund will enter into contracts with public and private hospitals, specialists, public clinics and private general practitioner practices to deliver healthcare services free”. It also reports that the World Health Organisation’s recommended workload indicator of staffing needs system is now being used to identify human shortages more accurately.

Yet healthworker shortages and demoralisation are deeper than admitted. It is also about the quality of conditions and support experienced by front-line workers.

Ironically, part of the problem is planning. We have a plethora of plans but little prioritisation, monitoring or accountability.

Plans are often so complex that those responsible for their implementation have no idea where to start. Chapter 10 of the National Development Plan (NDP), for example, is titled “Promoting Health”. It lists nine goals towards its 2030 vision for heath; goals seven and nine relate to the health workforce and are multipronged. It also has nine priorities, but only priority six relates to the workforce. 

Unfortunately, the NDP’s catch-all of goals and priorities fail to recognise that the first priority has to be to resolve the crisis that faces the health workforce. And, as with other plans, the NDP suffers fatally from being neither costed nor budgeted; it has no legally enforceable implementation plan setting out how and when its priorities will be effected.

My conclusion is that much of our public health policy on the health workforce is unconstitutional because it is failing to use all the “legislative and other measures” permissible by the government or to properly calculate or allocate “available resources” to health. It is therefore not compliant with the approach required by the Constitutional Court when it comes to the realisation of socioeconomic rights.

The result is that, although the minister of health may justifiably claim, in his July 2014 budget speech, that the number of health programmes and facilities is expanding, access to quality healthcare (measured fundamentally through equitable access to healthcare workers) is regressing.

This is an unlawful state.

To remedy this situation requires that we demand a return to the health revolution promised in 1994 by the National Health Plan. Because current staff shortages cannot meet the legal obligation to realise access to healthcare services, the government has a legal obligation to revisit and revise the medium-term expenditure framework for health, and to ensure sufficient finances are made available for expanding, retraining and supporting the health workforce. But in the short term, several measures would bring improvements, including:

  • Establishing the consultative and governance structures required by the National Health Act, so that healthworkers are actively involved in health monitoring and planning;
  • The finalisation and swift implementation of key policies whose delay is causing distress in the health system, particularly policies regarding community healthcare workers and clinical associates; and
  • There are many measures and best practices both locally and internationally that could be used to make quick and radical imporvements to the situation. But realising the right to health requires political will from across government, not just the minister responsible.

Finally, I would argue that a new civil society alliance for healthworker rights and employment must be created that unites health unions, activists and academia – focusing demands on healthworker employment and conditions.

Mark Heywood is the executive director of Section27. This is an edited extract from his presentation at the Public Positions on History and Politics series of discussions, hosted by the Wits Institute for Social and Economic Research (Wiser), the University of the Witwatersrand’s department of politics and the History Workshop. The next such event will be on October 7 at Wiser, starting at 5pm. Marie Huchzermeyer of Wits’s architecture and planning department will present a short paper on “The Right to the City” and discussion will follow. Go to for more information.

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