Launch of the Human Resource for Health Strategy

Minister of Health Dr A Motsoaledi

Wits University

11 October 2011

Programme Director

Regional Director of the WHO AFRO Region-Dr Sambo

My fellow Cabinet Colleague-Dr B Nzimande

Vice Chancellor Prof Nongxa and members of Senate and Council Health MECs

The Director General of the Department of Health

Provincial Heads of Health

Deans of Faculties of Health Sciences

Wits Academics

Distinguished guests

Ladies and Gentlemen

It gives me great pleasure to be here today to launch the Country’€™s Human Resource Strategy for Health. This launch, coincides with opening of the WHO’€™s ‘€œ3rd regional consultation on finding solutions to the human resource for health challenges in Africa‘€.

Colleagues from all over the continent are in the Country over the next 4 days to deliberate on ways of addressing the human resource challenges confronting the continent. It is therefore very fitting for us that we gather here to present to the people of South Africa and the rest of Africa what we are doing to resolve the human resource challenges we face.

South Africa is facing a quadruple burden of diseases that will only be addressed if we have adequate human resources for all our programmes and interventions. I have mentioned on many occasions that the Department of Health’€™s priorities are well articulated in the 10-point plan. Moreover, the Negotiated Service Delivery Agreement (NSDA) that I signed with the President last year further outlines our priorities in harmony with the Millennium Development Goals. This strategy, is addressing one of the key pillars of Health Sector’€™s Strategic Priorities. The policies and programmes recommended in this strategy emanate from the broader vision of improving health outcomes and attaining the MDGs.

Improving human planning, development and management is instrumental in the overhaul of the health system. It is a strategic intervention whose activities will contribute significantly to improved health outcomes.   Compensation of employees is one of the biggest cost drivers in any institution. The National and Provincial Departments of health are no exception in this regard. Therefore, as the most expensive asset, we have to manage human resources prudently. Ladies and gentleman, this means that the health sector has to be staffed by an appropriately skilled workforce that is able to respond to the burden of disease and citizens’€™ expectations of quality service.

A number of studies and our own assessment attest to significant gaps in the planning, production and deployment of human resources for health. Further evidence indicates that the training and production of certain key health worker categories has stagnated or reversed over the years. The weak management skills in the public service aggravate the situation even further.

The shortage of human resources is not solely due to production and training problems. Additional problems such as the inequitable distribution of health workers between the public and private sector can lead to understaffing of rural areas.   Lack of access to health care due to shortage of staff is not only affecting rural areas, poor communities living in peri-urban settlements also bear the brunt of having limited access to health care due to a shortage of health workers in these areas.

Emigration to developed countries, for better opportunities further compounds an already complicated problem with a multi-faceted set of push and pull factors. For any country to effectively address the enlisted problems, the determinants of these push and pull factors have to be comprehensively and systemically addressed.

As outlined above, the human resource challenges need a coherent approach that provides solutions at individual, organisational and health system level. This strategy proposes interventions to deal with these multi-pronged push and pull factors that result in an inadequate health workforce and weak HR capacity.

The health workforce can only contribute meaningfully to the improvement of health outcomes if health workers are available, competent and delivering quality service within the set norms and standards. We need the correct numbers and a fair and equitable distribution of health workers countrywide.

For this plan to succeed there needs to be improved coordination between health systems planning and health professional training and development.   To give momentum to improved coordination and collaboration, I met the Deans of all Health Sciences Faculties and the Colleges of Medicines earlier this year. I echoed a plea I had made to them the previous year to increase the intake of medical students.

All the Deans have in principle supported the call to increase the intake of medical students in 2012 pending approval by the university structures. Progress has been made as the Deans have submitted proposals which are being reviewed by the department in preparation for the increased intake as extra funding is required if this intervention is to be implemented successfully. This is just one strategy to take us out of our comfort zone and find solutions to the HR problems as the current approach is not taking us anywhere. If for example all the 8 faculties of health sciences were to take on 40 extra students by 2012, this would increase the intake by 26% overall. Such a strategy will go a long way in ensuring that we have adequate numbers of health care professionals in the public service.

The University Witwatersrand   took the challenge I posed to all universities last year and has increased its intake by 40 students in the medical programme. This was at an additional cost of R 8 million which I negotiated with the Minister of Finance who was very supportive of the idea. For the Wits programme, the target was students from disadvantaged backgrounds in order to begin to transform the student cohort nationwide to reflect the demographics of the country.   Vice Chancellor, your leadership was decisive and you allowed this faculty to increase the numbers already this year.

In South Africa, where you were born and what your parents can afford often determine your fate in life. As one of the most unequal societies in the world, with the highest Gini-Coefficient access to medical education also follows this socio-economic trend.

Programme Director, faculties of health sciences have to do more to improve access to medical education for the poor and underprivileged. We have had many ‘€œCODESAs’€ in health but I think in the near future we need to have one on access to health sciences training with a particular emphasis on medical education. I am told that MEDUNSA and Walter Sisulu have produced more Black doctors than all 6 faculties put together.

The high burden of disease and the new programmes such as the restructuring of the PHC and introduction of NHI demand that we address the shortage of staff in the public sector.

There are various strategies we are implementing to address the acute shortages. Some include bilateral agreements with countries such as Cuba to train our students in medicine. We have recently reviewed this agreement and increased the targets as we need to increase the numbers within a short space of time. Universities, the Health Professions Council and Colleges of Medicine must find innovative ways to assist us in increasing the intake of students to adequately respond to the disease burden.

The people of South Africa want universities to be responsive to societal problems and develop solutions to these problems. As a higher education institution, we expect your post graduate students to come up with new knowledge on how to solve similar problems on an on-going basis. Numerous studies tell us what the problem is and very few come up with practical solutions for implementation. As all other Deans are also present here, I challenge your post graduate programmes in MPH and other related fields to conduct research and come up   with solutions that we can use to implement so that we address these challenges.

Higher education institutions have to be socially accountable to the citizens. When the situation on the ground changes in terms of epidemiological profile the curriculum must reflect the priorities of the health system.   I am not sure if our curriculum is targeted towards the South African socio-epidemiologic profile with respect to the weighting of the curriculum content.   All I can say is that some young doctors cannot even insert chest drains, one time I had to assist a young doctor who could not insert a chest drain. With such high levels of injury and violence as part of the quadruple burden of diseases, I find it odd that a doctor can leave medical school without such a basic skill which they will certainly need in our health facilities. There is a strong need for a push towards a socially accountable health sciences training.

Last year Walter Sisulu University hosted a workshop on socially accountable medical education. I understand that a similar workshop will this year be held here at Wits. Please ensure that the department is invited and participates at such events to ensure that our policies are informed by the latest scientific evidence.

Programme Director, I have so far presented solutions to the training of health professionals. I would now like to turn my attention to solutions linked to staff in our system.   Recently, I have met retired nurses who have indicated that they are keen to come back and assist us to implement some of our interventions. So far 400 of them have registered on our database and we are in regular discussions with them. The objective is to use the skill of these nurses to fill in the gaps in the short term. While the efforts of retired health professionals will go a long way in plugging the current gaps, they are not a long term solution and we are working hard to find long lasting solutions to these problems.

Ladies and gentlemen, we have embarked on a process of reengineering Primary Health Care. As part of the reengineered PHC, we will be sending nurses to various schools in the country. Our initial focus will be on the poorest schools where learners have limited access to health services. The nurses and other team members will screen the pupils in lower grades for hearing, vision and dental problems. Those learners found to be in need of clinical intervention will be referred to an appropriate facility. In high schools, the nurses will provide health education for sexual and reproductive health, with a view to address HIV prevention and the high number of teenage pregnancies.   They will also deal with other social problems such as alcohol and drug use. Details about the launch of this initiative will be announced as soon as it is a joint programme between health, social development and basic education.

In addition to the nurses, I have had discussions with the professional bodies representing medical doctors who have also indicated that some of their retired colleagues are willing to assist in the short term. As part of the reengineered PHC, we are placing district clinical specialist teams with the aim of improving maternal and child health outcomes at district level. These district teams will be comprised of an

Obstetrician and Gynaecologist, Paediatrician, Family Physician, and an Anaesthetist all at Principal level. With respect to nurses there will be a Midwife, Paediatric Nurse and a Primary Health Care Nurse, all at Advanced Level.

These positions were advertised two weeks ago and the recruitment process will be managed at National level to ensure that rural provinces are not affected negatively by people wanting to stay in urban areas. If the public service regulations have to be amended in order to bring retired colleagues back to work I will request parliament to do so.

The last strategy in our reengineered PHC will put community health teams in all the municipal wards in the country. These teams consisting of 10 people per team will be deployed in all the wards. We therefore need 40,000 community agents to implement this intervention properly. This model has demonstrated an improvement in health outcomes in countries that are implementing it. For example in Brazil there are 30,000 such workers while India has 800,000 called community agents. The purpose is to deal with health at community level, focusing on promotion and prevention of disease rather than waiting for the diseased to show up at hospitals.

As outlined above, the new approach to primary health care will need a set of new skills and an increase in numbers of certain categories of health workers. All of them have to be oriented to work at community level rather than facility level. In line with our heightened focus on health education and disease prevention. There are also less known categories of health workers such as health promotion practitioners and environmental practitioners who are all part of the ward based PHC teams.   Numbers for these professionals have to be increased so that the health workforce can respond to the disease burden and new interventions.

Distinguished guests, ladies and gentlemen, I would like to turn my attention to infrastructure. People have to be trained in institutions that are well geared for this purpose. We have therefore improved facility planning, infrastructure development and refurbishment. This is instrumental in ensuring that there are places to train much needed health workforce.

With regards to nurse training, over the next three years we have earmarked R1, 24 billion for the revitalisation of 122 nursing colleges. For the current financial year we will spend in R220 million, and R510 million each in subsequent years. These institutions will be refurbished depending on their state. Some which require minor improvements will be refurbished in the current financial year. Those requiring major refurbishments or complete rebuilding will be dealt with in subsequent years.

For the training of other health professionals we have a number of flagship projects. These are:

·           A new Medical School , 9th Medical School of the country in Limpopo together with a new Academic Hospital

·           A new George Mukhari Academic Hospital, together with massive improvement of the Faculty

·           Chris Hani Baragwanath Academic Hospital (a new structure/break and build)

·           A new King Edward VIII Academic Hospital, together with a new Faculty of Medicine

·           Nelson Mandela Academic Hospital in Mthatha (new structure?/refurbishment, enlargement and improvement of the Faculty)

·           A new Tertiary Hospital in Nelspruit

 The investment in this entire flagship project will be more than the 2010 stadia budget put together.

As part of this strategy, we are putting up these facilities to ensure that the country is in a position to increase the number of health workers trained.

Universities therefore, will have to plan accordingly to increase their teaching capacity as we will provide an enabling environment for them to increase their numbers. Working in tandem with my colleagues in Higher Education, we have to link planning and training so that the numbers trained can supply the need and improve our ability to respond.

The capacity to respond to the health care needs of South Africans needs an inclusive approach. Over the years the role of private GPs has not been fully explored. Recently, the role of private sector professionals in the provision of health services in partnership with the public sector has risen to prominence since the launch of the NHI green paper. Last month I visited the UK and GPs there are gate keepers in the public health system. No one can go to a specialist without being seen by a GP.

Over the month of October, I have begun stakeholder consultations with the General Practitioners countrywide. So far I have been to four provinces talking to GPs about their role in the provision of health care for the public sector. I have received overwhelming support and GPs are waiting patiently to partner with the state in the provision of health services for our people. This is the model in many countries; people do not just wake up and see a plastic surgeon for a simple laceration on the hand. The reengineered primary health care will include General Practitioners as gate keepers working at community level with linkages to the other PHC streams I have introduced before. If we coordinate all these resources well, we should be in a position to respond to the health needs of all South Africans irrespective of their ability to pay.

So far I have presented a wide ranging set of interventions to address our human resource challenges. This involved a process of systematic planning integrating facility improvement, working with private providers, increasing the number of student intake, refurbishing institutions and constructing new faculties as part of our response to the Human Resource shortages we face.

The previous sections have addressed the push and pull factors within the HR system and have addressed individual and systematic issues. One of the weaknesses at organisational level is the management skill at facility and district level. Studies have demonstrated that it is not only financial incentives that make them   leave but sometimes how they are managed or ‘€œmismanaged’€. The public health sector has to ensure that environment in which health workers operate is conducive. The health system must provide safe facilities which have the appropriate technology and materials for health workers to discharge their duties diligently. We have embarked on strategies to ensure that all these factors are addressed.

There is a coordinated health facility planning that has developed revitalisation plans for hospitals and nursing colleges. I have appointed an advisory committee that has produced an essential technology list. This is a list of minimum equipment each facility must have to deliver quality and safe health care. An audit of more than 4000 facilities is currently underway, this audit assesses among others; human resources, facility management, supply and logistics, etc. We will be setting up teams to work closely with the facilities to develop quality improvement and health system strengthening plans for each facility. We believe this will result in well-equipped and better staffed facilities that will enable our health workers to focus on what they know best i.e. to deliver quality health care in facilities they are proud to be part of.

With regard to management skills, we have partnered with local and international institutions to develop interventions to improve the management training and skills of managers at facility and district level to ensure that the health workforce which is a scarce resource is recognised, rewarded and appreciated by the health sector. This will lead to motivation, improved morale and productivity, translating into quality of care for patients.

As part of strengthening health systems and improving human resource capacity, the health sector needs a concerted effort that will ensure our policy objectives do not have ambiguities but are harmonised and complement each other. Some of the policies issues that need a closer look include: exploring alternative ways to increase the training of health workers, moonlighting and RWOPS, developing a coherent policy on the issue of foreign workforce and the role of academic health complexes in the production of health care workers.

These are areas of policy that will need leadership from the National Health Council to provide an enabling environment for the implementation of this strategy.  

I am confident that the National health council, the Departmental officials at national and provincial departments of health and our partners will join hands in ensuring that this strategy becomes a living document which is revised from time to time based on the changes experienced on the ground.

Programme director, distinguished guests, ladies and gentleman-I have presented to you our strategic vision on improving human resource capacity and responding to the burden of disease to improve health outcomes.

Thank you.