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Spotlight on Universal Health Coverage and its implementation challenges

25 August - The Centre for Health Policy hosted a panel discussion during the School of Public Health Research Day on 25 August which highlighted universal health coverage and its implementation challenges.

This work, as part of the SA Research Chairs Initiative (SARChI), is covering a new chapter in SA’s history, outlining how a health system handles new reforms which are incorporated into old systems. It emphasises not only what is being done, but how it is being done, and demonstrates the role of organisational functionality in the new reforms. Panellists outlined their research along themes of accountability, governance, decentralisation and implementation of primary health care.

Kafayat Oboirien, a PhD fellow, is focusing on District-based Clinical Specialist Teams (DCSTs), an innovation of the Primary Health Care re-engineering reform in South Africa. Potential challenges for DCST functioning include varied expectations of roles among DCSTs and other actors. This raises concerns about extent of teamwork and duplication of roles. Limited resources and infrastructure, such as consulting rooms in facilities to provide mentorship in privacy, coupled with incomplete teams limits the scope for clinical governance support. DCSTs have advisory rather than statutory roles. Healthcare workers appear not to comply with their recommendations which undermines their ability to hold clinicians accountable.

Panellist Shehnaz Munshi, a Masters of Public Health student, outlined her research on ward-based outreach teams (WBOT). Insufficient training, working beyond their scope and a lack of equipment leads to a sense of inadequacy by these teams. A lack of space and basic resources, as well as an overburdened team leader who has to negotiate internal politics between the local health clinic and the provincial WBOT are further challenges. She referred to community health workers as ‘cultural brokers’ between clinics and the community and concluded that regular stakeholder engagement with communities was required to avoid community distrust.

Adam Fusheini is a post-doctoral fellow at CHP focusing on governance and accountability in hospitals as important organisations of healthcare delivery. His findings of an exploratory, qualitative study of middle-management staff showed that budgetary constraints were a key hurdle. Funding shortages affect plans and policies, as well as delivery of health services and recruitment of required staff. This leads to work overload and long waiting times for patients. Leadership challenges contribute to poor CEO relationships with the hospital boards.

PhD Fellow Shakira Choonara presented her research on the daily practices and processes of district financial and human resource management. Outdated IT infrastructure compounds the challenges of limited resources and difficulty in accessing resources. This has led to manual uploading of financial processes. Measures to overcome these frustrations were seen in exemplary ‘mentor’ managers who encouraged open door policies, ongoing learning and empowerment of staff. Casual visits to check on how staff were doing their work had a profound effect on one district’s financial management. She suggested a move towards people-centeredness which will support UHC and a better health system.

Faith Mambulu, also a PhD Fellow, outlined the initial phase of her research on referral systems for child health. She referred to her literature review which will guide her to explore gaps in referrals. In South Africa, 75 000 children die before they reach the age of five, mainly through pneumonia, diarrhoea and and malnutrition. Weak management and low morale among health workers account for most of the avoidable factors leading to child deaths. Understanding the healthcare processes and the role of providers responsible for these factors may help to address health systems problems. Her research aims to investigate the healthcare referral system policies, guidelines and practices for child illnesses in South Africa.

Audience comments confirmed the governance issues and that delegation was insufficient without accountability frameworks. New legislation is being drafted which will empower hospital boards which to date have been ‘paper tigers’. Information systems are critical to inform management processes for good governance. One delegate queried whether SA did indeed have a district health system. The panel agreed that in reality it was ‘centralised decentralisation’. The panel discussion revealed the tension between decentralisation and centralisation which was underpinned by issues of trust, flexibility and responses to the tensions.