versión On-line ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.103 no.1 Cape Town ene. 2013
No 'walk in the park' - new social compact
The South African health sector, long-riven by point-scoring across the public/private divide, has crossed its own Rubicon with the R40 million start-up social compact between government and 23 major health corporates aimed at addressing the dual human resource and management crises.
This is the view of a former South African director general of health and foreign affairs - turned group executive director of Discovery Holdings, Dr Ayanda Ntsaluba, who believes focusing on agreed national health priorities will open up wider co-operative vistas while breaking a 'psychological barrier'. He was referring to the South African Joint Public Health Enhancement Fund (SAJPHE), set up by Health Minister Dr Aaron Motsoaledi in November last year to urgently expand national capacity to train healthcare professionals, build and improve the management cadre and boost high-level research into HIV/AIDS and TB. Half the fund will go towards training an additional 100 specially selected aspirant doctors at R200 000 each, spread across the country's eight medical schools - with an emphasis on those from seriously disadvantaged backgrounds whose university scores would have excluded them as candidates. (The current total annual production is 1 200 for a population of 51 million, the doubling of which on the government's best advice will take 15 years, just to maintain the current doctor-population ratio.)
The other short-term intervention remains the sending of 1 000 medical students to Cuba for training this year, while universities engage government and the Health Professions Council of South Africa (HPCSA) on funding expanded training platforms of adequate output quality. The remaining R20 million will be shared equally between the still-conceptual Academy for Leadership and Management of Health and for high-level research studies in HIV/AIDS and TB. The academy, to be headed by the outgoing Dean of Medicine at the University of Cape Town (UCT), Professor Marion Jacobs, will train both student healthcare managers and up-skill existing healthcare facility CEOs, pulling together and standardising the numerous existing programmes into a single, needs-appropriate virtual institution drawing on the best available expertise. The research initiative will focus on developing high-level proficiency in understanding the effective clinical management of TB and HIV/ AIDS. On offer will be scholarships for PhDs, doctoral and postdoctoral and Master's studies in bio-medical, clinical and health systems in these fields.
Unprecedented chance for positive private sector influence
Ntsaluba told Izindaba: 'In addition to the usual corporate social investment programmes (in the private sector), this new social compact enables us to cover more ground when we pool resources and focus on areas of national priority at the time. By defining areas of national priority, it raises the possibility of discussion with policy makers, thus crossing a bit of a psychological barrier.' He said that in spite of private healthcare competition, 'stepping up like this' would enable co-operation at a national interest level. Instead of focusing on points of disagreement and point-scoring between the private and public sector (for example over the impending NHI), the focus would evolve into common interests and challenges. He firmly believed that in spite of the quadruple burden of disease and current delivery challenges, 'nothing is beyond our collective capacity'. When the enormity of the human resource challenge was put to him, Ntsaluba said Motsoaledi's philosophy was to 'use every gap possible, beginning immediately - precisely because it takes so long to produce qualified professionals. It's no good waiting until all the elements are there. We can identify the problem but not be paralysed.'
He said he already knew of several companies who, since the launch of the compact, were keen to come on board, thus significantly boosting the fund, enabling it then to come to grips with the acute shortage of pharmacists and pharmacy assistants in 2014. He was at pains to emphasise that the health minister's intention with the academy was not to create a new institution, but rather to leverage universities to produce a health leadership cadre that 'knows that it's doing'. Jacobs' committee, charged by Motsoaledi with setting up an induction programme for existing hospital CEOs by February and given a year to set up their virtual academy, now has its work cut out.
Academy to be 'virtual'
Jacobs told Izindaba that 'conceptually' the academy was an attempt to co-ordinate all the activities around support for leadership and management at all levels of care. She said the idea of an academy was born during the tenure of the late deputy minister of health, Dr Molefi Sefularo (a strong proponent of PPPs), but Motsoaledi had recently become increasingly agitated about the capacity and experience of hospital managers. She cited several excellent healthcare management courses littered around the country's campuses, some of them brand new (the latest an executive healthcare leadership programme at the University of Pretoria in collaboration with Harvard University) and a Centre for Disease Control programme for district health managers. Her first task would be to begin the induction of hospital CEOs this month (January), followed by identifying and aligning the needs of managers at different levels of care with existing programmes 'without creating chaos and confusion'. 'My role in leading the advisory group will be to set up a virtual mechanism to have oversight of the need. The provinces are diverse in their management of the health sector,' she noted.
Jacobs is particularly enthusiastic about a model she witnessed first-hand in Taiwan last November. Not only did that country have a facility accreditation system (as envisaged by Dr Carol Marshal's Office of Healthcare Standards Compliance as part of South Africa's NHI), but a parallel one for healthcare workers and leaders. 'It's absolutely fabulous and I'll be calling Carol in on this,' she revealed. The South African Medical Association (SAMA) recently re-launched the SA Society of Medical Managers (SASMM) which will work closely with the Division of Medical Management (DMM) of the College of Public Health Medicine of South Africa in re-establishing the specialty of medical management.1 Jacobs will almost certainly be calling on the expertise of both bodies. She will work intimately with national Health Director General, Precious Matsoso, and emphasised to Izindaba that 'flexible, experiential learning for CEOs without actually taking them off the job' would be pivotal.
Experiential, case-based learning for managers
Her working leaders would use case-based learning and/or examples from their own experience as training tools. Picking up on Ntsaluba's comments, the former paediatrician and Dean of Medicine at UCT (seven years) said the ongoing 'warfare' between the public and private sectors was too often based on 'generalisations'. 'I have close friends who (respectively) recently lost someone at Groote Schuur Hospital and were treated at a private hospital. The widow could not stop talking about Groote Schuur's 'phenomenal service' while the other friend kept going on about how caring the private nurses were. This new social compact is absolutely crucial ... to kind of tie in the captains of industry to a collective partnership is so essential. It's a real start.'
As for the doubling of the doctor output over 15 years just to maintain current healthcare delivery levels, she responded: 'Everybody seems be talking in silos (in suggesting solutions). There's this Cuban silo, the increase in local students silo . the fundamental issue is about producing human resources for health equity. Nobody is talking that kind of language. We need (and are starting) to change the curriculum content, to align it more closely with the health status of our country.' Ntsaluba, whose political and professional experience provides a unique perspective, had this to say at the end of his Izindaba interview: 'In a strange way I think the turbulence, service delivery protests and other unfortunate recent events speak to some degree of the restlessness in the population. People expect us to do things in a better way. Even from a purely enlightened self-interest point of view, the time has come to de-emphasise our differences and focus on the real needs of the people. It's not a walk in the park.'