Health systems crisis – Medical deans proffer solutions

South African medical deans say they stand ready to make available expertise in the university sector to help the country deal with the crisis in the national health system and “systemic failures” in the provincial health departments, which they say are negatively affecting both patient care and the training of the next generation of medical professionals.

“We are prepared to be part of the solution rather than the problem,” Professor Martin Veller, head of the South African Committee of Medical Deans, told University World News in a recent Skype interview. “There is a significant body of knowledge and experience in the country that can help in the search for positive outcomes, but we need to be given that opportunity.”

The deans, who represent the country’s 10 medical training facilities, took the unprecedented step of issuing a public statement through umbrella body, Universities South Africa on 30 May. In the statement*, they say they have “grave concerns about the future of academic medicine because of the chronic underfunding of health professional education and training”.

“We are committed to training predominantly within the public health system, but in order to do that we need to have a system that’s working,” Veller told University World News.

He said the lack of political intervention in the recent strike by health workers in North West province, where it is believed that organised labour actively prevented people from accessing health care, resulting in patient deaths, was of grave concern to the committee and had been a factor in pushing the committee into issuing the statement.

“There seemed to be no-one addressing the strike action at a political level, particularly given the fact that the union concerned, NEHAWU, is an affiliate of the ANC-government’s alliance partner COSATU,” said Veller.

Also in the North-West, Veller said, at the Tshepong Hospital in Klerksdorp, which is a training site for the University of the Witwatersrand health sciences faculty, a senior surgeon reported being prevented from gaining access to the hospital to help a more junior colleague perform an emergency operation. “We hold the view in our committee that this is unconscionable behaviour,” said Veller.

He said while the deans’ group had in the past developed “good relationships” with major government role players, in particular the national Department of Health and the Department of Higher Education and Training, they had recently experienced some frustration arising from “difficulty in getting many of our views heard”.

Constraints on training

Dysfunction in the system, particularly at the level of provinces, is obviously placing constraints on training. At undergraduate level, deans are concerned that students are not being exposed to effective health care systems.

“We think they are being disadvantaged to some degree because they are not being exposed to an ideal health system,” Veller said.

While the national Department of Health manages some health programmes, this amounts to only a small proportion of actual service delivery in the country.

“Most health care systems are run out of the provinces … and only one or two out of nine of these provincial departments are in fact managing to ensure that health care of quality is available to the vast majority of our population. The rest are failing or struggling,” said Veller.

There is also concern over insufficient exposure of trainees to primary health care and community health care services, currently also the responsibility of the provinces.

At postgraduate level, Veller said the situation was even more serious.

“The situation is worse at postgraduate level where there is significant technology and equipment involved in teaching or higher costs related to care of patients,” he said.

Referring to the widely reported shortage of oncologists in the KwaZulu-Natal province and the lack of functional radiology equipment and medicine shortages, Veller said the problem was just “the tip of the iceberg”.

“The problems being experienced in KwaZulu-Natal around radiation-oncology are true for most specialities and sub-specialities throughout the country. In cardio-thoracic surgery, for example, students are not exposed to enough operations to be able to train properly.”

No co-management

Veller said because academic institutions had no jurisdiction or influence over the health care system, tensions between the academic and service-delivery functions arose, particularly at postgraduate level where trainees are employees of the provincial department.

“We have the health care system available to us for training purposes only, and often when there are stresses in the sector, the training and academic components are put aside in favour of service delivery – and that is not always in the interests of students.”

Under the current system, universities also have no oversight over the placement of students in internships and community service. In their statement, the deans say the “constant failure” to adequately fund internship and community service placements represents “a serious human resources challenge as well as ethical disquiet”.

They argue instead that the government has a duty to ensure that all South African students, and those with permanent residence status, are placed in fully funded posts.

“We believe there’s a significant training component involved in both internships and community service, but they fall entirely outside of the university’s sphere of control. We have expressed our disquiet regarding the placement of students because we perceive it as a sign of poor workforce management and planning and we would be keen to help improve the situation,” said Veller.

Against this backdrop, universities are under pressure to increase their training numbers, with numbers of students growing in the last 10 years from 1,200-1,300 per year to 1,800 in 2018.

“One of the strengths of our training system up until now has been the healthy ratio of students to trainers with the result that students generally receive good clinical training. With increasing numbers, those ratios are under threat and we need to expand our training platform, particularly in the public health care setting, and there are constraints around that,” said Veller.

In this regard there is particular concern about the quality of the training that will be available to the 720 final-year students returning in August from Cuba as part of the Mandela-Castro Medical Collaboration programme. The deans’ statement calls for an assessment of all training sites for the returning students to be completed by 30 June.

“We’ve had to develop that platform rapidly … We will have to work hard to ensure they have adequate experience,” he said.

Solutions

Veller said the deans have proposed a number of solutions to government that are already well-aligned with a variety of policies already available in the health care system.

Putting in place strong governance systems is a priority.

“Firstly, we have to develop a process by which provinces and academic health complexes (defined as the country’s large teaching hospitals and their referral networks) have better levels of management with appropriate skill levels,” said Veller.

There was also a need for a separation of responsibilities so that bureaucracies run by appropriately skilled individuals would not be curtailed by political interference, but rather be measured against the deliverables outlined in a well-defined service level agreement.

To this end, the committee has proposed that academic health complexes should be managed as semi-autonomous entities. He said an appointed board made up of skilled managers would have the ability to intervene and provide insight where necessary. The board would enter into a service level agreement with the delegating authority, be it provincial or national government.

“This provision is already made possible in the White Paper on National Health Insurance and could therefore be quickly legislated and implemented as a pilot,” said Veller.

Working with the board, but with a clear set of responsibilities, would be a skilled CEO and skilled executive team.

Veller said there were many skilled people available in South Africa to fulfil these functions.

“Clearly people are available. This country has a highly successful, albeit for-profit, private health sector; universities themselves have a large number of people capable of contributing … This is a long-term process but over time one can develop a sector that has the necessary skills. It does require some training, and parachuting in of some skills but most of us believe it’s possible.”

* The deans’ committee released another statement on 15 June in which it reported it had held “fruitful and extensive discussions” with the Minister of Health Dr Aaron Motsoaledi during which the following had been agreed:

• • The minister will engage provincial authorities regarding the concerns related to academic medicine. In particular, he will again address the issue of rationing of clinical and clinical training posts.
  
  
• • Exploration of new and different models of governance of the academic health complexes. Although one such model is already included in the National Health Act of 2003, the minister believes the current Act would require amendment before implementation and this process is underway.
  
  
• • Joint inspection teams will be evaluating the state of readiness of the clinical training sites required for the integration of students currently studying on the Mandela-Castro Medical Collaboration Programme.
  
  
• • The committee will convene a sector-wide workshop to evaluate internship training and a subsequent workforce planning in the near future.