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HEALTH PORTFOLIO COMMITTEE
24 August 2004
DEPARTMENT HUMAN RESOURCES STRATEGIC PLAN: BRIEFING
Chairperson: Mr L Ngculu (ANC)
Documents handed out
Department Human Resources Strategic Plan
Representatives of the Department of Health (DOH) provided a presentation on its Human Resources Strategic Plan to the Committee. The plan seeks to improve capacity and management skills within the health sector and re-establish the sector as a career of choice. Challenges and strategies were outlined emphasising key areas of implementation.
Members concentrated on the continuing outflow of health professionals from South Africa; disparities in service provision between provinces; performance management; "poaching" of health professionals by foreign countries; the community services scheme; training and the use of private health practitioners in public health facilities.
Dr P Mahlathi, DOH Deputy Director-general, reported that in response to numerous challenges, the DOH had established the Human Resource division in April 2004 to operate within the framework created by the Human Resource Strategy of 2001. The main priority remained the improvement of general service delivery by revisiting earlier visions and realigning delivery with strategic objectives and priorities. The Department also wants to ensure compatibility with the Constitutional mandate of accessibility and quality services. Part of the process revolved around the reformulation of the vision and mission of the Department. The major strategic objectives were outlined, as well as the broad challenges. Of notable importance was positioning health care as a career of choice and improving the skills base, and improving the image of the Department as a caring institution. Part of the solution lay in returning ethics into the training mix and ensuring transformation within the sector. In terms of global imperatives, South Africa played a leadership role in the international community. Reference was made to the programmes envisaged by NEPAD and the specific challenges within the region.
Internally, specific challenges existed in terms of a shortage of management and clinical resources, and the migration of skilled workers to other countries and from the public to the private sector. Fiscal constraints needed to be considered when contemplating solutions. It was important to address low levels of staff morale, co-ordinate implementation of responses,and ensure adequate levels of evaluation. The principle of sound return on the initial investment would be adhered to as health training was an expensive exercise. The migration of skilled practitioners had received close attention and the need to reduce work pressure on those that remained had been identified. Various strategies were outlined to deal with local and international migration. The value of service excellence awards was emphasised as well as various agreements drawn up with other states to discourage movement of workers. The policy on the recruitment and employment of foreign health workers was discussed.
Certain strategies to address challenges included better facility provision, the creation of mid-level workers and improved management training. A workable response rested on a broad strategic plan that promoted sustainability and allowed for change. This plan required input from all stakeholders in a detailed manner. Positive feedback had been received from interested parties and a steering committee was being established. The production of an adequate communication plan was identified as a crucial component. A Country Plan was necessary to develop norms and standards. A priority was to attract skilled practitioners to the public sector and improve the overall functioning of this sector. They also needed to contribute towards effective partnership building with other stakeholders such as Statutory Councils and tertiary institutions. Issues pertaining to the Budget were highlighted. The DOH had received R27 million for Human Resource Planning.
Mr R Coetzee (DA) stated that the human resource issues within the health sector could best be described as a "massive disaster" and the important question was how it had been allowed to deteriorate to this level. Concerns had been raised for some time without adequate response and it was clear that the strategy of 2001 had failed. Approximately 2 500 nurses continued to leave the public sector every year and 52 000 posts remained vacant. The Department was engaged in an attempt to play "catch-up". The strategy contained serious contradictions and needed to be better integrated. For example, attempts were made to retain staff within the public sector and yet the Certificate of Need undermined this and drove health workers to leave the country. The community service programmes tended to drive staff away instead of facilitating a more loyal response and provided an unacceptable introduction to the nursing profession. A lack of respect for the medical profession seemed to prevail in South Africa, as ascertained by discussions with medical practitioners who claimed a lack of consultation and involvement in deliberations around health legislation. In terms of the National Plan, did any measurable goals and timeframe exist for implementation in order to assist in the task of monitoring? The Rural Doctors Association has complained for many years about the difficulty of acquiring foreign doctors due to unhelpful immigration legislation. Urgent action was needed in conjunction with the Department of Home Affairs to address this issue. Was there a proper plan to provide adequate levels of training to sufficient numbers of people. He proposed that all politicians make use of public health facilities in order to recognise problems and ensure that meaningful solution plans were put in place. Human suffering on a massive scale was currently being experienced in South Africa and skilled personnel were urgently needed to manage the response.
The Chairperson responded that Members needed to avoid unnecessary use of hyperbole in their comments. It was not correct to refer to the situation as a "massive disaster" as the system was working in many parts of the country. It was difficult to make a considered statement on the Certificate of Need because the relevant regulations were not yet available for discussion. The National Health Act was being implemented and addressed many of these issues. The issue of vacancies still needed to be addressed. The Committee needed to take cognisance of the Health System task report and acknowledge the positive developments.
Dr Mahlathi replied that the reference to the vacancies was a 'snapshot' that did not acknowledge subsequent movement and did not take into account contextual problems. Provincial Governments had to establish priorities with regard to recruitment of personnel as adequate financial resources were in place. The Human Resource strategy of 2001 was not a failure as there had been some notable achievements. For example, the creation of mid-level workers had proved highly successful. Training plans could not be determined by the Department in isolation from crucial role players such as tertiary institutions and statutory bodies. The plan would be determined by needs rather than dictated to by budgetary constraints and focused on short-term objectives. The needs of doctors were receiving attention from the Department and the community services initiative in rural areas was a worthwhile exercise that provided valuable experience. The issue of work permits for foreign doctors demanded close attention in order to ensure that adequate competency levels were maintained.
Mrs G Gumede (DOH Chief Director) stated that the strategy would be phased in over five years and remained on course. Primary health care was an area receiving close attention. Constraints existed in terms of training due to inadequate facilities and financial provision,but the plan sought to address these. The community service requirement for nurses should not be seen as an incentive to leave the country. The government wanted a return on its investment of subsidised health care training. As regards the purported lack of knowledge of grassroots issues, numerous roadshows had been conducted to acquire information and a number of forums involving key roleplayers from both the public and private sectors were in place. Research conducted by various academic institutions had revealed positive feedback on the efficacy and relevance of the community services system.
The Chairperson suggested that the filling of vacancies was an issue that the Committee needed to focus on and requested more clarity on the Department's strategy.
Ms M Madumise (ANC) asked for further detail on why South Africa was being targeted by developed countries to supply health sector workers and whether the present budget was sufficient to address the issues contemplated in the strategy.
Dr R Rabinowitz (IFP) stated that a major challenge lay in trying to balance the acquired rights of nurses with their stringent duties and responsibilities. How could one render nurses more accountable in terms of performance?. Greater powers should be accorded to provinces to deal with the health sector crisis as provinces appeared hamstrung due to overbearing national directives and controls. The rural dilemma could be addressed by providing improved incentives to workers. The community services scheme was a sound idea that was not being properly implemented due to a lack of capacity. Hospitals were generally in a poor state and suffering from low levels of morale driven by crime and HIV/AIDS. Part of the solution lay in greater devolution of powers to the provinces.
The Chairperson reminded the Committee that the health sector fell under Schedule 4 of the Constitution and was therefore both a national and provincial matter.
Dr Mahlathi responded that the devolution of responsibilities to the provinces without adequate capacity and standards could be a dangerous exercise leading to a drop in service delivery and rise in corruption. At present, capacity was not uniform throughout the provinces and this would need to be addressed through the health facilities programme. The envisaged awards system was based on the assessment of service delivery and required co-operation on the part of supervisors to provide objective evaluation. The community services programme did provide workers with a choice in terms of where they wanted to practice. Approximately 80% of applicants received the posting they requested. However, some individuals did not want to go to rural areas for a variety of reasons. In terms of incentives for rural areas, much rested on improved pay and discussions were ongoing with stakeholders to identify solutions. Provinces needed to provide guidance for training and it was important that they operate within a national framework setting norms and standards. Ideas needed to be circulated on how the Budget could be more creatively utilised. The vacancy figure had been affected to some extent by restructuring as some positions had been downscaled or removed. The advent of more mid-level workers had succeeded in addressing workloads and was not intended to reduce vacancies.
Ms Gumede added that South African workers were targeted due to the high standards of training and the Performance Management System that entailed constant evaluation of workers on a quarterly basis.
Ms P Tshwete (ANC) referred to the dangers faced by nurses in the workplace, particularly during the nightshift, and intimated that the 2010 Soccer World Cup would require high standards of health and security. Would the Department be ready?
Ms B Ngcobo (ANC) asked whether conditions in Limpopo and Eastern Cape provinces were improving. With regard to loss of staff, she recommended that the Department compare this with the developments in other departments.
Ms R Mashigo (ANC) inquired whether private practitioners at public facilities were there on a voluntary or paid basis. Private doctors should assist with the distribution of contraceptives and promote a public-private partnership.
Ms M Makgate (ANC) asked whether nurses employed within the community services system were being remunerated as students or trained nurses.
Dr Mahlathi agreed that the safety of workers in 24-hour facilities was a concern and presented a number of problems due to the close proximity of communities and security dilemmas. The Department was encouraging provinces to discuss these issues and identify solutions. One recommended avenue was to identify 'hotspots' and implement relevant strategies. In terms of the 2010 World Cup, the Department had an emergency services unit that could address future needs. The Department was learning lessons from other departments about staff losses and was implementing programmes. It was envisaged that private doctors should not dispense medicine and rather survive on their professional treatment skills. The Department intended to make better use of private practitioners in public institutions and was devising appropriate methods to achieve this. Some corruption could be present when doctors supplied contraceptives provided by the State, but overall the Department welcomed initiatives involving general practitioners. Payment within the community services programme was at an entry-level position.
Mr I Cachalia (ANC) questioned the public sector's apparent lack of skills in dealing with HIV/AIDS and asked whether adequate research had been conducted to identify shortcomings. He asked what plan existed to address the lack of capacity; what impact was HIV/AIDS was having on health workers and how those affected were cared for, and what developments had taken place around home-based caregivers.
Ms M Manana (ANC) asked whether nursing auxiliaries in the Eastern Cape were being phased out and whether this would increase the workload for professional nurses and serve to further demotivate them. Self-development for nurses was highly beneficial but created vacuums when workers moved to other sections. Managers within the system seemed to have issues with community doctors and needed further training to better handle the situation.
Mr Steyn (DA) referred to a recent case where an advertised position within the public sector dealing with communication had a higher salary scale than medical doctors, and asked whether this was in accordance with the overall strategy of attracting trained personnel into the system. Was the mid-level worker regarded as a step-in between and, if so, whether the monitoring of skills upgrading could be improved?
Dr Mahlathi stated that the Department was considering more creative ways to attract students into training and agreed that the training of managers required innovative solutions. Discussions needed to be conducted with the Public Servants Association (PSA) regarding salary scales and the monitoring of workers had to be improved through better management training. The Human Resource plan intended to identify gaps and devise appropriate corrective methodology.
Ms Gumede added that enrolled nursing assistants were not receiving adequate training as provinces had financial constraints. It was necessary to create a balance between career paths and skills training and allow for work under constant supervision by fully-fledged professionals. Training needs tended to be identified through knee-jerk reactions to current diseases. Targets for training had been established and primary health care was receiving close attention.
Dr A Luthuli (ANC) highlighted tensions between doctors and medical aid schemes as doctors were not being paid on time and developed cash-flow problems. Doctors felt marginalised by the system and were not interacting with established forums.
Mr S Njikelana (ANC) reminded the Committee that much of the present problems were the result of pre-1994 policy and it was not constructive to downplay the origin of the crisis. The Human Resource Plan was vital to highlight crucial areas that required attention. Resources needed to be utilised in a more efficient manner and in partnership with other developmental programmes. The Department tended to be weak on communication and needed an effective plan to address shortcomings. He asked what progress had been achieved with the Health and Welfare SETA. Trade unions wanted to participate in the planning process. Were they being accommodated? How was the plan going to incorporate the provinces?
Dr Mahlathi responded that a problem had existed between doctors and medical aid schemes for some time. Many schemes suffered from a lack of financial reserves and the Council of Medical Schemes had implemented a strategy to increase the percentage of reserves held to facilitate faster payment. Consideration was being given to involving medical aids within the public health system. Migration to other countries remained a contentious issue but the Department was not against workers gaining experience in a foreign environment and returning with increased knowledge.
Ms Gumede stated that discussions were being held with the Health and Welfare SETA to improve levels of training and allow provinces greater access to finance to support training initiatives. Human Resource issues were being linked between the provinces to encourage a consolidation of management and development needs. Accredited training providers were being sourced to assist community health workers. Communication plans needed to focus on the positive issues and promote a sound image of the health system.
Dr Rabinowitz asked how the 20 000 home-based carers were being financed and whether a public-private partnership was in place. Nursing assistants had expressed unhappiness over payment as training payment was inadequate. Could a distinction be made between training requirements and increased costs to alleviate conflict, and would Certificates of Need be applied widely or in accordance with certain conditions. The low levels of morale arising from crime and violence had to be addressed through better policing. Foreign qualified doctors were encouraged to work in South Africa but a close monitoring of skills standards needed to be enforced. Would labour laws continue to apply to all health workers?
Mr Coetzee agreed that most of the current problems were based in the previous dispensation but the Department still needed to produce workable solutions to a growing crisis. The Department was making an attempt to produce a working strategy but further effort was urgently needed. Evaluation of implementation needed to occur at a later stage based on the national strategy that required further detail. Members of the Committee were committed to improving health care and questions arose from concerns and interest. He asked the Department to return to the Committee with a more detailed plan as soon as possible.
Ms Manana raised the issue of chief professional nurses reaching a ceiling in career advancement and then becoming frustrated. How could this be addressed?
Dr Mahlathi stated that managers needed enhanced tools to provide a more efficient service but also the will to improve the situation. The Performance Management System was crucial in ensuring more effective management. Foreign workers should not be allowed to freely enter the local market without stringent checks. More training around labour relations and bargaining councils was recommended to ensure compliance with labour regulations. Human Resources was a challenging field that required intensive research and planning involving all stakeholders.
The Chairperson said that the briefing should be viewed as a first presentation and further interaction would occur to re-evaluate the draft plan. A guiding principle underpinning negotiations around remuneration was that more qualifications should translate into higher monetary reward in order to attract skills. Unionised workers needed to take greater responsibility for improved output and job commitment while continuing to engage the system. Essentially, a successful Human Resources programme depended upon a partnership between all roleplayers. The Committee would request a return visit from the Department in the near future.
The meeting was adjourned.