RESOLUCION DIRECTORAL Nº 545-2011-PRODUCE-DGEPP Lima, 25 de agosto del 2011

The NHI Green Paper27 is the most recent initiative to overhaul the South African public health care system. It is premised on the district health system and gains to be made from health system reforms such as the “re-engineering of primary health

xiii _{Unlike the American model where courses are typically run by autonomous schools of public}

health, independent medical doctor training, the usual model in South Africa, is a School within a Health Science Faculty.

care”.136 Together with the 2011 policy document on HRH,26 these documents

advocate system changes to deliver equitable, cost-effective services to address South Africa’s health needs. The human resources policy echoes calls from the international health educational community to train health professionals to be “systems based, to improve the performance of health systems by adapting core professional

competencies to specific contexts”,98 as well as the importance of trained, supported clinical personnel.

Whilst skills to transform systems are forefronted in these documents, and attention is given to the competencies of managers, little attention, however, is given to a cadre of skilled health professionals or doctors to develop and evaluate this reform. The HRH document does note that public health personnel are not institutionalised and that personnel performing public health functions are “not appropriately trained in epidemiology, planning and statistical analysis”.26

This recent health service reform initiative provides an opportunity to redefine the role of public health professionals in South Africa particularly PHM professionals. The roles implied or articulated in the three key documents are detailed in Table 3.

The table outlines public health technical functions – the provision of demographic and epidemiological information to inform strategic planning and prioritization of services; monitoring and evaluation of services; as well as health promotion and prevention. These echo public health functions and roles found internationally (Table 1), with little detail. No mandate regarding functions focused on policy, assurance, research and training are given.

Table 3: Comparing public health competencies and roles in key 2011 health policy documents

Component Re-engineering

monograph136 NHI Green Paper

27 Human Resources for Health

policy26 Stewardship

Planning elements Interpretation of information;

Demographics Epidemiology

Surveillance

Evidence for interventions; Health systems

research

Technology Strategic prioritisation

Whose responsibility?

?Family Physicians Department of Health

District specialist teams Composition of teams

Family physician, mental health, oral health and rehabilitation Principal specialists: Obstetrics, Paediatrics, Family Medicine, Anaesthetics

Principal specialists: Obstetrics,

Paediatrics, Family Medicine, Anaesthetics.

Midwife & primary health care nurse

Deliverables District teams impacting on social determinants of health

(Silent) (Silent)

Quality assurance

Mechanism (Silent) Office of Quality Improvement Standards Compliance

Accreditation of tertiary hospitals; Co-ordinating Council for Clinical Excellence.

Public Health presence Level in health system

National (Silent) National Provincial Provincial

District

Structure Public Health Units (Silent) Senior managers. Public Health Units

Adequate personnel?

Lack of capacity (Silent) Inadequate numbers and distribution

Posts for personnel

(Silent) (Silent) Limited numbers of posts

Public Health Medicine specialists?

(Silent) (Silent) Yes. For prevention, promotion, strategic planning, monitoring & evaluation

Gaps outlined & strategies

Capacity. (Silent) Make role of PHM and other PH graduates more explicit in management and strategy. Use

Universities/MRC

Public health professional training

(Silent) (Silent) Work with universities and College to develop job-frameworks and agreed competencies. Increase output.

Other General health personnel training

(Silent) (Silent) Integrate PH approaches into training health workers

The lengthier and more comprehensive human resources policy document26

recognises the importance of health system reform and acknowledges the skills set needed to support this. It echoes the memorandum of the Heads of Public Health Medicine276 to the national Department of Health that called for clarity about career paths for medical and other public health professionals, and the establishment of public health units at a provincial and district levels. Public health responsibilities outlined in the HRH document were to develop provincial, district health strategies, as well as monitoring and evaluation frameworks to evaluate the outcomes of the re- engineered PHC model. It quantified the shortage of PHM specialists, citing 97

professionals employed in 2011, which was half the required 0.04/10 000 population, and estimated that it will take 14 years to achieve this target.

Expertise to strengthen the health services is reflected in some provincial health plans. For example, the Western Cape Department of Health’s 2020 health plan295 aims to strengthen capacity through having their health and impact unit assess the impact of prevention initiatives and clinical services on the population’s health status. This unit monitors outputs against annual performance plans and implementation and provides “public health intelligence, guidance based on national and international research to demonstrate which interventions are most cost effective”.295

This initiative echoes health sector public health functions which had been highlighted in 1994 by UCT’s incoming professor of Public Health, Jonathan Myers, in his inaugural speech in which he drew attention to public health skills shortages, particularly at senior levels in the health services.102 He argued that public health functions in health plans and provincial organograms were dispersed in clinical services or in planning and human resources departments; he called for the establishment of public health units to play a “critical intelligence function in a context of shifting health priorities and needs with appropriate health interventions”.102 In Myers’ view, such a unit could house permanent public health consultants – specialists in Public Health Medicine, or post-doctoral employees, together with registrars and MPH graduates. Academic public health specialists would have service roles and co-supervise registrars who would rotate through district level units. He warned that public health needed to play

a critical role through advocacy, investigation and research so that it did not merely prop up a failing health system.

Other prominent South African researchers 296 have called on government to set up and finance institutions to lead public health initiatives to reduce the underlying risks to health. They have identified the lack of institutional capacity to collect, analyse and use population health data to identify appropriate interventions and to model

possible gains as well as their cost-effectiveness. At face value, these reforms appear to be critically dependent on skills held by PHM specialists.