5.2 SYSTEM DYNAMICS APPROACH TO TRANSFORM HEALTH POLICY DESIGN,
5.2.4 Decentralised Governance and Policy Design, Development, Delivery
Integral thinking and systemic methodologies in policy design, development and delivery are the leader’s responsibility in the decentralised governance health structures (Gilson, 2012) that need to direct diverse and fragmented health services towards attaining a unified, integrated, comprehensive health system. The skills which leaders require to ensure effective governance of policy
implementation include communication and negotiation skills (Burian et al., 2014); for example, clarification of how health priorities and changes are negotiated and what the core values and principles in the health system are. Other skills which leaders require are strategic vision, technical expertise, and political, organisational and administrative competencies to enable transparent participation among numerous actors (Olmen, 2011).
Health policy implementation is rooted in complex systems and frequently, policy guidelines for routine operational managerial decision-making are ineffective for policy design, analysis and governance. Actors in these complex systems act in non-linear, unpredictable ways, which cause challenges for decision-makers to implement standardised managerial approaches. One of these challenges experienced in KZN DOH was, for example, to improve the recruitment of specialists;
financial incentives were introduced but the imbalances on inter-related sub-systems like governance and information sub-systems resulted in counter-intuitive behaviour which was reflected in a lack of transparency, accountability, tracking and reconciling payments (KwaZulu-Natal Department of Health, 2015).
Another challenge is the deep-rooted habit of mental models in developing extensive target setting which is susceptible to the preference of one sub-system at the expense of other sub-systems. The results of these biased mental models were delays, apathy and policy resistance (Atkinson. et al., 2015). The White Paper for the Transformation of the Health System in South Africa, which is relevant to this study, includes policy guidelines on restructuring the health sector, developing the human resources available to the health sector and a National Framework for the Training and Development of Health Personnel.
Moreover, the policy on National Framework for the Training and Development of Health Personnel clarifies the positivism paradigm in which HR skills, experience and expertise of all categories of health personnel should be used optimally to ensure maximum service coverage and cost-effective service delivery. Guidelines on training of doctors note that the demographics of the specific province, based on health service needs, should be considered for the intake of doctors. In addition, the guidelines state that systematic reviews of the training of health personnel should be regularly conducted to meet the changing health needs.
Besides, active participation of relevant actors in training programmes should be designed by enrolling and developing personnel who are skilled, competent and responsive to the health needs of the communities they serve. Qualified, knowledgeable and experienced health practitioners are mandated to implement policies which align to Batho Pele or people first policy that will promote equal access and appropriate utilisation of integrated health services. The focus of integrated health service provision is on the vulnerable groups, for example, the elderly, new-born, mothers and children, in rural, peri-urban and among the urban poor. These strategies of integrated health services are an attempt to overcome the apartheid fragmentation. Integration also endorses greater equity between rural and urban communities and between individuals accessing the public and private health services, including health care financing policies based on the Public Finance Management Act, which were developed. The NDOH had recommended that the national organisational structure includes the following components and sub-components to ensure policies are implemented by Provinces at the various levels of care (NDOH, 1997).
Figure 32: NDOH Policy Organisational Structure (Adapted from the South African - White Paper for the Transformation of the Health System, 1997)
In Figure 32, the NDOH components were structured for policy development, monitoring, evaluating and implementation. The various components at NDOH are responsible for different functions which are aimed at developing norms and standards for health services, designing basic packages of care, developing systems and methodologies for quality assurance, planning of national health care finances, costing models, audit tools for human resource availability, equitable redistribution and appropriate skill mix. Provinces are responsible for implementing these NDOH policy guidelines within the provincial context. In analysing the implementation of the NDOH policies, the challenges which are encountered in the provision of tertiary services at provincial level include the lack of HR norms, for example, the number of specialists per clinical discipline has not been developed. The impact of the lack of norms on specialist training and employment in provinces is that the inequity
National Health Systems: Chief
Directorate
Hospital
Development: Sub- Directorate
AHSC Development:
Sub-directorate Hospital and Academic HealthService Complexes:
Chief Directorate
Operational and Technical Policy:Chief Directorate
Systems Development, Legislation and Policy
Co-ordination Directorate
POLICY CO-ORDINATING UNIT
Policy and Planning Branch
Health Services:
Directorate
Health Resource Planning:Chief Directorate
Health Finance and Economics: Directorate
Human Resource Planning:
Directorate
Health Facilities:
Directorate
among the provinces continues to exist, causing imbalances in the health system. Also, the norm for the number of doctors per bed for in-patient services and for clinical procedures in tertiary hospitals is absent, causing imbalances in the clinical sub-system. Another challenge is that the NDOH costing model which should inform policy direction and cost-effective employment of health personnel, is still outstanding from the NDOH; thus, the negative feedback in the health ecosystem surrounds disparities in allocating health resources (NTSG, 2017/18).