4.7 POLICY AND POLICY DECISIONS AFFECTING THE SUPPLY AND DEMAND OF
4.7.4 Effects of Policy Resistance, Policy Design and Implementation
Faezipoura (2013) described the social element of healthcare which emphases principles of equity, empowerment, accessibility, participation, cultural identity, and institutional stability.
Patients are the principal focus of healthcare systems. They can be regarded as customers in these complex systems, who have expectations of the type and quality of health services they receive.
Patient satisfaction is a significant dynamic in the social element of health systems. It is characterised by patient fulfilment in respects to the cost, accessibility to services, and resources, physician role, behaviour and patient well-being (Faezipoura, 2013).
An example of patient complaints on poor quality of care and delays in Oncology services, noted that several referrals to different state hospitals caused delays in diagnosing, which resulted in the patient being finally diagnosed with stage 2 cancer. The patient was kept overnight and then transferred to the referral hospital for further tests. According to a family member, when the patient returned to
hospital “all they could say‚ rudely‚ was that the machines are broken and there’s nothing they can do” (Daily News July, 2017).
Another case in point was the report on non-functioning Radiation Oncology services in KZN DOH compiled by the South African Human Rights Commission, which established that the provincial and national health departments had denied patients’ rights to healthcare (Daily News July, 2017). The oncology services reached a crisis when the last state oncologist in Durban resigned‚ leaving just two employed in the province, both of them in Pietermaritzburg (Daily News July, 2017).
Effective governance and systemic behaviour are regulated by constitutions, policy guidelines of the system or organisation as they define the scope, its boundaries, its degrees of freedom and social rules. The rules of the system, be they incentives, punishments or constraints, determine the behaviour of the system. The power of rules is high leverage points (Meadows, 1997).
In a system where policies are designed by organisations and managed by them, for the benefit of the organisation, but exclude any feedback from any other sector of society, enormous accumulations of power and huge centralised planning systems exists thereby destroying themselves (Meadows, 1997).
Using the system dynamics approach, determining and representing feedback processes, stock and flow structures, time delays, and nonlinearities, will determine the dynamics of a system (Sterman, 2000).
In this study, recent events like the protest action by doctors in KZN DOH has been acknowledged and information reports from the in- depth interviews conducted with aggrieved staff and media reports were used (SAMA May, 2017). To determine system behaviour feedback processes and to understand the KZN DOH system dynamics, a CLD was derived from the relationships, interactions, policies and direction of feedback among the actors involved in specialist training, recruitment and retention.
Figure 29: CLD Relationships among Actors, Policy and System Behaviour in KZN DOH (Focus Group)
The CLD in Figure 29 illustrates the measures, actors, and interactionsor the under-lying mental model and system behaviourthat stimulated results in the emergence of the moratorium on filling of posts policy, and the systemic responses over time in the KZN DOH. Delays by HR practices and labour relations officials in addressing grievances among specialists increased specialist resignations and specialist migration to other provinces and overseas. Thus, the reinforcing loop indicates the systemic impact on the increase in adverse health and health system outcomes. When the specialist migration decreases, the balancing loop reflects increase in the specialist pool.
Based on management mental models, economic evaluations and surveys, a number of vacant specialist posts were abolished and evidence of increased clinical services influencing demand is anecdotal due to deficient health information systems (HRH SA, 2012).
In KZN DOH, there is a lack of a health information system with a database for medical adverse events, thereby demonstrating non-compliance to national hospital management policy. The SA Policy on Management of Hospital (2012) objective is to address the negative perception of communities and build a culture of competence, effective, transparent and a caring ethos within the health care environment (Government Gazette, 2012). Explicit criteria on the hospital governance
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Delay in Addressing Grievances
Delay in Processing Applications
HR Practices and Labour
Relations
Specialist Resignation /
Protest
DOH and UKZN Management Professional
Association Advocacy
SPECIALISTS
Policy Restriction Moratorium on Filing of Posts
Adverse Health and Health
Systems Outcomes
Specialist Migration
structures and appointment of competent and skilled managers are stated in the SA Policy on Management of Hospital (Government Gazette, 2012).
In this study, reflections from the FGD noted that information from clinical governance audit reports were evaluated in cases where medical adverse events like incorrect operation or administrating incorrect medication occurred. According to Health Systems Trust’s,
“There is a human resource crisis in healthcare that is driven partly by government tolerance of incompetent staff” (SAHR, 2016, p.17).
Inadequate attention has been given to the underlying feedback mechanisms in the DOH. For example, according to the KZN National Tertiary Services Grant Annual Report (KZN NTSG AR, 2016/17), quarterly patient activity performance reports recorded how, when staff gain new skills by taking on different duties, they identify more patients requiring treatment.
The knock-on effect of the shortage of specialists, lack of competent skilled specialists and increasing patient demand, has resulted in remaining doctors working extra shifts or overtime, and cases of medical litigation in which negligence, illegible reports or missing records have been processed in KZN DOH (Auditor General of SA Report, 2015/16).
Moreover, Rwashana (2014) noted that by understanding how the various feedback mechanisms work, patient demand can be controlled by introducing stringent clinical guidelines and more effective governance policy interventions. According to SAHR (2016, p.21), Rispel noted:
There is a crisis of unprofessional behaviour, poor staff motivation, sub-optimal performance, and unacceptable attitudes of health workers towards patients, all of which compromise quality of patient care and health service efficiency…These problems are exacerbated by a general lack of accountability, reported by health service managers in several studies.
The degree of system dynamics awareness in terms of holistic understanding, the complexity of the KZN DOH ecosystem and the silo mentality, results in HR practices trying to resolve recruitment and retention of specialists independently. Not interacting as an integrated team results in these HR problems remaining pervasive (SAHR, 2016).
The systemic behaviour described is aligned to what Sterman (2000, p.12) refers to when he speaks of independent actions which trigger side effects like the emergence of policy resistance:
Policy resistance needs be addressed, for example reviewing high leverage policies like the Employment Equity Amendment Act 2013 which involves expansion of the boundaries of management mental models. By expanding their mental models management increases their
awareness and understanding of the implications of the feedbacks produced by the decisions they make (Sterman, 2000). An example of the effects of policy resistance in KZN DOH is the HR Practice official’s mental models in implementing the Employment Equity Act without understanding the system behaviour and implications of shortage of specialists
Consistent with Barber (2010), the feedback processes where management decisions to freeze or abolish specialist posts, require understanding of the disequilibrium these decisions cause on the health ecosystem. Disequilibrium in the KZN DOH ecosystem is caused by delays in unfreezing, creating and approving authority to fill posts, which results in underspent budgets on compensation of employees. According to the KZN NTSG AR (2016/17), this delay in the filling of specialist posts is between nine to eighteen months, which aggravates the problems caused by the shortage of
specialists.
To overcome policy resistance, policy design, development and delivery require integration and coordination among policymakers, clinical managers, HR, finance and institutional managers to ensure that sufficient personnel budget and relevant post structures are achieved (SAHR, 2016). A successful policy implementation was cited by a study in Spain: Barber (2010) noted that policies are required on recruitment of specialists in a system where the depopulation of rural areas still requires that a minimum number of doctors be maintained for reasons of equity.