The SAHR (2011) noted that delays in Human Resource (HR) Management results in conflicting goals, which in turn cause problems in dynamically complex systems like the KZN DOH. In 2019, the problem of a shortage of specialists still remains prevalent. Low morale among staff, lack of
incentives, and high staff turnover with work overload among specialists and, inevitably, brain-drain, are the results of policy directives. This is illustrated in Figure 11, delays in the HR processes for creating and filling specialist posts in KZN DOH. Exhaustion and behavioural changes among specialists are caused by work overload with the resulting poor quality of patient care, adverse medical events, increased medical litigation and a concomitant financial impact on the health system (SAHR, 2011).
Forrester (1961) described systemic behaviour as interactions or feedback among components of the system; the complexity of each of these components is not itself the cause of complex behaviours. In the present study, an example of systemic feedback is observed by interactions between the policy component and HR Practices sub-component in KZN DOH.
Figure 11: Causal Loop Diagram (CLD) of the Policy component interactions and HR Practices sub-component
Based on an analysis of the KZN DOH context, data obtained from the FGDs informed the CLD in Figure 11, which illustrates the causative factors leading to challenging work conditions. These conditions include specialists finding it difficult to maintain their professional Code of Ethics, and integrity on intention to deliver high-quality care. Senior management decision-making with regard to recruitment of specialists in the KZN DOH is inter-related with HR strategies to politically transform health institutions (Tomaselli, 2019). The restructuring of public health services institutions is expected to reflect this transformation, redress staffing quotas and democratise management. In this study, the FGD noted counter-intuitive behaviour among clinical head of departments and HR practices officials on specialist interview panels, where HR officials are instructed to appoint Black South African qualified specialists in response to this politically motivated decision. Specialist performance at these interviews and competency are disregarded in favour of filling posts based on racial quotas. If the clinical head of department, who chairs the interview panel, requires good performing specialists to be appointed, then an HR deviation motivation needs to be submitted to the deputy director general of HR to approve this appointment. This submission for approval invariably causes delays with dynamic systemic effects: for example, no specialist is appointed or posts need to be re –advertised. Delays in appointing specialists cause job insecurity, inability to retain staff, increased unemployment of specialists and lack of return on investment of staff trained and funded by DOH and UKZN. The dynamic systemic effect of the shortage of specialists and increased work overload among remaining specialists, causes cognitive, emotional, behavioural, spiritual and somatic symptoms of compassion fatigue, burnout, and the lack of a caring attitude among these specialists (Portnoy, 2011), with subsequent clinical errors and increased medical litigation. According to SAHR (2016) research, in an uncooperative management environment, staff shortages and health system
deficiencies are evident. The lack of management accountability also has negative consequences for implementing strategic policies. Thus, the gaps among these strategic policies, priorities and implementation exists, creating a challenging health ecosystem to achieve the desired results. The two types of feedback loop interaction in all system dynamics are positive or self-reinforcing and negative or self-correcting loops (Morecroft, 2015).
A Causal Loop Diagram (CLD) captures the feedback dependency. The arrows indicate the causal relationships, as shown in Figure 12.
Figure 12: An Illustration of the Causal Effect (Adapted from William, 2010) In this study, the number of registrars required in KZN DOH to provide health care in the forty-six clinical disciplines, the number in training, the number that qualified and the number of specialists employed, were identified in FGDs and the relevant CDLs developed. The positive and negative feedback and causal relationships affecting the health system behaviour over time were also recognised. Positive feedback or positive loops are self-reinforcing. Positive, + signs at the arrowheads indicate that the effects of variables related to the cause respond in the same direction, whereas negative feedback or negative loops –ve, are self-correcting. These negative loops balance feedback and counteract change.
Figure 13: Reinforcing Feedback Loop (Adapted from William, 2010) In Figure 13, the loop is self-reinforcing, and thus the loop polarity identifier is R.
Appointment of Specialists
Increased number of Patients
Examined
Increased Workload R
Identification of Need for Appointment
+
+
+ +
+
Number of Registrars Required
Number of Registrars In Training
Number of Registrars Qualified
Number of Specialists Employed
_
+
As described, the FGDs acknowledged that an increase in the number of specialists appointed causes the number of patients examined each day to increase and the workload to increase as well. A
decrease in the number of specialists increases the delays in examining the same number of patients.
Figure 14: Balancing Feedback Loop (Adapted from William, 2010)
As the number of specialist appointments increase, as shown in Figure 14, various positive loops will act to balance the number of specialists. The loop polarity identifier is a reinforcing vicious loop.
Since no real systemic quantity can grow constantly, there are limits to growth. These limits are created by negative feedback loops (William, 2010).
4.2.1 Lack of Policy Guidelines Affecting Health System Behaviour
In South Africa, a five-year National Human Resources for Health (HRH) Strategic Plan to address health workforce crisis exists. Yet this plan is deficient in that there is a lack of detail that provides guidelines to the Provincial and Local levels of government. The immense human resource
consequences for implementing the National imperative, namely, the National Health Insurance (NHI), is underestimated. The national HRH strategic plan lacks a structure or implementing system, for instance, on how to recruit the right skills and the right numbers of health professionals at various levels of the health system (SAHR, 2016). As the escalation in globalisation and interconnected ecosystems accelerates, reductionist approaches even with significant increase in health policy investments have been insufficient to impact on the present epidemiology complexities, or prepare health systems for future challenges (Swanson et al., 2012). Fragmented, non-systematic and isolated approaches to policy implementation, especially in health systems strengthening of HR for health strategy; results in a demotivated workforce. These disjointed HR attitudes exasperate already dispirited staff, especially in terms of those lacking development in the required skills or with appropriate remuneration (Rwashana, 2014).
4.2.2 Delays Affecting the Supply and Demand of Specialists
Delays in implementing strategies contained in the HRH plan are caused by inadequate health-related technical capacity at the NDOH, as well as high dependence on expensive external consultants and
+
+ R
+
Applications Submitted HR Practice Recruitment Policy
HR Procedures +
Staff Workload
inappropriate organisational structures at both national and provincial health departments. These systemic delays among interacting variables result in the inability to deal with the health workforce crisis (SAHR, 2016). Furthermore, Sterman (2000) noted that our inability to understand the structure and dynamics of complex systems is hindered by SD application failure and the misperceptions of feedback. All dynamic complex systems are made up of networks of positive and negative feedbacks interacting with one another (Sterman, 2000).
4.2.3 System Dynamics Approach and Feedback Processes
The System dynamics (SD) approach provides health care planners with insight into the elements’
interactions, the relationships among these, the nature of the feedback and effect of changes in the healthcare system (Olmen et al., 2012). Thus, health care planners can make informed decisions associated with healthcare systems and sustainability challenges. Sterman (2000) described the system dynamics approach which acknowledges learning, as a relational feedback process. Moreover, he referred to feedback from the health ecosystem to decision-makers also provides both quantitative and qualitative information. This systems thinker and SD researcher explained that information feedback is interpreted by existing mental models which are also referred to as single-loop learning. Similarly, this single-loop learning feedback works in an environment of existing policies, in which decisions rule, and strategies, culture, and institutions inter-relate and are a consequence of our mental models (Sterman, 2000). In his seminal work, Forrester (1961) supplemented this notion of feedback learning processes by emphasising that all decisions are based on our mental models.