How we can transform the public healthcare system

2018-12-20 00:00

Let’s reflect, adapt and innovate to transform the public healthcare system, writes Chris Maxon

Healthcare touches every person and every thing in society.

China’s President Xi Jinping once said: “Health is a necessary requirement of promoting the people’s all-round development; the basic condition for economic and social development; an important symbol of prosperity of the nation and country; and the common pursuit of the people.”

In May 1994, the ANC came out with a ground-breaking National Health Plan for South Africa that asserted, among other things: “The challenge facing South Africans is to design a comprehensive programme to redress social and economic injustices, to eradicate poverty, reduce waste, increase efficiency, and to promote greater control by communities and individuals over all aspects of their lives.

"In the health sector, this will involve the complete transformation of the national healthcare delivery system and all relevant institutions.”

Public health facilities are the only option for the more than 42 million people who do not have medical insurance and who are growing more ill by the day.

Our country has the highest HIV prevalence in the world, TB remains the leading cause of death and lifestyle diseases are on the rise.

The recent commemoration of the 30th World Aids Day became a “light bulb” moment as it dawned that, while we may extol on the progress in the fight against HIV/Aids thus far, there are fundamental systemic weaknesses that threaten the sustainability of public healthcare.

Commendably, government’s investment in health was no less than R1 trillion over the past decade, rising from an annual budget of R86 billion in 2009 to just over R205 billion this year.

But the symbol of a great public health system is not always in lavish achievements at the national scale, but rather in the “people’s all-round development” and perceived experiences when coming into contact with public healthcare facilities.

Patient experience is an integral part of quality healthcare and is concerned with what the patient values when seeking or receiving services.

A good and responsive public health system is one that is able to make services available when needed, instead of keeping patients on long waiting lists for treatment, diagnosis and even hospital admission.

Equally, patients need assurances that their prescribed medication will be available when needed, that their wards, bed linen and ablution facilities will be clean and safe from infections, and, most importantly, that healthcare professionals will treat them with respect and dignity.


Noting this, it is evident that we need a moment of reflection because the health situation shows signs of debilitation – almost.

Former president Nelson Mandela aptly said: “After climbing a great hill, one only finds that there are many more hills to climb.”

So, as we grapple with healthcare transformation, we must realise that the problems are not clinical, but structural.

We also need to adapt, innovate and bring to the fore the mass capacities in the health system – not think that solutions are only found in people with clinical qualifications.

The National Health Plan explains the three fault lines as:

. Tolerance of ineptitude, as well as leadership, management and governance failures;

. Lack of a fully functional district health system, which is the main vehicle for the delivery of primary healthcare; and

. Inability or failure to deal decisively with the health workforce crisis.

One could add systemic inefficiencies that stunt the realisation of results with fewer inputs, causing high costs and poor quality of delivery.

Confronted by an unsupportive organisational culture and environment, staff shortages and health system deficiencies, workers find it difficult to uphold their professional code of ethics and provide quality care.

The major problems with the current healthcare transformation trajectory are that, firstly, we are doing it from the top down and, secondly, we are not inspiring a vision-driven transformation.

At the top, a bloated bureaucracy works in an environmental context of regulations and finance, which seems to be focused on what is best for government.

The perils of out of control costs have forced government to embrace the concept of “anything at any cost”, an idea that was hardly mentioned 24 years ago. A lot of change happens at the top, but to what effect?

Substantive change can occur only at the interface of clinicians and their patients – in other words, clinics and district hospitals. The failure to recognise this is self-evident.

The top-down approach is failing. We need the fundamental knowledge of not only the healthcare workers, but also, and most importantly, the patients and their families. We need to create a true system from the bottom up.

The bottom-up strategy is change-driven by the true fundamental knowledge experts in healthcare – clinicians and their patients.

It is the interactions between these two groups that define the act of “healthcare”. They are mutually dependent on each other in ways that may not have been previously realised.

Clinicians and patients must accept that they have different perspectives and work together for mutual benefit in a framework of aligned incentives.

Shared responsibility and mutual accountability must be agreed on and maintained.

At its core, bottom-up transformation is cultural change, and culture is often easier to understand when you see it.

We need to move on from prescriptive, top-down approaches to change by progressing from “large-scale structural reforms towards locally derived solutions, ‘heroic’ pace-setting leadership approaches towards supporting staff to lead change and improvement, a focus on external pressures such as targets, and inspection towards supporting improvement ‘from within’,” said the UK’s Professor Chris Ham in 2014.


Addressing the fault lines involves asking hard and sobering questions.

The key question I believe we need to ask is whether we are delivering for purpose to achieve results and impact.

Simply put, do people know why they do the things they do every day?

So, good intentions, embodied in an operating model, will only take you so far. To realise the full benefit, mind-sets and behaviours – how people think and act every day – need to change.

Buying equipment for a gym at home doesn’t make you fit – the habit of exercise does.

Let me categorically state that organisations don’t change, people do – through their behaviours.

Of all the behaviours involved in a change effort, only a very few tend to produce the lion’s share of results.

We need to identify key behaviour that will propel change and the identified behaviours must be concrete in nature – specific and practical – and should cover “moments of truth” relevant to the front line, such as how to handle a client with a complex problem, or how a clinic supervisor deals with a potentially dangerous incident.

Blanket statements or top-down directives such as “we will be more customer centric” or “our leadership will manage by walkabout” might sound lofty, but each can be interpreted in many different ways, leading to inefficient or even conflicting behaviours across the organisation.

Leaders should decide, in concrete terms, what front-line employees and management should do differently during those moments of truth. We must recognise that change requires ownership and time commitments.

Let me emphasise that better staff engagement and ownership will lead to a clearer vision of expected results and impact.

Sustainable results performance can only happen if staff at all levels understand, own and take control of the leadership of the process.

Staff must be at the centre to continue to deepen the purpose and build a results and impact culture.

We need to be guided by a unifying ideology that says that, by raising our people’s health as a core goal, we will take the momentum by institutional reforms and innovation, focus on promoting healthy living, optimising health services, implementing universal health insurance, protecting a healthy environment, developing a health industry, put health in all policies, rapidly change the development mode of the health sector, and protect and maintain all-round, life-long health of the population (adapted from Healthy China 2030).

The 30 years of HIV response and 24 years of the health policy has, to some degree, allowed us to tolerate or accept “mediocre performance” in some areas.

The cost of delivering the service those with HIV require is rising, threatening its sustainability.

We need to create great purpose and value, and have significant impact. This requires a unique leadership purpose.

To be truly effective, leaders must do the same. Clarify the purpose, and put it to work.

Maxon is deputy manager of advocacy, communication and social mobilisation at the department of health in KwaZulu-Natal

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May 19 2019