This report shows both the gravity and the complexity of the HRH crisis for rural communities in South Africa. While many of the challenges described affect health services at all levels and in urban and peri-urban areas as well, it is clear that rural South Africans are uniquely vulnerable to the effects of staffing cuts, and disproportionately affected by them. In this report we argue that poor access to healthcare for impoverished communities plays a critical role in the vicious cycle of illness and poverty. Disability has also been shown to play a rapidly increasing role in the (ill) health of our citizens, and it is imperative that health services are staffed and equipped to address this. Based on these arguments, we have developed recommendations for HRH which take account of both fiscal constraints and human rights imperatives.
1. Prioritise posts in rural PHC services District HRH planning should take account of rural communities’ lack of service choice and the heavy burden of transport costs to reach facilities.
Research should be conducted to quantify the costs transferred to the community by cutting remote services (including outreach), including both direct (transport) costs, and the indirect costs of failing to access services. These calculations should be used to inform distribution of resources between facilities and subdistricts. HRH decision-making should also take account of the specific challenges in recruiting and retaining staff in rural areas, and seek to protect fragile health teams from across-the-board cuts. The increasing returns on investment in longer-term staff should be considered and retention prioritised.
2. Reconsider utilisation-based measures of need The regressive impact of utilisation-based measures of need has been clearly demonstrated, as well as the false assumptions which underpin them.
Such measures should be balanced against known prevalence rates for given conditions (for example the fertility rate to predict need for obstetric services) and against benchmarked utilisation rates in comparable well-functioning facilities. HRH planning should also be informed by the package of services to be provided. The WISN method offers a rational approach to planning for staffing needs, calculating time requirements for tasks against workload and available working hours. Expecting staff to carry a workload disproportionate to the hours available to them can only lead to deteriorating quality of service and ultimately system collapse. Where HRH cuts beyond this point cannot be avoided, the state itself must take public responsibility for the cuts in essential services required, and not simply transfer rationing decisions to remaining staff.
3. Plan for HRH as part of a complex system Healthcare worker posts cannot be planned for in isolation.
Non-clinical support staff, hospital transport, drug supply and decent staff accommodation have all been shown to play critical roles in rural healthcare. Unless HRH is understood as part of a complex system, investments in frontline posts may be wasted. 38 39 For this to happen, HRH decision-making should be devolved as far as possible to facility level, so that detailed insight into local conditions can be brought to bear on post allocation.
4. Include rehabilitation and mental health workers as essential services at PHC level.
The increasing significance of disability as a dimension of South Africa’s burden of disease, with all its health and economic impacts, must be recognised. Multidisciplinary PHC teams should include a full complement of rehabilitation professionals as far as possible. A mid-level rehabilitation worker cadre could offer the most cost-effective and sustainable route to ‘rehabilitation for all’, and could dovetail psychosocial rehabilitation with the needs of people with physical and sensory disabilities – in accordance with both the national Mental Health Strategic Framework, and the Framework and Strategy for Disability and Rehabilitation.
5. Consider the hidden costs
The costs to communities, the economy and ultimately South Africa itself of poorly functioning health services cannot be underestimated. Money is not ‘saved’ when service conditions result in deepening poverty and marginalisation of the sick and disabled. More easily quantifiable, medico-legal costs pose a monumental threat to the health system as a whole, and current cost-cutting measures will certainly drive claims yet higher. Radical approaches are needed to address this situation, and budgeting for healthcare must take account of these direct costs to the service of rendering inadequate care. Instead of the current short-sighted transfer of funds from service provision to medicolegal payouts, health planners need to invest in preventing incidents through ensuring the resources for decent healthcare.