It is a matter of public record that public health services in South Africa are facing challenges. Frequently one will hear of shortages of doctors, nurses and other health professionals. The shortage of clinical staff is advanced most often as an important cause of these challenges. In addition, the reason advanced for the predicament is that public health services are underfunded reflecting the constrained financial environment in which this country finds itself. While all of this is indeed correct, a factor that is largely ignored is that as a consequence clinical posts are prioritised over what are regarded as less essential non-clinical posts. Again while this appears to be a sensible and logical decision, the unintended consequences are that key non-clinical posts become and remain vacant.
Health services while absolutely dependent on the work of the clinical staff have many aspects that fall outside the direct involvement of the doctor, nurse or other health professionals. An efficiently functioning hospital or clinic requires an effective supply chain to provide the goods and services on which the health professionals depend to do their work. Well maintained specialised equipment located in similarly well maintained buildings are a prerequisite for a quality health service. These so-called “support services”, that is technical, financial and human resource management and administration often are the first victims of the “moratoria” placed on staff appointments in the South African public service. It thus not surprising that in many instances the shortcomings of the South African public service can be found to be the result of failings in these areas.
Visits to health facilities by both the users and pubic officials often highlight the shortcomings resulting from a shortage of appropriately skilled support staff. Facilities reflect the absence of routine maintenance including even the most basic issues such an absent light bulb in a consulting room or a leaking tap and non functioning toilet in bathroom. When questioned the facility manager may respond that the handyman post is vacant as a result of an inability to fill the post after the previous incumbent retired. If the reader is incredulous this is a real example that I experienced during a visit to a public health facility. Even more important is the efficient supply of pharmaceuticals and medical supplies to a hospital. In the South African context this is often supplied via a regionally located “medical store”. In a study that I was asked to undertake in a provincial health service I came across just such a medical store where a significant number of posts required for the effective functioning of the facility remained vacant as a result of a moratorium on the appointment of non-clinical staff. This impacted negatively on the efficient supply of key items to the surrounding hospitals and clinics.
Appointing staff, particularly in the public service, requires administrative processes that are people intensive. Since these staff again fall outside the ambit of clinical staff their posts often remain vacant when a moratorium on staff appointments has been imposed, at times at a national level. It will often be denied that an actual moratorium is in place, but with centralisation of appointments, a moratorium is in effect in place. Staff appointments are then hit by a double jeopardy of a lack of staff to appoint those staff falling outside the moratorium, either real or de facto, as well as a process that has become so slow due to multiple levels of approval that the normal staff attrition from retirement, resignations and dismissals cannot be matched.
Financial stringency, the rationale for limiting appointments outside the clinical area, ironically often impacts negatively on the financial staff required to manage and administer the financial affairs of the department. Logistics is a key factor in ensuring that a frontline health worker has the wherewithal to function and financial staff are the ones required to administer the procurement of items essential for the delivery of quality health care. This function can be hard hit by blanket limitations of staff appointments. Supply chain in the public service is labour intensive which requires adequate numbers of trained and skilled staff to ensure that the right products are delivered at the right place at the right time. The consequences of staff shortages in this area are both that key items are not delivered to enable the clinicians to function effectively but also that contracts are not renewed on time and suppliers are not paid within the prescribed 30 day period. Once again the shortage of funds will be advanced as the sole cause of failure to make payments on time but the fact that staff to do so are lacking is ignored.
My experience in the last decade on various task teams and as a consultant in the South African public health service have reinforced my view that oft times the complexity of the public health ecosystem is underestimated. Imposition of blanket staff moratoria, either actual or de facto, result in severe disruptions in the complex ecosystem of a health service. The need to address personnel costs in a health system functioning in a financially constrained environment is a reality. However, there is a need to ensure that steps taken to limit personnel costs are implemented in a manner that takes into account the complexities of the ecosystem within such measures are implemented. Blanket moratoriums or centralisation of appointment processes certainly have the potential to reduce expenditure, but a more nuanced approach has the potential to achieve a similar goal but with a more positive outcome for the delivery of quality health services.
As a well-known proponent of strict control and management of personnel costs in the healthcare environment many may question my approach as counter intuitive but my approach has always been that all categories of staff are important in the delivery of quality healthcare. An approach to manage staff costs is required that recognises that reality. The need for each post, be it a doctor, nurse, artisan or finance clerk post, must be weighed against the need rather than a blanket moratorium or restriction on particular categories of staff.
