Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening

Abstract

Background: Since the advent of democracy, the South African government has been putting charters, policies, strategies and plans in place in an effort to strengthen public health system performance and enhance service delivery. However, public health programme performance and outcomes remained poor while the burden of disease increased. This was also the case in the Free State Province, where major public health system challenges occurred around 2012. Assessment was necessary in order to inform health system strengthening. Methods: The study entailed a multi-method situation appraisal utilising information collated in 44 reports generated in 2013 through presentations by unit managers, subdistrict assessments by district clinical specialist teams, and group discussions with district managers, clinic supervisors, primary health care managers and chief executive and clinical officers of hospitals. These data were validated through community and provincial health indabas including non-governmental organisations, councils and academics, as well as unannounced facility visits involving discussions with a wide range of functionaries and patients. The reports were reviewed using the World Health Organization health system building blocks as a priori themes with subsequent identification of emerging subthemes. Data from the different methods employed were triangulated in a causal loop diagram showing the complex interactions between the components of an (in) effective health system. Results: The major subthemes or challenges that emerged under each a priori theme included: firstly, under the 'service delivery' a priori theme, 'fragmentation of health services' (42 reports); secondly, under the 'health workforce' a priori theme, 'staff shortages' (39 reports); thirdly, under the 'health financing' a priori theme, 'financial/cash-flow problems' (39 reports); fourthly, under the 'leadership and governance' a priori theme, 'risk to patient care' (38 reports); fifthly, under the 'medical products/technologies' a priori theme, 'dysfunctional communication technology' (27 reports); and, sixthly, under the 'information' a priori theme, 'poor information management' (26 reports). Conclusion: The major overall public health system challenges reported by stakeholders involved fragmentation of services, staff shortages and financial/cash-flow problems. In order to effect health systems strengthening there was particularly a need to improve integration and address human and financial deficiencies in this setting.

Effects of COVID-19 in South African health system and society: An explanatory study

“…South African health system is overwhelmed with COVID-19 pandemic in addition to the existing challenges in healthcare service delivery. Despite significant progress in the South African health system since 1994, the country faces challenges in healthcare service delivery which include lack of funding and insufficient budget [ 32 ], environmental change [ 33 ] and unequal distribution of resources (including health facilities, healthcare workers, inadequate production, and inadequate recruitment especially in rural areas, for both the public sector and private sector [ 34 ]. Other challenges include slow progress in restructuring the healthcare system [ 35 , 36 ], Increased disease burden [ 34 ], management and leadership crisis caused by poor leadership and inadequate management, and reflected in a lack of vision, lack of clear philosophy and poor goal setting in the healthcare sector [ 37 , 38 ].…”

Reflection on performance health indicators of the Free State Department of Health in comparison with North West, Northern Cape, Western Cape and Gauteng Provinces of South Africa

“…Primary health care (PHC) management is defined as "a process during which managers in higher levels of a health system (e.g. district) interact with peripheral health care workers to monitor work processes, understand the causes of problems and provide possible solutions, as well as general management to improve operations, clinical direction, review guidelines, and provide approaches to effective service delivery, including patient safety, treatment and health promotion" [2] . The PHC Management is a cardinal indicator because it fosters mutual rapport between the lower and higher structure of health systems in South Africa.…”

“…In pursuit of improving the health outcomes, the health system has prescribed periodic assessments of PHIs on the public health sector. The PHIs serve twofold objectives namely; to justify the incremental annual allocation and to raise the red flag where set targets are not being met [2] . PHIs also help the public sector to develop specific, measurable, attainable, realistic and timely (smart) targets, hence periodic reviews are conducted to ascertain the outcome.…”

The economic burden of deliberate self-poisoning: insight from a tertiary hospital in the Free State Province, South Africa

“…Similarly, in the United Kingdom, DSP accounts for 170 000 general hospital attendances each year with an estimated direct hospital cost of £56 million [ 10 ]. Over the past decade, the Free State Department of Health (FSDoH) has been experiencing an on-going financial crisis mainly due to poor financial management systems, insufficient health system financing, increasing costs, financial unsustainability and lack of financial autonomy [ 15 ]. This translated to a fragmented healthcare system, increased staff shortages and poor service delivery [ 15 - 17 ].…”

“…Over the past decade, the Free State Department of Health (FSDoH) has been experiencing an on-going financial crisis mainly due to poor financial management systems, insufficient health system financing, increasing costs, financial unsustainability and lack of financial autonomy [ 15 ]. This translated to a fragmented healthcare system, increased staff shortages and poor service delivery [ 15 - 17 ]. In South Africa, studies on the financial implications associated with the management of DSP cases are scarce [ 18 ], and no known study has investigated the financial implication of managing DSP in a resource strained health system as obtained in the FSDoH.…”