A Vision for a Better Healthcare System in South Africa 

Dr. Anuschka Coovadia outlines a vision for improving South Africa’s healthcare system through comprehensive reforms in public sector efficiency, strengthened private sector involvement, and enhanced intersectoral collaboration, aiming to create an accessible, efficient, and high-quality healthcare system for all citizens.

As a healthcare professional with a deep passion for improving healthcare delivery in South Africa, I believe we are at a crucial juncture. Either we will be walk deeper into an abyss from which we will never escape, or we will do ‘that South African thing’ – the one where we tend to pull a miracle out of a hat, but only at the very last minute. From all of the work I have done, from everyone I have been taught by, and all the lessons learnt over decades of service, I know the future of our healthcare system depends on the choices and actions we take now. 

I believe that the key to achieving a better healthcare system lies in decisively and bravely addressing the fundamental issues that have plagued our country for many years. In this discursive essay, I outline a vision for a better healthcare system in South Africa, which focuses on three key areas – drastic public sector reform, progressive strengthening of the private sector and more effective intersectoral collaboration. 

Public sector reform 

The first and most critical step in building a better, more sustainable, and reliable healthcare system in South Africa is public sector reform. Our public healthcare system is already tax funded, which means that if it were more efficient, effective, and patient-centric, we would have a de facto national health system. However, it is in dire straits and desperately needs to be revitalised. 

This repair requires the focus and efforts of our collective healthcare leadership. If trust and commercial barriers are overcome, the private sector could drastically impact the public system’s transformation by bringing critical local platforms, systems, and resources to expedite improvements. It must encompass a wide range of improvements, starting with a purchaser-provider split to separate the payer from the provider. This will ensure better control, more professional management, competition between facilities and clinicians, enhanced patient experience and outcomes, and greater accountability.

In addition, we need to urgently address our Human Resources for Health crisis. We need to increase healthcare workforce recruitment and retention, enhance training and education, improve working conditions, and ensure an equitable distribution of clinicians across urban and rural areas to meet our population’s health needs more effectively.  It is a travesty esty of justice that we have hundreds of qualified healthcare workers, in our country, who are unable to work due to bureaucratic processes and legacy thinking. We need to bring all our clinical resources back into practice. Reforms should also include skills development initiatives to ensure improvements in the quality of care and patient safety. A culture of care needs to be built, which humanises the treatment of healthcare workers and creates an enabling environment in the clinical facilities. 

An integrated digital platform, which allows comprehensive data collection and analysis and has telemedicine capabilities, is needed to streamline healthcare delivery, drive operational, financial, and clinical transparency, and enhance access to healthcare services, particularly in rural areas. 

Furthermore, strengthening primary and community healthcare is essential to shift the focus from treating diseases to preventing them, ultimately reducing the burden on the healthcare system. The provision of home-based care services, using community health workers, should be strengthened to provide ongoing support for patients, especially those with chronic or terminal conditions. Creating incentives for wellness and healthier behaviours is also crucial to promote a culture of health and well-being within our communities. 

Lastly, addressing the social determinants of health and integrating the provision of care with social services could create a more holistic approach to building healthier, robust, and stable communities. Community-based health education, accessible preventive services, maternal and child health programs, school-based screenings, and vaccinations; and support for socioeconomic stability through employment, empowerment, and housing initiatives, may resolve some of the underlying factors that contribute to the persistent health disparities that our people face. 

Private sector strengthening

In addition to public sector reform, the private sector also needs to play a critical role in the future of healthcare in South Africa. There are very deep sets of skills, systems and capabilities that exist, which are often world class; however, the sector has failed to achieve its full potential, as it has systematically been prevented from scaling in size and scope. 

Managed competition in the funding sector is necessary to ensure more efficient utilisation and allocation of resources. Easily comparable options, standardised benefits, risk adjustments, incentives for efficiency, greater transparency, and more effective regulation and oversight can fundamentally alter the value proposition of the private healthcare funding market. Regulating provider tariffs, introducing collective bargaining, and reviewing the Prescribed Minimum Benefits (PMBs) and the scheme solvency requirements could improve the sustainability of the system and lead to more South Africans being covered by the insured net. Moreover, the introduction of a low-cost benefit option to the medical scheme sector is a step toward Universal Health Care (UCH). It will enhance accessibility for underserved populations, under the auspices of an established and well governed system. 

The employed uninsured and informal sector are ripe and ready for insured cover, but they need novel products, accessible services, and appropriate models of care to meet their unique healthcare needs. Affordable premiums, consumer-friendly distribution channels, flexible payment options, coverage for occupational hazards, relevant benefits, access to a broad network of healthcare providers without stringent eligibility criteria, simplified enrolment process with minimal documentation; and increased education and awareness could drive uptake among these growing segments of the market. Improving the access, affordability, and quality of health services they consume will have a significant impact on the well-being of the largest segment of our workforce, unlocking great economic and social benefits for our country. 

Larger risk pools and fewer centres of administration will also help to develop more stable funding systems and ensure that more cents in a rand are spent on healthcare services,
rather than duplicative and largely undifferentiated management and administrative structures. Greater governance and alignment of benefits with the principles of UHC are imperative to ensure that all citizens have access to essential healthcare services. 

Good-quality primary healthcare services can quickly be provided, by tapping into the large pharmacy, clinics, and general practitioner networks, which already exist across the country. 

The private provider sector also needs an urgent overhaul. Providers need to move away from their current fee-for-service, fragmented and demand-driven model. A provider regulator agency needs to be rapidly set up to bring oversight and coordination to the largely unwieldy market. 

Quality accreditation and monitoring should be expanded to encompass a wide range of healthcare providers, promoting a culture of excellence and accountability. Adherence to predetermined tariffs and clinical pathways needs to be driven to standardise care delivery, improve cost-effectiveness and enhance patient outcomes. 

Utilisation of data, analytics and reporting must also become embedded in clinical practice to facilitate evidence-based decision-making and continuous quality improvement. 

The development of multidisciplinary practices, which provide ongoing and long-term management for patients with chronic conditions, needs to be progressed as these will optimise healthcare delivery. Better coordination of care, greater continuity, and a balance between the curative and preventative aspects of treatment could shift the needle on the tsunami of non-communicable diseases which we face. Utilisation of clinicians at the highest level of their credentials, supported by lower levels of trained clinical and administrative assistants, could also unlock economic benefits. By fostering collaboration among different healthcare professionals, we can create a more integrated, cost-effective, and patient-centric approach to care. 

Intersectoral collaboration 

Effective intersectoral collaboration is essential for a comprehensive and sustainable healthcare system. Public-private contracting could facilitate collaboration between the public and private sectors, leveraging the strengths of both to improve healthcare delivery. 

Good-quality primary healthcare services can quickly be provided, by tapping into the large pharmacy, clinics, and general practitioner networks, which already exist across the country. Additional public-private provider models could be sequentially rolled out to meet the needs of designated patient populations, in more specialised disciplines such as oncology and mental health. A defined referral system, interoperable technological interface, and fair contractual terms and clear lines of accountability are imperative to create a sustainable public-private partnership.

Broader access to a base level of medicines, consumables, equipment, and prosthetics through the state procurement channels may also serve to lower the cost of care, in the private sector. As an example, the existing Central Chronic Medicine Dispensing and Distribution’ (CCMDD) program, which distributes and dispenses medicine from a central point for patients with stable chronic conditions, could be extended across both the public and privately funded sectors. 

At A Glance

• Public Sector Reform: Focus on efficiency, effectiveness, and patient-centricity to transform the national health system. 
• Human Resources Crisis: Increase recruitment, retention, and training of healthcare workers, addressing bureaucratic barriers. 
• Digital Integration: Implement an integrated digital platform for data collection, analysis, and telemedicine to enhance healthcare delivery. 
• Primary and Community Healthcare: Strengthen services to shift focus from disease treatment to prevention. 
• Social Determinants of Health: Integrate healthcare with social services to address underlying health disparities. 
• Private Sector Strengthening: Enhance the role of the private sector through managed competition and regulation improvements. 
• Intersectoral Collaboration: Foster public-private partnerships to leverage strengths and improve healthcare delivery. 
• Depoliticized Management: Advocate for leadership based on expertise and evidence rather than political influence. 
• National Health Strategies: Establish a health information exchange, a national quality regulator, and a health technology agency. 
• Cultural and Structural Change: Promote a culture of health, accountability, and patient safety through regulatory and cultural reforms.

At a national level it is important to rapidly establish: 

A health information exchange, to enable seamless sharing of patient information, which will lead to stronger data analysis, research, and planning; better continuity of care; reduced errors and duplications; and enhanced efficiency, at a systems-level. 

An active and effective national quality regulator, to ensure that high standards of care are maintained across all healthcare facilities, promoting patient safety and satisfaction. 

A health technology agency, which is responsible for a set of evidence-based clinical treatment guidelines and formularies, used across both the public and private sectors.

Incorporating private sector entities into the health education and training system could increase the country’s capacity to produce more healthcare workers and it may also help ensure that our future healthcare professionals are equipped with the most current knowledge, experience, and skills, which are necessary to meet the evolving needs of our healthcare system. 

Lastly, a very exciting and important area of public-private collaboration is the development of our healthcare research and surveillance capabilities, which can significantly enhance our capacity to find our own solutions, innovate in new technologies and effectively respond to any future health crises our country may face. South Africa has made great contributions to the annals of global health in the past. It is my hope that we will continue to invest in developing our research capabilities, thereby creating opportunities for young South African medical scientists and innovators, while establishing our country as a leader on the global stage.

Did You Know…

Important issues on the table for any healthcare reform efforts

1. South Africa’s public healthcare system could function as a de facto national health system if it were more efficient, effective, and patient-centric, despite currently being in dire need of revitalization.
2. Hundreds of qualified healthcare workers in South Africa can’t work due to bureaucratic processes and legacy thinking, highlighting an urgent need for reform to improve healthcare delivery and worker deployment.
3. Introducing low-cost benefit options to the medical scheme sector is a strategic step toward Universal Health Care in South Africa, enhancing accessibility for underserved populations under a well-governed system.

Depoliticised management 

To ensure the success of these reforms, it is imperative that the healthcare system be depoliticised and run by professionals who are trained in finance, governance, operations, supply chain, human resources, and technology management. By depoliticising the ‘operational element’ of the healthcare system, decisions can be made based on evidence, best practices, and the needs of the population rather than political considerations. 

We need to be led by a new class of individuals, who care deeply about their conduct, the quality of their work and their contribution to our country. They need to perform their duties in a manner which is unbiased and professional, while valuing and respecting diversity amongst their colleagues and peers. Our new leaders need to have the ability to inspire and solve complex problems, while always remaining focused on the health and wellbeing of our citizens. This approach will help correct the culture, improve efficiencies, and drive greater performance from the healthcare sector, as a whole. 

It’s time to do ‘that South African thing’ once more. We need to pull a miracle out of a hat, we need to come together… we have to learn to lead again.

Conclusion 

In conclusion, the vision for a better healthcare system in South Africa includes comprehensive reforms across public and private sectors, along with effective intersectoral collaboration. By prioritising public sector reform, enhancing primary and community healthcare, embracing digital health innovations, addressing social determinants, and creating wellness incentives, we can develop a more resilient and efficient healthcare system.

Strengthening the private sector through managed competition, regulating provider tariffs, and aligning governance with UHC principles will ensure all citizens have access to high-quality care. Moreover, effective collaboration between public and private sectors, supported by depoliticized management, will enhance the system’s sustainability and success.

I firmly believe that with these reforms and collaborative efforts, South Africa can establish a healthcare system that is truly South African – accessible, efficient, and delivering high-quality care to all. 

Unfortunately, our healthcare system has become a part of the ongoing electoral campaigning, which is serious threat to the care of the sick. It is time for us to protect the sanctums of our medical services. 

We need to stop looking for unrealistic solutions and just go back to the basics of what we know – it is as simple and complicated as that! 

As in our key historical moments – our peaceful transition to a democracy in 1994, hosting the 2010 Soccer World Cup, and our victory in the 2023 Rugby World Cup—it’s time to do ‘that South African thing’ once more. We need to pull a miracle out of a hat, we need to come together, we need to have brave and honest conversations; and above all we have to learn to lead again, as active citizens who hold the ‘powers that be’ to account, so that the change we need is the change we get. 

As a healthcare professional dedicated to the betterment of our healthcare system, I am committed to working towards this vision, speaking truth to power, promoting social justice over self-interest, and contributing to the realisation of a healthier future for all South Africans. Will you join me? 

Health Care Outcomes

Enhanced System Resilience: Build a robust system capable of adapting to crises, supported by digital health integrations. 

Quality and Patient-Centric Care: Focus on humanising care for healthcare workers, standardising care pathways to improve patient outcomes. 

Addressing Social Determinants: Integration of healthcare with social services to tackle the root causes of health disparities.