Many health systems rely on health programmes to target interventions for specific diseases or populations. These programs can be effective while operating largely autonomously from one another in seeking to optimize the achievement of one or more specific objectives. This organizational approach, however, can also constrain the evolution of the health system in its ability to adapt to changing morbidity patterns, technological advances, among other issues.  Many countries are now moving away from this vertical organizational approach towards more coordinated and integrated systems.

The World Health Organization (WHO) has developed a diagnostic approach to enable countries to look across health programs that are part of their health system to detect “cross-programmatic” conflicting issues that can be addressed through changes to specific aspects of how programs are configured and operate within the overall health system.  This approach has been piloted in South Africa to identify and analyse critical areas of overlap, misalignment or duplication, focusing on the TB, HIV/AIDS, and Maternal, Newborn and Child Health (MNCH) programs, as well as with the overall health system. The output of this analysis also provides guidance as to how to improve overall system efficiency to maximize outcomes under the National Health Insurance (NHI) reform agenda. 

Key Findings

While the focus is on one province, it is important to note that many of the issues are broader and may be present in other provinces.  They may also have to do with organizational issues at the national level and the legislative framework within which the South African health sector operates.  Furthermore, given the timeline and scope of this analysis, the WHO team did not consult with all relevant actors and thus findings should not be qualified as exhaustive and relevant for all provinces, and there may be variation in the degree of these findings across districts and provinces more broadly. 

Notably, in addition to the National Strategy and NHI objectives, the approach to this analysis is well-aligned to the strategic goals of the provincial department of health has laid out for 2015-2019.  These include: strengthen health system effectiveness, reduce the burden of disease, UHC, strengthen human resources for health, and improve quality of care.  As a result, the findings intend to support the province’s ongoing ambitious efforts to meet these goals.  There are a number of interventions that are already underway and the findings provide further motivation to continue these reform plans. 

Overall, the intention of this analytical exercise was to identify inefficiencies resulting from overlaps, duplications and misalignments across the way which in the HIV, TB and MNCH programmes are organized in a large province in South Africa.  As a result, the findings centre on these inefficiencies, rather than on the multitude of positive and constructive actions taking place within the provincial and overall South African health system at the moment.

The five findings which were identified in the analysis and are described in detail below are:

1. Overly-segmented financing and planning arrangements
2. Misalignment between frontline needs and top-level allocations/management
3. Limited centres of financial or performance responsibility
4. Narrow approaches to human resources
5. No comprehensive information system

Policy options and proposed next steps

After consultation and validation of these findings with district, province and national authorities, the WHO team has also developed a proposal to design and implement policy interventions that can address the identified inefficiencies.  These steps are meant to serve as the basis for discussion with authorities in South Africa about how to feasibly move forward.  Importantly, a step-wise implementation process is proposed that begins in a sub-set of provinces or districts and expands based on implementation capacity and the findings from initial pilots.  The steps to reduce fragmentation, establish more coherent and coordinated planning and budget processes, and reduce inefficiencies are necessary steps for South Africa’s health system, and will facilitate the overall move to NHI. 

A set of steps are proposed to move towards an alternative organizational model based on the identified cross-programmatic inefficiencies in a set of districts.  These steps are a fundamental part of the proposed activities under NHI Work Stream 6: Strengthening the District Health System.  Based on the above referenced analysis, efforts to create an integrated primary care platform and to build district management capacity will not be fully leveraged without concerted efforts to integrate and coordinate certain programmatically-focused functions.