Democracy in South Africa has brought about many gains in health care. Free care for pregnant women and children, free primary healthcare services and a programme to build clinics have removed barriers to basic health care. The expanded immunisation programme and the largest HIV treatment programme in the world are among other encouraging developments.

The policies that have ushered in these changes are revolutionary. They have had an explicit focus on equity and redress. They benefit those most affected by previous apartheid policies and improve population health.

But they are not enough to turn around the overall performance of South Africa’s healthcare system. Although the country spends 8.5% or around R332 billion of its gross domestic product on health care, half is spent in the private sector, which caters for the elite. The remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector.

Despite its middle-income status, South Africa has poor health outcomes compared with other middle-income countries. An example is Brazil which has similar health spending as a percentage of its gross domestic product.

The new sustainable development goals are a sharp reminder of the “unfinished business” of unacceptable health inequalities. Evidence shows that a high-performing public health sector is one of the most redistributive mechanisms to reduce health inequalities.

Major faultlines in providing services

South Africa suffers from three:

• it has come to tolerate ineptitude as well as leadership, management and governance failures;

• it does not have a fully functional district health system, which is the main vehicle for the delivery of primary health care; and

• it has not dealt decisively with the health workforce crisis.

These have negative consequences for patients, health professionals and policy implementation. Patients, who are relatively powerless, bear the brunt through negative experiences and sub-optimal care.

Health care providers on the front line and at the bottom of the hierarchy also suffer. Faced with an unsupportive management environment, staff shortages and health system deficiencies, they find it difficult to uphold their professional code of ethics and provide good quality of care.

Faultline one: a lack of leadership

Despite the leadership by current Health Minister Aaron Motsoaledi and the commitment from competent health service managers and professionals, incompetence and leadership and governance failures still exist across the system. It is exacerbated by a general lack of accountability.

In 2009, my research showed management flaws and leadership gaps, particularly around service delivery and its quality as the underlying factors behind the overspending in provincial health departments.

The system’s performance was also compromised by:

• fragmented health service planning;

• inadequate co-ordination between national and provincial departments; and

• ten de facto health departments instead of one strong national health system.

Six years later, the National Development Plan and the 20-year review by the presidency found these problems were still there.

Corruption also plays a role. The auditor-general found that between 2009 and 2013 R24 billion in provincial health funds were classified as irregular spending. It is unknown exactly how much was related to corruption but the best-case scenario is that this amount was lost due to ineptitude of public servants and inefficient management systems.

Fault line two: compromised primary health care

South Africa still does not have a fully functional district health system. This would ensure improved quality and equitable health for all South Africans.

In 1996, our study into primary healthcare services set out recommendations on an essential package of integrated primary healthcare services. This included women’s health, mental health, and rehabilitation services.

Almost 20 years later, our studies highlight several constraints to achieve a fully functional district health system. These include:

• policy changes on the role of local government in primary healthcare service delivery;

• a lack of role clarity between the national, provincial and local government health departments which translates into tension and lack of trust;

• funding and capacity problems; and

• ineffective and inefficient management systems.

Fault line three: the health workforce crisis

In theory, South Africa has a five-year national Human Resources for Health strategic plan to address the health workforce crisis. But it lacks detail, largely ignores lower levels of government and underestimates the vast human resource implications of the planned national health insurance scheme.

Nor does the plan deal with the critical issue of how to get the right skills and the right numbers of health professionals to different levels of the health system.

According to the World Health Organisation, South Africa has higher ratios of health professionals than its minimum norms. Compared to many other countries it also has some of the best training institutions in the world, highly skilled health workers, effective professional regulation and sufficient fiscal space for relatively high remuneration levels.

Notwithstanding these strengths, the healthcare workforce crisis manifests in several areas.

Aside from the leadership crisis, there are still inequalities and maldistribution of health workers between urban and rural areas and between the public and private health sectors.

Second, there is a reported crisis of staff shortages. Moonlighting and agency nursing among nurses and private practice among public sector doctors fuel this. A 2010 study showed 40.7% of the 3700 nurses questioned were moonlighting or worked for an agency in the year before the study.

Third, there is poor staff morale, unprofessional behaviour, and unacceptable attitudes – all which impact on the quality of patient care.

Also, there is a crisis of inadequate human resource information systems. These are fragmented and unable to inform health workforce planning and training. There are also problems of data quality, coverage and comparability. Even where information is available, it is not used to inform decision-making.

So what needs to be done?

There must be a metaphorical repair of these faultlines. This requires political will, leadership and stewardship.

Public service managers with the right skills, competencies, ethics and value systems must be appointed. There must be effective governance across the health system to enforce laws, appropriate management systems, and citizen involvement and advocacy to hold public officials accountable.

The reforms envisaged by the national health insurance provide exciting opportunities for health system change in South Africa that is rarely available in most countries.

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This article is based on Professor Laetitia Rispel’s inaugural lecture on September 28, 2015.

Written by Laetitia Rispel, Head of the School of Public Health, University of the Witwatersrand

This article was originally published on The Conversation. Read the original article.