Looking back to look forward: a review of human resources for health governance in South Africa from 1994 to 2018

While South Africa has had a fairly consistent record of producing national-level strategic plans for human resources for health in the past 25 years, the country continues to face major problems of affordability, availability, distribution and management of its health workforce. There are several factors contributing to the state of health human resources in the country, but problems with governance stand out as one area requiring further research, analysis and critique. This paper presents a retrospective analysis of the historical patterns in national health human resources governance in South Africa, based on a desktop policy review spanning 25 years after democracy. The authors took a multi-pronged, iterative approach, reviewing policy documents alongside grey and published literature. This led to a timeline showing key legislation, relevant health system and human resource policies, interventions, reviews and evaluations from 1994 to 2018. The review identified three distinct periods that help to characterise the terrain of human resources for health governance over the concerned 25 years. Firstly, a foundational period, in which much of the constitutional and legislative groundwork was laid. Secondly, the HIV epidemic period, which presented a major disruption to the development of system wide governance interventions and improvements. Thirdly, the launch of National Health Insurance discussions and policy processes, which signalled a gradual return to a comprehensive systems focus in line with the founding principles of the first period. Using this periodisation, as well as a conceptual framework of health human resources governance functions based on international literature, the authors argue that South Africa has experienced both progress and challenges in human resources for health governance. This has affected the successful implementation of its policy and strategic planning over the past 25 years. Good governance for human resources for health requires capable stewardship, underpinned by an appropriate mix of technical and administrative skills and explicit political support. The review findings suggest that strengthening human resources for health governance roles, including fostering purposeful stewardship by the National Department of Health, may be key to shifting the terrain in the availability and performance of South Africa’s health workforce going forwards.