Achievement of equitable health care demands healthcare organizations to provide appropriate and accessible services equally to all the people. A wide range of people, especially in nations with low and middle-income encounter challenges accessing essential health services because they are unaffordable ( Harris et al., 2015) . The South African constitutions obligate healthcare organizations to deliver quality healthcare ( Burger & Christian, 2018) . The government has implemented various programs and developments to improve healthcare quality, safety, and efficiency of access and delivery to all users and the country has experienced numerous changes in health legislation and policy to ensure compliance in the delivery of quality care ( Burger & Christian, 2018) . However, reports by communities and media in South Africa reveals that services in health institutions fail to meet patients' expectations as well as basic standards of care ( Maphumulo & Bhengu, 2019) . Consequently, the public loses trust in the healthcare system and demands immediate attention to the ruined healthcare system. This research paper is a description of the health system issues in South Africa as well as the current interventions and recommendations and possible future directions for intervention.
Prevalence of Healthcare System Issues in South Africa
The South African health system consists of partly socialized and partly privatized healthcare. The public health sector is relatively large and serves individuals of the black race predominantly, with free primary healthcare services and tertiary and secondary care offered at state-owned health care organizations ( Burger & Christian, 2018) . The private sector provides world-class facilities for individuals who can pay for their care or for the insured minority. Most resources are accumulated in the public health sector although the public sector has the responsibility of ensuring the wellbeing of the entire population ( Delobelle, 2015) . The private sector consumes around 55 to 60% of the total budget allocated to healthcare, but only serves less than 15% of the population.
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A wide range of issues in the South African healthcare system can be traced back to 1948 to 1993 during the apartheid period. During this period, the healthcare system was fragmented highly with discriminatory impacts between mixed race, black, white, and Indian racial groups ( Harris et al., 2015) . The apartheid government worsened the situation by developing ethnic homelands or 10 Bantustans into which Africans were segregated unwillingly, where every segregation had its department of health with its professional body ( Burger & Christian, 2018) . The segregation promoted deterioration in the delivery of health system due to lack of resources, with considerable impacts on poor communities.
The government in South African has displayed great effort in improving the quality of healthcare delivery in the country since the 1994 elections. However, the public still raises issues regarding healthcare systems ( Burger & Christian, 2018) . The country’s apartheid history continues to influence the healthcare system, resource disparities, and service ( Harris et al., 2015) . Rural-urban and racial disparities in the results of healthcare and inter-sectorial differences between the private and public facilities remain challenging. For instance, medical expenses for every member of private medical schemes in 2005 was nine times higher than expenditures in the public sector ( Burger & Christian, 2018) . A single doctor in the public sector provided services to approximately 11,000 people and only served around 500 individuals in the private health facilities.
Issues Facing Healthcare Systems in South Africa
Shortage of Human Resources
South Africa’s health system, the supply of health professionals, and its human resources for health's establishment fail to reflect the dire constraints and shortages found in many African nations. The country’s human resource for health provisioning falls well above the World Health Organization’s critical 2.5 health staff per 1000 individual benchmark, and far above those of a wide range of African nations ( Burger & Christian, 2018) . The country benchmark indicates four doctors, midwives and nurses per 1000 individuals ( Van Rensburg, 2014) . However, the nation’s human resource for health is plagued by constraints and problems, just like the other developing nations. The issues include human resource shortages, disparities in the distribution of available human resource, inappropriate skills mixes, and severe public-to-private drainage. Other human resource challenges in South Africa include poor-to-wealthy settings and rural-to-urban migration ( Van Rensburg, 2014) . The healthcare system in the country is unequally and differentially apportioned to the people along state dependent-medically insured, poor-wealthy, rural-urban, and public-private lines ( Mburu & George, 2017) . The shortage of healthcare staff is caused by inadequate recruitment, inadequate production, and poor staff and retention management. The nurse and doctor deficit in South Africa within the public health sector are also caused by the increased burden of care as a result of the growing and large HIV/AIDS epidemic in the country, staff attrition, and insufficient training and recruitment.
Leadership and Management Crisis
Health system in South Africa experiences governance and leadership challenges that include weak public health management and leadership. Health care systems in the country suffer from limited community participation in management, planning, and monitoring of health services, inadequate legislation related to health and their enforcement, and inefficiency in resource allocation ( Van Rensburg, 2014) . The system also suffers from weak health research and information systems, vertical and horizontal inequities in health systems, and weak inter-sectorial action ( Van Rensburg, 2014) . The leadership and management crisis in the systems is reflected in the lack of clear philosophy, lack of vision, and poor goal setting.
The leadership and management crisis in the South African health system can be traced back to the history of democracy after government policies targeting the improvement of living conditions in poor households were implemented. The democratic government was responsible for transforming the public service through the removal of all discriminatory policies and practices in the employment line ( Burger & Christian, 2018) . The government implemented a public affirmative action to improve the conditions of the historically underprivileged population. The policy contributed to a wide range of problems in the health system such as placement of inexperienced managers in leadership positions as well as a loss of institutional memory ( Maphumulo & Bhengu, 2019) . The affirmative action promoted the delivery of poor-quality services because it was characterized by affiliation and nepotism instead of merit and skills. The delivery of poor services is exacerbated by lack of performance management and monitoring strategies and tolerance to misconduct that influence employees to ignore laws ( Burger & Christian, 2018) . Most managers in the South African health system are promoted to senior positions based on their length of service rather than skills, and they are motivated to promotions by increased salaries ( Maphumulo & Bhengu, 2019) . The poor promotion criteria widen the gap between the clinical outcome and management team. Corruption, coupled with misconduct and lack of accountability among health officials in different departments fails the government in fulfilling its constitutional mandate of delivering quality health care.
Increased Disease Burden
South Africa, like every developing nation, faces a high disease burden and seems to be failing to control it. The healthcare system has been devastated by the impact of HIV/AIDS to the extent that it is unable to cope with the high-quality delivery demand. A wide range of inadequacies and deficiencies caused by racial and economic issues, coupled with the fragmentation of the healthcare system have led to further proliferation of diseases in the country ( Maphumulo & Bhengu, 2019) . In addition to HIV/AIDS, South Africa suffers from TB epidemic as well as a large burden of conditions as a result of its health transition protracted disease associated with poverty, including a high child and maternal mortality, infectious diseases, and malnutrition ( Burger & Christian, 2018) . The country also suffers the burden of a predominance of chronic conditions because of socio-economic, environmental, and cultural risk factors and lifestyle changes ( Maphumulo & Bhengu, 2019) . The population's productivity and workforce are affected by the rise in non-communicable and chronic diseases, which include cancer, diabetes, cardiovascular diseases, mental illness, and chronic respiratory disease ( Delobelle, 2015) . The diseases affect the quality of life and increase healthcare expenses at the community as well as personal level.
South Africa health system suffers considerably because of healthcare-associated infections that are a major cause of mortality and morbidity in the public sector. Around one in every seven individuals entering the country’s hospitals risks acquiring the conditions because of poor control and prevention measures such as poor hand washing techniques and poor waste management ( Maphumulo & Bhengu, 2019) . Other causes of healthcare-associated infections include lack of isolation facilities, high patient-staff ratios, overcrowding in hospitals, inadequate disinfection of medical equipment, ageing infrastructure, and inter-transfer of patients with drug-resistant infections ( Maphumulo & Bhengu, 2019) . The impacts of the diseases include an increase in healthcare cost, lengthened hospital stays, and even the death of patients.
Unequal Distribution of Resources
The South African health system suffers from disparities in the distribution of resources. The country has an approximate population of 55.5 million, of which 84% get their services from the public health sector. The private sector only serves 16% of the people that belong to the medical aid schemes ( Obuaku-Igwe, 2015) . Unequal distribution of resources in the system is caused by rapid urbanization in the country. The sudden influx of populations into big cities burdens the health facilities because they are forced to work beyond capacity because they are designed and built to serve a certain number of people ( Maphumulo & Bhengu, 2019) . Urbanization has led to overcrowding, inadequate resources, and adds constraints to an already overtaxed healthcare system, because it is unconstitutional in South Africa to deny individuals, including immigrants the access to basic healthcare services ( Maphumulo & Bhengu, 2019) . Urbanization forces health facilities to function beyond their intended capacity, and leads to overcrowding and inadequate staffing, which in turn affects the quality of services delivered in urban healthcare facilities.
The unequal distributions of resources is the healthcare systems mostly impacts the black people and women in South Africa ( Coovadia et al., 2014) . The country indicates marked disparities in rates of mortality and diseases between people of color, reflecting racial differences in the accessibility of basic household conditions as well as other health determinants ( Coovadia et al., 2014) . For instance, whites, and Indian females and males indicate a low HIV national prevalence while the black population has the highest prevalence, 13.3% ( Coovadia et al., 2014) . The life expectancy in 2002 for the black women was 50% less than it was for white women while infant mortality rates varied between 7 per 1000 in the blacks and between 7 per 1000 in the whites.
Increased Healthcare Demand
The South African health system experiences an increase in consumer demand. The expectations of consumers in the country are high because of the increased use of the internet that widens the gap between the perceptions of healthcare workers and patients' anticipations ( Maphumulo & Bhengu, 2019) . The gap makes the country's patient care more complex, while a shortage in resources continues with unavoidable demand for delivery of high-quality care ( Burger & Christian, 2018) . The complexity threatens the lives and health of all patients and adds to the cost of the healthcare system.
Current Interventions and Recommendations
The government in South African has displayed considerable efforts in curbing the issues in the healthcare system. The country's change to a democratically elected government in 1994 enhanced a change in the health care system, supported by a wide range of policy documents ( Maphumulo & Bhengu, 2019) . The first intervention taken by the government includes the decentralization of the healthcare system.
Health Care System Decentralization
South Africa has adopted a decentralization process to restructure healthcare services. The healthcare system in the country is organized into local, provincial, and national government levels. The decentralization of the healthcare system has indicated a wide range of benefits. For instance, South Africa has experienced a strengthened capacity of local organizations in negotiations with the structures of the central government for increased allocation of resources to previously neglected populations ( Burger & Christian, 2018) . However, the decentralization encounters some challenges of disparities in vulnerable populations, leading to delivery of poor-quality healthcare ( Maphumulo & Bhengu, 2019) . The country has experienced a crisis in health delivery because of the separation of policy determinants from policy implementers ( Broomberg, 2016) . Implementers of policy failed to restrict funding for health at the provincial level, promoting redirection of health funds to other politically prioritized spending.
Legislation and Policies
The South African constitution is crucial legislation that advocates for the affordable health system. The constitution spells out citizens' duties and rights and describes the government's structure ( Burger & Christian, 2018) . The Patient's Rights Charter emerges from the constitution and sets common standards for achieving the awareness of citizens' rights. The national health department is mandated for the overall health policy and coordination ( Maphumulo & Bhengu, 2019) . The South African democratic government targets to curb health system issues through the district-based primary health care system and free-health policies.
Healthcare Delivery Programs
South Africa has developed a wide range of approaches to monitor the quality of healthcare delivery. For instance, the country developed an accreditation, although many institutions failed to comply with minimum standards ( Maphumulo & Bhengu, 2019) . The failure of the program led to the development of the South African Council for Health Accreditation (COHSASA) ( Thornton et al., 2016) . The program operates as a non-profit and independent organization, organized as a national cooperative effort involving private, state, and consumer organizations and healthcare providers. COHSASA is the only accreditation implementation body in the country.
South Africa has shown appropriate commitment to improving the delivery of health services in a public setting through the country’s health department. The department developed a Ten Point Plan Strategic Framework to pursue the improvement of quality service, administrative management, health technology, and hospital infrastructure ( Omotoso & Koch, 2018) . The department introduced an office of health standard compliance to introduce a mechanism for quality assurance to regulate the quality of health services ( Benatar, 2015) . The accreditation focused on providing confidence to health service end-users.
South African health department promotes the application of the national core standards to facilitate change in practice and facilitate inventiveness. The government uses national core standards as a benchmarking tool for quality of care ( Maphumulo & Bhengu, 2019) . The standards are applied in guiding healthcare managers at all levels, indicating how to plan for quality care delivery and the expected service delivery ( Maphumulo & Bhengu, 2019) . The standard’s tool is also used in the assessment of service delivery quality in health establishments in preparing for the introduction of the National Health Insurance. The implementation of national insurance is a considerable attempt to address healthcare disparities but has met critical opposition, causing a long delay in its implementation.
Future Direction
Despite the major efforts in the South African health system to curb issues in its health system, millions of people still suffer preventable harm on a daily basis. Therefore, much effort is necessary to prevent the issue of poor quality service delivery ( Maphumulo & Bhengu, 2019) . Much of the interventions to narrow disparities in South Africa were embedded in the desire to implement more equitable healthcare and reversal of legislated racial discrimination ( Mayosi & Benatar, 2014) . The interventions emphasize on biomedicine and legislation as the major strategies for healthcare improvement, without considering social health determinants and the challenges related to the appropriate practical application of health services and new laws.
South Africa faces long-term issues such as narrow disparities in health, wealth, education, and in generating opportunities for survival and leading productive and healthy lives. The highest priority focuses on improving access to effective and sustainable healthcare services ( Maphumulo & Bhengu, 2019) . Short term interventions would include improvement of policies for resource-allocation, reinforcing public health care services, and training an appropriate balance of healthcare professionals ( Scheffler, Visagie & Schneider, 2015) . Community health workers and nurses should be increasingly involved in rural areas.
Recommendations for improved healthcare systems to curb the existing issues include improved healthcare governance and management and widespread attitude shifts to do better with less. The shifts would ensure sustainable improvement in health with much reduced economic growth prospects and limited resources ( Maphumulo & Bhengu, 2019) . The best interventions to curb health system issues in South Africa include provisioning of additional human resource through massively increased training pipeline, cutting through certification and immigration bureaucracy, and contracting with private providers ( Burger & Christian, 2018) . Inadequate human resource issue can also be addressed through the management of disparities in skilled human resource distribution within the healthcare sectors.
The health system issues in South Africa can be solved through the improvement of chronic conditions in cost-effective ways. The strategy demands prevention interventions such as public education on lifestyle changes and screening for conditions to significantly reduce the growing epidemics ( Doherty, Gilson & Shung-King, 2018) . Health care systems should also be restructured to increase accessibility and offer quality primary health services to manage existing conditions ( Maphumulo & Bhengu, 2019). The restructuring should be done by strengthening the district health system through the resourcing of staff, better training, and effective assessment of referral needs to access tertiary or secondary care.
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