South Africa: Virchow Prize Winner Prof Lucy Gilson On SA's NHI - 'Service Delivery Requires People, Not Just Money'

Professor Lucy Gilson scooped the prestigious international Virchow Prize. She chats to Biénne Huisman about her upbringing, unexpected dive into the world of public health, and shares her thoughts on National Health Insurance. She says it will take more than money to fix our health system.

Inside the Falmouth building at the University of Cape Town's (UCT) health campus in Observatory, Professor Lucy Gilson leans back in her chair. Dressed in jeans, her demeanour is casual; her sentences thoughtful and precise. She's explaining how the health system works and opportunities for improving it.

Head of the Health Policy and Systems Division at UCT, Gilson says health systems consist of several building blocks - for example financing, human resource planning and drug availability - and also the individuals, relationships and routines that bind these.

It is this focus on the human element that makes Gilson's academic work so immediately relevant to what is happening in health systems today.

During our interview, Gilson stresses her belief in people - that they are inherently motivated and passionate, traits she says that can be coaxed to full expression in the right working surrounds.

"People are really important - such as staff," she says. "But they work in an environment not only of other people - other staff, managers, patients and communities; thus relationships - but also of routines."

Some of these routines are about clinical patient care, she says. Some are organisational routines, especially for managers - like meetings, processes of audit, reporting of different types of data, budget and planning cycles.

Then there are organisational cultures that reflect accepted practices; for example risk aversion, because staff may be afraid of being blamed for failures. Drawn further afield, there are political and government environments; for example how ministers exercise their responsibilities, and how provincial departments exercise their responsibilities in relation to national governance.

"These systemic features shape how people in the system behave, and whether or not and how they adapt to changing demands - like during COVID," says Gilson. "People's passion and commitment is an incredible resource - and it is there - but how can it be unleashed, supported and sustained? That needs systems. And often the current systems undermine people."

Will this change under NHI?

Gilson notes that the National Health Insurance (NHI) Act is still "unfolding". As it stands, she says the legislation "addresses some big picture issues and financing inequities" in South African health, but with room for expansion on human resource management in the public sector.

Apart from the NHI Act and related legislation possibly being amended in future, there will also be regulations and guidelines developed as NHI takes shape in the coming years.

So how do we build health system improvement into the NHI?

"The funding mechanism is only one part of the health system," Gilson says. "So even if NHI can pool financial resources in ways that address some of the inequities in resource distribution between South Africa's public and private sectors; even if it can do that and then direct those resources towards service delivery, that in itself is not enough.

"Service delivery requires people, not just money. It requires teams not just money. Shiny things - for example drugs, technology and buildings - can only go so far. They are the hardware of a system. But you need the software of routines, relationships, values, passion to make the system really work."

Gilson points out that the NHI legislation is silent altogether on human resource development and management issues.

"How will human resources be managed in the future? How will NHI processes and practices impact on that? How will those responsible for managing and leadership do their jobs? How will they think of their jobs? How will they enable the staff they work with?" she asks.

Building on the positive

Gilson says pockets of positive "system experience" could be harnessed to support people to work better. "For example, experience on how to build the confidence and nurture the skills of those entering into managerial positions, when initially they trained as nurses or doctors or allied health professionals."

Commenting on negative pockets, she says: "Experience about calling patients 'compliant' or 'non-compliant', 'adherent' or 'non adherent'; which dehumanises people and reflects an organisational culture of medical dominance over patients, that can undermine patient-provider trust."

All this, adds Gilson, needs to be the focus of current public discussions. "These are important issues in how the NHI will play out but they are not necessarily the things that we're getting regulations on."

In addition, she notes political pressures and a need for political administrative boundaries. "So particularly in the public sector, there is the question of political influence in the health system - what is legitimate political influence, and what is not?"

Though she would not say this herself, leading academic voices like that of Gilson arguably have not held enough sway in how health reforms have unfolded in South Africa. That may or may not have to do with the politicisation of health reforms in South Africa, an issue she does not dwell on in our interview.

International recognition

In July, Gilson jointly received the 2024 Virchow Prize - which celebrates "stellar achievements towards health for all" - with Professor Johan Rockström "for their holistic and systems-based approach to safeguarding human and planetary health".

With the Virchow Prize 2024, @Lucy_Gilson and @jrockstrom's pioneering contributions to the analysis and understanding of the importance of efficient health systems and the decisive role of climate and planetary boundaries to preserve the conditions for healthy lives on our... https://t.co/zaP77c4zVU

-- Spotlight (@SpotlightNSP) July 16, 2024

"I am honoured by this award, but recognise it as acknowledging the crucial importance of the field of health policy and systems research - a field that demands attention for social justice, supports understanding of complex systems, and generates ideas about how to work with complexity in promoting health equity," she said at the time.

"This field is founded on collaboration and engagement and I am humbled by the many partnerships with researchers, health system leaders and civil society organisations that have supported my own learning over the years," she added.

Health was almost an accident along the way...

Gilson was born in Zimbabwe, then known as Rhodesia. When she was seven her family moved to the United Kingdom, where she had a nomadic childhood as her father, a Methodist minister, took appointments in various towns.

Gilson says Africa (and issues of development, equity and social justice) remained with her, as she completed a BA in Politics, Philosophy and Economics at the University of Oxford, followed by a Masters in Development Economics from the University of East Anglia. Through global affairs think tank the Overseas Development Institute, her first professional placement was at the Ministry of Health in Eswatini, then called Swaziland.

Placement as an economist within Swaziland's health portfolio had been serendipity, and would come to shape her life. "I hadn't done any particular health related studying, and then health was almost an accident along the way," she says.

One of Gilson's roles at Swaziland's health ministry in the early 1980s, was engaging with donors.

"And there were two incidents that made me question donor assistance. One was the provision of funding for a medical supplies building, with submitted plans detailing a snow-bearing roof. See, the funders were Scandinavian. And so the context of Swaziland hardly necessitates that." Relaying the memory, Gilson laughs.

"The second, which speaks directly to the issues and concerns about equity was the conditionality brought by a funder, that healthcare user fees should be introduced as part of a loan agreement. And that was the period when donors to Africa started saying: 'okay, we want you to do these things in return for our money..."'

These "impositions" were problematic, says Gilson, as in many African (and other low income countries), collecting such user fees cost more than the actual fees. "And more importantly," she adds, "charging fees deters people from using services and that impacts most on the most vulnerable people in society".

Aged 26, Gilson returned to the United Kingdom to become "a reluctant academic" at the London School of Hygiene and Tropical Medicine (LSHTM). Through her own research, she endeavoured to "show that academia can be a practical place, that the ivory tower should have no walls; that we should be open to and influenced by the world around us".

Later, studying primary level healthcare in Tanzania would culminate into her PhD from LSHTM. In 1995 she joined the University of the Witwatersrand in Johannesburg.

In 2007, she moved to UCT, where she founded the Division of Health Policy and Systems eight years later. Here inside her office at the Falmouth building, works of art, including a tusk etched with a giraffe sketch, commemorate her time working in Tanzania and also in Botswana.

Throughout the interview, golden threads in Gilson's responses are empathy and a belief in human virtue. "I want to be the sort of researcher that accompanies people, as opposed to a researcher that just observes people," she says. One of her most cited academic papers published in 2003 in the journal Social Science & Medicine explores "trust and its role in facilitating collective action" in healthcare settings.

As the interview wraps up, she says: "People are amazing, and as a researcher to witness that is incredible. I suppose my parents influenced my outlook, their sense of social responsibility; their concern for the world and concern for others. It's just how I learned to do the work."

In her off time, Gilson enjoys hiking in Cape Town's nature reserves and reading detective novels, particularly by Canadian author Louise Penny, creator of fictional Chief Inspector Armand Gamache.

This article originally appeared in Spotlight.