Good governance in South Africa’s health system is ‘patchy’

The signing of the National Health Insurance (NHI) Bill into law last year sparked a renewed conversation on how the health-care sector is governed, making the release of a consensus study on what is needed to achieve good governance and management in the South African health-care system a few months later particularly timely. Commissioned by the Academy of Science of South Africa (ASSAf), the report was a three-year endeavour led by a panel of experts from multiple fields.

The spark for the project was concerns over the performance of the health-care system and the Life Esidimeni tragedy in particular, according to Prof Lilian Dudley, chair of the ASSAf report panel. The Life Esidimeni tragedy, in which 144 mental health-care users in Gauteng died due to starvation and neglect, highlighted what the public health medicine specialist describes as “not just poor performance but corruption and unethical practices in the health system”.

“There were concerns about the overall governance or oversight and leadership of the health system, and the panel was essentially asked to look at some of the challenges, as well as to go over the evidence and make recommendations which could be implemented to address it,” she tells Spotlight.

After describing the “magnitude, the spread, and the effects of the governance challenges in the health system”, as well as finding examples of where there was good governance, the report makes eight recommendations on practical strategies to improve the situation. This article focuses on three of these recommendations, so it is by no means exhaustive. The recommendations are interdependent, as is evident from the full report, which can be found here.

Good governance is ‘patchy’

Sharon Fonn, a professor of public health at Wits University who worked on the report, tells Spotlight that the panel found that good governance in our health-care system is “patchy”. She says there are two issues contributing to this: there are some people without the necessary competence and skills or sometimes motivation in key positions; and in some cases dysfunctional or inappropriate systems undermine the best efforts of those who are competent or have the right intentions.

There is no quick fix though. “You need to see this as a 10-year project,” Fonn says. “There’s some political leadership that’s needed, and then there are some technical interventions that are needed. It’s about having a plan and getting people around the table,” she adds.

Foundations for good governance are present but no longer ‘fit for purpose’

To contextualise governance within the health-care system, the report needed to look at the past, according to Dudley. She explains that democratic South Africa “inherited a very flawed, fragmented health system, which was not being governed to address the needs of the majority of the population”. Thus, a lot of work had been done after 1994 to set up a unified health-care system and establish systems and structures to lay foundations for good governance. “But we seem to have lost the plot along the way,” she says.

“One of our key findings was that there were some foundations that were put in place, but they would not be effective as governance structures and were no longer fit for purpose,” Dudley says. “Even though we have some structure, some systems, they are not really supporting and promoting the kind of governance that is needed.” In this regard, Dudley points to key legislation and policies such as the National Health Act (NHA) and the white paper on transformation for the health system.

“The other context within which we are operating is the overall political environment, and health is political … with levels of political interference,” Dudley adds. “Having the right people, the right competence and the right ethics in place has been a problem because a lot of senior managers in the health system are not necessarily accountable to the people they serve.”

The report states that a conflict between two pieces of legislation — the Public Finance Management Act (PFMA) and the Public Service Act (PSA) — could be contributing to some of these problems with senior leadership and “cadre deployment” in some provincial health systems. At issue are apparent contradictions and overlaps between the roles of purely political appointments, such as MECs for health, and those of senior officials like heads of health departments.

The PFMA is aimed at regulating the financial management of government and providing for the responsibilities of the persons entrusted with that financial management. According to the report, the act grants the power and responsibility for financial management, service delivery and human resource management to “accounting officers”, who are either the head of department or the director-general — depending on the level of government being referred to.

By contrast, according to the ASSAf report, the PSA aims to regulate the organisation and administration of the public service, granting ministers and MECs in the provinces the power of “executive authority”, which gives them the authority to, among other things, appoint people to government positions.

It is not unusual to have contradictions between pieces of legislation that were developed at different times and by different ministers or departments, Andy Gray, a senior lecturer in the division of pharmacology at the University of KwaZulu-Natal’s School of Health Sciences, tells Spotlight.

He says section 38 of the PFMA describes the responsibilities of “accounting officers”, clearly describing a managerial function. However, every head of department is also subject to governance by a minister. The PSA repeats the same definition for an accounting officer as the PFMA but adds an additional definition for an executive authority.

In the PSA, who the executive officer is depends on the level of government being referred to. For example, in relation to “a provincial department or a provincial government component within an executive council portfolio”, the executive officer will be the MEC responsible for that portfolio.

In the case of a provincial health department, this would mean the MEC for health is an executive officer, who is granted by this act all the powers and duties necessary for, among other things, “the recruitment, appointment, performance management, transfer, dismissal and other career incidents of employees of that department”.

Gray says: “That does appear to contradict the separation between management and governance, so the ASSAf criticism appears to be valid.”

Another function of governance that has not been working as it should, according to Dudley, has been the community participation aspect. She says the NHA delegates a lot of the power and responsibility for enabling community participation to the provincial governments. And in the cases where provincial governments have created appropriate regulations for the health committees that allow for community participation, it’s still inadequate.

As summarised by the report, the lack of clarity between these three acts — the NHA, PFMA, and PSA — has “contributed to conflicting mandates between politicians and senior managers in the public health sector, across levels of government, and between the health sector and structures for community representation”.

Legislation needs to be refined

To address some of these issues, the report recommends updating legislation and governance structures “to insulate them from vested interests and give them executive rather than merely advisory functions”.

To do so, it calls for making accountability structures more effective by amending the conflicts within legislation that weaken or undermine the delegation of governance. This includes, among other steps, aligning the PFMA and the PSA, as well as clarifying and strengthening the way the NHA delegates authority between levels of government, particularly to health districts and health facilities.

The report also proposes taking steps to strengthen community governance structures like clinic committees, hospital boards and other entities. This includes, among other things, reforming legislation to ensure “harmonised policies on roles and functions of such structures across all provinces” and extending community participation structures to the private sector. It also calls for a common policy defining the “criteria and processes for appointments, role and functions, reimbursement of community committee members for costs, induction, and continuous capacity building”.

Systems are not working

Also hindering good governance, according to Fonn, is dysfunctional systems, such as overly complicated procurement processes and ineffective information systems. She says that whenever a problem arose with procurement, another layer of control was added, making the systems impossible to navigate.

“It must be possible to review it and to work out a more manageable process around procurement. And procurement is particularly important because it’s sort of what keeps things turning over. It’s also the space where vested interests can be exercised,” Fonn says.

Accurate information is another essential component of the health system that overall isn’t working very well, though there are exceptions. Fonn explains that the report highlights functional information systems in some provinces. Part of what can be done to improve governance, she says, is to take what worked in those instances and try to replicate or adapt it to work in other provinces.

Need functional, fit-for-purpose systems

One of the recommendations in the report is to “surround managers and leaders with functional, fit-for purpose systems (including human resources, procurement, health information systems) so that they can do their work”.

Part of this is a call to improve procurement processes by simplifying the overly complex and sometimes contradictory rules and delegating more of the actual procurement to facilities and district or subdistrict managers.

“Overly complex procurement systems are inhibiting decentralisation, as the complexity of existing rules makes it difficult for decentralised managers,” the report states. “This does not mean that every facility should be issuing its own medicine tenders, but there is no reason why strong subdistrict offices or larger facilities should not be ordering supplies off transversal tenders without multiple layers of high-level signoff.”

Some of the suggested reforms include greater development and use of electronic systems like electronic catalogues, stock management systems, ordering systems and e-procurement systems. The report also suggests including medical supplies and medical equipment in transversal tenders to achieve economies of scale.

The report further advocates for giving health institutions greater power, where appropriate, over hiring, firing and disciplinary procedures. “Within labour law and labour agreements, space must be made to allow managers to follow agreed procedures without sacrificing the public value mission of the service,” it says.

Implementing the electronic National Health Information System of South Africa is also identified by the report as an urgent priority so that patient-linked data can be collected.

Alleged lack of vision and stewardship by the national department of health

Another trend observed by the panellists, Fonn says, is an overall lack of a vision of the health-care system that is being communicated by the government — particularly the national department of health. She uses the example of NHI, where the government has been, as she describes it, “unable to communicate [NHI] in a way that captures the public imagination and in a way that makes sense to people on the ground who are actually [health-care] providers”.

She adds: “The argument from the government is that the NHI Act is simply setting in place the fund, that’s all it’s supposed to do. I understand that … and it’s a legitimate argument. The problem is that it doesn’t tell people what it means. It’s that kind of lack of stewardship, lack of communicating a vision.”

Fonn also points out an apparent reluctance by the department to engage with stakeholders, instead fostering a “command-and-control environment”.

Another layer of this issue is that the health-care system is set up in a way that makes the national department responsible for steering the system but, according to Fonn, it hasn’t done this effectively and has focused on the wrong things.

“The way the South African health system is set up currently is that the department is responsible for stewarding the system, for making sure that the right legislation exists, the right checks and balances exist, and the right controls exist,” says Fonn.

“I think that at least in part, they haven’t [fulfilled that responsibility]. It’s a complex thing to do; I’m not suggesting it’s easy. But I don’t think they’ve had their eye on the right place,” she says.

“What our report does acknowledge is that there are many good people in the health system who actually want to see improvements, who are committed to good leadership and management and governance,” Fonn says. “But I think we need leadership to kind of show the way and one of the first things that we felt was important was to revisit what our public values are, what are the social goals that we want to set for the health system, and can we all agree on that and move towards that? [We need] that kind of leadership and stewardship from the political and national government level.”

Mixed response from the government

Spotlight asked the health department and minister Aaron Motsoaledi for their responses to the report and its findings. The spokesperson for the health department indicated he had only been able to access an abstract of the report and would not be able to respond without seeing the full report. A copy of the report was then sent to the spokesperson, but no response or comment was received by the time of publication (more than a week later).

However, according to Dudley, the report was presented last year to the health minister, senior managers in the provinces, and health MECs.

“There was actually quite a bit of interest from the new MECs … the MECs were quite keen to hear more about it, engage more about it and wanted to know what we need to do to actually respond and to start implementing some of these recommendations,” she says.

By comparison, Dudley says, there was less interest from the national department of health.

But she does point out that the burden of changing governance in the health-care system doesn’t rest entirely on the health department’s shoulders.

“There are multiple stakeholders that need to take action, we do try to emphasise that in the report. Yes, the government and politicians do have particular roles, but everybody has a role,” Dudley says.

These include academic institutions, she says, which need to ensure that when they train health professionals and leaders, they are provided with the kind of competencies that will improve the management, leadership and governance of the health system.

Research institutions also have a role to play in addressing some of the unanswered questions around governance and how to implement interventions that can bring about change. Civil society will also have a part to play through activism to hold those in positions of power to account. 

*This article was first published by Spotlight — health journalism in the public interest. Sign up to the Spotlight newsletter.