I have not posted on Househam on Health for some time for two reasons. Firstly, as with many others I am sure, I have been shocked, disillusioned and depressed by the scandal that has unfolded at the highest level in the South African public health sector. Secondly, I have been engaged in a project to assess financial management in a provincial department in South Africa which has been both an interesting and challenging experience. These events have led me to reflect again on a question that I was asked some time ago and one that I have asked myself many times. What are the differences between a department of health that functions effectively and one that does not? In short what goes wrong?
A seemingly straight forward question that led me to review recent events as well as my own experiences as a consultant and as a manager of health services over nearly three decades. The words that came to mind were “leadership and governance”
Leadership, so says conventional wisdom, requires strategic thinking and vision. That alone, however, does not describe the characteristics of a good leader who in addition to being able to communicate effectively must always act honourably and ethically. A leader must be able to stand alone and take difficult decisions decisively. As in times gone by, when kings and generals were at the front leading their soldiers into battle, a leader must be at the forefront, visible and inspiring. While leadership can be a somewhat ephemeral quality and one that is difficult to define, when it is lacking it is painfully obvious.
The word “governance” may be easier to define in technical terms encompassing as it does a complex system by which an organisation is controlled and operates. Through various mechanisms governance ensures that an organisation and its people are held accountable. After some thought I listed characteristics that are essential for good governance:
Accountability
Capacity
Systems and
Compliance
Reviewing this short list I am struck by the trite, even simplistic, nature of my list. In essence what many would regard as the accepted principles, the “101 of successful management”. Nevertheless, reflecting on my experience both during my career heading provincial health departments and thereafter investigating the functioning of departments and hospitals, deficiencies in these areas characterised those that, in many respects and to varying degrees, failed.
Organizations that flounder, stagnate or fall into decay lack both ethical leadership and good governance. This is a harsh reality of South Africa, most recently seen in the instance to which I alluded in the introductory paragraph and over the last decade which I have witnessed at first hand in health departments.
At the same time as being asked the initial question, I was asked what advice I would give to those in senior management to avoid the failings of others. Reflecting on the question, I came up with the following derived from my own, at times hard-won, on the job experience:
Define time bound leadership goals and objectives
Gather a competent, honest and stable team around you
Hold colleagues and employees accountable
Be intolerant of incompetence and dishonesty
Develop systems and structures to support management
Ensure the cost-effective utilisation of the available resources
Remain true to ethical “core” values … remembering that the “right” decision is not always the most popular.
In my book, Walking the Road of Healthcare in South Africa, I describe how I did just that and it was certainly not always easy. I have been criticised for an autocratic management style. In my defence, I would counter that when the department I headed faced a looming crises, as with the general of old leading his troops into battle, it was an asset. I do not deny that consultation and participative management are important but they become less so when faced by an impending threat that requires decisive and visible leadership.
In Government there is an additional factor and that is the interface between politicians and management, blurred in recent times in this country. Political leadership determines policies that reflect the political manifesto of the party in power. Managers implement policies set within the boundaries of the Constitution. Politicians cannot become involved in management, more especially the awarding of government contracts.This is the responsibility of management and bound by strict procedures and processes set down in law. When this is not the case, managers and politicians fail to remain true to the ethical core values of good governance.
A lot has gone wrong in government and sadly as evidence by recent events continues to do so. The solution however is simple, as simple as the few words and sentences that I have listed above. Ethical leadership and good governance are the cure if the patient is willing to take the medicine!
