Health commentary

From policy pronouncements to implementation … a seemingly difficult path!

I was struck that many of the pronouncements by President Ramaphosa in the 2022 State of the Nation Address (SoNA 2022) are noble in intent but fail to address the mechanism by which policy pronouncements become a reality. While it is correct, as the President did, to allude to the consequences of State Capture and the COVID-19 pandemic that have set the country back, these alone cannot be the reasons why South Africa finds itself in the perilous position that it does today. In fact, from the Constitution down this country has some of the most progressive policies and legislation in the world but has failed in many areas to improve the lives of the majority in this country.

There are islands of excellence but taken overall the country is far from what was envisaged in the heady days that followed the democratic transition in 1994. Be it electricity, water, housing, education and health, amongst others, the outcomes have been dismal taken against the targets repeatedly set by Government in plans that are drafted according to prescribed formats both annually and with commencement of every 5-year political term.

The President is correct that the private sector and not government creates job opportunities and yet on many fronts it is government that since 1994 has created the very “red tape” that the President seeks to remove with the appointment of a “special advisor”, which has stifled private initiative in many spheres across the economy. Legislation that has been drafted by career bureaucrats who have often had little if any experience in the private sector which they seek to regulate. Similarly in the public sector well intentioned regulatory frameworks, drafted rather to restrict than enable, have had the unintended consequence of delaying rather than expediting implementation.

Having had the privilege to serve in various senior positions in Government in the South African health sector, I have experienced at first hand the frustrating self-inflicted delays which result from overly bureaucratic processes. My first experience was when in 1995 I, then new to government administration, naively indicated to President Mandela that a basic clinic in the Free State could be built in six months which in the end took over two years to complete at a cost far greater that in my opinion was justified by the end result1. President Ramaphosa had already indicated in the SoNA of 2021 that a massive roll out of infrastructure is a government priority and certainly this would be a major step toward creating jobs and advancing economic development in South Africa. It would be interesting to determine the actual progress achieved over the last year. While COVID-19 as with many other issues could be advanced as a reason for the slow progress, it cannot be the sole reason for failure to progress. Rather like that clinic in the Free State in 1995, the challenge is to move from the comfort of the board room to grapple with the harsh realities of practical implementation of policies and decisions.

Even when pressurised by the COVID-19 pandemic the construction of public health infrastructure proceeded in some instances with glacial slowness. While undertaking hospital visits during late 2020 between the second and third waves of the pandemic in this country, I found that wards intended to provide additional capacity for patients requiring hospitalisation with COVID-19 in the previous waves remained incomplete. Granted, the construction of health facilities is certainly not a simple matter, but with the urgency of the situation and the capacity that existed in the country surely progress should have been faster.

More recently, a fire at the large Charlotte Maxeke academic hospital in Johannesburg destroyed key areas of the hospital, but over 10 months later in the midst of the pandemic, the affected sections of the hospital remained largely unrestored. In a recent press conference to address criticism government officials still referred to plans to address the problems rather than implementation. Lack of progress, as in so many other areas, was blamed on possible fraud and corruption and differences between government departments. While this may be the case a question that should be asked is what were the officials responsible for managing the process doing while progress stalled? I fear if the truth be told they were sitting in their offices or possibly working from home sending emails or WhatsApp messages and not on the site monitoring progress, asking the difficult questions and taking decisions when it appeared that the progress was not what was expected. Or was it that these officials tasked with managing the process did not have the technical expertise to do so or worse still did not have the will to do so?

In my role as a consultant over the last six years subsequent to my retirement from the South African public health service, I have repeatedly come across situations for which the remedy was not necessarily more resources, although without doubt that would have assisted, but rather the fact that no one either had the capacity or the will to address a problem directly. Meetings even workshops had been held, in some instances other consultants prior to my involvement had already identified the causes of the problems and recommended remedial action, but those accountable had failed to act, failed to take decisions and ultimately failed to assume responsibility for the problem that faced them.

Management is not an easy task and often made more difficult by circumstances beyond the direct control of the manager concerned, but in my experience persistence and a willingness to move beyond offices into the “real world” of the services or as is often stated, the “shop floor”, go a long way to address a problem. When I visited a hospital in 2020, that shall remain nameless, it was very clear that senior management had not visited the facility recently, possibly if at all, and yet felt comfortable to describe the situation at the hospital from their offices in a “virtual” meeting, which bore no reality to the situation that I was experiencing at the facility itself. Needless to say the problems at the hospital that required decisions and meaningful intervention from those in senior positions was not forthcoming.

So if President Ramaphosa and Government are serious about fulfilling the many undertakings in SoNA 2022, ministers and especially bureaucrats must leave the comfort of their boardrooms and offices to experience reality at the coalface. Honest and capable officials and contractors must be appointed to undertake the work required and where necessary take difficult decisions to ensure implementation. Finally incompetence and dishonesty cannot be tolerated even when political and other allegiances are at stake. Only if these criteria are met will the ambitious aims of the massive infrastructure program as alluded to in the last two SoNA addresses and many others be achieved.

Speeches and policy pronouncements alone will not deliver what is expected and what South Africa desperately needs, but people with the determination to make things happen will!

Note: If there was any doubt of the challenge please read Mark Heywood’s article, “Gauteng’s ‘new’ R1.2bn Covid-19 ICU hospitals still lie abandoned, unfinished or underused” in the Daily Maverick of 25th March 2022.

  1. Walking the Road of Healthcare in South Africa pages 70-72 KC Househam 2021

A health professional with over 40 years of experience both as a clinician and a senior health manager in South Africa