Learning Lessons From The Past 25 years

Why are the public health services in a perilous state in many areas of South Africa? These shortcomings have been brought into sharp focus by the impact of the COVID-19 pandemic. It is true that in 1994 at the time of the democratic transition in this country, that the health services bore the scars of decades of racial segregation. Hospitals and clinics were divided along racial lines with facilities for patients of colour inferior to those available to white patients.

When I moved into health management in 1995 as Head of the Free State Department of Health, this difference was a stark reality. It was mirrored by the realities experienced by my colleagues managing education and housing in the Free State. Based on the Health Plan of the African National Congress (ANC) that formed part of the election manifesto of the ANC in 1994, a complete transformation of the health service into a non-racial, equitable and quality health service for all was envisaged. In the immediate years after 1994, strenuous efforts were made to develop health policy and a new National Health Act to give effect to the noble intentions of that election manifesto.

Moving forward 25 years, how has the situation changed? In many areas there have indeed been indeed been significant changes. Racial segregation in the State health services has been eradicated. Extensive immunisation programs and the largest treatment program for AIDS have been implemented albeit that the latter was unnecessarily delayed. New hospitals and clinics have been built and doctors and other health professionals engage in community service. However, there is now segregation of a different sort based on the economic status of the patient with glaring differences in many aspects between the care provided in the public health sector as opposed to that available to people with the financial resources to access private health care.

But is a disparate allocation of resources the sole reason for the challenges faced by the public health sector in South Africa and if so will the introduction of a National Health Insurance (NHI) be the solution? Undoubtedly, a more equitable distribution of resources would have a positive impact on the public health sector, but in my opinion it will not alone solve the challenges faced by the sector. In fact, the experience with the COVID-19 pandemic has highlighted the fact that the allocation of more resources alone has not improved the situation as expected.

The management of health services is a complex task, but South Africa has sufficient talented and competent people up to the task. So to return to my initial question why are the public health services in a perilous state in many areas of South Africa and why after 25 years has the progress been so slow to address the quality of health services provided to the majority of the population in South Africa? My experience both up until my retirement in 2015 as the Head of the Western Cape Department of Health and subsequently, which have only been reinforced by recent experiences related to the COVID-19 pandemic, leads me to the following conclusions related to management:

(a) There are indeed honest, competent and committed people capable of effectively managing the public health sector in South Africa.

(b) These people have not necessarily been appointed into the positions of authority that would enable them to effectively manage the health services.

(c) There are islands of excellence within the public health sector that are models for the development of a quality health care service.

(d) Factors other than competence have determined the appointment of people into key management positions in the public health service including party political allegiance.

(e) Political interference and a blurring of roles between the politicians and managers especially heads of departments has hampered effective management.

(f) Incompetence and incapacity is tolerated and not dealt with expeditiously through consequence management.

(g) Management instability has resulted when managers are suspended for prolonged periods of time or transferred from one position to another without addressing the reasons for their real or perceived failure to adequately fulfil the requirements of their appointment.

Whilst the quality of management is a key factor ensuring that the public health sector is able to meet the expectations of the communities that they serve there are other factors that influence the ability of the services to function effectively which amongst others include:

(a) An organisational culture that places honesty, integrity and the well-being of patients above all else.

(b) NO political involvement in any aspect of management but especially supply chain management.

(c) Clear lines of authority and accountability between management and organised labour.

(d) An affordable staff complement that has the appropriate balance of clinical and support services.

(e) Budgets allocated that are appropriate for the health services required within the limits of affordability accepting that available resources will never adequately address the need for health services.

(f) Systems and management structures that enable effective hands-on management of the available resources.

(g) Checks and balances within a combined assurance model to ensure that resources are utilised as intended and that fraud and wastage is limited to the maximum degree possible.

(h) Fit for purpose facilities in the most appropriate areas constructed and equipped to ensure accessibility to the health services required by the communities that they serve.

The above may seem to reflect “Management 101” to many, but the failure to address that which I have derived from my experience in the South African public health sector since 1995, both while an active manager and subsequently as a member of various ministerial teams investigating hospitals and health services, is in my opinion the cause of the maladies suffered by the public health sector in this country today.

We must learn from the lessons of the last 25 years and not repeat that which has failed to deliver what was promised in the ANC Health Plan of 1994.