I recently read about the two disasters affecting the American Space Shuttles. The Challenger exploded shortly after launch in 1985 while the Columbia was destroyed 20 years ago over Texas on its 2003 return to earth after a 16-day mission. In both cases an accident investigation board (AIB) was established to investigate the causes of the disasters and make recommendations to address what had occurred.
In the case of Challenger, a faulty o-ring on one of the solid rocket booster rockets, due to the abnormally cold weather during the launch, lead to flames leaking from the rocket igniting a catastrophic explosion in the shuttle’s external fuel tank destroying of the space shuttle. Vulnerability of the o-rings during cold weather launches of the shuttle had been identified previously but were ignored as an “acceptable risk” by management despite the concerns expressed by engineers. At an urgent meeting prior to the Challenger launch, an engineer was told by his manager colleague, “take off your engineering hat and put on your management hat.”
With Columbia debris from the external fuel tank damaged the heat resistant covering of the leading edge of the left wing during the launch. Although this was identified after the launch the damage was deemed of such a nature as to allow re-entry through the earth’s atmosphere. This proved not to be the case and as a result during re-entry superheated air progressively melted the aluminium structure of the shuttle’s left wing resulting ultimately in its destruction. In both cases all seven crew members on board died.
The detailed reports by the respective Accident Investigation Boards are available from the internet and contain a vast amount of technical data related to each of the events not relevant to this discussion. Considering the events of these decades old disasters, with the space shuttle program having been closed down in 2011 with the completion of the International Space Station in which the space shuttles played a major part, may seem strange. However, I was fascinated by factors identified in the organisational culture of the National Aeronautics and Space Administration (NASA) in both reports to have contributed significantly to what occurred. In the Columbia AIB report, the board indicated that “NASA’s organisational culture and structure had as much to do with this accident as the External Tank foam.”
Thinking, as I often do, about the impending introduction of National Health Insurance (NHI) in South Africa I found echoes of what was identified in the organisational culture and structure of NASA as contributory to the shuttle disasters to what is happening currently with government’s approach to NHI.
NASA is a large organisation that is described in the reports as “path dependent” referring to the “tendency for organizations to make decisions based on, and have their present state defined by their history.” Budgets initially were of less importance for the agency during the “space race” sparked by President Kennedy’s 1961 pledge to put a man on the moon. However, by the 1980’s while the directions of the agency remained unchanged, it was faced by major budget cuts that impacted on its ability to meet many of its goals and targets. As a result there was what is termed “normalisation of deviance” when pragmatic decisions were taken to accept certain deviances to meet these goals and targets. Driven in the case of NASA by budgetary pressures when nothing occurred as a result of these deviances, this became an accepted norm. In the case of the space shuttle, which in many aspects remained an experimental space vehicle, the pressure to meet budget pressures and delivery deadlines, resulted in the circumstances that lead to the two disasters.
By way of illustration, before the delayed launch of Challenger, concerns were raised by engineers to senior management at the company that manufactured the solid rocket boosters. However, due to albeit subtle political pressure for the launch to proceed due to the fact that then President Reagan was due to mention the launch and the presence of the civilian educator on the flight in his State of the Union address the next day, these concerns were ultimately overridden at a late night meeting prior to the launch.
Similarly after the Columbia launch, engineers were concerned that the debris had caused significant damage and requested a detailed photographic imaging of the damaged area and even a possible space walk to do so. Again, it appeared that NASA senior management “shut down” the imaging request believing that the foam damage did not pose a “flight safety risk”. It is noteworthy that the AIB found that even if the damage had been confirmed that undertaking a successful rescue mission of the seven people onboard the shuttle would have been unlikely. Nevertheless this option was not taken further with the tragic consequences that ensued.
How then does this connect with my thoughts regarding NHI? After reading the two AIB reports, I was left wondering what would happen if once implemented NHI does not fulfil the very idealistic goals that it sets? Many have raised concerns regarding the feasibility of what is currently contained in the draft NHI legislation given the parlous state of the South African public health sector. What happens if through its implementation there is system failure? Rather like the engineers advising NASA management, the policy makers and senior bureaucrats seem to be victims of “path dependency” and blithely appear to accept the “normalisation of deviance” as evidenced by the many reports of failures in the public health sector.
When NHI was initially conceptualised the budget realities that South Africa faces today were not as pressing. However the budget realties of South Africa are brushed aside with the oft quoted references to the stark discrepancies between funding in the public and private health sectors. A recent comment by a senior bureaucrat in the National Department of Health was that while there is clearly inadequate funding in the public health sector, that this could and indeed would be addressed by redistribution of the current resources available within both sectors i.e. robbing Peter to pay Paul. Are the consequences of this action clear from our current vantage point?
What if when NHI is launched and becomes a statutory requirement, the health system suffers a “critical system failure”? While currently there is a reasonably functioning private health sector, what if this too becomes grossly dysfunctional when incorporated into a national health service that is centrally administered and funded by a state entity, the NHI fund? What if as with many other public entities, the NHI Fund, which will control all funds available for healthcare in South Africa, becomes the victim of fraud and corruption? Financial, affordability and service standard challenges faced by the National Health Service (NHS) in the United Kingdom should, as at the NASA mission control decades ago, be warning signs to South Africa that should be heeded.
Who will launch the “rescue mission” for those citizens left stranded in a system failure? Given the nature and immediacy of healthcare, it could, as with the space shuttle disasters, be termed a “catastrophic system failure” with consequent morbidity and mortality amongst those dependent on the system. Like the engineers at NASA, it is concerning that warnings from many of those with insight into the operational and financial realities of the South African health system, and indeed of the country, are ignored and often categorised as reactionary. Are the policy makers listening to these concerns or are they being ignored due to political pressure to implement NHI? Are dissenters, as with NASA engineers, being told to take off their expert hats and put on their political hats.
No-one will argue that the South African health system is not in need of urgent reform, but as with the space shuttle, one should not confuse an experimental vehicle with a fully tested flight safe vehicle.
I would like to end quoting Professor Richard Feynman, a Nobel laureate, and member of the Challenger Accident Investigation Board referring to the fact that despite ignoring identified flight safety risks, various space shuttle flights had ended successfully.
“When playing Russian roulette, the fact that the first shot got off safely is little comfort for the next”
Food for thought and a heavy responsibility for those in positions of power and influence.
