The Road to Better Healthcare … we are at a crossroads.

Following my last post, I have been reflecting further on the failures in public health care in South Africa since 1994. In doing so I reread a book, “Yenza – a blueprint for transformation”, published in 1998 that has been on my bookshelf since then. I worked with the author, Dr. Piet Human, on several occasions during the early days of my time as Head of the Free State Department of Health. Read some twenty years later, the optimism, idealism and hope of the years immediately after 1994, reflected in the book, are poignant given what has transpired since.

The opening sentences of his book read as follows: “The present generation of South Africans (sic in 1998) bears an enormous responsibility for the future of this society. What we decide and do now will determine what kind of society we will become”

He quotes from a Robert Frost poem, “The Road not Taken”,

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I -
I took the one less travelled by,
And that has made all the difference.

He reflects in 1998 that although the opportunity was there, that “the probability of South Africa, and for that matter, any other society, taking the road less travelled, which would make all the difference was slight no matter how good our intentions”. What he wrote at that time has turned out to be sadly prophetic and not in the public health sector alone.

In my initial years heading a provincial health department I utilised much of the approach outlined in this book and while now reflected to a great degree in the defined planning processes of government in South Africa this was not available to me as a senior public service manager at that time. The book in some measure reflects a time capsule of the years immediately following the democratic transition in this country, but I would still recommend it as an interesting and useful read with many aspects that remain as relevant today as they were then.

I am totally in agreement with a sentiment expressed in the book that “true management skill is the ability to operationalise” … a sentence that is underlined in my copy of his book. In my experience we have developed a generation of many boardroom managers able to develop elegant policy documents and plans but who many a time fail woefully on the implementation of these plans. The boardroom is a comfortable place where managers, supported by others, are cocooned safely away from the harsh realities of over crowded, under-equipped and understaffed health facilities. The pressures of the COVID-19 pandemic have brought this fact sharply into focus in many instances.

I do not intend to paraphrase the book and will leave it to those who are interested to find a copy and read it for themselves. (Yenza A blueprint for Transformation Piet Human 1998 Oxford University Press) However, the Yenza approach (isiZulu – Do it) has always been at the core of my management style as a senior public servant. In similar vein, I once wrote, with a degree of frustration on a white board, as a message to my management team … “If is to be, it is up to me!” Rather than referring to myself I was encouraging my colleagues to assume a personal responsibility and accountability to ensure that which we planned and discussed actually happened!

Given the state in which we find public sector healthcare in South Africa the need is for managers to leave the boardroom and their offices, roll up their sleeves and become hands-on in their management style. With the advent of virtual meetings and “working” from home, the temptation to avoid visiting the frontline becomes even greater. But the frontline is where it happens and where things either go well or they don’t … and where it is important when they don’t, that there is intervention to ensure that they do. How is it that projects to add additional beds to hospitals were not complete during the first wave of COVID-19 and in some cases not even as the second wave crashed over the country? I can only assume that managers were either not aware of the lack of progress or relied on the reports of others which indicated that progress was being made when it was not. I sincerely trust that is was not that they did not care.

Management is not an easy task but it requires active involvement of managers in the business of the enterprise and cannot be achieved from afar. Organisations where management is at arms length are doomed to fail just as many areas of the South African public health sector has failed the communities that it is intended to serve. Organisations where accountability is not an immutable principle never to be breached and where the needs of the client are not paramount are doomed to a similar fate. South Africa has people with the talent and capacity to meet these challenges but what is required is for people of this caliber to be placed in positions of authority to ensure that the challenges are met. We find ourselves again at a crossroads both as a country and as a healthcare sector. This time let us indeed take the road less travelled … a road to success!

“Yenza!” Do it!