Chapter 15
GOVERNANCE, LEADERSHIP AND MANAGEMENT
Beth Engelbrecht and Lucy Gilson
Introduction
Review of the first 25 years of democratic governance in South Africa highlights achievements in post-apartheid social and economic transformation, including health system successes (RSA, 2019). Improvements in life expectancy and maternal and child health outcomes in the 2014–2019 period demonstrate that collective action across provinces has been harnessed for positive results.
However, the 25-year review also notes a range of governance challenges. One health system experience has come to symbolise a ‘system of public governance that is broken’ (Kruger, 2019): the Life Esidimeni tragedy in Gauteng province. The 2015–16 death of 144 mentally ill patients due to neglect, after being transferred to unlicensed and ill-equipped non-governmental organisations (NGOs), is recognised as a failure of ethics, process and oversight (Freeman, 2018; Office of Health Ombud, no date). Supply chain and financial management irregularities across the public and private health sectors also indicate longstanding accountability failures and were further revealed in the 2020–21 COVID-19 responses (Auditor-General, 2020–21; Rispel et al., 2016). Meanwhile, for patients and their families, governance failure can be experienced as preventable death and disease, as well as drug shortages, long waiting times, and disrespect (Rispel et al., 2019). Such quality of care weaknesses have generated medical negligence claims that threaten the resourcing of the public health system (RSA, 2019; Rispel et al., 2019).
Contextual factors only exacerbated the challenges of health governance in 2015–20. The VUCA context (of volatility, uncertainty, complexity and ambiguity) included ‘austerity budgets’ that impacted directly on public health spending and staffing (Harding et al., 2020), service delivery protests in poorly served communities and growing economic inequality (Visagie et al., 2021). Meanwhile, conflict and change within the ruling African National Congress party had varied consequences within the health system. The COVID-19 pandemic was yet
another element of the VUCA context that demonstrated the impact of globalisation on population health across countries.
However, it is also important to acknowledge and learn from the pockets of positive health system governance experiences demonstrated in this period. In this chapter, we examine both the challenges and the positive experiences in order to consider how to strengthen governance to deliver better outcomes, especially for the most vulnerable. Our specific focus is on the processes and practices of governance, which are intertwined with leadership and management. These were identified as areas of weakness in a 2009–2014 review of South African health reforms (Levendal et al., 2015).
In section 2 we clarify the governance and leadership concepts that underpin the chapter and describe the key governance interfaces and relationships within the South African health system. Section 3 examines the experience of frontline (district-level) governance; section 4 focusses on provincial and national levels – considering how they impact on frontline governance in the multi-level health system; and section 5 summarises critical issues of leadership and management highlighted in earlier sections. Finally, section 6 draws out key conclusions for the future about the action needed to strengthen governance, leadership and management.
The chapter is founded on a set of 15 anonymous in-depth interviews and group discussions with senior health managers from across the country1 . It also draws on relevant, empirical research reported in peer-reviewed publications from the 2015–20 period, documentary material and media reports. International literature provides the conceptual foundations of the chapter.
The relationships and interfaces of health system governance
Governance actors and concepts
Globally, the critical role of governance in attaining health system goals has been recognised since the publication of the World Health Organization’s landmark 2000 Health Systems report (WHO, 2000). Understanding governance as ‘stewardship’ – a ‘function of a government responsible for the welfare of the population, and concerned about the trust and legitimacy with which its activities are viewed by the citizenry’ (WHO, 2000: 129) – this report also noted that governance ‘percolates’ across all levels of the health system. In a successor document (WHO, 2007), ‘leadership and governance’ was considered in relation both to health services and the wider action needed to tackle the social determinants of health. It was defined as ‘protecting the public interest by influencing all actors that impact on health, through an array of instruments, processes and “institutions”, such as other ministries, parliament, statutory bodies, NGO “watchdogs” and the “free media”’ (WHO, 2007: 24).
More than 20 years after the WHO 2000 report, understandings of health system governance are still evolving in response to experience and ever-changing health and socio-political contexts.
1 This work received ethics clearance from the University of Cape Town, Faculty of Health Sciences Human Research Ethics Committee (HREC) REF 265/2021.
Governance, leadership and management
Attention has been paid, first, to three sets of critical health system governance actors (Bigdeli et al., 2020):
(1) Policy-makers – at central and sub-national levels, including the legislative and executive branches, elected politicians and professional civil servants;
(2) Health service providers – both public and private (for profit and not for profit), clinical and non-clinical, labour organisations, professional bodies, health professional training organisations and more;
(3) People – citizens, residents, patient groups, NGOs and civil society organisations (CSOs), and the media.
Recognising this array of actors, the early WHO frameworks have been criticised for seeing governance as an internal function of government, paying too much attention to national ministries of health, and ignoring other governance actors (Abimbola et al., 2017).
Second, a relational view of governance has gained prominence, focused on the formal and informal rules that shape the relationships between actors, through which governance is exercised (Abimbola et al., 2017).
From this perspective, governance, especially in decentralised systems, is acknowledged as a multi-level and polycentric process, rather than solely the function of the national sphere of government. Policy change, for example, entails complex processes of interactions between the centre and periphery, rather than being a centrally-controlled, top-down process (Gilson et al., 2017a). Whilst ‘dependent on arrangements set at political or national level’, governance must ‘be operationalized by individuals at lower levels in the health system’ (Pyone et al., 2017: 720). The everyday practice of decision-making is, consequently, a critical governance concern. Actors such as mid-level managers, local-level managers and frontline health workers are acknowledged to play key governance roles, alongside social actors, such as community actors, CSOs, trade unions and professional bodies, and local political actors. Their decision-making is influenced both by governance hardware (e.g. governance structures and the delegations of formal decision-making power) and by the software of personal values, communication practices and power or trust relationships (Abimbola et al., 2017; Gilson et al., 2017).
Third, whole-of-society (WoSA) and whole-of-government (WoGA) approaches have been recognised as key to tackling ‘wicked’ problems, such as disease outbreaks, growing economic inequality and climate change. Kickbusch and Gleicher (2012) argue that the interdependence and complexity of these problems demands networked and system-wide responses in which governance is ‘co-produced’ by multiple actors. Rather than focusing only on the governance of health care, it is critical, then, to think about governance for health – that is, as ‘the attempts of governments or other actors to steer communities, countries or groups of countries in the pursuit of health as integral to well-being through both whole-of-government and whole-of-society approaches’ (Kickbusch & Gleicher, 2012: vii).
Such approaches demand what has been called collaborative governance: ‘the processes and structures of public policy decision-making and management that engage people constructively across the boundaries of public agencies, levels of government, and/or the public, private and civic spheres in order to carry out a public purpose that could not otherwise be accomplished’ (Emerson et al., 2012: p.3). Although influenced by contextual factors, such governance is enabled by principled engagement among actors, shared motivations (for example, mutual trust and shared commitment), procedural and institutional arrangements, incentives to engage and leadership.
Collective action for health and well-being, moreover, requires approaches to leadership that move beyond the dominant command and control managerial styles of public sector bureaucracies. Systems leadership is, instead, a ‘collective form of leadership’ concerned with ‘the concerted effort of many people working together at different places in the system and at different levels’ (Bigland et al., 2020). It entails both vertical and horizontal governance relationships. Within health care it embraces staff in all levels, professions and sectors, as well as service users and carers (Vize, 2016). Exercising such leadership requires both the individual skills that ensure actions are adapted to issue and context, as well as a wider authorising and enabling system environment (Bigland et al., 2020).
The governance relationships of the South African health system
With these concepts in mind, Figure 15.1 presents a detailed view of health system governance actors and relationships in South Africa, considering those of most importance in the everyday practice of governance 2015–20 (drawing on interviews). It highlights, first, the multi-level and polycentric nature of governance. The three levels of public governance (national, provincial, local) are integrally connected, as the South African state is a unitary, albeit quasi-federal state, in which health is constitutionally defined as a ‘concurrent’ (shared) responsibility across levels. The current funding flows to the public health system reflect this shared responsibility. With oversight from the Financial and Fiscal Commission, the National Treasury allocates resources directly and separately to provincial and local governments, which then determine budget allocations to health activities and the other functions for which they are responsible. At the same time, the National Department of Health (NDoH) funding for specific purposes is through conditional grants to Provincial Departments of Health (PDoHs). Some PDoHs also enter into service-level agreements with large metropolitan municipal authorities (in the local sphere), providing resource support against clearly defined health service targets.
Figure 15.1 The dominant relationships of everyday governance practice within the South African health system (2015–2020)
Governance, leadership and management
The figure also reveals four other overall elements of everyday health system governance practice. First, given their particular and strong influence in the South African health system, ‘oversight actors’ (yellow boxes) are added as a category separate from ‘policy-makers’ (black and blue boxes). These include international organisations (e.g. WHO), the legislatures at national and provincial levels, specific national government actors, such as the Auditor-General’s (AG) office, established in the Constitution, and the Office of Health Standards Compliance (OHSC). Organised Labour (trade unions) is also included as an oversight actor, although outside government. Second, across levels, most relationships (black and yellow lines) are those among Bigdeli et al’s (2020) ‘policy-makers’, considering political, public service and oversight actors. This suggests that governance is primarily seen as an internal function of government and the public health system in South Africa. Third, few formal relationships (pink lines) with social actors (the ‘people’ actors, pink boxes) exist, although provincial- and district-level oversight bodies do include some that offer spaces of engagement with such actors (e.g. clinic committees and hospital boards). Fourth, governance relationships with public ‘health care providers’ (solid green lines) are most important at district/provincial level, and across levels there are, currently, few formal relationships with private sector actors (dotted green lines).
Governance at the frontline
The District Health System (DHS) represents the base and frontline of the South African health system, with responsibilities for effective and equitable service delivery and the development of a District Health Plan (National Health Act, Act 61 of 2003). As Figure 15.1 shows, the DHS lies across the provincial/local government interface, and health district boundaries are contiguous with municipality boundaries. This section discusses the governance relationships of, and everyday governance practice within, the DHS – illuminating both challenges and pockets of positive experience.
The District Office (DO) manages a wide span of governance relationships, which can be considered in three groups (Bigdeli et al., 2020):
1. Policy Accountability relationships – Within the DHS the key concern is policy implementation, and relationships with political leaders and health managers across governance levels are particularly important in current practice, in contrast to those with other government sectors. Relationships between the DO and politicians are, in principle, mediated through the PDoHs, with respect to the Member of the Executive Council (MEC) for Health (provincial Minister of Health), and through the municipality, with respect to mayors and municipal councils. In practice, however, district managers may find themselves engaging with political leaders at all levels, including ward councillors, around community-level health and health care challenges (interviews). Although shielded by the PDoHs from the full weight of their demands, the DO and health facility staff also interact with two sets of national-level actors: staff from the NDoH and national oversight organisations (specifically, the AG’s Office and the OHSC).
2. Service Provision relationships – The DO, through sub-district offices, has governance responsibility for public health service delivery across all provincially-managed facilities, from the district hospital to community-based services offered by community health workers. It must also coordinate with higher-level hospitals and the Emergency Medical Services (EMS), for example. The governance relationship with local government (municipalities) for service provision is important, as municipalities are responsible for environmental health services (National Health Act, Act 61 of 2003) and may also manage other PHC services. The DO sometimes also engages with private health care providers as well as, in some settings, higher education institutions involved in research and health professional training. Finally, health facility managers engage with organised labour groupings in employer–employee negotiations, with support from district managers as needed.
3. Public Accountability relationships – Relevant district-level relationships include interactions between the DO and the provincial legislature, which has oversight over all provincial activities. Where functional, district managers may also interact with the District Health Council (DHC) in the development and implementation of District Health Plans to meet the needs of communities (National Health Act, Act 61 of 2003). At facility level, District Hospital Boards and Clinic Committees are assigned governance roles. However, a 2017 survey found that only 17.9% of 168 clinics sampled across the country had functional committees (RSA, 2019). Wider research illustrates that the functionality and influence of clinic committees is undermined by legislative weaknesses, skills’ limits, facility manager and ward councillor attitudes, limited resources and lack of recognition (Haricharan et al., 2021a, b). Finally, there may be relationships between the DO and NGOs/ community-based organisations. Some are public accountability relationships. For example, Ritshidze, a community-led monitoring system developed by organisations representing people living with HIV/AIDS, is collecting facility-level data on critical aspects of primary care experience in facilities spread across provinces. It uses the information collected to engage community members and clinic staff in generating solutions to the problems identified, engaging also with clinic committees, provincial and national health managers, as well as conducting wider advocacy work (https://ritshidze.org.za). However, when NGOs are contracted to support service provision, they are more appropriately categorised as service delivery governance relationships (Mukinda et al., 2020a; Nxumalo et al., 2018a; Orgill et al., 2021).
Managing these relationships is challenging in practice. Although there are excellent examples of district managers, inadequate delegation of key financial and human resource management decision-making authority may constrain their work. In some provinces, managers may not be appointed at commensurate levels of seniority within the public service or have the necessary skill sets (interviews). Empirical studies of experience across the country (such as the Gauteng experience around emergency obstetric care, see Box 1 below) demonstrate that district-level governance relationships can also be problematic (e.g. those with organised labour; see also: Fana & Goudge, 2021; Nxumalo et al., 2018a, b; Mukinda et al., 2020b).
Box 1: Emergency Obstetric Care (EmOC) challenges at district level, Gauteng province (Source: Thwala et al., 2019)
Background: EmOC services were managed by the PDoH, through different directorates, and clinical governance was supported by the District Clinical Specialist Team, managed by the NDoH.
Service delivery challenges:
• Limited communication and coordination of EmOC services: routine district management team meetings did not include all relevant health managers
• Weak provider accountability: indicated in late arrival at work and absenteeism
• Resource shortages: inadequate drugs, ambulances and infrastructure
• Staff shortages at primary care level: led to delays in attending to patients, under-qualified staff members dealt with patients
• Quality of care weaknesses: patients queueing for obstetric emergencies and unsatisfactory patient monitoring turned smaller complications into emergencies; patients experienced poor maternal and neonatal outcomes leading to medico-legal challenges
Underlying governance, leadership and management weaknesses:
1. At district and sub-district levels
• Budget constraints impacted on staff recruitment and led district managers to appoint senior staff into acting positions, limiting their authority and commitment
• Labour organisations frustrated staff disciplinary processes, discouraging managers from holding staff accountable
• Vacant posts, including CEO posts, took long to fill because of slow provincial approval processes
• Budgeting and expenditure data were not sufficiently disaggregated to allow efficienct EmOC management
2. At higher governance levels
• EmOC was not adequately funded by national or provincial government, despite being a national policy directive
• Inadequate communication between PDoH and NDoH managers and lack of clarity over managers’ roles led to duplication of efforts
• Unstable PDoH leadership, with three acting heads of department over a five-year period, led to changing EmoC priorities over time, undermining implementation
• Weak accountability of the provincial procurement office led to stock-outs of drugs and life-saving equipment
In addition, governance challenges at the district level often stem from higher levels. This may reflect the dominance of vertical lines of accountability within the public system – to the PDoH, NDoH, including health programme managers, to oversight actors such as the AG’s Office and OHSC, as well as to key provincial/local government political actors. A rich body of recent research reports experience from the frontline and makes clear the continuing presence of ‘the inverted pyramid’ of power within the public health system (see Figure 15.2; Gilson & Daire, 2011). At every level actors feel subject to the top-down, command and control exercise of power by those at higher governance levels. This exercise of power translates into huge reporting and meeting burdens that undermine district support for service delivery (for example, 19 maternal and child health accountability mechanisms were identified in one district, involving 22 reporting meetings a month: Mukinda et al., 2020a; see also Gilson et al., 2017b). In addition, the top-down exercise of power has generated a culture of compliance to audit demands (Mukinda et al., 2020a; Nxumalo et al., 2018a; Scott & Gilson, 2017)
and a climate of fear, blame and responsibility shifting. The knock-on consequences include punitive personal performance processes (Nxumalo et al., 2018b), and a failure to report problems when identified (which might in turn lead to medico-legal claims: Thwala et al., 2019). Vertical accountability processes, therefore, limit the development of organisational quality of care improvement strategies and prevent proactive consideration of how to strengthen public accountability (Mukinda et al., 2020a). They undermine policy implementation by stifling the local creativity, innovation, and frontline agency needed to implement policy changes and meet local needs (Kawonga et al., 2016; Nxumalo et al., 2018a; Scott & Gilson, 2017). The culture of avoiding responsibility and accountability has, finally, been identified as underlying the Life Esidimeni tragedy (Kruger, 2019).
Figure 15.2 The inverted pyramid of power in the South African health system, 2015–20 (adapted from the Local Government and Health Consortium, 2004)
Despite the challenges, there are positive district-level governance experiences. Four examples are presented in Boxes 2–5, focusing on service delivery (quality improvement in Limpopo and Mpumalanga, and hospital leadership in the Eastern Cape) and intersectoral action (in KwaZulu-Natal and the Western Cape). For governance of health, these experiences highlight the importance to service provision governance of relationships between clinicians and managers for (Box 2), and between primary care facilities and hospitals (Box 2 and 3). Box 3 also highlights the value of constructive relationships with the hospital boards that serve as a bridge to communities (see also: Nxumalo et al., 2018a; Mukinda et al., 2020b; Schneider & Nxumalo, 2017). Collaboration across government sectors is, meanwhile, central to governance for health. However, multiple relationships are entailed in such collaboration – cutting across the three sets of governance actors and the multiple governance levels (Box 4 and 5; van Rensberg et al., 2018; Marais & Petersen, 2015). Purposefully crafting new institutional arrangements to support and manage these relationships is essential (Box 4 and 5).
Box 2: Improving maternal, neonatal and child health (MNCH), experience from Mpumalanga and Limpopo provinces (Source: Schneider et al., 2020)
Background: A new governance mechanism for MNCH care was implemented in two districts to improve outcomes, with no additional budgetary resources. An experienced external facilitator supported the districts through regular visits, deliberately making connections with other district-level initiatives and key persons, such as the District Clinical Specialist Teams (DCSTs).
After three years there was a steep drop in cause-specific under-five mortality in both districts and maternal mortality had halved in one of them. Many frontline actors felt that the monitoring and response unit (MRU) was a key contributor among the various relevant interventions implemented.
Key features of the MRU:
• Principles: a systems approach, comprehensiveness and a focus on leadership and governance
• A ‘triangle’ of actors worked together across community to district levels: managers as ‘drivers’, clinicians as ‘experts’, and information officers as ‘navigators’
• A monthly meeting brought a wider range of district and sub-district actors together to define and implement priority actions for achieving the MNCH targets, using a set agenda for reporting, analysis and response to MNC deaths
• A system of 24-hour reporting and 48-hour review of MNC deaths by district programme managers and the DCST, who consequently supported frontline staff to implement agreed solutions
Governance relationships and practices supporting achievements:
• A collective vision for MNCH allowed alignment of all actors towards shared goals, and collective action across levels was also driven by interdependence and shared responsibility
• New relationships supported implementation, e.g. between PHC actors and district hospitals at sub-district level, between sub-district and district managers, between units within hospitals, and between clinicians and managers
• Collaboration between hospital heads and senior medical/nursing managers was key; nursing managers and dieticians remained in post even as senior managers and doctors
• Mid-level managers at the district and sub-district levels were purposefully engaged in driving change, rather than bypassed by higher-level programme managers
• A systems-level perspective was developed through multi-level teamwork, so staff could see the link between preventive actions and hospital outcomes
• A new culture of engaging with clinical guidelines was established, increasing ownership and accountability of managers and professionals, and intensifying in-service training
• New systems of meaning around data and actor roles were constructed that supported implementation: staff better understood the rationale behind data collected; senior clinicians better understood their public health and governance roles
• National-level endorsement and engagement (through the facilitator) increased the credibility of the MRU
• Supportive problem-solving by the DCST and programme managers increased staff willingness to report and account for deaths
• The external facilitator, specifically: engaged district, sub-district and facility actors in a process of collective sensemaking, and developed supportive relationships with actors outside the district; built consensus on problems to be prioritised and appropriate responses to them; and employed metaphors to provide the rationale for collaboration between PHC and hospitals
Box 3: District hospital leadership in the Eastern Cape (Source: Mathole et al., 2018)
Background: Two district hospitals in the Eastern Cape province, both located in the same district, with largely similar resources, caseloads and patient demographics, were compared. Over the previous seven-year period, perinatal mortality had fallen more significantly in one of the hospitals. A supportive yet firm leadership style characterised this hospital, in contrast to the more traditional, hierarchical leadership practices in the other hospital.
Factors enabling stronger performance in better performing hospital
1. Enabling leadership practices:
• Staff considered senior managers as supportive, approachable, friendly and firm
• Hospital managers valued and consciously assembled diverse staff teams, emphasising ‘listening’, open and continuous communication
• Staff contributions were valued and good suggestions implemented and acknowledged, empowering staff and enhancing trust among them
• Managers were proactive and innovative in problem-solving
• Senior staff made frequent and supportive ward supervision visits
2. Organisational practices and culture:
• A collective approach to finding organisational solutions was adopted, with all staff invited to meetings (including support staff, e.g. cleaning staff).
• An inherent culture of learning from mistakes existed, recognising that learning is part of professional development, and a continuous process – this supported a willingness to discuss mistakes and problem-solve for them
• Meetings were used as learning platforms, in which a collective and systems approach to accountability was established, without blaming individuals
• One adverse event was discussed at each perinatal meeting: staff were broken down into small groups to discuss mistakes made and lessons learnt; feedback sessions included in-service training on relevant topics
• Scheduled meetings always occurred and meeting minutes were actively used to increase accountability: actions and responsible persons were noted; at subsequent meetings, feedback was given on progress made on previous action points
• Good performers were acknowledged, while those who had performed less well were encouraged and given suggestions for how to improve responses to challenges
• Data were used in meetings to identify areas that needed improvement and to track action; they were (well) captured, and graphs were created and publicly displayed
• Staff were proactive in reporting low levels of stock, with one staff member dedicated to coordinating procurement of equipment for all departments
3. Wider engagements:
• Hospital managers sustaining relationships with all key partners working in maternal health in their catchment areas
• Hospital managers actively involved their board: using board members to bridge across sectors: to youth, traditional leadership, business and local community; board members also lobbied at provincial level to help speed up otherwise slow bureaucratic processes
• Hospital managers frequently engaged with district managers to address hospital challenges, and also directly contacted provincial/ national managers, bypassing district/ provincial levels, to tackle problems, e.g. to unfreeze posts or order drugs/equipment
Governance, leadership and management
Box 4: The Western Cape Provincial Government Whole-of-Society Approach (WoSA), 2016–20
The WoSA approach is a place-based collaborative governance approach, initiated in 2016, that mobilised local, provincial and national government actors, as well as civil society, business and community-based organisations to collaborate in tackling the multiple and multi-generational determinants of vulnerability (‘the stories of the lives of people’).
Activities:
• Working in four learning sites, a trusted, independent, external facilitator assisted in building relationships between government/sectoral actors, whilst data from various sectors were integrated to create a shared vision and monitoring frame of improving dignity and quality of life along the life-course
• A WoSA coordinating committee in each learning site was supported by cross-sectoral working groups to address specific community needs, engaging community-based workers in community interactions. For example: in one site the ‘first 1000 days’ (conception to two years of age), including early childhood development, was the unifying target. Two wards were selected for more intense collaborative action with the approval of the mayoral council which included ward councillors. Members of the WoSA working groups addressing particular issues accompanied the Integrated Development Plan officers during scheduled evening sessions to listen to community inputs, and supported proactive communication with communities. They also engaged with the ward councillors, who, together with community health workers, were offered training to support them in their community engagement role
Achievements:
• Community-level impacts were observed from reports on local priorities (tackling community safety and policing concerns, infrastructural and refuse removal problems and spatial development and early childhood development)
• Lessons about how to work differently across sectors and levels of governance informed new activities, initiated in 2021 across multiple geographical areas, to tackle the critical issues of unemployment and community safety within the province
Enabling governance factors
1. Authorising and accountability
• The Premier and extended Cabinet authorised and held departments, political leaders, and municipalities accountable for intersectoral engagement
• The Cabinet-endorsed PSPs of 2014–2019 and 2019–2024 enabled intersectoral and intergovernmental collaboration, as did the Integrated Development Plan process, a policy imperative for municipalities
2. Governance mechanisms and decision-making practices supporting WoSA teams
• A politically-led steering committee of clustered departments developed focus areas for WoSA implementation, indicators of improvement, and action plans, and reported to Cabinet at six-monthly intervals
• The PDoH played a leading role, as steward of provincial population health and well-being
• At municipal level, the mayoral executive committee held the municipal manager, WoSA coordinating committee and ward councillors accountable for improvement work in communities
• At local level, decision-making entailed listening to community voices and using evidence in the identification of priority places and levers for impact
3. Leadership practices and capabilities enabling intersectoral collaboration:
• Leadership behaviours that reflected the values of respect, humility, cultural sensitivity, being responsive, collaboration, learning, adaptiveness, serving the goals of others
• Leadership actions that demonstrated support for investing in partnership development towards shared goals that address community needs, rather than pursuing sectoral interests, as well as for co-creation, joint learning and authorising frontline staff to network outside their organisations – including with communities
• Leadership mindsets that support comfort with uncertainty, and the disruptive realities of community dynamics and innovative approaches, whilst important leadership practices were supporting collective sensemaking and applying systems-thinking approaches in identifying the interconnected, root causes of vulnerability and community challenges
Challenges
• The shift from vertically-directed governance to horizontal governance interactions was problematic, given differing levels of decentralised autonomy and authorisation for decision-making across departments, and the vertical lines of accountability for annual performance plans, and their auditing by the Auditor-General
• Poorly aligned strategy and policy across provincial departments, and fragmented provincial data management
• Political cycles and election processes across government levels (local, provincial and national) stall progress towards intersectoral collaboration over time
Box 5: Operation Sukuma Sakhe (Sources: Interview material; Ndlovu & Msweli, 2016; Phakati, 2019; Tshishonga, 2016)
Background: Operation Sukuma Sakhe (OSS), meaning Stand up and Build in isiZulu, is a multilevel, multisectoral governance approach implemented across KwaZulu-Natal province since 2009 in response to a directive of the South African National Aids Council. Over time, OSS has been institutionalised and expanded to address various social determinants of health, as well as, most recently, the COVID-19 vaccination programme. Overall, OSS seeks to leverage the skill of various sectors and com munities to address community-level challenges impacting on health and well-being.
Health care delivery is also strengthened through the OSS, e.g. the PHC outreach programme is strongly aligned with the ward war room, ward councillors support clinic and hospital advisory boards, ensuring that members on these structures are of good standing. However, the District Health Council stands separate from the district-level OSS structure, as it focuses only on health and oversees the District Health Plan.
The approach:
• The principal design feature is ward-level localised governance, involving all sectors and civil society actors in a ‘war room’
• The ward councillor acts as the war room champion, and an administrator appointed by the Cooperative Governance and Traditional Affairs Department supports the councillor, also coordinating field workers within the local community (also accountable to their line departments)
• The field workers conduct home visits to explore household needs, and channel to relevant government departments for action
• District health managers nominate health ward officials, who account to the war room on progress in tackling problems on a weekly/two-weekly basis and also report back to the district health managers
• Ward-level activities are reported to the District HIV/AIDS/TB Council, which is co-chaired by the district health manager and a representative of civil society, and supported by the district health manager
• The district mayor, supported by the district health manager, reports to Cabinet meetings, alongside the Health HOD
• the provincial Cabinet regularly visits 20 wards in one district once per month to obtain feedback from ward councillors and to meet directly with communities to obtain feedback about delivery issues
These experiences all demonstrate how the forms of governance and leadership that focus on building relationships create collaborative cultures of reflection, problem-solving and action (Boxes 2–4). Such cultures enable strengthened governance practices – such as teamwork within and across levels of care, coordinated action across governance interfaces and horizontal accountability to peers and the public (Nxumalo et al., 2018a, b; Mukinda et al., 2020a; Scott & Gilson, 2017). Meetings were identified as particularly important spaces of collaborative problem-solving, also allowing proactive engagement with available data (e.g. Box 2 and 3). Table 15.1 summarises wider district-level experiences about how routine meetings can become spaces that bring people together across hierarchies and silos in order to collaborate around shared goals. Small changes can have significant governance impacts (Gilson et al., 2020; Orgill et al., 2021). Governance,
Enabling governance relationships and practices
• The provincial premier mandates the OSS, and holds district council mayors and Cabinet MECs accountable within it
• A cascade of accountability pivots around district council mayors, who receive feedback from ward councillors through local municipalities and are supported by the district health managers
• The ward councillors monitor the extent to which community problems have been resolved, reporting to district councillors
• Despite the frequency of elections associated with the political cycles across local, provincial and national and government levels, the continuity of the OSS system has been sustained over time due to entrenched administrative processes
Challenges experienced
1. System and structural capabilities
• War room attendance is inconsistent, given the range of competing demands, and variable across departments, as not all have staff located at this level
• The large number of meetings and linked reporting demands pose a considerable administrative load and has impacted on time to deliver care
• There is an imbalance between reactive work and the systematic, intersectoral actions of system strengthening that tackle the root causes of ill-health and can generate health and social system resilience
• A particular challenge is the speed with which interventions need to be implemented which negatively impacts on the required administrative processes, as well as equity and fairness in service delivery
2. Leadership capabilities
• The functionality of war rooms depends on the calibre and leadership capability of ward champions, which is uneven
• The cascaded accountability mechanism also relies on leadership capabilities, which are variable, to coordinate a range of actors (politically and administrative), and make sense of a large set of information
Table15.1 Strengthening governance through new approaches to managing meetings (Sources: Gilson et al., 2020; Orgill et al., 2021)
Contextual changes to support meetings
• Institutionalise use and engagement with data to develop sensemaking skills, to diagnose problems, monitor progress and support forward planning
e.g. by creating new routines to produce reports covering core indicators which are shared prior to the meeting and expected to be read by all
• Develop a systems approach by including NGOs, community representatives and all service providers in district management team meetings, and extending the planning processes to longer than the usual one-year cycles
• Recognise the power of words e.g. change the names of existing meetings to orient attention, encourage a proactive focus and break with historical associations
Meeting management practices
• Establish key principles to drive meetings (e.g. be positive; value people; listen to others and ask questions which allow others to contribute; share own challenges)
• Streamline meetings to encourage more proactive engagement (e.g. by introducing a focused agenda, oriented to the district’s core functions; managing time proactively by allocating a set time for each agenda item and a dedicated time-keeper)
• Encourage participation and share power (e.g. by rotating the chair of the meeting to share power and responsibility; asking challenging questions and using ‘rounds’ where each person present responds to a common question)
• Create opportunities to share ideas/knowledge and to learn from and challenge one another (e.g. by adapting existing meetings to allow space for team work among health facility managers, and with col leagues working in support functions; discussing what enables and prevents progress and developing collective responses to challenge)
• Strengthen collective sensemaking through encouraging investigation of problems
(e.g. by collecting information ‘on the ground’ and engaging with solutions; presenting problems and proposed solutions at meetings, with regular follow-up reports of progress on the issues; presenting resolved problems to build capacity and provide for collective learning)
• Develop practical habits in meetings to support strong, positive organisational relationships and diffuse power (e.g. by using information and data purposively; allowing reflection in pairs and small groups on issues and problems)
‘Mid-level’ DHS managers play critical roles in creating new cultures, mediating top-down imperatives and bottom-up realities. Through their values, behaviours and actions these managers support frontline providers to re-orient their work better to meet the needs of their populations (e.g. Box 3; Gilson et al., 2020; Orgill et al., 2021). Such managers must be empowered, skilled and have sufficient confidence to practice governance differently. Beyond knowledge of public sector procedures and processes, they need the leadership skills required to: navigate relationships; challenge rules upwards as appropriate, even whilst respecting vertical reporting and accountability; instil new ‘just’ cultures, of collective inquiry and mutual accountability; encourage data and evidence use; and motivate and enable those they work with and nurture leadership in others (Boxes 2–4; Gilson et al., 2014, 2017b, 2020; Mukinda et al., 2020b; Nxumalo et al., 2018a, b; Orgill et al., 2021; Scott & Gilson, 2017). Such skills are also important in supporting policy implementation, such as for mental health care (van Rensberg et al., 2018; Marais & Petersen, 2015), going to scale with CHW programmes (Schneider & Nxumalo, 2017) and integrating HIV monitoring within the DHS (Kawonga et al., 2016).
Governance,
Governance at provincial and national levels
The multi-layered nature of health system governance means that provincial and national governance experience impacts on frontline governance. This section discusses in more detail the governance challenges at higher levels that undermined frontline governance in the 2015–20 period. It also highlights experiences that demonstrate how governance at higher levels could be strengthened to support relational governance at the frontline.
The district–province governance relationship
A critical influence over all aspects of provincial health governance is widely acknowledged to be the specific relationship between the MEC and Head of Department (HOD), i.e. the ‘executive interface’ (Public Service Commission, 2019). Instability in this relationship undermines service delivery and policy implementation across levels (see Box 1), as well as the long-term visions required for provincial health system development.
Several interviewees noted that the division of powers between these two positions is a ‘structural design flaw’ in governance. Although the HOD is the formal accounting officer, responsible for financial management, the MEC is responsible for the internal organisation of the department and has power over human resource decisions (Public Service Commission, 2019). Despite expectations, MECs have often not delegated these powers to the HOD and, in some instances, have even been involved in appointments at the lowest levels. This blurring of political and administrative decision-making (commonly called ‘political interference’, and rooted in political party loyalties) is a key governance challenge (interviews), only compounded by regular turnover in MECs and HODs. Several interviewees suggested, however, that HODs must develop the political skills to navigate their relationship with the MEC – paying attention to political goals and imperatives and holding fast to public sector regulations and long-term health system visions. Shared health system visions between the MEC and HOD are also important in supporting governance action. Further, PDoHs must work proactively to strengthen and deepen health system leadership at district and hospital level, as a foundation for leadership stability. Interviewees hailed the Western Cape PDoH, for example, for its smooth HOD transitions in 2015 and 2020.
Two other provincial relationships that impact on the DHS are those between the PDoH and provincial and national treasuries and between the PDoH and AG’s Office. Both can challenge frontline governance, as described earlier. However, constructive relationships allow PDoHs, for example, to clarify the context of health care as the AG’s Office conducts audits and, in the case of treasuries, support collaboration around budgets and budgeting. Positive relationships can both buffer demands on the system and support system development (interviews).
Current experience suggests three other areas of action to strengthen provincial support for district governance. First, the exercise of facilitatory and participatory leadership approaches at higher levels is needed to enable similar leadership at DHS level. Such approaches support frontline actors to modify and adapt policies, to experiment and innovate, to better meet population needs (Nxumalo et al., 2018a; Mukinda et al., 2020b; Scott & Gilson, 2017). Although holding frontline managers accountable for the responsibilities assigned to them remains important, PDoH managers might therefore best be seen as facilitators of the frontline (Box 2), role modelling leadership practices that are enabling (Box 4).
Second, intersectoral collaboration at district and local levels requires provincial authorising mandates, provincial-level collaboration across sectors and provincial–municipal government engagement (Box 4, 5). The provincial premier’s leadership is crucial in securing provincial cabinet support for WoGA and WoSA initiatives. A new mindset is also required so that PDoHs become stewards of population health and support investments of time and resources beyond the formal boundaries of health care (Box 4, interviews). However, as shown in Figure 15.1, the governance relationships and practices important for WoGA and WoSA are not fully prioritised in everyday governance practice at the frontline, including relationships with ‘people’ actors, such as CSOs. Boxes 4 and 5 highlight that structural challenges to intersectoral collaboration within the public sector must be offset through provincial action.
Third, improving health care quality at district and primary care levels requires adequate delegation of decision-making power and clarification of organisational roles, relationships, responsibilities and accountability lines (Box 2, 4 and 5; Kawonga et al., 2010; Moosa et al., 2017; Schneider & Nxumalo, 2017). A 2015 WC DoH departmental policy statement, for example, clarifies and aligns roles and responsibilities across the PDoH in order to improve staff accountability and strengthen service delivery, emphasising the inter-connectedness of different components of the provincial health system (WCG:H, 2015: 3-4). Although other provincial health departments have also sought to revise their overall governance framework and structures in order to strengthen the DHS for improved service delivery they have faced political challenges (interviews).
The provincial–national governance relationship
The relationship between PDoHs and the NDoH is central to health system governance nationwide (Figure 15.1). The National Health Council (NHC), chaired by the national Minister of Health, is the mechanism for cooperation among political heads across levels/provinces. It must advise the national minister on, for example, policies, proposed legislation, norms and standards, and integrated plans for the country (National Health Act, Act 61 of 2003). The NHC has established the NHC Technical Committee (NHC-Tech, chaired by the NDoH Director General) as its advisory body, also serving as the main governance interface between PDoHs and the NDoH senior management team. Draft policies, strategies, performance and planning matters, underpinned by sound technical work, are intended to be considered in its quarterly meetings. Technical advisory sub-committees and ad hoc committees of the NHC-Tech also conduct technical work, involving provincial department staff and technical experts, and making recommendations to the NHC-Tech.
In practice, however, interviewees indicated considerable frustrations about the provincial–national relationship in recent years. Weak follow-up of decisions made at either level and the lack of an agreed long-term national health vision to drive a coherent nationwide policy and reform agenda for health system development were identified as governance challenges (interviews). The implementation challenges resulting from the disjuncture between national decisions and realities on the ground was another widespread concern (interviews; see also: van Rensberg et al., 2018; Marais & Petersen, 2015 (mental health); Schneider & Nxumalo, 2017 (CHW programmes); G:ENESIS/CHP/PWC, 2019 (NHI pilot sites)). The Ideal Clinic
Governance, leadership and management
policy (Box 6), for example, highlights weak policy coherence, poor coordination and communication challenges, as well as frontline governance challenges similar to those discussed earlier (Box 1). Interviewees suggested that limited consultation with provincial HODs during policy development meant that inadequate attention was given to conflicting policy priorities, levels of system preparedness, and resource requirements across contexts. The common complaint of ‘unfunded mandates’ was seen as an indicator of this problem, i.e. PDoHs being tasked to implement new policies from within their existing budgets, regardless of the policies’ additional resource needs (see Box 1, 6).
The underlying factors identified as contributing to the problems included the limited functionality of the NHC and NHC-Tech as mechanisms of cooperation, the lack of shared understandings about the role and purpose of each governance level, or the features and values of an effective inter-level relationship, and the high rate of provincial MEC and HOD turnover. The NDoH capacity weaknesses were another factor. These ranged from an inability to attract and retain adequate numbers of skilled technocrats and to hold them accountable for their work, leadership tensions and styles that were de-motivating, to limited succession planning. The NDoH weaknesses were reflected in, for example, weak HRH stewardship (van Ryneveld et al., 2020), as well as the failure to tackle problems such as medico-legal challenges and budget accruals across provinces (interviews).
It is also important to recognise that provincial and national departments work within multiple regulatory frameworks that influence their scope of responsibilities and decision-making power, and establish the vertical lines of accountability dominant within the health system. Many of these are government-wide frameworks that make no allowance for this system’s specific needs (interviews).
Despite the challenges, there were experiences of collective action across the national–provincial levels in the 2015–20 period that offer suggestions for how to strengthen this relationship for improved system-wide governance. The clustering of provinces and their HODs, for example, enabled collaborative learning, although challenged by HOD turnover. Experience around strategic planning, monitoring and evaluation processes over 2015–20 was particularly positive. It shows how constructive and well-managed relationships within the NHC-Tech, drawing on frontline experience, can support governance practice and service delivery improvements across provinces.
Box 6: Policy implementation challenges across health system levels: Ideal Clinic Realisation and Maintenance (ICRM) policy experience
(Sources: Muthati & Rispel, 2020; Muthati et al., 2021)
The aim of the ICRM was to support the achievement of national core quality standards in primary health care
Responsibilities
National actors Provincial actors Local actors (DHS, municipalities)
• Conceptualise the policy and develop policy documents to support implementation
• Communicate the idea to other levels of government
• Establish a delivery unit, with funding
• Set targets for provinces and establish teams to oversee provinces
Challenges to implementation
• Develop memoranda of understanding across departments in other sectors e.g. between provincial health and education
• Support the districts
• Implementation: support PHC facilities and maintaining ‘ideal clinic’ standards by providing resource motivation
Challenges across levels
• Contestation about whether national or provincial governments should allocate the funding
• National policy actors consulted more amongst themselves than with provincial actors who are the main implementers
• Provincial government experienced the ICRM as an unfunded mandate
• Conditional grant funding was only allocated for two years and the conditions did not fully consider ICRM implementation needs
• Provincial actors perceived national actors to be slow to produce supporting policies for the ICRM implementation
• Districts communicated directly with the NDoH, bypassing provincial managers
• Provincial government criticised local government for not cooperating and refusing to implement provincial instructions
• Provincial actors did not engage adequately with local actors, neither in giving advice nor in gaining advice from local government
• Poor relationships across government spheres
• Perceived top-down approach of NDoH
• Lack of ownership and sense of exclusion due to insufficient involvement of implementers
• District actors felt that provincial actors did not take ownership of the ICRM programme and districts lacked support
• Infrastructure challenges to implementing ICRM; lack of consideration of the difference between rural and urban facilities
• Delays in procuring equipment and confusion of task execution due to poor role clarity
• Nature of communication across government considered hierarchical, uncoordinated and rigid, often excluding local actors
• PHC facility managers experienced disempowerment as a result of unfulfilled roles and responsibilities by various departments and levels of government
• PHC facility managers penalised for non-compliance with prescribed standards that were either Provincial or National Department of Health responsibilities, as a result of inad equate support
• Mismatched goals and ambitions and poor policy coherence between Ideal Clinic and National Core Standards led to duplication of effort, demotivation and frustration
• Confusion regarding overlapping roles and responsibilities and poor accountability
• Ineffective and weak communication
• Poorly developed sense of power and agency at lower system levels to influence implementation
The national Director General (DG) and provincial HODs are required by the National Health Act (Act 61 of 2003, sections 21 and 25) to prepare strategic, medium-term and annual performance plans across the national and provincial levels. Section 33, meanwhile, obliges district managers to table annual District Health Plans with the DHC and MEC. District Health Plans roll into provincial annual performance plans, which in turn link to the national annual performance plan. The DG is tasked to integrate the health plans of the national department and provincial departments and submit the integrated health plan to the NHC. Practically and coherently complying with these directives is complex due to the various processes across a range of administrative offices at different system levels (NDoH, nine PDoHs, 52 districts –eight of which include metropolitan municipalities’ PHC plans) and differing contexts, including various political aspirations at national and provincial levels. Uneven capabilities in data governance, leadership, and strategic planning capabilities exacerbate the difficulties. Reducing fragmented planning, and meeting various deadlines related to health and budget planning have been challenging.
Box 7: The maturing annual health planning process supported by the National Strategic Planning Committee (Source: interview material)
Principles
• Planning should be approached in a synchronised, systematic and structured way.
• Planning from the top needs to connect to planning from the bottom and the District Health Plan should be prioritised as the basis of health system planning for the country.
• District managers should be empowered with the necessary information and tools to execute their responsibility to govern for health and not only to manage district health services. Monitoring and evaluation, and planning processes need to therefore reflect the interconnections and interdependencies with other components of the system, other sectors and communities – by, inter alia, incorporating data from downstream contexts into district data, e.g. hospital mortality.
• Indicators and target setting should be iterative, starting from the bottom, and linked to problems to be solved.
Critical elements of the District Health Planning process
• Publication of annual district health profiles (that show a colour-coded, district-based, data matrix by condition, indicator set and age group) at national level.
• Providing a practical guide to support district teams in using the profiles to i) consider coverage and quality of facilities as equally important, and ii) identify geographic area and age groups to prioritise for interventions.
• Provincial teams using district health profiles to identify districts with less than provincial average performance, as areas where to target interventions.
• Stronger joint planning involving managers and clinicians to generate shared understanding both of the problems and of the modifiable factors around which the system can take action (related to patients, providers or the system), generating improvements to test.
Additional support
• Action was taken to streamline the burdensome National Indicator Data Set (NIDS) to focus exclusively on the data sets needed for the district health profiles.
• The NIDS and official population figures, disaggregated to sub-district level, are also now formally agreed and signed off at NHC-Tech level by October every year to ensure provinces and districts have sufficient time and necessary data to craft their annual performance plans. Governance,
To address these concerns, the NHC-Tech subcommittee responsible for health planning (the National Strategic Planning Committee) coordinated efforts with the subcommittees for District Health Systems and information systems (the National Health Information System for South Africa). Over the 2015–20 period, annual planning showed increasing maturity, building on a set of principles agreed within the NHC-Tech (Box 7). The subcommittee’s work was also enabled by active and facilitatory chairing, consultations with district and provincial managers and national programme managers, and purposefully drew from district-level experience with mortality audits and monitoring processes (see Box 3). Over time, the subcommittee’s leadership systematically tabled sound and well-argued recommendations that enabled decision-making at the NHC-Tech.
The role of the NDoH
As Figure 15.1 makes clear, the NDoH sits in a web of international and national, cross-level governance interfaces, all of which are policy and oversight relationships. The lack of engagement with public health service providers is not surprising, given the constitutionally defined roles of the different governance levels. In terms of the private health sector, the Medical Schemes Council, an oversight body, represents a national governance interface with health insurers, but there is no equivalent for private health care providers. It is also noteworthy that there are no current, formalised spaces for health governance interactions at national level with the broad array of ‘people’ actors, such as CSOs. However, the National Health Summit of 2018 (only the third since 1994) was judged to generate value through engagements with multiple stakeholders from across the country (interviews).
Given the current experience, Box 8 highlights the critical governance roles that the NDoH could, in future, further develop in order to strengthen frontline governance.
Box 8: The critical roles of the NDoH in governance (Sources: interview material; see also G:ENESIS/CHP/PWC, 2019; Muthati & Rispel, 2020; Muthati et al., 2021; Njau et al., 2021)
• A national political champion for health and well-being
• Establishing long-term national health visions and planning to support alignment and coherence across levels within the sector
• Developing new national-level governance relationships to strengthen governance for health, such as with other sectors, CSOs, organised labour, academics, and the private health sector
• Coordinating action in supporting Business Cases for Health System Investment submitted to National Treasury
• Taking action nationally in managing the regulatory context for health (e.g. interceding on behalf of the health system with government departments that stablish and implement national regulatory frameworks impacting across provinces) and to support the delegation of decision-making powers across the system to enable frontline governance
• Supporting action to foster connectedness across spheres of governance
• Supporting and enabling provincial and district health system development
• Supporting and enabling the strengthening of key governance processes across the system e.g. annual planning, leadership development
• Enabling policy implementation through new approaches to policy development, monitoring and evaluation approaches linked to outcomes and supporting experimentation and learning
• Coordinating action across provinces to tackle critical health system governance problems e.g. medico-legal claims bills
Leadership and management practice
As highlighted in previous sections, leadership and management practice has a critical influence on the form and strength of governance relationships at every level of the health system, with consequences for quality of care, intersectoral collaboration and cross-level collective action. Reflections on the Life Esidimeni tragedy and patterns of health system corruption also highlight the critical need to strengthen system leadership and stewardship practices to improve governance and accountability (Kruger, 2019; Rispel et al., 2016).
Interviewees judged that governance interfaces were undermined where leadership practice was regarded as autocratic and excluded professional groups, clinicians, organised labour, civil society actors or other government actors within and across levels. They also identified a tendency for government officials and managers to hold on to power in the face of challenging or complex circumstances, leading to decision-making without adequate information and experience.
In contrast, trusting relationships were judged to underpin robust governance relationships across the health system, as well as enabling innovative and creative responses to challenges. Strong teams and teamwork were identified as critical, and as based on: open communication, mutual respect, recognition of shared humanity and the offering of support in any way or form required (interviews). Boxes 2–4 clearly highlight the critical enabling practices and capabilities of system leadership that underpin both governance of health (for quality improvement, for example) and governance for health (collaboration within and beyond government boundaries).
Finally, interviewees reflected on the importance of robust leadership, working within established government procedures and sensitive to legitimate political pressures, but able to withstand illegitimate pressures. They expressed strong concern about the evidence of unethical and corrupt practices across the health system and within the wider public sector.
Strengthening health leadership and management is a longstanding government priority that was recognised in pre-2015 efforts to establish a country- and system-wide leadership development approach (Levendal et al., 2015). Although there were no national-level related developments in the 2015–20 period, the Western Cape PDoH published a leadership behaviours charter, leadership competency framework and leadership development strategy (WCG:H, 2016a,b). These documents continue to shape and influence a wide range of leadership development activities, and reflect the central role of leadership development within the WCG: health system transformation vision. They indicate that comprehensive plans and broad-ranging activities are needed to encourage, incentivise and support managers across the health system to develop relevant leadership competencies across their careers. The wider importance of public sector leadership development was also noted in this period (National School of Government, 2020), picking up the demands for a professional public service made in the National Development Plan, Vision 2030 (RSA, 2012). However, the specific needs of health system leadership are not clearly recognised. Interviewees noted, for example, the specialised nature of health care and the particular sets of critical stakeholders, including clinicians, health professional groups and private health sector actors, who must work together to achieve collective health system goals.
Conclusions and way forward
The structural and legislative foundations of governance in the South African public health system are well established. However, across sectors, the everyday practice of governance is weak. In the public health system, the consequences are seen in access inequities and disrespectful experience, as well as in large-scale crises such as the Life Esidimeni tragedy. The development of a capable state, founded on strong ethical practice, is therefore necessary to address the country’s social, economic and well-being needs. It is the most critical challenge currently facing the country (Kruger, 2019; Heywood 2021a, b; RSA, 2012).
Pockets of positive governance experience within the health system show that there is capability within this system, but this capability must be deepened, spread and sustained. Four governance re-sets are needed: one requires action outside the system, and three address health governance specifically.
Recommendations
It is essential that the broader governance environment is recognised as having a critical influence over health governance. New public management (NPM) practices, such as centralised control of lower-level public managers through target-setting and audit processes undermine public administration across sectors; as does the undue politicisation of public governance (Chipkin & Lipietz, 2012). As noted in the health system, NPM practices have worked to create a ‘system of regulatory compliance’ that ‘paralyses service delivery and decision-making, makes it difficult if not impossible for the state to work with informality, sets government apart from communities, undermines cross-sector partnering, stifles innovation and prevents system change’ (Boraine, 2021). These practices have ‘deprofessionalised major areas of public service’, and heightened policy accountability at the expense of public accountability (Cronin, 2021).
Some currently proposed reforms tackle at least some of these challenges. The draft National Implementation Framework towards the Professionalisation of the Public Service (NSG, 2020), for example, presents proposals that seek to ‘insulate’ the public service from politics and political parties. They include reforms to the terms of office and process of appointing senior public servants, recognition of specialist competencies and new efforts to manage the political-administrative interface. Such proposals could bring the leadership stability globally acknowledged as necessary for health system development (Balabanova et al., 2013). However, until such changes in current regulatory frameworks are achieved, senior health leaders at different levels must work to buffer the frontline from regulatory demands as well as heighten public accountability.
In looking to the future, three health system governance re-sets are also needed. First, communities and the DHS must be placed at the heart of the health system, with frontline governance strengthened to support quality improvement and local, place-based intersectoral action. This requires adequate and appropriate authority delegations to district managers, nested within coherent and aligned roles and responsibilities across the multi-level system. This re-set will require PDoH and NDoH managers to offer enabling leadership for frontline actors, even as they hold them to
Governance, leadership and management
account for outcomes – supporting them to work towards health and well-being goals. PDoH officials could, for example, become coaches for district health managers, whilst those in the NDoH must act as overall system facilitators (see Box 7). Deepening the already initiated bottom-up health planning processes will also be important. As is globally recognised (Hallsworth, 2011; Kickbusch & Gleicher, 2012), policy-making to address complex issues must combine appropriate central (national/provincial) guidance and accountability mechanisms (for example, in terms of monitoring outcomes), with the local-level flexibility needed to respond to implementation realities (G:ENESIS/ CHP/PWC, 2019; Kawonga et al., 2016; Muthati & Rispel, 2020; Schneider & Nxumalo, 2017).
Within this re-set, the PDoH/NDoH interface demands specific attention. One interviewee suggested co-creating a health governance charter that clarifies the values underpinning this interface, the roles of various actors, the spaces of engagement, and forms of reciprocal accountability. Nested within, but more detailed than, the existing legal frameworks, such a charter could provide the basis for maintaining stable structural relationships over time, despite provincial and national leadership turnover. Previous positive experiences of collaboration and coordination within the NHC-Tech also illustrate the everyday governance practices important in sustaining constructive governance relationships across levels. Consultation, engagement and holding actors to account for following through on agreed actions, are key.
Second, given the complex nature of future health and well-being challenges, as previewed by COVID-19, intersectoral collaboration and deepened engagement with social actors at local levels are essential. This will require that provincial health departments, specifically, adopt a new mindset of stewardship for health. They must look beyond health care as they seek, and work within, provincial government mandates for WoSA and WoGA approaches, to enable intersectoral action for health at district level (van Rensberg et al., 2018; Marais & Petersen, 2015). Political support from local government is also needed, and the Integrated Development Planning process could assist in institutionalising collaboration. However, collaborative governance requires flexibility, working across structural boundaries and the boundaries of formality/ informality, and being willing to engage openly with other actors rather than pre-determining the terms of engagement (Bigland et al., 2020; Bolden et al., 2019; Emerson et al., 2012).
Greater openness to civil society is also important in strengthening accountability to patients and the public. Simply recognising ‘people actors’ as legitimate governance actors, as well as becoming less defensive towards them, could be first steps in engagement. This could entail inviting, supporting and learning from local-level initiatives addressing specific needs, such as the Ritshidze initiative. Provincial and District Health Councils might thereby be opened beyond current mandates as spaces for engagement with civil society, even as strengthening the functionality of clinic committees and hospital boards remains important. More regular engagements with a wide range of ‘people’ governance actors through provincial and national health summits could, moreover, support relationship-building, and draw in the multiple forms of evidence needed for decision-making. Strengthened, productive relationships with organised labour would ideally be part of this effort.
Third, implementing these health governance re-sets requires both new mindsets and deepened skillsets, including those of ethical practice. Kickbusch and Gleischer (2012)
specifically stress the importance of ‘systems thinking’ skills, drawing on complexity science and interdisciplinary insights, in governance for health. These skills are integral to the concept of system leadership (Bolden et al., 2019). Formal leadership and management training programmes have a role to play in developing such leadership (Bolden et al., 2019; Doherty & Gilson, 2015), and can be guided by relevant frameworks – such as those of the Western Cape DOH (WCG:G 2016a,b).
Establishing a national institutional home for health leadership and management development could support relevant programming. However, it is even more important that everyday governance practice both nurtures and supports the deepening of health system leadership. Appropriately managed meetings (see Table 15.1) and group coaching interventions (Cleary et al., 2018) are relevant practices. New quality improvement (Box 2) or WoSA initiatives (Boxes 4–5) that pay attention to governance relationships and practices offer opportunities to deepen system leadership.
Formally-designated managers across the system play vital roles in role-modelling relevant leadership practices, such as respectful and active listening, putting oneself in the shoes of others, having robust and difficult conversations and acting ethically. Senior managers can also be held accountable, through their performance agreements, for enabling the spread of system leadership.
A final consideration is whether and how these governance re-sets fit with the macro health system reforms proposed in the 2019 NHI Bill. On the one hand, governance strengthening is needed to support implementation of the reforms, as noted in the NHI pilot site evaluation (G:ENESIS/CHP/PWC, 2019). On the other hand, the reforms may work against the governance re-sets. More specifically:
• the proposed, centrally-controlled purchasing and contracting mechanisms may enhance the existing top-down audit and accountability approaches that undermine frontline governance, and new sub-district-level structures may fragment health care governance;
• there is no clear place for PDoHs in the reforms proposed, ignoring their important roles of enabling and coaching lower system levels, and acting as stewards for health;
• the potential influence of the national Minister of Health over the NHI Fund’s governance structures ignores wider concerns about political/administrative interfaces;
• the reforms focus on health care financing and related structures, inadequately considering how to address the social determinants of health or support the required intersectoral collaboration.
In conclusion, strengthening governance for health is a long-term endeavour in every setting (Kickbusch & Gleischer, 2012). Past experience as well as the needs of the future demand that the lessons of 2015–20 drive a new South African health governance, leadership and management agenda. The health system must work better, and especially for those who are most vulnerable. Existing positive experiences offer ideas of what is possible. Governance re-sets must build on these experiences and embrace regular reflection on experience through the lens of system stewardship. Implementation of the NHI reforms must also work to support, not undermine, the re-sets. Recognising that some of the roots of health system governance challenges lie outside the health system, wider political and public service action must, finally, accompany health system reform.
Governance, leadership and management
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