Can well being be mounted with out fixing politics?
In a current article printed on Every day Maverick, Mark Heywood remembers a second of hope when activists, healthcare staff and others got here collectively in 2013 to search out options to the power dysfunction within the public healthcare system within the Jap Cape. On the time, a hard-hitting report was produced, and partly in response to that report, the then well being minister Dr Aaron Motsoaledi introduced a collection of emergency interventions. However whereas a few of these interventions made some distinction in some locations, as soon as the second of political disaster handed, issues quickly reverted to their baseline dysfunction.
9 years after that second of hope, little has modified within the Jap Cape. A number of investigations and damning however in the end ineffectual stories have come and gone from the Public Protector, the Human Rights Fee and the Public Service Fee. In 2022, the province’s healthcare system continues to be making headlines for all of the mistaken causes.
The Jap Cape is just not distinctive.
After the totally preventable Life Esidimeni tragedy, one may need thought that these in energy in Gauteng can be shocked into taking reform of the province’s healthcare system extra significantly. Since then, nevertheless, one devastating headline has adopted one other. From the botched rebuild of Charlotte Maxeke Johannesburg Tutorial Hospital after final yr’s fireplace to Covid-19-related corruption, the victimisation of Dr Tim de Maayer of Rahima Moosa Mom and Baby Hospital, and the division’s shameful failure to meaningfully examine the rot uncovered by Babita Deokaran who was assassinated for doing the proper factor, the province’s well being division stays mired in lethal dysfunction.
Heywood involves the disturbing conclusion that: “Except the response to HIV – the place activism has pushed the response for twenty years – civil society advocacy has not made the well being system higher and we should always admit it.”
The truth is extra difficult.
Activism has typically helped make issues higher than they’d have been in any other case. Consider the introduction of latest TB medicines in South Africa forward of most different nations, the ceaseless work attempting to stop after which search accountability for the Life Esidimeni tragedy, civil society’s help of neighborhood healthcare staff within the Free State and the federal government’s eventual choice to in-source these staff throughout the nation – even the well being division’s overdue announcement final week of latest measures to counter load shedding at well being services most likely got here in response to outdoors stress. With out activists, be they in civil society organisations or healthcare staff, our well being panorama would fairly merely be a lot bleaker.
However in a broader sense Heywood is, in fact, proper. One thing has gone mistaken at a systemic degree that we merely haven’t come to grips with but. Final week, well being ombud Professor Malegapuru Makgoba told Parliament that, having visited all 9 provinces up to now yr, he discovered deteriorating well being providers in all however the Western Cape. {That a} remark like this from somebody of Makgoba’s stature hardly causes a stir, solely confirms how desensitised we’ve develop into to the rot.
Why have we not made extra progress?
In South Africa, the implementation of well being insurance policies and reforms is the work of provincial well being departments. These departments – division heads, district managers, hospital CEOs and so forth – are the place energy is centred in provinces. No matter dedication or innovation healthcare staff might present, they continue to be in the end on the mercy of those officers.
To finest help our healthcare staff, our provincial well being departments must be centres of excellence, but, as we’ve previously argued, they typically repel fairly than appeal to the perfect expertise. The rationale for that is no thriller: political interference. Whether or not it’s cadre deployment or simply easy cronyism, the top result’s that the perfect candidates are sometimes not appointed and that the work atmosphere turns into poisonous for anybody who doesn’t toe the occasion line.
The affect of this can’t be understated.
Situations of corruption make the headlines, however the extra insidious affect on the general public service has been the gradual erosion of capability. Individuals who don’t ask too many questions are sometimes safe of their jobs, whereas individuals who insist on appearing lawfully and being robust on corruption are sometimes sidelined.
Accordingly, one motive for the decay in our well being system is just that provincial well being departments have been systematically decapacitated. Even when there’s some political will to wash up procurement or implement essential reforms, most well being departments merely wouldn’t have the folks and experience required to hold it out. As with different spheres of our public service, the seeds of reform – be it the perfect clinic programme or the much-touted district improvement mannequin – are doomed to wither away on fallow floor.
Learn in Every day Maverick: “Healthcare problems persist at ‘Ideal Clinics’, studies show”
Activists, NGOs, healthcare staff or advisers might persuade provincial well being MECs to attempt to do the proper factor, however when a MEC lastly pulls the proper lever, she or he may discover that nothing occurs. In a more healthy system, the friction between the coverage path set by politicians and the pragmatism and administration smarts of competent technocrats would hold the gears turning productively. However with hardly any technocratic resistance left in our provinces, the gears are spinning freely, however to no impact. This lack of resistance might go well with the short-term political pursuits of sure people, however for everybody else it’s a catastrophe.
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In fact, in some provinces, in some districts, and at some healthcare services, healthcare staff and dedicated officers have achieved exceptional issues in tough circumstances. It is very important acknowledge these efforts, and, the place doable, to study from them.
But when we don’t tackle the underlying dysfunction, any inspiring new initiative, and any dedicated group of healthcare staff, for that matter, will stay basically susceptible. At any second, a vindictive hospital CEO or a district supervisor, appointed purely due to who she or he is aware of, can pull the rug from beneath you. Equally, some technocratic reforms or new programmes can and do have some affect on the well being system, however the affect is inevitably constrained by the pervasive lack of capability in well being departments.
What to do?
Political interference, and the associated hollowing-out of provincial well being departments, arguably have two associated causes. One is the issue of the authorized mechanisms that permit or fail to stop it. The second is particular political events that, of their actions not less than, embrace the concept of political interference in well being departments.
Relating to the primary, except politicians who depend on patronage to cement their energy, my impression is that there’s broad settlement that guidelines stopping political interference must be tightened. A few of this may require some legislation reform – for instance, to scale back the say that well being MECs have on appointments – however a few of it might merely contain implementing current guidelines extra rigorously. Extra tightly managing appointment processes in well being departments and introducing extra significant consequence administration must also have vast help.
That many individuals are on the identical web page about these points is confirmed by the wide range of organisations which have expressed concern concerning the in depth powers given to the well being minister within the present model of the NHI Invoice. Because it stands, the invoice leaves the door vast open to precisely the kind of political interference that has been so dangerous to well being governance in South Africa during the last decade.
Learn in Every day Maverick: “Mixed feelings about NHI at public health conference”
The second concern is way trickier however arguably as essential.
Many individuals or organisations in well being circles – whether or not healthcare staff, affected person teams, activists or NGOs – are understandably cautious of getting concerned within the soiled enterprise of occasion politics. However, whether or not they wish to admit it or not, via its devastating affect on provincial well being departments, occasion politics is usually already concerned with them.
There’s something of an irony right here. Whereas on the one hand we take the sacredness of our Structure and our democracy very significantly, there’s a exceptional reticence in well being circles, except some commerce unions, on the subject of the essence of what democracies are about – voting out individuals who govern badly, and even simply saying we should always vote out individuals who govern badly.
Which isn’t to counsel that everybody ought to affiliate with and marketing campaign on behalf of political events. The first perform of healthcare staff is, in spite of everything, to offer healthcare providers. Equally, aligning with or opposing particular political events is mostly a nasty technique for activist organisations – the TAC’s choice to oppose particular authorities insurance policies fairly than the ANC itself was crucial to its success.
However there are actual and critical questions right here. Whether it is appropriate that political interference is a key driver of the dysfunction in provincial well being departments, is it real looking to suppose we are able to tackle the dysfunction with out addressing the politics behind it? And if we want to tackle the politics, how ought to we go about it?
These are tough questions with no simple solutions. DM/MC
Marcus Low is the editor of Highlight. He was beforehand the pinnacle of coverage, communications and analysis on the TAC.
Notice: Highlight is editorially unbiased and isn’t affiliated with, nor does it endorse any political events. Highlight is a member of the South African Press Council.
This text was printed by Spotlight – well being journalism within the public curiosity.
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