FROM THE EDITOR

ASSAf launches its consensus study: Achieving good governance and management in the South African health system

The Academy of Science of South Africa (ASSAf) recently launched its consensus study 'Achieving good governance and management in the South African health system'.^[1] For readers who are not familiar with the ASSAf, it was established in May 1996, in response to the need for an academy of science that would be in line with the dawn of democracy in SA. Its mission includes activism whereby science and scholarship are used for the benefit of society. Its activities encompass an open-minded and evidence-based approach in the process of building knowledge. The SA Parliament passed the Academy of Science of South Africa Act (No. 67 of 2001), which came into force on 15 May 2002. Hence, ASSAf is the only academy of science in SA which is officially recognised by government, and which represents the country in the international community of science academies and elsewhere.

For this consensus study, a seven-member consensus panel comprising a multidisciplinary group of SA public health and health systems researchers, academics and practitioners set out to determine and describe the magnitude, spread and effects of the governance challenges in the health system; identify any effective strategies, best practices or interventions that could be adapted and/or leveraged to address these governance challenges; and make implementable recommendations on how to improve governance, management and decision-making in the overall health system for better performance and sustainability. The study, which commenced in September 2020, was conducted over a 3-year period.

The five key principles of governance identified in the conceptual framework by Mikkelsen-Lopez et al.^[2] were utilised in the panel's study. These are: strategic vision and policy design; transparency; participation and consensus orientation; accountability; and addressing corruption. There was extensive discussion and debate over the National Health Insurance (NHI) Bill, which was passing through various parliamentary processes during the review period. The panel took special interest in strategic purchasing, a notion that underpins the formulation of the NHI.

The report produced by the consensus study comprises seven chapters. It describes the historical context of health governance in SA, summarises the international and local literature on health governance, provides a detailed reflection on strategic purchasing and financing in the context of the NHI, discusses what should be done to enhance good governance in the SA health system and ends with a set of recommendations that the panel believes to be both implementable and essential for the constitutional promise of the right to access healthcare and equality to be realised in SA.

The panel's analysis of the overall picture indicates that despite some important positive examples of good health system governance in SA, widespread problems in governance arrangements continue. Multiple indicators of dysfunction are highlighted, including the many managers in acting positions, frequent changes in senior leadership (for example, the Gauteng Department of Health has had 10 accounting officers in 10 years), worse health outcomes than similarly resourced countries, and overall deterioration of morale and trust in the public health system. This underscores that much needs to be done to improve governance of the SA health system.

With regard to the NHI and strategic purchasing, the report points out that corruption, which was defined as the abuse of resources, power and connections for private gain, afflicts the SA healthcare system in both the public and private sectors. This has also been confirmed by the auditor-general's reports over several years, with the extent of corruption reported in SA in general and in the health service in particular being considerably in the spotlight of the public eye and in policy considerations. Examples in the report include the murder of Babita Deokaran, the chief director of financial accounting in the Gauteng Department of Health, and the related investigations into the Tembisa Hospital corruption scheme through which close to ZAR1 billion was fraudulently paid by officials to companies. Corruption is pulled off primarily through procurement. Other mechanisms through which corruption is enacted include nepotism in appointments, bribery and ghost salaries. The panel drew attention to the fact that NHI and strategic purchasing may not prove effective if relevant governance challenges are not appropriately addressed in SA's health system, nor will NHI on its own address inefficiencies and other problems facing the sector. NHI and strategic purchasing operate within a system, and require other elements to be present, such as good stewardship and accountability.

In its anlaysis the panel drew from, among other reports, the 2019 Consensus Report of the SA Lancet National Commission on a High Quality Health System in the Sustainable Development Goal era, based on a country-specific analysis on quality of care, where a key finding was that gaps in ethical leadership, management and governance contributed to poor quality of care in SA. Corruption and fraud were seen as major threats to equitable access to quality healthcare. The report also pointed to governance weaknesses in the regulators of most healthcare professionals, similar to the 2015 Ministerial Task Team findings on the Health Professions Council of SA, where poor governance and extensive mismanagement plagued the regulator. It was noted that the National Department of Health had provided inadequate stewardship of the governance of this and other statutory regulatory bodies. With regard to the law, some core legal provisions of governance might be interpreted as contradictory. An example provided is the Public Finance Management Act No. 1 of 1999 under the Treasury. It empowers accounting officers or heads of department responsible for financial management, service delivery and human resource management. Simultaneously, ministers and members of the executive committees (MECs) in the provinces are designated as executive authorities by the Public Service Act No. 103 of 1994, which gives them substantial powers (for example, the right to make appointments). This may lead to cadre deployment or political interference. It is stressed that one of the most complex aspects of public governance is the political-administrative interface. It was also highlighted that constitutional and legal provisions introduce both complexities and difficulties. Section 41 of the SA Constitution makes provision for co-operative governance, with health as a concurrent responsibility of national and provincial governments. However, the National Health Act No. 61 of 2003 is not entirely clear on the precise functions of the spheres of government, and several national ministers of health have cited lack of powers to intervene in provincial service delivery problems. This came to the fore during the Life Esidimeni tragedy, where at least 144 long-term psychiatric patients died after they were forcefully discharged by provincial authorities from a long-term facility as part of cost-cutting. The then national Minister of Health (who has come back as the current national Minister of Health) noted that the issue 'never came to the National Health Council to be dealt with', and so he was unaware of the matter.

The report concludes with a set of eight key recommendations, which the panel recognises may not be simple to implement. However, it is emphasised that not using these opportunities to address the gaps in governance will render quality healthcare for all even more unlikely. This consensus study highlights the many challenges in good governance and ethical leadership, and proposes sound methods to address the issues. A concerted effort by key stakeholders is necessary to take the guidance it provides forward.

Conflicts of interest. None. The acting editor is a member of ASSAf, but had no involvement with the consensus study.

Ames Dhai

Acting editor

Ames.Dhai@wits.ac.za

References

1. Academy of Science of South Africa. Achieving Good Governance and Management in the South African Health System. ASSaf, 2024. http://doi.org/10.17159/assaf.2024/95 (accessed 26 July 2024).         [ Links ]

2. Mikkelsen-Lopez I, Wyss K, De Savigny D. An approach to addressing governance from a health system framework perspective. BMC Int Health Hum Rights. 2011;11:1-11. https://doi.org/10.1186/1472-698X-11-13        [ Links ]