Can health be fixed without fixing politics?

The current version of the NHI Bill leaves the door wide open to exactly the type of political interference that has been so harmful to health governance in South Africa over the last decade. (Photo: Rosetta Msimango / Spotlight)

By Marcus Low

19 Oct 2022

Several provincial health departments have stumbled from crisis to crisis over the past decade with no sign of sustained or meaningful improvement. One reason for this, argues Spotlight editor Marcus Low, is political interference and the cadre deployment and cronyism that usually go with it. If this is correct, is it realistic to think we can address the dysfunction in our health departments without addressing the politics behind it?

In a recent article published on Daily Maverick, Mark Heywood remembers a moment of hope when activists, healthcare workers and others came together in 2013 to find solutions to the chronic dysfunction in the public healthcare system in the Eastern Cape. At the time, a hard-hitting report was produced, and partly in response to that report, the then health minister Dr Aaron Motsoaledi announced a series of emergency interventions. But while some of those interventions made some difference in some places, once the moment of political crisis passed, things soon reverted to their baseline dysfunction.

Nine years after that moment of hope, little has changed in the Eastern Cape. Several investigations and damning but ultimately ineffectual reports have come and gone from the Public Protector, the Human Rights Commission and the Public Service Commission. In 2022, the province’s healthcare system is still making headlines for all the wrong reasons.

The Eastern Cape is not unique.

After the entirely preventable Life Esidimeni tragedy, one might have thought that those in power in Gauteng would be shocked into taking reform of the province’s healthcare system more seriously. Since then, however, one devastating headline has followed another. From the botched rebuild of Charlotte Maxeke Johannesburg Academic Hospital after last year’s fire to Covid-19-related corruption, the victimisation of Dr Tim de Maayer of Rahima Moosa Mother and Child Hospital, and the department’s shameful failure to meaningfully investigate the rot exposed by Babita Deokaran who was assassinated for doing the right thing, the province’s health department remains mired in deadly dysfunction.

Heywood comes to the disturbing conclusion that: “With the exception of the response to HIV – where activism has driven the response for two decades – civil society advocacy has not made the health system better and we should admit it.”

The reality is more complicated.

Activism has often helped make things better than they would have been otherwise. Think of the introduction of new TB medicines in South Africa ahead of most other countries, the ceaseless work trying to prevent and then seek accountability for the Life Esidimeni tragedy, civil society’s support of community healthcare workers in the Free State and the government’s eventual decision to in-source these workers across the country – even the health department’s overdue announcement last week of new measures to counter load shedding at health facilities probably came in response to outside pressure. Without activists, be they in civil society organisations or healthcare workers, our health landscape would quite simply be much bleaker.

But in a broader sense Heywood is, of course, right. Something has gone wrong at a systemic level that we simply haven’t come to grips with yet. Last week, health ombud Professor Malegapuru Makgoba told Parliament that, having visited all nine provinces in the past year, he found deteriorating health services in all but the Western Cape. That a comment like this from someone of Makgoba’s stature hardly causes a stir, only confirms how desensitised we’ve become to the rot.

Why have we not made more progress?

In South Africa, the implementation of health policies and reforms is the work of provincial health departments. These departments – department heads, district managers, hospital CEOs and so on – are where power is centred in provinces. Whatever commitment or innovation healthcare workers may show, they remain ultimately at the mercy of these officials.

To best support our healthcare workers, our provincial health departments should be centres of excellence, yet, as we’ve previously argued, they generally repel rather than attract the best talent. The reason for this is no mystery: political interference. Whether it is cadre deployment or just simple cronyism, the end result is that the best candidates are often not appointed and that the work environment becomes toxic for anyone who does not toe the party line.

The impact of this cannot be understated.

Instances of corruption make the headlines, but the more insidious influence on the public service has been the gradual erosion of capacity. People who don’t ask too many questions are often secure in their jobs, while people who insist on acting lawfully and being tough on corruption are often sidelined.

Accordingly, one reason for the decay in our health system is simply that provincial health departments have been systematically decapacitated. Even if there is some political will to clean up procurement or implement important reforms, most health departments simply do not have the people and expertise required to carry it out. As with other spheres of our public service, the seeds of reform – be it the ideal clinic programme or the much-touted district development model – are doomed to wither away on fallow ground.

Read in Daily Maverick: “Healthcare problems persist at ‘Ideal Clinics’, studies show”

Activists, NGOs, healthcare workers or advisers may convince provincial health MECs to try to do the right thing, but when a MEC finally pulls the right lever, he or she might find that nothing happens. In a healthier system, the friction between the policy direction set by politicians and the pragmatism and management smarts of competent technocrats would keep the gears turning productively. But with hardly any technocratic resistance left in our provinces, the gears are spinning freely, but to no effect. This lack of resistance may suit the short-term political interests of certain individuals, but for everyone else it is a disaster.

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Of course, in some provinces, in some districts, and at some healthcare facilities, healthcare workers and committed officials have achieved remarkable things in difficult conditions. It is important to acknowledge these efforts, and, where possible, to learn from them.

But if we don’t address the underlying dysfunction, any inspiring new initiative, and any committed team of healthcare workers, for that matter, will remain fundamentally vulnerable. At any moment, a vindictive hospital CEO or a district manager, appointed purely because of who he or she knows, can pull the rug from under you. Similarly, some technocratic reforms or new programmes can and do have some impact on the health system, but the impact is inevitably constrained by the pervasive lack of capacity in health departments.

What to do?

Political interference, and the related hollowing-out of provincial health departments, arguably have two related causes. One is the problem of the legal mechanisms that allow or fail to prevent it. The second is specific political parties that, in their actions at least, embrace the idea of political interference in health departments.

Former health minister Dr Aaron Motsoaledi. (Photo: EPA / Georg Hochmuth)

Regarding the first, with the exception of politicians who rely on patronage to cement their power, my impression is that there is broad agreement that rules preventing political interference should be tightened. Some of this might require some law reform – for example, to reduce the say that health MECs have on appointments – but some of it may simply involve enforcing existing rules more rigorously. More tightly managing appointment processes in health departments and introducing more meaningful consequence management should also have wide support.

That many people are on the same page about these issues is confirmed by the wide variety of organisations that have expressed concern about the extensive powers given to the health minister in the current version of the NHI Bill. As it stands, the bill leaves the door wide open to exactly the type of political interference that has been so harmful to health governance in South Africa over the last decade.

The current version of the NHI Bill leaves the door wide open to exactly the type of political interference that has been so harmful to health governance in South Africa over the past decade. (Photo: Rosetta Msimango / Spotlight)

Read in Daily Maverick: “Mixed feelings about NHI at public health conference”

The second issue is much trickier but arguably as important.

Many people or organisations in health circles – whether healthcare workers, patient groups, activists or NGOs – are understandably wary of getting involved in the dirty business of party politics. But, whether they want to admit it or not, through its devastating impact on provincial health departments, party politics is often already involved with them.

There is something of an irony here. While on the one hand we take the sacredness of our Constitution and our democracy very seriously, there is a remarkable reticence in health circles, with the exception of some trade unions, when it comes to the essence of what democracies are about – voting out people who govern badly, or even just saying we should vote out people who govern badly.

Which is not to suggest that everyone should affiliate with and campaign on behalf of political parties. The primary function of healthcare workers is, after all, to provide healthcare services. Similarly, aligning with or opposing specific political parties is generally a bad strategy for activist organisations – the TAC’s decision to oppose specific government policies rather than the ANC itself was critical to its success.

But there are real and serious questions here. If it is correct that political interference is a key driver of the dysfunction in provincial health departments, is it realistic to think we can address the dysfunction without addressing the politics behind it? And if we wish to address the politics, how should we go about it?

These are difficult questions with no easy answers. DM/MC

Marcus Low is the editor of Spotlight. He was previously the head of policy, communications and research at the TAC.

Note: Spotlight is editorially independent and is not affiliated with, nor does it endorse any political parties. Spotlight is a member of the South African Press Council.

This article was published by Spotlight – health journalism in the public interest.

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Why have we not made more progress?

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