In an era of gross financial mismanagement, corruption and budget cuts, what does it take to get an ‘unqualified audit with no findings’? Mark Heywood writes in Spotlight that according to Beth Engelbrecht, superintendent-general of Western Cape Health, it’s inclusive management and servant leadership. She explained what this means.
The report says managing a provincial health department is not for the faint-hearted. Apart from the fact that the health, dignity and lives of millions of people depend upon your decisions and effectiveness, a health department (probably more than any other government department) is an enormous, multilayered and complex bureaucracy. Western Cape Health (WCDH) is a case in point.
It serves 6m people; a number that, according to the Stats SA 2019 mid-year population estimates, grows by 28,000 people a month, and 76% of its population is uninsured. That means it has the third-largest number of users in the country, after Gauteng and KwaZulu-Natal. It has an annual budget of R32bn, spends R7bn of that on goods and services and employs 32,000 staff.
One would think when the number of users of a health system increases, so would its budget. You’d think wrong. The report says according to Engelbrecht, this financial year marks the fifth year in which the budget has been cut in real terms. “We need to do more for less,” she says. So, not surprisingly – if perhaps a little perversely – a lot of our discussion centres on financial management and good governance, rather than health outcomes.
The report says a vein that runs throughout our conversation is “the tough decisions” and how they are implemented. “We can’t just grow staff numbers, because there’s a higher need,” Englebrecht says, “but this makes you more innovative and creative.” She puts particular importance on having the right staff mixes, investing in leadership development and culture and the decentralisation of decision-making, what she calls “dispersed leadership”.
Despite the budget cuts she says the department is intent on shifting money towards services. She also insists that certain areas of delivery are protected from budget cuts: “maintenance, medical registrars, community services and interns” are what she lists, but admits too that central hospitals “are at the sharpest end” of budget restrictions.
But, she can see, this does take its toll.
According to the report, she calls health services a “burning platform”, that causes “massive pressures”, especially at primary healthcare level and on emergency medical services. But in this difficult context – austerity is the word – her philosophy seems to be upfront and straightforward about the financial crisis and involving all stakeholders in planning about how best to dig out of the hole. She claims to consult with staff, the unions and the universities on the budget. I ask “to what extent communities are consulted” and she’s quick to admit there’s much room for improvement here. Clinics committees are “still maturing”; hospital boards are “more mature” and the MEC engages with the private sector and NGOs through various private forums.
What are the ingredients for successful good governance in the WCHD? The report says Engelbrecht starts by crediting all her team then lists four – all of equal importance. In addition to inclusive and consultative governance and tight financial management (which we had already canvassed) she stresses stability in leadership: she says the WCHD has combined services of over 150 years in its top executive. She herself has worked in government since 1989 (except for three years with the Health Systems Trust) and a clear division of labour between the political head, MEC, and operations – she is quoted in the report as saying that there is clear agreement and respect with the MEC, Nomafrench Mbombo, on where the boundaries are.
The report says an official from the National Treasury confirms these factors but adds to the list some advantages the WCDH has over other provinces: “Appointments based on merit, not political; Cape Town popular place to live so attracts and retains people; wealthier population, so higher revenue base and fewer public users; three universities close with lots of joint staff and some pressure from universities; kept people with skills.”
And, the report says, asked how the WCDH, under the control of the Democratic Alliance, is working with national health priorities, particularly the National Health Insurance (NHI) Bill with which they make plain their disagreement, the response is straightforward. She says Health Minister Zweli Mkhize is willing to listen and “treats the provincial health departments as partners”. In July the Bill was tabled at the National Health Council and when comments were invited from each MEC, “he listened”. In this context, she also talks positively about a growing collaboration between provincial health departments, mentioning four provinces the WCHD is collaborating with.Daily Maverick report Western Cape Health material