The Human Face of Decentralisation and Integration of Health Services: Experience from South Africa

Abstract

This paper explores the processes of policy-making, budgeting and service implementation in three provinces of South Africa, drawing on interviews with health managers at different levels of government. It illustrates how the process of decentralisation creates disjunctures between the policy-making authority of higher levels of government and the implementation capacity of service provision levels. It also explores the complex dynamics between those responsible for specific policies, such as reproductive health policies, and those responsible for managing the integrated delivery of all policies, with their resultant contestations over authority and resources. The pace of change in South Africa and the enormous capacity it requires, both in relation to financial management and the technical skills needed for specific programmes, has created a sense of frustration and demoralisation. Whilst shortage of financial resources, particularly as reflected in shortage of staff, is frequently assumed to be the biggest constraint in this context, most managers identified other issues, particularly staff morale, as greater barriers to the delivery of high quality health services. The paper concludes that it is the complexity of experience and feelings described by health managers that may determine the extent and quality of service delivery. For this reason, both practice and research need to give greater attention to issues of power relations and personal experience of change.

Résumé

Cet article étudie les processus de définition des politiques, de budgétisation et de prestation de services dans trois provinces d'Afrique du Sud, grâce à des entretiens avec des responsables de la santé à différents niveaux administratifs. Il montre que la décentralisation crée des fractures entre l'autorité responsable des politiques aux niveaux supérieurs et la capacité d'application des niveaux de prestation des services. Il aborde également les dynamiques complexes entre les responsables de politiques spécifiques, comme sur la santé génésique, et les responsables de la gestion de l'application intégrée de toutes les politiques, avec les contestations qui s'en suivent sur l'autorité et les ressources. Le rythme du changement en Afrique du Sud et l'énorme capacité qu'il demande, en gestion financière et en compétences techniques requises pour des programmes spécifiques, a créé un sentiment de frustration et de démoralisation. Alors que le manque de ressources financières, particulièrement reflété dans la pénurie de personnel, est souvent considéré comme la principale entrave, la plupart des administrateurs ont jugé que d'autres facteurs, particulièrement le moral du personnel, faisaient davantage obstacle à la prestation de services de santé de qualité. L'article conclut que c'est la complexité de l'expérience et des sentiments décrits par les administrateurs qui peut déterminer la mesure et la qualité de la prestation des services. Pour cette raison, la pratique et la recherche doivent accorder davantage d'attention aux questions de relations de pouvoir et à l'expérience personnelle du changement.

Resumen

Este trabajo examina el proceso de elaborar polı́ticas y presupuestos, e implementar servicios, en tres provincias de Sudáfrica. Se basa en entrevistas con administradores de la salud a diferentes niveles del gobierno. Muestra como el proceso de descentralización crea disyuntivas entre la autoridad para elaborar polı́ticas a los niveles más altos del gobierno y la capacidad de implementación a los niveles de prestación de servicios. Examina además la dinámica compleja entre los responsables de polı́ticas especı́ficas, como las polı́ticas de salud reproductiva, y los responsables de administrar la provisión integral de todas las polı́ticas. El ritmo de cambio en Sudáfrica requiere una capacidad enorme de manejo financiero tanto como capacidad técnica para implementar programas especı́ficos, la cual ha creado una sensación de frustración y desmoralización. Se percibe la falta de recursos financieros como el limitante mayor, especialmente en lo que se refiere a la falta de personal capacitado. Sin embargo, la mayorı́a de los administradores identificaron otros problemas, sobre todo el bajo moral del personal, como obstáculos mayores a la provisión de servicios de salud de alta calidad. El artı́culo concluye afirmando que la complejidad de la experiencia y los sentimientos descritos por los administradores de la salud sea lo que quizás determine el alcance y la calidad de los servicios prestados. Por esta razón, se debe prestar más atención a las relaciones de poder y la experiencia personal del proceso de cambio, tanto en la investigación como en la práctica.

Key Words:

• health sector reforms
• decentralisation of services
• integration of services
• health worker attitudes
• South Africa

This paper explores the processes of policy-making, budgeting and service implementation in three provinces of South Africa. It draws on interviews with public sector health managers at different levels of government regarding their experience of rapid policy changes and health sector restructuring in South Africa since 1994. It focuses on decentralisation, combined with efforts to promote integration, as a cornerstone of this health sector restructuring.

South Africa's health policy since 1994 is based on the primary health care approach with a strong emphasis on equity and a commitment to universal access to integrated, comprehensive primary care services. A key policy aim was to reduce disparities and increase access to improved services: “emphasis should be placed on reaching the poor, the under-served, the aged, women and children, who are among the most vulnerable”.¹

In line with this commitment, high priority has been given to maternal, child and women's health (MCWH) through a number of specific policies, including:

• free care at all levels of the health service for pregnant women and children under six years of age,²

• free health care for all South Africans at primary care level,³

• abortion on request in the first trimester of pregnancy and on medical and socio-economic grounds thereafter,⁴

• national cervical screening programme,⁵

• a system of confidential enquiries into maternal deaths,⁶ and

• a school feeding programme.⁷

Policy requires that these services be provided in an integrated manner: “All health facilities, as far as possible, will render MCWH services on a one-stop, ‘supermarket’ basis.”¹ However, this policy has not been fully implemented and many facilities do not yet provide integrated services.

Decentralisation and the health system

Decentralisation, which is the transfer of responsibility for planning, management and financing from central government to peripheral levels of government, has been a key health sector reform in a wide range of low- and middle-income countries over the past decade or more.^{8 9 10 11} Consideration of the South African experience of decentralisation may thus provide valuable insights for other countries that have recently, or are currently, decentralising health services, particularly if they are simultaneously facing challenges relating to integrating reproductive and other traditionally vertical health programmes into comprehensive service delivery.

Decentralisation can take different forms, which are distinguished in terms of the extent and nature of decision-making authority that is granted to the peripheral level. The most frequent forms are: (i) devolution, which is the creation or strengthening of sub-national levels of government, such as provincial and local government authorities, to have considerable political and managerial decision-making authority with respect to a range of functions (e.g. health, social welfare, education), and (ii) deconcentration, in which some authority over administrative decisions (but no political authority) is given to locally-based offices of a specific government department, such as creating district offices of the health department.⁸

Two parallel processes of decentralisation impacted on the health sector in South Africa.¹² Firstly, there was a process of devolution of considerable authority to provincial and local governments. A quasi-federal structure with substantial autonomy for provincial governments was introduced shortly after the 1994 elections. Full devolution to local governments came somewhat later, as the process of demarcating local government boundaries and holding local elections was only finalised in late 2000. Nevertheless, the Constitution envisaged considerable autonomy in decision-making for this sphere of government as well.

In terms of the Constitution, the national, provincial and local government spheres have concurrent powers for the health sector. Thus, all spheres are envisaged as having some responsibility for health services, but for different aspects. National government is primarily responsible for policy development and overall health sector co-ordination. Provinces have the greatest responsibilities for service provision, including all hospital services and some, mainly curative, primary care services. Local governments have traditionally been responsible for the provision of preventive primary care services. There are now efforts to provide comprehensive and integrated health services at all primary care facilities (i.e. health promotion plus a full range of preventive and curative services), whether they are part of provincial or local government health departments.

The second form of decentralisation in South Africa was that of deconcentration within provincial health departments to health districts, and in some provinces to regions (which is a tier between the district and provincial level). The creation of health districts occurred in most provinces before local government boundaries had been finalised. As a result, health district boundaries are frequently not co-terminous with local government boundaries.¹²

The lack of clarity about certain responsibilities and lines of accountability created by these parallel processes of devolution and deconcentration has been exacerbated by the continuation of management structures for a number of formerly vertical health programmes. In the past, programmes such as communicable disease control, nutrition, STDs/HIV/AIDS, and certain maternal, child and women's health (MCWH) services were organised vertically; planning and management for each programme occurred separately from other services from the central level down to service delivery level. These services are now supposed to be provided in an integrated way, with district and facility managers responsible for planning and management of all services. Despite the policy move towards integration, there are still “vertical” programme managers at national and provincial level. For example, there is a separate directorate and programme manager for MCWH (renamed sexual and reproductive health (SRH) services in some areas) in the national health department and in each provincial health department. These managers are responsible for overseeing the implementation of policy relating to any MCWH/SRH issues (e.g. pregnancy care, cervical cancer screening, abortion) at facility level. The national and provincial level MCWH/SRH programme managers do this by engaging with district and facility level managers, who are primarily concerned with delivering integrated services, and by appealing to them to implement MCWH/SRH policies appropriately. They have very limited power themselves, however.

Health care financing issues

Devolution of political and considerable service delivery responsibility to provincial and local government has been accompanied by fiscal decentralisation, i.e. granting significant autonomy in decision-making on the allocation of resources between and within sectors. Provinces and local governments are funded through a combination of revenue they generate themselves and from block grant transfers from the national level.¹³ Decisions about the allocation of these resources between sectors are made by provincial treasuries and legislatures and similarly by local government treasuries and councils. Budget allocations to local government health departments are supplemented by subsidies from provincial health departments.

MCWH/SRH services are primarily funded through the budget allocations for integrated service provision to individual facilities. The national and provincial MCWH managers have very small budgets, which are used to fund their oversight functions and to support the implementation of MCHW/SRH policies (e.g. to train staff to deliver particular services). Sometimes, these managers are given special allocations to enable them to initiate a new service (e.g. termination of pregnancy).

Methodology

This paper draws extensively on research that was undertaken in late 1999 and early 2000.¹⁴ It is based on interviews with one national level health manager, nine at provincial and seven at local government level, as well as three facility managers and five regional or district managers. Interviews with the nine provincial managers were undertaken in three provinces and those selected for interview included managers responsible for overall district level or primary care services, those responsible for reproductive or maternal and child health programmes and financial managers.

Interviews were conducted telephonically by a single interviewer using a structured, open-ended questionnaire. The objectives of the questionnaire (and the research) were to obtain insights into:

• the relationship between the three spheres of government, and between provincial, regional and district levels, in policy development and policy implementation;

• the budgeting process, involvement of various stakeholders in budget decision-making and mechanisms for taking policy changes into account in budgeting;

• interviewee's personal involvement in policy and budgeting processes and whether this matched their expectations;

• interaction between ‘vertical’ programme managers and integrated service delivery managers (at provincial, regional, district and facility levels as well as within local government health departments); and

• the quality of care provided and factors influencing service quality.

Analysis of interview data was guided by the policy analysis approach of Walt and Gilson.¹⁵ Their approach highlights that it is not only important to focus on policy content or design issues. It is equally important to consider the context within which policy is developed and implemented, the values and roles of different actors in policy development and implementation, and the process of identifying, formulating and implementing policies.

Given the qualitative nature of the data, a number of key informants (health system researchers and senior managers) were asked to review the draft findings to ensure that appropriate conclusions were being drawn. In addition, supporting evidence from other recently published research is referred to.

Formulating policy

Constitutionally, the major health sector policy-making responsibility resides with the national Department of Health. However, provincial and local government health departments expect to input to this process extensively. Interviewees consistently expressed this expectation.

Certainly no decision will be accepted if there hasn't been a SALGA [South African Local Government Association] input. National have realised you have to have local government input.

(Local government manager)

This expectation is directly related to the political context prevailing in South Africa. The process of political transformation and achieving the country's first democratic elections created considerable expectations of greater participation in decision-making within South African society. When this is coupled with the substantial autonomy granted through the devolution process, there is a strong sense that policy-making should be democratic and transparent and should certainly involve all three spheres of government.

There are also pragmatic reasons for expecting such participation. As the implementation of health policy is primarily the responsibility of provincial and local government health departments, these spheres of government have a legitimate interest in ensuring that policies are realistic and feasible.

Within this context, the process of policy development, particularly the extent to which key actors are consulted, and the policy implementation process, especially whether the objectives of the policy are adequately communicated and implementers are involved in planning this process, are critical. There are a number of structures in place to ensure that senior provincial and local government health managers are involved in determining new policy directions. For example, a Provincial Health Restructuring Committee (PHRC), comprising the heads of the national and all nine provincial health departments as well as representatives of SALGA, meet monthly to discuss policy and implementation issues.

Although efforts are made to ensure that senior provincial and local government representatives are involved in key policy decision-making processes, involvement of other health managers does not occur to any great extent. Managers at the regional, district and facility level feel excluded from decision-making processes, and thereby feel undervalued and disempowered, and are resentful that they are merely expected to implement decisions made by those above them. Managers at these levels frequently referred to the policy-making process as follows: “It's totally top down” and “They just tell us that ‘This is the policy from national and you have to implement it’”. As senior provincial and local government officials expect to be consulted by the national Department of Health, so the managers below them have an expectation that they too will be consulted.

While it may not be feasible to fulfil these expectations, it is of considerable concern that there are limited efforts even to communicate policy decisions adequately to managers at lower levels and to front-line health workers. Those who are expected to implement policy decisions frequently receive little advance warning and therefore have little time to plan. One regional manager commented in relation to a new policy to include Hib (Haemophilus influenzae Type B) among the standard childhood vaccinations:

“When we heard about it, it was in June and it was to be implemented in July, so we didn't even have time to argue about the whole issue.”

The lack of consultation in developing new policies and the lack of communication about policy changes can have significant adverse effects on staff morale. This has been demonstrated in relation to a number of new policies. For example, there was considerable health worker resentment about the process of introducing free health care for pregnant women and children under six.¹⁶ All health workers and managers, with the exception of a few of the most senior national health department officials, first heard about the policy when the President announced it in a public address, a few weeks before it was to be introduced. The lack of communication, particularly about the reasons underlying it, has resulted in health workers and lower level managers forming their own opinions, frequently negative, about the value of this policy. Previous research, conducted a year after the policy was introduced, indicated that health workers believed the policy exacerbated poor working conditions, particularly overcrowding and staff shortages at health facilities. In particular, frontline health workers feared that patients would abuse this policy, with some arguing that it “would encourage women to become pregnant”, even though there is no empirical evidence that this has occurred.^{2 17}

Figure 1 Cape Town, 1999

Similar concerns have been raised in relation to the implementation of a new policy aimed to increase access to legal and safe abortions. Service managers have expressed concern at the failure of programme managers to consult with them regarding where, when and how to implement abortion services.¹⁸ In one province, abortion providers ranked the problem of management resistance to making abortion services available in their facilities as the greatest obstacle to implementing this policy.¹⁹ The exclusion of managers from the National Termination of Pregnancy Advisory Group may account for this.¹⁸ Moreover, no steps were taken during the policy development process to consult with health workers or to proactively address the negative feelings of many health providers regarding abortion, although some values clarifications workshops were facilitated by sexual and reproductive health NGOs after the legislation had been passed and implementation initiated.²⁰ Possibly of greater concern is the failure of the policy implementation process in most provinces to provide support to nurses working in abortion services, who have been experiencing considerable stress. There is a shortage of providers willing to conduct abortions, and nurses are paying a heavy emotional toll due to their support for the plight of women needing abortions on the one hand, and being scapegoated by colleagues and community members on the other.²¹

It is of considerable concern that many of the policies that are the subject of negative health worker attitudes, due to inadequate consultation and policy communication processes, relate to reproductive health, pregnancy-related and non-reproductive health-related services provided to women. This is partly due to the lack of coherence in interactions between provincial level MCWH programme managers and district and facility managers and front-line providers. At the same time, however, policies which may raise personal concerns among health providers, such as abortion, should be introduced with a careful process of building understanding of the motivations for the new policies and fostering health provider willingness to participate in service provision for health and rights reasons.²⁰ Regional and district managers in particular should be involved in these communication and value clarification exercises, with support from the national and provincial level and relevant NGOs (in the form of materials and facilitation expertise).

Improved communication on changes in health policy is critical in order to motivate lower level managers and front-line workers to implement new policies. As noted by another research project based on interviews with facility managers:

“If you explain the policy before implementation, you are likely to stand a better chance of attaining their co-operation …rather than circulars that are coming from the province.” ²²

Operations research conducted in three provinces created mechanisms for general consultation with health providers about health service problems and possible solutions, whilst also engaging them in self-reflection about their roles and behaviour. This helped to establish an enabling environment for the introduction of reproductive health policies. Where health providers had not been through such processes, they were less open-minded about both abortion and cervical screening services.²³

Budgeting and financial resources

The introduction of fiscal decentralisation has resulted in considerable autonomy within the provincial and local government spheres in deciding on the allocation of resources between health and other sectors. The provincial and local government treasuries have considerable power in determining these inter-sectoral allocations.^{24 25} Although each sectoral department makes budget submissions to its respective treasury, treasuries often do not make an explicit or direct link between budget allocations and changes in sectoral policies. Ensuring that there are adequate resources to facilitate the implementation of new policies is a key aspect of policy design and an appropriate implementation process.

This lack of consideration of the resource requirements of policy changes impacts negatively on the implementation of these policies. Managers interviewed repeatedly referred to the frustration of attempting to implement new policies which require additional services (e.g. the provision of abortion on request) but which are not supported by budgetary changes. Where policies are introduced in the middle of a financial year, national or provincial government sometimes provides additional materials for the remainder of that year but expects the implementing level to cover the costs under their normal budget from then on. For example, a provincial programme officer described how she provided equipment and long gloves for all regions when abortion on request was introduced, and vaginal specula and sterilisers for the new cervical screening policy but that was: “…for a start; then from then it's from their budget”.

Recent research has highlighted the fact that there has been very little real growth in health sector budgets in most provinces over the past few years.²⁶ There is certainly little evidence that the increased resource requirements of new policies are adequately considered.

“I don't think that from the national or provincial side they're aware of what is going on at grassroots level. They're sitting with all these bills and acts and policies that we try to apply. But sometimes we're not able to. We don't have the human resources and financial resources.”

(Lower level manager)

“Our policies are pie in the sky rather than real… We started off saying things would be delivered because they were the right things and people were entitled. But entitlement without resources doesn't get you anywhere.”

(Provincial manager)

“We asked ‘where does the money come from for AZT? [referring to a policy directive that rape survivors should receive AZT]’ We just have to provide it because someone has approved the policy… We didn't have any chance to give our view on the issues.”

(Regional manager)

While the provincial health department has little power to influence the budget allocated to it, it has considerable autonomy in determining the allocation of these resources to individual districts, facilities and “vertical” programmes. However, this budgeting process is still highly centralised, and sometimes feedback on the final allocations is not even provided to lower level managers.

“We do plan and give it to [provincial managers] and it comes back being a different thing altogether …We're asked to budget and send figures, and then it gets cut.”

(District manager)

“Every year we sit down, plan and budget. Then we present it. Then they'll tell you it'll be discussed by senior management but you're never told ‘Yes, you can spend X much money or more’.”

(Programme manager)

Given the extent of decentralisation that has occurred within the health sector, lower level managers have a justifiable expectation that they would have responsibility for developing their own plans and budgets and that these should be given due consideration. It is extremely demoralising for lower level managers to prepare plans and budgets, which are then effectively ignored. Another research project found that provincial managers complained that budgets developed by decentralised units were “completely unrealistic” and therefore need not be taken into account when determining budget allocations.¹³

However, part of the problem is that lower level managers are not fully informed of overall budget constraints, and this problem could easily be addressed by providing guideline allocations within which “vertical” programmes, facilities and districts should budget. Inadequate budgeting practices are also exacerbated by the lack of financial management capacity at decentralised levels.¹³ While there are initiatives to develop such capacity, other simple interventions such as providing guideline budget allocations are still absent in many provinces. By continuing to allow unrealistic budgeting at lower levels, provincial managers merely contribute to the disempowerment and demoralisation of lower level managers.

Although it is evident that there is greater financial management capacity in many local government health departments than in lower levels of provincial departments,¹⁴ there are similar concerns that improved resourcing is not accompanying the multiple new policy requirements. Local government health departments are in a particularly difficult position, as they are to some extent dependent on subsidy allocations from provincial health departments. Recent research into local government health care financing has indicated that many local governments complain of delays in receiving the subsidies, while some have reported that the subsidies are sometimes arbitrarily cut by the provincial health department halfway through a financial year.²⁵

The resentment that lower level managers and frontline workers feel about their exclusion from the policy-making process is compounded by the lack of financial resources to appropriately implement the numerous policy directives.

Implementation and service delivery

Various factors have contributed to policy implementation difficulties and have adversely impacted on the quality of services delivered. The pace of change has been rapid and the extent of restructuring substantial. The process of restructuring health services from the previous administration, which was fragmented along racial lines, to a unified yet decentralised health system was an enormous undertaking. Many felt that the focus on restructuring during the initial phases detracted from improved service provision. When this restructuring is combined with the introduction of a range of new policies on an ongoing basis, many managers complained that massive changes were being expected while “often we're not doing basic things right yet”.

“We are moving too slowly for expectations and much too fast for the capacity of the system to sustain it… Our staff are reeling… We focused too much on restructuring and transition and not enough on service.”

(Provincial manager)

Further, despite the official policy of integrated primary care service provision, the historical practice of certain staff providing a single service (e.g. family planning) and of providing some services only on certain days of the week (e.g. well baby clinic on a Monday morning) continues in many facilities. Service users, on the other hand, prefer integrated services.

“Users complained that the clinics offered different services on different days and argued for a range of services provided at one service-delivery point (dubbed “the supermarket approach” in South Africa). Senior staff also favoured a supermarket approach; however, many front-line providers, while not questioning the value of offering multiple services on one visit, contended that this would increase their workload too much.” ²³

Other recent research has indicated that “district managers emphasised the negative impact of provincial vertical programmes on integrated planning at the district level”.²⁷ This has been exacerbated by the deconcentration to health regions and districts, given that programme managers only exist at the national and provincial levels and there are no dedicated programme managers on the regional and district health management teams. Instead, the regional, district and facility managers are expected to assume some responsibility for all of these programmes. As a district manager interviewed in another study indicated:

“…in the provincial office there are so many people who are running programmes, each one is running one programme; when it comes down to the district level they all pour over one head, which makes it so difficult.” ²⁷

One of the key problems relates to conflicting lines of accountability; for example facility staff involved in the provision of services falling under a “vertical” programme should be accountable to their facility manager in line with the decentralisation process, yet provincial programme managers also try to hold them to account. Many lower level managers and health workers regard the competing demands placed on them by the different programme managers as even more problematic. This is particularly evident in relation to training, where programme managers frequently expect service providers to be available for training relating to their particular programme.²² One regional manager indicated that their staff were spending 40% of their time in training courses:

“We're starting to decide [on training] more and more at a regional level but the reality of what happens is that the provincial office sends you a fax saying that next week there's training on burns, please send someone. Then that there's an HIV summit and the Minister wants someone to attend…Everyone's trained up to their eyeballs.”

Programme managers themselves face considerable frustration as their role is to provide programmatically vertical technical support to the districts and to assist in the monitoring of programme implementation.²⁸ While they have responsibility for programmes, they have to rely on others, over whom they have no authority, to implement these programmes. One programme manager expressed this challenge as follows: “You have to achieve things through others—you facilitate but you don't have the power to say ‘This should happen on this day’” (referring to the continued practice of only delivering certain services on particular days of the week). Another programme manager felt disempowered by her lack of influence over the implementation process:

“I have to say ‘Please, please do this or that’…But then the regions will raise their own constraints and will do it at their own pace.”

The above discussion highlights the importance of careful consideration of how “vertical” programme managers should interact with managers and health workers in integrated service facilities. Clear delineation of roles and responsibilities, the granting of authority in line with responsibility, and clear lines of accountability are critical. This is particularly important in a decentralised system. If service management were still concentrated at the provincial level, facility managers and health workers would be more inclined to respond to provincial directives, whether from a general or a “vertical” programme manager. However, where service management has been deconcentrated to district level, district and facility managers and front-line workers are unlikely to take kindly to interventions from provincial programme managers. As one regional manager expressed:

“There's a tendency for programme managers to interfere with operational issues, which drives us berserk.”

As has been highlighted in the decentralisation literature, it is as important to restructure the centre, in this instance to restructure “vertical” programme management within national and provincial health departments, as it is to develop management capacity at the lower levels when decentralising health services.²⁹

Staff morale and working conditions

The final factor that impacts significantly on policy implementation and the overall quality of health service provision is that of staff morale and attitudes. Many recent studies of health services in South Africa have highlighted significant problems in this regard. For example, a recent review article indicated that factors contributing to health service quality weaknesses “include infrastructural problems, gaps in drug availability and perhaps most pernicious, staff discourtesy towards, and even abuse of, patients”.³⁰ This has also been noted more specifically in relation to reproductive health services:

“The primary complaint of women about reproductive health services, whether family planning or maternal services, was the hostile attitude of health workers.” ³¹

In the current study, when asked if lack of financial and other resources was the major impediment to providing high quality services, the vast majority of managers indicated that staff attitudes and morale were more important in this regard. One interviewee cited the following example to support this claim:

“There was a clinic which was always full and another maybe seven kilometres from it which was not busy. But patients came from the empty one to the busy one. We took one nurse from the busy clinic and put her in the quiet clinic and that clinic within a short time was busy. So we could see this was an attitudes thing.”

(Provincial manager)

Staff morale and attitudes are influenced by many factors including dissatisfaction with salaries and other conditions of employment. A provincial official noted:

“There's a shortage of trained nurses… They go outside the country to Saudi Arabia, to England… Hard working people are not getting any incentive and a person will say ‘I've worked 20 years but there's no promotion, no extra money, no night duty allowance’.”

Other interviewees were less sympathetic to this argument, and made statements such as the following:

“There's a moral apathy in the country at the moment. A sense of entitlement—why should I work for what I get?”

Further research is required to assess the extent to which these competing views are prevalent and reflect the reality on the ground.

Another contributory factor is the uncertainty created by ongoing health sector restructuring. A clinic manager noted that “people are not very happy about change all the time—people fear change”. The restructuring process in South Africa has involved cutting of posts, which creates considerable job insecurity. This is exacerbated by a lack of transparency in this transformation process:

“You get corridor gossip that this or that directorate is going to go. If only someone would come and tell people that there's no hidden agenda and spell it out up front.”

(Provincial programme manager)

Some interviewees identified another contributory factor, that staff have little sense of being valued or appreciated by their seniors or the public.

“The public are demanding. They don't come back and say ‘Thank you for the service’. Nursing staff also have human rights. The public expect too much.”

(Regional manager)

Conclusions and recommendations

This paper aims to contribute to an understanding of the personal dimensions of policy change. It highlights that institutions are made up of people in relationships of power. It particularly indicates that lower level managers and front-line health workers are important actors in the policy implementation process. How key actors experience the process of change will influence the way in which policies are designed, and whether they are implemented or ignored. These processes have to take account of the prevailing context, which in the South African case has included heightened expectations of transparent and consultative processes since the 1994 elections, and the implications of introducing a highly devolved political and management system. Also of importance within the South African context has been the lack of consideration of how “vertical” programme managers, including those for sexual and reproductive health programmes, engage with decentralised, integrated service provision, which can exacerbate confusion about roles and responsibilities, and lines of accountability, that frequently accompany the introduction of decentralisation.

• It is important to clarify expectations of health managers and frontline workers when health services are structured in a decentralised way, particularly when combined with a process of political democratisation. Where policy-making at national level used to be completely centralised, and decentralisation is only expected to result in greater participation of the most senior managers at the decentralised levels, this needs to be made explicit to lower level managers and health workers, to avoid unrealistic expectations.

• As a minimum, it is essential to improve communication with these groups once policy decisions have been made, in order to promote acceptance and successful implementation of policies. District and facility managers need to be empowered through timely communication from the provincial level about new policies, so that they can in turn adequately communicate with and motivate their staff. These communication processes should include values clarification discussions and allow for staff participation in planning and policy implementation.

• It is equally important to ensure that decentralised units are given the authority and capacity to prepare their own budgets and to support policy implementation with realistic assessments of their resource implications.

• The value of separate national and provincial level programme management for MCWH/SRH requires careful evaluation. There is undoubtedly some value in having a provincial level manager who consistently reinforces the importance of these services to lower level managers and health workers, can support the implementation of new policies and monitors sexual and reproductive health service delivery. If this programmatic structure continues, programme planning needs to occur with the active participation of district managers to improve the extent to which these programmatic services are seen as an integral part of district services. However, it may be more appropriate to give district and facility managers full responsibility for integrated services within the context of clearly specified policy priorities, combined with skills development to improve their understanding of the key aspects of such existing “vertical” programmes. Further consultation about these alternative approaches is required.

• Further research into the extent and causes of low staff morale is required as a matter of urgency, in order that appropriate measures can be taken to address this critical problem.

Much of the decentralisation literature focuses on structural and technical issues, with little consideration of what are viewed as “softer” issues, such as manager and health worker buy-in to restructuring and policy changes, and recognising and addressing health worker morale issues. If the human face of decentralisation is ignored, key health policies, such as those for sexual and reproductive health, will not be implemented successfully.

Acknowledgements

The longer paper on which this article is based was commissioned by the Women's Budget Initiative, which comprises the Parliamentary Committee on the Status of Women, the Community Agency for Social Enquiry (CASE) and the Institute for Democracy in South Africa (IDASA). It was published as: Klugman B, McIntyre D. From policy, through budgets, to implementation: delivering quality health care services. In: Budlender D, editor. The Fifth Women's Budget. Cape Town: IDASA, 2000. We would like to thank Debbie Budlender of the Initiative for her inputs and editorial support, those who participated in initial conceptualisation and those who agreed to be interviewed.