Understanding managers’ experiences of public financial management policies and reform: a qualitative study from a South African provincial department of health

Abstract

Introduction Public financial management (PFM) is the vehicle through which public funds are spent in pursuit of delivering public services, like healthcare. PFM and health service delivery have historically remained siloed. Health departments can receive an unqualified audit opinion, signalling good PFM, alongside poor health outcomes and ailing infrastructure. This could be due to insufficient funds that do not allow for optimal service delivery. It could also signal a health system where the PFM processes are strong but are not enabling service delivery sufficiently.

This research aimed to understand South African provincial department of health (PDoH) managers’ experiences of PFM reforms and practices. The research elicited evidence of how PFM reforms, and their enforcers, influenced organisational culture and power dynamics. It also sought to examine how the culture shaped the actions and choice of strategies used to improve service delivery during a period of constrained funding and rising medical negligence claims that further deplete the health budget.

Methods The research was qualitative, using an ethnographic case study design. The data were collected over one year in one South African PDoH. Thematic analysis was used to analyse the data. Trustworthiness was ensured through peer debriefing; prolonged engagement; and member checking.

Results Negligence claims have negatively impacted on available funds and illustrate how power has shifted toward finance managers because of their control of the health budget. This control was linked to their role in the health system as the protector of public funds and the team responsible for all financial management outputs. This desire to centralise PFM during periods of constraint was attributed to the low appetite for risk of finance managers and the strongly regulated PFM environment which uses punitive, bureaucratic accountability mechanisms. The centralisation reform negatively impacted on organisational culture and reduced opportunities for collaboration. However, ways of working that supported ‘authentic collaboration’- wherein engagement is intentional and active - were more successful.

Conclusion This research showed interdependencies between power, trust, collaboration, and accountability. ‘Authentic collaboration’ was found to be transformative in being able to bring together managers whose relationships are generally marked by mistrust and a power imbalance.