Decentralized co-operative governance of the public health system in South Africa

Abstract

The design of the decentralized co-operative governance system, conditioned and regulated by the South African constitution is of critical importance for policy design and implementation. The division of powers falls within a unitary form of government. This study, which is about the processes, mechanisms and modalities of public policies design and implementation uses the public finance and health sectors, as a case study or lens through which policy design and implementation is examined within a decentralized cooperative governance system. The study is per se not about the public health system, but rather a review and an analysis about how the decentralization and cooperative governance nature, practice and dynamic of government system, influences and condition the policy processes and practice on finance and health, separately and collectively within the public health system. In its attempt to unbundle the health function, but also reform the public health system, central and provincial governments have introduced a number of reforms. These reforms were ostensibly driven by different policies and programmes originating either from the public finance or public health sectors with significant consequences for the provinces. Moreover, these different policies also outlined structural and functional responsibilities and authority among the central and provincial government departments. The implementation of these policies was at times based on different interpretations of policy design and implementation responsibilities and authority between the central and provincial governments within co-operative governance system. The argument of this study is that despite intentions implicit to public policy, co-operative governance system is contested at a central government level within the public health system, as well as between levels of government and the public health and finance sectors. This dissertation explores the nature of the relationship between the central and provincial governments by exploring co-operative governance in the health sector on policy and financing processes and mechanisms. The central question is how does decentralized co-operative governance really work in the public health system? A case study method was used to conduct this research. Data was collected over a four and half year period using a variety of data collection methods, including semi-structured in-depth interviews; documents and reports analyses; policy content review and analyses; and revenue and expenditure reviews and analyses. The study’s findings are: a) the functional and structural decentralization of policy-making and implementation within the co-operative governance system contributes to undermining the cooperative governance relationship between the public finance and health sector and central and provincial governments; b) the central government is using its overriding powers to “impose co-ordinated solutions” to problems within the co-operative governance system, leading to situations where ‘imposed co-ordination’ is considered as ‘co-operative governance’; c) the theory provides a classical distinction between state control, supervision and interference models. This dissertation shows that, depending on the policy context and circumstances, the uniqueness of South Africa’s co-operative governance system allows the central government to mobilize any of these models to achieve its policy intentions, whether written or unwritten; and d) the classical arguments of decentralization, particularly within a devolved system of co-operative governance where greater autonomy and authority are given to subnational governments, are found wanting within the South African governance system, given both the policy-making and fiscal resource strength of the central government relative to the provinces. This dissertation leads me to conclude that the South African practice of co-operative governance in the health system is actually imposed co-ordination and that provinces are de facto administration outposts of central government policies, programmes and service delivery responsibilities. Therefore in reality there is no autonomy and independence of the provinces from the central government as envisaged in the Constitution of the Republic of South Africa. In fact, provinces only exist, in terms of their constitutional competencies as far the central government allows it to exist given its plenipotentiary powers over both micro and macro matters affecting institutions, fiscus and social policies.