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

Abstract

The design of the decentralized co-operative governance system, conditioned and
\nregulated by the South African constitution is of critical importance for policy design and
\nimplementation. The division of powers falls within a unitary form of government. This
\nstudy, which is about the processes, mechanisms and modalities of public policies
\ndesign and implementation uses the public finance and health sectors, as a case study
\nor lens through which policy design and implementation is examined within a
\ndecentralized cooperative governance system. The study is per se not about the public
\nhealth system, but rather a review and an analysis about how the decentralization and
\ncooperative governance nature, practice and dynamic of government system, influences
\nand condition the policy processes and practice on finance and health, separately and
\ncollectively within the public health system.
\nIn its attempt to unbundle the health function, but also reform the public health system,
\ncentral and provincial governments have introduced a number of reforms. These reforms
\nwere ostensibly driven by different policies and programmes originating either from the
\npublic finance or public health sectors with significant consequences for the provinces.
\nMoreover, these different policies also outlined structural and functional responsibilities
\nand authority among the central and provincial government departments. The
\nimplementation of these policies was at times based on different interpretations of policy
\ndesign and implementation responsibilities and authority between the central and
\nprovincial governments within co-operative governance system.
\nThe argument of this study is that despite intentions implicit to public policy, co-operative
\ngovernance system is contested at a central government level within the public health
\nsystem, as well as between levels of government and the public health and finance
\nsectors. This dissertation explores the nature of the relationship between the central and
\nprovincial governments by exploring co-operative governance in the health sector on
\npolicy and financing processes and mechanisms. The central question is how does
\ndecentralized co-operative governance really work in the public health system?
\nA case study method was used to conduct this research. Data was collected over a four
\nand half year period using a variety of data collection methods, including semi-structured
\nin-depth interviews; documents and reports analyses; policy content review and
\nanalyses; and revenue and expenditure reviews and analyses.
\nThe study’s findings are:
\na) the functional and structural decentralization of policy-making and implementation
\nwithin the co-operative governance system contributes to undermining the cooperative
\ngovernance relationship between the public finance and health sector and
\ncentral and provincial governments;
\nb) the central government is using its overriding powers to “impose co-ordinated
\nsolutions” to problems within the co-operative governance system, leading to
\nsituations where ‘imposed co-ordination’ is considered as ‘co-operative governance’;
\nc) the theory provides a classical distinction between state control, supervision and
\ninterference models. This dissertation shows that, depending on the policy context
\nand circumstances, the uniqueness of South Africa’s co-operative governance
\nsystem allows the central government to mobilize any of these models to achieve its
\npolicy intentions, whether written or unwritten; and
\nd) the classical arguments of decentralization, particularly within a devolved system of
\nco-operative governance where greater autonomy and authority are given to subnational
\ngovernments, are found wanting within the South African governance
\nsystem, given both the policy-making and fiscal resource strength of the central
\ngovernment relative to the provinces.
\nThis dissertation leads me to conclude that the South African practice of co-operative
\ngovernance in the health system is actually imposed co-ordination and that provinces
\nare de facto administration outposts of central government policies, programmes and
\nservice delivery responsibilities. Therefore in reality there is no autonomy and
\nindependence of the provinces from the central government as envisaged in the
\nConstitution of the Republic of South Africa. In fact, provinces only exist, in terms of their
\nconstitutional competencies as far the central government allows it to exist given its
\nplenipotentiary powers over both micro and macro matters affecting institutions, fiscus
\nand social policies.