By James Grant

Times change, and so do the pressures on governments which are expected to respond to health-related emergencies - but not often with the intensity associated with Covid 19. A few years ago my theme would have been very different, the pandemic under discussion then might have been HIV-AIDS.

A couple of months ago I had a discussion with a journalist friend about the meaning of dystopia. I had not come across the word until 2018. We agreed that we are now living in such a world every day because of the current pandemic. Dystopia implies chaos, despair and fear, all of which are relevant not just to the current South African experience but to other countries as well. I intend to show that the current crisis places in sharp relief some issues of broader significance for the governance of the country.

THE HEALTH CARE SYSTEM

South Africa is arguably one of the better resourced and managed African states. But it is not well placed if wider international comparisons are made. The inadequate quality of care in the public health sector has been evidenced in numerous ways. The resource scarcity that exists has been worsened by procurement processes which have been seen as sufficiently corrupt to cause some members of the governing class to face charges in the courts. The dossier of alleged transgressors includes a former Minister of Health who held that portfolio when alarm bells about the pandemic were first heard and was soon after accused of illegally manipulating tender processes. Covid can be seen as yet another area of policy implementation symptomatic of continuing weaknesses in the state and the ruling party, as observed in this publication in 2018 (Davidson 2018) (1). It is also a feature of governance elsewhere in Africa.

Although better placed than most African states, South Africa does not have a unified and reasonably coherent health system resembling those of welfare states such as the United Kingdom’s National Health Service (NHS). What it does have is a dual system in which the private sector is a very powerful player, with expensive facilities and services which would not be out of place in California, whilst the public sector runs a large number of lower quality hospitals and clinics all over the country. These public facilities are under resourced in relation to need whilst at the same time are expected to serve the majority of the population. What does exist is a radical plan drawn up a decade ago, but not yet approved, which is partly based on the original idea of UK’s NHS (Brauns and Wallis 2014) (2). Although this plan was powerfully driven by the then Minister of Health (not the one accused of corruption), himself a doctor with experience of practising in some of the more disadvantaged areas of the country, it has faced resistance from the private sector and a cautious Treasury. It is clear that capitalism has been a dominant factor in holding the plan back. However, it appears to have been given a revival as announced in the recent President’s State of the Nation Address (SONA 2022) (3); but it may be stymied again. Thus what seems highly desirable from the perspectives of public health and social justice may still fall foul of influential mind sets including many in the medical profession. In the health sector there are significant interests driven by capitalism, health care being big business in South Africa. For example, there are private companies that are major players such as Netcare and Life, and some universities - for example, the University of Cape Town’s private hospital (the university is a public institution but its hospital is private). This consequential inequality is part of a wider legacy of apartheid in which race is not necessarily the only stand-out factor which is creating inequality as class is more of a factor than it once was.

Also important is another dimension of the country’s health system, much of which falls within the sphere of local government. Public health is not just about curing the sick. It is also about the conditions in which people live, as Engels showed us in nineteenth century England (Engels 1845) (4). If he were to visit the ‘townships’ of Cape Town, for example, he would be saddened to see such health risks as over-crowding, poor sanitation, hunger, dangerously constructed housing which is poorly maintained and serviced (often shacks made out of unsuitable material and in areas liable to floods) and conditions conducive to crime. All of this can be found five minutes’ drive from the city’s international airport. It is almost equally close to bourgeois suburbs where ostentatious wealth prevails and where even a modest home can cost the equivalent of £150, 000, which is a hugely excessive amount for the vast majority of people, most of whom are black. In addition, the signs are that unemployment is close to 50% and rising. Precise figures cannot be given as unemployment is not fully documented but the situation is especially dire for school leavers and even university graduates. In Marxist terms, this can be called ‘the reserve army of the unemployed’ (oddly this useful term is not often deployed in South African debates despite its aptness). I gather that in the USA reference is now made to ‘environmental racism’ (Lexington 2022: 40) (5). It would be reasonable to apply this term to South Africa. Much of the spatial profile of South Africa as a whole has serious health care implications (for example, even the cost of travelling to be vaccinated is difficult if you are unemployed).

COVID AND FRONTLINE WORKERS 

All of the above helps to show why Covid has been no ordinary challenge for South Africa’s health system. It has been a difficult task for it to overcome the apartheid legacy. The addition of Covid to the mix has made the pressures much harder to face.

Part of the pressure of course falls upon those whose role is to provide a wide range of health services. A key point arising here is the critical role played by front line workers such as nurses, hospital clerks, the providers of emergency services, and carers (who are often unpaid or low paid family members). Mostly these are working class people. There has been a tendency to take such workers for granted despite their strategic importance. The role of top leadership in health policy and management has to be given its due weight but the danger is that such a perspective can become a distortion of the reality. The effectiveness of any health system rests on what happens at the point of delivery where vaccinations are done, tests are conducted, patients admitted to hospitals and provided with conditions which are as conducive as possible to their recovery. Even if there were no pandemic, the need for more focus on such workers would be clear. It is perhaps an unintended consequence of Covid that this issue has emerged so strongly.

There is also a more general point to be made. Do we give enough attention to other types of frontline workers such as refuse collectors and school teachers? In both cases their roles are relevant to Covid as, for example, schooling has had to be changed drastically in all sorts of ways, and refuse collectors are essential to minimise environmental health risks. Such workers are far more important parts of the state than is often assumed, only being noticed when the functions they serve malfunction (e.g. refuse not being collected, classroom toilets flooded after a storm, strikes).

As elsewhere, what has also been brought into focus by the pandemic is the importance of data and the difficulties associated with it. This has several dimensions but in broad terms there are three points of particular relevance. One is the fact that the collection of reliable data is highly important in the management of the pandemic but is difficult and therefore unreliable, especially in remote areas. Secondly, interpretation of the numbers needs to be carried out with care; failure to do so can distort policy and its management. For example, in the South Africa case it is not easy to pinpoint reasons for differences between geographical areas unless all relevant variables are duly considered. For instance, the provinces with the most Covid cases are also those in which the most economic activity takes place and with higher population densities, but what does that mean in terms of some sort of causal link? Population density is certainly a major factor but other conditions such as inadequate sanitation and poorly resourced local clinics and hospitals are also problematic. Thirdly, the problem of data interpretation appears to have worsened because of the ascent of social media into very many aspects of people’s lives including the realm of policy debate in ways not dreamt of two decades ago. In relation to Covid, the ‘anti-vaxxer’ phenomenon is an example.

CORRUPTION AND STATE CAPTURE 

Covid has provided eagerly grasped opportunities for what in South Africa are termed ‘tenderpreneurs’. This word was invented at the turn of the century and is used to describe business persons who depend heavily on the award of state tenders within all ‘spheres’ (tiers) of government. It is very much part of what has been termed ‘state capture’ which is currently the subject of a comprehensive commission headed by a senior judge. Some devastating conclusions have already emerged. The signs are that some further devastating conclusions will emerge. Tendering and corruption have been combined with some frequency. There has also been a widespread and distorted use of the word ‘comrade’ which, shorn of any revolutionary meaning, refers to business connections between persons disingenuously claiming to be political activists who are associated with the ruling African National Congress. Cronyism would be another word to use. Covid opened up all sorts of such opportunities, the taking up of which sometimes fell short of acceptable ethical and legal standards. Another term that might be used to describe the South African situation is ‘kleptomania’ to refer to people who cannot resist the temptation to make money illegally and/or unethically. The urgency of the need to speed up the response to the pandemic created enough chaos for formal processes to be flouted too easily and thus made it essential to take corrective action. For example, a key area has been the procurement of personal protective equipment such as latex gloves, eye and face protection and clothing. This has occurred despite legislation aimed to rectify processes. The National Treasury has been concerned by the situation and its possible consequences (National Treasury 2020, http//www.news24) (6).

Covid 19 is important but it is just one example of a bigger problem facing African states, albeit a hugely important one. It highlights the continuing need to build a developmental state based on more than just political leadership but on bureaucracies which have expertise together with merit recruitment, which are much more responsive to the needs of a largely impoverished and black public, and are as close as possible to practising zero tolerance to corruption. Perhaps such a state would be one that corresponds to what some on the South African left call the National Democratic Revolution - which, however, should be seen merely as an aspiration as it is not yet an achieved reality. It is difficult to see any of the two opposition parties coming to power or, if they were to, improving on the increasingly discredited African National Congress – as shown, for example by recent elections. One – the Democratic Alliance – would probably promote capitalism more robustly, while the other, the Economic Freedom Fighters, has a populist slant which might have the effect of hastening the tide of corruption.

The picture I have painted may appear bleak, that of a curmudgeon, but there is room for hope. For example, the resilience, competence and compassion of those who are directly involved in the provision of health services cannot be ignored. In many cases the conditions under which health staff work make high demands which have largely been met, much as in other parts of the world. The vaccine programme has been reasonably successful after a patchy and somewhat delayed roll out. There has been some resistance among members of the public to taking the needle but it seems to have been less problematic than in most other countries.  A similar point can be made about Covid 19 testing and treatment. Six months ago a new Finance Minister was appointed. There are signs that one result may be that there will be more focus on building an effective state (Whitehouse 2021:92) (7).

The overall effort has benefited from the involvement of private sector and non-governmental organisations (your correspondent was twice vaccinated in a temporary facility in a church which he would not have otherwise entered). But this does not mean that delivery of health services can readily benefit from involving the high cost private sector. This is for various reasons, not least of which is that the majority of people needing care are too poor to pay the costs likely to be charged. It is better to argue differently. The pandemic in South Africa has demonstrated both the need for, and potential of, a public sector which is well regulated, separated from predatory business and well resourced – even if a comprehensive and affordable ‘cradle to the grave’ service along welfare state lines has to be deferred for now.

This article has a similar focus to a presentation made by the author to a virtual seminar in 2021 convened by the Morocco based organisation United Cities and Local Governments of Africa addressing contemporary issues facing public management in Africa. The talk was titled: ‘Public Management in Africa in the time of Covid’. He is a participant in the health care sector in South Africa as an educator, patient, researcher and employee of the non-governmental organisation – Dementia SA.

 

(1) Davidson, A. 2018. ‘What now for South Africa and the ANC? In The Socialist Correspondent. Issue 30

 

(2) Brauns, M. and Wallis, M. 2014 ‘Performance management and public policy. The case of the health sector in South Africa’ in Administratio Publica, 22/1 pp149-170.

 

(3) SONA (State of the Nation Address) 2022.https://www.stateofthenation.gov.za

 

(4) Engels, F. The Condition of the Working Class in England. (London: Penguin 1987).

 

(5) Lexington. 2022. ‘Environmental Justice in the balance’ in The Economist (January 29^th).

 

(6) National Treasury 2020 https://sacoronavirus.co.za.

News 24 https//www.news24//southafrica/news/ppecorruption.police officers among 15 arrested in connection with r15m-latexglovestender1022027.

 

(7) Whitehouse, D. 2021. Interview in The Africa Report (October-November-December).

President Cyril Ramaphosa photo by ITU Pictures

South African health care workers photo by Mnish96