HEALTH Minister Aaron Motsoaledi frequently voices his dissatisfaction with the way public hospitals are being run, but plans to install a "command and control" solution raising eyebrows in medical circles.
In late December, Dr Motsoaledi grabbed front-page headlines with his announcement that the African National Congress had resolved at its national conference to centralise control of South Africa’s 10 "central" hospitals, commonly referred to as teaching hospitals.
His reasoning is that they are national assets supposed to provide highly specialised healthcare services for the whole country, yet patients living in the provinces in which they are located are given priority. He said some provincial health departments have diverted funds intended for training specialists at these facilities to other purposes, such as service delivery.
It has become such a pressing issue, he said, that the deans of medicine have appealed to him to intervene to protect the funding for registrar posts. The solution proposed is a rather statist one, putting control of these hospitals in the hands of his department.
Critics such as University of the Witwatersrand health economist Alex van den Heever argue that the issues could be resolved far more effectively by improving the way hospital financing is managed.
"If the government wants to protect registrar posts they should make them nationally funded, ring-fenced with conditional grants," with an agreement on how many such posts South Africa needs, says Prof van den Heever, who holds the Old Mutual chair of social security systems administration and management studies.
Properly managed conditional grants enable a national department to hold provinces accountable for the way they spend the money, he says. By contrast, managing teaching hospitals from Pretoria will diminish the government’s accountability to patients in the regions they serve.
"If the management of a hospital is a national function, it is much harder for people to vote them out of power," Prof van den Heever says, suggesting that the Democratic Alliance is particularly careful about service delivery in the Western Cape because it does not have a stranglehold on power.
Dr Motsoaledi has singled out central hospitals for attention, but the training issues he raises apply equally to the regional hospitals and clinics that are part of their referral network, collectively known as academic health complexes. Increasingly, training is taking place throughout the referral chain. Academic health complexes face a host of challenges as the competing agendas of service delivery, teaching and research vie for limited resources.
Funding comes from provincial health departments, the central departments of health and higher education, and to a lesser extent science and technology.
"The costs of managing services are huge and we find that when there is a financial crisis, our registrar posts are not filled, yet they are the training ground for specialists for the whole country," says Prof Errol Holland, chairman of the Committee of Medical Deans.
University of Stellenbosch medicine and health sciences dean Prof Jimmy Volmink says the minister’s sudden focus on managing central hospitals has taken the sector by surprise, as he established a committee last year to investigate the financing and development of healthcare professionals.
"I can’t see how operational day-to-day management of the hospitals from Pretoria would help anything, even if the Department of Health had the capacity to do it. (And) there is potential for a conflict of authority and fragmentation," he says.
Today, everybody associated with public hospitals seems to be unhappy, complaining of too much work, too little money, and too few services. Whether Dr Motsoaledi’s plans will change any of that remains to be seen.