By Joan van Dyk for Spotlight
South Africa’s public healthcare system finds itself caught between two incomplete revolutions – the democratic dream of a decentralised District Health System, and the march toward National Health Insurance. Health systems experts argue that structural changes won’t save a system that is scared stiff. The most urgent task facing the system, they say, is to help frontline doctors and nurses reimagine what is possible.
Part of what makes an octopus such a nimble, wily creature is that there’s more brain outside its head than in it.
In fact, about two-thirds of an octopus brain is spread across its eight tentacles, each one controlled by a tangle of neurons, its own mini-brain.
These semi-autonomous processing centres allow the octopus to control hundreds of individual suckers, which means tentacles can investigate crevices the eyes can’t see, and even learn from each other without much of the big brain’s help.
The suckers can sample the seafloor and decide whether what it finds is safe to eat, at which point a tentacle turns into a temporary elbow to bring the morsel to its beak.
This is the kind of intelligent and adaptable network that was envisioned for South Africa’s District Health System (DHS).
Where apartheid-era planning demanded top-down compliance, among others to enforce racial oppression and dispossession, the DHS, with its 52 districts and 240 sub-districts, promised to empower staff to respond to patients’ everyday realities, whether they live in a city or a rural village.
In reality, much of the system’s financial and administrative power has pooled at provincial head offices, trapping staff on the ground in the old command-and-control way of doing things.
As a result, frontline healthcare workers clock in every day with the task of executing more than 175 new clinical guidelines (that’s just since 2012) while also racing to meet sometimes out-of-touch performance targets. That is according to 2020 research conducted among district managers in the Eastern Cape, Western Cape, KwaZulu-Natal and Limpopo.
What’s more, layers of red tape added to catch corruption have not deterred politically connected syndicates. Research suggests it has only overwhelmed clinical managers and facility heads who are held accountable for patient experiences but can’t replace even the most basic equipment needed for care, such as a scale, without kicking off a months-long procurement effort.
Under these conditions, health workers have said repeatedly that the work of caring for people gives way to constant administrative self-preservation.
One Eastern Cape manager told researchers: “We will comply now and complain later. If you don’t comply, it means you are failing your district, or your sub-district, or your clinic or your people.”
Much like an octopus might become a danger to itself if it only believes its eyes, the health system’s top-down leadership style is damaging to those it employs and ultimately, to those it serves.
Fear and loathing in the platinum belt
It is possible to bring the original DHS dream to life by shaking the systemic fear out of daily operations.
Leading the charge is SALAD, the South African Learning Alliance for the District Health System.
Established in 2023, SALAD connects academic researchers across several South African universities (including UWC, UCT, NWU, and Stellenbosch) with national, provincial, and district health managers, clinicians, and non-profits to help tackle governance problems.
The team recently completed a pilot project in the North West province’s Rustenburg sub-district with more than 50 managers.
“We started at the sub-district level because if you can strengthen it there, you can learn a lot. There’s much less politics than at the top,” explains Beth Engelbrecht, the former Western Cape health department head and an adjunct professor at NWU and UCT.
Their initial analysis revealed staff were dealing with a mix of helpful and harmful experiences. Mistrust was among the more pervasive issues. “Even in regular meetings, it’s a toxic space,” Engelbrecht says. “If you don’t achieve your target, it’s like a ton of bricks coming down on you.”
To address all this, SALAD teamed up with the North West Systems Leadership Development Programme and the provincial health department to co-design a four-pronged plan.
The executive team got support to transform review meetings into learning spaces, managers attended an accredited short course, and everyone received mentoring, and real-time evaluation.
The most important part of the plan was that all the learning and assessment was happening in sub-district’s wards and daily meetings, using the real problems it faces. Workshops ran in short one or to day blocks spaced over four months, which also minimised disruption to clinic operations.
“When people see the effect of adopting different leadership processes in their relationships with colleagues, that builds its own desire to keep working differently,” explains Lucy Gilson, professor of Health Policy and Systems at UCT.
Unfreezing the frontline
The SALAD team also spent a lot of time coaxing staff out of their panic-stricken state and instead focussing on the power they do have using an adapted version of Stephen Covey’s spheres of control, influence, and concern.
They gave staff explicit permission to stop expending energy on systemic issues (such as national budget cuts) they cannot alter, says Professor Helen Schneider, a professor of public health at UWC.
“Acknowledge the system-wide issues, but don’t kill yourself worrying about them,” she explains, “focus on what you can do, and then suddenly people discover a certain kind of agency, and they recognise they do have power.”
For instance, managers and clinicians can directly control in their immediate daily operations, how facility meetings are structured, staff schedules, internal communication tone, queue management, and creating psychological safety within their immediate team.
Outside their own facility, they can build strategic alliances, Schneider says, by navigating local trade union relations or engaging clinic committees, negotiating with sub-district support units, or coordinating across public-private boundaries.
The pilot is complete, and the SALAD team is still in touch with health authorities in the North West to figure out how to scale the programme.
This will take time, Gilson says, because leadership development is not written into provincial annual performance plans. Although it’s a frontline change that’s needed, backing from the top is still crucial.
Engelbrecht and Gilson met with a number of national oversight bodies (including the Department of Planning, Monitoring and Evaluation, the Department of Public Service and Administration, and the National Department of Health) to figure out how leadership was being managed on a national level.
“All three of those national bodies said leadership is critical, but all of them confirmed that leadership development is nowhere in any plan an explicit, funded priority.”
Unlike most other national or provincial departments, the Western Cape has embedded leadership development into its structures, budgets and working practices.
Through the Partnership for Health Leadership and Management Capacity Development (PAHLM), for instance, the Western Cape health department and three universities developed a leadership competency framework and a leadership behaviours charter. The framework was tested and developed through two rounds of workshops involving more than 800 public health-system managers and was commissioned and approved by the provincial health department.
The case of the disappearing paramedic examiners
Years of fear and resentment can crystallise in unexpected ways.
In KwaZulu-Natal, a meticulously planned paramedic examination was nearly derailed when a number of paramedic educators and examiners booked off sick at the same time, Caleb Wang tells those gathered for a SALAD online seminar.
Wang, who coordinates in-service training for clinical employees in KZN, is a paramedic by training. Paramedics are an important link connecting household emergencies, clinics, and district hospitals, though training colleges are often regional or provincial facilities.
These assessments are labour intensive, Wang says, and they require large panels of examiners for clinical skills, oral boards, and simulation exercises. It’s a high-stakes situation for students too, since failing means they can’t progress, get promoted or qualify for salary increases.
The exams continued with fewer examiners for the sake of the students, but the sudden changes created a high-pressure environment for everyone involved.
At first, Wang and his colleagues suspected a stomach bug might be behind the chaos, but upon closer inspection, a stranger reality emerged; the examiners were afraid to attend the assessment, and afraid of saying why.
As it turned out, course coordinators leading the different academic tracks were locked in interpersonal feuds. Educators felt helping to assess a rival coordinator’s exam could be seen as a betrayal. Unsure of how to raise such worries without also facing reprisals, people instead took sick leave in self-defence.
Such a fraught emotional landscape can’t be fixed with rules and reprimands. Though managers started to track sick leave application trends for signs of a coming crisis, the underlying issues could only be remedied using a more collaborative, relational style of leadership.
Wang focussed directly on the relationships between co-ordinators. After they had completed a series of communication exercises, management also instituted regular meetings where structured, open dialogue was encouraged.
Topics previously taboo in administrative settings (feelings, assumptions, perceptions, and hidden dynamics) were reframed as important operational intel.
The formerly warring co-ordinators aren’t personal friends today, Wang says, but the approach succeeded in breaking down the seemingly intractable silos and has restored cooperation across the different academic components.
These days, paramedic examinations go off without a hitch.
Psychologically safe doctors = physically safe patients
People who have the confidence to speak up, admit mistakes, or take calculated clinical risks are much better at saving lives and preventing hospital infections than those who keep their head down out of fear.
Nomlindo Makubalo, a paediatrician in an Eastern Cape district clinical specialist team, has seen this first-hand.
Speaking during a webinar on psychological safety in the DHS, she shares an anonymised story of a junior medical officer and ward nurses at a cash-strapped district hospital who were confronted with a critically ill, ventilated 11-month-old infant.
The baby urgently needed intensive care but there were no available ICU beds in the regional or central referral complexes. The rural ward nurses had no formal ICU ventilation training.
In a traditional, fear-based culture, the local team might have panicked and passed responsibility upward or allowed the infant to deteriorate while waiting for official transport sign-off.
But Makubalo and the district clinical specialist team had intentionally built a relationship of psychological safety, so the junior doctor felt safe to call her directly.
She reassured the team and provided real-time, telephonic clinical supervision for two consecutive nights.
The hospital management authorised additional nursing support to relieve ward strain. Supported by this protective leadership umbrella, the frontline team safely ventilated the infant locally for 48 hours until an ICU bed opened.
The baby was transferred and made a complete recovery.
Makubalo says: “Psychological safety and trust translate directly into quality care. When people know you have their back, they will do everything to save a life.”
The physics of success versus failure
In the Western Cape, the provincial government explicitly measures the energy all civil servants expend that never reaches the public.
In a healthcare setting, patients might lose out because health workers’ energy is spent navigating internal friction, administrative hierarchies and coping with interpersonal conflict.
The technical term used across the province is “organisational entropy”. Very loosely related to the scientific concept of entropy, it measures the percentage of total energy within an institution consumed by unproductive work.
In the proprietary tool used by the Western Cape government, called The Barrett Model®, wasted energy is measured using a survey. It offers a list of personal and organisational values and asks staff to choose 10 personal values, 10 values that describe the current culture of the organisation, and 10 organisational values they’d like to see in the future.
The cultural entropy score comes from the percentage of current organisational values staff pick that the Barrett Model classifies as “limiting,” such as conflict, friction, and frustration.
At the Retreat Community Health Centre, a facility that provides 24-hour emergency and maternity care in Cape Town, researchers found staff operated in a pervasive climate of fear. Their baseline survey suggested that staff viewed management as administrative police designed to catch staff making mistakes, and as a result, communication broke down into departmental silos.
To break this cycle, the facility embarked on an 18-month participatory action research initiative.
The three key facility leaders, the facility manager, family physician, and nursing manager underwent leadership assessments and six months of individual coaching. They engaged in weekly reflective learning sets, mapping out communication flows, and examining how their own management behaviours generated fear.
The results were transformative.
When researchers followed up 18 months later, limiting values had dropped out of the top 10 current organisational values, although they still represented 13% of all values selected (down from 33%). In their place emerged positive, unifying values: caring, open communication, teamwork, respect, fairness, and accountability.
This phenomenon is not confined to isolated research sites. The Western Cape Department of Health and Wellness formally tracked cultural entropy across its entire workforce as an official performance metric, achieving a department-wide entropy reduction from 23% to 20.9% between 2013 and 2016.
This systematic drop in friction directly correlated with improved employee retention, stronger teamwork, and smoother service delivery across health districts.
The latest annual report puts cultural entropy cross the provincial public health system at 16%.
The province also tracks leadership skills on an individual, team, and system level.
Tendani Mabuda, who leads the provincial health department’s People’s Development team, argues the proof of the value of strong leadership can be found in the department’s eight year run of consecutive unqualified audits.
“Leadership development cannot alone resolve structural failures or challenges, but it enables managers to be agile and cope with the environment they are facing,” he says.
‘Trust is not a luxury’
For three decades, the unwritten rule within South Africa’s public sector clinics and hospitals has been to hide errors, follow flawed directives to the letter, and brace for new instructions from headquarters.
Stamping out this culture of fear in favour of psychological safety will be crucial to the success of South Africa’s next big healthcare revolution, the National Health Insurance (NHI) scheme.
The scheme, which currently faces about a dozen legal challenges, will change the way resources and healthcare services are pooled and purchased.
At the moment, most provincial health funding comes from nationally raised revenue transferred by National Treasury to provincial governments. The amount each province gets is determined by the provincial equitable share equation. The formula determines each province’s share using factors such as population, poverty and demand for health and education services. Provincial governments then decide how much of their budgets to allocate to their health departments. Separately, the national health department administers conditional grants for specified health services and programmes.
Under the proposed new system, funding would shift from this passive approach, where facilities receive budgets shaped by previous allocations to cover costs such as salaries and supplies, to strategic purchasing.
This means actively deciding which services a population needs, which providers should deliver them and how to pay those providers, with funding decisions guided by health needs and provider performance rather than simply historical spending.
For primary healthcare, contracting units would organise networks of public clinics, district hospitals and participating private providers to serve people within a sub-district, with the NHI Fund purchasing services through these arrangements.
These are hardware updates but, as multiple governance studies have shown, a hardware solution won’t fix a software problem.
And strategic purchasing will require sophisticated cultural software and strong leadership from district and sub-district managers with the ability to build trust, negotiate, manage networks that combine public primary care clinics, district hospitals, private doctors, nonprofits, and municipal health services.
At the heart of all of this, is trust between people, explained health economics professor Susan Cleary during a June webinar.
“You don’t get good quality results if you don’t have good quality relationships, they’re part of performance, and trust is not a luxury.”
Incidentally, an octopus can overcome incredible barriers once it decides to seek safety.
In 2016, staff at the Napier Aquarium in New Zealand arrived at work to find that Inky, one of its star inhabitants, had escaped. Finding the glass lid of his tank left slightly ajar after routine maintenance, he slipped out overnight, navigated a 50-metre drainpipe, and disappeared into the sea.
*This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.
