When saints prop up broken health systems

Spend long enough working in public health and you will eventually meet every type of person.

You meet the idealists, the pragmatists, the empire builders, the quiet fixers, the activists, the bureaucrats, the researchers, the politicians, the consultants and the people who appear to have made attending meetings into a full-time occupation.

You also meet the saints and sinners.

The saints are not difficult to recognise if you really look but do not expect to find them lauded in the media or receiving national accolades. These are often people who prefer to keep out of the spotlight.

The district manager who somehow manages to keep services functioning despite frozen posts, procurement delays and budgets that never seem to match the expectations placed upon them. The doctor who chooses to work in a rural hospital when there are easier and more lucrative alternatives. The public servants who could almost certainly earn more money elsewhere but remain because the words “public service” mean something to them.

I have been fortunate to meet many saints, exceptional people who have made extraordinary contributions.

There is no question that South Africa’s public health system contains “pockets of excellence”: services and institutions where committed people continue to provide good, sometimes exceptional, care despite substantial systemic difficulties.

I admire these people but I have also realised that they inadvertently create a danger.

Because when exceptional people repeatedly rescue dysfunctional systems, they mask the dysfunction.

A hospital may be functioning well because a chief executive spends every waking hour fixing problems that should have been prevented by functioning systems.

I am not complaining; society benefits and services reach patients. However, higher up the management chain, everyone is congratulating themselves. After all, targets have been met and the uncomfortable attention of the media has been avoided.

Herein lies the danger: the system learns almost nothing or, much worse, does not even realise that a few exceptional people are keeping disaster from its doorstep.

It blissfully meanders along, leaving it to a few key individuals to absorb the consequences of bad decisions, staff shortages, bureaucratic delays and weak management.

What really concerns me is that most of the saints I have met over my career are exhausted, reaching retirement age and disillusioned by a tarnished rainbow nation. They retire, burn out and stop volunteering for the extra tasks.

That is when the façade cracks. That is when we discover that institutions we thought were functioning collapse. That is when you notice who is left in the system.

You may not immediately notice the villains. Their survival instinct makes them avoid the spotlight. What you start noticing are the empire builders and the professional meeting attenders, the hangers-on and all those who add little value to the system. The people whose principal contribution to public health sometimes appears to involve being photographed standing next to people who do public health.

There is the management consultant who has diagnosed the same problem for the fourth time but knows that the report will never be implemented and can always be dusted off and presented again with the next contract.

There is the person who attends every strategy meeting, commission and advisory board. They are vocal in the discussions and seem never to have realised that the right to your own opinions cannot be based on the absence of evidence. When the report writing needs to be done, they are always missing. When implementation has to happen, they move on to the next talk shop.

And then there are more sinister characters. People who have discovered that dysfunctional systems create opportunities. Procurement opportunities. Patronage opportunities. The opportunity to exercise power without being held accountable for the consequences.

The temptation is to divide the people neatly into good and bad, heroes and villains, saints and sinners. Reality is more complicated. Most of us operate somewhere between the two extremes. We make compromises. We protect institutions. We choose our battles. Sometimes we remain silent when perhaps we should speak. Sometimes we push harder than is comfortable because something matters.

The important public-health question, therefore, is not whether we can find more saints. It is whether we can build systems that do not require them.

Good governance practices have been codified precisely because institutions cannot depend on everyone behaving exceptionally well.

The Academy of Science of South Africa’s 2024 consensus study, Achieving Good Governance and Management in the South African Health System, makes this point repeatedly. It acknowledges “pockets of excellence”: examples of good service and health workers committed to providing good, even excellent, care.

But it also identifies system-wide failures, including instability in senior leadership, inadequate delegation of authority, weak accountability mechanisms, a lack of transparency and public-sector systems that are no longer fit for purpose.

That combination should concern us because a health system that depends on unusually good people to compensate for unusually weak institutions is inherently fragile.

The solution is not complicated in principle. Put competent and ethical people into leadership positions. Give managers enough authority to manage. Measure outcomes that matter. Make appointments transparent. Protect whistle-blowers. Act decisively when people neglect their responsibilities. Make it possible to identify who is accountable when something goes wrong. Perhaps most importantly, create organisations in which doing your job well is easier than finding ways around the system.

The saints have taught me what a public health professional should be. I am often humbled by their selflessness. The sinners have taught me why transparent and accountable governance should be non-negotiable.

But perhaps the most important lesson is simpler. A functioning health system cannot be built on the assumption that everyone will behave like a saint. Good systems make it easier for good people to do great work. Great systems make it difficult for bad people to do harm.

• Dr Wolvaardt is the founder of the Foundation for Professional Development and has recently stepped down as managing director.

Sunday World