The Development Bank of Southern Africa (DBSA) has been doing work in the healthcare sector for quite some time focused on policy direction. More recently it started repositioning in order to assist government on infrastructure delivery.
The major and lengthy delays in the delivery of health infrastructure around the country, coupled with the consistent under-spending of health capital grants, has long been a matter of great concern. In order to address these delivery challenges, in 2010/11, the Department of Health (DoH) launched the Infrastructure Unit Support Systems (IUSS) programme.
The IUSS programme is a partnership between DoH, DBSA and the Council for Scientific and Industrial Research (CSIR), where the DBSA has been tasked with supporting the DoH as well as provincial departments to accelerate infrastructure delivery as well as building the requisite institutional capacity to improve the quality and accessibility of health facilities.
“The work we are doing now is not a radical step change for the DBSA. It is basically moving from an advisory role to helping government implement some of the key proposals put forward in the 10 Point Plan announced by the presidency in 2009,” says Sinazo Sibisi, the divisional executive for development planning at the DBSA. But the transition has not been without challenges.
She says that as an organisation, the DBSA has had to think about how it gears up for working with a multi-level government and the different divisions within government. Expertise across sectors touching on project finance, implementation, and policy work are required which is resulting in the need to work across the different parts of the DBSA more than at any time in the past.
Supportive stakeholders
“The strong drive of the DoH and the support of the National Treasury are instrumental to the success of the programme but we also cannot discount the importance of support from the provinces. After all, they are the ones ultimately responsible for infrastructure delivery,” says Sibisi. She says that the DoH/DBSA programme had to position itself in such a way as not to create the perception that it is national government trying to take over from the provincial level.
Ultimately, this is about how the different stakeholders work together to solve a problem. To this end the provinces are beginning to embrace the programme and are open with the DBSA on the challenges they are facing in a variety of areas. “This is providing us with the platform, in partnership with the DoH, to develop customised support programmes for the provinces. Having targets and deliverables across procurement and implementing agents are vital to show the various stake- holders that we are assisting them in unlocking other areas for development,” she adds.
Sibisi says that there are times when the DoH/DBSA team is called in to do emergency interventions which are not the easiest to manage as these happen on-site working with contractors. “The DBSA has strong programme management, systems management, and facilitation and convening capabilities. We therefore have a responsibility to bring those strengths to bear and not replace the actors on the stage. Our job is to optimise performance,” she says.
Good news stories
She cautions that people tend to focus too much on the challenges and write off everybody in government as people who drag their feet and who underperform. Yet, there are many people in the system who do wonderful things with the support they are getting from the stakeholders.
The DBSA is supporting government to do what it needs to get done. The leadership and the drive in government exist to reform things in the health sector in South Africa. The DBSA is one of the tools that allow them to do so.
“South Africa has a strong systematic leadership both at administrative and ministerial level. It is this drive and leadership within the DoH that helps us with implementation. The touch points on national and provincial levels have important roles to play through the key contact people there,” says Sibisi.
There is also a need to have more public-private partnerships in place to help in areas of institutional weakness. On the one hand, the DBSA is looking at accelerating delivery and improve health infra- structure information. On the other, there is the CSIR which is looking at norms and standards.
“Our work with the DoH has already piqued the interest of the Department of Water Affairs and other key national departments. This partnership model has also seen other government departments pulling in the SA Revenue Services to help them with their billing. So the more we partner up to drive delivery, the sooner all the stakeholders can make a difference in South Africa,” she says.
In terms of South Africa Inc, it seems that the long-term message is that everybody needs to take ownership of the common challenges and what needs to be done for a better country. Taking ownership is required for the future of the country, says Sibisi.
“So how can we work together to make our collective efforts better than the sum of its parts? There has been a lot of investment in the health sector since 1994 but these need to be pulled together to bring about systemic change,” she says. The National Healthcare Insurance programme is a case in point.
The elephant in the room
The DBSA is assisting the DoH on infrastructure delivery and needs to ensure that the health facilities exist which can better support public access to quality health services.
“We are currently involved with the DoH to look at the infrastructure requirements for the different pilot projects on the go as well as what is required for better health services across the board. But while planning for infrastructure is done on a provincial level, planning capacity remains a major challenge. The DoH/DBSA team therefore needs to assist the provinces in improving health planning,” says Sibisi.
“Of course, when people are planning separate from one another, then there is a risk of under-or over-servicing taking place. To minimise this, we would need to map existing services and link where the gaps are. A quick win with health planning would be to produce a map indicating where healthcare facilities are, what services they provide, the infrastructure inside the facilities, and the travel details around them,” says Sibisi.
In addition, while district health information is good, there is still room for improvement. In the past, the DBSA worked closely with the Health Systems Trust to help enhance district health information systems. We hope to continue to support government to improve the quality of its data and to ensure it is up-to-date, accurate, and supportive of long-term planning.
Making a sustainable difference While the DoH/DBSA partnership is leveraging external resources to make a high impact on infrastructure delivery in the short term, the idea is to build institutional capacity over time to ensure that the system runs optimally. A daunting task, Sibisi admits due to the number of factors that need to be addressed such as changing institutional cultures, improving skill levels and bringing additional expert resources on board.
This process requires baby steps and one has to be realistic about what can be achieved within what timeframes. The danger lies in focusing too much on rapid delivery elements that could come at the expense of improving the delivery system.
It’s all about the end-user.
“This is a programme which deals with people’s lives making it so much more daunting,” adds Sibisi. “An example of this is to ensure that air conditioning control is in place as this has a direct impact on disease control. You need to ensure that people adhere to basic cleanliness, have access to water, and not have an overloaded sewerage system.
“Our work with the DoH is not about producing a strategy or a policy document or taking people on a training course. We have the daunting task of making sure more lives are not lost,” she says. But it is the size and intensity of the task that gives the DBSA additional impetus to keep moving forward. “The involvement of the end-user is absolutely critical in rolling out infrastructure delivery and helping improve health infrastructure services.
“These things are normally decided by provincial officials and contractors. Health care professionals working at the facilities and patients who have to go there are often not centrally involved in the decision-making process. This is why you need an integrated approach to ensure that the voice of the end-user is heard. Ultimately, this will result in better health infrastructure facilities that are fit for purpose and responsive to patient needs,” ends Sibisi.
This article originally appeared in the Mail & Guardian newspaper as an advertorial supplement