January 18, 2021

‘Responsibility without authority’ prevents Ministers from doing their job

The Minister of Health, Dr Aaron Motsolaedi, had tried three times to warn the Premier of the North West province against employing the current provincial Minister (MEC) responsible for Health.

“But he did it anyway,” Motsolaedi told the National Council of Province’s Social Services Committee during a discussion on the Health Department’s budget and Annual Performance Plan.

“When the province collapsed people wanted to know where was the Minister?” a clearly frustrated Motsolaedi said. “Yet when I saw it coming I could not stop it.”

Speaking frankly to the Committee, the Minister said that the main problem he faced was that a Minister “has responsibility without authority”.

In a very open exchange with the Committee, Motsolaedi expressed his frustration at what he saw as an anomaly at provincial government level, particularly with regard to his department. He repeatedly made the point that Cabinet Ministers had responsibility without legislative authority at provincial level.

'Premiers do not believe that they report to Ministers' - Motsolaedi.

“North West is in a crisis because the HOD they had was a director in the department of health and he was one of the most mediocre directors. It is not a secret. He was quite mediocre,” he said to barely concealed laughter among Committee members.

He said he was surprised to learn that Premiers appoint HODs. “The Minister is not anybody” when it comes to making appointments. The President appoints and fires departmental Directors General and Ministers cannot make an input, yet it is they who are ultimately held responsible if matters go wrong.

Today the North West province is wracked by strikes in the health sector that have virtually destroyed health services. Now under national administration, it has faced a complete shut-down of hospitals and non-availability of medicines, including critically needed treatment for chronic conditions like HIV and TB, since the strikes started in February.

“Premiers do not believe that they report to Ministers,” Motsolaedi said.

He was at pains to explain he did not mean that Ministers could not intervene in the provincial governance, but the problem was that they can only intervene after the fact, when something has gone wrong.

He said national government’s lack of legislative authority in provinces was the greatest challenge facing the health sector, he said, topping even the serious staff and skill shortages and lack of infrastructure.

Motsolaedi referred to this as “post-mortem powers”, and compared it to the role of the auditor general who can only act against irregular expenditure after the funds have been spent. This is how corruption happens, Motsolaedi warned.

That is why there is the office of the Chief Procurement Officer, which ensures that any procurement above R10million follows the correct procedures and satisfies the requirements of that Office. But he said illicit procurement was conducted in “dark corners” and the Minister only gets to hear about it when it is too late.

Ministers are called upon to address lack of service delivery and general performance weaknesses in their sectors, but it is provincial government ministers (MECs) who hold the power.

This is what happened in the Life Esidimeni tragedy, said Motsolaedi. Under the previous legislation of 1973, this tragedy could not have happened because the then National Health Act made the President, the Minister of Health and the magistrate the custodians of all mental health patients. Without their authorisation these patients could not have been moved and “nothing could happen to the patients”.

New legislation introduced in 2002 included very necessary provisions for the protection of human rights, but the legislation shifted all those powers “to the MEC,” he said. This is why the ombudsman in the Life Esidimeni case, Justice Dikgang Moseneke, asserted that certain decisions should not be made without the Minister’s approval.

Motsoaledi welcomed Section 100 powers which allowed him to intervene, but that happens only when national administration takes over ailing provinces. He said proposed new legislation included amendments to address this lack of ministerial authority.

Motsolaedi quashed rumours that the problem in North West province was that it had run out of essential medication for chronic conditions like HIV and TB. As soon as he took over he had visited the province’s central medical depot where he had found boxes of medication, some on the floor because shelves were full. The problem was that the dept was closed off and no deliveries had been allowed.

When national government took over, the army was called in to distribute the medication to accessible collection points, where he hoped unmarked trucks could make deliveries to the clinic and hospitals where needy and desperate patients were waiting for medication that they relied upon.

He explained to the Committee that with the help of Vodacom a centralised stock visibility system was introduced. Based in Pretoria, a map signalled where supplies were running low. But this required that nurses in every one of the 3,500 clinics in the country scanned barcodes on medicine supplies, which was not being done in the North West during the strike.

Prior to the current crisis, North West had been one of only two provinces whose health departments were given clean audits. The Committee heard that the province used to be the leading performer in primary health care in the whole country, yet its most recent audit was qualified, he said.

The health sector is currently regulated by 108 laws, of which 39 require amendments in Motsolaedi’s view, or alternatively should be repealed or consolidated. This, he believes, is the only way to address the challenges presented by concurrent responsibilities and confusion over authority.

He indentified four areas of capacity needed for the health sector to function optimally, and none necessarily required medical expertise. Successful management of human resources, finances, and procurement, and the maintenance of infrastructure and equipment would provide for a well-functioning department of health. None of these require expertise in health, said the Minister, but if they were provided, the health professionals would be able to do their jobs.

In addition, in 2015 the Department introduced the concept of “non-negotiables,” such as medicines and vaccinations, infrastructure and laboratory services. These were the necessary basic requirements of a functioning health system. When he realised that in some provinces even these were lacking he appointed a Ministerial Task Team (MTT) to visit 100 underperforming hospitals to assess their needs.

After visiting only 25 hospitals in six provinces (not Gauteng, North West and Western Cape), the MTT reported back that they would be wasting tax-payers’ money if they continued with the hospital visits because the problem, according to the MTT, did not lie in the hospitals themselves, he was told. It was the result of a breakdown within provincial governance.

Building and maintenance of clinics was not the responsibility of the health department, the MTT reported to him. Even changing a light bulb at a hospital fell to another department such Public Works.

Motsolaedi added that Treasury is increasingly taking over control of HR functions in provincial government as decisions about whether appointments are made are referred to Treasury. Despite personal appeals by Motsoaledi to avoid staff cuts in crucial departments such as health, and assurances that cost-cutting measures would not extend to “the coalface of service delivery”, the MTT told him there was a subtle moratorium. This was denied by Treasury, but the Minister had no say in these decisions and he said “approval [from Treasury] never comes.”

Unfilled internships was another example he gave to illustrate how provincial governments exercised overriding authority. In the Western Cape about 50% of internships remained unfilled but Motsoaledi said the reason he was given was that funds for internships were being re-directed to drought relief.

Even provinces’ share of the budget is transferred directly from National Treasury to the Provincial Treasury, where Executive Members are responsible for distributing it to the Departments, without the participation of the Minister.

Moira Levy

Additional information sourced from the Parliamentary Monitoring Group.

Additional Info

  • Author: Moira Levy

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