Guest post: Accountability in South Africa's healthcare system is on life support

But are desperate times turning knowledge into power?

Users of the South African health system were the big losers from a high court ruling that was passed in the week of 6 February 2023.

According to the ruling of the high court in Bhisho, in awarding medical negligence settlements, it is now acceptable for medical negligence-related healthcare to be provided in government health facilities. Previously, the victims of medical negligence were, as part of their settlement, provided with enough money to receive treatment in the private sector.

I read a newspaper report on the ruling a week later with a sinking feeling. The judge, in his ruling, referred to the broken nature of the small part of the legal system chasing these medical negligence cases. It is acknowledged and widely known. However, medical negligence settlements serve as an accountability signal to the public health system. A health system where users have not been enabled to provide clear accountability signals, or at least signals that matter, back to the system. How can they when no co-payment (and thus no voting with your money) is possible? How can they when nurses and doctors often have far more power and status than patients?

It is a system that generates daily newspaper reports on babies that are not provided with critical life-saving care. Mothers in labour who are sent away, or for whom the ambulance simply does not arrive. Or people who lose a limb while waiting for healthcare.

In the context of this system, a large financial penalty to the system for not providing patients with high-quality, dignified healthcare was one remaining accountability signal. There are questions on whether the system was able to absorb and respond to the signal. Irrespective of the quality of the signal, it has now been lost. Victims will be sent back to the very same health system which caused them harm in the first place.

The idea of accountability signals seems to have fallen out of vogue in the development world. There was a time when much was written about it.

The World Bank’s World Development Report of 2004 was an important accountability publication. It created and popularised language around concepts such as top-down and bottom-up accountability. It was followed by a series of reports by global development funders in the early 2000s examining different ways of supporting government accountability in low- and middle-income countries. The British government’s Department for International Development (DFID), at the time, led the way, with others like the Overseas Development Institute also contributing. There are others. The focus of these reports was often a mix of ideas and theories on how to strengthen citizen voice and government accountability.

The reports mention many potential sources of globally available data sources that measure how well governments are doing at different types of accountability. These include indices such as the International Budget Partnership’s Open Budget Survey Rankings, the Civil Society Sustainability Index, the World Bank Institute’s Governance Matters Indicator and the Ibrahim Index of African Governance and the Reporters Without Borders’ Press Freedom Index. There are many more besides the ones mentioned here.

Some of these measures relate to governments’ openness to allowing accountability-supporting institutions (such as free media) to flourish (or wither and die) within their borders. Others (such as the Open Budget Index) consider whether governments share the information that allows citizens, the larger civil society, and the free press to keep it accountable.

In a world of complex political economy arrangements, there is reason to be skeptical of information alone being the lever for accountability. Katrina Kosec and Leonard Wantchekon explored the conditions under which information enabled accountability in a special issue of World Development published online in 2018. The authors find that in rural areas citizens typically only act on information when it is 1) seen as relevant at the moment (defined as “being salient”), 2) carrying some clear identifiable truth (“having a high perceived signal-to-noise ratio”) and 3) if they have the power and incentives to act on it. Accountability interventions have typically failed where at least one of these three elements has been missing.

How does South Africa fare in terms of accountability indicators? If newspapers in South Africa during the last two weeks are anything to go by, you would certainly not feel as if accountability had improved, or had even remained the same.

The Open Budget Survey measures countries’ openness in sharing central government budget information (transparency), allowing public participation in the budget process, and enabling oversight of the budget development process. South Africa has, historically, performed very well at the Open Budget Index score. However, in 2021 (the last year for which data is available), it lost its position of first in the world in having an open budget to Georgia. It also only scored 19 out of a possible 100 for public participation, a performance area in which the National Treasury has publicly committed to doing better. Concerningly, South Africa’s budget transparency score has fallen from 92 in 2010 to 86 in 2021.

South Africa scored 67.7 out of 100 in 2021 on the Ibrahim Index of African Governance (comprised of several sub-indices) and was ranked 6^th in Africa. Governance, in this context, is defined as “the provision of political, social, economic and environmental goods that a citizen has the right to expect from their state, and that a state has the responsibility to deliver to its citizens”. During the last ten years (2012-2021) our overall score experienced a small upward trend.

 What does the picture look like if we ignore the government and rather focus on the structures that support accountability outside the government?

The U.S. Agency for International Development (USAID)-funded Civil Society Sustainability Index has been running for the past 20 years. South Africa has led the way in the Sub-Saharan African region in its performance on this index, where a lower score indicates strength. While there has been some slight deterioration over time in some of the sub-indices, importantly, civil society advocacy and service delivery capacity increased in 2021. I’ll be watching what it does in 2022.

The Reporters Without Borders Press Freedom Index is published annually for countries where sufficient data is available.  South Africa was ranked 35^th out of 180 countries in 2022. It lost three positions last year, having moved from 32 out of 180 countries in 2021, and has lost quite a few over the last ten years. In publishing South Africa’s ranking, the following was shared:

Journalists are rarely arrested in South Africa but the police sometimes fail to protect them when they are exposed to violence. The resurgence of verbal and physical attacks against journalists by political activists is worrisome. Surveillance of investigative journalists by the state security agency is also a source of concern. In 2021, the Constitutional Court ordered changes to the law on intercepting communications in order to safeguard the confidentiality of journalists’ phone conversations and sources.

There is a strong sense from reading newspaper reports that government accountability is rapidly decreasing. Whether this is true (in a factual sense) is hard to know. The indicators I’ve captured here, and others not written about, do not provide a clear sense of extreme decline.

If we accept Katrina Kosec and Leonard Wantchekon’s pre-conditions under which information provided to citizens supports accountability, the incentives of citizens in South Africa to act on information on government performance are getting stronger.

Economic growth is precariously low, jobs are scarcer, prices are higher, electricity is in shortage, and life in South Africa is objectively and subjectively harder. Whether citizens have the power to act on this information (in and outside general elections) is another matter. I would argue they do, as long as elections are free and fair.

As economic conditions are not rapidly improving for the better, the incentives to act on government performance are larger than ever before. This can support citizen voice and mobilisation if accurate, understandable information on government performance is shared with citizens at the right time.

Our media freedom continues to flourish (though we should be watching the drop in our Media Freedom Index ranking with concern). Our next democratic election is waiting in the wings. There is reason to be hopeful. Even if, for now, the victims of medical negligence will be sent back to the same health system that caused them harm. And even if a valuable signal on its performance (and how it is judged by its users and the courts) to the health system has been lost.

Photo by Marcelo Leal on Unsplash.