Centre for Health Policy, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
Centre for Health Policy, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
BMJ Glob Health. 2020 Oct;5(10). doi: 10.1136/bmjgh-2020-003524.
International calls for universal health coverage (UHC) have led many countries to implement health sector reforms, however, since the 2008 global recession, economic growth has slowed in many lower-income and middle-income countries. In a renewed interest in public financial management (PFM), international organisations have emphasised the importance of giving spending control to those responsible for healthcare. However, centralisation is a common response when there is a need to cut expenditure due to a reduced budget; yet failure to decentralise often hampers the achievement of important goals. This paper examines the effect of centralising financial decision-making on the functioning of the South African health system.
We used a case study design with an ethnographic approach. Primary data collection was conducted through participant-observation and semistructured interviews, over 1 year. Member checking was conducted.
New management implemented centralisation due to a reduced budget, a history of financial mismanagement, the punitive regulatory environment financial managers face, and their fear of poor audit outcomes. The reform, together with an authoritarian management style to ensure compliance, created a large power distance between financial and clinical managers. District managers felt that there was poor communication about the reform and that decision-making was opaque. This lowered commitment to the reform, even for those who thought it was necessary. It also reduced communal action, creating an individualistic environment. The authoritarian management style, and the impact of centralisation on service delivery, negatively affected planning and decision making, impairing organisational functioning.
As public health systems become even more financially constrained, recognising how PFM reforms can influence organisational culture, and how the negative effects can be mitigated, is of international importance. We highlight the importance of a participatory culture that encourages shared decision making and coproduction, particularly as countries grapple with how to achieve UHC with limited funds.
国际上呼吁普及全民健康覆盖（UHC），促使许多国家实施了卫生部门改革。然而，自 2008 年全球经济衰退以来，许多低收入和中等收入国家的经济增长放缓。在对公共财政管理（PFM）重新产生兴趣的背景下，国际组织强调了将支出控制权交给负责医疗保健的人的重要性。然而，由于预算减少需要削减支出，集中化是常见的应对措施；然而，权力下放的失败往往会阻碍重要目标的实现。本文研究了集中财务决策权对南非卫生系统运作的影响。
我们采用案例研究设计，采用民族志方法。通过参与观察和半结构化访谈，在 1 年多的时间里进行了主要数据收集。进行了成员检查。
新管理层实施集中化是因为预算减少、财务管理不善的历史、财务经理面临的惩罚性监管环境以及对审计结果不佳的担忧。改革以及确保合规性的独裁管理风格在财务和临床经理之间造成了很大的权力差距。地区经理认为，关于改革的沟通不畅，决策不透明。这降低了对改革的承诺，即使对于那些认为改革有必要的人也是如此。它还减少了共同行动，营造了一种个人主义的环境。独裁的管理风格以及集中化对服务提供的影响，对规划和决策产生了负面影响，损害了组织的运作。
随着公共卫生系统受到更多的财务限制，认识到 PFM 改革如何影响组织文化，以及如何减轻负面影响，具有国际重要性。我们强调了鼓励共同决策和共同生产的参与性文化的重要性，特别是因为各国在努力用有限的资金实现全民健康覆盖时。
