CONTEMPLATING A CHALLENGING FUTURE : A PUBLIC MANAGEMENT APPROACH TO HEALTH SERVICES

A varying proportion o f health services in alt societies is delivered by public sector institutions. Managing these public sector service institutions for performance represents a major management challenge. This management challenge is amplified for South Africa as a country which is contemplating major changes while being simultaneously confronted with having to cope with problematic results o f the past and the challenges o f development. In this article a public management model is used to analyse relevant health trends and provisional management strategies are provided to assist health managers to cope with these challenges. Finally a checklist for personal survival is presented for personal evaluation and future planning.

In this article a public management model is used to analyse relevant health trends and provisional management strategies are provided to assist health managers to cope with these challenges.Finally a checklist for personal survival is presented for personal evaluation and future planning.Uittreksel 'h Wisselende gedeelte van gesondheidsdienste in alle samelewings word deur openbare sektorinstellings verskaf Die bestuur van hierdie openbare sektor diensinstellings virprestasie verteenwoordig 'n baie belangrike bestuursuitdaging.

IN T R O D U C T IO N
Health Services are typically delivered by service institutions in modem societies.These service institutions are important actors on the socio-econom ic and political terrains o f any state and society.As such their management is o f primary importance to society.Peter Druckcr (1977:131) em phasises this point w here he states: "M anaging the s e n 'ice institutions fo r perform ance will increasingly be seen as the central managerial challenge o f a de\>eloped society and its greatest m anagerial need." This real need for managing service institutions for performance is even more complex when these service institutions are situated within the public sector o f the economy and the politicised context o f the executive institutions o f the state.
A varying proportion o f health services in all s o c i e ti e s is d e liv e r e d th r o u g h s e r v ic e in stitu tio n s and especially through public service institutions.In the South African case it is indicated that public service institutions will retain a major role in health services provision.It is also probable that -depending on the scope and nature o f change in the South African political scenario -the involvement of public service institutions in health service provision will increase rather than decrease.This will amplify the already im portant need to address not only the clinical aspects of health services provision but also the management o f public health services.
The goal o f this paper is to provide a number of provisional insights into issues regarding a public m anagement approach to health services in S o u th A frica.T o reach this goal the fol lowing objectives have been identified which will receive attention in the paper:

T IIE P U B L IC M A N A G E M E N T M O D E L
A basic assumption o f the public management model is that the challenges facing the public m a n a g e r n e c e s s ita te a d is tin c tiv e public management approach.
With this point in mind a descriptive model of public management is provided.This model is illustrated in Figure 1.This model will be utilised for the purposes of further discussion.The exposition o f the health management challenge in South Africa will be contcxtualised in terms of environmental trends in accordance with the model in the next section.

T IIE H E A L T H M A N A G E M E N T C H A L L E N G E
The central health management challenge in South Africa is represented by the need to reconcile the health needs (demand) o f all South A fric a 's citizens w ith the available health re s o u rc e s (s u p p ly ) g iv e n th e p a rtic u la r socio-economic and political climate prevailing in South Africa.
An im p o rtan t co ro llary to this c h allen g e particularly relevant to public health services is the vexing question o f the respective roles of public and private sector health institutions in h e a lth s e rv ic e p ro v is io n .T h is in v o lv e s m acro -p o licy d e cisio n s w hich are highly politicised and relates to the central political and economic debates in South Africa to-day.
Finally, the internal efficiency o f the systems of health scrvice provision is important as these micro-management aspects wi 11 determi ne what will be attained within the obvious situation of scarce resources for South A frican health services.
For present purposes analysis focuses on some o f the more important trends in the general and specific environments.

The General Environment
S t a t i s t i c s r e g a r d in g S o u th A f r i c a 's dem ographic situation are well known.It therefore suffices to summarise by pointing out that South A frica's population is expected to increase from 33,2 million in 1985 to 47,2 million by 2000 and to 70,8 million by 2020.(Business Futures 1990:61).This represents a doubling of the population within a period of merely 25 years.It is also o f interest to note that o f the esti mated 1990 population o f 37,4 mi 11 ion 76% is black, 13% is white, 8% is coloured and 3% is A sian1.Whereas whites made up 20% of the population during the late 1950's their relative proportion is expected to decrease to 11% by 2000 (Business Futures 1990:76).
When the age structure of the South African population is considered it is significant that the m ajo rity o f the p o p u la tio n is a "young" p o p u la tio n .T h is is a n a la g o u s to o th e r developing regions o f the world.It is expected that by the year 2020 the black population below 15 years o f age will number more than 23 million or approximately 62% of the current total population o f South Africa (B usiness Futures 1990:85).
In respect of urbanisation it is noteworthy that South A frica's urban population is also on the brink of major increase.According to Business Futures (1990:98)  W hen th e s e tre n d s re g a rd in g the social environm ent are considered in context with trends in the econom ic environment such as extreme poverty, a highly skewed distribution o f income and serious backlogs in the provision o f basic infrastructural services, the challenges regarding health service provision arc daunting.Som e o f the more im portant health trends im pacting upon the public health management challenge can be sum marised from Business Futures (1990:110-111).It is accepted that there is a correlation between disease patterns and levels o f socio-econom ic development.W ilson and R am phele (1989:10-12) quote re lia b le s tu d ie s w h ere it w as found that approximately a third o f black, coloured and Asian children below the age of 14 years are underweight and stunted for their age.This indicates widespread malnutrition.The IMR (Infant Mortality Rate) measuring the number o f children dying before their first birthday out o f every th o u san d c h ild re n born alive is regarded as a measure o f health conditions and general econom ic conditions.African children in South Africa are eight to ten times more likely to die before their first birthday than are white children.For coloured children the risk is four times greater.South A frica's IMR, averaging between 94 and 124 over the period 1981-1985, w as co n sid erab ly w orse than the national average in B otsw ana (72), Zim babw e and Kenya (76), Congo (77), Tunisia (78), Algeria (81) and Zambia (84).It w as rated in the order o f 12 o th e r A fric an c o u n trie s in clu d in g Morocco (90) and Burundi (119).
Business Futures (1990:110)   This alarming but by no means complete picture of the social environment for health service provision in South A frica translates into a daunting health management challenge.'ITiis challenge is amplified by trendsin the economic and political environment as part o f the general environment.
E conom ics and the econom ic environm ent influence the supply side o f resources to meet demands on the demand side.
In respect o f the supply of resources in South Africa the popular belief has been that South Africa is a country richly endowed with natural resources.Van Wyk (1988:255-261) sounds a sobcri ng note in this regard where he argues that these resources arc not as plcnti ful as the popular p e rc e p tio n h o ld s and th a t the re s o u rc e s increasi ngly are coming under pressure through the exploitation o f non-renew able m ineral deposits and technological substitution.
In regard to one o f the basic life supporting systems Van Wyk (1988:256-257) describes a number o f constraints.South Africa is an arid region with an average rainfall o f 500 mm per annum compared to the world average of 1 000 mm per annum.The per capita availability of water in South Africa is just over 1 000 cubic meters per annum as opposed to 6 000 cubic meters for the world as a whole.South Africa is subject to periodic droughts that create havoc for agricultural production.It is a well known fact that climatological borders are changing and that arid and semi-arid zones arc expanding at a rate of 1 000 meters per annum.This Karoo penetration in conjunction with soil erosion is consuming productive and habitable land at an alarming rate.All in all the econom ic picture is gloomy.Scarce resources are going to become even scarcer.From a health service perspective, demands are expected to increase while supply is expected to decline.The implications for the p u b lic h ealth m an ag e m en t c h a lle n g e are obvious.
A final and brief view has to be given about politics as a very important part o f the general environment.Many of the demands made upon the economy and especially the public sector and public health service delivery systems are mediated through the political process.It seem s clear, given the trends in the general social, economic and political environment that the m anagem ent o f public health services present interesting challenges for the future.These general trends are spccifica!ly mani fcsted through the specific environment.In the next section som e trends regarding the specific environm ent which have been observed are discussed.

The Specific Environment
The specific environment, for the purposes of th e p u b li c m a n a g e m e n t m o d e l, is conceptualised in terms o f regulators, suppliers, consumers and competitors.The components o f the sp e c ific en v iro n m en t are concrete manifestation o f general environmental forces, and may be seen as the set o f organisations, groups and influential individuals with which the organisations have relations.Each of these units constitute a concrete force with which the organisation must reckon, particularly if there is d ependency involved (B row n and M oberg 1980:45).The public health service delivery system th erefore m ust analyse forces that impinge upon it from the specific environment.
A detailed analysis o f this is not possible within the scopc of this discussion.A few general observations regarding some influences suffice for present purposes.
In respect o f regulators, it is clear that the composition o f the important regulatory bodies will change dram atically with concom itant changes in terms o f policies and emphasis.The new regulatory bodies will have to be more re p re se n ta tiv e o f the total south A frican population and their emphasis will be on equity in service provision.Non-discrimination in terms o f equal opportunities are likely to be linked to programmes o f affirmative action in service provision as well as personnel provision and utilisation.The reaching of such objectives will be mandatory and controlled by regulators.
A highly visible present trend is the granting to p u b lic h ealth se rv ic e in s titu tio n s greater " fra m e w o rk au to n o m y " and m anagem ent autonom y.T his is ostensibly a strategy to deregulate the management o f health service institutions such as academ ic hospitals.In principle this may be a fine concept, but if it is linked to drastic cuts in terms o f the availability o f financial and human resources it really means very little by means of deregulation; it succeeds merely in a shift in the method of regulation from bureaucratic to economic means.This situation probably will worsen in the future and the percen tag e o f reso u rces obtained th r o u g h s e r v ic e c h a r g e s a n d /o r u s e r contributions will decrease.The result of this is that political decision-m akers will have to use public resources through a process o f taxation and re-allocation to provide for public health care.The priority that this will receive in the national budget may be influenced by the political composition o f bodies making supply decisions.Even if future policy makers are sensitive to demands for more resources made by the needy users o f public health services, such health demands must compete with other priorities in a severely constrained national budget.
The composition and needs o f consum ers o f public health services are sure to change.D em ographic and epidem iological profiles indicate that the pressure on public health serv ices w ill in crease d ram atically .The demand for these services will rise and the priority of needs as well as the way they will be mediated through the political process points to a shift to primary health care and preventative services.This has serious implications for high tec h n o lo g y c u ra tiv e h e a lth s e rv ic e s and expensive tertiary health edu catio n .The consumer profile will change with concomitant changes in the management of public health management delivery systems.
Although it may seem unlikely that a system facing the management challenges o f the South A frican p u b lic health system w ould have competitors, there are at least two forms of competition that may be contemplated.The first competitive situation is concerned with the diversity o f the health and related professions.The past drift towards over-professionalisation and the je a lo u s guarding o f m onopolistic practices through forms o f professional job reservation will come under scrutiny.Increased p ressure w ill be exerted to allow a team approach to health service provision as well as to allow all health service workers to practice procedures previously reserved for the select few.An interesting trend illustrating this is the p e rm is s io n th a t m e d ic a l p a th o lo g y te c h n o lo g is ts h a v e o b ta in e d to se t up independent practices.
Another group o f competitors may com e from the fields o f traditional and alternative health care systems.It suffices to stale that South African conditions create many opportunities for these fields o f health care to operate.These competitors (if they are seen as such) will have to be considered.
This provisional and speculative perusal of some trends within the specific environment of the South African public health delivery system Curationis, Vol 15, No. 1, 1992 confirm s conclusions regarding the public m anagem ent challenges to w hich previous reference has been made.
In the next sections some strategies regarding the functions, skills and techniques o f public m anagem ent are presented.It is argued, how ever, that mere technical efficiency as public managers may be a necessary but not a sufficient condition to handle this challenge.
The emphasis the public management model places on relevance in terms of the environment is an indication that mere technical management capabilities will not carry the day alone.

P R O V ISIO N A L PU BLIC M A N A G E M E N T ST R A T E G IE S
The emphasis the public management model places on public management functions, skills and techniques does not propagate a value free public m anagem ent science.M anagem ent ap p ro ach es, fu n ctio n s and sk ills arc only important to the extent that they are relevant and legitimate within the context o f the environment o f service delivery systems.They have to contribute to the philosophical ideals o f the "good society" and "democratic and legitimate gov ern m en t".For th is reason the model em phasises the political, moral and ethical environment o f public management where the ideal is to link public management to the public interest.The democratic nature of the process of public management is emphasised toenhance p a rtic ip a tio n and le g itim a c y .T h is is a necessary pre-condition for the economically efficient functioning o f the system through professional public management.With the above as background a provisional attempt is made to focus on possible public m an ag em en t stra te g ie s for health serv ice provision systems.This is done in terms of the p u b lic m an ag e m en t fu n ctio n s, sk ills and techniques identified in the public management m odel.

Strategies in respect of Public Management Functions
In re sp e c t o f p o lic y -m a k in g as a p u b lic management function it is necessary to include political variables into the policy enhancing its legitim acy.T h is necessitates a deliberate attempt to involve clients and employees as citizensin the process o f policy-makingthrough the creation o f participative structures and requires commitment from public managers to democratic and participative decision-making.
From their inception policies should consider economic variables to enhance their efficiency, econom y and productivity.In this regard strategies should be introduced to al low officials as experts to provide inputs regarding the factual bases o f policy and to assess policy applicability in terms o f professional and technical criteria.
T h e p u b li c m a n a g e r s h o u ld m a n a g e opportunities to enable the inclusion of all relevant inputs resulting in improved policy legitimacy and efficiency.
Planning as a public managem ent function should take into account many o f the intricate variables that influence planning in public sector settings.
A strategy to improve planning within such settin g s follow s the step s o f the planning process.The seven phases that may be used are: The challenge for the public manager is manage th is p la n n in g p ro c e ss w ith the necessary political and econom ic inputs at the relevant stage.
Organisation is concerned with the setting of objectives, the division o f labour, delegation o f authority, co-ordination o f activities and control measures to ensure that objectives are reached.Internal control measures have to be realistic in terms of their economy and applicability.They have to be as "unbureaucratic" as possible.Regulations merely for the sake o f regulations arc uneconomical, inefficient and frustrating.They tend to inhibit initiative and suppress motivation.Some general guidelines about stra teg ie s for internal control have to be considered.Robbins (1980:384) identifies six guidel ines for an effective system o f control and evaluation.These are: The traditional control mechanisms such as inspections, reports, statistical returns and au d itin g are still in place.N ew control mechanisms are being developed and include value for money or perform ance auditing, m a n a g e m e n t b y o b je c tiv e s , g r e a te r management autonomy linked to performance standards and programme evaluation.To the extent that these mechanisms could alleviate some o f the dysfunctional consequences of traditional control mechanisms, they should be utilised.It should be realised however that these newer m echanism s must take the particular context o f publ ic management into account and will not prove to be the panacea they arc sometimes held out to be.The public management functions and skillscan b e s u p p o r te d by p u b li c m a n a g e m e n t applications such as policy analysis, strategic m anagem ent and organisation development.These applications attempt to apply knowledge in a system atic way to policy, planning and organisational challenges.They provide very useful approaches to the handling of change in a systematic way but should be applied with sensitiveness in the public sector context.F in a lly , n u m e ro u s ty p e s o f s u p p o rtiv e technology and techniques are available to public m anagers.These include com puter technology for information management and e s p e c ia lly fo r m a n a g e m e n t in fo rm a tio n systems.

Strategies in respect of
Public managers o f the future face tremendous challenges requiring a particular type of person and personal approach.In the next section an overvi ew wi 11 be gi ven o f t he necessary atti tudes to cope with change and the future in public management.This is seen as a personal survival checklist for future public managers.

A P E R S O N A L S U R V IV A L C H E C K L IST
W h en th e c h a lle n g e s o f th e fu tu re are considered as well as the challenges of new approaches to public management, it becomes clear that future public managers will have to adopt a set o f new attitudes.These attitudes will reflect the rejection o f the static, rigid and bureaucratic inclinations so often found in the past.Caiden (1971:286)  * an optimistic leader not easily discouraged in adversity but able to command attention and stimulate subordinates.
To adopt these desirable postures a public manager will have to be critical of his own position and should be susceptible to change personally.T his is logical as the public manager will not be able to escape change and rather should be inclined to manage for change.This includes a realistic self-assessment and, if necessary, a personal re-adjustment.

S U M M A R Y A N I) C O N C L U SIO N
It is useful to focus on public health delivery systems by means of the public management model.In this process it is clear that the management of health services in South Africa will present enorm ous challenges in the future.
T hese c h a lle n g e s n e c e ssita te new p u b lic management strategies in accordance with the needs presented by the challenges from the environment.Public health managers will have to adopt new and innovative approaches if they expect to survive the expected rapid changes.
the urban population is e x p e c te d to in c re a se from an u rb a n ise d population o f roughly 15,2 million in 1980 to ap p ro x im ately 33,5 m illion in 2000, 44,7 million by the year 2010 and 56,9 million by 2020.It is expected that on average 956 000 people will urbanise per year over the next 20 years.

Figure 1 A
Figure 1 A Public Management Model (designed by W. Fox, E. Schwella and H.F. Wissink) In the p ast the p o lic y o f a p a rth e id ig n o re d or su p p ressed m any ju s tifie d and legitim ate demands of large segments o f the South African population leading to biased and discriminatory policies.These policies in turn created serious backlogs and unjustifiable differences in quality of public services delivered along racial lines.Irre sp e c tiv e o f the o u tc o m e o f p o litic a l negotiations, any future government will have to address these deficiencies if it is to gain and retain legitimacy and political support to hold power.'1110 necessary implication o f this is that differential spending and service provision patterns will have to disappear.I am personally o f the opinion that the role o f public health services delivery systems will increase under any g o v ernm en t w hich is elected by and a c c o u n ta b le to th e to ta l S o u th A fric a n population.
T h e ab o v e p o in ts lead to th e s u p p lie r's c o m p o n e n t o f th e sp e c ific en v iro n m en t. S u p p lie rs p ro d u ce , m o b ilise and allocate v a r i o u s k in d s o f s c a r c e r e s o u r c e s to organisations.The general problem regarding the scarcity of resources has been discussed under the economic environment.The typical client groups for the public health services are by and large those people w ho are in the worst position regarding ability to pay for health care.
A s s u c h , it is a m ic ro c o s m o f p u b lic m a n a g e m e n t fu n c tio n s fu n c tio n in g at an in t e r m e d ia t e le v e l r e g a r d in g the im p lem en tatio n o f p olicy.S trateg ies for improved organisation require a proper analysis o f relevant aspects o f the general and specific environment.The appropriate approach has to be selected from various alternatives given the most im portant situational variables.This may result in different patterns of organisation for different situations depending on contingency fa c to rs .P u b lic m a n a g e rs in v o lv e d in organising therefore have to be analytic and k n o w le d g e a b le a b o u t o r g a n i s a ti o n a l possibilities.One has to accept that public organisations arc often not organised de novo but are organised w ithin given param eters p lacin g lim ita tio n s on c o m p le te ly novel a p p r o a c h e s .F u r th e r m o r e e x is ti n g organisational parameters are often not only the result of technical organisational realities but a re in f lu e n c e d h e a v ily b y p o litic a l considerations.L e a d e rs h ip from a p u b lic m a n a g e m e n t perspective has little to do with romantic visions of charismatic hero-type leaders.Leadership has to be related to the a c h ie v e m en t o f organisational goals and objectives.Leaders use their organisational authority to influence behaviour and actions o f individuals and groups towards the achievem entoforganisational goals and actions.In this process leaders have to be knowledgeable about: * the nature o f the goals and objectives; * the capabilities, com petency, knowledge and skills o f their subordinates; and * the nature of the tasks involved.Given the relative position in respect o f these variables leaders have to select the applicable leadership approach for given circumstances.T h is m ay im p ly a v ery d e m o c ra tic and participative style under some conditions and a much more individual and autonomous style under other circumstances.A general trend, given changing social conditions, is that leaders have to respect basic human rights and needs o f th e ir s u b o r d in a te s .A u to c r a tic an d commanding styles tend to create problems wi th employees of the present generation who come from social backgrounds incorporating liberal world-views.Public m anagem ent control and evaluation efforts must provide for external control by the people or citizens providing the political and financial resources for public services.It also has to provide internal control over the effective and efficient utilisation o f these resources.E x te rn a l c o n tr o l in v o lv e s im p o r ta n t mechanisms toensure democratic responsibility and public accountability .Public service delivery systems have to be subject to public scrutiny through mechanisms such as legislative bodies, the law courts, ombud institutions, state auditors and also the press.The notion o f public accountability is often viewed as cumbersome and u n n e c e ss a ry in te rfe re n c e by p u b lic managers.This is a dysfunctional attitude given the tenets o f d em ocratic g o vernm ent and administration.The strategy should rather be to a llo w fo r as m uch p u b lic s c ru tin y an d participation as possible because this provides effective cauterising m echanism s to avoid corruption and maladministration.
Public Management Skills and TechniquesP u b lic h ealth se rv ic e s m anagem ent often involves decision-making by groups of people in c lu d in g h e a lth p r o f e s s i o n a ls , h e a lth administrators and the community.For this reason strategies to enhance group decisions are valuable.Some o f the techniques that could be used to improve group decisions are democratic participation, the nominal group technique, b rain sto rm in g , the d e lp h i-tech n iq u e and synectics.Synectics, for example, is a method by which problems are solved by attempting creatively to fit together di fferent and secmi ngly irrelevant elements to form new solutions to problems.It recognizes that most problems are not new but that the challenge is to view the problem in a new way.Through this a basis for a new s o lu tio n is e s ta b lis h e d (R o b b in s 1980:81).All such techniquesaim at useful and thorough involvement of people into groups for improved decision-making.There are many factors that impede proper communication skills in public organisations.T h ese in clu d e e m o tio n s, the filte rin g o f information by senders, language factors such as ja rg o n , d ifferen t language g ro u p s and s e l e c t i v e p e r c e p t io n .T o im p ro v e c o m m u n ic a tio n te c h n iq u e s , s im p lify in g language using feedback and the development o f listening skills are important and necessary.
lists a number of attitudes that the public manager should take in future.Me suggests that the public manager should become: * a crusading reformer intent on transforming some aspects o f communi ty I i fe aocordi ng to preconceived notions of the ideal society; * a pro-active policy formulator ready with passible strategies to meet the unknown; * a social change agent ready to accept new ideas and to lead others into accepting them; * a crisis manager w ho is slow to bum but quick to act and b rilliant at im mediate improvisation; * a dynam ic program m e m anager able to shape new courses and adept at analysing activities; * a humanitarian employer treating personnel with respect and meting out balanced and cquitablejustice; Curationis, Vol 15, No. 1,1992 * a political campaigner w ho is responsive to public needs and a cham pion o f public causes; * a com petent m anager ensuring effective p e rfo rm a n c e w ith m in im u m p o litic a l embarrassment; * an in t e r e s t b r o k e r c h o o s in g a m o n g com peting interests and reconciling all parties to the outcome; * a public relations expert adept at building support to the advantage o f the public; * a speedy decision-m aker prepared to assume responsibility and to give clear instructions; * a constructive thinker not easily lead astray; To excel they should enhance their public management knowledge and skills.This may be done, inter alia, by attending courses in public management such as those presented by the Stellenbosch School of Public M anagement and other institutions.BROW N, W B AND MOBERG, OJ. 1980.Organization Theory and Management: A Macro approach, John Wiley & Sons; New York.BUSINESS FU TU RES.1990.Unpublished R esearch R eport.In stitu te for F utures Research, University of Stellenbosch.CAIDEN, JE. 1971.Public Administration: A Synthesis, Palisades Publishers, California.DRUCKER, P. 1977.Management, Pan Books, London.FOX, W. SCHW ELLA, E. AND WISSINK, F. 1 9 9 1 .P ub lic M anagem ent, Ju ta , C ap e Town.R O B B IN S , SP. 1980.The A dm inistrative Process, Prentice-Hall, New Jersey.