In South Africa, the responsibility for providing healthcare is a complex web of three spheres of government: national, provincial, and local. This intricate system, known as cooperative governance, is designed to ensure access to healthcare services for all citizens, as guaranteed by Section 27 of the Constitution. However, the question of who is ultimately responsible for restoring access when it is disrupted or blocked is not always clear, as seen in the court battle over blocked access to Johannesburg clinics.
The national government holds the constitutional mandate to ensure access to healthcare services, with the National Department of Health developing policy and coordinating the health system. The implementation of health services, however, takes place at the provincial level, where departments manage hospitals, clinics, and health personnel, including primary healthcare services such as school health, maternal and child health, and the treatment of long-term conditions. Local government, on the other hand, plays a different but important role, focusing on preventing illness before people reach clinics or hospitals, through what are known as municipal health services, which include monitoring the safety of drinking water, ensuring waste is collected and disposed of safely, and inspecting food outlets for hygiene and safety.
In reality, the lines between these spheres are not always neat. In some metropolitan municipalities, like the City of Cape Town and the large Gauteng metros, local government also plays a role in delivering primary healthcare services. This is where things get particularly fascinating, as it involves negotiated arrangements between different spheres of government, shaping the delivery of healthcare through service level agreements (SLAs).
One such SLA is between the City of Johannesburg and the Gauteng health department. At the operational level, the City manages the day-to-day functioning of the facility, such as medicine collection, patient queues, and the basic organization of service delivery. However, the provincial health department plays a crucial role in setting service standards, determining what care must be available, where clinics are located, and what services are offered. This includes defining operating hours and service targets, shaping how services are organized over time.
The functioning of a single Johannesburg clinic is often shaped through multiple administrative, financial, and logistical circuits that extend far beyond the facility itself. Even the presence of healthcare workers reflects this division of responsibility, with staff employed by the provincial department but temporarily assigned to City-managed facilities. This complex division of responsibility is rarely visible to most patients, but it becomes most apparent in moments of strain or breakdown, such as when queues lengthen, medicines run out, or access is disrupted.
The legal showdown in the South Gauteng High Court over the blockades at Yeoville and Rosettenville clinics highlights the contestation of accountability in these situations. The court ruled that the SLA does not outsource anything but rather assigns management of clinics to the City while preserving the provincial department's oversight responsibilities. This means that all three spheres of government must work together to ensure that reasonable measures are taken in restoring access to healthcare services.
As local government elections draw closer, the question of responsibility for healthcare becomes even more relevant to all voters. While the provision of primary healthcare services is a provincial responsibility, environmental health, which is also a critical aspect of healthcare, is a local government responsibility. The upcoming elections will therefore have an impact on the quality of healthcare services, particularly in the three big Gauteng metros and the City of Cape Town, where SLAs are in place that delegate some provincial functions to the metros.
In conclusion, the responsibility for providing healthcare in South Africa is a complex and multifaceted issue, involving multiple spheres of government and negotiated arrangements between them. The court battle over blocked access to Johannesburg clinics highlights the importance of ensuring that all three spheres of government work together to restore access to healthcare services when they are disrupted. As South Africans go to the polls in the local government elections, the quality of healthcare services will be at stake, particularly in the areas where SLAs are in place. This raises a deeper question about the role of local government in delivering healthcare services and the need for clear accountability in times of disruption.
