Community Participation or speed?

At the beginning stages of the CUBP programme, the emphasis was on departmental consultation with community committees and associations. Community consulta-tion had, in some cases, lasted for a year and a half before building commenced.

This was also true of the IDT’s clinic building programme.

The task team formed by the national DoH used a different tack. Their imme-diate priority was to develop a fast-track approach to delivery. They developed a

modular design for a clinic. Officials could look at the demographics of a commu-nity and what they could afford, and then go to the commucommu-nity and tell them that, for the size of their population, according to the norms and standards, they war-ranted a clinic of a certain size – and not a community health centre or a maternity ward. With these more realistic expectations, the community consultation was com-pleted within a week or two. While this approach resulted in communities receiv-ing new clinics very quickly, it may have compromised the communities’ need for consultations. According to a CUBP co-ordinator, when the model of a clinic was presented to communities, they were usually happy with it – “as long as it was ex-plained properly”. A model had been built, and community representatives were able to see what the clinic would look like and choose between two different de-signs. As the task team did not expect to build the same type of clinic all over the country, they provided various options which would be suitable for each context.

The heads of planning from all the provincial departments of health and works met with the task team to find out how the system worked. The provincial heads ap-proved of the plan and accepted the standard plans, but their own consultants remained responsible for putting the clinic onto the site, and for site inspections, quality control and the payment of contracts. While the national consultants designed the modules, the provincial officials liaised with communities, and deter-mined where and what types of clinics were required. Once that information reached the national office, they could go out to tender. This resulted in a savings of an estimated 17 weeks on the pre-contract time.

The co-ordinator of the CUBP strongly recommended the merits of using a modular system for clinics, and there seemed to be general consensus from the prov-inces that the system has worked well. The modular clinics were designed within the ambit of South African norms and standards for clinics, and the final cost was 21% below the norms prescribed for government clinics. A large amount of mon-ey was thus saved, which enabled the building of 150 more clinics than anticipated.

A Gauteng district official observed that “community consultation is time con-suming” and saw this as a constraint to the implementation of projects. Yet, most other officials offered a more mixed response. Prior to August 1995, community consultation took many months and limited delivery took place as a result. After August 1995, the CUBP reduced the extent of community consultation and deliv-ery increased dramatically. Consultation and community involvement versus speed of delivery is a difficult balance in most delivery sectors. A “long” process of con-sultation may empower the community, make them feel part of the project, and access the best sources of information about community needs. Yet, consultation may take long. It should also be mentioned that community consultation could also save some time by accessing information more easily. It is also difficult to assess

whether the “two to three weeks” of consultation in the new approach was adequate, or whether the consultation that took place was a token gesture.

Determining priorities?

In deciding where clinics were needed, the surveyed provinces mentioned having used fairly vague criteria such as “greatest need” or “the neediest communities”.

Northern Province officials spoke of the use of norms and standards; for example, where an area of 5,000 -20, 000 people warranted a “small clinic” while an area with fewer than 5,000 people warranted a “visiting point”, and so on. In addition, the focus has been on rural areas and trying to bring about equity between regions.

Before 1996, KwaZulu Natal already had an efficient system of identifying needy areas. Nurses were appointed who travelled through the province speaking to the communities and determining where clinics were needed. The national DoH encouraged KwaZulu Natal to continue with this approach, but also to embrace the aspects of the new fast-track approach that would speed up delivery. In many areas however, the criteria for delivery are unclear or controversial. Developing national criteria is a further challenge to be dealt with in many areas.

Government co-ordination

Government officials, consultants and private sector representatives all spoke of the crucial role that communication plays in co-ordinating infrastructure and most said that it could definitely be improved. An official from KwaZulu Natal felt that this co-ordination was not very effective and that “planning is taking place in isolation”.

Some officials at national level seemed to think that communication and co-ordi-nation among the various levels of government was good, although they recognised the need for facilitators on the ground in the provinces to feed information up to national level. Other national officials said that no formal system of interaction is in place, and that this is one of the most urgent needs to be addressed. For exam-ple, links should be established between the DoH and other departments such as Transport, Housing, and Minerals and Energy because “health is more than just health services”. A KwaZulu Natal official said that the Health Department liaises with the Works Department (implementor of projects), Telkom and Eskom through the regional office, and with Transport when required. There was no mention of Housing, Water Affairs or Education. This official warned that, while co-operation is good, too much liaison can delay the process and “suffocate” projects. Co-ordi-nation needs, in other words, to some extent to be balanced against the speed of delivery.

While a lot has been done in terms of co-ordinating policies between the various government departments, several officials mention the need to co-ordinate actual delivery better. Officials felt that there was limited joint planning between depart-ments at provincial level. An example given was that while the Housing Depart-ment was planning delivery of houses in one area, the Health DepartDepart-ment was plan-ning to build a clinic in an old township that had been neglected for ages, and the Education Department may be planning a school somewhere else. A Gauteng pro-vincial official mentioned the Gauteng Intergovernmental Forum meetings, which are held on a monthly basis between the Health, Education and Welfare depart-ments and the Provincial District Health Systems Committee. Similar structures have been established in several other provinces, but many government officials seem to think that they could function more effectively.

Lack of actual co-ordination result in problems on the ground. Contractors in Northern Province and KwaZulu Natal mentioned the difficulties they experienced in implementing projects due to the lack of infrastructure, especially in rural areas.

One official spoke about the impassability of roads in KwaZulu Natal. Another official mentioned that other infrastructure, such as electricity, telephones, roads and water was often not available where clinics were required. The improvement of roads would facilitate delivery by enabling contractors to reach and transport their materials to the construction sites.

Gauteng did not work through their Public Works Department, but with their local authorities. Local authorities generally did not have funds available for infra-structure projects and so the contractors who were involved in building the clinics submitted their claims directly to the national DoH, who then processed the claims and issued payment. Gauteng DoH also mentioned that they had used the Gauteng Community-Based Public Works Project (CBPW) to channel funds to projects. The Gauteng project manager, a consultant paid by the National DoH, held monitor-ing meetmonitor-ings on a weekly basis with the CUBP co-ordinators in each district who, because they were on the ground dealing with communities and building commit-tees, could provide detailed information on the projects. Northern Province and KwaZulu Natal worked through their Public Works Departments. The provincial DoH paid their Works Department and claimed the money back from the nation-al DoH. According to the nationnation-al DoH, they tried to be fairly flexible and to avoid the impression that they were imposing national programmes on the provinces.

The Public Works Department in the Northern Province managed the various clinic-building projects on behalf of the DoH after they had been appointed by the Provincial Tender Board, and the Works Department was ultimately responsible for the execution of the projects. In KwaZulu Natal, as in the Northern Province, the provincial Works Department acted as project manager for the various projects, and was directly responsible for monitoring and supervision of progress, finances etc.

Yet, many officials felt that the procedure of having to work through the Depart-ment of Public Works contributed to additional stresses, strains and delays.

From building to operation

At national level, the CUBP seemed to be considered a success by those involved.

The number of clinics built and the amount of money saved by fast-tracking the process and using the modular design are indicators that the programme has been successful. At provincial level, while most of those involved in the process appear to think the programme has been successful, there were also some reservations. These centred around the fact that, while a number of clinics had been successfully con-structed, there had been a shortage of funds needed to “operationalise the clinics”

(Gauteng district official); “some clinics are still without water and/or electricity”

(Northern Province project manager); and, “they erect a clinic only to let it stand for ten months without staff and furniture” (Northern Province quantity surveyor).

In KwaZulu Natal, the success rate of the CUBP was considered to be “extremely high”, with more than 2.5 million people having gained access to health facilities.

Again, however, problems were mentioned. For example, in nine of the projects, the builders had gone bankrupt; in two cases community violence interrupted progress; and, two clinics were “difficult to staff”. Success was also measured accord-ing to whether projects were completed on time. In the Northern Province, approx-imately 60% of the projects were completed outside of the original contract peri-od, and “some exceeded this period by more than 200%”.

A large number of clinics were reported to be functioning at lower than their optimal level. Some RDP clinics were little more than service centres because of the lack of staff, equipment and drugs that would enable them to provide basic prima-ry health care. To prevent this from happening, a Northern Province private sector representative suggested that the government should “build only what can be af-forded – five equipped and staffed clinics are worth more to communities than ten clinics which are built but cannot be equipped or manned due to a lack of funds”.

KwaZulu Natal officials also mentioned instances where clinics stood empty as they had been difficult to staff.

A point raised by a private primary health representative was that “looking at structures is an indicator of absolutely nothing” – i.e., the number of clinics and health facilities built was not an adequate indicator of whether primary health care services were being delivered. Rather, indicators such as the number of people be-ing immunised, or the control of TB and HIV, should be used, because they are indicators of a basic level of administrative efficiency. Monitoring these processes would provide more accurate information about health delivery than counting struc-tures.

Regulation and provincial differences

Government officials in all three provinces said they were influenced by the National Health Bill and the RDP document. However, there was some variance between the provinces in terms of the supporting regulatory frameworks they apply. Thishas a potential impact on the actual type and standard of delivery. Officials in KwaZu-lu Natal said that their decisions on where health infrastructure should be built were influenced by primary health care legislation which is aimed at increasing the pro-vision of and access to health services. Gauteng district health officials spoke about the Land Development Objectives (LDOs). The LDOs developed out of the real-isation that the central responsibility of local government is to enhance the growth and development of local communities. Local government’s LDOs are based on the principles in the Development Facilitation Act (DFA), which also forms the basis for all decisions taken by a municipality relating to the development of land. The DFA tries to encourage an integrated approach to development by all departments.

Neither the Northern Province nor KwaZulu Natal officials mentioned being guided by LDOs or the DFA.

The challenge of provincial differences is, however, not easily solved. The prov-inces have extended autonomy and the national government limited power to in-tervene. The various provinces have implemented their own ways, not only in terms of goals and priorities, but also in terms of strategies for delivery. In some provinc-es, Public Works holds unified maintenance budgets for all departments and de-cides priorities itself; in others Public Works holds a separate budget for health and decides on its own how to use it. In yet other provinces, the departments of health have more influence over the allocation of the maintenance budgets. The question of national standards becomes important in this setting and, at the present time, there are still major controversies about the standards and norms to be applied at the provincial level: numbers of hospital beds, numbers of doctors etc.

Emerging contractors

In all three provinces, officials mentioned the increased use of emerging contrac-tors and small, medium and micro-enterprises (SMMEs) as an important issue for delivery. Attitudes towards affirmative action were ambiguous, especially in the private sector. In constructing new health facilities, national officials have insisted that the provinces use emerging contractors and SMMEs. However, the effective enforcement of this awaits the gazetting of the White Paper (approved by cabinet).

They feel this is hampering implementation.

All of the provinces mentioned continuing problems with the lack of capacity of emerging contractors in the completion of the CUBP. It was clear from their comments on the problems experienced and the ways to improve the process that

they would have fewer reservations about the success of the CUBP if successful skills transfer or capacity building of emerging contractors had happened to a greater extent.

The National DoH mentioned “ensuring that contracts are awarded to contrac-tors who can deliver in time and good quality work” as the major challenge the department faces. Many complained about poor on-site management, lack of ade-quate financial management, lengthy delays and “lack of commitment”. A KwaZulu Natal official mentioned nine builders (out of a total of 174 projects) who had gone bankrupt in the middle of projects. A Gauteng official complained that, after com-pletion of the projects, some of the contractors were not prepared to repair faults resulting from poor quality workpersonship. At the same time, however, one of these groups complained of a “lack of support and backup from government”. The Gau-teng DoH is currently addressing these issues through the KAP programme, which is carefully considering how best to use emerging contractors.

A provincial project manager believed government should play a greater role in facilitating skills transfer to emerging contractors, and proposed that the provin-cial Works Departments should “strengthen their technical supervision and admin-istrative capabilities to smooth the flow of projects”. He suggested that delivery is often hindered by the inability of the Works Department to effectively manage projects or to ensure proper quality control, although he conceded that slow deliv-ery by emerging contractors was also a factor.

The task team for the CUBP translated their “fast-track” pre-qualification doc-ument into all nine official languages, as a way of including all potential contrac-tors, and of saving time. The CUBP co-ordinator believed that, when using emerging contractors, it is essential to put assistance procedures into place so as to avoid sub-stantial delays. The Department of Trade and Industry was working on a plan to assist emerging contractors to win tenders. This involved changing the requirements for emerging contractors to prove that they have collateral, or can guarantee the contract. Now, they simply need to prove that they have bridging finance in order to be able to buy the necessary materials. The Council of South African Banks (COSAB) has agreed to a system of guaranteeing emerging contractors bridging finance, on condition that they have a “mentor”. The system of mentorship will involve each emerging contractor selecting a mentor whose task it will be to deter-mine the existing knowledge and experience of the contractor and thereby assess in which areas they might need assistance. The mentor will initially be involved in each stage of an emerging contractor’s project, providing assistance with the tendering procedure, the financial management, the costing, sub-contracting, and so on. As the emerging contractor learns the various processes, the role of the mentor will decrease. Finally, training programmes have been initiated jointly by the Depart-ment of Public Works and the DepartDepart-ment of Labour.