Create the correct context for NHI transformation

NATIONAL Health Insurance (NHI) will be funded through payroll taxes, a surcharge on personal income tax, the reallocation of medical scheme tax credits to the NHI Fund, and general taxes. Chris Collingridge African News Agency (ANA)

“Yesterday’s success formula is often today’s obsolete dogma … We must continually challenge the past so that we can renew ourselves each day.” – Sumantra Ghoshal (1948 – 2004). 

Kodak was a known company that provided packaging, functional printing, graphic communications and professional services for businesses around the world. Its main business segments were Print Systems, Enterprise Inkjet Systems, Micro 3D Printing and Packaging, Software and Solutions, and Consumer and Film. Kodak was founded by George Eastman and Henry A. Strong on September 4, 1888. Kodak held a dominant position in photographic film, before filing for bankruptcy in 2012.

Similarly, Blockbuster Video is an American-based provider of home movie and video game rental services through a video rental shop, DVD-by-mail, streaming, video on demand, and cinema theatre. Blockbuster expanded internationally throughout the 1990s. Blockbuster Video became defunct in 2013. Likewise, Borders, which was one of the largest book retailers in United States, went out of business in 2011. Why did these companies with such great brands ultimately fail? Because they failed to adapt to change. Additionally, they failed to unlearn and relearn.

Although it is well known that the only constant in the world is change, people resist change due to various reasons, including the fear of failure, criticism, and the unknown. They often think the known devil is better than an unknown angel. They settle for the status quo and ultimately become extinct. Similarly, companies that fail to change with the times and technologies find themselves on the road to extinction.

In the current health dialogue which seeks to bring about drastic change that is desirable and should be pursued without apology. However, changing laws and policies may (at times) bring about undesired results.

For too long, government agencies have implemented various change efforts from the top down. Yes, our policy development framework starts from the political mandates which must be implemented religiously, but excluding the people who will implement the change, you want to see, is a disaster in making. And, lest we forget that organisations (including government) don’t operate in a vacuum.

Not so long ago someone shared with me an amazing video on YouTube explaining the concept of “Smell of the Workplace”. This was a brilliant speech delivered by Professor Sumantra Ghoshal, a management guru, a thinker, an author, a theorist, at the World Economic Forum several years back. This video is about transformational leadership and is a must-watch for all leaders.

Professor Ghoshal used the metaphor of “smell” to refer the corporate environment and culture and explained what should be the top-management mind set to improve the “smell” of the workplace for the sustainable success of the organization.

In the context of the NHI discourse, it is clear that the current transformation ignores the ‘smell’ of our healthcare system, in particular the public healthcare system. This could be looked at from the consumer side and/or the workers (healthcare professionals and workers) who continue to offer services in spite of a dissatisfied client based.

An evaluation report, titled; “Evaluation of Phase 1 implementation of interventions in the National Health Insurance (NHI) pilot districts in South Africa” (2019), notes; “NHI requires complete reorganisation of the health system; a process of immense change in institutional and individual functions, roles and responsibilities.”

It goes further to quote an official in the National Department of Health (NDoH) who decries lack of consultation; “I report to the DDG (Deputy Director General) of NHI in the new structure but that wasn’t communicated to us. We saw it in a meeting on an organogram. I’m not sure what is happening. We are expected to implement change management with provinces but the same is not done for us”.

Another official is quoted saying; “NHI was forced on provinces, they weren’t volunteering to participate. In the first few years this was the stumbling block. National and Provincial had same projects at different levels that didn’t speak to each other.” It was the late Prof Sumantra Ghoshal (1948 – 2004) – a management theorist and academic – who said; “Yesterday’s success formula is often today’s obsolete dogma … We must continually challenge the past so that we can renew ourselves each day.”

The military styled organisational culture that craves hierarchy and titles creates makes an environment that makes ordinary workers in the frontline feel tired due the high temperature and humidity instead of feeling re-vitalized and energetic. Professor Ghoshal explained how the corporate environment are analogous and how top-management’s strategy, organization, process, infrastructure, policy etc. can leads to “smells” namely constraint, compliance, control and contract. 

People work for three reasons: the money, the challenge, and the sense of accomplishment. In a job that only fulfils one of these needs, money, most people will spend their time looking to move on. Or, they will look for engagement elsewhere. This may be okay – each person makes choices, and if they want a job where they can just go, do their job and come home and focus on family and hobbies, that’s fine. But, for transformation not to face backlash from within, it needs people who are engaged at work. For that to happen, workers (and communities) need a challenge and a sense of accomplishment.

Ghoshal suggests that leaders can shift the environment by “revitalizing” people as opposed to “changing” people by creating a right “context” around them namely stretch, discipline, support and trust to maximize their personal contribution to the vision. The current NHI debate has not taken workers and communities on board. It has left them out as spectators. There are already vital examples from where we can learn that living workers out may have disastrous repercussions.

Take the ‘Choice of Termination of Pregnancy Act’ which was implemented from the top without proper engagement with workers. While it offered conscientious objection, the uptake by those in the frontlines of care was very poor. Till today, it remains a topical issue where workshops on value clarifications are being run in the hope that workers will be able to make a ‘choice’ between the obligation to care and their (moral/religious) conscience. What a choice!

If workers are simply expected to do what they’re told, it may challenge them, but it’s not going to challenge them as much as a job in which they have to figure out the details and plan. They’ll experience a small sense of accomplishment when they complete any task, but they’ll experience a better sense of accomplishment if they’ve had to figure out what to do and how to do it. They’re more likely to feel satisfaction when they’ve put some brain power into the work.

The report on the NHI pilot further notes; “…process of consultation and consensus-building requires time and resources, which should not be underestimated. Stakeholders…also emphasised that the timing and frequency of consultative fora is sometimes insufficient to ensure that it is feasible to gain useful inputs and consensus. This is an observation that is triangulated across stakeholders across national, provincial and district levels.”

Elsewhere I note that as we argue the merits and demerits of the NHI, we ignore entirely the source from which we must draw all the energy to employ in crafting our solutions, and we ignore all the effects on other members of society than the ones we have in view – usually those with whom we share comforts of the current arrangement. I also warned that the NHI discourse must not be turned into a patronizing weapon against those on the bottom of the pyramid. The NHI discussions should include all of us so we can be the change we want to see.

We need to admit that the ‘smell’ of our health is suffocating. We shall never forget the ‘kidney gate’ (a kidney transplant scandal) where Netcare (the biggest private hospital group) admitted receiving R3.8million from an illegal organ trafficking syndicate in a scam that included the removal of kidneys from five children, according to The Guardian (10 November, 2010).

The paper reported that Netcare took part in an international scam that allegedly saw poor Brazilians and Romanians paid $6,000 for their kidneys to be transplanted to wealthy Israelis. Netcare in KwaZulu Natal, pleaded guilty on 102 counts relating to illegal operations between June 2001 and November 2003 and fined a trifle of R7,8 million.

We also know that medical-litigations in public health have risen to an estimated R10 billion and this figure is rising as more cases are lodged. All this is a clear sign of a health system approaching paralysis and in need of care (itself). The Health Compact, an agreement resulting from the Presidential Summit held in 2018, agrees that there is a lot of work that is needed to improve governance and accountability.

The four surgeons, according to News24 (8 April 2016), who were prosecuted claimed they were merely the scapegoats in a far larger, country-wide illegal kidney transplanting scheme. The report further states that Professor John Robbs, one of the four surgeons, claimed that the organ transplants weren’t only happening at St Augustine’s, but were also taking place at Charlotte Maxeke and Garden City Hospitals in Johannesburg, and Christian Barnard Memorial Hospital in Cape Town. He claims that a further 220 illegal transplants took place across these hospitals. The stench is deep!

As we forge ahead with the NHI project, it is clear that leaders need to keep a focus on defining our change theory. Developing a change theory or model offers an effective way to collectively design smart, simple, financially sustainable solutions tailored to the context – and these solutions are at the core of building elements of, capacity for and momentum towards the NHI.

Developing a theory will also help describe the causal logic of how and why the change we seek will reach its intended outcomes. This will, in turn, bring focus on three interdependent but equally important areas during this change project: firstly, content, i.e. what, specifically, is to change in the organisation. This includes processes, strategy, structure, technology, habits, ways of thinking, and/ or culture (values and identity).

Second, process i.e. how change will occur in the organisation. Considerations about process include who will direct and be accountable for aspects of the change, the speed of change, communication about the change, and monitoring change success (milestones). Lastly and importantly, the people i.e. the role that human dynamics will play in achieving successful outcomes (or otherwise) from the change, as well as the impact that the changes will have on human dynamics. Particular consideration needs to be given to the emotional impacts of change and the behavioural responses prompted by change.

Professor Ghoshal believes individuals do not change fundamentally, who they are, without any serious personal crisis of some kind. Revitalizing people has a lot less to do with changing people and has a lot more to do with changing the context (smell) that organisations, that senior managers, create around their people. So, there’s an urgent need to create the context where workers and communities accept change before the change is thrust on them. If people don’t perform, they perish. If companies don’t innovate, they become obsolete. If we had not changed, we would have remained in the Stone Age.

While we need a well-considered legislation and policies for NHI, the real test is the context that is created that will shape the behaviour of people to stretch, to discipline, to trust and support the NHI. Benjamin Disraeli rightly said, “Change is inevitable in a progressive society. Change is constant.”


Chris Maxon works for KZN Department of Health and a social commentator. The views here are his own and not those of the department.