Strengthening public financial management in the health sector: a qualitative case study from South Africa

INTRODUCTION: Effective public financial management (PFM) ensures public health funds are used to deliver services in the best way possible. Given the global call for universal health coverage, and concerns about the management of public funds in many low-income and middle-income countries, PFM has become an important area of research. South Africa has a robust PFM framework, that is generally adhered to, and yet financial outcomes have remained poor. In this paper, we describe how a South African provincial department of health tried to strengthen its PFM processes by deploying finance managers into service delivery units, involving service delivery managers in the monthly finance meeting, using a weekly committee to review expenditure requests and starting a weekly managers’ ‘touch-base’ meeting. We assess whether these strategies strengthened collaboration and trust and how this impacted on PFM. METHOD: This research used a case study design with ethnographic methods. Semi-structured interviews (n=30) were conducted with participant observations. Thematic analysis was used to identify emergent themes and collaborative public management theory was then used to frame the findings. The authors used reflexive methods, and member checking was conducted. RESULTS: The deployment of staff and touch-base meeting illustrated the potential of multidisciplinary teams when members share power, and the importance of impartial leadership when trying to achieve consensus on how to prioritise resource use. However, the service delivery and finance managers did not manage to collaborate in the monthly finance meeting to develop realistic budgets, or to reprioritise expenditure when required. The resulting mistrust threatened to derail the other strategies, highlighting how critical trust is for collaboration. CONCLUSION: Effective PFM requires authentic collaboration between service delivery and finance managers; formal processes alone will not achieve this. We recommend more opportunities for ‘boundary crossing’, embedding finance managers in service delivery units and impartial effective leadership.