Essays on accountability and service delivery in education and healthcare in South Africa

Hompashe, Dumisani MacDonald (2021-03)

Thesis (PhD)--Stellenbosch University, 2021.

Thesis

ENGLISH SUMMARY : South Africa’s public service is characterised by poor quality of services and a weak record of accountability and service delivery. Despite high investment of resources towards the poor, there has been no corresponding improvement in the quality of education enjoyed by the disadvantaged majority. In the health sector, South Africa has not managed to significantly improve health outcomes despite sizeable resource shifts in health expenditure since 1994. Most health indicators are at a lower level than other middle- and even low-income countries whose health expenditures are substantially lower than South Africa’s. This dissertation contains three chapters on the principal-agent problem and accountability in health and education, with a focus on primary healthcare facilities and primary schools in South Africa. The contribution of the dissertation, through the analysis of novel data, is to consider how informational asymmetries in public services such as health and education conspire with low expectations from clients to act as binding constraints for delivery of high-quality primary healthcare and basic education services. It also presents evidence on how clients are able to distinguish between high- and low-quality services, providing a potential lever for quality improvement. Chapter 2 considers the correlation of patient satisfaction with clinical quality of healthcare and what such correlation suggests about patients’ ability to read signals about the quality of care. The findings reveal that non-activated or RPs (uninformed clients) provide higher ratings than activated or SPs (informed clients) about the quality of care at facilities. Although positive and significant correlations between reported satisfaction and protocol adherence were found, there were fewer correlations for the RPs: in other words, RPs’ assessment of quality is less rooted in objective clinical measures than SPs who have been trained in assessing clinical quality of care. Chapter 3 provides a comparison between SP and RPs on the role of the non-clinical dimensions of care in patient satisfaction. More positive experiences of the non-clinical factors were positively and significantly associated with an overall more satisfactory experience of health services for both the SPs and RPs. However, among SPs, the non-clinical dimensions of healthcare were more often strongly related to patient satisfaction with overall care, while fewer of these dimensions were significant among RPs. Chapter 4 examines how school principals manage curriculum delivery and how their practices influence student performance. Many school principals and teachers indicated that curriculum Stellenbosch delivery monitoring was not conducted as expected. From this chapter’s findings, both from principals’ experiences and student performance data, it is clear that less informed parents and students are not able to effectively evaluate or monitor performance of their schools. These findings have important implications for the design of bottom-up monitoring and social accountability policies. Such policies may be in the form of participatory engagement of the community, including explicitly delegating some authority over monitoring activities to community structures. Insights into clients’ ability to discern quality provides potential to hold service providers accountable, given the right support from policymakers.

AFRIKAANSE OPSOMMING : Publieke dienste in Suid-Afrika word deur lae kwaliteit dienste en swak verantwoordbaarheid- en dienslewering gekenmerk. Ten spyte van hoë besteding aan hulpbronne vir armes was daar nog geen ooreenstemmende verbetering in die gehalte van onderwys vir die minderbevoorregte meerderheid nie, en in die gesondheidsektor het Suid-Afrika nog nie daarin geslaag om gesondheidsuitkomste te verbeter nie, ten spyte van groot verskuiwings in gesondheidbesteding sedert 1994. Baie gesondheidsindikatore is swakker as in ander middel- en selfs lae-inkomste lande, ook lande met noemenswaardig laer gesondheidsbesteding as Suid-Afrika. Hierdie tesis bevat drie hoofstukke oor die prinsipaal-agent probleem en verantwoordbaarheid in gesondheid en onderwys, met ʼn fokus op primêre gesondheidsorg en skole in Suid-Afrika. Die tesis se hoofbydrae is die gebruik van nuwe, innoverende data om te ondersoek hoe gebrekkige inligting tesame met lae verwagtinge van die kliënte van hierdie dienste, saamspan om die lewering van hoë gehalte primêre gesondheid- en basiese onderwysdienste te beperk. Die tesis bevat ook bevindinge oor hoe kliënte tussen hoë- en lae-kwaliteit dienste onderskei en bied daardeur ʼn moontlike roete vir kwaliteitsverbetering. Hoofstuk 2 ondersoek die korrelasie tussen pasiënte se tevredenheid en kliniese kwaliteit van gesondheidsorg en wat so ʼn korrelasie impliseer oor pasiënte se vermoëns om seine oor die gehalte van gesondheidsorg te interpreteer. Die bevindinge wys dat ongeaktiveerde of werklike pasiënte (WPs) (oningeligte kliënte) die kwaliteit van gesondheidsorg hoër aanslaan as geaktiveerde of gestandaardiseerde pasiënte (GPs) (ingeligte kliënte). Alhoewel daar positiewe en statisties beduidende korrelasies tussen gerapporteerde tevredenheid met dienste en die navolging van ʼn kliniese protokol is, was daar minder van hierdie korrelasies vir WPs. Met ander woorde, WPs se beoordeling van kwaliteit is minder in objektiewe kliniese maatstawwe geanker as dié van GPs, wat opleiding in die beoordeling van die gehalte van kliniese gesondheidsorg onvang het. Hoofstuk 3 vergelyk die rol wat nie-kliniese dimensies van gesondheidsorg tussen onderskeidelik werklike en geaktiveerde pasiënte se tevredenheid met gesondheidsorg speel. Meer positiewe ervarings van die nie-kliniese faktore word positief en statisties beduidend geassosieer met ʼn meer bevredigende ervaring van gesondheidsdienste vir WPs en GPs. Vir GPs was die nie-kliniese dimensies van gesondheidsorg egter sterker verwant aan pasiënt-tevredenheid met algemene sorg, terwyl minder van hierdie dimensies statisties beduidend vir WPs was. Hoofstuk 4 verken hoe skoolhoofde kurrikulumlewering bestuur en hoe hul praktyke leerderprestasie beïnvloed. Baie skoolhoofde en onderwysers het aangedui dat monitering van kurrikulumlewering nie volgens verwagtinge geskied nie. Uit hierdie hoofstuk se bevindinge, beide uit skoolhoofde se ervaringe en data oor leerderprestasie, is dit duidelik dat minder ingeligte ouers en leerders nie die prestasie van hul skole effektief kan moniteer nie. Hierdie bevindinge het belangrike implikasies vir die ontwerp van monitering vanaf voetsoolvlak en beleid rakende sosiale verantwoordbaarheid. Sulke beleid kan die vorm van deelnemende gemeenskapsmonitering aanneem, waar deel van die monitering van dienslewering eksplisiet aan gemeenskapstrukture gedelegeer kan word. Insigte oor kliënte se vermoë om hoë kwaliteit verskaffers te identifiseer hou die potensiaal in om diensleweraars verantwoordbaar te hou, veral met die regte ondersteuning van beleidmakers.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/109945
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