Decentralizing South Africa’s Health Systems
Thomas Bossert has built a career focused on global health. At the Harvard School of Public Health (HSPH), in Boston, Bossert is Senior Lecturer on Global Health Policy in the school’s Department of Global Health and Population. He’s also Director of the school’s International Health Systems Program, a multidisciplinary team of faculty, scholars and experts. Through research, training and technical assistance, that team works to improve health and living standards for the disadvantaged in countries including Ghana, Chile, Pakistan and China.
Bossert is responsible for HSPH’s partnership in South Africa’s Albertina Sisulu Executive Leadership Programme in Health (ASELPH). The other partners are South Africa Partners, the University of Pretoria and the University of Fort Hare, which, Bossert notes, “is the university that [Nelson] Mandela and many of the ANC leaders attended.”
ASELPH offers an integrated approach to professional development for South Africa’s health leaders. Its focus is on improving the skills of the practitioners and leaders who will drive a true health system transformation in South Africa.
Bossert’s personal focus is on decentralization of health systems, including the challenges of its execution and the nuanced relationship between decentralization and health sector performance.
Let’s start with the big picture. What does ASELPH bring to the healthcare conversation in South Africa?
Doctors are not particularly good at managing. It takes certain additional training to do it well. In South Africa, there’s not a parallel path as there is in the United States for hospital managers. Here, hospital managers don’t have to be physicians — they can be managers, and that can be their career path of choice.
The objectives of the whole program come out of a recognition that one of the problems in the South African healthcare system is the lack of good leadership and management skills at almost all levels. This is particularly true at the district level, and particularly in the public sector working in primary healthcare, although it’s also a problem in the hospitals.
So we have developed a program to build that kind of capacity, using some of the existing Harvard courses with which we train people all around the world in leadership, management and ways to think about policy and how to improve the health system.
How do you believe ASELPH’s approach is unique?
It’s getting managers to think beyond concerns such as, “What forms do I have to fill out? How can I hire this person?” Instead they are focusing on the leadership that’s necessary to get people to work harder and to do better things.
We’re also trying to motivate leadership thinking on the broader policy issues, so that managers understand where their institution and their work fit into the possible changes. These changes are coming down the pike with the new insurance program, which will mean there’ll be different ways people are going to be paid and different kinds of incentives in the system.
The ASELPH Fellows are people who are highly motivated. They’ve been carefully selected. They are probably going to be in leadership positions where they’re making broader decisions than just the local management decisions, and so we’re trying to prepare them for the future.
Can you describe Harvard’s specific role in the ASELPH partnership?
Harvard is known for its case method teaching, so we try to develop cases that illustrate some of the major pedagogical points that we’re trying to make. We are adapting the material, because we want the content to have more South African cases and examples. We are working with the South African faculty to develop that.
One of the things about using cases is that it is very useful not to have a simple answer. You want to have a situation where the participants or students struggle to figure out the best solution. Getting that kind of material for a management problem is quite useful.
We also put on policy seminars and round-tables where we bring in experts from Harvard faculty to have discussions about international experience on, say, the establishment of national health insurance. We also create forums for discussions on decentralization and how to organize at the district and provincial levels. And we have sought to build the capacity of the local institutions to continue and sustain this effort in the future. So it’s a really major, major effort.
The South African universities already are able to teach basic management. Harvard’s involvement is to focus on a higher level of training for leadership and for the people at the district level who are going to be the future leaders who will improve that health system.
Tell us a little about your background. How did you get involved in global work?
My family participated in the Experiment in International Living, which brought foreign students to our house during the summers before they went into U.S universities. That organization exposed me as a child to lots of other cultures — Italians and South Africans and others came to our house.
The organization had a conference of families that had participated, and it happened in Mexico when I was just starting high school, so I went down there. I grew up in Westchester County, New York, in one of the wealthiest parts of the world, and I was shocked by what I saw. The poverty really affected me. That got me to think that what I wanted to do is what I’m doing now.
After I got out of high school and went to Princeton, I had some very good professors who were interested in working in Latin America, and I started learning Spanish and started on that track. I went on to the University of Wisconsin in Madison to get my PhD in political science. My thesis was on the Allende government in Chile, and I was in Chile in 1973 at the end of his period. I have been working in Chile since then, and I take students down every January for a three-week course on health reforms in Chile.
There must be many things about teaching and researching that are challenging.
Always. That’s part of why I do it. For a long time at Harvard there has been considerable interest in teaching in ways that aren’t just lecturing and telling people what you know, but to have them struggle with the problem. Now there’s a lot of talk of what is called the “flipped classroom,” where maybe a lecture is put online, where the students are supposed to be working on their own and then they come to the classroom to work together. The faculty is a coach rather than a lecturer.
I think some people go overboard in these new methods, because I don’t think that people learn the same way all the time. There’s a place for lectures and there’s a place for doing things together and there’s a place for letting people cogitate in their own rooms reading stuff. What we’re working on is trying to mix the new methods with the old methods and find ways to teach people that are dynamic and exciting and fun for everybody.
Partnerships are a big part of what you’re engaged in with ASELPH.
It’s one thing that we have to spend a lot of time thinking about and working on, because since we are in the position of having the skills that our partners want to learn, we have to avoid saying we are the ones that run this thing. On both sides, we have learned how to work better together because of that.
We trust that we’re trying to work toward the same kind of objectives. In a recent meeting on Skype, Dr. Mvuyo Tom, who is an overall leader on the South African side and one of our key partners, described this collaboration as a soccer game. It’s something we all have to play together and have to do right. I agree with that. It’s been just wonderful to work with the staff there. It’s an exciting process.
Finally, are there any observations you would like to share about your work with South Africa Partners in particular?
Mary Tiseo and her team have been really critical in supporting us, raising administrative issues and playing a key role in making sure that things happen. They were so critical in getting the funding necessary. We have three major funders, each of whom is contributing a third of the funding, and they’re all very different. South Africa Partners really deserve a lot more recognition.