Abstract
This thesis illuminates the centrality of street-level bureaucracy in the delivery of health services in the public health sector, with Frere Hospital as an area of focus. Lipsky (1980:3) describes street-level bureaucrats as public employees who are frontline workers. Examples include teachers, police officers and other law enforcement personnel, social workers, judges, public lawyers and other court officers, health workers and many others. For this research, I used qualitative methodology, with semi-structured interviews and non-participant observations as my methods of data collection. Additionally, I used non-probability sampling to select my study population which comprised 30 participants, 20 of whom were Frere’s staff and 10 were patients. With street-level bureaucracy as my theoretical framework (Lipsky:1980), this thesis reveals how street-level bureaucracy unfolds at Frere Hospital and how it shapes the treatment of patients. Noteworthy is that street-level bureaucracy is based on the following tenets, discretion, resource scarcity, non-voluntary clients, ambiguous expectations, face-to- face interactions, limited control over their clients’ performance, threats, and impact. In 2007, Frere Hospital was the subject of negative nationwide publicity because of stillbirths having occurred at the hospital. Even now, in 2024, this public health facility continues to experience challenges in the form of staff shortages, shortage of both equipment and theatres, disproportionate budget allocations and unnecessary referrals. The way that Frere is functioning presents a picture of a hospital struggling to provide quality health care, which is further hampered by lacklustre support from the Eastern Cape Department of Health (ECDoH). This lack of leadership prevails even though the transition from apartheid to democracy in respect of health services provision has been progressive. This can be tracked through the adoption of legislation intended to effect the constitutional rights of patients vis-à-vis the actual improvement in terms of people’s access to health care. Further to the above, the centralisation of staff appointments has made staffing ponderous, as Frere’s Human Resources department can only make recommendations for the absorption of employees. This has resulted in delayed appointments that invariably impact the quality of care being provided by the hospital. Patients, as the ultimate recipients of the public hospital’s services, give varying perspectives regarding their experiences. Some cite “caring attitude” whilst others complain about “delayed services”. The poor service provided by Frere is largely a reflection of a poor working relationship between itself and the ECDoH. To this extent, some doctors have conveyed that they could join the private sector and only stay at Frere because of their empathy for the poor who rely on the public health care system. With staff shortage permeating almost every department and clinical unit at Frere, I suggest that panelists conducting the staff interviews must be empowered to determine and appoint successful candidates, to eliminate red tape and expedite appointments. Noting the challenges facing Frere Hospital, I recommend that staff, through management, should be allowed to contribute ideas towards budget planning and request the ECDoH to abandon its practice of basing the budget on historical allocations. Ideally, Frere’s pharmacy unit should request the Procurement Cost Containment Committee (PCCC) to facilitate an increase in stock or work with other hospitals. To avert the suspension of Frere’s pharmacy unit as a training site, Frere’s Chief Executive Officer (CEO) must inform the Member of the Executive Council (MEC) when the ECDoH does not fulfil its obligations of paying the annual registration fees with the South African Pharmacy Council. Additionally, the ECDoH should ensure strict adherence to patient-referral policy, improve services in district hospitals, and build more operating theatres at Frere Hospital to avoid extended waiting periods.