Delivering his budget speech on 22 February, Minister of Finance Enoch Godongwana focused on the major infrastructure — electricity, water, and municipal projects. This heavy focus is understandable given that spending on public sector infrastructure over the 2023 medium-term expenditure framework (MTEF) is estimated at R903-billion. Of this, state‐owned enterprises (SOEs) and public entities are the largest contributors to capital investment, at a projected R302.1-billion over the next three years. Over this period, infrastructure spending on social services infrastructure will account for 17.6% (down from 18.2% in the 2022 MTEF).

Health and education account for 5% and 7%, respectively. And while this may pale in comparison to what the government calls “economic infrastructure”, the importance of social infrastructure should not be underestimated in a country still gravely challenged with inequality, particularly in the delivery and access to quality health services.

Finance Minister Enoch Godongwana. (Photo: Gallo Images / Ziyaad Douglas)

This unequal access to quality health services was recently underscored when Health Minister Dr Joe Phaahla, in response to a DA MP’s question in Parliament, confirmed that only 55% of all clinics in the country have gained ‘ideal clinic status’. An ideal clinic is a facility that must comply with a range of criteria, among which is good infrastructure. Yet, judged by observations by the community-led clinic monitoring project Ritshidze, there are many clinics across provinces with inadequate infrastructure — from broken toilets to waiting areas that are way too small and inadequately ventilated.

Effective procurement — a social justice imperative

So, given the billions spent on addressing infrastructure challenges across sectors and the fact that poor maintenance and oversight of these big infrastructure projects are well-documented — monitoring closely these trends across the public sector, particularly where procurement and contracting are concerned will be vital. In the health sector, now also plagued with rolling blackout challenges that require their own infrastructure overhaul, this need for transparency will be particularly pronounced as spending in the health sector is often a matter of life and death for patients.

Arguably less documented are the interventions to address these issues in an ethical and just manner through progressive procurement systems. Effective procurement is a social and environmental justice imperative which, in South Africa, additionally carries constitutional obligations to tackle the consequences of apartheid-era discriminatory policies. On a global policy level, targets within Sustainable Development Goal 16 make the links between human rights, participation, and anti-corruption efforts clear. These aim to “substantially reduce corruption and bribery in all their forms” and to ensure “responsive, inclusive, participatory and representative decision-making at all levels”. This is important in the context of health infrastructure, which is outlined in the National Development Plan as a national priority.

Notably, the National Anti-Corruption Strategy (Nacs) has identified the health sector as having a high vulnerability to the manifestation of corrupt or unethical practices. Who can forget the Digital Vibes scandal, where almost two years after it exploded in the headlines — no high-profile arrests have been made?

Former minister of Health, Dr Zweli Mkhize during a visit to Livingstone Hospital. (Photo: Black Star / Spotlight)

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The looting of the health system by ‘tenderpreneurs’ that was exposed in the context of Covid-19 personal protective equipment and infrastructure purchases illustrated the need for full cycle procurement transparency and open publication of contract data. To this end, it is encouraging to note that the National Infrastructure Plan prioritises effective monitoring and evaluation as a means of ensuring infrastructure quality and accountability. Amongst these is the intention to implement open reporting on infrastructure projects at various stages. Importantly, the plan is to align with the Open Contracting Partnership’s open data standards and the CoST Infrastructure Transparency Initiative. CoST is one of the “leading global initiatives improving transparency and accountability in public infrastructure”. 

Nurture greater community involvement

Anti-corruption initiatives must be radically strengthened in the health sector where abuse and maladministration can have life-threatening consequences. What is needed, therefore, is the nurturing of greater community and civic involvement in anti-corruption efforts to support the approach outlined in the Nacs. The National Health Act also makes allowances for community involvement in the governance of the health system at facility, district, and provincial levels. One might therefore assume that meaningfully involving health facility users in on the ground infrastructure project oversight is not a far-fetched possibility.

So how do we, in the spirit of SDG goal 16, “substantially reduce corruption and bribery in all their forms”, especially with eye-watering billions earmarked for infrastructure projects?

One key answer, among others, in South Africa is the Public Procurement Bill, which essentially aims to streamline government procurement processes to enhance transparency. However, the silence on the Public Procurement Bill in the Budget Speech accompanied by only fleeting references to important reform in an Annexure of the Budget Review does not bode well for broader reform.

Only 55% of all clinics in the country have gained ‘ideal clinic status’. An ideal clinic is a facility that must comply with a range of criteria, among which is good infrastructure. (Photo: Black Star / Spotlight)

Still, South Africa is in dire need of a more sustainable, social justice-oriented response to the devastating poverty and inequality in the country. Open government initiatives can offer significant safeguards against capture of the procurement system. They may also increase opportunities for more robust public and parliamentary oversight. The data from such platforms can be used by diverse stakeholders, including journalists and civil society, to identify signs of irregularity where competition and contracting are concerned. For instance, included in the 2023 public infrastructure updates for health is the construction of the Limpopo Central Hospital — a 488‐bed hospital in Polokwane, which will form part of an academic health complex attached to the University of Limpopo’s medical school. Others include the R10.4-billion Inkosi Albert Luthuli Central Hospital Project (a public-private partnership), Tygerberg Hospital (R4.2-billion), and Klipfontein Hospital (R4.3-billion).

Now, imagine any member of the public having access to project plans, contractor and contract information, as well as expenditure and performance data for each of these projects at every stage of development. Imagine all R903-billion worth of infrastructure projects across SOEs (yes Eskom too), departments, and public entities being open to direct, near real-time scrutiny.

This is entirely possible. 

However, in the absence of coherent policy, well-resourced plans, and institutions, as well as active political support for such reforms, the encouraging plans that can make this kind of transparency possible will be severely limited in their impact. 

Either way, if we are to track and safeguard efficiently the promises for public healthcare infrastructure, we must urgently finalise South Africa’s long-awaited procurement reforms. DM

*Kota is the Programme Head at the Public Service Accountability Monitor (PSAM) at Rhodes University.

*This article was published by Spotlight – health journalism in the public interest.