Monitoring and evaluation policy as a tool for performance enhancement in the public service: The case of the Eastern Cape Department of Health S Mahlala orcid.org / 0000-0001-6194-5612 Thesis submitted for the degree Doctor of Philosophy in Public Management and Governance at the North-West University Promoter: Prof BR Hanyane Graduation Ceremony: July 2019 Student number: 26769549 DECLARATION I, Sandiso Mahlala, do solemnly declare that, this thesis entitled, Monitoring and Evaluation Policy as a tool for Performance Enhancement in the public service: The case of the Eastern Cape Department of Health is my own original work and all sources used or cited have been duly acknowledged by means of complete references, and that this thesis has not been submitted in part or its entirety by me or any other person for degree purposes at this or any other institution. Signature Date ii DEDICATION I dedicate this study to my late father’s brother Lizo Mahlala and my friends Mcebisi Ntakani and Xabiso Makapela for motivating me to finish my studies I will always and forever be indebted to you my friends. iii ACKNOWLEDGEMENTS Firstly, I would like to give praise and thanks to God the Almighty for blessing me with the strength, patience, and endurance to complete this part of my academic and life journey. I was also in a privileged position to be supervised by Professor Barry Rhulani Hanyane, who provided me with the scholarly direction and was always available to share his extensive experience on the subject. He helped to keep me focused and motivated, enabling me to complete the research. For this, I am sincerely appreciative. Thank you for inter alia, the advice, positive criticism, insights and patience in ensuring that I complete my research. I am grateful to both my parents and siblings for making the sacrifices over the past years, by allowing me the time to conduct this research. I remain indebted to my parents again for the solid foundation they laid in my life and my sisters and relatives for their on-going encouragement. My friends and colleagues have also been very supportive. It has been a long and tiring journey, but one which I hope has and will continue to advance the quality of governance and development. It is of utmost importance to thank my buddies, Dr. Maxwell Haurovi, Dr. Rulashe for their academic assistance; friendship and brotherhood he has shown me in the entire process of doing this study, his views, assistance, and friendship are truly treasured especially given that he too was busy with his studies. Doc, you left no vacuum, so that I can be able to prove your intelligence. Aluta continua. Thank you to the Eastern Cape Department of Health officials for their time and valuable responses while conducting interviews and giving me relevant documents and records. To the National Research Fund (NRF) and NIHSS, I am thankful for the financial assistance bestowed upon for my Ph.D. studies. To all those who have assisted me in any way, encouraged me when I needed it and offered me kind words, I thank you for being part of my journey. To my employer, Walter Sisulu University, I will forever be grateful. Last but not least, my colleagues in the Department of Management and Governance where I serve as a Lecturer, thanks for allowing me to continue with my studies while concurrently imparting knowledge on my students. iv ABSTRACT The study sought to interrogate the practice of Monitoring and Evaluation (M&E) as a useful performance enhancement tool for the Eastern Cape Department of Health (ECDoH). In so doing, the study proposes an M&E model for enhancing performance in the ECDoH. As a pro-efficiency practice, public entities can take advantage of M&E to ensure a timeously rendering of services. In the context of this study, public healthcare services are enshrined in Section 27 of the Constitution of the Republic of South Africa (1996) making it a fundamental legal right of all citizens. The ECDoH has to ensure that the delivery of public healthcare services is improved in terms of both access and swiftness of how citizens get access to this critical service. Furthermore, the study is premised on the problem explained as follows. Above all, the problem of less efficient processes and activities used to ensure a progressive realisation of public healthcare rights by the healthcare users in the Eastern Cape Province of South Africa. The haphazard manner in which the ECDoH presently delivers its public healthcare services has left consumers of public healthcare services living in rural enclaves which are remote and somewhat secluded from receiving quality healthcare. In addition, the continued use and reliance on the Performance Management and Development System (PMDS) to manage the Department’s performance stalls progress. This is mainly due to the fact that the PMDS is obsessed with individual employee performance at the expense of overall organisational progress. A triangulated approach was used to gather data included both a literature study and empirical evidence collection. A literature review was done where a dominant golden thread emerged showing M&E as a catalytic tool for public entities such as government departments specifically the ECDoH due to its ability to enable tracing and tracking of performance thereby allowing room for remediation to ensure goals remain attainable. Data was collected through semi-structured interviews, from a sample of 50 respondents who included members of the senior management as well as the PMDS unit in the ECDoH. The respondents were spread across the ECDoH in Bisho, King Williams Town, and East London. The analysis of data was done qualitatively using the Grounded Theory approach to enable the objective thematic coding and holistic analysis. The findings of the study included an evident existence of poor public healthcare service delivery due to the absence of an M&E framework. Other impediments affecting the efficient delivery of healthcare by the ECDoH were v established comprising the massive infrastructural shortfalls. A nine-phase model was further proposed to markedly mitigate the negative effects of the identified challenges and keep the ECDoH on track with the sustainable achievement of its mandate; and above all, delivery of this vital healthcare service to its constituencies. Keywords: public healthcare, efficiency, service delivery, monitoring and evaluation, Eastern Department of Health, performance management vi LIST OF ACRONYMS AND ABBREVIATION AD Anno Domini ADB African Development Bank AIDS Acquired Immune Deficiency Syndrome ANC African National Congress BC Before Christ BCMM Buffalo City Metropolitan Municipality BSA Balanced Scorecard Approach CASRA Centre for Applied Social Research and Action CEOs Chief Executive Officers CVPs Constitutional Values and Principles DPME Department of Performance Monitoring & Evaluation DPME Department of Performance Monitoring and Evaluation DPSA Department of Public Service and Administration EC Eastern Cape ECDoH Eastern Cape Department of Health ECHCAC Eastern Cape Health Crisis Action Coalition GEAR Growth Employment and Redistribution) GIMPA Ghana Institute of Management and Public Administration GPRA Government Performance and Results Act GWMES Government Wide Monitoring and Evaluation System HIV Human Immunodeficiency Virus HODs Heads of Departments ICT Information and Community Technology IDP Integrated Development Plan IDRC International Development Research Centre KPIs Key Performance Indicators KSG Kenya School of Government M&E Monitoring and Evaluation MGDs Millennium Development Goals NDP National Development Plan NEPF National Evaluation Policy Framework NGO Non-Governmental Organisation NHI National Health Institution NHS National Health Service vii NPA New Public Administration NPM New Public Management OECD Organisation for Economic Cooperation and Development PAIA Promotion of Access to Information Act PFMA Public Finance Management Act PM&E Performance Monitoring and Evaluation PMDS Performance Management and Development Systems PMDS Performance Management and Development System POA Programme of Action POSDCORB Planning, Organising, Staffing, Directing, Coordinating, Reporting and Budgeting PSC Public Service Commission RDP Reconstruction and Development Programme RSA Republic of South Africa SAHRC South African Human Rights Commission SAMEA South African Monitoring and Evaluation Association SASQAF South African Statistical Quality Assessment Framework StatsSA Statistics South Africa STI Sexually Transmitted Infection TB Tuberculosis UN United Nations UNDP United Nations Development Programme UNESCO United Nations Education, Scientific and Cultural Organisation USA United States of America USAID United States Agency for International Development WHO World Health Organization viii Table of Contents Declaration ................................................................................................................ ii Dedication ................................................................................................................ iii Acknowledgements ................................................................................................. iv Abstract .................................................................................................................... vi List of acronyms and abbreviation ...................................................................... viii 1.1. Orientation and Problem Statement ................................................................ 1 1.2. Introduction and Background of the study ..................................................... 4 1.3. Problem statement .............................................................................................8 1.4. Research questions ..........................................................................................10 1.5. Research objectives ........................................................................................ 11 1.6. Central theoretical statements ....................................................................... 12 1.7. Significance of the study ................................................................................ 13 1.8. Limitations of the study .................................................................................. 14 1.9. Preliminary outline of the study ..................................................................... 15 1.10. Conclusion ..................................................................................................... 18 CHAPTER TWO: MONITORING AND EVALUATION DISCOURSE IN PUBLIC ADMINISTRATION .................................................................................................. 19 2.1. Introduction ..................................................................................................... 19 2.2. Overview of the history of public administration ......................................... 20 2.2.1. A look at the history of Public Administration in South Africa .......... 26 2.2.2. Conceptualising the locus and focus of Public Administration ........ 31 2.3. Views on public administration ...................................................................... 35 2.3.1. Public administration as a practice ...................................................... 36 2.3.2. Public Administration as a theory ........................................................ 38 2.3.3. Putting Public Administration on a scientific level ............................. 40 2.4. Philosophical, Ontological and Epistemological Aspects ........................... 43 2.5. Monitoring and Evaluation in Public Administration ................................... 49 2.6 Curriculum challenges and dynamics of M&E............................................... 51 2.7. Status of research ........................................................................................... 58 2.8. Concluding remarks ........................................................................................ 59 CHAPTER THREE: CENTRAL THEORETICAL FRAMEWORKS OF THE STUDY ..................................................................................................................................60 3.1. Introduction ......................................................................................................60 3.2. Good governance ............................................................................................60 3.2.1. Unpacking the concept “governance” .................................................61 ix 3.2.2. Good governance in the context of monitoring and evaluation ........ 65 3.2.2.1. Principles of good governance ................................................. 69 3.2.2.1.1 Transparency ……………………………………………………….72 3.2.2.1.2 Public participation ……………………………..…………………73 3.2.2.1.3 Public accountability ……………………………………………...74 3.2.2.1.4 Efficiency and effectiveness explained ………………………..74 3.3. New public management as a theory of the study ....................................... 76 3.3.1. Conceptualising New Public Management ................................. 76 3.3.2. New Public Management in the context of South Africa ........... 80 3.3.3. Criticism of New Public Management ......................................... 87 3.4. Monitoring and evaluation and the theoretical framework .......................... 90 3.5. Conclusion ....................................................................................................... 96 CHAPTER FOUR THEMES EMERGING IN MONITORING AND EVALUATION . 97 4.1. Introduction ..................................................................................................... 97 4.2. Monitoring and evaluation as good governance .......................................... 99 4.3. Monitoring and evaluation as an enforcer of public accountability ........... 102 4.4. Monitoring and evaluation as an enforcer of public transparency ............. 104 4.5. Public participation and monitoring and evaluation .................................. 105 4.6. Monitoring and evaluation as corporate governance.................................. 106 4.7. Expansion of the existing body of knowledge ............................................ 108 4.8. Conclusion ..................................................................................................... 109 CHAPTER FIVE: LINKING MONITORING AND EVALUATION WITH PERFORMANCE MANAGEMENT ........................................................................ 110 5.1. Introduction ................................................................................................... 110 5.2. Monitoring and evaluation in the South African context ............................ 115 5.2.1. Objectives of GWMES ......................................................................... 123 5.2.2. Processes of the GMWES ................................................................... 124 5.3. The South African monitoring and evaluation system ............................... 126 5.4. Performance management in the public service ........................................ 129 5.4.1. The historical context of performance management ........................ 130 5.4.2. Objectives of performance management policies ............................ 130 5.4.3. Criticisms levelled against performance management .................... 132 5.4.4. The balanced scorecard approach in performance management ... 135 5.4.5. Conceptual and regulatory framework for performance management ......................................................................................................................... 136 5.4.6. Challenges in the implementation of performance management .... 138 5.4.6.1. Use of technology ...................................................................... 138 x 5.4.6.2. Performance management feedback and fear to account ...... 139 5.4.6.3. Linking compensation and rewards with performance ........... 139 5.4.6.4. Measuring and evaluating the performance ……………………140 5.4.6.5. Rater problem ............................................................................. 140 5.4.6.6. Organisational fear ..................................................................... 141 5.5. Linking performance management with monitoring and evaluation ........ 141 5.5.1. Indicators .............................................................................................. 142 5.5.1.1. Direct ........................................................................................... 144 5.5.1.2. Objective ..................................................................................... 144 5.5.1.3. Adequate ..................................................................................... 145 5.5.1.4. Quantitative, where possible ..................................................... 145 5.5.1.5. Disaggregated, where appropriate ............................................ 145 5.5.1.6. Practical ....................................................................................... 146 5.5.1.7. Reliable ........................................................................................ 146 5.6. Conclusion ..................................................................................................... 146 CHAPTER SIX: Research Strategy, Design, Procedure and Methods.............147 6.1 introduction .................................................................................................... 147 6.2. Research strategy ..........................................................................................147 6.3 Research design ..................................................................................148 6.4 Research procedures and methods Data analysis methods ............150 6.4.1 Research and data collection instruments…………………………..150 6.4.1.1 Literature study…………………………………………………………150 6.4.1.2 Semi-structured interviews…………………………………………...151 6.4.2 Target population and sampling……………………………………….152 6.4.3 Ethical consideration…………………………………………………….154 6.4.3.1 Ethical clearance……………………………………………………….154 6.4.3.2 Informed consent………………………………………………………155 6.4.3.3 Voluntary participation or autonomy…………………………........155 6.4.3.4 Avoidance of harm……………………………………………………..155 6.4.3.5 Confidentiality…………………………………………………………..156 6.4.4 Research data processing and analysis……………………………..156 6.4.5 Reliability of findings…………………………………………………….158 6.4.6 Limitations of research instruments………………………………….158 6.4.7 Description of research respondents………………………………...159 6.4.7.1 Performance management and development system directors.159 xi 6.4.7.2 Performance management and development system deputy directors…………………………………………………………………………..160 6.4.7.3 Performance management and development system managers…………………………………………………………………………160 6.4.7.4 Senior administrators…………………………………………………160 6.4.7.5 Junior administrators and practitioners…………………………..160 6.5 Justification of research strategy from previous studies…………..161 6.6 Conclusion…………………………………………………………………..161 CHAPTER SEVEN: ANALYSIS AND DISCUSSION............................................. 163 7.1. Introduction ................................................................................................... 163 7.2. Public administration and sustainable healthcare provision.................... 165 7.3. Analysis of the case study ........................................................................... 167 7.3.1. Impediments to efficiency, monitoring and evaluation in the ECDoH ......................................................................................................................... 168 7.3.1.1. Delays in adopting and implementing modern M & E practices .................................................................................................................. 169 7.3.1.2. Ambiguity in the public sector ................................................. 172 7.3.1.3. Infrastructural challenges in remote areas.............................. 174 7.3.1.4. Political commitment deficiencies ........................................... 176 7.3.1.5. Shortcomings of the organisational culture ........................... 178 7.3.1.6. Human capital constraints and rural stigma ........................... 181 7.3.1.7. Poor accountability enforcement ............................................. 183 7.3.1.8. Professionalism shortfalls........................................................ 185 7.3.1.9. Burden of manual record keeping............................................. 188 7.3.1.10. Budgetary constraints ............................................................. 189 7.4. Discussion of findings .................................................................................. 191 7.5. Conclusion...................................................................................................... 197 CHAPTER EIGHT: PROPOSED MONITORING AND EVALUATION MODEL..... 198 8.1. Introduction ................................................................................................... 198 8.2. A proposed monitoring and evaluation model ........................................... 199 8.2.1. Problem identification phase............................................................... 199 8.2.2. Preparatory phase ............................................................................... 202 8.2.3. Planning phase .................................................................................... 203 8.2.4. Design phase ....................................................................................... 204 8.2.5. Centralised implementation phase .................................................... 205 8.2.6. Performance data collection phase ................................................... 206 xii 8.2.7. Analysis of feedback phase ................................................................ 207 8.2.8. Itemised reporting phase..................................................................... 208 8.2.9. Ex-post evaluation phase..................................................................... 210 8.3. Expected outcomes of the proposed model ................................................ 211 8.4 conclusion ....................................................................................................... 212 CHAPTER NINE: SUMMARY, CONCLUSION AND RECOMMENDATIONS.......214 9.1. Introduction ....................................................................................................213 9.2. Summary and conclusions of the study...................................................... 216 9.3. Recommendations of the study.................................................................... 221 9.3.1. Recommendations on the proposed performance enhancement Model............................................................................................................... 221 9.3.1.1. Organogram redesign ............................................................... 221 9.3.1.2. Investment in performance enhancing technologies ............. 222 9.3.1.3. Addressing the rural assignment stigma................................ 223 9.3.1.4. Human capital training and development ............................... 223 9.3.1.5. Intergovernmental approach to performance enhancement. 224 9.3.1.6. Improving political will in enhancing performance ................ 225 9.3.1.7. Creating a uniform public sector ............................................. 226 9.3.1.8. Using impromptu facility visitation .......................................... 226 9.3.1.9. Pledges and ensuring a stricter code of conduct................... 227 9.3.1.10. Legislative and policy interventions....................................... 228 9.3.2. Recommendations on future studies ................................................. 229 9.4. Concluding remarks....................................................................................... 230 REFERENCES ....................................................................................................... 233 ANNEXURES …………………………………………………………………………….261 List of Figures Figure 1: A framework illustrating the chapter layout ........................................ 20 Figure 2: Linking good governance to M&E....................................................... 100 List of Tables Table 1: Sample size and structure......................................................................159 Table 2: Summary of Research Questions, Objectives and Evidence.............. 214 xiii CHAPTER 1 ORIENTATION AND PROBLEM STATEMENT 1.1. INTRODUCTORY REMARKS The intellectual and practical discourses in the field of study and practice of Public Administration make provision for debate and application of monitoring and evaluation (hereafter referred to as M&E). M&E plays an important role in evaluating the performance of any administrative system in the public service, including the public healthcare sector. This study does not focus on any administrative system but rather focuses on exploring M&E policy as a tool for enhancing performance in the Eastern Cape Department of Health (hereafter referred to as ECDoH). M&E is the pillar upon which public service economy, effectiveness, and efficiency are realised in a bid to attain public service delivery goals including public healthcare goals. Defining the concept monitoring and evaluation is critical to this study because this is the unit of analysis in this study. The researcher perceives M&E as the independent variable and performance enhancement as the dependent variable in this study. Thus the assessment of M&E as a catalyst for public healthcare service delivery in the Eastern Cape Province is the locus of the study. For the sake of further clarity, it is essential for the researcher to give a detailed explanation of what M&E entails. According to Naidoo (2011:39), monitoring as part of M&E is a continuous function in the public service that entails the systematic collection of data on specified indicators. The aim is to provide public managers in the same public sector/service of an on-going development intervention with indications of progress and achievements in public service/sector programmes, and on how funds have been allocated. The World Health Organisation (WHO, 1969:14) conceptualises evaluation in the public sector/service as a systematic process seeking to determine the extent to which a public action or set of actions were successful towards the achieving of pre-determined public objectives. WHO (1969:14) further expands that the process of evaluation as part of M&E in the public service/sector involves the realisation of public goods and services utilisation based on adequacy, effectiveness, and efficiency. In light of the above definitions, the researcher is of the opinion that public service M&E has various definitions, but overall, public service M&E functions interdependently towards 1 ensuring that the public policy programmes, for instance, are tracked and traced to allow timely correction of variances and deviations. According to the Presidency (2007:5) in the South African context, M&E has been and still remains complex, multidisciplinary and skills intensive. The South African mainstreaming of M&E is a work in progress as discussed hereunder. Fundamentally, the local framework for M&E and the Government-Wide Monitoring and Evaluation System (hereafter referred to as the GWMES) was approved by the Cabinet in July 2005 (Cloete, 2009:293). Due to M&E’s relevance in shaping the local M&E practices, the GWMES is discussed in details in section 5.2 of the thesis. The GWMES describes three data terrains which underpin the M&E system, namely programme performance information, socio-economic and demographic statistics as well as programme evaluation (Presidency, 2011:2). GWMES relies on inputs from the three spheres of government that is national, provincial and local government to provide the information from which the performance of the whole system of government can be monitored and evaluated. (Presidency, 2011:3). Such inclusion involves the public performance management operations of the ECDoH in relation to M&E. Specifically, the GWMES functions through the pooling of data and detailed knowledge from public policy and planning programmes, such as Ukhetho Transition Planning Programme (sic 2012) managed by ECDoH. The relative applicability and usefulness of M&E in the ECDoH as an effective tool for performance enhancement in the South African public service are complicated when government machinery is decentralised, with powers and functions being distributed across the three spheres of government. This decentralised nature of governance modality in South Africa, as established by Chapter 3 of the Constitution of the Republic of South Africa (1996), presents a challenge to the use of M&E due to an absence of uniformity in the public service, with implications for ECDoH. Hence, the establishing of a uniform M&E framework for the national, provincial and local governments (the GMWES in 2005) has been an Achilles heel for government South Africa, 13 years on in 2018. Precisely, it is this complicated intergovernmental arrangement with dispersed powers and functions that requires strong M&E systems to promote coordination and prevent inefficiencies especially at the provincial and local spheres of government (Naidoo, 2011:23). The observation by Naidoo (2011:23) 2 furthermore corroborates the situation in the ECDoH. Public healthcare service delivery suffers because of the poor adoption and implementation of M&E in provincial entities such as ECDoH as the researcher purports. The researcher observed that in the South African public service (including the ECDoH) M&E was not a popular practice since 2005 to date. At the time of conducting this study as observed by the researcher, the practice of the day was that public performance management was established and implemented without the proper application of an effective M&E system. M&E helps to provide an evidencebase for public resource allocation decisions and helps to identify how performance enhancement challenges faced by public managers in public entities should be addressed (Presidency, 2011:2). The researcher is of the view that performance management can be seen as a strategic and integrated approach to delivering sustained success to public entities such as ECDoH by improving the performance of the employees and by developing the capabilities of teams and individual contributors within the ECDoH for instance. In the case of ECDoH, the Ukhetho Transition Planning Programme (sic 2012) serves as an example of a policy and a planning tool to improve the performance of individual and collective efforts of the healthcare workers in the same department. The researcher is of the opinion that M&E can provide lasting solutions to the problem of access to quality healthcare in the Eastern Cape Province by way of tracking and tracing the areas such as human capital deployment in rural areas, infrastructural development and budgetary support. Public healthcare policies can improve through the elimination of obstacles to access to quality public healthcare services like providing more budgetary commitments to healthcare in the Province. For instance access to public healthcare services such as Tuberculosis and Anti- Retroviral Therapy (ART) for those affected and infected by these ailments serve as an example. Public service M&E in SA is solidly linked with performance management since both seek to establish organisational efficiency and effectiveness (Mackay, 2007:18). The rationale behind M&E is to make the system of governance effective through an impartial assessment of policies, public plans, programmes, projects, strategies, the performance of personnel, and the public organisation as a whole. Overall, M&E helps 3 in a general sense to improve performance and achieve desired results. M&E can be described as the measurement and assessment of public management performance to effectively manage the outcomes and outputs that are collectively referred to as development results (United Nations Development Programme, 2002:5). The following section of the study provides a background to the study. 1.2. BACKGROUND OF THE STUDY The Constitution of the Republic of South Africa (1996), establishes provinces as part of the three spheres of government, and the Eastern Cape is amongst the 9 provinces and has a vastly rural provincial area of jurisdiction. Nonetheless, the Province has some major urban centers, which include its capital town of Bisho, and cities such as Port Elizabeth and East London. The Province is considered to be relatively poor when compared to the rest of South Africa but has a vibrant industry, which contributes towards its socio-economic development (Buffalo City Metropolitan Municipality, 2016:102). The majority of the industries and sectors in the Province are in the automotive assembly sector and manufacturing sector and heavily concentrated in the Nelson Mandela Bay Metropolitan Municipality (NMBMM). There are also commercial activities in the Province including fishing, forestry, and agriculture (BCMM, 2016:100). Regrettably, despite many efforts, the Province has service delivery and health backlogs that need to be addressed. The high prevalence rate of poverty in the Province, standing at 27.1% of absolute poverty is attributed to the lack of ample economic activity (Stats SA, 2017:64), disparities of the apartheid legacy and the lack of primary extractive industries and sectors, such as mining and commercial farming (BCMM, 2016:100). Recent years have seen a surge in public service delivery protests in the Eastern Cape Province, indicating a growing discontent between people of the Province and their government (Chikulo, 2016:2). To further compound the situation, there is uncertainty as to the scale and range of the existing public service delivery backlog and a general pessimistic perception amongst the inhabitants of the Province on their government’s 4 ability to timely deliver public goods and services including public healthcare related services and goods to its disgruntled people (ECDoH, 2014:27). The Eastern Cape Provincial geopolitical setting and demographics is spread over an area of 168 966 square kilometers and constitutes 13.8% of the total South African land mass. According to the 2016 national population census data the province has a population of 6 562 053 (Stats SA, 2016:3). Demographically, the Province has a relatively young population since 61.1% of its inhabitants are below the age of 30 years (BCMM, 2016:102). Due to various factors which include poverty and unemployment which was alarmingly high in 2014, the people of the Province cannot afford private health insurance with a total of 88% of the population relying on the public healthcare system, while medical aid coverage in this province is a paltry 12% (ECDoH, 2016:20). The discussed background strongly sets the foundation for the study and the basis for undertaking empirical research to prove that the adoption of an M&E model can improve public healthcare service delivery in the Eastern Cape Province. As seen in Chapter 7 of the thesis, the study gathered theoretical and empirical data to that effect and subsequently proposed to the ECDoH, an implementable M&E framework for consideration. If adopted and implemented properly, M&E can be an ultimate solution to the transformation of public service delivery in South Africa at large (Presidency, 2007:2) as seen in the findings in Chapter 7, 8 and 9 of the thesis. Furthermore, in sections 3.2. and 3.3 of the thesis, the study sought to establish a theoretical standpoint that seeks to endorse the relative importance of M&E since different scholars have postulated arguments for and against the usefulness of M&E in the public service in South Africa. In section 3.3 of this thesis, the study also sought to position M&E within the New Public Management (NPM) and good governance theories and practice of modern Public Administration in order to factually prove its efficacy as a tool for performance enhancement in the South African public sector/service. Public service delivery programmes like public healthcare need to be traced and tracked against set goals in order to timeously correct variances and deviations and M&E should assist in that effect. In addition, M&E enables the effective implementation 5 of performance management which improves individual and organisational productivity through periodic trace and track of the relevant performance. Consequently, M&E aims to provide public service managers with the ability to draw connections between choices of policy priorities, resourcing those policy aims, and programmes designed to implement them, services delivered as well as assessing the impact of community development programmes on targeted communities (Naidoo, 2011:14). The study takes a look at the above-mentioned M&E goals in the ECDoH context. The local prototype of M&E, the GWMES, was a brainchild of former President Thabo Mbeki who in the 2004 State of the Nation Address emphasised on the critical importance of M&E as follows: The government is also in the process of refining our system of Monitoring and Evaluation, to improve the performance of our system of governance and the quality of our outputs, providing an early warning system and a mechanism to respond speedily to problems, as they arise. Among other things, this will necessitate improvement of our statistical and information base and enhancing the capacity of the Policy Coordination and Advisory Services unit (Public Service Commission, 2008:4). As detailed in the words of President Mbeki, M&E serves as an early detection and warning system whereby problems will be diagnosed and corrected as soon as they emerge. Unless waiting for the entire policy programme to elapse in a given public institution, an ex-post remedial action should be established and implemented which is not always favorable to the utilisation of public resources such as time and finance. Thus, M&E has been utilised as a proactive way of correcting public service delivery issues. However, M&E requires the equal dedication of public entities and government departments to cooperate and collectively provide periodical performance information. The National Treasury (2011:2) indicates the new public service regulations require national and provincial departments, state institutions and public entities to develop programme performance information plans describing and detailing strategies to improve the performance of their programmes. To this end, performance information 6 is critical in the development of a sound M&E framework for the public service entities like the ECDoH. The researcher holds the view that integration of the National Development Plan (2030) (hereafter referred to as the NDP) into these plans will enable implementation of the plans to be monitored as it is also important to keep track of progress against the NDP (2030) as a whole. In order to ensure that public performance management in the public sector including the Eastern Cape Province is implemented according to official M&E plans, such public performance should be monitored. Such public monitoring should not only focus on public financial performance but should also include public non-financial aspects of performance. Additionally, the turnaround strategies for public healthcare services, public rights of consumers and public quality assurance in relation to public performance management should be considered. Public reporting should be targeted at public decision makers and managers as consumers and users of useful data (Van der Waldt, 2004:95). The DPME (2011:2,12) sees the relative success of public M&E solely resting upon the equal contribution of public entities to manage their public performance, timeously correcting mistakes related to the public monitoring and evaluation of public policy programmes. Periodic, constant and consistent reflection of the path taken by a public entity such as the Office of the Presidency always ensures that goals are achieved with little or no deviations and variances at the national sphere of government. The study focuses on the preceding background and orientation as the premise from which both theoretical and empirical evidence was collected in Chapters 3, 4, 5, 6 and 7 of the thesis in order to determine the prospects of improving the functionality of the ECDoH and its effectiveness as well as efficiency in delivering public healthcare services to the people domiciled in the Province. This data was collected and analysed to determine the usefulness of M&E in sections 7.2, 7.3 and 7.4 of the thesis, as a tool for enhancing public service delivery. In light of this, the proposal now undertakes to identify, mention and characterise the problem that the study seeks to resolve, in the section that follows. 7 1.3. PROBLEM STATEMENT The historical imbalances created by segregation development used by the pre-1994 apartheid government have left predominantly black communities in dire need for public service delivery. These public services include public healthcare, which is a crucial human right. The poor living standards for non-whites were not only affected through the socio-economic deprivation of opportunities but also took effect on the lack of access to quality public healthcare. As a constitutional human right (South Africa 1996), one of the aims of the study is to explore how the utilisation of public M&E can improve on the right to access to quality public healthcare services for the people of the Eastern Cape Province. As highlighted in the preceding section, the historical legacy of the apartheid has left the Province as one of the poorest in contemporary South Africa, not only on the socio-economic development perspective but also in terms of the delivery of public healthcare services (ECDoH, 2016:25). Currently, 64.4% of the inhabitants of the Province live in poverty with unemployment pegged at 52.6%. As a result of the lack of economic opportunities and disposable incomes, approximately 87.9% of the people in the Province do not have access to medical insurance, thus relies heavily on the public healthcare system (ECDoH, 2016:25). Public healthcare is vital to the improvement of the standards of living of the people as evidenced in the Sustainable Development Goals (SDGs) (2030) which seek to improve access to good public healthcare and wellbeing of global citizens by 2030. In a decentralised intergovernmental arrangement, public healthcare services in the Province fall under the jurisdiction of the ECDoH, which has a wide array of responsibilities such as:  providing patient transport;  providing emergency medical services;  administrating the public medical schemes;  providing public health services and facilities;  ensuring that the healthcare staff is well-trained staff; and  managing and servicing the equipment of the department (ECHCAC, 2013:5). In order for the ECDoH to deliver effective and efficient public healthcare services to the people of the Eastern Cape Province, there is need for the track and trace of the 8 programmes and initiatives undertaken to give effect to the right to public healthcare as stipulated in section 27 of the Constitution of the Republic of South Africa (1996). Tracing and tracking of public performance management are observed with limited success due to the reliance of on the old ECDoH PMDS model. According to Javu (2013:16), 52% of employees disagree that the then PMDS policy has been widely communicated by the ECDoH to all employees, while 63% of employees vehemently disagree that employees understand the content of the system. Javu (2013) further laments that with regard to compliance at least 50% of employees disagree that there is an established functional and coordinated PMDS committee. This led to the ECDoH employee’s judgment that there has been lack of compliance regarding the application of PMDS in the ECDoH which left the majority of employees not understanding the content of the system and the various components within it. The ECDoH has been affected by the lack of a robust M&E framework as bemoaned by the ECDoH annual report (ECDoH, 2016:25). According to the ECDoH (2016:27), the absence of a strong M&E framework affects the ability of the Department to foster accountable and effective delivery of public healthcare services. As indicated by the ECDoH (2016:27), the absence of a pragmatic monitoring and evaluation framework in the ECDoH has led to a myriad of challenges affecting the operations of the department including inter alia, hospitals are ordering directly from suppliers instead of procuring these products through Umtata Medical Depot. Such a scene shows a disjointed procurement practice, an urban-biased deployment of community service doctors which robs rural areas of much-needed doctors. Moreover, there is the existence of a huge human capital base with many public employees occupying positions in an acting capacity or as interns. There is also a lack of skilled and proficient staff in the field of financial management and the lack of commitment of effective and efficient utilisation of public resources to finance the filling of vacant positions (ECHCAC, 2013:14). Mutatis mutandis, corruption and other malpractices which are robbing the residents of the Province from receiving effective and efficient public healthcare services would not persist if the ECDoH had a working M&E framework. Also, the implementation and use of public performance management approach to track and trace employee 9 performance have been compounded by the absence of a credible M&E, thus the timely correction of variances in staff expectations and actual measurement of employee performance has been evidently difficult for the Department (Mkhutshulwa, 2017:23). As discussed in the preceding section, the study revolves around the problem of the absence of a working M&E framework in the ECDoH. This problem has led to other subsequent problems as discussed in section 1.3 of the thesis. The study gathered theoretical and empirical evidence to aid in the resolving of this identified problem in Chapters 6, 7, 8 and 9 of the thesis. In other words, the study proposes a framework of how an operational M&E framework can help improve in the functioning of the ECDoH in section 8.2 of the thesis. Such a model can help the Department achieve its mission and vision of providing effective public healthcare services to the people of the Eastern Cape Province and possibly beyond the borders of the Province. The study will now focus on the research questions and objectives in sections 1.4 and 1.5 of the thesis and provided as follows. 1.4. RESEARCH QUESTIONS As discussed in the problem statement, the key research question rests on the following: How an operational, effective and efficient M&E framework can be designed and implemented in order to encourage the improvement of the performance management of the ECDoH? How can the ECDoH execute the official public activities related to public performance management in providing quality public healthcare services to the people of the Eastern Cape Province in relation to establishing and implementing an effective and efficient M&E framework? In light of this, the following subsequent research questions are asked:  Which theoretical framework and orientation can form the foundation of M&E in the public sector with particular reference to the ECDoH?  What is the nature, content, and character of the M&E discourse in Public Administration in relation to public service efficiency and effectiveness with respect to the ECDoH? 10  Which themes emerge from this study on M&E framework to enhance performance management that could serve as prescripts to assist the ECDoH to develop a tailor-made M&E system for improving the delivery of public healthcare service(s) in the Province?  What is the correlation between the M&E framework and performance management and how can this relationship be utilised to enable the former to improve on the latter’s prospects of improving public service efficiency in relation to the locus and focus of this study?  What challenges are inhibiting on the prospects of the ECDoH to fully have and utilise an operational M&E framework?  How can a feasible M&E model be designed in order to assist the ECDoH significantly improve its efficiency and effectiveness in performance management towards delivering quality public healthcare services to the inhabitants of the Eastern Cape Province? 1.5. RESEARCH OBJECTIVES The main aim of the study was to resolve the problem of poor performance management by the ECDoH in the provision of public healthcare services through the utilisation of an operation monitoring evaluation framework. Thus, the subsidiary research objectives were to:  Determine the central theoretical framework and orientation which can form the foundation of M&E in the efficient provision of public healthcare services with particular reference to the ECDoH.  Establish the nature, content, and character of the M&E discourse in Public Administration as a scientific study, and as an enabler of public healthcare service delivery efficiency and effectiveness in relation to the ECDoH and its prospects of improving the rendering of public healthcare services.  Ascertain scholarly themes emerging from M&E that inform the role and significance of the service delivery discourse in Public Administration in relation to the provision of public healthcare goods and services.  Determine the relationship between public service M&E and performance management in the public healthcare service area in relation to how the former 11 can effectively help improve the prospects of the latter towards the delivery of quality public healthcare services in relation to the ECDoH.  Investigate the challenges that the ECDoH is facing in using public service M&E in improving its effectiveness and efficiency in the delivery of public healthcare services to the inhabitants of the Eastern Cape Province.  Explore the avenues through which a pragmatic public service M&E model can be developed in order to help the ECDoH improve the delivery of public healthcare services in the Eastern Cape Province. 1.6. CENTRAL THEORETICAL STATEMENTS The study acknowledges the huge contribution to the modern day public sector/service, which the NPM discourse observes. As a movement towards the liberating and re-invention of government into an entrepreneurial culture, NPM is the pivot on which improved government efficiency rests upon. According to Morenikeji and Oluwafemi (2014:68), NPM refers to a mixture of splitting large bureaucracies into smaller agencies, the encouraging competition between public sector entities, as well as the use of economic incentives to motivate the performance of public servants. In the case of this study, NPM is the premise upon which efficient public healthcare delivery by the ECDoH is built. From the preceding definition, the study deduces that NPM becomes prominent due to the pitfalls associated with the global classical organisation and management practices such as bureaucratic public sector structures in the 1990s, which virtually crippled the ability of governments to introduce tighter controls and measures of output (Vil-Nkomo, 1998:202). For example, bureaucratic organisational cultures discouraged individual innovation by using mechanistic decision-making practices which no longer have space in an NPM centered entrepreneurial organisational culture. Such practices can be, in the context of the study, linked to the existence of poor public healthcare service delivery. According to Osborne and Gaebler (1992:325), NPM infuses the practice of business entrepreneurship into the management practice of the public sector. In doing so, NPM adopts the private sector customer concept and hence improvement on the prospects 12 of a more efficient public service rendering that is linked to more citizen satisfaction. Hood (1991:15) sees the constant and consistent management of performance in the public service to be the pinnacle of NPM. Consequently, public performance management instills a culture of tracking and tracing of performance and productivity which promotes the achievement of public organisational goals. In the context of the study, NPM can be a driver to the adoption of efficiency-inspired practices in the ECDoH. In section 3.3 of the thesis, the study also deduces that in the early and late 1990s before the adoption of the paradigm of NPM in the South African public service, orthodox public performance management was neglected at the expense of bureaucratic mechanistic organisational structures thereby affecting the efficiency of the entire system of government. A culture of public performance management is thereby solidly linked to M&E as discussed in the introductory section of the study. As elucidated in the preceding paragraph, M&E and public performance management complement one another because public performance management is both a catalyst and key ingredient to a successful M&E framework or system (Hood, 1991:15). An in-depth discussion of the central framework of the study is discussed in section3.2 and 3.3 of the thesis. Overall, the study uses NPM because it advocates for a business-like system of government which emphasis on inter alia, measurement of outputs, total quality management, trace and track of public performance management. In the context of the study, ECDoH’s need to enhance its public performance to deliver public healthcare services through an operational M&E framework is premised upon NPM practices as mentioned in the preceding section. 1.7. SIGNIFICANCE OF THE STUDY Public healthcare provision in the Eastern Cape Province is lagging behind due to the absence of a working M&E framework in the ECDoH (Mkhutshulwa, 2017:15). This study proposes a possible M&E framework for the ECDoH to consider in attempting to enhance the public performance of the ECDoH in the delivery of public healthcare services in the Province as discussed in section 8.2 of the thesis. Such a framework emphasises the relative importance of undertaking effective and efficient PMDS in the Department as the nexus for an effective M&E culture. The Department under study 13 has a responsibility to provide public healthcare services to the people domiciled in the Province. In section 9.3.1 of the thesis, the study demonstrates the potential that could make significant contributions to the ECDoH through additional recommendations that are offered at the end of the study on how strengthening M&E framework and systems can enhance the performance of the ECDoH. Sections 2.2, 2.3 and 2.4 of the study make specific contributions to the area of knowledge in Public Administration, policy and strategy in relation to M&E and public service performance management. An empirical assessment of how public service M&E policy operates in the ECDoH as a tool for performance enhancement was undertaken towards improving public policy and strategy for public service M&E. The findings of this study may also assist the management of the ECDoH to understand better the complexity and problems associated with the perceptions of PMDS and contribute to the body of knowledge in the M&E discourse. In section 8.2 of chapter eight of the study, the framework for a performance-oriented framework will be proposed as a contribution to the body of knowledge of Public Administration. Lastly, the study will benefit the public healthcare service consumers and citizens domiciled in the Eastern Cape Province through improved public healthcare services. 1.8. LIMITATIONS OF THE STUDY Limitations of the study are the challenges that the researcher might encounter during a given study. The limitations which acted upon this study are discussed hereunder. Foremost, the study gathered data using interviews and literature survey which can be affected by the incompleteness of some documents, unavailability of relevant officials of the ECDoH. This is a key limitation as mentioned by Babbie (2005:285). In order to increase credibility, findings were triangulated to harmonise findings from both primary and secondary sources. Data from interviews were compared across different types of interviewees to highlight the consistency and inconsistency of various perspectives as highlighted by Patton (2002:11) and also experienced in this study. Lastly, the subjectivity of biasness of the respondents in the study was beyond the control of the researcher. Hence the study ensured that the research instruments are 14 scientifically constructed to cover all aspects of under investigation, the prospects of public service M&E to enhance the performance of the ECDoH. Also, the research diversified in the sample to include respondents from various levels of ECDoH’s hierarchy to get diverse opinions. The study highlights that in spite of the limitations mentioned in this section, the study findings were characterised by adherence to the principles validity and reliability which implies that the limitations had no marked detrimental effect on the findings of the study. Adherence was made through strict observation of the ethical issues as discussed in section 6.3 of the thesis. 1.9. PRELIMINARY OUTLINE OF THE STUDY The thesis has nine chronological chapters covering the respective topic areas as follows: Chapter One: Introduction and background of the study The opening section of the study provides the introduction and background of the study. The chapter further covers the problem statement, research questions as well as the objectives of the study, the significance, limitations of the study and issues to do with the structural layout of this thesis. This chapter discusses the mentioned aspects in the context of assessing M&E as a catalyst of performance in the ECDoH. Chapter Two: Monitoring and Evaluation discourse in Public Administration The Chapter discusses the theoretical debates in the subject of M&E in relation to public healthcare debates in the discourse of New Public Management in the discipline of Public Administration and how various scholars have approached the epistemological and ontological issues of the field. Moreover, the discussion is premised on the postulation that there is a need to reconceptualise and reconfigure the theoretical assumption of the discipline as shown in Chapter 3 of the thesis. The discussion also considers the debates in the philosophy of research and indicates that public administration is both an art and a science. The main aim of the Chapter is to place the discipline of Public Administration within modern public service and scholarship practices, with a view of establishing the importance of factoring in M&E in the mainstream public sector practice and debate. In the context of this study, this will be 15 the application of M&E in the provision of healthcare goods and services by the ECDoH. Chapter Three: Central theoretical frameworks of the study The second chapter reviewed the existing body of literature. Chapter three intend to give details on the analysis and discussion of the central theoretical framework which underpins monitoring and evaluation in the public sector. This was discussed in the context of M&E being utilised to improve the performance of the ECDoH. Chapter Four: Themes emerging in monitoring and evaluation The crux of this chapter is based on discussing the various themes linked to the practice of public M&E. These themes serve as the benchmarks for M&E related public service efficiency, and they include inter alia, good governance, accountability, and transparency. Such themes are discussed as well as their role in supporting the use of monitoring and evaluation to enhance performance in South Africa, more specifically in the ECDoH. Chapter Five: Linking monitoring and evaluation with performance management Focus in chapter five is on the link between public performance management and public service M&E in relation to the ECDoH. Such linkage is provided due to the two equally important public sector practices being inseparable and is presented in Section 5.2, 5.3 and 5.4 of the thesis. These practices are discussed in a manner that shows that they are both critical to the enhancement of public service efficacy in the ECDoH. As discussed in chapter three of the thesis, public performance management has been the brainchild of public service M&E and when NPM advocates for consistent and constant management of performance, NPM seeks to achieve the same goals which the present-day monitoring and evaluation practice seeks to achieve in the public service. Thus the chapter discusses this linkage in details within the context of the effect of such a relationship to the enhancement of the public sector performance in relation to the ECDoH. 16 The Chapter also focuses on the characterisation of the local version of monitoring and evaluation which is the GWMES. The chapter discusses the transitional period (from 2005 to 2017) which the GWMES is going through and the prospects of GWMES influencing other monitoring and evaluation frameworks across the South African public service, including that of the ECDoH. Chapter Six: Research methodology The Chapter covers the research and methodology that was used in the study. Such aspects include; the research paradigm, the research approach, data collection methods, sample and sampling methods, data analysis methods, and ethical consideration observed in this study and discussed section 6.2 of the thesis. The chapter also discusses issues surrounding the reliability of the findings discussed in section 7.4 of the study. In summary, Chapter Six is the roadmap of the study because it lays out the research plan of the study by discussing the different methods and techniques employed in gathering both empirical and theoretical evidence towards the achievement of the objectives of the study. Chapter Seven: Analysis and discussion of findings This chapter analyses data and discusses the findings of the study. The chapter examines the inhibitions affecting the use of monitoring and evaluation in the ECDoH. Such challenges are discussed by exploring the status quo of the department and ascertaining how the lack of monitoring and evaluation has hugely affected the public performance of the department. Furthermore, the challenges are closely discussed alongside the premise of the problem statement in order to establish the direct and subsequent problems which such challenges are causing in the ECDoH. Chapter seven has a bearing on the development of a suitable monitoring and evaluation model for consideration by the ECDoH in order to enhance its public performance management framework in executing its goal of delivering quality public healthcare to the people domiciled in the Province. Chapter Eight: Proposing a monitoring and evaluation model After analysing the challenges affecting the utilisation of monitoring and evaluation and other aspects of the study, chapter eight develop an implementable monitoring and evaluation model for use in the ECDoH. The developed model seeks to build upon the 17 shortfalls of the current system and modify the existing framework to ensure that it serves the purpose of significantly improving on the public performance of the department as outlined on section 8.2 of the thesis. The model adopts local best practices of public service M&E from the GWMES to contextualise a tailor-made framework towards the improvement of the delivery of public healthcare services by the ECDoH in the Eastern Cape Province. Chapter Nine: Summary, conclusions, and recommendations The last chapter of the study is based on the findings of the study, the purpose of this chapter, summarises the study. The chapter concludes and proposes certain study recommendations aimed at improving the performance of the ECDoH through the use of a new effective and efficient M&E as a policy instrument. The chapter outlines clearly how the objectives of the study have been achieved through the provision of sufficient findings to the study as outlined in chapter one of the study. 1.10. CONCLUSION Access to public healthcare services is a basic human right according to section 27 of the Constitution of the Republic of South Africa (1996). In a decentralised system of government chapter three of the Constitution of South Africa (1996) (which establishes 9 provinces spread across the Republic and the Eastern Cape Province is one of them) and bestows on provincial governments, powers, and functions related to the delivery of public services like public healthcare services. The study on the demographics established by public research institutions such as Statistics South Africa shows evidence of poverty and poor living standards including access to public quality healthcare (ECDoH, 2016:25). Public healthcare services are offered by the government through the ECDoH which has been affected by numerous problems and public management challenges that the study links to the absence of a strong monitoring and evaluation framework in the department. In this regard, the study seeks to explore the prospects of enhancing the performance of the ECDoH through inter alia, the implementation of an M&E framework as stipulated in section 1.5 of the thesis. Overall, the public service M&E model proposed in this study seek to solve the problems as discussed in the problem statement, most of which affect access to and/or the quality of public healthcare services rendered by the ECDoH. 18 CHAPTER TWO MONITORING AND EVALUATION DISCOURSE IN PUBLIC ADMINISTRATION Without research transformation in the discipline, innovation and progress cannot be realised (Barry.R. Hanyane). 2.1. INTRODUCTION This chapter focuses on Public Administration as a discipline and a discrete body of knowledge concerned with the ontological (concepts) and epistemological (methodological) realities of monitoring & evaluation (M&E) (including the relevant policy) as a tool for performance enhancement in the case of the Eastern Cape Department of Health (hereafter referred to ECDoH). In this chapter, an overview on the evolution of the field of Public Administration in relation to the ontological realities of M&E (the actual experience and presence of monitoring and evaluation) will be briefly explored (see section 2.3) so as to give an orientation of the current thesis on M&E policy processes. In addition, the chapter gives the historical epistemological and ontological foundations of the discipline of Public Administration in relation to the current thesis’s methodological approach and emphasis on the need for M&E policy practice in the South African public administration (practice). In this light, the chapter will seek to unveil the historical trends in the epistemological and ontological philosophical aspects of the discipline of Public Administration thus offering a scholarly anchor for the study’s theoretical chapter (see section 2.4). The current discussion of M&E policy as a tool for performance enhancement in the case of the Eastern Cape Department of Health (hereafter referred to as ECDoH) is paramount to this study as it will help elucidate the nature of the M&E debate in the discipline of Public Administration. Furthermore, the debate by various scholars of M&E around epistemological and ontological issues in the field of Public Administration in relation to M&E broadly has brought about a reaction to M&E as a tool of public service efficiency. Moreover, this discussion is premised on the need to expand the current scope of existing Public Administration scholarship knowledge in relation to M&E as a tool for performance enhancement in the ECDoH. The coming discussions cover debates in the philosophy of Public Administration research in relation to M&E as a tool for performance enhancement in the ECDoH and thus indicate that Public Administration is both an art and a science. The researcher is of the opinion that Public 19 Administration as a discipline is both an art and science has given the presence and preoccupation of scholars in the discipline towards theorybuilding and the need to improve the practice by practitioners involved. Figure 1: A framework illustrating the chapter layout (own diagram) 2.2. OVERVIEW OF THE HISTORY OF PUBLIC ADMINISTRATION There are conflicting views over the origin of Public Administration as a discipline. Riccucci (2010:6) states that there are innumerable divergent accounts of the historical development of Public Administration. This is echoed by Schacther (1998:16) who alludes that Public Administration as a discipline is not clearly confined in the historical account(s) as it has borrowed the natural science approach of progress in a given scholarship discipline, such as Physics and Mathematics in the opinion of the 20 researcher. Lamenting this assertion Box (2008:104) says, “excluding useful [memories and histories] because they carry an undesirable residue from the past renders Public Administration scholarship weak and less effective in dealing with current problems for the future” (as cited in Raadschelders, 2009:2). In laymen terms, this implies that the evolution that the discipline underwent meant that it has to embrace contemporary or modern approaches which help in both diagnosing and resolving emerging problems such as lack of theory in modern discourses such as M&E. Yet, it is not only the historical account which is contentious. Coetzee (2012:16) argues that academics in the discipline of Public Administration in South Africa often have incommensurable debates on concepts and the name of the discipline. In such conflicting discussions, one can understand that scholars are bound to have relative accounts on the origin of the discipline as scholars hold different views. In this debate, Schacther (1998:16) argues that the identity of Public Administration in the South African context is inextricably attached to the scholarly perceptions of its history. The researcher shares the abovementioned sentiments with Schacther’s (1998) views that Public Administration is intimately attached to its antiquity as the discipline is rooted by its history. Schacther (1998:19) further states that “Public Administration’s identity as a field of inquiry is rooted or grounded in accounts of our history”. This implies that the identity of the discipline is premised on how it evolved through history to become what it is today. From this, it can be argued that there is a need to consider the historical account of the development of Public Administration. There is an overarching scholarly agreement that the discipline was first documented universally through Thomas Woodrow Wilson’s 1887 work entitled ‘The Study of Administration’ which appeared in the Political Science Quarterly (Maserumule, 2011:313; Raadschelders, 2009:3; Basheka, 2012:35). The researcher holds a panache view that there is a great deal to admire about Wilson’s Study of Administration’ and there are ample grounds on which to credit him with formative influence in the founding and shaping of modern Public Administration, With the emergence of an emphasis on M&E in recent times, it is evident that the discipline has a character of changing its shape in order to keep abreast with developments in a globalised world. Thus, in order for the discipline to remain relevant, there is a need 21 for it to grasp current and emerging trends such as M&E as a tool for performance enhancement in the public service (in the case of this thesis the ECDoH) in order to make sure that there is a sustainable ability to resolve concomitant M&E problems. Wilson (1887:197) commenced with a discussion on the need for proper public administration strategies in the United States of America (USA). According to Wilson the ‘early administration’ system which was being employed in the USA in the early 1800s contributed to administrative challenges as it was rife with corruption, nepotism, misappropriation of state resources and abuse of office positions (Hughes, 1994:225). The researcher holds a view that the ‘Study of Administration’ as authored by Wilson (1887) is an important document in the body of knowledge of Public Administration internationally. However, the developments in the discipline of Public Administration since the contribution of Wilson (1887) have been hastened to accommodate different paradigms including the Business Management epoch (1930s to 1950s), the bureaucratic epoch (1960s), the rationalisation epoch (1970s to 1980s), the New Public Management epoch (1990s in South Africa), the Governance (2000s) and post-governance epoch (current period). Maserumule (2011:314) perceives the early administrative system (post-1994) in South Africa to be synonymous to the spoils electoral system which was predominant in the United States of America (USA) in the 1830s. During the postapartheid period in South Africa from 1994 to late 2009, government officials were mostly appointed on the basis of cadreship by the ruling party the African National Congress. In describing the nature of public staffing of that time, Maserumule (2011:315) indicates that there was less emphasis of competences, knowledge or skills in appointing public officials in South Africa, something which tainted issues of efficiency and effectiveness in the public sector. This less meritorious appointment of public service employees elsewhere in the world including in the USA led to encroachment of politics into administrative processes leading to conflicts between the executive and the legislature which contributed to the impeachment of President Jackson of the USA in 1868 (Mosher, 1982; Wilson, 1887:216). The researcher shares the same opinion with Maserumule (2011) who argues that public administration must consist of a body of trained officials, as it is a plain business necessity. 22 From Wilson’s (1887) article one can deduce that an argument for a new science of administration which shows a clear detachment from politics was a necessity (Ostrom & Ostrom, 1971:204). Basheka (2012:34), Coetzee (2012:35) and Basu (2009:16) hold the view that the late 1800s period refer to this era as the politicsadministration dichotomy as the major epistemological issue that scholars in Public Administration sought was a separation between politics and public administration (both the science and practice). The researcher is of the same opinion as to the above scholars that the article called for a new science of administration and separation between politics and administration. Wilson (1887) at that time argued that although international governments may have varying political philosophies, their administrative principles should be the same and aimed at ensuring good effective and efficient governance (Rosenbloom et al. 1994:22; Hughes, 1994:27). Basheka (2012:35) indicates that Wilson’s article was premised on four key recommendations namely, firstly, the separation of politics and administration; secondly, the comparison of public and private organisations; thirdly, improving efficiency through employing private capital strategies and fourthly enhancing efficacy through competency-based recruitment of public servants and continued inskilling of employees. The principles noted above are directly related to the discourse of M&E as a tool for performance enhancement in the ECDoH as will be discussed in the findings of this thesis (see chapter 7). The researcher is sharing the preceding sentiment as Chapter 10 section 195(1) of the Constitution of the Republic of South Africa (1996) stipulates how the local public administration must be governed by the democratic values and principles to promote good governance. In this sense, Maserumule (2011:315) argues that Wilson’s article also emphasised the need for promoting public servant’s competencies through training and development programmes to ensure efficiency in the public sector. The researcher is sharing the above sentiment as stipulated in chapter 10 (section 195(1) (c)) of the Constitution of the Republic of South Africa (1996) which dictates that public administration must be development-oriented. This is reiterated in Section 195 (1) (b) of the Constitution of the Republic of South Africa (1996) which indicates that government efficiency and effectiveness must be promoted at all times. The 23 researcher holds the view that M&E policy as a tool for performance enhancement in the public service (including the ECDoH) connects handsomely with the above scholarly and constitutional values and principles as M&E is an excellent governance tool for public checks and balances. Wilson (1887:197) stated that “the object of administrative study was to discover, first, what government can properly and successfully do, and secondly, how government can do these “things properly” (promoting the welfare of the people) with the utmost possible efficiency and at the least possible cost either of money or of public resources. In this way, Wilson’s study called for Public Administration as a discipline to promote the proper management of government or public related resources and services. The Wilsonian thesis influenced major changes in the public discourses since the late nineteenth century to date, as noted by Basheka (2012:37); Uwizeyimana and Maphunye (2014:92) that Taylorism and its principles of scientific management, for instance, were the guiding pillars upon which the discipline of Public Administration was constructed emanating from Wilsonism. Following Thornhill and Van Dijk (2010:100) Wilson might have been falsely termed the founding father of the discipline, yet history reviews that public administration was practiced uniformly much earlier in Europe than indicated through the proWilson debate regardless of the region where a particular state is situated. Thornhill and Van Dijk (2010:101) argue that public administration has a long history that can be traced prior to the 1887 synopsis by Wilson. Thornhill and Van Dijk (2010:99) write that from the 16th century, the national state was the reigning model of the administrative organisation in Western Europe. These states such as Spain and Portugal needed certain public organisations for the implementation of law and order and for setting up of defensive structures against incursions internally and/or externally. The need for expert civil servants, with knowledge about taxes, statistics, administration, and the military organisation grew during that period. In the 18th century, the need for administrative expertise grew even further and academics were introduced in the public service/sector environment. Accordingly, Basheka (2012:26) notes that public administration principles and its practice were already noticeable as early as 124 BC in China, in this he quotes Biot 24 (1845:97) and Zhang (2001:58) who highlight that as early as the Xia dynasty Public Administration was being practiced as a science although it may not have been more like the modern day systematised study. In addition, Basheka (2012:29) suggests that the practice of public administration can be traced back to the ancient and medieval era around 1491 BC, in which the primitive division of labor as construed by Cladden (1965:40) was due largely to the over- tasking by the chief who prompted the delegation or sharing of responsibility with an assistant or deputy. Maserumule (2011:318) follows the practices of public administration to around 387 BC in which Plato established the Academy in Athens, widely referred to as the first European university. Philippoussis (1999:119) notes that the academic Plato taught his disciples that it was, “fundamental that a democratic societal polity and successful policy need and demand for self-conscious and responsible people who are well-educated and well-informed, otherwise true democracy does not work” (Maserumule, 2011:319). According to Basheka (2012:29) in 400 BC Plato had already recognised management as a distinct field and thus promoted the usage of principles of specialisation which shaped the ideas of Taylorism. These ideas are related to the study since they all promoted efficiency and effectiveness in the undertaking of the organisation (whether public or private) duties. Ancient practices in public management were the brainchild of modern-day practices of efficiency as seen in the study’s focus on M&E as the tool for effective public health service delivery. Thornhill and Van Djik (2010:99) argue that the discipline commenced in the 16th century in Western Europe due to the need to promote efficiency and effectiveness in public or government organisations. Some also argue that public administration was also practiced in the 18th century through King Frederick William I of the then Prussia. According to Nasrullah (2005:198) King William, I then developed a system known as Cameralism in which a group of ‘Professoriates were trained, in the specialty of Public Administration and this became a subject of German scholarly discourses of that time. All these episodes in the evolution of management and administration are a sure sign that Public Administration always embraced new ideas towards improving its identity and government efficacy. This places M&E on the fore of modern day government 25 emphasis on effectiveness. Furthermore, the researcher is of the view that M&E practitioners need to be trained and educated within the discipline of Public Administration as M&E is a good governance tool. However, the preceding presentation of history marginalises the existence of the practice of public administration in Africa. According to Basheka (2012:30) in precolonial Southern Africa, there were well-established patterns of governance reform systems. The researcher is of the opinion that King Shaka of the Zulu kingdom, King Ngqika of Xhosa kingdom all utilised Public Administration as power was decentralised to Induna’s (chiefs) to administer primitive areas and report back to the Kings. Shafir and Russel (1996:56) indicate that in pre-colonial Africa governance was organised around the king or clan head who had to delegate his authority to other members of the society such as the wright's hands so that they can help him in ensuring that every citizen had equal access to the means of production such as capital. Shafir and Russel (1996:57) posit that the most notable aspects of administration in pre-colonial Africa were legal as the leaders were more determined in promoting accountability, restoration, and discipline. Mazrui (1986:78) further notes that primitive Africa was characterised by different administrative tiers such as the city- states, empire-state and the conquest states. An example is the Zulu stateled by Shaka. Elaborating on this (Basheka, 2012:33) states that, primitive (precolonial) Africa had well-established principles of public administration which saw a division of task amongst the societal bodies such as the Council of Elders, Chief of Priests and Moral Elders and Chiefs. All these administrative arrangements had collective engagements in distinct tasks so as to promote the smooth running of the state of a vibrant society. In this regard, the historical account of the discipline does indicate that for ages since ancient times, man has persistently attempted to promote good governance principles. 2.2.1. A look at the history of Public Administration in South Africa According to Sindane (2011:5) from the early 1980s, Public Administration in South Africa was taught at most universities, technikons (now referred to as universities of 26 technology), colleges as well as private institutions, such as Damelin. However, Cameron (2008:2) notes that Public Administration was historically taught at Afrikaans-speaking and ethnically-based universities in South Africa. Whilst traditionally, English-speaking universities did not offer subjects in Public Administration, with the exception of the University of Cape Town. Although of recent origin, Public Administration prevalent popularity is not surprising considering the extensive positions and activities of public sector institutions. From early 1980 to 1991, the generic administrative process had been the dominant paradigm in teaching Public Administration in South Africa Sindane (2011:6). According to Cameron (2008:2), sharing sentiments with Sindane (2011:5) writes “during apartheid the administrative processes approach was the dominant academic paradigm”. This approach was narrowly focused and did not engage with the governance problems of apartheid. Ever since the Mount Grace Conference I in 1991, the advent of democracy and the establishment of the then-new Constitution in 1996 there has been more Public Administration debates at an academic level locally as seen in the evolving scope of offerings in this discipline (Sindane 2011:5). Subsequently, some private and public academic institutions such as Damelin, Nelson Mandela University and North-West University (Mafikeng campus), maintained the title Public Administration; other private and public academic institutions, referred to this field of study as Public Management, Public Administration and Management, Public and Development Administration and Public Management and Governance (NWU Vaal and Potchefstroom campuses). Thus, there is no uniformity in the naming of the discipline in various universities in South Africa at the time of conducting this study. On the other hand, McLennon and Fitzgerald (1991:23) argue that the landmark initiative in South Africa was the founding of the New Public Administration Initiative (NPAI) held in Magaliesburg at the Mount Grace Hotel in November 1991 (also see Sindane, 2011:5). Cameron (2008:2) posits that the Mount Grace Initiative (hereafter Mount Grace I) in 1991 was the South African version of Minnowbrook Conferences (1968, 1988 and 2008 in the USA). (Cameron & Milne 2009: 386) state a clear message from the Mount Grace Conferences I (1991) & II (1999) was that “the theory, 27 teaching, and practice of Public Administration was in crisis in that it was too descriptive, reductionist, fragmentary and ignored other dimensions and approaches to public administration”. The initiative was an attempt by progressive academics to transform the largely conservative Public Administration academic discipline, which had been closely associated with the apartheid regime. Resolutions of the conference, contained in the ‘Mount Grace Resolutions’ were to set the teaching and practice of Public Administration in South Africa on a new course based on new approaches. This shows Public Administration wanted to transform how South African higher education institutions were teaching and putting into practice the discipline. Envisaged in the new approach is Public Administration that entailed, among others an explicit normative focus that promotes democratic values of participatory governance and public service at all spheres of government (Wessels & Pauw, 1999:338). Democratic values should form the basis of public administration, as opposed to the undemocratic values of the Apartheid regime which are as follows: • Promoting a just, equitable and non-racial society that enjoys equal access to societal resources to improve their quality of life; • The teaching and practice of public administration should be tools to promote equity and non-racialism in the spirit of reconciliation and reconstruction; • The pursuit of economic sustainability, political and social growth as well as development; • Promoting values like efficiency, effectiveness, accountability, responsibility, and responsiveness in meeting peoples’ needs and expectations; and • Promoting critical debate that is focused on development, pro-active and networks internationally (Wessels & Pauw, 1999:338). The researcher is of the opinion that adopting M&E policy as a tool for performance enhancement in SA can add great value to the discipline of Public Administration and body of knowledge through extensive research and gatherings such as conferences, organised workshops, attended and conducted by academics. Having intellectual input and insights into emerging efficacy-based practices such as M&E sought to enrich both existing Public Administration scholarship while improving government efficacy. Hanyane (2016:32) states that one such stage is the annual South African Association 28 of Public Administration and Management (hereafter SAAPAM) held in South Africa. Sharing these sentiments is Mubangizi and Theron (2011:34) stating that academic conferences are invaluable in shaping both the theory and practice of academic disciplines. Hanyane (2016) also continues to describe other avenues of academic and research significance like the Association of Schools and Departments of Public Administration and Management in South Africa (ASSADPAM). The researcher is of the view that these are one of the few instances where researchers and scholars of Public Administration and Management in South Africa, can give intellectual engagement on M&E policy in the Republic of South Africa. Deriving from the preceding assertion, it is apparent that public administration and its practice are based on its ability to track and trace (M&E) its activities. Maepa (2015:26) argues that although public administration is an applied field, the application of public administration must have an empirical, rigorous and systematic core. The researcher is of the opinion that the study (exploring M&E as a tool for public service efficacy) has the potential of developing and advancing the discipline of Public Administration, as well as a testing ground for research. However, McCurdy and Cleary (1984:54) reason that the criteria for judging research in the field of Public Administration should be the presence of a basic research purpose, internal and external validity, theoretical impact and demonstration of causal relationships, an important topic, and presence on the cutting edge of the field and characteristics which have been met by this study. The latter is especially useful in identifying the rationale for research in a thesis. The requirements cited above serve to indicate attempts at making Public Administration and its practice accountable, ethical and in harmony with the wishes and expectations of the South African society that is in line with the spirit of the new political dispensation. The discussed changes in how governments function have had a great impact on the practice of public administration, especially when focussing of how efficiency can be fostered (Sindane 2011:14). Sindane further reasons to say in light of the Constitution of South Africa (1996), it can be argued that South African public administration is legally positioned for moral, accountable, ethical and just action in its practice (RSA 1996:83), this is evident to chapter 10 section 195(1) that prescribes the values and 29 principles. This view emanates from the fact that the constitution caters for public administration in its chapter 10. Emanating from the constitutional prescriptions regarding public administration, the public service has been transformed (or is transforming) and a White Paper (1997) on the Transformation of the Public Service has been drafted for this purpose (RSA 1995). Guidelines on how public services and goods should be provided to the community to ensure accountability and correct conduct are in place in the form of a White Paper (RSA 1997). Optimistically, as the country still passes through a period of the second transition, the impact of the constitutional prescriptions on public administration is still to be realised by both academics and practitioners. Based on the nine constitutional principles governing public administration in South Africa (RSA 1996) namely, a high standard of professional ethics must be promoted and maintained, efficient, economic and effective use of resources must be promoted, public administration must be development-oriented, services must be provided impartially such as public healthcare with specific reference to the ECDoH, fairly, equitably and without bias, people’s needs must be responded to, and the public must be encouraged to participate in policy-making, public administration must be accountable, transparency must be fostered by providing the public with timely, accessible and accurate information, Good human-resource management and career- development practices, to maximise human potential, must be cultivated and public administration must be broadly representative of the South African people, with employment and personnel management practices based on ability, objectivity, fairness, and the need to redress the imbalances of the past to achieve broad representation (RSA 1996). The researcher is of the opinion that just like the current study of M&E policy as a tool for performance enhancement in the public service in relation to the ECDoH provides an opportunity for the development and advancement in the field and also transparency on government activities or programmes such as public healthcare whilst promoting a high standard of professional ethics. According to the White Paper on Transformation of the Public Service (1995) , White Paper on Transforming Public Service Delivery (1997) and White Paper on Public Service Training and Education (1998) as well as the Skills Development Act (No. 97 30 of 1998) makes it is clear that both the Department of Public Service and Administration and the South African (hereafter DPSA) Government envisage a particular role for public administration in the development and transformation of the country (Sindane, 2011:15). Frank (2014:48) further states that the DPSA review (1999-2000) identified certain shortcomings in the public service transformation project: timelines were overly optimistic, tackled too many interventions at the same time in an unplanned fashion, the need for management development had been underestimated which led to a public service job summit held in 2001 which reached a framework agreement with labor. The researcher shares the same sentiments with the above scholars that DPSA and the South African government see Public Administration having a crucial role to play in the development and transformation of the SA public service/sector as outlined in chapter 10 of the constitution RSA (1996) with specific reference to the ECDoH. Frank (2014:48) sharing the same sentiments states that in the 1990s a number of policies such as RDP were speedily produced in order to bring about the desired transformation of the SA public service. From these reasons, Public Administration as a discipline in South Africa can thus not afford to shirk its responsibility to collaborate with the practice of public administration in the design, implementation and continuous improvement of the subject field. The preceding discussion was a brief overview of the historical antecedents of the discipline of Public Administration an ensuing argument shall be followed in Chapter 3 in section 3.2. The thesis will look at the paradigms that have been followed in Public Administration as well as the theoretical lenses applied in the discipline and the legislative framework upon which the current discussion on M&E as a tool for performance enhancement in the public service is anchored. The following section in this Chapter considers the locus and focus of the discipline of Public Administration. 2.2.2. Conceptualising the locus and focus of Public Administration According to Hanyane (2005:48), “the discipline of Public Administration and Management requires a process of pre-conceptualisation and re-thinking of its focus and area of operation” (cited by Louw, 2012:88). The researcher shares positive sentiments with the above scholars advancing that for the discipline to survive researchers in the field have to look at new trends that respond to our modern societal 31 problems. Hanyane (2005:48) further argues that for Public Administration to survive as a discipline, researchers in the field have to observe certain responsibilities and respond to the challenges presented in a postmodern world. The modern challenges in relation to M&E as a tool for performance enhancement in the public service discussed elsewhere in this thesis present a new frontier that researchers in the discipline must respond to and resolve. Frank (2014:52) argues that rise on issues of public service delivery has and is still leading to a dynamic conversation to this day amongst academics, practitioners and civil society organisations on challenges facing the public service. The researcher is also of the opinion the current study of M&E policy as a tool for performance enhancement in the public service provides an opportunity for the development and advancement in the field for solving challenges presented in a postmodern world such as healthcare, infrastructure development, and other related challenges. According to Van der Waldt (2013:3), Public Administration is a broad-ranging and unstructured combination of theory and practice, its purpose is to promote a superior understanding of government and its relationship with the society it governs. Furthermore, to encourage public policies that are more responsive to social needs and the instituting of managerial practices which are accustomed to effectiveness, efficiency and the deeper human requisites of the citizenry. Van der Waldt (2013) also argues that Public Administration has become an essential part of society and a dominant factor in producing successes or failures of government. The researcher is of the opinion that just like the current study of M&E policy as a tool for performance enhancement in the public service in relation to the ECDoH provides an opportunity for public sector policies to be assessed as to their responsiveness to social needs and advancing the field of public administration and the ability to track and trace successes and failures in government programmes. The researcher is also of the opinion that practical considerations must be at the forefront of the field, but theory becomes the basis of best practices. Kuye (2014:179) is also of the opinion that “Public Administration must not be dogged with the stringent regulatory ordinances alone but one that could adapt to the demands of society”. The researcher is of the same view as Kuye (2014:179) that the field of 32 Public Administration must not be determined by strict controlling laws alone but must be able to adapt and have the flexibility to the demands of society at large. For example, Public Administration needs to explore how it can augment its potential through borrowing practices from across other disciplines such as Economics of Sociology. Kuye (2014:180) further drives the issue that there must be a balance between theory and practice. The researcher shares these sentiments with the above scholar by stating that what is being done on the left hand must be done on the right. This simply means there must be a balance between theory and practice, what we learn (theory) must be implemented (practice). Practitioners and a growing number of scholars in Public Administration approach theory in a different way, but there would appear to be a high degree of unity between academics and practitioners concerning what could be called a macroparadigm for understanding and dealing with the phenomenon of M&E as a tool for performance enhancement in the public service. In both academic and practical discourses in Public Administration, M&E as a tool for performance enhancement in the public service plays an important role in evaluating the performance of any administrative system in the public service although this study does not focus in just any administrative system but specifically the ECDoH. Foremost, defining the concept of M&E is critical to this study because this is the central concept throughout the thesis (see Chapter 1 section 1.1). According to the Presidency (2007:5) in the South African context, M&E as a tool for performance enhancement in the public service has remained complex, multidisciplinary in nature and skills intensive. According to Cloete (2009:1, the Presidency is currently coordinating the implementation of the programme known as “Government-Wide Monitoring and Evaluation System”. Ijeoma (2010:343) moreover states that this initiative has undoubtedly influenced the establishment of the Performance Monitoring and Evaluation Unit in the Zuma Presidency. The South African mainstreaming of M&E is a work in progress as discussed hereafter. Foundationally, the local framework for M&E, the Government-Wide Monitoring and Evaluation System (hereafter referred to as the GWMES) was approved by the Cabinet in 2005 (see Chapter 1 section 1.1). Ijeoma (2010:343) state that GWMES in 2006 was well applauded by many South Africans who had for many years since the arrival of a democratic state desired public accountability and better public service 33 delivery. Cloete (2009:1) further states that this programme is intended to establish a uniform system of monitoring and evaluation across all spheres of government. M&E as a tool for performance enhancement in the public service plays an important role in evaluating performance in the public service although this study does not focus on just any administrative system but specifically the ECDoH. The rationale behind M&E as a tool for performance enhancement in the public service is to make the systems of governance more effective through an overall impartial assessment of policies, programmes, projects, strategies, the performance of personnel, and the organisation as a whole. Overall, M&E helps in a general sense, to improve performance and achieve excellent programme results. Cloete (2009:1) laments that if the implementation of this programme is successful it will have huge potential for the improvement of public policy outcomes and likely to impact positively in this country. Moreover, successful policy implementation, however, depends on doing the right things right. More precisely, M&E (as a tool for performance enhancement in the public service) can be described as the measurement and assessment of performance to more effectively manage the outcomes and outputs that are collectively referred to as development results (United Nations Development Programme (UNDP), 2002:5). On another note, M&E (as a tool for performance enhancement in the public service) produces new knowledge, and scrutiny of public service activities at all levels and uses findings available to be transparent to the people (PSC, 2008:5). The rationale behind M&E is to make the system of governance more effective through an impartial assessment of tracking and tracing to find valuable findings. The researcher is of the view that the clearly mentioned statements constitute the science and discourse of Public Administration. Overall, how M&E as a tool for performance enhancement in the public service helps in a general sense, to improve public service/sector performance and achieve excellent programme results is a critical focus of this study. Public administration as an academic field is relatively new in comparison with related fields such as Political Science, Economics, Sociology, and Geography. However, Public Administration is a multi-disciplinary field which only emerged in the 19th century. Concepts and theories from Economics, Political Science, Sociology, Administrative law, Business management and a range of related fields are used to 34 enrich this field of study. The goals of the field of Public Administration are related to the democratic values of improving equality, justice, efficiency and effectiveness of public services. The researcher also posits that the rationale behind M&E is to also make the system of governance more effective and multi-disciplinary through an impartial assessment of policies, programmes, projects, strategies, the performance of personnel, and the organisation as a whole. 2.3. VIEWS ON PUBLIC ADMINISTRATION According to Kuye (2014:180), Public Administration has gained a recognisable and identifiable acceptance in the circle of social science disciplines and the professional practice including the public sector/service. The motive for such a position in the professional practice is that Public Administration as a discipline is a multidisciplinary field with democratic values of improving equality, justice, efficiency and effectiveness of public services. The researcher is of the view that M&E has gained recognition through its ability to track and trace programmes in the public service/sector. Kuye (2014) further suggests that leaders of the profession and academics must recognise the need for independence and a base for training and certification to ensure that the discipline establishes and maintains a recognisable identity. Kuye (2014) further argues that because universities are well placed to achieve that, public institutions and universities in SA must echo the values of the new professions through the exposition of knowledge, the dispensation of the principles of meritocracy and the provision of adequate utility. In this instance, the development of M&E as a tool for performance enhancement in the public service serves a purpose. Friedson (1994:200) contends that the relatively close intellectual relationship between professional schools of Public Administration and Management and public policy and the other disciplines have made it difficult for these professional schools to sustain their autonomy in SA. Furthermore, Friedson (1994:200) notes that the autonomy in Public Administration is necessarily based on a unique body of theoretical knowledge, skill and judgment that ordinary people do not possess, may not wholly comprehend, and cannot readily evaluate. The researcher is of the opinion that this involves the use of human capital in the process of providing public goods and services to the broader society. The portrait emerging from these writings by the above academics is clear, there is a 35 particular reality or practice, and a science based on that reality or practice. Hanyane (2016:31) concedes that in the field of study of Public Administration, this reality (unique body of theoretical knowledge) has for some time become the way of life in the quest for the truth. Henry (1999:22) complements the discussion by stating that Public Administration is a broad-ranging and amorphous combination of theory and practice, its purpose is to promote a superior understanding of government operations and its relationship with the society it governs. Public Administration also encourages public policies to be more responsive to social needs and to institute managerial practices attuned to effectiveness, efficiency and the deeper human requisites of the citizenry (Van der Waldt, 2013:2). The researcher is of the opinion that M&E as a tool for performance enhancement in the public service fits in quite nicely with the assertion of the above scholars as M&E is attuned to effectiveness and efficiency and this is plausible only if a unique body of theoretical knowledge and skills is acquired. 2.3.1. Public administration as a practice Basheka (2015:470) posits that Public Administration involves the delivery of mail, collection of trash and licensing of motor vehicles to the dramatic event of getting a man to land on the moon, the dispatching of Peace Corps volunteers to scores of countries and the development and control of energy resources. In the same vein, he further stipulates that, first, there have to be people, as administration involves people, people should be present before the administration can be undertaken, secondly, the administration is action and thirdly administration is interaction. The researcher is of the same opinion as Basheka that Public Administration involves the use of human energy in the process of providing public goods and services to the broader society. Thornhill and van Dijk (2010:95) in the same vein as Basheka state that Public Administration studies human beings engaged in administrative or managerial duties in organs of state. These include such activities as the provision of public healthcare to the residents of the Eastern Cape Province by the ECDoH. Cloete (1981:1) makes the above assertions stronger, stating that administration is found wherever two or more people take joint action to achieve an objective. Public administration takes place wherever people work or play and, thus, is found in all spheres of human activity. He further posits that administration does not take place in a vacuum and has as its aim the effective and efficient realisation of goals. The researcher is of the opinion that 36 M&E as a tool for performance enhancement in the public service precisely fits in with the assertion of the above scholars as M&E is accustomed to effectiveness and efficiency. In the South African context, Section 197 of the Constitution (1996) states that within public administration there is a public service for the Republic, which must function, and be structured, in terms of national legislation, and which must loyally execute the lawful policies of the government of the day. The process of public administration can be described as a number of related activities that need to be performed in public institutions such as the ECDoH. For instance, the provision of public healthcare services which can be enhanced by the use of M&E as an activity performed by public institutions such as the ECDoH can be tracked and traced in relation to the progress achieved in public health service delivery as in the case of the ECDoH. The tenets of public administration include, but not limited to, accountability to the voters, the body politic playing a role, the importance of community values and public service delivery. The achievement of these tenets such as public participation can be made possible through effectiveness and efficiency in the processes involved in public service delivery such as public healthcare. Finally, public administration can be defined as the management of scarce resources to accomplish the goals set by public policy. The researcher is of the opinion that this study of M&E policy as a tool for performance enhancement in the public service in relation to the ECDoH provides an opportunity for the development and advancement in the field of public administration whilst tracking and tracking progress on public service delivery programmes such as the public health care services in the ECDoH. Gladden (1966:12) describes (public) administration as a process with three stages, namely the stage of decision, the stage of administration and the stage of fulfillment. Such decisions include the design and implementation of public health services in South Africa with reference to the ECDoH. Pauw (1995:28) refers to public administration as the organised non-political executive state function, while Gildenhuys (1988:14) describes public administration as the detailed and systematic execution of public law. The researcher is of the opinion that these scholar’s views are a reflection of the South African public administration which involves people and the 37 execution of public policy such as National Health Insurance (NHI). The researcher also holds a strong view that M&E policy as a tool for performance enhancement in the public service adds great value to public administration through tracking and tracing of government activities such as public healthcare programmes. 2.3.2. Public Administration as a theory A theory represents a mental view of a system of ideas or a statement used as an explanation of a group of facts or phenomena and it is based on facts and values (Alasuutari, 1998). The researcher agrees with the preceding argument because theories are abstracts informed by facts. In the context of Public Administration, Maserumule (2013:481) argues that in many instances in the development of the discipline the prevalence of a ‘theory-less (empiricism)’ and ‘data-less’ kind of discourse may be real. The researcher is of the opinion that the discipline regardless of its efforts to be identified, still borrows theories from other disciplines such as Political Science, Sociology and Economics to name a few disciplines. The discipline needs to close the gap of lack of an exclusive theoretical foundation through the formulation of its own theories of Public Administration. Furthermore, Maserumule (2013) ensures that regardless of the major strides made in the discipline, there is a need to close the theoretical vacuum that already exists. Riccucci (2010:6) argues that Public Administrator scholars agree on the nonexistence of a single or central/core theory guiding the field rather all have tended to celebrate its rich intellectual heritage. Scholars such as Ostrom (2008); Riccucci, (2010); and Maserumule (2013) have inconsistent explanations regarding the scope of the discipline, therefore, depicting the discipline as having an identity crisis. In Public Administration, academic space is characterised by infinitive relative accounts such as academic workshops. It is the duty of the Public Administration scholars to relentlessly discuss and formulate theoretical ideas that will shape the future of the discourse. In this sense, Riccucci (2010:7) states that “the lack of a core theory has had implications for Public Administration which has led to a multitude of approaches or theories about how its practitioners ought to manage and how its scholars ought to engage in theory building and testing”. The researcher also holds a strong view that M&E policy as a tool for performance enhancement in the public service ought to add value to the 38 discipline of Public Administration through theory-building, tracking and tracing of government activities. The genesis of theoretical paradigms in South African Public Administration may be derived from the debate of Minnowbrook 1968,1988 and 2008 and Mount Grace 1991 including 1999, together with a state of discipline as outlined by Cameron and Milne (2009:38) coupled with the neoliberal policies South Africa adopted after the dawn of democracy in 1994. Both the Minnowbrook (USA) and Mount Grace (South Africa) are known as watershed conferences that tried to reshape Public Administration in times of troubles. The researcher holds a strong view that the above conferences in South Africa and USA have provided for principles governing the discipline of Public Administration in a quest for findings a theoretical disposition to be applied in practice. However, the public service as it is today owes much of its existence to the Public Administration theory (is the amalgamation of history, organizational theory, social theory, political theory and related studies focused on the meanings, structures, and functions of public service in all its forms. It often recounts major historical foundations for the study of bureaucracy as well as epistemological issues associated with public service as a profession and as an academic field) that prevailed at the beginning of the 20th century including respect for the rule of law; a commitment to serving public good; and an expectation that public servants will exhibit integrity, probity, and impartiality in serving public trust (Nkuna & Sebola, 2012:69). M&E becomes the new feature to help augment the current character of the discipline. In principle, this implies that the development of theoretical discourse in Public Administration is dominated by trends that prevailed in the 20th century. Those trends such as NPM were striving to develop the discipline of Public Administration alongside positivist ontology of science such as taking a controlled and structural approach in conducting research by identifying a clear research topic, constructing appropriate hypotheses and by adopting a suitable research methodology (Nkuna & Sebola, 2012:69). Such development strove to come out with simple universal guidelines for Public Administration. It sought a unified rational theory of Public Administration that can be applied across the board. 39 As a movement towards the liberating and re-invention of modern day government into an entrepreneurial culture, NPM is the pivot on which improved government efficiency rests upon. NPM, as stipulated by Morenikeji and Oluwafemi (2014:68), refers to a mixture of splitting ancient large bureaucracies (body of non-elective government officials) into smaller agencies, therefore encouraging competition between public sector entities, as well as the utilisation of economic incentives to motivate the performance of public servants. From the definition, the study deduces that NPM becomes prominent due to the pitfalls associated with the classical organisation and management practices such as bureaucratic public sector structures which crippled the ability of governments to introduce tighter controls and measures of output. Louw (2012:88) opines that South Africa’s NPM movement was seen as a reform administrative agenda that included practices like privatisation, deregulation and the re-conceptualisation of the appropriate role of government in the South African economy and society. The Batho Pele (people first) (1997) framework in South Africa aligned itself with the global trend of adopting the NPM philosophy. NPM is essentially a philosophy of generic management because it argues that all management activities such as planning, coordinating and reporting have similar challenges such as inefficiency and ineffectiveness. Such inefficiency and ineffectiveness should be resolved in similar ways as in public- and private-sector organisations (Peters, 1996: 5). The researcher is of the opinion that NPM has been inspired by various theoretical perspectives like public-choice and principal-agent theories. This study has deliberately chosen the NPM theory as the main basis of analysis. 2.3.3. Putting Public Administration on a scientific level The debate on whether Public Administration is a science or an art is something that will never be resolved in the social sciences and in other instances the humanities. According to Sebola and Nkuna (2013:697) and Siswana (2007:91) science is a systematic enterprise that builds and organises knowledge through testable explanations and predictions about the universe, while art is associated with skills to perform administrative tasks. The debate about whether Public Administration is an art or science has been philosophical and important in the Public Administration 40 discipline. The debate is still relevant in modern day Public Administration and will enable scholars and practitioners in the field to ascertain what is ‘scientific and artistic’ about the discipline of Public Administration. Siswana (2007) further asserts that Public Administration is not only art or science but both of them and science is characterised by precision and predictability. On the basis of the above assertions by the mentioned authors, it is evident that art and science are a characteristic of Public Administration. Maserumule (2011:316) notes that when Woodrow Wilson (1887) first popularised Public Administration as a scholarly field, the discipline becomes a distinct body of science concerned with the systematic inquiry of the work of government and public officials in a public space. The researcher agrees that Public Administration is a distinctive discipline that seeks to determine its real identity continuously. According to Dimock and Dimock (1964:64) and Guerrero-Orozco (2013:3), it was the work of scholars such as Bonnin and Waldo that Public Administration became a more established discipline based on some clear cut scientific principles and philosophical considerations of inquiry. In this sense, Cloete (1995:61) and Aiyegoro (2011:27) argues that Public Administration is a science, a field of study and an academic discipline focused on the study of and research into the functions and activities of the public sector collectively known as public administration. In a government department such as the ECDoH, employees need skills to be able to perform their tasks, a point argued in this thesis in (chapter 7 section 7.3). An art presupposes human skill and calls for knowledge its emphasis is on practice rather than theory. Science is a collection not of particular truths but of universal truths. Science is a body of knowledge acquired as the result of an attempt to study a certain subjectmatter in a methodical way, following a determinate set of guiding principles (Walsh, 1967:35). Science for Plato (427-347) is the contemplated truth; for Aristotle (384322), pure knowledge as opposed to the practical analysis of a phenomenon, but an abstraction from practice and the principle from which the practice actually proceeds (Runes, 1944:317; Solomon, 1994:13). Wessels (1999a:365) considers Public Administration as an existing body of knowledge made up of valid scientific statements. Whilst Pauw (1999:9) affirms that Public Administration is the scientific study of public administration as a field of practice. 41 The domain of Public Administration as a science and discipline is concerned with research in a given public context and public socio-cultural spaces such as public monitoring and evaluation of public programmes and public projects, including public service delivery. According to Dobuzinkis (1997:298), the discipline is in some sort of disarray because its ancient philosophies no longer hold ground in the broader spaces of public engagement and research in Public Administration. This allows for both infusing both the scientific and artistic methods in the determination of the discipline’s current identity. Riccucci (2011:16) argues that the practice of public administration will always need the use of wisdom and experience which reflect its artistic character and also the presence of studies in the natural settings of human beings as its subject entails that it cannot be reduced to the science of natural sciences hence it’s a branch of the social sciences. Deductively, Public Administration is regarded as a social science due to its lack of well-defined facts and parameters that are part of the pure sciences field. It is therefore critical for public officials or public servants to be ‘scientific’ and be ‘artistic’ in order to improve public service delivery and in ensuring public accountability. This can be achieved through the adoption and use of both principles of science and skills of art in the execution of public service delivery such as public healthcare. It is also expected of the managerial leaders to be highly skilled and have the requisite expertise to manage and implement government programmes. Gladden (1964:23), states that administration is a distinct activity calling for specialist knowledge and techniques (monitoring and evaluation techniques in Public Administration) and in exercising of the art of public administration. The public administrator in the public service/sector needs to acquire more and more knowledge to be able to execute public tasks well. The discipline of Public Administration also shapes the practice through the skilling and equipping of public servants with requisite skills such as monitoring, evaluation, and delivery of public services and goods through training, tuition, and workshops. Public Administration science also assists public decision-making so that public managers are able to estimate or predict consequences for public organisations. These predictions are key in the efficacy of M&E which strongly relies on proper track and trace of public service delivery programmes. 42 The researcher is of the opinion that public administrators use scientific laws, techniques, and data, they do so in ways that help them to tackle particular administrative problems such as reporting and M&E. A creative public administration may even devise a new solution. For instance, the use of NPM and other efficiencybased practices such as good governance and M&E that call for improved public programmes, the relevant design, implementation and review of such public programmes go hand-in-hand with a scientific way of executing tasks. As a result, public administrators share traits with the arts as well as the natural sciences like Engineering, Mathematics, and Physics. Public administration as a practice is an art, the organised knowledge underlying it may be referred to as a science, art, and science are not mutually exclusive but are complementary. This is concurred by Merson (1923:220) in Maserumule (2015: 447) that "practice is often in advance of science". 2.4. Philosophical, Ontological and Epistemological Aspects Philosophy is the starting point for every science, including Public Administration. In addition, philosophy provides students in every discipline with a fundamental grasp of that discipline by clarifying its philosophical significance. Cahan (2003:10) argues that philosophy relies solely on the power of the human intellect to investigate the nature of things and their causes such as M&E of government programmes. The current literature in Public Administration sometimes uses terminology in an unfamiliar way to the current cohort of students and this is particularly true of courses in administrative theory and ensuing administrative behavior. When authors use words such as ‘ontology’ and ‘epistemology’, they will be using philosophical terms because these are not normal or literal terms that the social science field or humanities are used to. Their meaning goes beyond a mere laymen interpretation. Mouton (2005:178) explains that philosophical studies are aimed at analysing arguments that propagate or reject a particular epistemological position, sometimes of a normative or value-laden kind. Philosophical studies develop substantive points of view about the meaning of life, morally acceptable behavior and coherent and consistent forms of reasoning (logic). Such types of studies address, according to 43 Bak (2004:10), “some problems in thinking”. This category of studies is concerned with seeking better ways of thinking and understanding of intellectual phenomena. The philosophical studies deal with ‘questions of meaning, explanation, understanding, and normativity’ and their analytical methods take the form of normative analysis, ideology critique, deconstruction and phenomenological analysis (Mouton, 2005:178). The researcher is of the opinion that, an examination of the history, philosophy and social ideas are both necessary and desirable for the study of Public Administration. Spicer (2004:353) states that, as a field of inquiry, Public Administration has occasionally drawn on the history of political and social thought for insight. Indeed, quite a few early writers in Public Administration, including Woodrow Wilson, Leonard White, and John Gaus, displayed a notable interest in the subject. Spicer further asserts that in recent years, a number of contemporary writers, such as Rohr (1986), Stillman (1998) and Stivers (2000), have demonstrated that an examination of the history, political and social thought can be helpful to the study and practice of contemporary Public Administration. However, the researcher is of the opinion that, an examination of the history, philosophy and social ideas are both necessary and desirable for the study and practice of Public Administration with reference M&E towards locating its origins and philosophical foundations. To ascertain the origins of the current discipline of Public Administration one should trace the evolution of government efficiency into the modern day Public Administration discipline where M&E as the object of study in the context of this thesis, has become one feature of the study of contemporary Public Administration. Hanyane (2005:42) regards the field of Public Administration as a discipline that must graduate from merely carrying out the mandates of legislated policy to a field that is grounded in a strong philosophical tradition. This thesis argues that in view of the above scholarly discussion there is a need for one to understand and get to know the philosophical foundation of the epistemological and ontological issues in Public Administration. Such an approach should help in shaping future theory formulation and empirical discourses in the discipline. Hanyane (2005:42) posits that the philosophy of Public Administration would provide the basic values needed towards meeting 44 challenges of organisational renewal and changing technology. He further states that this philosophy should embrace a culture of inclusiveness, in which contributions from other disciplines such as Sociology are accommodated rather than taking what he calls a ‘single-minded approach’ in response to a need of establishing a philosophy of Public Administration. In this regard, the researcher is of the opinion that a more inclusive philosophical foundation of Public Administration can provide a richer intellectual context to help Public Administration scholars and practitioners to evaluate administrative ideas and reforms. Such reforms include the adoption and infusion of modern practices such as M&E which strengthen the discipline through certain skills in enabling a robust performance of public servants. Hence, the study probed how M&E can be a catalyst to the effective delivery of public healthcare to the people of the Eastern Cape Province. Theoretical thinking requires philosophical arguments and dialogues amongst those who are interested in changing our field of study. Pauw (in Wessels & Pauw 1999:464- 465) quoted by Hanyane (2005) mentions that philosophical thinking is thinking about the way in which we order ideas (see also section 2.4 of this chapter) in our minds and judging the usefulness of the concepts and intellectual patterns we use. The researcher partly construes with the preceding arguments by cited scholars in the preceding paragraphs. However, the researcher holds a strong assertion that to advance Public Administration as a discipline, scholars, academics in universities and practitioners in the public service/sector need to take into consideration the philosophy of Public Administration and for universities to teach the fundamental history and philosophy of the discipline to its students. This implies that the evolution of the philosophy of Public Administration would now need to incorporate issues such as M&E and its effect on public service delivery in the wake of continued complaints of ineffective service delivery in South Africa. The researcher is also in agreement with Hanyane’s (2005:48) concluding remarks in his article that from his academic perspective, a need for a philosophical grounding of the discipline remains an important objective to be achieved. Philosophical skills of researchers in the discipline need to be nurtured in an attempt to capacitate them to overcome challenges faced by the discipline. Hence, treating Public Administration as an evolving discipline enables the adoption of new approaches such as M&E as they emerge towards a 45 continuous improvement path to both an improvement of the discipline and practice of public administration. Moreover, Riccucci (2010:45) indicates that the philosophical discussions in Public Administration and social sciences, in general, have been more of ‘chicken-and-egg’ puzzle. Scholars are always in an endless discussion on which approach to take first, inductive or deductive (whether the theory has primacy of data) and so forth. As such the deductive research philosophy is mostly about testing or falsifying a hypothesis or explaining the causality of the phenomenon in an objective manner, whilst the inductive approach seeks to get an in-depth subjective understanding of meanings attached by humans (public officials) to societal processes (Riccucci, 2010:48). However, this study notes that the discipline of Public Administration’s ontological and epistemological assumptions is wide-ranging. Ontology is now discussed in the context of its influence on shaping modern Public Administration. Ontology relates to the science of reality and thus reflects claims made by a particular approach to social inquiry about nature of social issues or reality, as such it purports to a thorough examination of the nature of reality (Riccucci, 2010:49; Fard, 2012:56; 2011:563; Narh, 2013:2). In this way, ontology reflects our widely held assumptions about the nature of reality. Ontology is about phenomena such as public healthcare service delivery which exist as in reality or an assumption (subjectivism) (Narh, 2013:2). Guba and Lincolin (1989:83) concurringly argue that ontological assumptions help in delineating what can be studied or known in a given field. Epistemology on another hand seeks to know the nature and origin of the discipline’s knowledge, and as such uses different methodological orientations so as to arrive at what we know (Tronvoll et al., 2011:561). Epistemology is generally understood as the theory of knowledge such as the advancement of M&E based on the need to improve the contribution of efficiency and the assumptions and beliefs that we have about the nature of knowledge about what exists. Fard (2012:59) argues that epistemology deals with nature and scope of knowledge, also it provides the basis upon which such knowledge can be critically evaluated and considered as adequate or legitimate. In this regard, the researcher infers that epistemology plays a role in the understanding 46 of the theoretical development and status of Public Administration, and the evolution of M&E based on the need to improve the contribution of efficiency to shaping the discipline. In light of this, Tronvoll et al. (2011) highlight that the view of reality (ontology) influences ones’ epistemological and methodological orientation to a given issue such as the study of M&E as a tool for performance enhancement in the ECDoH. This reverberates in Jun (1993:49) who says, “these two philosophical approaches are not mutually exclusive, rather reciprocal, because our ontological stand on human nature and social reality is influenced by our epistemological presupposition and vice versa”. In this sense, Grix (2002:177) alludes that ontology is the starting point of all research, after which one’s epistemological and methodological positions logically follow. Hence in Public Administration discourses in the ontology and epistemological assumptions shape the entire scholarly field including M&E as they are the criterion for how governance and social issues are known and how governance and social issues can be empirically examined and how the relevant theories can be formulated from governance and social issues. This is evident when Fard (2012:59) indicates that ontological and epistemological assumptions are the basis upon a research study and such assumptions are formulated and also specifies the nature of the behavior that is expected of the researcher. Grix (2002:179) asserts that whilst the two are closely related, they need to be kept separate yet interdependent, for all research necessarily starts from a person’s view of the world (ontology), which itself is shaped by the experience one brings to the research process (epistemology). Ontological position leads to an epistemology where hypotheses are tested in search of some law-like generalisations that are building blocks for theory (Raadschelders, 2012:22). Such hypothesis includes one that is based on the testing of whether M&E is a catalyst for performance enhancement in the ECDoH. At the end of this study, data will determine if indeed M&E can be a tool for performance enhancement in the ECDoH which is tasked with the delivery of public healthcare services in the Eastern Cape Province. 47 Public Administration has from the onset adopted a more interpretivist approach although scholars might have argued in favor of scientific rigor (positivism). Such scholars observed their empirical work through qualitative methodologies Riccucci (2010). According to Bauer (2004:644) “scientism of positivism” gives supremacy to science in all its adherents, and the author argues that “science and only science could find answers to any and all the questions that human beings might ponder”. Whilst Dubnick (1999) as cited in Terman (2010:7) suggest that in Public Administration positivism has always been the most promising point of scientific inquiry and analysis. It is through positivistic lenses that most theoretical approaches in Public Administration (including M&E) have become generalisable and been able to explain the causal nature of governance variables (such as M&E). Such an approach when conducting studies in M&E promotes the realisation of objective findings which can be replicated by different scholars. The humanistic nature of Public Administration allows for a shift from the objective and more scientific positivism to a more meaningful or grounded study of human and social processes through inductive approaches or through interpretivist philosophy. Terman (2010:8) deduces that the utilisation of qualitative designs such as case studies (in the case of this thesis – the ECDoH) by researchers allows public administrators and scholars to get the perspective of actors engaging in different societal processes. Most of the development processes that need M&E can be best understood from the perspective of the actors rather than from the use of scientific instruments. Berger and Luckman (1966) as cited in Terman 2010:10) also note that the usage of the interpretivist and social constructivist philosophies in Public Administration studies allows researchers to get a more comprehensive definition and redefinition of social meanings (such as M&E concepts) or views attached to a given policy practice such as monitoring and evaluation in the public service or sector. Maserumule (2012) in his argument has indicated that Public Administration needs to shift its focus from employing positivist or realist epistemologies and start accepting and embracing other epistemological approaches like interpretivist, phenomenology, and social constructivism if there is a need to produce more theories. In this Bauer (2004:644) notes that the current discourses (including NPM) in Public Administration 48 fail to satisfy public curiosity about pertinent issues of governance such as M&E. In light of this, when it comes to epistemological and ontological issues in Public Administration such as theory-testing and probing of certain realities, there is no consensus on the appropriateness of use between qualitative and quantitative approaches whilst some even feel that a combination of both epistemic values is good for the discipline if it is to address social issues. 2.5. Monitoring and Evaluation in Public Administration Monitoring and Evaluation (M&E) is as a continuous function that uses a systematic collection of data on specified programme indicators. Such data provides management (in a public entity such as the ECDoH) and main shareholders of an ongoing development intervention with indications of the extent of progress and achievement of objectives and allocated funds (Naidoo, 2011:39) (see Chapter 1 section 1.1 of this thesis). The World Health Organisation (WHO) (1969) defined “evaluation” as the systematic and scientific process determining the extent to which certain public action or set of public actions were successful in the achievement of pre- determined goal(s) and involves variables such as adequacy, effectiveness, and efficiency of health services for instance delivered to citizens. The terms monitoring and evaluation differ in their meaning, but both of them are working in a symbiotic relationship since it is hard to separate them (Mahlala, 2014:14). The researcher is of the view that both terms and variables “monitoring” and “evaluation” cannot be separated, as they are pillars of gaining knowledge on programmes and projects in the public service. The researcher’s statement is supported by Ijeoma (2010:350) by stating that monitoring and evaluation are closely linked and closely related. M&E, as seen in this study, is the tool that catalyses public healthcare service rendering by the ECDoH. The DPME in the Presidency (2007) notes that M&E is a complex, multidisciplinary and skills intensive practice. Government-Wide Monitoring and Evaluation System (GWMES) is even more complex since it requires detailed knowledge both across and within sectors, and interactions between planning, budgeting as well as implementation. The picture is complicated even further when the machinery of the government is decentralised, with powers and functions being distributed across the 49 three spheres of government. It is precisely this complicated intergovernmental structure with dispersed powers and functions which require strong M&E systems to promote coordination and prevent collapsing (Mahlala, 2014:14). The significance of M&E is that it helps determine how well a programme such as the delivery of public healthcare services in the Eastern Cape Province by the ECDoH is working to meet its goals and objectives. M&E specifically serves to inter alia, manage and measure programme performance, improve the quality of programmes and promote accountability (Mahlala, 2014:14). In the South African public sector/service, M&E has gained hegemony in South African public service over the past two decades due to its increasing influence in ensuring efficiency in public service delivery programmes. The researcher is of the opinion that M&E has gained great recognition as there are more professionals and practitioners embracing and utilising it to improve the existing Public Administration scholarship and service delivery respectively. Apart from the distinction lies in the fact the past two decades have seen an intensified awareness of the importance of governance in society, and more specifically a focus on the conduct and operations of the government in effectively managing performance in the South African public sector (Mahlala, 2014:14). The researcher is of the opinion that M&E fits perfectly like pieces of a puzzle in the discourse, as Public Administration is a science and an art, a field of study, practice and an academic discipline focused on the study of and research into the activities collectively known as public administration. The researcher holds a view that M&E in many academic institutions such as the University of Fort Hare, is offered in their Public Administration curriculum for undergraduates and postgraduates under the discipline and Department of Public Administration as a module at third-year level (PUB 313 & 323) and a post-graduate diploma with the Stellenbosch University offering a postgraduate diploma programme in Public Administration Code 62340 - 788(120), in M&E as a one-year programme providing training to students who require knowledge and skills in M&E methods. This training is aimed at professionals or individuals who are tasked with the design, implementation, monitoring, and evaluation of public service/sector programmes. 50 Whereas a Doctorate in Evaluation Studies under the Centre for Research on Evaluation, Science and Technology (Stellenbosch University online). The Department of Business Management at the University of Pretoria offers short courses in Monitoring and Evaluation Process Implementation in the Workplace and Impact Evaluation the Return-On-Investment Approach, Course Number: P001651. The Institute for Monitoring and Evaluation at the University of Cape Town offers a short introductory course on M&E in the Institute of monitoring and evaluation. Clear (2015:2). The University of the Witwatersrand’s at the Centre for Learning Evaluation Results (CLEAR) offers short courses on M&E that address a range of topical issues and methodological developments in the practice of M&E. CLEAR currently partners with the Kenya School of Government and Ghana Institute of Management and Public Administration in offering M&E training. These short courses are endorsed by the South African Monitoring and Evaluation Association (SAMEA). While Rhodes University offers a Certificate in M&E for Programme Managers NQF Level 8 Accredited, 15 Credits at the Centre for Applied Social Research and Action (CASRA) (CLEAR, 2015:2). The researcher is of the view that since M&E is offered in various universities in South Africa, some even at doctorate levels and others in short courses in various departments as discussed above, sets a strong precedence that Public Administration as a body of knowledge is changing with times by infusing M&E as a discourse, governance tool and technique for good governance. This trend could assist public administration as an activity to promote the application of M&E techniques and tools (including M&E policy) in promoting good governance in South Africa. Practitioners for monitoring and evaluation need to understand the relationship between the theory and the practice of M&E as a discourse of Public Administration. 2.6 Curriculum challenges and dynamics of M&E Stufflebeam and Coryn (2014:6) posit that M&E is an academic discipline, unlike other disciplines, M&E is still a young discipline and it’s often a sub-discipline that falls under other major disciplines such as Public Administration and Management Stufflebeam and Coryn (2014:6) state that evaluation (as the first process of M&E) draws concepts, 51 criteria, and methods from other fields such as Philosophy, Sociology, Political Science and Public Administration. These concepts, criteria, and methods build a symbiotic relationship between evaluation and other fields of study and practice. Wotela (2017:1) states that African politicians, bureaucrats, and technocrats have thrown their weight in support of M&E. Wotela (2017) further states that this weight has compelled public training institutions such National School Government to add M&E in their offerings under the In-Service Learning and Development programme. Moreover, Basheka and Byamugisha (2015:75) further posit that as an academic field of the study several universities now offer programmes in M&E such as Fort Hare. The researcher is of the opinion that this study advocates that M&E practitioners need to be trained and educated within the discipline of Public Administration as M&E is a good governance tool for effective service delivery. This study briefly examines the offering of M&E in the discipline of Public Administration at various local universities in South Africa such as North-West University, Nelson Mandela University (NMU) and University of Fort Hare (UFH) and the NSG. For the purpose of this study, it is pivotal to name a few of these universities and public institutions that offer Public Administration with M&E in South Africa, with a specific focus in or partially incorporated M&E course work into various curriculum offerings (both undergraduate and postgraduate levels). Such universities and public institutions that offer M&E within their curriculum are the North-West University, Mandela University (NMU) and University of Fort Hare (UFH) and the NSG. The following section discusses these courses and codes being offered by these public institutions. In the North West University in all campuses (NWU), Public Management and Governance or B Admin Degree Public and Development Admin & Local government for Mafikeng campus (equivalent name for the department and qualification offerings in Public Administration elsewhere in South Africa) entails the study of the way in which public theory for instance and the practice of public administration combine to satisfy the most important needs of the citizens of South Africa. The delivery of public services 52 and goods is promoted by means of effective and efficient delivery of quality public services and goods by the government and sustained by public policy-making, judicial proclamations, and executive public institutions within national, provincial and local government spheres. Given the focus above, the qualification in Public Management (degree) offered at the NWU include courses or chapters in M&E. For instance, public policy at the third-year level on a prescribe textbook of improving public policy for good governance. More specifically, Public Management and Governance at the NWU studies the following matters scientifically: • locus and role of the subject in the public sector of a country such as South Africa; • nature and scope of the Constitution; • the way in which the state’s policy-making, executive and judicial institutions are constituted; • nature and scope of public service delivery within the three spheres of government; • management processes, for example, planning, organisation, and staff and financial management; and • place and role of ethics in the processes. Specific courses offered in the programmes include: Public Administration, Economics, Business Management, Industrial Psychology, and Accounting these are offered in the Mafikeng campus while Potchefstroom and Vaal include Sociology in their curriculum. These are offered from the first year to the third year of the programme van Dijk (2013:5). Moreover, the Nelson Mandela University in the Department of Public Management and Leadership studies (the equivalent name for the department and qualification offerings in Public Administration elsewhere in South Africa) offers instructional programmes from diploma up to doctoral level. The Bachelor of Administration course code (10070) degree is a multi-faceted and comprehensive programme which aims to 53 develop excellence in the practice and analysis of Public Administration, Industrial Psychology, Sociology, Business Management, and Political Studies these are taken in the first year to the third year of the programme. Depending on their area of specialisation, students will be equipped for careers in the clerical, administrative and management divisions of the public and private sectors and in consultancy, entrepreneurship, non-government organisations, and community-based organisations. The specialist trained through this programme will, among others, have knowledge of: • Public Policy Formulation and Analysis • Governance and Administration • Human Resource Management • Public Service Delivery • Public Finance Management • The nature and functions of state and parastatal institutions • The relationship between government and business • International Public Administration (Nelson Mandela University online) In the context of the NWU and NMU offerings in Public Management and Governance\Leadership offerings, M&E is not even offered as a module across the entire curriculum thereby making it just a sub-theme in courses such as Local Government Administration at second year and Public Policy at third year. The study deduces that having M&E as a theme or the topic within a bold course that does not prioritise M&E is a factor that affects the equipping of students with required skills in this concept and practice whose value and importance continues to increase. Furthermore, since universities are responsible in making input from the discipline into the practice of public administration, an absence of an exclusive M&E module in the NWU and NMU curriculums makes the resourcing of public administrators and specialisation in M&E impossible to achieve. In this regard, the study underscores the need for both students and specialists to be given a chance to be tutored, mentored and exposed in M&E as a field of study. The provisioning of M&E studies in both universities can happen through having a specialised degree in M&E with dedicated modules in the same field and enough resources to familiarise and acquire required expertise for expanding the existing body of knowledge in Public Administration. That can help improve an understanding of what M&E entails as well as its catalytic role in 54 improving public service delivery and the concomitant goal of promoting efficacy in public entities such as the ECDoH. The NSG has to play a significant role in overseeing the professional common purpose in addressing the systemic challenges of public service delivery through the teaching and development of public officials. In doing so, the NSG has to integrate lessons and experiences from the past to develop and improve on current skills of public officials and empower the current generation of public servants; and determining a conduit for producing future public servants with a vastness of competitive opportunities and abilities to innovate. The National Development Plan 2030 in chapter 13 confirms that the uneven performance at national, provincial and local government results from interplay between a complex set of factors including tensions in the political- administrative interface, instability of the administrative leadership, skills deficits, the erosion of accountability and authority, poor organisational design, inappropriate staffing, and low staff morale NDP (2012:410). Therefore, the NSG is a call to build a capable and developmental state that will assist in correcting some of the inefficiencies in the public service (National School of Government, 2013). More specifically, the NSG studies the following courses for M&E training under In-Service Learning and Development programme: • Introduction to M&E: to provide managers in the South African Public Sector with an introduction and overview of the key monitoring and evaluation initiatives currently underway in the South African government with a focus on using evidence to improve performance as well as the insights to critique and improve their own Departments’ Monitoring and Evaluation systems. Monitoring and Evaluation are seen as an integral part of planning, reviewing and reporting activities and therefore, managers should have some of these responsibilities. • Apply monitoring and evaluation principles in the public sector: A programme for M & E practitioners, the programme is intended for M & E practitioners to apply monitoring and evaluation principles in the Public Sector in assessing organisations and/or programme performance in a specific context. 55 • Organisational Design: the purpose of this programme is to enable departments in the public service to conduct organisational design processes. This will be done by guiding participants to use the information and tools in the DPSA Guide and toolkit on organisational design to improve the organisational structures of their department. • Job Evaluation Initial: to enable job analysts to analyse and understand jobs in all their facets, use the information to evaluate jobs and understand the Human Resources legislative framework as it relates to job evaluation in the Public Service NSG (2013:53,55). • Selecting Appropriate Methodologies for Evaluation in government: the purpose of this course is to equip middle and senior managers in the public service to strengthen their understanding and application of the National Evaluation System. It is part of the initiative to build evaluation capacity within government departments and to improve overall performance, accountability, and effectiveness. The course intends to provide basic knowledge of key concepts in evaluation approaches and guidance on how to apply them to evaluations. Its aim is to provide the learner with interactive learning material that stimulates the thinkingthrough of key concepts which the learner can then apply to the programmes that he manages or participate in. • Managing and Commissioning Evaluations in government: the purpose of this course is to equip middle and senior managers in the public service to strengthen their understanding and application of the National Evaluation System. It is part of the initiative to build evaluation capacity within government departments and to improve overall performance, accountability, and effectiveness. This course is intended to enable government departments to use evaluations such that they will contribute to sound governance by improving evidence-based policy making (including budget decision making), policy development, management, and accountability. Evaluation, in particular, is a decisionmaking tool to be incorporated into the planning cycle and the performance management of government. It assesses achievements to satisfy external requirements, and provide information that can be used to improve policies and programmes and to document accomplishments of failures. 56 Evaluations can provide feedback and motivation innovations and support continued programme improvement. This course aims to support participants to develop terms of reference for managing their evaluation. Also to provide support to programme managers and Monitoring and Evaluation advisors through the eight important stages of effectively undertaking evaluations NSG (2013:53, 55). • Job Evaluation Follow-up: to build on the knowledge and skills gained during the JE Initial Training, by enabling job analysts to analyse and understand jobs (in all their facets), use the information to evaluate jobs and understand the Human Resources legislative framework with regard to job evaluation in the Public Service. • Job Evaluation Panel: ensure that participants have the necessary knowledge to make decisions that are fair, objective and equitable on the grading of posts in the public service. • Deepening Evaluations in Government: the purpose of this course is to equip middle and senior managers in the public service to strengthen their understanding and application of the National Evaluation System. It is part of the initiative to build evaluation capacity within government departments and to improve overall performance, accountability, and effectiveness. The emphasis for this course is on critiquing and analysing evaluation reports, quality assurance processes in the design and conduct of evaluations and the applications of the key concepts of the national standards for evaluation in Government. The course also covers evaluation review and validation processes, communication in evaluation, management responses and an improvement plan as the final stage in the evaluation process. This course aims to support participants to develop terms of reference for managing their evaluation. Also to provide support to programme managers and monitoring and evaluation advisors through the eight important stages of effectively undertaking evaluations NSG (2013:53,55). The idea to establish the NSG is a noble idea to equip public servants and other stakeholders on the fundamentals of public service efficiency. Arguably, the NSG has a crucial role in making sure that M&E is entrenched into the human capital of the 57 South African public service. However, since the NSG offers short courses such as deepening evaluations in government and introduction to monitoring and evaluation, usually less than a week, the study argues that this kind of training although important, it is somehow superficial in skilling public servants on vital public service/sector skills. In the case of UFH, which restructure its Public Administration curriculum to include a module on Public Sector Monitoring and Evaluation at third-year level (PUB 313 & 323), there still is some deficiency as far as entrenching M&E in the curriculum is concerned. The study observes that the UFH has made efforts by having this M&E module in its curriculum. There is still a need to ensure that M&E courses are taken by students from entry points at first year till their final year of the programme. Furthermore, UFH still needs to ensure that M&E can be offered as an exclusive degree at undergraduate. This can also be applicable to all other higher learning institutions in South Africa. Arguably, most students and specialists who end-up being public servants usually pursue an undergraduate and honors degree in Public Administration. The study also argues that it will be feasible if either M&E courses are taken from the first year upwards, or there is a dedicated accredited and full undergraduate degree in M&E. Such a degree should equip students, specialists, current and future public servants on the fundamentals of M&E. Beginning with the restructuring of the discipline of Public Administration of how best it can equip the activity of government in public administration is one giant step towards making sure that an M&E culture is entrenched in the South African public service. 2.7. STATUS OF RESEARCH With the assistance of the NWU main library, electronic searches were conducted in the various databases such as PROQUEST of current and completed research in M&E in South Africa, with a view to ascertaining whether research relevant to the subject of the present study has previously been done or embarked upon in South Africa. The key terms used were, “monitoring and evaluation”, “performance enhancement”, “performance management”, “performance monitoring” and “evaluation”. There were no doctoral thesis or master’s dissertation dealing with monitoring and evaluation as a tool for performance enhancement in the ECDoH was 58 found. A Ph.D. thesis by Motingoe (2012) dealing with M&E system utilisation for municipal support of national and provincial Departments of COGTA and DCoG, and Radebe (2013) focussed on the impact of a performance management system on service delivery in the City of Johannesburg (CoJ) municipality. While Zwane (2014) covered M&E mechanisms for sustainable development in Sedibeng District Municipality and Naidoo (2011) focussed on the role of monitoring and evaluation in promoting good governance in South African public service with reference to the Department of Social Development. All these studies did not address the research problem as revealed in section 1.3 of chapter one in this study. 2.8. CONCLUDING REMARKS When thinking about the future of Public Administration, it is imperative, first, to reflect on the nature of the study and how attention to research objects and methodology should be embedded in epistemology and ontology. Ontology and epistemology are important since ontology in Public Administration generates theories about what can be known (epistemology) and how knowledge can be produced. Given that Public Administration is art, and science, only interdisciplinary can serve both generalist and specialist interests, on the one hand, and academics and practitioners interests, on the other hand, this implies that theory and practice cannot be separated. Public Administration should focus as much on theory and practice of the discipline so that there’s no longer a gap between practice and theory. Moreover, public administrators need to be concerned with both theory and practice. Practical considerations such as M&E are at the forefront of the field of Public Administration, but the theory of the discipline is the basis of best practices. This implies that the practical work being undertaken by public servants must be aligned with the theory being taught in our universities within the discipline of Public Administration. The study also purports that it would be feasible for M&E courses to be taken from a first year upwards in most universities in South Africa, or determine the possibility of a dedicated accredited and full undergraduate degree in M&E. Such a degree should equip students, M&E specialists, current and future public servants on the fundamentals of M&E. The next Chapter deals with the central theoretical frameworks of the study. 59 CHAPTER THREE CENTRAL THEORETICAL FRAMEWORKS OF THE STUDY 3.1. INTRODUCTION This study is premised on two key theoretical foundations, namely good governance and New Public Management. Chapter two discussed the ontological and epistemological position of the discipline of Public Administration (see section 2.4). That discussion played a crucial role in positioning the discipline on a trajectory that helps trace and tracks the evolution of best practices for public sector success. With the emergence of an emphasis on Monitoring and Evaluation in recent times, it is evident that the discipline has a character of changing shape in order to keep abreast with developments in a globalised world such as M&E. In order for the discipline to remain relevant, there is a need for it to grasp current and emerging trends such as M&E in order to make sure that there is a sustainable resolving of problems specifically public healthcare in the ECDoH as advanced in this study. M&E further ensures that there is sustainable development in society. In support of the overarching aim of the study, the current chapter offers discussion on two key central theoretical frameworks that guide the utilisation of M&E to improve public sector performance with reference to the ECDoH. In specific terms, the study centers its theoretical foundation on the practice of good governance and NPM, which are detailed in the section which follows. 3.2. GOOD GOVERNANCE In this section of the study, there are discussions on the concept “good governance” as the first central theoretical framework of the study, in the context of the South African public service. There is also a need to use M&E as an enabler of optimal government performance specifically in the ECDoH since the same organisation is the focus of the study. The next sub-section covers an exposition of the meaning and implications of good governance as a practice of public sector entities. 60 3.2.1. Unpacking the concept “governance” Since good governance as a phrase is derived from the concept of governance, it is important for the study to first conceptualise governance. According to the United Nations Organisation (UNO) (1997), governance is, “The exercise of economic, political and administrative authority to manage a country’s affairs at all levels. It comprises of the mechanisms, processes, and institutions, through which citizens and groups collectively articulate their interests, exercise their legal rights, meet their obligations and mediate their differences”. The African Development Bank (ADB) (2010:23) describes “governance” by identifying four elements underlying it, which are, accountability, participation, predictability, and transparency. This definition is applicable to South Africa as a developmental state, especially when referring to public sector/service best practices such as public participation. The ADB conceptualisation of governance addresses issues of participation of ordinary citizens, the importance of improving the interface between the public and private sector and views NGOs as an important role player. The issue of predictability is important, as this is necessary for investment and growth, as too frequently political changes tend to prevent development from gaining momentum for instance changes in political leadership. Also, the issue of policy continuity and stability are measures of governance and means that public policies ought to have sufficient time to be implemented, provided that they are appropriate and meet the tenets of good governance. Form the preceding definitional perspective; it is clear that public governance involves an exercise of political, economic and administrative authority necessary to manage the affairs of a nation (such as South Africa), usually the attainment of predetermined strategic and tactical goals. Governance as a phenomenon further encompasses the acts of partnership and collaboration amongst key stakeholders. Sindane (2007:213) sees the concept “governance” in broader terms that refer to its normative nature and as a value-filled character that focus on its overall process, as the concept focuses on the processes, values, and networks of various public institutions collectively seeking the achievement of both personal, organisational and 61 group goals. Huberts (2012:188) precisely defines “governance” as, “an authoritative policy-making process on a wide assortment of socio-economic problems and the implementation of such policies”. For Naidoo (2011:47) government is the institution, the administrative machinery for effecting policy, but the quality of that which is produced is governance. It is a higher level outcome and goes beyond the traditional services of government and needs to align with ethical and democratic standards. Governance implies going beyond the legal authority and implicitly implies the existence of some form of validation or judgment of activities, to see whether these are aligned to the values of good governance. Deductively, given the need for validation, good governance requires sound M&E to indicate whether or not this ideal is achieved. Lloyd (2007:2) however, differs in the interpretation of governance by focusing on its foci in Public Administration by noting that, “governance ensures that the government does the right thing, in the correct manner for the citizens in an approach that is timely, honest and above all accountable”. Public Administration as a field of study contextualises governance as the act of administering in a political context as described by scholars such as Green and Hubbell (1996:38). Whereas Govender (2013:812) argues that “governance” involves the mixture of numerous related elements of decision-making inter alia, compliance with rules and regulations and stakeholder participation. Conversely, Ewadlt (2001:9) lays-out the foundation for the understanding of the solid relationship between governance and administration and clearly links the two by outlining the five principles premised on the facts that “governance”:  refers to institutions and role players internally and externally to the government;  identifies the distortion of certain boundaries and responsibilities for addressing social and economic issues;  identifies the power dependence involved in relationships between institutions;  is about autonomous self-governing networks of the role-players; and  recognises the capacity to be self-sufficient and not rely on the power held by government Ewadlt (2001:9). 62 In simple terms, “governance” as a brand in the preceding section coupled with the elements of governance as underlined by Govender (2013) essentially focuses on the conditions which precipitate the undertaking of the various activities of government through administrative processes. Lloyd (2007:2) identifies elements of governance as a phenomenon which include public accountability, democracy, ethics, rule of law and transparency as being relevant and linked to each other. Therefore, from the preceding viewpoints, governance (both concept and phenomenon) within the context of M&E policy as a tool for performance enhancement in the ECDoH incorporates a complex range of administrative processes, policy-making mechanisms and organisations and role players which must conduct their affairs in a transparent, accountable, ethical, democratic manner which abides by the rule of law. This study observes that it is imperative to acknowledge the crucial importance of accountability, ethics, professionalism and transparency in the management of public entities and service delivery. These factors can best be realised when public officials and stakeholders in society collectively work together to attain common goals. In this regard, good public administration is crucial to improve service delivery and promote the social welfare of people. Foremost, governance, or the practice of good governance as will be discussed in the ensuing sections of the chapter (see section 3.2.2), is constitutionally entrenched in South Africa. Section 195 of the Constitution (1996) provides guidelines for governance by outlining basic values and principles of Public Administration which include that, public administration must; be representative; foster transparency; promote and maintain a high standard of ethics by public servants; and be accountable. Such values are in sync with the Constitution (1996) and should be the crux of public service rendering. The basic values and principles referred to in Section 195 of the Constitution (1996) include the values enshrined in the Bill of Rights. The nexus between Section 195 and the Bill of rights is created in Section 8(1) of the Constitution (1996), which binds the legislature, the executive, the judiciary and all organs of state, and section 7(2) of the Bill of Rights, which provides that, “the state must respect, protect, promote and fulfill the rights in the Bill of Rights”. The cited two 63 sections confirm that governance should happen in accordance with the Bill of Rights and the Constitution at large (1996). According to Mpa (2015:61) “governance’ as a concept refers to the relationship between a particular government and its civil society organisations in a given context. It is, therefore, a concept that includes all societal actors within and outside the terrain of the state and within and outside the borders of a country. Governance as a phenomenon can then be seen as a partnership and collaboration between the state and the non-state actors such as business, academia, state actors, and civil society, among others. Williams (2009:22) gives a more articulate explanation of governance by asserting that, the term “governance” has emerged as a compelling descriptor of a more interactive and symbolic relationship, it describes, in effect the creation of partnerships. Kjaer (2004:24) and Nelson (2016:27) illuminates that the starting point of the governance debate was when, within the public sector, a shift occurred in the public administration field away from the ancient or traditional thinking. This movement identified inefficiency in public service delivery as a major weakness in public administrations. The implication is that serious governance debates started at the fall of bureaucracy as the socio-economic landscape at the time in western countries were inefficient and ineffective in providing services to citizens (Kjaer, 2004:2). The preceding arguments bring the study to the all-important practice of good governance, something which significantly solves the plethora of problems which have been faced in the modern day public sector/service. Good governance punctuates a growing trend of public sector/service reforms aimed to give effect to sustainable socio-economic development, especially in developing (developmental) states like South Africa. The following section explains vividly the concept “good governance” as it will be used as one of the theoretical foundations underpinning M&E policy as a tool for performance enhancement in the public service in relation to ECDoH, and to also guide the utilisation of M&E to enhance public sector performance in relation to the ECDoH. 64 3.2.2. Good governance in the context of monitoring and evaluation According to Nzimakwe (2005:56) government reform is a worldwide trend and good governance is the latest flavor of the reform agenda to accelerate socio-economic growth in the developing world. Such a reform agenda is premised on three ideas viz, systemic, political and administrative imperatives. Firstly, the systemic utilisation of governance is broader than government covering the ‘distribution of both internal and external political and economic power’. Secondly, the political use of governance refers to a state enjoying both legitimacy and authority, derived from a democratic mandate. Lastly, the administrative use of governance refers to an efficient, open accountable and audited public service (Pierre, 2000:57). The researcher holds the view that the three ideas of the uses of governance show that governance is that overall process that can promote socio-economic development and the improvement of living standards of the people. Such a goal is possible because the three ideas can be used by a legitimate authority, which can dictate the direction of service rendering through various policy interventions. Since governance is a function of Public Administration, which has been defined as the use of managerial, political and legal theories and processes to fulfill legislative, executive and judicial governmental mandates for the provision of regulatory and service functions for the society in part or as a whole. It is also important for the activity of governance to be executed in a competent way through good governance. According to Feris (2010:4), good governance depends on how decisions are made, implemented and executed by those in positions of power for the public. Moreover, Section 195 of the Constitution (1996) is instructive in this regard, it requires that Public Administration be governed by the democratic basic principles and values enshrined it enshrines incorporating transparency and efficiency. Section 195 of the Constitution (1996) thus sets a yardstick for decision-making from a good governance perspective. To achieve efficiency in public sector organisations, there is a wide array of good governance reforms and interventions which should be considered such as inter alia, encouraging of internal public sector competition and markets; privatisations of public enterprise; reforming the civil service by downsizing the staff, introducing 65 budgetary discipline, decentralising administration and making greater use of non- governmental organisations in the making, implementation and evaluation of policies or service delivery programmes (Pierre, 2000:57). The researcher holds the view that M&E policy as a tool for performance enhancement in the public service (including the ECDoH) connects handsomely with the above scholarly and constitutional values and principles as M&E is an excellent governance tool for public checks and balances and for reforming the civil service. Maserumule (2011:264) mentions that governance is a conceptual presentiment of good governance. The concept governance, good governance would not have been part of the conceptual scheme in the parlance of the contemporary development discourse which shapes thoughts and perceptions in the description of the paradigm of thinking in state formation or re-invention (Maserumule, 2011:264). However, it should be understood that governance does not owe its conceptual existence to good governance. The use of governance without good governance is logically possible. Conversely, the same cannot be said about good governance without governance since good is an adjective qualifying the noun governance. The researcher holds the view that M&E policy as a tool for performance enhancement in the public service cannot be effective without good governance. Hence, good governance owes its conceptual existence to governance. In this regard, good governance is solidly linked to governance, and it helps capacitates the latter towards the attainment of the goals of the government. Furthermore, Maserumule (2011:280) writes that the concept “good governance” is traced back to the propositions of the early philosophers such as Plato, Aristotle, and Aquinas. In the debate on democracy and the quest for responsible governance in Southern Africa, Omoyefa (2010:111), links good governance to the notion of common good is associated with Plato and Aristotle philosophies on the question of a just and good society. Omoyefa (2010:112) states that the outcome of good governance ought to be ‘the good of all’ which implies common good. Omofeya (2010) further states that the concept of common good has a long history that dates back to ancient Greek philosophy. Also, Olowu (2003:04) and Maserumule (2011:57) affirms that the conception of good governance is based on the normative values of inter alia, “the rule of law, public accountability, participation, transparency and the equal 66 enjoyment of human and civil rights”. Lastly, Maserumule (2011:57) notes good governance as referring to a government, “that lives up to its responsibilities by ensuring the promotion of the public welfare, the effective delivery of public goods and services, the maintenance of law and order, and the administration of justice”. The researcher is of the view that M&E policy as a tool for performance enhancement in the public service specifically in the ECDoH promotes public welfare and the effective delivery of public goods and services. Moreover, Jonas (2011:33) states that good governance is generally understood to have at least three aspects. Firstly, the need for a rule-based, transparent, efficient and accountable government. Secondly, the need for government to undertake its task in a manner that is participatory, consultative and that usually abides by precepts of formal democracy (Jonas, 2011:33). Thirdly, the need for the state and government to ensure that substantive aspects of democracy, which would be compatible with the need to attain sustainable human development in the long run, are achieved (see also Mhone & Edigheji, 2003:3). For Naidoo (2011:32) good governance implies, “a governance system that requires processes in decisionmaking and policy formulation for the public, to be transparent and accountable”. While Sayeed and Pillay (2012:3) have defined good governance as the levels of accountability, ethical standards and the extent to which the government is responsive to the needs of its citizens. Naidoo (2011:47) asserts that a system of good governance requires that the process of decision-making and public policy making is transparent and accountable. This echoes sentiments by Weiss (2000) who notes good governance to be broad and relates to the way of doing things, or conducting activities that are proper, transparent and accountable. Also, the concept extends beyond the capacity of public sector/service to the rules that create a legitimate, effective and efficient framework for the conduct of public policy. Good governance further implies the managing of public affairs in a transparent, accountable and equitable manner. The phrase of good governance entails the effective participation of the people in policymaking, the prevalence of the rule of law and judiciary independence, institutional checks and balances through the horizontal and vertical separation of powers, and effective oversight agencies. There is the argument that the nature of the bureaucracy of government tends to dilute noble policy intent, which may include good governance 67 imperatives, and has been blamed for slowing down the progress of government. This has led to the drive that private-sector solutions be introduced to improve government efficiency, which is generally referred to as the Washington consensus, although it has not been fully supported in many states to date, particularly in developing countries Williamson (2005:40). The researcher is of the view that M&E policy as a tool for performance enhancement in the public service specifically in the ECDoH promotes and improves government efficiency. According to the World Bank (1994), good governance can be defined as, “epitomised by predictable, open and enlightened policy-making; a bureaucracy imbued with professional ethos; an executive arm of government accountable for its actions; and a strong civil society participating in public affairs; and behaving under the rule of law”. Similarly, the UN (2006:4) views good governance as, “governance being seen as good when resources are allocated and managed correctly but put more simply when government efficiently provides the much-needed services and goods of quality to citizens”. Also, the Organisation for Economic Cooperation and Development (OECD) (2006:4) has conceptualised good governance as “referring to the management of government in a manner that is essentially free of abuse and corruption and with due regard for the rule of law”. The rule of law, apart from accountability and transparency, are common features across all good governance definitions. The researcher is of the view that M&E policy as a tool for performance enhancement in the public service specifically in the ECDoH promotes accountability and transparency which are also common features of good governance Cloete (1999a:8) argues that “governance has developed out of a particular Public Management school of thought”. He further argues that this “good governance” thinking was aimed at giving new meaning to the traditional bureaucratic role of government within society. For Cloete (2003:5) good governance is prescriptively conceptualised as an achievement by a democratic government of the most suitable developmental policy aims to sustainably develop its society. Such a development of society is undertaken in a way by mobilising, applying and coordinating all available resources in the public, private and voluntary sectors, domestically and internationally, in the most effective, efficient and democratic way (Cloete, 2003:5). A closer look at this classification tells that there are two key aspects that underpin 68 Cloete (2003)’s conception of good governance, namely developmental policies, and sustainability. In as much as the provided preceding definitions and arguments on the meaning of good governance are concerned, it is evident that all these positive outcomes which it seeks to achieve can be augmented by infusing it with M&E as a tool for improving the performance of public sector organisations in South Africa. Therefore, M&E is the modern day form of government seeking to achieve community development and service delivery goals in a sustainable manner. 3.2.2.1. Principles of good governance As highlighted in the preceding definitions of good governance in Section 3.2.2 of the thesis, specific principles apply to its application to the modern public sector/service. These are listed by Vyas Doorgapersad and Ababio (2010:413) as:  Public participation including citizens exercising their right to express their opinion in decision-making processes;  Rule of Law refers to the enforcement of the law which must be fair and impartial;  Transparency includes the provision of government information which is accurate and adequate;  Equality referring to establishing equal opportunities for all members of the society to improve their welfare;  Responsiveness including government administrators becoming sensitive to the needs of the public;  Vision referring to the government based on a clear vision and strategy, with the participation of the citizenry in all the processes of development;  Oversight ensuring that increased efforts of supervision in the operation of government and the implementation of development by involving the private sector and the general public;  Efficiency and effectiveness including service delivery to the public by utilizing all available resources optimally and responsibly; and  Professionalism referring to enhancing the capacity and moral disposition of government administrators so that they are capable of providing accurate and affordable services. 69 According to Nelson (2016:34), key principles of good governance such as accountability often overlap and conflict with regards to context and application but are imperative in the enhancement of good governance within the public sector/service. This is evident as public officials and departments find it difficult to account to the society it serves. The principles of good governance as proposed by Vyas Doorgapersad and Ababio (2010:413) which include ... are prerequisites of good governance conditions and priorities that need to be determined by government. With the preceding assertions, this implies the need for M&E to demonstrate at one level where value is added by government. In simple terms, M&E is a practice that gives effect to the attainment of good governance due to its promotion of trace and track of government policymaking and programme implementation. The researcher is of the view that M&E policy as a tool for performance enhancement in the public service specifically in the ECDoH gives effect to the attainment of good governance due to its promotion of trace and track of government programmes. In this regard, good governance can be established and maintained through the ensuring of best practices for M&E. This can form the foundation of M&E in the efficient provision of public healthcare services with particular reference to the ECDoH. Good governance is based on key principles mentioned by Vyas- Doorgapersad and Ababio (2010) in the current section. There are additional principles categorised into two main classes, which is the political and economic view of the said principles. Downer (2000:320), mentions that good governance has political principles, which spell that good governance:  is based on creating a representative and accountable form of government;  requires a strong and pluralistic civil society with freedom of expression and association;  requires good institutions, sets of rules governing the actions of individuals and organisations and the negotiation of differences between them;  requires the primacy of the rule of law, maintained through an impartial and effective legal system; and  requires a high degree of accountability in both public and corporate processes Downer (2000:320). 70 Additionally, good governance has economic principles as discussed below. Firstly, good governance requires policies to promote broad-based economic growth, a dynamic private sector and social policies that will lead to poverty reduction. And economic growth is best achieved in an efficient, open, market-based economy. Secondly, good governance requires investment in people as a high priority, through public policies and institutions that improve access to quality education, health and other services that underpin a country’s human resource base. Third and lastly, good governance needs effective public institutions and good corporate governance to support the development of a competitive private sector. In particular, for markets to function, social norms as well as the respect of property rights (Downer, 2000). Ghaus- Pasha (2007:17) perceives good governance as necessary for progress as its focus is on sustainable and equitable economic development. Ayee (2008:27) goes further, stating that good governance is a requirement for sustainable growth and development because it is related to the creation of extra economic conditions as it refers to the adaptation and improvement of market-oriented systems. This means good governance creates an environment that allows programmes aimed at economic growth and social development. Figure 3.1 below shows the underlying principles promoting good governance. These principles as propounded by Jonas (2011:56) show that M&E can effectively create a conducive environment where they can collectively push improved public sector performance. This is particularly critical when applied in the context of the ECDoH and its provision of public healthcare services in the Eastern Cape Province. 71 Figure 3.1: Principles of Good Governance [Source: Jonas (2011:56)] The illustration in figure 3.1 indicates the wide range of principles of good governance. Some of the identified principles are discussed in detail in the sections which follow. 3.2.2.1.1. Transparency According to Mpa (2015:51) transparency as one of the good governance principles demands that citizens be informed about the daily activities of different departments within their government. This information should be available to the public domain in terms of inter alia, annual reports, strategic plans and service commitment charters. In the same sense, citizens should be told where to bring complains of any dysfunctional service or department and how to do it (Mpa, 2015:51). This can form the foundation of M&E in the efficient provision of public healthcare services with particular reference to the ECDoH. Furthermore, transparency is achieved when citizens or tax-payers have access to information and decision-making forums such as imbizo’s so that the general public knows what is happening and is able to judge whether it is appropriate. Above all, the use of enabling statutes and regulations such as the RSA constitution to give effect to the transparency of public service organisations, should be emphasised (Mpa, 2015:51). Transparency should also be clearly stated that public sector/service decision-makers ought to consult with and report to the public on a regular basis either monthly or annually. 72 In the context of the preceding discussion on the key principles of transparency as an enabler of good governance, the study infers it in the context of the need to use M&E to accelerate service delivery in the ECDoH. Foremost, interventions such as those of tracing and tracking performance are most likely to thrive if there is transparency in every aspect of the delivery of public healthcare services. Transparency would enable the availing of reports, departmental performance trends and challenges affecting the smooth functioning of the department as well as human capital aspects that need to be constantly managed. In that way, the swift identification of inhibitions and other antecedents that have a negative bearing on the sustainable provision of public healthcare services in the Eastern Cape Province are timely exposed. Therefore, corrections of variances and the implementation of related remedial and preventative action are done before it affects the functionality of the ECDoH drastically. 3.2.2.1.2. Public participation Participation is, “the direct involvement or engagement of ordinary people in the affairs of planning, governance and overall development programmes at the local or grassroots level” (Williams, 2009:197). The concept “public participation” remains an illusion until materialised through a range of core conditions which show meaningful participation such as inter alia, 1) the ability of people to input into the designing of policies to achieve specific concrete goals; 2) grass-roots drove; and 3) informed by rational and rigorous debates. The “grass-roots driven aspect” of public participation has an effect of reinforcing the notion of the bottom-up as opposed to the top-down process where ordinary people define and determine their aspirations and ways in which such aspirations have to be realized. In the true sense of the word, public participation is about putting people in the center or in the heart of decision making. Public participation is best understood in light of participatory governance which suggests that “the task of running public affairs is not solely entrusted to government and the public administration, but involves cooperation between state institutions and civil society groups” (Friedman, 2006:4) also see Section 152(e) of the RSA Constitution provides the same as the above scholar. For Maserumule (2011:52), the public participation of citizens in the development processes and the impact of such in 73 enhancing the quality of life of the citizens are considered critically important variables in the conception of good governance. In contextually configuring the key principle of participation in the case of the study, it can be argued that the public participation of the “owners” of government such as citizens, the people have valuable input in ensuring the success of M&E policies. This is mainly due to the ability of the government to tailor-make public goods and services according to the choices and preferences of the people thereby making the task of monitoring or evaluation the process of service provision smooth. Hence the ECDoH can significantly benefit from the use of public participation in sneering the success of the service delivery programmes. 3.2.2.1.3. Public accountability Cloete (1995:3) explains accountability as the duty to answer and report to a higher authority, functionary or institution about the results obtained with the performance of one or more specific functions. Public accountability should be seen as a process whereby the subordinates report to their superiors on what they did or failed to do to give effect to allocated responsibilities or orders. Mpa, (2015:70) also affirms that public accountability is a concept in ethics and governance with several meanings. Additionally, the concept “accountability” is often used synonymously with concepts such as “responsibility”, “answerability”, “blameworthiness”, “liability”, and terms associated with the expectation of “account-giving”. As an aspect of good governance, it has been central to discussions related to problems in the public sector, the non- profit sector, and the corporate world. Nzimakwe (2005:56) notes on the establishment of numerous independent statutory public institutions in terms of Chapter 9 of the Constitution (1996) to assist in ensuring accountability, for example, the Auditor- General, the Public Protector, the Human Rights Commission, and the Electoral Commission. The study is of the view that accountability is the acknowledgment and assumption of responsibility for actions, decisions, and policies. Accountability also incorporates administration, governance, and implementation within the scope of the role or employment position and encompassing the obligation to report, explain and be answerable for resulting consequences. (Mpa, 2015:70) states that accountability 74 cannot exist without proper accounting practices; in other words, an absence of prudent accounting practices forestalls accountability (Sinclair, 1995). However, following the preceding assertions the current thesis predicates public accountability on the policy praxis of M&E in the public sector/service. Public accountability is understood as an obligation of public enterprises and agencies (who are entrusted with public resources) to be answerable for fiscal and social responsibilities, to those who have assigned such responsibilities to them such as public healthcare. In the context of the study, ensuring that the ECDoH upholds the best practices for public answerability (accountability) serves as a yardstick to determine the smooth utilisation of M&E practices. Public accountability is premised on the reliance on professional behavior by those tasked with executing the various tasks aimed at achieving sustainable public healthcare in the Province. 3.2.2.1.4. Efficiency and effectiveness explained Limited resources dictate that the government needs to identify, as accurately as possible, the needs of people and to deliver services in an efficient and effective manner in relation to the numerous needs that exist. Continuous review of the manner in which the government renders its public services is necessary to ensure efficiency and effectiveness. In this regard Hakim (2003:314) postulates that good governance, “transcends government to encompass an efficient and effective functioning market and a society that is responsible, engaged and empowered to take part in the formulation and implementation of public decisions affecting them”. In layman terms, efficiency denotes, “doing things right” while effectiveness implies “doing the right thing”. In this regard, therefore, government or a system of government based on the ensuring of efficiency and effectiveness can be a precondition for the success of M&E initiatives such as tracking progress towards public health care. Tracing and tracking of performance are particularly important since public healthcare services are a determinant factor in the ascertaining of the standards of living of people. Besides this, access to public healthcare is a basic human right stipulated by Section 27 of the RSA Constitution (1996). The need to diversify the theoretical foundation of the study has seen the use of two main theoretical statements, good governance as detailed in the foregoing sections and NPM is discussed in the coming section of the thesis. NPM is conceptualised and 75 contextualised in the study since it is that pro-reform agenda that emphasises on inter alia, the continuous measurement of outputs and results. This makes it ideal for the supporting of the use of M&E in the public sector of today. 3.3. NEW PUBLIC MANAGEMENT AS A THEORY OF THE STUDY The second theoretical framework of the study is NPM. In this section, NPM is discussed from an angle where the orientations, principles, and foundation of public service M&E in the public service are linked to the 21st-century practice of NPM which improves government efficiency. 3.3.1. Conceptualising New Public Management Public dissatisfaction with vague justifications for poor government performance paved the way for a much-needed revival of concepts such as effectiveness and efficiency. NPM in the 1980s was seen as a solution to address poor performance and reinstate the citizens’ trust in the public sector’s management abilities. NPM is viewed as a post- bureaucratic movement where competition for public resources was and is effectively increased and accountability measures to determine the effectiveness of outputs were and are employed in the managing of the public sector. For Nzimakwe (2005:56) NPM has two meanings, namely, corporate management and “marketisation”. Firstly, corporate management refers to the introduction of private sector management methods to the public sector through performance measures, managing by results, introducing the practice of value for money, and closeness to the customer (including the public consumer/customer). Secondly, “marketisation” refers to the introduction of incentive structures into the public service/sector service delivery provision through contracting-out, quasi-markets, and consumer choice. The researcher is of the opinion that NPM introduces crucially important concepts such as inter alia, competition, value for money, decentralisation, focus on quality and feedback from clients, and professional management, amongst other things, to the public sector/service arena specifically in the ECDoH. NPM is best defined as being a set of particular management approaches and techniques borrowed from the private- for-profit sector and applied in the public sector/service (Batley & Larbi, 2004:41). 76 According to the UNESC (2006:5), NPM is a global public management reform movement that redefines the relationship between government and society that originated in the 1980s in Australia, New Zealand and the United Kingdom of Great Britain and Northern Ireland. Spurred by citizen dissatisfaction with government performance, widespread fiscal problems and ostensibly successful restructuring in the private sector calls for public sector reform and the reinventing of government became rampant and grew louder with time. According to the UNDP (2015:8), NPM approach took root in the UK, New Zealand, the USA and Scandinavia from the mid-1980s and in the African continent from the 1990s. The NPM’s theoretical foundations lay in public choice and principal-agent theory, which claim that individual self-interest drives bureaucratic behavior such as influencing public policies. Competition, delegation, performance, and responsiveness offer yardsticks to regulate bureaucratic behavior and generate improved outcomes (Dunleavy & Hood, 1994; McCourt, 2013). NPM resulted in significant changes in the public sector ethos and approach, especially the cultivation of new management practices, marketisation and contracting out of core services to private companies and non-profit entities, and the creation of ‘arms-length’ executive agencies responsible and accountable for the implementation of public policy programmes. A greater focus on management by results replaced a public sector orientation governed by inputs and outputs, while performance management increasingly pervaded the public sector UNDP (2015:8). For Mouton (2010:64) the NPM movement can be viewed as a pivotal influence on policy programme performance evaluation through the emergence of the famous performance management paradigm. The study supports the thesis of Mouton (2010) that NPM as it is vital for programme evaluation, it is also vital for M&E as a policy to enhance performance in the public service with reference to the ECDoH. UNDP (2015:7) credits the NPM model as arising in reaction to the limitations of the ancient public administration in adjusting to the demands of a competitive market economy. While cost containment was a key driver in the adoption of pro-reform NPM approaches, injecting principles of competition and private sector management lay at 77 the heart of the NPM approach. The key elements of the NPM are summarised by Osborne (2006:379) as follows:  Attention to lessons from private-sector management;  The growth of hands- on management.  A focus upon entrepreneurial leadership within public service organisations;  An emphasis on input and output control, performance management and audit;  A disaggregation of public services to most basic units; and  Growth of the use of markets, competition and contracts for resource allocation and service delivery within public services Osborne (2006:379). Osborne and Gaebler (1993:316) assert that NPM calls on governments to focus on achieving results rather than primarily conforming to procedures and to adopt market- like competition, innovations, and entrepreneurial strategies. In order to be market- like, government and public administration generally are called upon to be customer- driven and to rely on market-based mechanisms to deliver public services. While Vyas Doorgapersad (2011:238) asserts that NPM is seen as a body of managerial thought or as an ideological thought system based on ideas generated in the private sector and imported into the public sector. Hood (1995:97) defines NPM as, “a move towards more explicit and measurable (or at least, checkable) stands of performance for public sector organisation, in terms of range, level and content of service to be provided”. NPM is also about improving government performance through strategic planning, the effectiveness of service, transparency, participative management, quality management, and the use of information technology systems. Frederickson and Gher (2005:165) cited in Keita (2014:24) added that NPM is intended to, “fix issues of public sector ethics and government corruption” through incorporating principles of transparency, accountability, effectiveness, and efficiency in financial resource management”. The principle of transparency means the validity of concepts, such as best practices in accomplishing administrative tasks, knowledge management, organisational learning, and information to citizens about public sector activities. The principle of accountability relies on, “improvement in the quality and quantity of performance information [which] opened up possibilities for the utilisation of methods such as benchmarking and examination of performance” (Christensen & 78 Laegreid, 2011:32) also see section 3.2.2.1.1. The principle of efficiency is the commitment of administrators to use scarce state resources in an adequate manner for the achievement of, “objectives of an institution or service” (Dent, Chandler & Barry, 2004:130). For Keita (2014:24) the principle of effectiveness implies that the government is supposed to be lean and purposeful about: • efficiency and effectiveness regarding the functioning of government itself and the production and distribution of goods and service; • the right and adequacy of the government process, concerning the relationship between government and its citizens; and • representation and power checks in relation to the ability of the public to scrutinise the functioning of government. Burger (2005:4) goes further by stating that the competitive environment of NPM often results in a scenario where service providers only focus on required outputs and ignore the importance of the service to be delivered. Burger (2005:3) further adds that NPM assumes that highly professional managers are in total control of their respective business units and that service payers or clients are kept at a safe distance after they have paid their extravagant fees.NPM is described as being a more holistic challenge to traditional administration (Batley & Larbi, 2004:40). Minogue (1988:34) notes that the model should be flexible and able to adapt to different administrative and political contexts meaning that irrespective of the government structure NPM should be able to provide the answer to the various problems faced in the public sector of today. According to Hope (2001:6) in the context of NPM, decentralisation is seen as the means through which governments are able to provide high-quality services that citizens value for; increasing managerial autonomy, particularly by reducing central administrative controls; demanding, measuring, and rewarding both organisational and individual performance; enabling managers to acquire human and technological resources to meet performance targets. (Borins, 1994:58) states that creating a receptiveness to competition and open-mindedness on objectives that should be 79 performed by public servants in contrast to private sector practices empowering citizens through their enhanced public participation in decision-making and development planning and management; improving economic and managerial efficiency or effectiveness, and for enhancing better governance. Tshukudu (2014:2) mentions that decentralisation in relation to NPM is; 1) the transfer or delegation of the legal and political authority to plan; 2) to make public decisions and manage public functions from the central government and its agencies to field organisations; 3) to support subordinate units of government; 4) to provide semi- autonomous public organisations and entities or regional development authorities; and 5) to establish autonomous local governments entities or NGOs. The researcher is of the opinion that democracy, decentralisation, public participation, and public accountability have been considered to be objectives of good governance in NPM. The researcher further utters that for the study NPM plays a crucial role as M&E founding principles are good governance, accountability and reaching performance targets. Decentralisation can also facilitate the administration of societies with cultural, social issues and it could promote national unity by accommodating the demand from diverse groups for political participation and limited self-government. The study covers the local perspective and context of NPM in the next section. 3.3.2. New Public Management in the context of South Africa Jansen (2009:32) states that NPM is not an unfamiliar concept to the South African government. Going back to 1955, one of the main building blocks of our democratic dispensation was the RSA Constitution (1996), was the Freedom Charter. The Freedom Charter was written in 1955 by the African National Congress (ANC) in cooperation with anti-apartheid groups such as the tripartite alliance to express their goals and objectives for a free South Africa. The Freedom Charter document, one of the ten propositions in this document was that “The People Shall Govern” (ANC, 1955). In the State of the Nation Address on 15 February 2005 the former Minister of public service and administration Geraldine Frazer Moleketi explained that under the heading of “The People Shall Govern” (Build People’s Power, 2005), the Freedom Charter asserted, amongst other things, that “all people shall be entitled to take part in the 80 administration of the country” (Frazer Moleketi, 2005:1). The former minister further noted that the needs of the people should give direction to the administration (Frazer Moleketi, 2005:2). Although the honorable former minister did not spell it out clearly, such a statement can be interpreted to imply that the government should be responsive to the needs of the population. Jansen (2009:32) states on the people-centeredness of government by pointing to one of the ten principles of NPM as spelled out by Minogue (1998:18) namely, the need to “steer the ship (control), rather than row it”. As stated by former Minister Frazer Moleketi, the South African government will allow the citizens to actively participate in government decisions in order to guide the government to meet the needs of their citizens. She further quotes Osborne and Gaebler (1993) in saying that business does some things better than government, but government does some things better than business such example are treating people like customers. (Moleketi, 2005:7). It is clear that the former Minister acknowledges the importance of private sector principles in government and vice versa and also acknowledged the fact that NPM and reinvented government have been effective tools in improving the efficiency of the public sector and in reducing costs. In its value statement, the Department of Public Service and Administration (DPSA) states that the establishment of efficient government is aligned with the Constitution (1996) and Batho Pele principles (DPSA, 2007). Notably, the study acknowledges the active role which the DPSA plays towards creating a 21st-century public sector class in South Africa. The DPSA, therefore, ensures that it develops this objective within the macro framework created by the national government. When one refers to the Batho Pele principles such as the ‘value for money’, it is exactly what NPM calls for (Meyer & Theron, 2000). This principle states that public services and goods should be provided economically and efficiently. The DPSA, being the department that oversees government service delivery, this department sets the tone for fellow government departments not to create unnecessary service costs. Furthermore, the DPSA introduced a new management framework for the South African public sector in July 1999, to ensure improved service delivery in the public 81 service departments (DPSA, 2007). This includes, but is not limited to; firstly, continuously auditing the progress achieved by the departments in complying with the dictates of the management framework. This is to ensure compliance with relevant service delivery and performance targets. Continuous auditing will not only prevent possible problems within a department but also ensure that the department keeps in touch with its mission. Minogue (1998:18) goes further by saying that regular auditing may even improve efficiency. Secondly, the new management framework will include a performance management system that is supported by a competency framework. Minogue (1998:18) as well as Pieterse (2002:8) regard a performance management system as one of the important principles of NPM. Minogue (1998:18) argues that NPM focuses on funding the outcome rather than the need. The researcher holds the view that M&E policy as a tool for performance enhancement in the public service (including the ECDoH) shares the sentiment with the above scholar as M&E is linked to performance management which is a principle of NPM. From the preceding aspects of the mentioned DPSA framework, it is vivid how government departments sometimes create the impression that their outcomes are medium to long term, and therefore cannot be measured. It is maybe for this reason that some government officials cannot produce desired or definite results, making their existence questionable by the public meaning there work they are supposed to be doing has no significance in society. With the designing and subsequent introduction of a performance management system, officials and ultimately public departments can be measured on outcomes, provided that the performance management system functions correctly. If the DPSA implies that they want to provide value for money, the public (being the client) does have a right to know how their money was spent to determine whether it was a fair value exchange. However, Gumede and Dipholo (2014:46) assert that in the context of South Africa, bureaucratic red tape is affecting most government departments including the ECDoH. Since the early 1990s, South Africans across the political and professional divide have expressed grave concern about governmental efficiency, effectiveness, and competitiveness in service delivery. With the creation of a single public service after 1994 that resulted from the merging of the four states of the Transkei, 82 Bophuthatswana, Venda, and Ciskei that were established by the apartheid regime for black people and the self-governing territories, government bureaucracy became too large and extraordinarily hierarchical. It is worth noting that South Africa embraced the democratisation process as an impetus for public sector reforms and liberalization of the markets. The rationale for decentralisation is that local government is closer to local communities hence better placed to respond to their needs timely. However, between 1994 and 2010 the South African government has failed to take full advantage of the new wind of change thrust upon by the NPM vibe Gumede and Dipholo (2014:46). Gumede and Dipholo (2014:46) further state that South Africa still suffers from bureaucratic red tape, systemic corruption, inefficiency, ineffectiveness, poor service delivery, poor accountability and nepotism particularly in the award of government tenders to political dynasties of former liberation movements who claim their legitimacy from the liberation struggle. Due to this liberation dynasty disorder, the appointment of senior personnel especially at the level of Director-General, Deputy Director General and even at Chief Director is not based on merit. Thus, in most departments, the whole operational stratum is politically corrupted leading to low productivity as a result of a shortage of skills. This disorder also affects the way procurement is done as exemplified by the recent police buildings saga which led to the withdrawal and removal of the Police Commissioner from the office and the former minister of public works in South Africa (Gumede & Dipholo, 2014:46). Essentially, NPM is a pro-reform management culture that emphasises the centrally of the ‘customer’, as well as public accountability for results. The main objective of implementing NPM in the public service is to achieve more transparency, more efficiency, and more quality as well as reduction of expenses. As a tool of public sector/service reform, NPM consists of several elements. Reformers from all parts of the world can avail all these elements as fundamental tools in transforming the public sector. These elements include the following: • Lean state where there are reduced tasks performed by state; • Separation of decision making levels by separating the strategic and operative level with politics deciding the what and administration how; 83 • Lean management as a combination of various practices such as management by objectives, flat organisational hierarchy, projects management, performance-related payments, modern methods of leadership; • New services attitude of customer orientation with satisfaction in the center of all consideration, behavioral changes; • A new model of control which centers on steering by clear targets, measurement of results, transparency of resources allocation: • Decentralization implying that tasks, responsibility, competence, and budget in the hand of the projects manager or department manager; • Quality management ensures high service quality through qualification, competition, transparency; and • Product approach that describes all administration services as “products” highlighting factors such as features, cost, needed resources, and time to deliver (Gumede & Dipholo, 2014:47). Gumede and Dipholo (2014:47) affirm that it should be noted that these elements of the NPM philosophy shore up or act as pillars of good governance. However, because of the incompetence of the human capital in South Africa, the NPM principles are not implemented objectively. For instance, most senior public servants are inadequately trained or educated and are mostly appointed on the basis of political patronage or along tribal lines, therefore, they are not able or are unwilling to appreciate the core principles of good governance (Gumede & Dipholo, 2014:47). Most liberation activists who obtained communist or socialist education and training during the struggle against apartheid rule dominate the public service, yet many have questionable qualifications and in some extreme cases have none at all (Gumede & Dipholo, 2014:47). Dipholo (2014) states that the government may have many good policies for public sector reform but effective implementation is weak owing largely to the corruption that often results in the employment of unqualified personnel. The emergence of the NPM theory is associated with increasingly popular and intellectual disenchantment with the growth and role of government and increasing taxation and consequently, pressures to curb the expansion of government and shift towards privatisation Larbi (2003:15). 84 Furthermore, Gumede and Dipholo (2014:47) state that it has been argued that the performance reward system in the public sector of South Africa is not geared towards improving performance and as a result there are no incentives for politicians and bureaucrats to fully control costs of government operations at all spheres of government especially after 1994. The consequence of this is deliberate financial waste and over-expenditure because politicians interfere with the system to benefit votes during election time at the local, provincial and national sphere of government. Productivity, efficiency, effectiveness, and competitiveness are not immediate priorities of the public servants in South Africa. The public choice theory contends that public administration is very slow and suffers from lack of greater responsiveness, allocative inefficiency, distributive incapability and weak redistributive efficacy in South Africa which led to the adoption of NPM with its business strategies of improving efficiency. On the other hand, Gumede and Dipholo (2014:47) mention that, the principal-agent theory argues that the general public or citizens (as principals), on whose behalf politicians and bureaucrats (as agents) are supposed to govern, is unable to hold the latter accountable because of challenges such as inter alia, insufficient information (information asymmetry), incompleteness of the contracts of employment and the problems of monitoring behaviour (Larbi, 2003). Also, Gumede and Dipholo (2014:47) the public sector underperforms because state officials pursue their narrow self- interests rather than the public interest. Gumede and Dipholo (2014:47) assert that it is difficult to demand accountability and good performance from the public servants (agents) because of the monopoly of public services for example being the only provider of public services such as public healthcare. There is also some imperfect information about the public services and about the interest of public employees and the huge transaction costs that would be involved in the efforts to write and monitor complete contracts (Larbi, 2003). It is critical to foster competition in the delivery of public services and reduce the monopoly of the traditional government on public services. Larbi (2003) concedes that the result of the above drivers for change is that the role and institutional character of the state has been under increasing pressure to be more market-oriented and management-oriented with the emphasis on doing more with less (Larbi, 2003). The researcher is of the opinion that just like the current study 85 of M&E policy as a tool for performance enhancement in the public service in relation to the ECDoH provides an opportunity in the delivery of public services and is more market-orientated in providing public healthcare. Gumede and Dipholo (2014:48) states that another conjecture which stimulated and propelled the rise of the NPM is what may be termed the colonial independence- globalisation phenomenon which traces the philosophy of public administration in modern-day South Africa back to the pre-democratic era. This perspective contends that colonial apartheid public administration was very rigid, hugely- bloated, and acutely geared towards material exploitation and extraction of resources and creations of colonial markets, with very little interest on improving the quality of life for the colonised. Notably, also, this was achieved mainly through institutionalised autocratic administration. From Anglo-phone Africa, Franco-phone and to Lusophone countries dictatorial administration of the proportions of a police state was common. In particular, apartheid South Africa practiced autocracy based on the Weberian organisation model that has no respect for the NPM principles. Historically, racial segregation did not permit equitable, transparent, effective and competitive allocation and management of public resources such as public healthcare. The urge to adopt NPM principles at independence was apparent with the adoption of the democratic and transparent constitution of South Africa. Therefore, decentralised spheres of government were adopted to help the democratisation of public administration and give South Africa a renewed impetus for good governance. To this effect, the nine robust basic values and principles governing public administration were incorporated in the new Constitution (1996). In addition, the Public Finance Management Act (No. 1 of 1999), the Preferential Procurement Policy Framework Act (No. 5 of 2000), the Preferential Procurement Regulations of 2001and the Municipal Finance Management Act (No. 56 of 2003) are all pieces of legislation which embrace the pro-reform principles of the NPM trajectory reasons being efficiency in the utilisation of government funds . From the colonial apartheid public servants to post- independence civil servants, the need to globalise public services meant accepting the NPM. 86 The scholarship is premised on NPM as a theory of the study, Gumede and Dipholo (2014:48) assert that there global best practice became the brazen buzz word amongst government bureaucrats and consultants. The shift from Reconstruction and Development Program (RDP) to GEAR (Growth Employment and Redistribution) and New Growth Path is a clear sign of the victory of NPM principles in the new democratic South Africa. Given the foregoing, it is clear that the colonial independence globalisation phenomenon has taken the NPM paradigm to novel levels in the history of public administration. In a bid to ameliorate service delivery efficiency, effectiveness, productivity, and competitiveness the post-independence bureaucrats have no choice except to adhere to global best practice which is NPM trajectory. From the preceding discussions on the NPM principles and aims, the study deduces that the use of M&E can drastically resolve the challenges linked to the residue left by the ancient models of public administration such as bureaucracy, red-tape, nepotism, inefficacy, ineffectively and political interference. Succinctly, a well-executed M&E model in the ECDoH can expose malpractices since it’s a timely trace and track on the various interdependent activities undertaken to give effect to the right to public healthcare as enshrined in Section 27 of the Constitution (1996). The next section covers some of the criticism leveled against the NPM paradigm. 3.3.3. Criticism of New Public Management Bao, Wang, Larsen, and Morgan (2012:445) identify three major weaknesses of using private sector business principles associated with NPM to improve the performance of government: • Firstly, there is no common denominator like ‘profit’, ‘market share’ or ‘return on investment’ that can serve as a common comparator across the wide range of public programmes and criteria that count for building trust and legitimacy of citizens in their political institutions. In the same vein, efficiency, effectiveness, and responsiveness to citizens (customers) do not exhaust the legitimating possibilities. In western democratic countries, values like fairness, equity, protection of rights, and transparency play an important role in determining the legitimacy of political institutions, processes, and outcomes. 87 • Secondly, the public sector in all countries around the world comprises increasingly fragmented structures of authority that confound the possibility and even desirability of moving in a straight line from objectives to instrumentally linked performance measures. To this scale of governance is pinned the hopes of better service delivery and private enterprise promotion” with new forms of participation and citizenship (Wescott, 2003:20). • Lastly, NPM tries to use administrative approaches to solve problems that are essentially political in nature (Kettl, 2000; Larsen, 2008). The private market model assumes that consumers are the keepers of their own particular utility functions. But in the public sector, the utility is contested and decided politically. Consequently, one of the chief functions of government is to collect the values of the community and create integrated responses to these values across increasingly fragmented government systems where values are in conflict (Kelly, 1998; Lynn, 1998). Rhodes (2002:218) and Jansen (2009:36) states that NPM is fairly focused on results. The introduction of third-party actors to government creates an interorganisational network, where a single actor is not responsible for an outcome. Public actors may differ on the desired outcome and how to effectively measure performance, and the center (the government) is in no position to enforce any preferences. Eventually, many actors have contributed to the success of an enterprise and a single actor can therefore not be highlighted and not be held accountable after the event. It is again pointed out that NPM may suit line bureaucracies but does not accommodate inter- organisational networks. These networks simply undermine NPM with its specific focus on objectives and results. Pollitt and Bouckaert (2000:174) and Jansen (2009:36) add to the criticism of NPM by saying that NPM may distance political leaders from government problems, for example, public healthcare. Political leaders may refer to the government as if it is an alienated entity and go as far as to blame the government for certain problems. Hence, by inviting third-party public actors to take part in government activities, political 88 leaders may conveniently distance themselves when service delivery is not to the satisfaction of clients. They may use the arrangement as a scapegoat and act as if they are not accountable in any way. Jansen (2009:36) citing Burger (2005:40) criticises the NPM approach for creating fragmentation as a result of a lack of integrated vision. He argues that NPM became so focused on outputs and results that it eventually lost track of the bigger picture. Burger adds that NPM assumes that clients or customers are independent with the right to choose and the ability to pay the less fortunate individuals may, therefore, be marginalised. The study acknowledges the preceding critique on NPM especially that of it creates fragmentation as a result of a lack of integrated vision, NPM may distance political leaders from government problems, and the study of NPM seems to provide the right answers for the right time. Also, the NPM paradigm is ideal for the use of M&E to improve public sector performance due to the wide array of pro-efficiency practices which it uses. This is deduced to be in line with the main research question of how an operational, effective and efficient M&E framework can be designed and implemented in order to encourage the improvement of the performance management of the ECDoH. Evidence of NPM can be found in structures of developing countries such as South Africa. NPM makes use of techniques and strategies commonly known in the private sector and introduces them to the public sector. These techniques include the use of competition, value for money and decentralisation, amongst other things. These techniques were adopted to make the public service more responsive, efficient and affordable. Furthermore, good (public) governance emphasizes on enhancing public sector management to enhance efficiency, effectiveness, economy, productivity, and competitiveness in service delivery. Thus, in good governance prescriptions, public management reforms are a key aspect in the quest for market-based and privatedomain-based paradigms to public sector management, with a flavor called NPM is a label that captures a range of reforms inspired by the idea that private sector management techniques and market mechanisms increase public sector efficiency. NPM type reforms include, for example, quantification, the introduction of performance management systems, the increase in the responsibility of public administrators, the 89 introduction of market mechanisms into the public sector, the introduction of quality management techniques, among others. 3.4. MONITORING AND EVALUATION AND THE THEORETICAL FRAMEWORK De Kool and Van Buuren (2004:173) and Basheka and Byamugisha (2015:77) conceded that the rise of NPM which was constructed around key philosophies that emphasised outputs and outcomes, transparency and accountability, created a growing demand for M&E in Africa. The researcher is of the same opinion as to the above scholars that NPM and M&E emphasise outputs and outcomes. Basheka and Byamugisha (2015:77) note that NPM is characterised by accent on results both in planning and an evaluation of programmes and people, service to the public with a special concern for quality, citizens as clients, delegation of authority as close as possible to the level of action and empowerment of employees, greater attention to cost through comprehensive auditing, contracting out, and introduction of competition, as well as private sector techniques for motivating employees such as merit pay, mission statements and quality assurance circles (Dwivedi & Williams 2011:31). The shift towards more performance measurement and quantification led to an increased interest in measuring the worth of policies, projects, programmes or various interventions. As a result, M&E grew in popularity in developed countries determining how policies, projects, programmes, and interventions were working or not working (Basheka & Byamugisha, 2015:77). According to Siswana (2007:273), M&E of government programmes and systems is beneficial for both the organisation being evaluated and the evaluation entity. The researcher is of the view that M&E policy as a tool for performance enhancement in the public service specifically in the ECDoH gives effect to the attainment of government programmes due to its promotion of trace and track of government programmes. The Public Service Commission (hereafter referred to as the PSC) (2005:58) notes that M&E is a key tool for effective and good governance and provides essential information for the fostering of transparency and accountability. Kusek and Rist (2004:13) argue that at the evaluation stage of most public sector programmes, the fiscal management of the government’s systems could be considered. This means 90 that in ensuring good governance, programme evaluation must inter alia, focus on the financial management of government systems. Performance measures and indicators provide the vital tools for M&E whether or not organisational objectives are realised (Abedian, Strachan & Ajam, 1998:92). Furthermore, Siswana (2007:274) argues that M&E is crucial, especially within the context of the NPM model that has been applied and is still being applied by some countries worldwide, is that South Africa as part of the global village has had a paradigm shift towards pro-NPM reforms. Siswana (2007:274) also states that the said paradigm shift, among others, proposes a managerial, outcomes-focused and value for money-oriented service delivery. Therefore, what is important is an evaluation and monitoring system that is conceptualised or based on the features of the paradigm shift given above, more especially a shift that is based on an outcomes or results model. The researcher is of the view that M&E policy as a tool for performance enhancement in the public service specifically in the ECDoH gives effect to the attainment for value for money-oriented service delivery on tracing and tracking of government programmes. Siswana (2007:274) further argues that the political, economic and social demands require M&E to be outcomes-based or have an impact perspective so that the service delivery framework of a country could be assessed on the basis of whether services to people are delivered appropriately, effectively and efficiently. In the same vein, Kusek and Rist (2003:13) agree that the aim of M&E within good governance and NPM is to determine the relevance and fulfillment of developmental objectives, development efficiency, effectiveness, impact, and sustainability. On the other hand, evaluation gives evidence of why targets and outcomes are not being achieved and causality is central is this particular aspect, that is evaluation (Kusek & Rist, 2004:13). Based on its constitutional mandate, the PSC monitors and evaluates the Public Service; it uses the constitutional values of section 195 as an assessment tool. In order to aid the grounding of the two key central theoretical statements in the M&E practice, the study values the need to present a discussion on the conceptual definitions in the wake of persisting outcry from the public about the continued failure 91 and inefficiency in public service delivery. Zwane (2014:13) asserts that “M&E as a source of check and balance, requires a uniform framework with measurable indicators in both public and private sectors, the utilisation of M&E is comparatively new and there is some variation on exactly what it involves”. As discussed in the preceding chapters of the thesis, the study revolves around the problem of the absence of a working and effective M&E framework in the ECDoH (see section 1.4) (ECDoH, 2014:27) which has led to other subsequent and subsidiary problems as discussed. Zwane (2014) further articulates that M&E is a device that can improve the way in which governments and other public organisations are able to achieve positive results through the use of good governance as a theoretical foundation in the study. This chapter has presented in the preceding sections key arguments related to the practice of good governance and NPM by way of describing each area, in order to show the commonalities and their mutual support of each other. These are further intertwined with the practice of M&E policy as a tool for performance enhancement in the ECDoH, which is only effective if used in a manner which increases transparency by putting credible results in the public sector domain (see section3.2.2.1.1). In such a case, it serves as an accountability function. Also, in order to achieve the accountability objective requires that information is gathered and sustainably utilised towards continuously improving the performance of public entities. Against this background, the chapter now explores the meaning and nature of the concept of M&E in relation to good governance and NPM. Van der Waldt (2004:67) states that monitoring in the public sector/service involves the constant tracking of performance to determine whether or not the achievement of objectives is likely to occur. Naidoo (2011:39) on the other hand asserts that monitoring is seen as a continuous function in the public service that entails the systematic collection of data on specified indicators to provide management in the public sector of an on-going development initiative or intervention with indications of the progress and achievements and on how funds have been allocated. Nel (2005:5) also adopts a more comprehensive view and confirms that monitoring in the public sector/service is the routine checking of information on progress so as to confirm that progress is occurring against the defined direction (see chapter 1 section 1.1). It commonly involves the 92 monthly to quarterly reporting on outputs, activities, and use of resources such as people, time and money. For the World Health Organisation (WHO), 1969:14) evaluation in the public sector/service is a systematic process seeking to determine the extent to which an action or set of actions were successful towards the achieving of pre-determined objectives. WHO (1969:14) further expands that, evaluation in the public sector/service as involving adequacy, effectiveness, and efficiency of public services. Van der Waldt (2004:67) expands on this by indicating that evaluation is an in-depth process of investigation which determines whether or not stated objectives have been reached and the nature of the process undertaken. Kusek and Rist (as cited in European Quality Assurance in Vocational Education and Training, 2012:1) define monitoring as, “a continuing function that uses systematic collection of data on specified indicators to provide management and the main stakeholders of an ongoing development intervention with indications of the extent of progress and achievement of objectives and progress in the use of allocated fund”. In other words, evaluation can be deduced to be a best practice for good governance and can establish an effective government as prescribed by the NPM paradigm. The researcher is of the opinion that the study of M&E policy as a tool for performance enhancement in the public service using of the ECDoH to encourage the best practice of good governance in its establishment of effective governance and public service delivery. For Zwane (2014:19) M&E provides a clear direction of assessing the implementation of a strategy. In doing so, M&E offers significant indicators for a successful review of strategies and suggestions for an effective outcome. Furthermore, it alerts the policymakers with potentially identified challenges that can hamper the process of achieving established outcomes. Above all, M&E offers corrective tactics to overcome identified policy-making and implementation identified challenges. Similarly, Gopane (2012:3) is of the opinion that M&E is an effective tool, which is utilised by developed countries to achieve good governance and effective service delivery. South Africa has also followed a culture of M&E and established the Government-Wide Monitoring and Evaluation System (hereafter referred to as the GWMES). Mention is made thus that; it is critical for M&E systems to be effective. Because with effective systems, the 93 government can detect early warning signs of corruption or any other forms of ineffectiveness. The reality observed in the ECDoH is the absence of a working M&E policy framework. Based on preceding definitions, M&E can thus be considered as a tool that constantly reviews the public institutional policies and programmes, establishes public actions to assess the targets for identifying challenges and provide public strategies for improvement. In light of these definitions, the researcher is of the opinion that public service M&E has various definitional perspectives, but overall M&E functions interdependently towards ensuring that public policy programmes are tracked and traced to allow for the timely correction of variances and deviations (see chapter 1 section 1.1). According to the Presidency (2007:5) in the South African context, M&E has remained complex, multidisciplinary in nature and skills intensive. The South African mainstreaming of M&E is a work in progress as discussed hereafter. Foundationally, the local context of M&E, the GWMES was approved by the Cabinet in 2005. Principally, the GWMES describes three key data terrains which underpin the South African M&E system, namely programme performance information, socioeconomic and demographic statistics as well as policy programme evaluation (Presidency, 2011:2). GWMES hugely relies on input from the three spheres of government that is, national, provincial and local government to provide the information from which the performance of the whole system of government can be monitored and evaluated. Specifically, the GWMES function through the pooling of data and detailed knowledge from public policy programmes, both across and within the spheres of government from the respective frameworks employed in these spheres be it a miniature M&E system or their Performance Management Development Systems (hereafter referred to as the PMDS). The relative applicability and usefulness of M&E as an effective tool for performance enhancement in the South African public service specifically the ECDoH is complicated when government machinery is decentralised, with powers and functions being distributed across the three spheres of government namely national, provincial and local. This decentralised nature of government in South Africa, as established by 94 Chapter 3 of the RSA Constitution (1996), presents a challenge to the use of M&E. Hence the establishment of a uniform M&E framework for the national, provincial and local governments has been the Achilles heel for the government since the inception of the GMWES in 2005. It is precisely this complicated intergovernmental arrangement with dispersed powers and functions that requires strong and effective M&E systems to promote coordination and prevent inefficiencies especially on the provincial and local spheres of government (Naidoo, 2011:23). According to Mkuyana, Skade and Mofolo (2014:6) section 196 of the RSA Constitution (1996) postulate that the issue of M&E is placed in the jurisdiction of the PSC as an independent body, to ensure effective and efficient performance within the public service/sector. This then indicates that the PSC has been making use of M&E since 1996, and the nine basic values and principles of public administration, which are enshrined in the Constitution (1996), have been in operation for nearly two decades (PSC, 2012:5). The PSC, in its mandated quest for good governance, “is empowered to investigate, monitor and evaluate the public organisation, administration and personnel practices of the public service and to advise national and provincial organs of state, as well as promote a high standard of professional ethics” (PSC, 2007:2). In fulfilling such an obligation, the PSC annually investigates the compliance of Public Service entities and departments with the nine principles for public administration as outlined in Section 195 (1) of the Constitution (1996). Public sector M&E is but one part of instilling a performance culture and ethos in the public service. On the other hand, public entities and organisations in South Africa are guided by the Batho Pele principles. In this regard thus, the study deduces that best practice for M&E become the much-needed boast which can significantly help the public sector/service (including the ECDoH) achieve its socio-economic development aims in a sustainable manner. Also, when contextualised within good governance and NPM, the practice of M&E becomes the enabler to the creation of an effective government that executes its mandate guided by benchmarks such as inter alia, public accountability, transparency, and public participation. 95 3.5. CONCLUSION Detailed in this chapter is a discussion on the two theoretical foundations of the study, namely good governance and the paradigm of NPM. The chapter unpacked both theoretical statements through an exposition of the definitions, key features and implications to the use of M&E to improve public sector performance in the South African public service with specific reference to the ECDoH. Through the synthesis of the discussion in the various sections such as (3.2, 3.2.2.1) of the current chapter, it was revealed that good governance, NPM, and M&E can collectively achieve effective government in the wake of the need to sustainably improve living standards through public healthcare provision in the Eastern Cape Province. In addition, the chapter in section 3.2.2.1 gave a discussion of the features of good governance such as public participation, transparency, and public accountability. With the ECDoH facing challenges with the optimisation of public service delivery, the two theoretical foundations namely governance and NPM are instrumental in the development of a model for best practices for M&E. This comes from the background of the inability of the GWMES to serve as a universal approach towards the consistent trace and track of public policy implementation in the entire system of government. The ECDoH is no exception to this reality. Hence the need to develop a contextually relevant M&E model that speaks to the unique circumstances of the Eastern Cape Province (see chapter 8 section 8.2). Although there is serious criticism of NPM by other scholars it does not defeat the purpose of good governance being solidly linked to NPM which emphasises on the constant measurement of outputs as a way of creating an effective government, a principle that has eventually crystallised into renowned modern-day M&E. Hence, the attainment of economic, effective and efficient government in the ECDoH and the South African public sector at large depends hugely on the ability of the developing of various tailor-made M&E models which gives effect to the achievement of a better life for all in the new South Africa. The next chapter of the study offers themes emerging from M&E giving effect to the utilisation of M&E for improved public sector efficiency in the particular context of the ECDoH. 96 CHAPTER FOUR THEMES EMERGING IN MONITORING AND EVALUATION 4.1. INTRODUCTION There is a broad sum of literature which has investigated the impact that M&E has on the performance of both public and private sector institutions. An exploration of the literature on monitoring and evaluation establishes various themes. There are various arguments and dimensions that the various scholars adapt to describing M&E. In succinct terms, M&E is associated with best practices for the effective government such as good governance, accountability, transparency, and public participation. In order to evaluate and monitor private and public sector policies, a set of performance indicators are needed so that benchmarks are set which would be used in evaluating and assessing performance, especially in the public sector/service. The UNDP (United Nations Development Programme) (2009) defines monitoring as an on-going process by which stakeholders obtain regular feedback on the progress being made towards achieving organisational goals and objectives. This definition makes monitoring more than just about the reviewing of progress made in implementing actions and activities but extends to reviewing progress against the achievement of set goals. Good governance is crucial in the light of ensuring proper allocation and management of public resources, an area that is persistently affected by many challenges in the context of the South African public service/sector. This is important with the view that this study focuses on the ECDoH in the Eastern Cape Province. The study is prudent to mention that the aspects and key tenets of good governance are all key underlying tenets of monitoring and evaluation in return. For efficiency-conscious public organisations, M&E plays an important role in generating information on the implementation and results of a public program or project, but in addition has to assess policy impacts and provide the basis for improved management and decision-making as well as for accountability to various stakeholders in a given public programme or project (Pound et al., 2011). On the contrary, evaluation of public programmes is a rigorous and independent assessment of either completed or on-going public activities to determine the extent to which the related 97 and stated public objectives are achieved and contribute to public decision-making. Similar to monitoring, evaluation can apply to many things including a public activity, public project, public programme, public strategy, public policy, topic, theme, sector/service or public organisation. The key difference between the two is that evaluations are done independently to provide public managers and staff with an objective assessment of whether or not they are on track. It is prudent therefore for the ECDoH to hire external specialists (knowledgeable individuals and/or organisations) to evaluate the department. This function though can be executed by the DPME in the Presidency. The aforementioned public organisation is a ministry or a government department that is solely focused on ensuring that government plans are being implemented and objectives of the current government and administration are met. On another note, public evaluations are more rigorous in their procedures, design, and methodology and generally involve more extensive analysis. Despite the differences, the aims of both monitoring and evaluation are very similar, since they both seek to provide information that can help inform public decisions, improve public performance and achieve public planned results. The ECDoH (2009) report of the integrated support team asserted that its M&E is inadequate this is reiterated in chapter 1 section 1.5 that explores the avenues through which a pragmatic public service M&E model can be developed in order to help the ECDoH improve the delivery of public healthcare services in the Eastern Cape Province. Furthermore, though much time and public resources are invested in data collection these data are not analysed, interpreted or used for public decisionmaking and there is little or no feedback of information from one level to the next. There is a limited link between public financial reviews and public service related data. The two may easily be linked together through public M&E tools but little attention is given to M&E within the ECDoH. Also, the ECDoH (2009) asserts that an appropriate climate of mutual responsibility (rather than blame) is required for successful implementation of an effective M&E programme (also see section 7.3.1.1). This thesis endeavors to understand whether the findings of the ECDoH report of the integrated support team were implemented as far as M&E is concerned since this relates with the objectives of the study (also see section 1.5 and 7.3.1.1). 98 This is further assessed to determine how best the ECDoH can use M&E to enhance its performance (also see chapter 9 section 9.3.1). The thesis now provides discussions of the various themes emerging from M&E in the sections which follow. 4.2. MONITORING AND EVALUATION AS GOOD GOVERNANCE Governance refers to the process of public decision-making and the process by which public decisions are implemented. Good governance is defined as governance that is seen as “good when resources are allocated and managed correctly” to give a greater value for money. Good governance has eight major characteristics. These characteristics include public participatory initiatives, consensus-oriented approach to public decisions, an accountable public authority, transparent governance system, a responsive authority, effective and efficient public service delivery machine, equitable and inclusive democratic public processes and the promotion of rule of law. Key benefits of good governance are that there is a high possibility that public sector/service corruption is minimised, the views of minorities are taken into account and that voices of the most vulnerable in society are heard in the process of public decision-making. Good governance is also responsive to the present and future needs of society. In this regard, it can be deduced that good governance is the panacea of sustainable community development. Motingoe (2012:51) offers a broader perspective of the term “good governance” when stating that “good governance” refers to the way in which the government undertakes its tasks within a democracy and lives up to public participatory and public consultative requirements. Van Rooyen and Naidoo (2006:458) remarks that public good governance includes initiatives to strengthen the institutions of government and civil society with the objective to make government more accountable, open, transparent, democratic, participatory and promoting the rule of law. Gildenhuys and Knipe (2007:291) agree with this assertion by concluding that good governance broadly refers to when government attains its ultimate goal of creating conditions for a good and satisfactory quality of life for each citizen. 99 Figure 2 Linking good governance to M&E [Adapted from Naidoo (2011:20)] Good governance which is an ideal outcome in a world where bad governance is being increasingly regarded as one of the root causes of all public sector/service evil in modern-day societies. When intermittent shortages of medicines both in hospitals and clinics occur which affects many aspects of public health service delivery then one appreciates the need for good governance practices. Figure 4.1 above shows that M&E can be used as a tool to achieve the ideal output (also see section 7.3.1.1). Both good governance and M&E embody transparency and accountability. Zwane (2014) and Naidoo (2011) both argue that public monitoring and evaluation plays a crucial role in promoting public good governance. The terms governance and good governance are being increasingly used within Public Administration discourses and discipline and public development literature. However, good governance is the compound or element that seeks to achieve a people-centered effective public service delivery outcome that is desirable. Public good governance can be used in several contexts; corporate governance, international governance, and national and local public governance. Public governance may be defined as a set of values and principles which promote elements of public transparency and accountability. Nelson (2016:21) quoting Leftwich (1993:46) asserted that there is a mixed bag of interpretations and understandings by scholars of what should be included in the all-inclusive definition of (public) good governance, however, the following are key features: • An efficient public service; • A judicial system that is independent; • A legal framework that is enforceable; 100 • Management and administration that is accountable for public funds and to an independent public auditor; and • Respect for human rights and the law in all spheres of government. In making public governance a reality, the question that arises is what specific use does M&E have in relation to achieving public effectiveness and efficiency?; in other words how can one achieve greater management accountability and promote good governance through M&E? Opponents of public good governance debate may suggest that there is a major difference between the private and public sector and may argue that the nebulous nature of public goods means that it is not measurable, as there is no bottom line. However, public goods can and must be measured, which Smith and Bratton (2001:15) show when they say that the public sector is, “not special, as it uses public resources and must account for it”. Public good governance should, therefore, demonstrate its value-addition and also be subject to the same levels of scrutiny that the corporate sector experiences. Also, with increasing private-public partnerships, the sharp divide between the private and public sector/service has become more blurred and interchangeable, resulting in more demanding expectations from citizens of the governments they elect, and the government benefits they expect. This implies the need for public M&E processes to demonstrate at one level the value added by the government. Public good governance marks a shift from an unaccountable government, operating within an opaque and peculiar bureaucracy. The researcher is of the opinion that based on the above assertions of different authors, it may be contended that the principles of public good governance are key for the effective functioning of the system of public M&E. The same principles are the unchanging, non-negotiable values that underlie a public system (Levin, 2005:3). The principles of public good governance which should assist the public M&E processes include unity in policy-making, efficient and effective public services delivery, and accountability by democratic institutions. 101 4.3. MONITORING AND EVALUATION AS AN ENFORCER OF PUBLIC ACCOUNTABILITY Monitoring and evaluation for enforcing public accountability commonly focus on upward accountability within government institutions or a public funding agency. M&E in the public service/sector is often an obligation to demonstrate that the contracted public work, as well as public expectations towards a given public organisation (such as the ECDoH) by stakeholders, are executed and satisfied in compliance with agreed standards. M&E also involves a process of reporting on results vis-a-vis public plans drawn and implemented. The downward accountability involves making public programmes and plans transparent to the primary stakeholders which are public service/sector clients such as public healthcare awareness to the public. Public performance monitoring helps to establish whether “accountabilities” are met for implementing a public plan. Evaluation helps to assess whether “accountabilities” are met for an expected public programme results. Thus, both public M&E are equally crucial towards ensuring that all stakeholders (mostly public) who have vested interests in the functioning of the ECDoH in relation to this study are kept informed about the on-goings in the public entity. This, in turn, enables the ECDoH institution of interventions timeously as and when required. Possible indicators of downward accountability in the public service (also affecting ECDoH) (see also chapter 7 section 7.3.1.7) include: • Mechanisms to incorporate feedback from all the stakeholders of the organisation; • Clients knowledge of available service providers; • A willingness by patients to pay for services; • Methods including concrete requirements and measures for response to concerns raised by clients; and • Availability of alternative service providers if clients are dissatisfied with the quality of the services they receive (Christoplos, Sandison & Chipeta, 2012:10). Public accountability has to be understood in light of the principal-agent model where a principal delegates authority to an agent (public) to act in the interests (public) and ensures public accountability via public economic and legal incentives and sanctions. 102 However, this understanding is limiting, as it only affords those with formal authority over a public organisation the right to be held to public account. According to Naidoo (2011:127) government departments, as publically funded institutions are subject to various forms of accountability, each of which uses different means to solicit, analyse, report and act upon different types of performance information. The need for the government to demonstrate its commitment to accountability has been widely cited and relates to the interest in the measurement of the state (Fox, 2010). Naidoo (2011:112) further assets that accountability is a key measurement dimension. The primary thrust for accountability comes from the political sphere, and as Taylor and Balloch (2005:261) illustrate gives M&E impetus. Kusek and Rist (2004:15) indicate that apart from evaluation being used for making political decisions, it is also used for making economic decisions. These studies indicate that there is a broad acceptance that M&E plays a key role in ensuring accountability. Ntshakala and Nzimakwe (2013:114) as cited in Nelson (2016:86) further define (public) accountability as the quest for decision-makers in the private, public and community sectors to be held accountable to the general public and institutional stakeholders. Nelson (2016:86) citing Fox (2010:140) conceptualises public accountability based on the following: • The responsibility of government towards the public to achieve the predetermined goals and objectives and to hold accountable; • The commitment required from public officials to accept public responsibility for either action or inaction; and • The understood obligation of the subordinates’ role in the public sector to keep senior managers informed of their execution of duties. Furthermore, Nelson (2016:87) posits that accountability is then the duty of the executing organisation to provide disclosure about the information that impacts on individuals aligned to the executing organisation. Public accountability is influenced by public M&E by making public resources readily available and the ECDoH (as the locus of study) being open to public scrutiny from the community they serve. From the preceding definitions of the good governance principle of public accountability, public 103 M&E can significantly improve on the need for public answerability and responsible public decision-making in the public sector. 4.4. MONITORING AND EVALUATION AS AN ENFORCER OF PUBLIC TRANSPARENCY Public transparency is of importance especially in the context of a principle-agent problem as well as in cases where public officials are custodians of public resources and funds. Citizens must be allowed to review performance metrics and scoreboards and judge how well they are being serviced in the context of this study. This has actually been made easier with the advent of sophisticated tracking and performance management software such as the performance management system. In the past monitoring how well a government was providing public services and goods were either not done at all or just scratched the surface in SA. Bauhr and Grimes (2012:25) asserts that policymakers and researchers (especially in Public Administration) focus increasingly on the importance of government transparency for accountability and good governance in recent times. For Nelson (2016:86) citing Fox (2010) transparency in the public domain related to all public activities and pertaining to public management and administration is critical and should not be observed under the guise of secrecy or confidentiality. In addition, Ntshakala and Nzimakwe (2013:114) explain that transparency in the public domain can be understood as the free flow of information. Therefore, M&E influences the good governance principle of transparency, since all information in the possession of government must be made publically available. Transparency in the public domain is argued for as a necessary condition for better government quality services and goods, greater public accountability and the ability to promote a limited scope for corruption and impunity (Kaufmann et al., 2002; Kurtzman et al., 2004; Stiglitz, 2002). In addition, the concept and phenomenon of transparency in the public domain have been the subject of a number of studies (including Public Administration) in such varying fields and discourses as the negotiation theory (Stasavage, 2004), international security (Florini, 2002) and state or regime effectiveness. However, an agreed upon definition of the concept of transparency is lacking (Relly & Sabharwal, 2009; Florini 2007). Transparency is often conflated with 104 “good governance” more generally which limits its applicability and lead to difficulties in finding good operationalisation of the term (Grigorescu, 2003). The information that M&E programmes and systems generate is critical for raising awareness and promoting debate about the efficiency of public programs and policies. M&E information can empower citizens to hold their government accountable, as long as there are mechanisms in place for the government to use feedback to make changes in budgeting, planning, or efficiency of programmes. The ECDoH needs to take cognisance of this as they daily endeavor to provide quality health care to the people of Eastern Cape Province (see chapter 7 section 7.2). 4.5. PUBLIC PARTICIPATION AND MONITORING AND EVALUATION Growing evidence suggests that client involvement is a key requirement for successful public evaluation practices. The same Involve those who are genuinely interested in finding out whether an M&E system is working or not, facilitates data collection and generates lessons learned (Martin et al, 2011:15). Importantly, “clients” need to be also involved in defining the indicators for such an M&E system. But how do we involve stakeholders in an efficient and effective manner? Pound et al. (2011) argue for mixed evaluation teams of internal and external evaluators, combining the benefits of an “impartial” perspective with increased ownership led by active public participation of internal actors such as communities. Public participation in a public program-level evaluation involves a continuum that ranges from public consultation at key points of public decision making to full public collaboration at all M&E stages. Planning for a sufficient level of public participation and consultation in the public evaluation process should take place at the programming stage since this materially affects the time frame and budget for the same evaluation. Public participation in the evaluation process should also be considered as part of the M&E policy programme, since program-level evaluations are not conducted in isolation, but often build on earlier ones and set expectations for future ones. Ntshakala and Nzimakwe (2013:114) explain that public participation is the expectation that communities will be directly involved in public decision-making within 105 government affairs. Furthermore, Silima and Auriacombe (2013:45) stated that community participation is important for: • Addressing the needs of the community; • Informing the community becomes with the aim of educating such members about government workings; and • Fostering cooperation from the community and relevant stakeholders. Over the years, public participation in the platform used to educate communities and interaction by government departments (including the M&E division of the ECDoH) to ensure their community (and public clients) is/are actively involved in public decisions that directly affect public services and goods delivered to the same community. Public participation also allows opportunities for communities to monitor government departments in delivering public services and goods. The community participation principle will be represented by the functionality of ward committees for instance as an indicator of public participation in relation to M&E. In the end, the involvement of the people or citizens (including public clients) in the monitoring and evaluation of the public policy and programmes of the ECDoH can serve to enhance the department’s performance in the delivery of healthcare services. 4.6. MONITORING AND EVALUATION AS CORPORATE GOVERNANCE Montingoe (2012:47) citing Gildenhuys and Knipe (2007) contend that most constitutions provide for a multi-level government system. Smit and Cronje (1996:62) defined a “system” as a set of interrelated elements functioning as a whole. Gildenhuys and Knipe (2007:6) further emphasise that a multi-level government system means that government institutions of the same type are repeated, for instance, at national, regional and local levels, for example, each is distinctive, interdependent and interrelated. Van der Waldt et al. (2007:17) point to the fact that South Africa opted for a three-layered system, namely, the national, provincial and local spheres of government. Motingoe (2012:47) citing Malan (2005) writes that any democratic constitution envisages a state that supports interaction and cooperation among the three spheres of government on a continuous basis and therefore provides a set of principles to direct the manner and quality of those interactions for example in public 106 health services. The recurring theme in the practice of the system of cooperative government is the pursuit of an integrated and coherent government to achieve the objectives of the state such as providing public healthcare for the public it serves. Chapter 3 of the RSA Constitution (1996) outlines the principles according to which cooperative government and intergovernmental relations must be conducted. In this regard, Section 41(h) of the RSA Constitution (1996) stipulates that cooperation of the three spheres of government must be implemented with the purpose of coordinating activities and supporting one another. In order to have all the conditions for good corporate governance, it is necessary to ensure information integrity and prevent abusive use of all information by all those involved in the internal or external governance system of the companies (Musson & Jordan, 2005). Good corporate governance has five essential elements such as fairness, transparency, accountability, responsibility, and independence. It is important that the organisations reveal their information punctually, adequately accurately and comparable, and it should be easy for stakeholders to access. Keeping these in view supporting tools for providing this information particularly in public decision-making is obviously needed. Thus, e-governance becomes one of the major factors needed in a bid to improve good corporate governance and its controlling mechanisms. For Nelson (2016:86) corporate governance is founded on the various policy documents which include Constitution (1996); White Paper on Transforming the Public Service (Batho Pele White Paper) of 1997; Performance Management Regulations of 2001. According to Visser (2013:2), corporate governance goes beyond public management and that corporate governance is essentially determining if the public service is effective and efficient in its service provision. According to Govender (2011:22) citing Fourie (2009), the aim of corporate governance is to ensure that public organisations within the public sector undertake public accountability and that public activities are conducted according to ethical standards. It must be noted that corporate governance includes the following measures: • Risk management; • Anti-corruption and anti-fraud; and 107 • The effective functioning of an audit committee. Bekker (2009:7) proposes that corporate governance which is effective must include public officials with the necessary knowledge and skills; understand their purpose and role as government officials; work towards achieving the vision and mission of the public service, and report on the government activities in achieving its strategy. Furthermore, Nelson (2016:86) citing Govender (2011) states that corporate governance can be deemed as good firstly when it would enable the public service to operate in an effective and efficient manner and secondly when compliance with relevant statutes is achieved (see also chapter 7 section 7.3.1.2). Thus corporate governance from the preceding arguments are founded on various policy frameworks and legislation, which has seen the development of measures such as risk management; anti-corruption and anti-fraud; and the establishment and functioning of audit committees. In addition, the arguments presented to highlight that, for corporate governance to be effective and efficient, it must go beyond management practices. The purpose of the utilisation of the M&E policy to enhance performance, particularly when the powers and functions of the state are distributed across the three spheres of government, should include the provisioning effective public service delivery. 4.7. EXPANSION OF THE EXISTING BODY OF KNOWLEDGE The thesis generates knowledge in a number of areas. An insight into the relationship between governance as well as M&E is one such potential area. The concepts and terms though the difference is greatly intertwined. M&E can be used to achieve global standards of public service delivery and good governance. The study investigates whether M&E has become a central component of all managerial activity with the use of objective information is the basis for decision making in the ECDoH (see also chapter 7 section 7.3.1.4). The study investigated the application of M&E to all aspects of management, including financial and HR and not only service related data. ECDoH (2009) argued that there needs to be an iterative link between planning, implementation, and monitoring. The thesis seeks to establish whether that iterative link exists (see also chapter 7 section 7.3.1.1). 108 4.8. CONCLUSION Discussed in this chapter are themes emerging from M&E in the context of the study. As details in the various sections, M&E has become an enabler and catalyst for the establishment of good governance, accountability, transparency, corporate government, and people-centered service delivery. The arguments presented in this chapter of the thesis have proposed that, if implemented correctly, M&E can bring about the much-needed change in terms of establishing a bottom-up approach to tailor-making public service delivery, open government systems, establishing greater public value for money and the timely undertaking of public remedial action(s) whenever policy implementation fails to keep track of expected public objectives. As inseparable as they are, the discussed themes are the panacea of public service efficacy. This is particularly important within the context of the study, especially given the relative vitality of healthcare public service delivery to the people of the Eastern Cape Province as envisaged and delivered by the ECDoH. The next Chapter focusses on linking M&E with performance management. 109 CHAPTER FIVE LINKING MONITORING AND EVALUATION WITH PERFORMANCE MANAGEMENT IN SOUTH AFRICA What gets measured gets done. If you do not measure results, you cannot tell success from failure. If you cannot see success, you cannot reward it. If you cannot reward success, you are probably rewarding failure. If you cannot see success, you cannot learn from it. If you cannot recognise failure, you cannot correct it. If you can demonstrate results, you can win public support (Osborne & Gaebler, 1992). 5.1. INTRODUCTION The thrust of the study centers on the need to utilise M&E both as an accelerator and catalyst for improved public service efficiency and effectiveness in relation to ECDoH. In recent times, the South African government has become under immense pressure to address the development needs of its citizens. This has to be executed in an open and citizen-centered manner. In the wake of the need to ensure that M&E improves such delivery of public services to the populace, the aim of this chapter of the thesis is to offer the solid connection between performance management and M&E, enablers that have become critical to the success of public service delivery in the 21st century. Challenges such as inadequate delivery of public services including water, health, sanitation, refuse removal and housing, an additional challenge exists in the need to demonstrate that public policy and developmental programmes are achieving desired results (Montingoe, 2012:71). Furthermore, the current state of public affairs reflects little knowledge about how well public programmes are able to sustain the delivery of public services over time and even less about the extent to which they produce their intended impacts. A multifarious look at the meaning of M&E is now provided as follows. For Nelson (2016:47) the concept of M&E has been popularised and used by public servants within the South African public sector/service towards the transformation of the government institutions within the state. The Government-Wide Monitoring and Evaluation System (GWMES), the Constitution of South Africa (1996), and various public service and public finance related statues and policy blueprints such as the (GWMES) provide for the foundation for public sector M&E in South Africa (Nelson, 2016:47). The said frameworks provide an integrated guide, define the boundaries of M&E, state its principles and define M&E practices and standards for use throughout the public sector. The most recent attempt at a cohesive framework was the 110 promulgation of the National Evaluation Policy Framework (NEPF) in 2011. The result has been the government institutions within the state aligning all available public resources to achieve numerous goals through M&E. Zwane (2014:31) regards M&E as a source of checks and balances which require a uniform framework with measurable indicators in both the public and private sectors. Zwane (2014) further posits that the use of M&E is comparatively new in the public service/sector as there is some variation on exactly what it involves. In addition, dissimilar philosophical and conceptual approaches can lead to confusion, so it is very important to standardise concepts and approaches in order to enhance public service delivery. Furthermore, Zwane (2014:31) observes that the role of the government within a state is inevitably changing over time and it is now vividly clear that good government measures are required to achieve sustainable development. States are under substantial pressure to meet challenges of the global economy while sustainably seeking social, economic and technological equality in the process of enhancing good governance in democratic systems. Thus, M&E is a stratagem that can improve the way in which governments and other organisations (national and/or global) are able to achieve positive results. The researcher is of the opinion that M&E can provide lasting solutions to the problem of access to public quality healthcare services in the Eastern Cape Province by way of tracking and tracing the areas such as human capital deployment in rural areas, infrastructural development and budgetary support for instance. Public healthcare policies can improve through the elimination of obstacles to access to quality public healthcare services like providing more budgetary commitments to healthcare in the Province. On the other hand, Gorgen and Kusek (2009:2) and Nelson (2016) argue that M&E addresses the accountability fears of stakeholders because it gives public sector/service officials information on progress in achieving specific public goals and provides findings for any corrections in public policies, programmes or projects. Mackay (2007:17) holds the view that the system of M&E is utilised to measure the quantity, quality, and targeting of public service delivery that government provides, as well as to measure the outcomes and impacts resulting from these and other related outputs. This is connected to Kusek and Rist’s (2004:1) understanding of the concept, 111 which brings in the aspect that M&E is a powerful public management tool that can be used to improve the manner in which government and developmental organisations can achieve results as they also need good performance feedback systems. Hence from the preceding postulations and arguments, M&E helps in a general sense, to improve performance and achieve results. More precisely, it is viewed as the measuring and assessing of public performance towards effectively managing the outcomes and outputs that are collectively known as development results. Performance would be progress towards and achievement of set goals and targets (United Nations Development Programme (UNDP), 2002:5). The researcher is of a panache view that M&E enables the effective implementation of performance management which improves individual and organisational productivity through periodic trace and track of the relevant performance (also see chapter 7 section 7.3.1.1). Due to their inseparability as argued in this thesis, M&E is solidly linked to an equally crucial practice of public performance management. Performance management (in the public sector/service) uses performance information to manage public organisational capacity and processes, for example, to review public programmes, assesses and revises public policy objectives, check progress against targets, conduct public employee evaluations and formulate as well as justify public budgets (Zwane, 2014:42). The researcher is of the view that M&E enables the effective implementation of public performance management which improves individual and public organisational productivity through periodic trace and track of the relevant performance specifically in the ECDoH. Performance measurement in government is required as a management tool to clarify public goals, document the contribution toward achieving those goals and the benefits received from the investment in each programme. M&E helps public organisations in a general sense, to improve performance and achieve results. More precisely, it can be described as the measurement and assessment of performance to improve the attainment of public policy outcomes collectively known as development results. In actual fact, any performance would be perceived as progress towards the achievement of set goals of targets (UNDP, 2002:5). Zwane (2014:40) also puts it differently, M&E 112 focuses on assessing the contributions of various factors to a given development outcome. These factors could include inter alia, outputs, partnerships, public policy advice and dialogue, public advocacy and brokering or coordination of public programmes (UNDP, 2002:5). Based on the preceding arguments and discussion, it can be stated that the key issues in M&E include the establishment of a business plan of a public organisation emphasising the desired vision and mission of that public organisation. As a result of a merger between the practices of monitoring and evaluation, M&E is further discussed in this chapter in the coming discussions (see section 5.2). The monitoring process sets the performance targets aligned to a given public organisational strategic plans, vision and mission including the ECDoH. The key performance areas are benchmarks to measure performance. The evaluation process thereafter confirms the availability of resources (financial and human resources) required for the achievement of set targets (also see chapter 7 section 7.3.1.1). This brings the study to a deduction that M&E is a management device to manage policies and programmes of an institution, in line with the writing of Zwane (2014:40). The researcher is of the opinion that M&E can provide lasting solutions to the problem of access to quality healthcare in the Eastern Cape Province by way of tracking and tracing set targets (also see chapter 7 section 7.3.1.1). In conducting M&E efforts, the specific areas of consideration depending on the actual intervention and its stated outcomes. Areas and examples of questions include, as discussed by Sera and Beaudry (2007:23) and Zwane (2014:40). These are listed and explained as follows: • Relevance: Do the objectives match the problems or needs that are being addressed? • Efficiency: Is the project delivered in a timely and cost-effective manner? • Effectiveness: To what extent does the intervention achieve its objectives? • Impact: What were the outcomes of the project? This may include intended and unintended positive and negative effects. • Sustainability: Are there lasting benefits after the intervention is completed? 113 The researcher is of the opinion that based on the preceding examples, it can be stated that the key issues in M&E include the business plan of any public organisation (such as the ECDoH as discussed in this thesis) emphasising the established vision and mission. Thus, the monitoring process sets performance targets to enable the achievements that are aligned with the public organisational strategic plan. The key performance areas and key performance indicators are the benchmarks to measure performance. The evaluation process thereafter confirms that the availability of resources (financial and human resources) required for the achievement of set targets. M&E is a management device to manage policies and programmes of an institution such as the ECDoH (also see chapter 7 section 7.3.1.1). According to Nelson (2016:23), it is important to note that within the South African public sector/service, the first official government-centered policy document with regard to M&E efforts was the GWMES policy framework. The aim of this GWMES policy framework was to encourage a public management system within the public sector/service that supports and drives related management processes and activities including planning, budgeting and reporting systems (Presidency, 2007:80). In addition to the preceding reality, part of the rationale for this policy framework was and still is to improve governance through transparency, accountability, participation, and inclusion (Presidency, 2007:7). The NEPF is also aimed at improving effectiveness and impact of government by reflecting on what is and is not working and revising its public programmes and policies accordingly which further contributes to the guidelines for M&E in the public sector/service (DPME 2011:1). In this instance, it is against this background that this chapter explores the meaning, relationship, and nature of M&E and performance management and the related significance to the South African public sector/service with reference to the ECDoH. Furthermore, the chapter analyses how the GWMES policy framework introduced in 2007 became a game-changer with reference to the functionality of the local public service/sector, and in turn, as it relates to the ECDoH. The following section gives a discussion of M&E in the context of South Africa. 114 5.2. MONITORING AND EVALUATION IN THE SOUTH AFRICAN CONTEXT This study purposefully utilises the phrase M&E, in contrast to just monitoring or evaluation (also see chapter 1 section 1.1). This declaration is about the interrelatedness between them, whilst distinct at one level, are in fact necessary for a general understanding. The researcher is of the notion that if these terms are separated in their usage they might not convey the exact meaning that is essential for the study being undertaken, the researcher thus combines these concepts to reveal the meaning and implications to the functionality of the South African public service. The study now quotes a scholar, who had bold words towards the utilisation of M&E in improving the public service. In South Africa, there have been several high-level political pronouncements supporting monitoring and evaluation, and internationally the relationship between monitoring and evaluation and development has helped to put monitoring and evaluation in the forefront, as being more than a tool but also helping to concretely address development issues (Naidoo, 2011: 51). From the above excerpt, it means that M&E has been reinforced at different levels and has become accepted countrywide as being compatible within the context of the daily political, administrative and social terrain as a useful tool to promote sustainable development and performance enhancement in the case of the ECDoH (also see chapter 7 section 7.3.1.2). The pronounced nature of M&E in South Africa results from its use not only to assist public sector management but also to support the transformation agenda of the developmental state. Given the history tainted by the disparities of apartheid, M&E can significantly strengthen democracy by promoting numerous activities that lead to greater transparency and accountability of government and its operations (Naidoo, 2011:53). In this regard, The Presidency (2007:7) noted that the government’s major challenge is to become more effective in the conceptualisation and implementation of the M&E imperatives. Thus, M&E processes can assist the public sector in evaluating its performance and identifying the factors that contribute to its service delivery. 115 Naidoo (2011:39) mentions as plausible the definition of M&E by the Organisation for Economic Cooperation and Development (OECD) which conceptualises it in a manner that has seen most organisations and development practitioners adapt and use the definition as quoted in the following excerpt. Monitoring is seen as a continuous function that uses a systematic collection of data on specified indicators to provide management and main stakeholders of an ongoing development intervention with indications of the extent of progress and achievement of objectives. Evaluation is the systematic and objective assessment of an on-going or completed project, programme or policy, the aim is to determine the relevance and fulfillment of objectives, development efficiency, effectiveness, impact, and sustainability, it should involve incorporation of lessons learned into the decision-making process, it also relates to the worth or significance of an activity, policy or programme (OECD, 2002:27). In a bid to bring further clarity on this noble practice, Naidoo (2011:39) assets that the ‘M’ is interrelated to the ‘E’. Thus monitoring, whilst seen as an on-going management function, and evaluation as the post-event function, which feeds information back to management for the next event, is a simplistic analysis and distinction. In undertaking monitoring, one is evaluating as one is making a judgment about progress and intervening on the basis of this judgment. Similarly, when one undertakes an evaluation, one does so on the basis of monitoring data. From the preceding excerpt and discussion, M&E henceforth provides a clear direction of assessing the implementation of a strategy. M&E offers significant indicators for a successful review of strategies and suggestions for effective attainment of socio- economic developmental outcomes. It alerts policymakers with potentially identified challenges that can hamper the process of achieving the established outcome (also see chapter 7 section 7.3.1.1). Above all M&E offers corrective tactics to overcome the identified challenges (Zwane, 2014:37). The practice of M&E has taken center stage globally as discussed in the following sentences. Zwane (2014:39) states that an international review shows that globally M&E was reformed to enhance the capacity 116 of governments. In 1993 The United States of America (USA) passed the Government Performance and Results Act (GPRA) that emphasised on great apprehensions regarding good government elements which include transparency, accountability, and performance of government departments. Therefore, M&E is a vital function of management in any development programme and in any organisation. The process should begin as early as the planning stage of the particular policy programme or project. M&E systems are particularly crucial in the state or public programmes at all three levels of government that are aimed at addressing widespread social and economic problems such as public healthcare. In South Africa, these socio-economic issues also incorporate unemployment, poverty, and inequality. Khan (2003:45) and Zwane (2014:39) explains that a combination of macro- and micro interventions call for a comprehensive multi-level M&E system to ensure an effective policy implementation, efficient delivery of services with intended outcomes and sustainability any policy programme. These envisaged public programme benefits must be provided to all the relevant communities and lead to the envisaged changes and improvements to the wellbeing of these communities. There has also been a growing trend of M&E being a precondition of public funding and donor aid in recent times. Shapiro (2010:5) elaborates on this by explaining that in some public organisations, M&E is considered a donor requirement rather than a management tool and adds that donors (business entities, sponsors, civic organisations and private sector stakeholders) are certainly entitled to know whether their money is being properly spent and whether it is being well spent. However, the use of M&E should primarily be about ensuring the smooth running of the organisation or project itself and to establish whether these are meeting original goals. In other words, is it working efficiently and how can it be sustainably improved? If so, how can variances be timeously addressed to get the best value for money and quality service delivery? Naidoo (2011:30) argues that in South Africa the thrust for M&E stems from several critical events at the political, administrative and civic level. At the highest political level pronouncements for strong M&E and performance management have been made by former President Thabo Mbeki in the State of the Nation Addresses for 2004, 2005 and 2006. The citing of the PSC in the 2008 address has underscored the importance 117 of this M&E practice. The implementation of the GWMES, driven from the Presidency has also been important in this regard (Naidoo, 2011:30). The profiling of numerous M&E findings by the PSC has placed critical evaluation findings in the public domain and is evidence of the PSC exercising its constitutional mandate. Collectively, there now appears to be a critical mass of M&E supporters to keep performance issues on the public agenda. This has probably and inevitably raised public consciousness about the importance and power of M&E to hold government accountable with specific reference to the ECDoH. Naidoo (2011:30) further writes that the growth of M&E in South Africa has taken on a particular emphasis as it is seen as critical to supporting transformation. This has meant that more emphasis has been on accountability (short term) than supporting organisational learning (long term). In advanced democracies like the USA where administrative fundamentals have been established, there has been more space to focus on methodological rigor and emphasise organisational learning. This is not a problem per se and should be where M&E eventually evolves to in South Africa. The current emphasis on utilising M&E to entrench accountability and transparency is needed to support public sector reforms and instill a professional performance culture (Naidoo, 2011:30) see chapter 7 section 7.3.1.7. Nelson (2016:47) on the other hand states that the concept and practice of M&E have become popular and is increasingly being used by public servants within the South African public sector towards the transformation of the democratic developmental state. As identified in the preceding section, GWMES, the RSA Constitution (1996) and various public service and public finance-related legislation provide the foundation for public sector M&E locally. The South African conceptualisation of the term ‘monitoring and evaluation’ according to the PSC is the following: Evaluation is understood as a process of comparison between what occurred and what was expected while monitoring is understood as the continuous checking of progress towards the achievement of a particular objective (PSC, 2008:11). 118 Nelson (2016:47) states that the PSC conceptualisation provided offers scholars an opportunity to factually deduce that the PSC understands M&E as a practice that can help provide a clear understanding of the causes of good and poor performance within government institutions. This is further supported by the strong legislative foundation including the RSA Constitution (1996), the White Paper on Transforming Public Service Delivery (Batho Pele White Paper, 1997) and most recently, the NEPF (2011). In substantiation, Nelson (2016:47) citing Mouton (2010) argues that, the implementation of M&E and the results-based approach begun as a slow process that only gained momentum due to the adoption of the Millennium Development Goals (MDGs) in 2000, which was an international effort towards alleviating poverty and promoting socio-economic development. In addition, Mouton (2010:133) states that M&E in the South African public sector/service has been applied in the following examples. • State bodies at the national and provincial level which have had M&E units established for example the department of performance monitoring and evaluation. • Employees within the public sector have been appointed and tasked with being responsible for M&E such as Minister Nkosazana Dlamini Zuma. • The establishment of the National Planning Commission and the subsequent DPME. • The introduction of the outcomes approaches, which involves twelve specific outcomes areas with accompanying evaluation studies. According to Stolyarenko (2014:14) and Nelson (2016:448) the establishment of the DPME at the national sphere of government in the South African context gave it the mandate to ensure inter alia, the development of plans for the outcomes of government institutions and the public monitoring of the same government institutions as well as the evaluation of the implementation of these plans, monitoring the performance of government’s national and provincial departments and municipalities, monitoring frontline service delivery, managing the presidential hotline, implementing the evaluation of the aforementioned plans and processes in conjunction with other government departments and promoting good M&E practices. These various 119 initiatives, highlighted in the preceding argument have ensured that M&E is practically applied within the South African public sector/service at the national and provincial spheres of government. These initiatives also indicate that the government is in the process of reforming its activities so that better service delivery can be experienced. It must be noted that these initiatives ultimately contribute to the availability of information for improved policy and decision-making. Monitoring and evaluation processes can assist the public sector/service in evaluating its performance and identifying factors which contribute to its public service delivery outcomes which are uniquely oriented towards providing users with the ability to draw causal connections between the choices of policy priorities such as public health and education. M&E can also assist in the resourcing of those policy objectives, and the designing of policy implementation action plans, auditing of the public services that are actually delivered and their ultimate impact on communities. In his 2004 State of the Nation address, the former president Mr. T. Mbeki emphasised the importance of monitoring, evaluation, and reporting in government institutions. He explained that the public sector/service was currently refining the M&E systems in an effort to improve performance and the quality of public outputs. This was aimed at providing an early warning system and a mechanism to respond speedily to problems. President Mbeki said he would necessitate the use of M&E as a tool for the improvement of government’s statistical and information base (PSC, 2008:4) also see chapter 7 section 7.3.1.1. The former president‘s statement indicates the government’s commitment to carry out its obligations and there has since been an increased focus on monitoring and evaluation in South Africa. To date, in South Africa, several departments including the ECDoH are improving their capacity for M&E by contextually developing monitoring and evaluation systems (PSC, 2008:4). Within the local public service, until 2005, only individual staff performance evaluations were institutionalised which were quite regularly and systematically carried out (also see chapter 7 section 7.3.1.1). Policy programme monitoring and evaluation, however, was not undertaken, managed and coordinated systematically in the public service till date. These activities were only undertaken sporadically by line function departments for purposes of their annual departmental reports and some government 120 departments were more rigorous than others in this process. The PSC monitored and evaluated the government’s adherence to a restricted number of principles of good governance such as public participation (Cloete, 2009:6). A role that it can still play, in the era of intensified M&E best practices for improved public service delivery. The cabinet, therefore, decided to hugely improve on M&E mechanisms for numerous reasons (Cloete, 2009:298), Firstly, there is a need for regular national government report-backs to the MDGs on the progress with halving poverty in South Africa by 2014 (UNDP 2003). The fact that South Africa hosted the World Summit on Sustainable Development in 2002 and at the time had no working national M&E system to assess sustainable development as required by the Rio Convention of 1992, was a major reason for the institutional improvements in this area. This need was reiterated at the 2002 Johannesburg Summit where South Africa was again the host country. Secondly, the undertaking by the South African president Thabo Mbeki to inform citizens on a regular basis of progress made with the government‘s national programme of action (POA) was another stimuli to improve on M&E systems (info.gov.za, 2016:2). Thirdly, donors and funders increasingly require systematic M&E of government projects and programmes that they fund. Lastly, the institutionalising of national M&E systems have for the reasons summarised in the previous section 5.1 in this Chapter, proved to be international good governance practice. In order to resolve public sector/service-related challenges such as skills shortage, the need for good governance and improved public service delivery the GWMES framework has been established in 2005. According to Zwane (2014:56), the formation of the GWMES in South Africa in 2005 was a major innovation and one which led to improved governance in the country. The GWMES provided a coordinated framework for the systematic M&E activities that will be institutionalised in the future as one of the major components of South Africa‘s public administration and management processes in the public sector. Cloete (2009:18) comments on the rolling out of M&E as follows. These developments are in line with international good governance processes and have interesting potential for improving the quality of governmental decision and implementation outcomes and impacts in this country. 121 As a gradually crystallising system, the GWMES has risen to prominence in recent times, and it has proven to be a good way of fostering transparency and accountability in the public service. The following are the principles that underpin the GWMES, as adapted from Nieuwenhuyzen (2012:10): • It is rights-based; • It is characterised by enhanced governance, transparency, accountability, participation, and inclusion; • It is development-oriented, in that it is pro-poor, has a service delivery, learning, and impact awareness focus; • It was undertaken ethically and with integrity, based on confidentiality, respect, fair reporting; • It is utilisation-oriented since it defines and meets expectations and supports utilisation; • It is methodologically sound in having consistent indicators, evidence-based findings, appropriate methodology and triangulation; and • It is operationally effective, being planned, scoped, managed, cost-effective, and systematic. For Nieuwenhuyzen (2012:12) the implementation of GWMES strives to meet the various goals which include improved quality of performance information, improved monitoring of all outcomes and positive or negative impacts, sectoral and thematic evaluation, improved M&E of a wide variety of national outcomes, improved project performance and above all, it aims to foster a culture of sound governance. By way of summary, the objective of the GWMES is to provide an integrated, encompassing framework of M&E principles, practices and standards which should be implemented at all levels of government. It should function as a comprehensive information system for good governance (Ijeoma, 2010:17) also see section 7.3.1.2. Discussed in the following section are the objectives of the GWMES, a practice that has gradually reshaped government functionally in post-apartheid South Africa. 122 5.2.1. Objectives of GWMES The policy framework for the GWMES (2007) is the main policy document for M&E in South Africa. It outlines the objectives of the GWMES on various fronts as discussed here. Firstly, improving quality of performance information and analysis at programme level within state departments and municipalities (inputs, outputs and outcomes); secondly, improving M&E of outcomes and impact across the whole of government; thirdly, improving sectoral and thematic evaluation reports; fourthly, improving M&E of provincial outcomes and impact in relation to Provincial Growth and Development Plans; fifthly improving M&E performance in selected institutions across government; and lastly building capacity for M&E and foster a culture of governance and decision- making which responds to M&E findings (Presidency, 2007:7) also see section 7.3.1.2 in chapter 7. Additionally, the GWMES aims to facilitate all the stages of a policy or project success, namely adoption, design, implementation, and evaluation, to ensure that service delivery is effective and meeting the needs of the people (Presidency, 2007:5). The NEPF (2011) states that periodic evaluations should be conducted in the public service/sector in a bid to improve the performance of government institutions as well as the accountability of the same. Furthermore, periodic evaluations referred to above generate knowledge and are designed and implemented for sound decision-making for public service interventions (Presidency, 2011:2). In conducting credible and quality evaluations in the public sector/service government institutions would be able to plan policies and allocate budgets, reduce unwanted results of policy and strengthen the culture of using evidence to improve performance (Presidency, 2011:2) also see section 7.3.1.1 in chapter 7. In the same vein, the NEPF (2011) suggests that state or public service departments ought to undertake quality evaluations, implementation evaluation recommendations, design evaluation and economic evaluation methods and techniques (Presidency, 2011:8). In this regard, therefore, the GWMES strives to ensure that the policies, POAs, and resourcing of public services remain on the right track to ensure that variances are addressed in time before they detrimentally harm the noble cause of improving standards of living in modern day South Africa. 123 5.2.2. Processes of the GMWES Discussed in this section are the various processes which have made the GWMES a gradual success story in South Africa. Foremost, the development of the South African Statistical Quality Assessment Framework (SASQAF) seeks to enhance and extend transparency in data evaluation as applied in the public sector/service (Statistics South Africa (StatsSA, 2008: i)). The SASQAF provides the framework and criteria used for evaluating and certifying statistics produced by government departments and other organs of state and by NGOs (StatsSA, 2008:1). Thus Statistics South Africa (plays an authentication role to avoid feeding half-baked statistics to the public. SASQAF outlines the data collection processes involved when collecting M&E information. The framework provides standardised norms and processes that collectively aim to promote quality information across the public sector (Presidency, 2007:9). StatsSA is the agency responsible for the collection and dissemination of official statistics and has a central role in the evaluation and improvement of data quality (StatsSA, 2008:1). At the national level of government, the GWMES Working Group was established in 2005 by the Presidency to develop the principles and practices; information and reporting needs; and the evaluation practices of the GWMES (Presidency, 2007:17). In addition, there is an M&E Coordinating Forum, as well as a Provincial M&E Forum, were established to develop the implementation plan of the GWMES at a national and provincial level (Presidency, 2008). The role of the Premiers’ offices in the design and implementation of the GWMES policy document (2008:8) states that all government departments must develop M&E systems which should be aligned with the National and Provincial Growth and Development Strategy. Furthermore, “M&E strategies outline how related findings will inform strategic and operational planning, budget formulation, and implementation as well as in-year and annual reporting” (Presidency, 2008:10). The GWMES Policy Framework (2007) defines the various institutional roles and responsibilities related to M&E of national and provincial departments. Executive authorities are responsible for using M&E information for accountability and decisionmaking and to report on the performance of their respective institutions. Accounting officers and accounting authorities, including Chief Executive Officers 124 (CEOs) of public entities and Heads of Departments (HODs) in government departments, are responsible for the regularity and quality of M&E. These officials are responsible for the reliability and validity of M&E information and ensuring that M&E issues are addressed without delay. Programme managers, project managers, and other line managers and officials are responsible for developing and maintaining M&E systems by collecting, analysing, verifying and using M&E information. Lastly, M&E units are also responsible for ensuring the implementation of M&E strategies by providing expertise for M&E functions, capacity building and reporting on the M&E strategies (Presidency, 2007: 14). The M&E units should be located in the office of the HOD in the department, to ensure M&E practice and information is taken seriously (Presidency, 2008: 36). The offices of the Premiers’ need to be able to access information already being collected by provincial departments for managing purposes and so that they can focus on analysing the information provided by provincial departments (Presidency, 2008:10) also see chapter 7 section 7.3.1.2. Streamlined reporting of information emphasises the sharing of information and the Premiers’ offices role would shift to the greater analysis of information and reduced emphasis on gathering and reporting information. It can, therefore, be presumed that GWMES is the overarching policy framework for monitoring and evaluation in the South African government. It lays down the policy context for other government support systems such as the Treasury's policy on managing programme performance information, and StatsSA’s Quality Assurance Framework. It is also complemented by the legislative mandates of the various stakeholders that have been tasked with its implementation. Importantly it also guides future implementation initiatives. This GWMES framework is applicable to all spheres of government from national, local to provincial (Presidency, 2007). Hence the GWMES has become an all stakeholder arrangement where various agencies such as the StatsSA have equally vital roles to play towards accurate, timely and reliable reporting as well as track and trace of progress in the public service. 125 In order to further improve M&E locally, the following operational improvements and adjustments as discussed by Cloete (2009) as cited by Zwane (2014:62) must be made as soon as possible to its structure and operation. Foremost, government institutions should adopt as a matter of urgency a coherent and feasible, integrated and holistic national vision guided by the content of an M&E activity. There is a need for a sectoral integration of policy indicators such as M&E should be undertaken to accommodate environmental and sustainability indicators such as health in communities, and to explicitly distinguish the output from outcome and impact indicators. In addition, the roll-out of the system to provincial and local government levels should be fast-tracked and better coordinated within realistic timeframes also see chapter 7 section 7.3.1.2. Furthermore, the capacity of the M&E coordinating unit should be improved to implement improvements on an ongoing basis. There is also a need for effective communication and marketing programmes in government institutions and ought to be implemented for the GWMES. As a matter of critical importance, the internal dissent (difference of opinion) and overlapping M&E mandates among its main stakeholders should be reduced to single-point management responsibility. In the same vein, an organisational culture of network cooperation rather than hierarchical competition should be implemented. Another aspect that needs to be solved is that the GWMES should not be fully controlled by a single agency or hierarchy. It must rely on the co-operation of a number of network stakeholders located across different governmental tiers and spheres for its success. Lastly, GWMES’s complex characteristics should not be forced into a top-down control straightjacket. This will paralyse the system and be to the detriment of its operations and potential. An analysis of the South African M&E system is provided in the section that follows. 5.3. THE SOUTH AFRICAN MONITORING AND EVALUATION SYSTEM The GWMES Policy Framework (2007) with complimentary policy documents such as the Framework for Managing Programme Performance Information, the South African Statistical Quality Framework and the guiding statutes and policies of the local M&E 126 system constitute the main tools for M&E in the South African public service/sector. In addition, the development of the policy documents was followed by the establishment of the DPME in January 2010 which was decided upon by the President of South Africa and the NEPF in 2011. Mouton (2010:101) contends that results-based management that was introduced in the South African public sector/service was regarded as a public management tool that allowed policymakers to review the outcomes and impact of a particular public policy or programme even though in the South African context measuring performance was the norm. Dassah and Uken (2006:711) are of the opinion that the late response of introducing public sector M&E in South Africa is due to the lack of transparency and accountability existing at all spheres of government. However, Stolyarenko (2014:5) highlights that the fundamental moment of the M&E context shifting within the South African public sector/service was observed after the national elections of 2009. The then realities of service delivery protests becoming rife at the municipal level decreased voter support for the ruling party in the 2009 elections and the detrimental results of a 15-year review of government performance were some of the factors that necessitated the shift in the context of M&E in South Africa. The South African government acknowledged weaknesses such as poor education, poor performance results relative to expenditure per capita and frequent quality problems with public service delivery and the persistence of corruption as practical indicators of poor governance. Optimistically, M&E was perceived to offer the potential public value to mitigate the adverse effects of mal-administrative practices and restore public sector efficiency in these trying times. It must be noted that the 4th administration that came to power in 2009, according to Goldman et al (2015:1), viewed M&E as a tool for the improvement of government performance which would address issues around the delivery of public services and goods to the South African citizens. The result was, as noted by Goldman et al (2015:1), a policy decision to create the Ministry in the Presidency for Performance Monitoring and Evaluation in 2009 and the DPME in 2010 which was a defining moment for M&E in South Africa. When analysing the M&E system of the public sector/service in South Africa the institutional stakeholders which Cloete (2006:8) maintains are: 127 • National Treasury responsible for measuring the ‘value for money’ aspects of governmental policy programmes; • Department of Public Service and Administration (DPSA) responsible for staff performance evaluations; • StatsSA responsible for data collection, storage, and quality control; • PSC responsible for interdepartmental evaluations of those few constitutional process principles and publishers of guidelines about M&E in an attempt to synchronise the different perspectives of all the main governmental agencies involved in this venture; • Department of Cooperative and Governance responsible for assessing the policy programme performances of provinces and local authorities; and • National School of Government responsible for the capacity-building through training exercises to improve M&E skills among thousands of officials who will be responsible for the implementation of the system. The South African public sector M&E system is described by Latib and Goldman (2012:165) as having quality systems that encompass an outcome-based approach, frontline service delivery monitoring, management level performance tools, and a national evaluation system. Additionally, the draft Standards of Evaluation Framework (2012) is aimed at encouraging the use of findings, and the consideration of standards with regard to the five stages of evaluation, which include considerations before evaluation, planning the evaluation, the evaluation process, the evaluation findings, and the use of the findings. Currently, the South African M&E system has the various characteristics namely accountability which according to Goldman et al (2015:8); above all, the NEPF (2011) gives clear direction to the system from the beginning. The M&E system has developed very quickly, as it was able to build systematically from previous experience and has maintained strong links to other exponents with a demanddriven approach, stimulating departments to ask for evaluations and to encourage them to use evaluation results. It also works with national departments and provinces. Thus, the M&E system in South Africa is well coordinated although it is still evolving, it has the potential of bringing about much-needed change towards sustainable government 128 efficiency and effectiveness in the ECDoH. M&E if correctly applied, ought to provide public and private sectors with ways to improve service delivery with available resources. The following section covers a discussion of performance management as an equally important aspect of 21st-century public service efficiency. 5.4. PERFORMANCE MANAGEMENT IN THE PUBLIC SERVICE According to Armstrong (1995:429), performance management is a means of getting better results from an institution, teams, and individuals (including the public sector/service) by way of understanding and managing performance within an agreed framework of planned goals, standards and competency requirements. Cardy and Dobbins (1994:2) on the other hand, define performance management in the public service/sector as a formal and systematic process by means of which the jobrelevant strength and weakness of employees are identified, measured, recorded and developed. It is an on-going performance monitoring and evaluation process done in good faith towards getting the best out of employees. It is not as misconceived, a way of finding loopholes to instill punitive measures against poor performance. Although performance management may sound as if it has the same meaning as a performance management system, they are different. A Performance Management System (PMS) is an authoritative framework for managing employee performance that includes a policy framework as well as a guide relating to all aspects and elements in the performance cycle, including performance planning and agreement, performance monitoring, review and control, performance appraisal and moderating and managing the outcome of appraisals (Simeka Management Consulting, 2004:12). To be precise, a PMS gives guidelines on how everything to do with performance management is to be done, from goal setting and deciding how to measure accomplishments in providing regular assessments also see chapter 7 section 7.3.1.1. The study now gives a look at the historical genesis of the important practice of performance management, especially in the wake of its role as a feeder into wide M&E practice. 129 5.4.1. The historical context of performance management According to Jones (2005), performance management has been a necessary part of public organisational life for as long as there have been public organisations. The ancient Egyptians had to ‘encourage’ their workers to build the great pyramids and, unwittingly, they used performance management systems to do so. The Egyptian system revolved around whipping/ physical punishment those workers who did not perform as required, to achieve their goals. This system called slavery worked effectively for them as evidenced by the splendid pyramids that they have built (Furnham, 2004). However, over time, as our understanding of human nature and the environment in which we exist has changed, the importance of managing performance to align individual goals with a common vision has been recognised as being vital to an organisation’s success including government institutions. In this study, the researcher sought to connect M&E and performance management (also see chapter 1 section 1.5). Confusingly the practice of performance management can be used on organisational performance or individual performance meaning how the organisation and employees perform to meet their objectives, and the terms performance measurement and performance management are oftentimes used interchangeably. In this instance performance measurement has been used to describe the “act of measuring the performance” (Radnor & McGuire 2004:246) which is usually at an organisational or business unit level, and performance management is used to mean a system that, “aims to react to the ‘outcome’ measure using it in order to manage the performance” (Radnor & McGuire, 2004:246) which is usually at an individual level. It has been noted that performance measurement as we know it now can be recognised as having started in the mid-1800s with the cost and management accounting profession (Radnor & McGuire, 2004). 5.4.2. Objectives of performance management policies Performance management policies encompass all those aspects of human resource management that are designed to improve the efficiency and effectiveness of both the individual employees and the organisation at large. For Brown and Armstrong (1999) performance management means anything that an organisation (public) does to 130 improve its total performance. These authors postulate that performance management has four key purposes. Foremost, performance management assists organisations (public) in managing both organisations and employee expectations. This is achieved by enabling individuals and the same organisations to clarify the nature of the psychological contract between them (Argyris, 1960; Schein, 1970). Performance management also aims to provide a framework which facilitates the integration of corporate and individual objectives, beginning with communication and integration of the core values and principles of the organisation in relation to the study the ECDoH. Performance management further aims to motivate towards established and clearly communicated expectations, and further provide a developmental process for the organisation (public) by setting vivid guidelines that assist in establishing future needs and outcomes. Normally, performance management policies in public organisations typically involve “the setting of performance objectives, the measurement of performance against these objectives, the identification of developmental support and a review process to develop performance and subsequent objectives” (Brewster, Carey, Dowling, Grobler, Holland & Warnich 2003:261). The performance management policies are a way of providing a measurement of the performance of the organisation (public), the team and the individual(s) through a variety of performance measurement techniques (Price, 2000). Performance management policies depend on performance measurement but have a wider role in evaluating and developing different individuals to encourage improved performance results and assisting in managing for results achievement. Nel, Gerber, van Dyk, Haasbroek, Schultz, Sono, and Werner (2002:516) note that there are three major aims of performance management, which are first, it is a process for strategy implementation, secondly, it is a vehicle for culture change and lastly, it provides input to other human resources systems, such as development and remuneration (also see section 7.3.1.1 in chapter 7). From the synthesis of arguments and definitions in the preceding section, the main purpose of performance management in public organisations or in the public 131 service/sector can be seen to be to enhance the achievements of the concerned public organization and the individual(s) attached to such organizations. Performance management policies are “concerned not only with what is achieved but also with how it is achieved” (Jones (2005) as cited in Price, (2000:177). All effective generic government-related performance management systems have certain specific components in common, without which the system would be ineffective. These are the principal steps that must be implemented to ensure the effective functioning of the system. According to Price (2000:181), “in every case, effective performance management requires an organisation to do three things well: which entails to, define the characteristics of good as opposed to average or bad performance, facilitate employees to perform well by removing obstacles and encourage performance through reward, praise or promotion” (also see section 7.3.1.1 in chapter 7) Similar to fellow organisational management practices, performance management has not been spared equal criticism, as shown in the following discussion. 5.4.3. Criticisms levelled against performance management Brown and Armstrong (1999); Rademan and Vos, (2001); Furnham, (2004); Hazard, (2004); IOMA (2004) have criticised performance management policies in the public service/sector including staff demotivation, unfair application, too subjective, unclear, unethical and very time-consuming. Another noted criticism of performance management policies the public service/sector is that although it might be easy to devise a good performance management in the public service/sector process on paper, the reality of those policies might be vastly different, and it might actually be very difficult to implement (Brown & Armstrong, 1999; Furnham, 2004). Performance appraisals, as part of the performance management policies the public service/sector, can be seen to be time-wasting and having no value as the information received during the appraisals is just filed afterward and not used fully (Alfred & Potter, 1995; Rademan & Vos, 2001) that is, the theory behind the system might be relevant, but in practice it does not work effectively (see chapter 7 section 7.3.1.1). 132 Performance management policies in the public service/sector need to be developed along ethical lines (Rademan & Vos, 2001). Brown and Armstrong (1999) propose an ethical framework that should be considered in the designing of performance management policy in the public service/sector. Items such as, respect for the individual, mutual respect, transparency of decision-making and procedural fairness (Brown & Armstrong, 1999:263) need to be adhered to. The ethical component is very important, particularly given the reliance on the judgment of the appraiser, and the relationship between the appraisee and appraiser. It is an issue that the appraiser comes with their own set of biases, and judgment systems, which affects the outcome of the appraisal. In fact, higher than average ratings can be attributed to factors such as preserving morale, avoiding confrontation, and the perceived image of the management of an underrated department (Price, 2000). Alfred and Potter (1995) similarly noted that a person’s appraisal could be subjective (that is based on the relationship between the person interviewing and the person being interviewed). According to Pettinger (2002:28) issues also arise, “when the appraiser-appraisee relationship is not honest, or if the scheme is known, believed or perceived to be a bureaucratic or some punitive exercise”. According to Pettinger (2002), performance management policies in the public service/sector are implemented for many reasons they are often overburdened with expectations. If the reason for the performance management policy is to reward individuals, then staff will expect their pay to be linked to their performance. Senior staff might be told that the performance management system will enable them to identify and make provision for achievers and underperformers. They will expect that the system is able to assist them in making these identifications. Directors might feel that the performance management policies will improve organisational effectiveness, and will then expect it to do so (also see section 7.3.1.1). Whilst a performance management policy in the public service/sector can do all of these things, the main purpose of the system must be clearly stated and communicated within the organisation. Links to pay, succession planning, organizational strategy and performance and many others (Furnham, 2004) states implementing performance management system must be made clear, but users of 133 these policies must be wary of relying on performance management policies to do everything as systems can become overloaded and then expectations cannot always be met. In spite of the highlighted factors, the fact that performance management policies in the public service/sector are utilised almost universally (Furnham, 2004), there are many and varied criticisms of these systems. Thus, that does not discount PMS to be ineffective or less valuable to organisational success. To give a performance management system in the public service/sector a fair chance of success there must be management buy-in and support from the top management. The system in place must be developed ethically, implemented fairly and accurately and its expectations must be effectively communicated to all concerned. It is necessary to use the information collected and to feedback to staff. The data from these systems can primarily be used for two main purposes either to develop people through training or to evaluate their performance (Fischer, 1997). The performance management policy must clearly reward behaviors and achievements that actually contribute to the improved efficiency and effectiveness of the organisation, thus playing both evaluative and developmental roles. PMSs in the public service/sector must be the “living documents” and must be adaptable, particularly in our turbulent rapidly changing public service/sector environment and with the advent of the knowledge worker (Tobin, 1998). In the wake of public service effectiveness and efficiency, PMSs need to input to M&E and should not be viewed as a way of instituting punitive measures to poor performance. Rather, PMSs should be treated as a window of opportunities and a continuous improvement of basic organizational and individual performance evaluation in good faith. This should be done to avoid hostilities and other demerits of poorly undertaken performance management practices. One example of a PMS method is covered in the following section (also see section 7.3.1.8 in chapter 7). 134 5.4.4. The balanced scorecard approach in performance management Kaplan and Norton (1992) state that the Balanced Scorecard Approach (BSA) is a multi-dimensional approach to performance management, planning, control and decision-making process in the public service/sector that is linked specifically to organisational strategy. The technique was developed by Kaplan and Norton at the Harvard Business School since the early 1990s. The BSA is utilised to indicate a technique which has addressed one or two questions in some detail, but which has also neglected other important questions. The BSA is potentially a powerful tool by which senior public managers can be encouraged to address the fundamental issue of effectively deploying an organisation’s strategic intent in assessing the importance played by M&E policies in governance and performance management policies in ECDoH. (Kaplan and Norton, 1992). BSA literature also indicates that it is as much the process of establishing a scorecard that yields benefit as the resultant measurement schema. Kloot and Martin (1998) argue that in practice, PMS requires the four dimensions of the BSA that is, financial, community or customer, internal business processes; and growth or innovation and learning. The BSA is designed to be the center of an organisation’s performance management planning and control mechanisms to effectively deploy strategy, to link operational practices with strategic intent and facilitate objective performance measurement. However, it cannot stand-alone and its links with more traditional planning and control systems need to be reviewed. The BSA is thus a potentially powerful tool by which senior managers can be encouraged to address the fundamental issue of effectively deploying an organisation’s strategic intent. It focuses on establishing links between strategic objectives and performance measures, it also pays some attention to measuring the achievement of the components of the strategic plan the organisation has espoused (this means that it is believed will lead to the desired ends) also see section 7.3.1.8. 135 5.4.5. The conceptual and regulatory framework for performance management Armstrong (1995) as cited by Munzhedzi & Phago (2014:108) notes that performance management is a means of getting better results from an institution (public), teams and individuals by understanding and managing performance within an agreed framework of planned goals, standards and competency requirements. On another hand, Cardy and Dobbins (1994:2) define performance management as a formal and systematic process by means of which the job-relevant strengths and weaknesses of employees are identified, measured, recorded and developed (Munzhedzi & Phago, 2014:108). Although performance management may sound as if it has the same meaning as a performance management system, they are different. A PMS is an authoritative framework for managing employee performance that includes a policy framework as well as a framework relating to all aspects and elements in the performance cycle, including performance planning and agreement, performance monitoring, review and control, performance appraisal and moderating and correctly managing the outcome of appraisals (Simeka Management Consulting, 2004:12). To be precise, a PMS gives guidelines on how everything to do with performance management is to be done, from goal setting and deciding how to measure accomplishments to providing regular assessments. The necessary element of the PMS entails performance improvement and productivity to ensure effective and efficient public service delivery. According to Van der Waldt (2004) cited by Munzhedzi and Phago (2014:108), it is usually difficult to measure performance improvement and productivity in the public service/sector because the outputs are usually intangible. For example, the general welfare of a given local community, effectiveness and efficiency and the general satisfaction of society in public services provided are not readily measured as usually compared to the private enterprises whose survival and sustainability is based on profit margins. The requirements set for the public service/sector in terms of Section 195 of the RSA Constitution (1996) is that good public human resource management and career development practices to maximise human potential must be cultivated. It is further stated that efficient, economic and effective use of resources must be promoted. 136 Section 195(1) of the RSA Constitution (1996) serves as a reference point guiding the conduct of public officials on several issues including performance in all spheres of government. Van der Waldt and Du Toit (1999:384) also believe that the RSA Constitution (1996), through Section 195, makes provision for the effective performance of administrative functions in this regard. Deductively, therefore, the study argues that the RSA Constitution (1996) is a key founding legal prescript from which the PMS emanates. According to Section 2(1) of the Skills Development Act (No. 97 of 1998), emphasis should be placed on employee development in order to facilitate the good and effective performance of employees in the institution. A skills audit is necessary to determine the gaps between the job requirement and competencies of a particular employee as a requirement of a PMS. This Act makes provision for the development of a Workplace Skills Plan by the employer. According to Coetzee (2002:95), Workplace Skills Plans refer to the strategic human resource training and development aimed at developing a skills capacity, which then helps institutions to achieve their own goals and objectives. A performance management process must be legally bound to avoid unnecessary litigation (Nel, Van Dyk, Haasbroek, Schultz, Sono & Werner, 2004:488). Schedule 8 of the Labour Relations Act (No. 66 of 1995) contains a provision that deals with the incapacities of employees and poor performance. Maila (2006:26) is critical of the Labour Relations Act (No. 66 of 1995) in that it makes it impossible to dismiss an employee when such employee has not reached the set and agreed on performance targets. Furthermore, the Act makes provision for how to manage poor performance by employees without opting for dismissal as a first option. Before any dismissal can be affected, lengthy and remedial measures including an investigation to establish the reasons for poor performance, in the process has to be applied (Munzhedzi & Phago, 2014:108). In the same vein, Part VIII of Chapter 1 of the Public Service Regulations (2001) provides that the executing authority should determine, in consultation with their department, a system that links individual performance to institutional goals. Part III of 137 Chapter 4 in the Public Service Regulations (2001) also states that the performance of all members of Senior Management Services (SMS) should be managed through performance agreements. It is further stipulated in the regulations that a supervisor must monitor, supervise and assess the subordinate’s performance on a regular basis, using the prescribed format of performance assessment within an organisation (Munzhedzi & Phago, 2014:108) also see section 7.3.1.8. Various challenges can inhibit the success of performance management initiatives in organisations as discussed in the sections which follow. 5.4.6. Challenges in the implementation of performance management Makamu and Mello (2014:107) writes that performance management in the public service/sector can be affected if a union is present in the organisation. Some unions support while others oppose the formal performance evaluation of the organisation. Some unions oppose the use of immeasurable, non-production-related factors in performance evaluation. These problems are oftentimes evident mostly in public sector departments. The following are challenges which may affect the implementation of performance management in an organisation. 5.4.6.1. Use of technology Mello et al., (2014:108) states that technology is rapidly changing the ability of the employer to measure where and what their employees say and do as well as the results they produce. On the other hand, technology raises some concerns about the issue of the employee’s privacy and the use of employee information that employers are able to obtain as they monitor their employees. In the private sector, managers can monitor their employees by voice recording and video recording. For example, all the calls may be recorded at a call center and the supervisor has the right to monitor any call any time as part of their functions and responsibilities. However, technology has also made continuous supervision of an employee’s performance by means of computer software (Wayne, 2003:350). 138 5.4.6.2. Performance management feedback and fear to account Mello et al., (2014:108) state that giving employee feedback is never easy. Individuals (workers) do not want either to give or receive negative feedback. Therefore, constructive criticism may come across as an attempt to undermine one’s self-esteem. It is evident in some public service/sector organisations where inexperienced managers are afraid to account and do not allow anyone to rate him or herself below the average of five specifically in the ECDoH. The reason is that such public officials do not want to account for a possible low score since evidence will need to be provided of such a rating. According to Beaumont (1993:83), PMS feedback should not be presented through loaded terms, which produces an emotional reaction and raises defense; also it should refer to the relevant performance, behavior, or outcome but not to the individual as a person. While De Cenzo and Stephen (1994) as cited in Mello et al., (2014:108) state that if feedback, development, and documentation are to function effectively, appraisal must have a performance system that is appropriate for their needs, a system that facilitates giving feedback and development information to the employees which permit employee input. 5.4.6.3. Linking compensation and rewards with performance Mello et al. (2006:205) state that linking compensation with performance is the best way to motivate public sector/service employees to perform at their level best. Unfortunately, the greater the advancement in employee motivation the greater the challenge. This tool has its own challenge associated with merit pay, which is that it increases the public employee’s base pay. Thereafter the public employee receives the additional amount each year and they are placed on the payroll regardless of performance levels (also see section 7.3.1.1). Therefore, it is difficult to justify merit pay increases. While Werner (2011:244) states that compensation comes into play as a way to attract, retain and reward top talent so that they achieve public service/sector goals that can overcome economic slumps. Every public sector /service has three groups. The middle group which is the largest and gets the job done, are those who 139 truly make a difference, and a small percentage at the bottom that is not getting the job done for a variety of reasons. 5.4.6.4. Measuring and evaluating the performance Measuring and evaluating performance is one of the major challenges facing the South African public sector/service. The supervisors and managers in the public service/sector have a major problem when measuring and evaluating performance. The major reason is that most managers or leaders do not have an understanding of performance management in the public service/sector entails. Consequently, it becomes difficult for them to evaluate performance which they are unsure of. Employees in the public organisation have different job descriptions which means that a public manager cannot evaluate employees because all their jobs are completely different Mello et al., (2014:108). Mello et al., (2014:108) agree that measuring and evaluating performance in the public service/sector has its own challenges, for instance, in system design issues, there is no single method or format of performance approaches that are not subject to a limitation, for example, the fact that there are so many different formats of varying complexity from which to choose is a direct result of trying to overcome deficiencies of previously conceived formats. 5.4.6.5. Rater problem According to John and Ivan (1998:34) and Mello et al., (2014:108) performance management appraisal challenges arise even if the system is well designed. A problem can arise if the raters (usually supervisors) are not cooperative and well trained. In such a scenario, the supervisors may not be comfortable with the process of evaluation which often happens if they are inadequately trained or have not participated in the designing of the programme. Inadequate training of raters can lead to challenges in completing performance management evaluation (see section 7.3.1.1 in chapter 7). For example, a manager who is appointed towards the end of the year can create a challenge for both management and employees, because salary increases as usually announced before closure. The new appointee usually does not bother to undergo 140 training so that they can familiarise themselves with the programme or what was the intention of designing such a programme. 5.4.6.6. Organisational fear According to Michael (2008:1) and Mello et al., (2014:108), departments and agencies in the public service/sector are apprehensive about implementing the performance management system due to fear on how the results will be interpreted, what it may indicate about the department’s performance, and or a lack of clarity of how it will affect the department and its employees. The study now gives a compound discussion of M&E together with performance management in the context of the need to utilise these to improve efficiency in the ECDoH. 5.5. LINKING PERFORMANCE MANAGEMENT WITH MONITORING AND EVALUATION Zwane (2014:43) states that performance management uses performance information to manage organisational capacity and processes in the public service/sector. For example, to periodically review programmes, assess and revise objectives, check progress against targets, conduct employee evaluations, and formulate and justify budgets. Performance measurement is needed as a management tool to clarify goals, document the contribution toward achieving those goals, and benefits received from the investment in each programme. For Zwane (2014:43) monitoring is a continuing function that utilises a systematic collection of data on specific indicators to provide the management and the main stakeholders of an ongoing intervention with indications of the extent of achieving set objectives and progress in the use of allocated funds (unodc.org, 2017:2). While evaluation is the systematic and objective assessment of ongoing and or completed projects, programmes or policies, with respect to their design, implementation, results (unodc.org, 2017:2). 141 Zwane (2014:44) deduces that it can be stated that due to the connectedness between performance management, and M&E, a concept of performance-based monitoring and evaluation (PM&E) has emerged. The performance-based M&E is an integration of conventional and modern approaches of checks and balance. Through a conservative approach, the PM&E utilises the implementation element of monitoring complemented with the review-inclined modern evaluation methods. The aim of integration is to assess the progress of policies or programmes phases, rectify, modify and correct the processes, and hence obtain desired favorable outcomes. Zwane (2014:43) states that the concept moreover requires identification of appropriate indicators, explained in sub-sections that follow. 5.5.1. Indicators Nel and Goldman (2005:6) cited in Montingoe (2012:91) conceptualise indicators as the means of knowing that the objective will be achieved. Minnaar (2010:68) concurs with this view and states that indicators help an organisation define and measure progress towards organisational goals. They reflect the success factors of an organisation. This is consistent with the observation of Kusek and Rist (2004:69) that an indicator is a quantitative or qualitative variable that provides a simple and reliable basis for assessing achievements, change or performance. Indicators are clues, signs or markers that measure one aspect of a programme and show how close a programme is to its desired path and outcomes. Van der Waldt (2004:53) strongly confirms this view when arguing that indicators are measures that describe how well a programme in the public service/sector is achieving its objectives. Indicators define the data to be collected, measure progress and enable actual results achieved over time to be compared with planned results. Thus indicators reveal and measure trends (Montingoe 2012:91). The Monitoring, Evaluation and Impact Assessment Policy and Implementation Framework (2010:16) summed-up the scenario by showing that indicators are signals that reveals progress or lack thereof towards objectives. They are a means of measuring what actually happens against what has been planned in terms of quantity, quality, and timeliness. The Framework for Managing Programme Performance Information (2007:7) issued by the National Treasury explains that suitable performance indicators need to be 142 specified to measure performance in relation to inputs, activities, outputs, outcomes, and impacts. The same framework further shows that determining a set of appropriate performance indicators depends on the nature of the institution’s mandate. This means that managers need to be selective when defining performance indicators as that requires careful analysis of what is to be measured. Performance indicators are measures of inputs, processes, outcomes, and impacts for development projects, programmes or strategies (also see section 7.3.1.1). When supported with sound data collection, perhaps involving formal surveys analysis and reporting, indicators enable managers to track progress, demonstrate results, and take corrective action to improve service delivery (World Bank, 2004:6). Performance indicators form the core of any performance monitoring system because they prescribe the type of information that must be collected to measure the level of progress and enable the assessor to compare the actual results achieved with the planned outcomes (USAID, 1996:1). Performance indicators are hence the imperative instruments for rational decision-making processes in the performance management system for measuring the success of organisational policies, plans, programmes, and hence achieving desired results. Zwane (2014:44) states that performance indicators in the public service/sector enable project managers to track project progress, to demonstrate results and, if necessary, to take corrective action to improve the project, a point confirmed by Hunter (2009:24). In the process of selecting performance indicators in the public service/sector, a step- wise approach is required starting from an analysis of the management functions at each level, identifying their information needs according to those functions and deciding on performance indicators that cater to those information needs (Amjad, 2012: 4). This is furthermore confirmed by the Presidency‘s Policy Framework for the GWMES (South African Management Development Institute, 2010:38) which states that a performance indicator is a predetermined signal that a specific point in a process has been reached or result achieved. The nature of the signal will depend on what is being tracked and needs to be very carefully chosen. In management terms, an indicator is a variable that is used 143 to assess the achievement of results in relation to the stated objectives Zwane (2014:45) also see section 7.3.1.1. In addition, Zwane (2014:45) observes that, it is imperative that performance indicators in the public service/sector be selected as programme per se, feasible to achieve, logical in implementation, able to measure and assess the strategies, and must be signed in alignment and achievement of monitoring and evaluation processes. It is equally important to realise that a performance indicator must have practicality in monitoring results. In other words, how easy is it to obtain and analyse data for that particular indicator? Obtaining valid and representative data can be both highly complex and very costly. For example, asking everybody‘s opinion by means of an extensive survey is impractical, it is easier to obtain a smaller but representative sample of respondents. Performance indicators should, therefore, be as simple and few as possible while demonstrating some measure of progress or magnitude of change. It will be difficult to understand or analyse the indicators if they are too complex‖ (UNDP, 2002:69). The seven criteria for assessing performance indicators are covered in the section that follows. 5.5.1.1. Direct A performance indicator should measure as closely as possible the result it is intended to measure. It should not be pegged at a higher or lower level than the result being measured. If using a direct measure is not possible, one or more proxy indicators might be appropriate. For example, sometimes reliable data on the direct measurements are not available at a frequency that is useful to managers, and proxy indicators are needed to provide timely insight on progress. Proxy measures are indirect measures that are linked to the results by one or more assumptions. For example, in rural areas of Africa, it is often difficult to measure income levels directly. Measures such as percentage of village households with roofs (or radios or bicycles) may be useful if somewhat rough proxy. The assumption is that when villagers have the higher income they have a tendency of buying certain goods. If convincing evidence exists that the assumption is sound (for instance, it is based on research or experience somewhere), then the proxy may be an adequate indicator, albeit second best to a direct measure. 144 5.5.1.2. Objective An objective indicator has no ambiguity about what is being measured. That is, there is general agreement over the interpretation of the results. It is both uni-dimensional and operationally precise. Uni-dimensional means that it measures only one phenomenon at a time. Avoid trying to combine too much in one indicator, such as measures of both access and operational precision means no ambiguity over what kind of data would be collected for an indicator. For example, a number of a successful organisation specifically the public service is ambiguous, something like the number of government departments experiencing an annual increase in revenues of at least 5% is operationally precise. 5.5.1.3. Adequate Taken as a group, a performance indicator and its companion indicators should adequately measure the result in question. A frequently asked question is how many indicators should be used to measure any given result. The answer depends on either the complexity of the result being measured or the level of resources available for monitoring performance and the amount of information needed to make reasonably confident decisions. 5.5.1.4. Quantitative, where possible Quantitative performance indicators are numerical in nature such as questionnaires. Qualitative performance indicators are descriptive observations. While quantitative indicators are not necessarily more objective, their numerical precision lends them to more agreement on the interpretation of results data, and are thus usually preferable. However, even when effective quantitative indicators are being used, qualitative indicators can supplement the numbers and percentages with a richness of information that brings programme results to life. 5.5.1.5. Disaggregated, where appropriate Disaggregating a people-level programme by gender, age, location or some other dimension is often imported from a management point of view. Experience shows that development activities often require different approaches for different groups and affect those groups in different ways. Disaggregated data help track whether or not specific groups participate in and benefit from activities intended to include them such 145 as public participation. Therefore, it makes good management sense that performance indicators be sensitive to such differences. 5.5.1.6. Practical An indicator is practical if data can be obtained in a timely way and at a reasonable cost. Managers require data that can be collected frequently enough to inform them of progress and influence decisions. 5.5.1.7. Reliable A final consideration in choosing performance indicators is whether data of sufficiently reliable quality for confident decision-making can be obtained http://www.info.gov.za, (2006:17). 5.6. CONCLUSION Every single programme calls for M&E to measure the performance and assess the effectiveness of the initiative. To meet the desired outcomes, the capacity-building of the monitoring and evaluation system is imperative. A well-structured M&E system is also a source of knowledge capital that enables government entities on all three levels of government to develop a knowledge-base on the type of project, programme, and policies that have the potential to succeed. This will facilitate a platform from which decision-makers are able to assess the outcomes and what still remains to be done to ensure success in providing service delivery. Discussed in this chapter is the linkage between M&E and performance (see section 5.5). As the discussion in the various sections in the preceding synthesis, there exists a solid link between performance management, which acts as a feederprocess into mainstream M&E. The South African public service can reap positive benefits from rolling-out the GWMES to the minutest state institution or entity since it has shown that it is the pinnacle for managing and improving performance. Thus, there is a need to improve and intensify performance management and wider M&E practices in the public sector. This encompasses the ECDoH, a crucial entity that gives effect to the realisation of the healthcare rights of the people. In the end, an effective and efficient government is most likely to lead a citizen-centred service delivery, one that keeps the people satisfied while uplifting their standards of living, which have been dented by discriminatory practices of the pre-1994 social Darwinist government. 146 CHAPTER SIX RESEARCH TECHNIQUES, PROCEDURE, AND METHODS 6.1 INTRODUCTION This chapter seeks to discuss the various research techniques which were used to gather and analyse data in a bid to attain the objectives outlined in section 1.5 of the study. Of particular importance in this chapter is the discussion of the research roadmap followed by the study towards achieving the stated research objectives. The researcher has weighed the merits of the various research paradigms available for social scientists and chose the best fitting design to ensure that there is a match between this and the nature of the study. As a pre-emptive move, the study highlights that since the study is more into the analysis of the feelings, perceptions, behaviors, and thoughts of the various identified stakeholders (qualitative research) in relation to how M & E can be utilised to enhance performance in the ECDoH. A qualitative research paradigm was chosen and used based on the facts advanced in Section 1 and 6.2.1 of this thesis. In addition, the study ensured that the respondents were accorded enough time and opportunity to engage in the various issues pertinent to this research by way of in-depth semi-structured interviews. The chapter now looks at the various aspects of the research methodology in specific and minute-details in the sections that follow. 6.2. RESEARCH STRATEGY The research strategy refers to the research methodology is also known as the methods of research writing which vary from research to research, depending on the type of research design in question. Research methodology as a scientific process that seeks to provide answers to questions through a systematic approach with the support of data (Kumar, 2019:59). This assertion influenced the research design in this thesis. Furthermore, the research strategy explains how the researcher chose to conduct their study in a particular manner. Overall, a research methodology instrumentation details the adopted paradigm of the research, the relevant sampling techniques applied, the identified research population, the relevant and appropriate data collection and analysis methods. These several aspects of the research strategy are discussed hereafter in the context of the study. 147 6.3. RESEARCH DESIGN The paradigm of a study is usually a philosophical perspective on particular research design. As Sarantakos (2012:30) argues, a paradigm seeks to legitimise, analyse the complex nature of the research design and outlines the significance of such a research design. Research design a plan or blueprint of how one intends conducting the research (Kumar, 2019:154). It is about what type of study one will be conducting and whether it will provide the best answer or solution for the question or social problem that has been formulated or identified. A qualitative study was undertaken by the researcher to prove that M & E policy can be an effectual tool for performance enhancement in the public service using a case study of the ECDoH. The qualitative research paradigm is used within the context of a case study as discussed hereunder. The study infuses the qualitative research paradigm with the case study approach as the chosen research design. Kumar (2019:195) writes that qualitative research is characterised by the fact that the researcher is trying to get to multiple meanings and interpretations rather than impose one dominant interpretation. It is a way of collecting information on the knowledge, values, feelings, attitudes, beliefs, and behaviors of the population through the sample of representatives. Details of the population and sample are covered Section 6.2.4 of this current chapter of the thesis. Qualitative methods are descriptive, meaning that they can reveal the nature of certain situations, settings, relationships or people. In the case of this study, the qualitative data analysis is descriptive in nature, as covered in detail in Chapter seven of the thesis. Since qualitative methods are interpretative in that they enable the researcher to gain new insights about particular phenomena through qualitative methods as evident in the analysis done in Section 7.3 of this study. Through the qualitative approach, a researcher is able to gradually develop new theoretical perspectives about a particular phenomenon as discussed in Section 7.3 of the study. A qualitative approach is also evaluative in that, it provides means through which a researcher can judge the effectiveness of a particular policy, practice or innovation. For instance, the researcher uses qualitative research to gather enough evidence towards resolving the research problems described in Section 1.3 of the study. 148 Bryman (2012:247) notes that a case study involves an in-depth exploration of a bounded system (bounded by time, context and place) or even single multiple cases, over a period of time through detailed, in-depth data collection involving multiple sources of information. Contextually, the study was bound within the case of the ECDoH, which was the unit of analysis where all conclusions and deduction about M & E were drawn. Schurink (2009:321) articulates that the purpose of case studies is both theory-building and theory testing. Case studies can be particularly useful for producing theory and new knowledge, which informs policy development, and in the context of the study, various theoretical framework discussed in Section 3.1 of this thesis was discussed as enablers of policies that improved public healthcare delivery in the Eastern Cape Province. Schurink (2009:322) further states that case studies can also be used for theory testing or more specifically, critical testing of the theory’s proposition. In this regard, therefore, the ECDoH has been chosen as the bounded system where the study analysed the prospects of improving its performance through best practices of M & E. The qualitative research paradigm has been seen to be some watertight approach to doing empirical studies. Schurink (2009:322) state that generalisability is particularly problematic for qualitative researchers because discussions about generalisability are informed by the ontological and epistemological standpoint and methodological preference of the researcher. Though one can use a single method, the use of multiple methods of collecting data is a crucial aspect in the qualitative paradigm, namely in interviewing and obtaining information from secondary records. In order to compensate for the said flaws of the qualitative research paradigm, the study ensured that the research instruments are expertly designed and data was also augmented by secondary or literature source(s). For this study, the unit of analysis in the study were selected public officials from the ECDoH representing and employed in the same entity, which are the ten directors (see sections 6.2.4.1 and 6.2.4.2), five managers (see section 6.2.4.3), twenty administrators (see section 6.2.4.4) and fifteen practitioners (see section 6.2.4.5) within the PMDS component. These were mainly interviewed as discussed in the incoming section 6.2.2.2 of this Chapter of the thesis. 149 6.4 RESEARCH PROCEDURE AND METHODS Since the study is qualitative in nature, also supported by case study research design as its research approach, the study required particular instruments through which data was collected. The instruments selected to support the inquiry are highlighted as a literature study and semi-structured interviews. These are discussed in detail in the section that follows. 6.4.1. Research and data collection instruments The study utilised the following data collection instruments. 6.4.1.1 Literature Study De Vos et al. (2011:376) citing Ritchie and Lewis (2003) state that a literature analysis involves the in-depth study of existing documents (mostly official), either to understand their substantive content or to illuminate deeper meanings or understanding which may be revealed by their style of coverage. Mouton (1996:86) identifies a literature study as the originating stage of an empirical study. According to Hofstee (2006:91), secondary literature is that which has been published by other scholars and which is relevant to the research must be reviewed. There are many purposes of the literature review, one is mainly to lend support and credence to the work one has done. Analysing literature removes doubt and establishes credibility (Hofstee, 2006:92). Also, the literature study helps identify policymaking and implementation gaps, which can serve and feeders into the M & E system. For this study, Chapters one, two, three, four and five are all analyses and discussion of literature in relation to the study. Furthermore, the review of existing documents helps in knowing how things were done in the past, and track developments as well as highlights flaws in design and execution of components of being performance management of M & E in general. Relevant documents from the ECDoH such as policy frameworks, audit reports and legislation within the South African context were studied to obtain reliable information. These were discussed in the legal and policy frameworks covered in section 3.2 of the study. This information was studied and consulted to gain further understanding of how performance management and M & E should be implemented. Also, academic literature on the topic was consulted from relevant books, journals, papers and legislation to help identify the developmental challenges confronting the ECDoH in a 150 bid to find possible solutions and interventions. Lastly, academic literature was consulted on M & E to aid in the subsequent development of a framework for enhancing the performance of the ECDoH through a robust monitoring and evaluation system. 6.4.1.2 Semi-structured interviews Bless, Higson-Smith and Kagee (2006:98) explain that the interview is a method in which the interviewer obtains responses from a subject in a face-to-face encounter or through a telephone call or electronic means. In this case, the face-to-face interviews were held as a follow up to the semi-structured questionnaire. Generally, researchers use interviews as data collection method in order to gain a detailed picture of a participant’s belief about, or perceptions on a particular topic of interest (De Vos et al., 2012:351). Interviewing in this study was done to give the researcher and participant more flexibility. In addition, the researcher is able to follow up particular interesting possibilities that materialise in the interview, and the participant is able to give a fuller picture. Face-to-face interviews were held with participants, using the interview guide attached to annexure 3 in this thesis. Semi-structured interviews are especially suitable when one is particularly interested in a complex process or less-complex process, or when an issue is controversial or personal. With this kind of interviews, a researcher uses a set of predetermined questions on an interview schedule. However, there is ample flexibility to allow follow- up questions and discuss other relevant pieces of information that might fall outside the scope of the interview guide. According to Mabila (2014:29), semistructured interviews allow for flexibility and for better flow of the interview, thereby allowing for a more exploratory study. In this study, interviews were conducted in a comfortable environment or environment agreed upon by the participant and the researcher. For accuracy purposes, the interviews were also recorded upon the consenting of participants. De Vos et al. (2011:342) regard the interview as some social relationship designed to exchange information between the participants and the researcher. Semi-structured interviews generally last for a considerable amount of time and can become intense and involved, depending on that particular topic. The researcher could 151 also hand the interview schedule to the participant and they could read it together. The interview session in this study lasted for between 30 and 40 minutes per participant. Semi-structured interviews were conducted in the ECDoH. As detailed in section 6.2.4 of this chapter, the sample consisted of 10 PMDS managers, 5 senior administrators, 20 administrators, and 15 practitioners, all of which participated in the interviews of the study. These semi-structured interviews were conducted to get data (information) on how performance is managed, what are the reasons for non-compliance in performance management, and how it can be better implemented. As highlighted in the preceding section, the researcher utilised one-on-one interviews to elicit information (data) in order to achieve an understanding of the participants’ point of view. The study conducted 50 face-to-face semi-structured interviews which were between 30 and 45 minutes long in a boardroom with a single respondent at a time. As shown in table 6.1, all the respondents were interviewed in various healthcare stations and premises of the ECDoH. There was also a pre-arrangement between the researcher and the interviewees to ensure that there was ample time to engage in the discussion with limited disruptions. Due to the impracticality of working with a voluminous study population, sampling is always feasible in empirical studies as argued in the following section. 6.4.2. Target population and sampling Kumar (2019:296) writes that sampling theory guides sampling since that a small set of observation can give an idea of what can be expected in the total (target) population of the intended study. Sampling can be defined as a process of selecting observations required for a specific subset of a population in order to make inferences about the nature of the total population itself (Kumar, 2019). In this study, sampling was used to pick a representative group of respondents from whom data was collected for inference to the population of the entire ECDoH. Sample size depends on what we want to know, the purpose of inquiry, what is at stake, what will be useful, what will have credibility and what can be done with the 152 available resources and time (Kumar, 2019:296). A crucial factor when undertaking the selection of cases as representatives is the manageability of the sample and its character of being fairly representative of its target population. According to Mellenbergh (2019:36), a target population is a population to which the researcher would generalise the results of the study. Since the study looked into a nationally adopted policy of M & E which all public entities or employees are aware of, 50 careful selected respondents were selected as covered in this current section. The study chose to use the non-probability sampling method to pick on respondents for interviewing. Non-probability sampling is a sampling procedure whereby the odds of selecting a particular individual are known to the researcher because one does not know the population size of the members (Kumar, 2019:296). This was applicable to the ECDoH since the researcher did not personally know the population, but knew that most public service employees were aware of M & E and its emergence as a common practice in public entities. Kumar (2019:290) further defines non-probability sampling as any sampling method where some elements of the population have no equal chance of selection or where the probability of selection cannot be accurately determined. There are numerous merits of working with samples over using the whole population when undertaking social science research. Sampling enables the researcher to study a relatively small section of the population and still be able to gather data representative of the whole. Sampling is also less time consuming and less costly for the researcher. Sampling provides a valid alternative to a census when: • it would be impractical for one to survey the entire population; • budget constraints may prevent a survey of the entire population; • time constraints may also prevent a survey of the entire population; and the researcher may have collected all the data but needs the results quickly (Warner, 2018:3). In the context of the study, a purposive sampling procedure was used since the study was aware of the potential interviewees in advance, and the selection is based on the fact that the group has the relevant knowledge and experience with which to contribute to the study (Kumar, 2019:296). Purposive sampling is a procedure based on a case, 153 individuals or communities judged as being appropriate or very informative for the purpose of the research underway as covered in section 6.2.4 of this chapter. The participants within this unit could choose to exercise their right to participate or not. The case study recognises the diverse nature of the population and, therefore, the choice of purposive sampling would seem the most appropriate for the study. Purposive sampling is appropriate for use when the researcher has an in-depth knowledge of the study population. The researcher ought to know who can make an informative respondent(s). In this regard, the researcher had resourceful knowledge about the ECDoH, hence selected the sample representatives carefully and accurately as depicted in table 1. The purposive sampling method determined the selection of a representative sample size of participants (See Table 1) regarded to be key informants in the population size of this study. The reason for this choice of sampling method is that the sample frame needed for this study included people who are aware of performance management in the ECDoH such as PMDS directors and managers. Insight on performance management of the department understudy was gained through these anticipated employees of the ECDoH and who have further knowledge of the PMS in the department. The sample size of the study was 50 permanently employed employees in the ECDoH and including managers from level 5 to 16. The target population size in this study was 150 employees of the ECDoH. 6.4.3 Ethical considerations In recent times, it has become paramount for social science researchers to abide by a strict code of ethical behavior when undertaking they're studied. Equally so, the study observed these ethical requirements as shown in the following discussions. 6.4.3.1 Ethical clearance Bak (2004:28) explains that any empirical research that involves people must show an awareness of the ethical considerations and an agreement to conduct the research in accordance with ethical procedures. Therefore, research institutions have made it clear that prior permission should be sought and ethical clearance is given on such projects. The study was therefore ethically cleared by the North-West University 154 Research and Ethics Committee on the 29th of June 2017 for an initial period of five years. The ethical clearance number of the study is NWU-00567-17-A7 and the clearance letter is appended in Appendix 1 of this thesis. 6.4.3.2. Informed consent According to La Rossa and Bennett (2018:150), in every discipline, it is considered unethical to collect information without the prior knowledge of participants. Thus, there should be an expression and a willingness to participate in any study. Hence, in this study, respondents were fully informed about the study, its aims and purpose. The respondents’ were also informed that they were free not to participate and to withdraw from the study at any time. Participants in the study were asked to sign a standard consent form, to indicate their agreement to being part of the respondents of the study. Annexure 2 shows the study’s informed consent form. Respondents were first debriefed on the study and emphasis was made on their right to willingly participate in the freest manner possible. 6.4.3.3. Voluntary participation or autonomy Autonomy refers to the freedom of will, the right to self-government and personal freedom (Oxford Dictionary Online, 2016:5). In research, autonomy refers to strictly voluntary participation. The person involved must have the legal capacity to give consent (La Rossa and Bennett, 2018:150). According to Kilinc and Firat (2019:1466), nobody should be coerced into participating in a research project because participation should always be voluntary. The researcher made sure that the respondents participated voluntarily in the study and no force whatsoever was used in the course of the study through the signature of the consent form and explanation of their right to withdraw at any time when they feel so. Respondents who felt the need to withdraw from the study at any time were notified of their right to such. 6.4.3.4. Avoidance of harm According to Dixon and Quirke (2018:16) in social research, subjects can be harmed in a physical, psychological or emotional manner. The responsibility for protecting the respondents against harm reaches further than mere efforts to repair or minimize such harm afterward. In this study, harm was minimised by avoiding the violation of the rights to which every respondent is entitled. Hence, respondents were thoroughly 155 informed beforehand about the potential impact of the research as this offered the respondents an opportunity to withdraw from the investigation if they so wished. Due to the need to protect the wellbeing of the interviewees in the study, there was never any information that would identify particular individuals to the data collected. Also, the consent form appended in Annexure 2 of this dissertation only contained signatures to avoid retribution and victimisation of participants. 6.4.3.5. Confidentiality Beardsley (2017:65), declares that ethical researchers must always protect the right to privacy by guaranteeing full anonymity or confidentiality. The two concepts are often confused or used synonymously, but they are not the same. A participant may be considered anonymous when the researcher cannot identify a given response with a given participant. This means that an interview survey participant can never be considered anonymous since the interviewer collects information from an identifiable participant. In a confidential survey, the researcher can identify a given participant’s responses but essentially promises not to do so publicly (Beardsley, 2017:66). The study ensured that the privacy and confidentiality rights of the participants in this survey were not violated through the whole research process. This was ensured by ensuring that the interviewer did not ask questions that were personal or prejudicial, or do anything that would make the interviewee uncomfortable. There were no group interviews, and the researcher ensured that interviewees felt comfortable with the venues to avoid issue related to the violation of participation’s confidentiality. 6.4.4 Research data processing and analysis Data processing involves ‘breaking up’ the data into manageable themes, patterns, trends, and relationships. In this study, the researcher used existing material of past studies to gain insight for both methodological and theoretical purposes. It is generally understood that empirical data is meaningless until it is analysed, interpreted and deductions are made about it. The study analysed and presented data using qualitative content analysis. Firstly raw data was put into various themes, under which detailed descriptive analysis was done to best understand the issues under study, which is M & E in the ECDoH. There was also the use of interview excerpts where the direct words of the various respondents were quoted and analysed in order to maintain the 156 originality of data. Bryman (2012:392) states that qualitative content analysis is probably the most prevalent approach to the qualitative analysis of the document and that it comprise a searching out of underlying themes in the materials being analysed. Bryman (2012:542) further defines content analysis as an approach to documents that emphasizes the role of the researcher in the construction of the meaning of and in texts. Therefore, since the qualitative paradigm analyses the non-quantifiable such as feelings, perceptions, and emotions of people towards the phenomena under study, analysing the data in a qualitative manner is also quite compatible with the paradigm in this regard. Maree et al. (2007:99) assert qualitative data analysis to be based on an interpretative philosophy that is aimed at examining the meaningful and symbolic content of qualitative data. The process of qualitative content analysis often begins during the early stages of data collection, this enabled the study to identify themes emerging from the interview session to aid in the final data analysis phase. This early involvement in the data analysis phase helped this researcher to move back and forth between concept development and data collection and helped direct subsequent data collection toward sources that are useful for addressing the research questions. Content analysis can be used to analyse various types of data, but generally, the data needs to be transformed into written text before analysis can start. If the data comes from existing texts, the choice of the content will be justified by what the researcher wants to know. Lastly, content analysis requires the researcher to have extensive qualitative data be properly organised for analysis, and the guidelines which have been established for documenting the process to ensure completeness and accuracy of data and its classification has been followed (International Development Research Centre (IDRC), 2008). In the context of the study, the researcher gathered data from the 50 interview sessions, making content analysis easier for the study. The study employed content analysis to analyse data, gather information both empirically and theoretically in order to establish the prospects of enhancing the performance of the ECDoH through adopting an operational M & E framework. This analysis was able to identify gaps which needed bridging, flaws in the design of the current performance management policy and procedures in the ECDoH as established 157 in problem statement in Section 1.3 of the study, the effect of the absence of mainstreamed M & E as well as the potential of improved public service efficiency and effectiveness. 6.4.5 Reliability of findings Reliability can be regarded as the extent to which results are consistent over time and an accurate representation of the total population under study is referred to as reliability and if the results of a study can be reproduced under a similar methodology, then the research instrument is considered to be reliable (Kumar, 2019:273). In laymen terms, validity in research is concerned with the accuracy and truthfulness of scientific findings. A valid study should demonstrate what actually exists and a valid instrument or measure should actually measure what it is supposed to measure. Through the use of multiple sources for information to assess validity, experience, and assumptions that undergird the study the questions above will be answered fully. Qualitative research seeks to understand phenomena under study. It is concluded that the claim of validity rests on data collection and analysis of research techniques and instruments, of the researcher in qualitative paradigm. Given that this study will fall within the qualitative approach, the question of validity is important. The use of multiple sources of information to assess a particular area is thus important and increases the reliability of the findings. Furthermore, the researcher revised the interview transcripts to ensure that the original voices are captured and analysed. The study improved the reliability of findings by also re-engaging the respondents to revise the transcripts to accord them a chance to add or nullify some information. Also, the use of a literature survey also ensured that the findings of the study are reliable and in unison with other findings of similar scope and magnitude. 6.4.6 Limitations of research instruments In social research limitation speak of the factors that can influence the conclusions of deductions about a given phenomenon in any given study. The choice of the qualitative research approach meant that the study was limited in terms of its ability to have quantitative statics and figures. This limitation did not have too much bearing because the research was focussing on understanding, through having an insider’s perspective, 158 of the absence of or potential of performance improvement in the ECDoH through adopting and implementing fully-fledged M & E practices. Therefore, the use of interviews, literature study and content analysis was done on the most objective manner towards improvement on the believability of the findings of the study as details in Chapter 7 and 8 of this thesis. 6.4.7 Description of research respondents A detailed description of the sample size and composition is now provided as follows. The sample consisted of PMDS managers (5), senior administrators (10), junior administrators and practitioners (10). The sample details are presented in Table 1. Table 1: Sample size and structure Respondents’ Organisational Number of Data Designation Unit Respondents Collection Method Directors 5 Deputy Director Performance 5 Management Managers 5 and Senior Administrator Development 10 System Junior Administrator 10 (PMDS) Practitioners 15 n=50 N=150 6.4.7.1 Performance Management and Development System directors Key respondents heading in the PMDS unit, respondents in this category have detailed information on the overall and specific functioning of the performance management. Like the heads, the directors were a crucial part of the sample since their level of responsibility helped the study locate the gaps that can be exploited by a mainstreamed M & E practices for improved performance in the ECDoH. 6.4.7.2 Performance Management and Development System deputy directors 159 As the second-in-command, the deputy directors are sometimes delegated to do similar tasks. As public servants are closer to the shop-floor employees of the PMDS unit, there are minute details of performance that the study obtained to the effect of achieving the goals of the study. The deputy directors also helped the study in exploring synergies with other public entities whose well-articulated and implemented M & E system have become a success story. 6.4.7.3 Performance Management and Development System managers As the performance management ‘foot soldiers’ these managers had a critical role as part of the sample. The unit entrusts most of the tactical planning on the managing of performance to the PMDS managers, and they were key informants in the study because the PMDS unit has most of its responsibilities placed in their hands. This category of respondents helped the study to develop an intimate relationship with the importance of the PMDS unit to the ECDoH and the need to make it more effective due to its knowledge of PMDS and prospects of M & E being adopted and implemented in the ECDoH. 6.4.7.4 Senior administrators Although this category of respondents appears to be lower-level employees on the organogram of the ECDoH and the PMDS unit, they too had an equally vital role in the study. They might look less valuable in terms of decision making and authority in their own space, but they are resourced when it comes to performance management skills and knowledge and the prospects of developing the PMDS into the ‘next big thing’, the M & E ‘engine room’. 6.4.7.5 Junior administrators and practitioners Awareness on the situation on the ground is what this category of the sample has because they are responsible for administrating all performance related data and information in the ECDoH. Junior officers and performance management practitioners are tasked with doing the most tasks and responsibilities with the actual managing of performance. Therefore, these are respondents who had hands-on experience on the 160 success, challenges, weakness, opportunities, and threats to the practice of performance management in relation to the ECDoH. 6.5. JUSTIFICATION OF RESEARCH STRATEGY FROM PREVIOUS STUDIES The study was guided by the choice of methods from existing studies of a similar nature. These are discussed as follows. A doctorate thesis by Motingoe (2012) dealing with M & E system utilisation for municipal support of national and provincial Departments of COGTA and DCoG, and Radebe (2013) focussed on the impact of a performance management system on service delivery in the City of Johannesburg (CoJ) municipality. While Zwane (2014) covered M & E mechanisms for sustainable development in Sedibeng District Municipality and Naidoo (2011) focussed on the role of monitoring and evaluation in promoting good governance in South African public service with reference to the Department of Social Development. In all these three cases, the researchers used qualitative research approaches were data was collected using inter, literature study and interviews. It was evident from these studies that the underlying need for M & E in improving the performance of public entities in South Africa was established and emphasised. In this regard, the study made prudent choices in the use of the various research methods and procedures as discussed in this chapter. The only difference was that the current study was premised on the ECDoH. This was chosen due to the vital nature of access to quality healthcare services to the people of the Eastern Cape Province of South Africa. 6.6. CONCLUSION Covered in this chapter is the research methodology that is the blueprint which the study followed in gathering enough empirical and literature evidence towards the attaining of the objectives of the study. In summary, the study adopted a qualitative research paradigm (as discussed in section 6.2.1. of this thesis) within the confines of the case study research design. Data were collected from a representative sample of 50 respondents who were chosen using a non-probability judgemental sampling technique (see section 6.2.4 of the study). Also, data were qualitatively analysed (as covered in Section 6.2.3 of this Chapter), there strict ethical principles of social science research were also followed (as presented in section 6.3 of the thesis) and data was gathered through interviews and literature study (see Section 6.2.2 of this Chapter). In 161 addition, the study used various benchmarks to improve on the reliability of findings as presented in the respective section of the Chapter. As discussed in detail in Section 6.2.1 of this Chapter a qualitative approach was chosen since it is the one that best fits the study, which sought to explore the feelings, perceptions, behavior, and attitudes of the sample on how performance is being managed in the ECDoH and the prospects of utilising M & E as a performance enhancer. Furthermore, the qualitative research paradigm accords the researcher to take an insider’s perspective on the analysis of the phenomena of M & E in the public service. An analysis of the data collected in the study was done and detailed in the coming Chapter of the thesis. 162 CHAPTER SEVEN: DATA PROCESSING, ANALYSIS, AND DISCUSSION 7.1. INTRODUCTION In a setting where the delivery of public goods and services persistently faces insurmountable challenges, monitoring and evaluation can be the antidote for improving government efficiency. This is particularly of great value to the Eastern Cape Department of Health, a public entity that needs a massive facelift towards attaining its core ‘business’ objectives. One such an objective is the sustainable provision of healthcare public services to those living in the Eastern Cape Province of South Africa. One should take cognisance to the fact that this region is regarded as one of the poorest provinces in the entire Republic. That further places the same province on a collision course with huge public service delivery backlogs and demands. In this regard, there is great public demand and need to deliver public healthcare services in the province of expeditiously. In harmony with the aims of the study, M & E can be that catalyst which can serve to improve the public healthcare service delivery in the Eastern Cape Province. The thesis now revisits the research objectives in making sure that this data processing and analysis is within the context of the research objectives of the study. From section 1.5 of this thesis, the six objectives of the study were chronologically laid out as to:  Determine the central theoretical framework and orientation which can form the foundation of M & E in the efficient provision of public healthcare services with particular reference to the ECDoH.  Establish the nature, content, and character of the M & E discourse in Public Administration as a scientific study, and as an enabler of public healthcare service delivery efficiency and effectiveness in relation to the ECDoH and its prospects of improving the rendering of public healthcare services.  Ascertain scholarly themes emerging from M & E that inform the role and significance of the service delivery discourse in Public Administration in relation to the provision of public healthcare goods and services. 163  Determine the relationship between public service M & E and performance management in the public healthcare service area in relation to how the former can effectively help improve the prospects of the latter towards the delivery of quality public healthcare services in relation to the ECDoH.  Investigate the challenges that the ECDoH is facing in using public service M & E in improving its effectiveness and efficiency in the delivery of public healthcare services to the inhabitants of the Eastern Cape Province.  Explore the avenues through which a pragmatic public service M & E model can be developed in order to help the ECDoH improve the delivery of public healthcare services in the Eastern Cape Province. In light of the above, this data analysis and processing gives effect to the attainment of the fifth research objective, which sought to unearth the challenges faced by the ECDoH in utilising M & E to improve its performance and public healthcare delivery. In this chapter, an analysis of data is hereby undertaken based on the empirically collected data. In summative form, the data was collected using qualitative data gathering techniques and tools which were semi-structured interviews and literature study. As alluded to in the methodology chapter of this thesis (see section 6.2.2), the analysis of data is further executed using the qualitative research methods of data analysis namely thematic and content analysis, interpretation and deduction. This analysis aims to espouse and expose gaps in the efficacy of delivery of public healthcare services to the citizens in the Eastern Cape Province of South Africa. Since the study aims to assess how the adoption and implementation of an M&E framework in the ECDoH, the analysis of data additionally strives to ascertain the prospects of improving healthcare service delivery efficacy in the Eastern Cape Province by means of proposing the use of M & E as a tool for instilling effectiveness public service rendering. Meanwhile, the following section discusses the study of Public Administration and the implications of efficient healthcare delivery in the Eastern Cape Province, and South Africa at large. 164 7.2. PUBLIC ADMINISTRATION AND SUSTAINABLE HEALTHCARE PROVISION Public Administration has been characterised as being both an academic discipline and an activity of public entities (Shafritz, Russel & Borick, and 2015:22). This assertion concurs with Hughes (2003:7) who postulates that “the term Public Administration is referred to as the study of the public sector, in addition to being an activity and a profession”. Within the context of it being an academic field of study, the discipline is concerned with the skills and equipping public servants in required aptitudes of performance as a way of ensuring that such public servants are well acquainted with the required norms and standards of performance (Shafritz et al., 2015:23). Furthermore, the discipline of Public Administration strives to keep abreast of changes and public administration developments in the global world such as M&E and remain to impart the relevant and time compliant skills to public servants. In the current era of public governance, there has been a genesis of practices of M&E which has sought to revolutionalise the manner in which activities of public entities are undertaken. The activities of public entities are at a stage of being monitored and evaluated by established public institutions and dedicated M&E units and/or divisions in the public sector, and regarded as the public administration in a given public service and state. Hence there exists a cordial relationship between the activities of public administration (M & E included) and the discipline of Public Administration. Within the context of the activities of government or public entities, there is a need to ensure that public services and goods are delivered to the public consumers in an efficient, effective and economical fashion. The proverbial 3Es of efficacy, effectiveness, and economy had been centripetal to the need to attain sustainable public service delivery in the 21st century. Such encompass the rendering of public healthcare services by the ECDoH. Briefly, efficiency is about managing public costs and the usage of public resources while effectiveness is about doing the right thing. The economy has something to do with the optimal utilisation of scarce resources. Also vital to the study is the concept of sustainability in the delivery of public healthcare services. Precisely, sustainability talks to the need to take cognisance of ensuring that the provision of public services to the society of today does not jeopardise the prospects of future generations to get a decent living standard 165 from the same resource base. In the context of the study, sustainable public healthcare provision deductively implies the delivery of public healthcare in a manner that takes cognisance of the future needs of the societies in the Eastern Cape Province. For example, investing in the public healthcare infrastructure today, ought to have a long lifespan so that future generations can derive some benefit from such an inheritance or legacy. Based on the empirical data gathered in this study (see section 7.3.1), the most plausible tactic to attain sustainable public healthcare service delivery is undoubtedly the ability of public entities such as the ECDoH to keep abreast with prevailing trends such as M&E. The obsolete and scant practices of PMDS need to be transformed into efficacy-conscious ones which enable the track and trace of public service delivery progress in a timely manner. The study now covers the foundational prescripts for sustainable public healthcare service delivery in the ECDoH including some statutory provisions in the coming sections. South Africa has an advanced constitution which guarantees both fundamental and human rights to its citizens. Consequently, therefore, Chapter 2 of the RSA Constitution (1996) exclusively covers the various rights that citizens are entitled to enjoy. One interesting fact about this Bill of Rights (Chapter 2 of the Constitution (1996) is that it has clauses mandating the government to take reasonable measures to ensure that all people freely and fully enjoy these rights. Legally binding prescripts such as Section 9 of the same Constitution (1996) introduces and promotes the idea of equality and equal enjoyment of the law while guarding against unfair discrimination by the state or its entities. The Bill of Rights is the cornerstone of the human and fundamental rights in South Africa. It can only be the failure of the government to make the ‘reasonable’ measures towards the progressive realisation of the enshrined rights. Of utmost importance to this study in Section 27 (1) (a) of the Constitution (1996) which posits the citizens’ right to public healthcare including reproductive healthcare. While the stipulated public healthcare right is promoted in the public sector of South Africa, this study notes that there remain shortcomings in terms of the sustainability 166 and efficacy of the delivery of public healthcare services. As revealed in the reveled literature in this study, these shortcomings can take various forms from the availability of timely public healthcare attention to infrastructure availability in deeplying rural areas such as those villages in the Eastern Cape Province. These shortcomings further encompass downtime for the public healthcare ICT systems when there is a blackout or the waiting period of patients in queues before being given attention as well precious time lost to unwarranted breaks by medical healthcare staff. Also of great concern are issues surrounding the operational times for healthcare service centers, lag times between the request and arrival of emergency medical facilities such as ambulances when requested, staff morale and client services and the management culture, as in the ECDoH in the context of the study. From Section 1.1 in Chapter 1 of the study and aided by a survey of existing literature (in Chapters 2, 3, 4 and 5), the research interviews conducted and the researcher’s own observation of the phenomenon, the study hypothesised that M&E can play a huge part in resolving public healthcare challenges in relation to the ECDoH. Public healthcare service is one critically important public service system in any society and more cardinal is the need to timely deliver these services since delays may prove to be life-threatening patients. A survey and probing of literature in chapter one (see sections 1.1) to chapter five (see section 5.1) established that modern public sector/service practices such as M&E have a positive effect of dealing a blow to government inefficiency and poor delivery of public goods services. 7.3. ANALYSIS OF THE CASE STUDY As discussed in the preceding section 7.2 of the thesis, the study utilised a case study premised on the ECDoH. Conceptually, case studies are a form of qualitative research approach, which are intensive analyses, and descriptions of a single unit or system bounded by space and time (Hancock & Algozzine, 2016:9). In the end, case studies enable researchers to gain a more profound understanding of various situations and implications for those involved. Overall case studies produce insights which can directly shape policymaking, implementation or evaluation of public goods and services and public programmes, policies and projects (Hancock & Algozzine, 2016:10). In the context of this study, the analysis centers on the physical public and 167 authoritative space in a form of the ECDoH within the geographical boundaries of the Eastern Cape Province. Data analyses and interpretation presented in this chapter was executed through various procedures collectively and categorised as a qualitative method using thematic and content analysis. The data analysis began with the collating of empirically collected data, followed by the coding of the data which was later categorised or placed into various themes using the AltasTi programme. In brief, these themes covered the challenges affecting the adoption and implementation of M&E in the ECDoH and the prospects of the ECDoH overcoming current obstacles, adopting and implementing M&E and attaining the much-needed healthcare delivery efficiency. These broad thematic areas of this study are instrumental in transforming how the ECDoH plans, executes and monitors its healthcare service rendering in the Eastern Cape Province. The following are insights and analyses of behaviors, attitudes, feelings, and perceptions of respondents relating to how the status quo can be improved by adoption and implementation of a working M&E framework for the ECDoH. Such is derived from the argument in the opening Chapter that the current level of performance in the ECDoH has some loopholes that make it hard for this public entity to sustainably fulfill its mandate. Such an onus is the provision of healthcare services to the people living in that Province. The fifth research objective sought to investigate the challenges that inhibit the ECDoH effectively and efficiently deliver healthcare services. In this regard thus, this Chapter overall seeks to attain such an aim. While the following section covers and discusses the impediments which have been affecting the efficacy of the ECDoH to deliver services, mention is hereby made that the various sub-sections address challenges related to human capital provisioning, organisational culture, liquidity, political factors, and government structure constraints. 7.3.1. Impediments to efficiency, monitoring, and evaluation in the ECDoH Data collection done through interviews and literature study probed various topical areas related to this research. A significant component of these semi-structured interviews and literature survey utilised surveyed the constraints and impediments which affected the ECDoH’s quest of efficacy. As a result, numerous challenges have been identified 168 as being the causal factors that the respondents attributed to the inability of establishing and monitoring sustainable public healthcare service delivery in the Eastern Cape Province. These constraints and challenges are discussed under the various segments as follows. 7.3.1.1. Delays in adopting and implementing modern M & E practices In a world economy where globalisation and the influence of modern practices have growing influence, one cannot ignore the need for public and private organisations, to adapt and survive the wave of 21st-century reforms. In the public service/sector specifically, ancient practices such as orthodox bureaucratic management styles or practices have died a natural death inflicted by obsolescence. In addition, the contemporary public service delivery environment requires a continuously flexible and adaptive style of organisational management. In that regard thus, those public entities that remain rooted in old-fashioned practices are bound to have their chances of efficient public delivery services minimised. In the context of the study, data gathered indicated that the ECDoH is lagging behind in terms of its embracing and assimilation of the M&E practice in its process. Be it the rolling-out of the public healthcare infrastructure such as clinics or hospitals in remote parts of the Eastern Cape Province or the timely deployment of dedicated healthcare professionals, there has not been enough efficacy. On the question of whether the current practices of performance management used by the ECDoH give effect to effective public healthcare service delivery (question 2 as contained in Annexure 2 (interview guide), one respondent in the following interview extract echoes this perpetual utilisation of somewhat expired practices. The ECDoH does not have a functional M&E framework, but rather utilises the PMDS introduced during the 2006/7 fiscal year, since its inception, it has merely been a policing of performance with little impact on improving productivity. Of course, the PMDS is working for us but it needs to be partnered by M&E in order for all our processes to benefit from the trace and track done with the latter. Myself I *(sic) arrived in the ECDoH in 2007, but it was only in 2009 that performance- based remuneration linked to the PMDS begun. And now, almost 8 years later, we have not moved with the times, we are still stuck with PMDS. So in precise words, we are always lagging 169 behind. And that automatically cripples our healthcare delivery. We do not have an exclusive monitoring or evaluation practice here. It is something that we so much desire (Respondent 24). From the preceding excerpt, the study deduces that the Department is well behind in terms of modern-day pro-efficacy practices are concerned. These include the ability to ensure both individual and organisational accountability as discussed in Section 4.3 of Chapter 4 of this study. In addition, there is also a feeling that performing is sort of being policed without paying attention to the policy process especially the monitoring and evaluation of the ECDoH’s public healthcare delivery policies. In relation to the purported reliance that the ECDoH or precisely its PMDS has with employee performance, a respondent had this to say: We do not have M&E arrangements within the ECDoH, but we still trying to achieve our goals with the PMDS. We use Key Performance Indicators linked to an employee’s job description and individual employees work together with their supervisors towards attaining these goals, which will also lead to achievement of organisational goals. The gauging of performance is done to determine the cause of poor, average or below par performance. This is because we need good performance which furthers our obligation to deliver healthcare services. Although there is not much of an emphasis on overall organisational performance tracking, individual employee performance is prioritised (Respondent 27). The study further managed to reveal the demerits associated with the continued use of the PMDS. Respondents felt that this has led to employees being obsessed with financial rewards regardless of whether such levels of performance are in sync with organisational goals or societal expectations for the delivery of healthcare services. It was further established that the PMDS is somewhat merely presiding over whatever level of performance and skills that individual employees currently possess without inputting much into the training need analysis in the ECDoH. Inferably therefore, it leads to the ECDoH having to find maybe the best on a mediocre level of individual performance. Overall, that dents the ability of the Department to improve on its service delivery or operational efficacy. Respondent 38 expounded this effect as follows: Let us do away with the PMDS thing since it is some kind of performance policy. Employees in the ECDoH have long perceived it to be linked to compensation, while it pays little attention to the progression of policy implementation. It also makes it hard for gathering and utilising data that is not 170 related to financial rewards. For example, we currently cannot gather data on critical aspects like the training needs of the people and the resource requirements for attaining our healthcare targets. Yes, we need a universal framework for gathering as much data on how both employee and organisational performance is kept in check towards continuous improvement (Respondent 38). One cannot ignore the great value that the human capital value has on public organisational success. This point has a bearing on the ability to get individual employees to be productive assets of the organisation and the ability of the public organisation to ensure that its mandate if fulfill through competent employees. One such determinant factor is the ability to continuously improve the skills of the individual employees. In addition, individual employee skills improvement enables the public organisation such as the ECDoH to take stock in determining if the existing skills set is still relevant to the mandate of the organisation. It is such evaluation interventions that can ensure that the training or development of individual employees takes place. As mentioned in the interview extract from respondent 38 above, the ECDoH needs a working M & E framework in order to broaden the scope of organisational improvement while moving away from the current individual or employee centeredness practice and approach. The Department has been castigated for failing to adopt M&E processes and systems correctly, something that has seen the concomitant public healthcare service delivery decreasing and some related programmes going wayward and offcourse. In the absence of an effective trace and track programmes for the rolling out of effective and efficient public healthcare facilities in the province, rural enclaves have been negatively affected. Such a scenario has affected the ability of the ECDoH to minimise walking distances for patients. Some of the worse affected are those on antiretroviral therapy who have to endure long distances to the next clinics to collect their HIV or AIDS treatment as observed by the researcher. In this instance, there needs to be adoption and implementation of effective and efficient public healthcare systems and processes aimed at promoting the citizens’ right to the proper public healthcare system in the Province. Such a new and proper public healthcare system should not be hindered by either physical long distance challenges or unavailability of public healthcare facilities in certain localities. One respondent in the study had the following words on the absence of M&E in the ECDoH. 171 Our entities are obsessed with planning while emphasising less on evaluation (or monitoring) that is bad since programmes sometime go wayward without much timely scrutiny. In my opinion, that would be significantly mitigated if we had in place, a system of M&E where everything from our physical infrastructure and services is traced and tracked. This important because sometimes we fail to have factual details on what do we have and what progress have we made in implementing a given programme, and if there is need to take timely corrective action (Respondent 45). From the discussion and excerpts in this section, it is evident that the continued use of the now obsolete and shallow PMDS-based system has to change. The respondent (45) felt somewhat neglected by those holding the levers of authority and responsibility since the Department is lagging behind in various respects like the deployment of qualified doctors in rural areas. Mention is hereby made that the only way in which the ECDoH can gain the advantage(s) of an effective and efficient M & E system that it so many desires is through the transformation of existing M&E policies, programmes, human capital projects and related components which collectively work towards achieving its public healthcare services delivery mandate. These are practices which universally look at markedly improving productivity in a holistic way, without taking a bias towards a particular component of the M & E system in relation to the public healthcare system in the ECDoH. The next section presents and discusses another constraint that has affected the promotion efficacy in the ECDoH in relation to the M & E system. It covers the lesscoordinated manner that some functions in the ECDoH have operated. 7.3.1.2. Ambiguity in the public sector The intergovernmental relations provision as set out in Section 41 of the RSA Constitution (1996) indicate the need for “oneness and togetherness” of state organisations across all the three spheres of government in South Africa. Notwithstanding the above position, there exist challenges with policy fluency and uniformity across the three tiers of government, an impediment which has negatively impacted on the rolling-out of pro-efficiency practices in relation to M&E. While the year 2005 saw the emergence of a pro-efficacy government-wide monitoring and evaluation system (GWMES), it has not deservedly been cascaded down to lower 172 levels of government. Further to this, the lateral rolling-out of GWMES has been less smooth with various national government departments including the ECDoH adopting less unformed models of M & E. While emphasis is on the underlying trace and track of public service performance, mention is hereby made in this study that the cascading of an equally uniform system of M & E does not only lead to public policy (and implementation) congruency but ensures that such practices are benchmarked. In this regard, the prevalent policy ambiguity in the public sector has been lambasted for poor efficiency especially in the ECDoH when it comes to the utilization of M&E systems and processes in improving public healthcare service rendering. These views were voiced by one respondent as shown in the following interview extract. While there is a potential positive welcome reception and embracing of M&E in the ECDoH, efforts to roll-out the systems into the department and province at large have not been equally forthcoming. As a result, we at present in the ECDoH, have not fully embraced it mainly due to ambiguity and lack of national and provincial government commitment to sell and keep the idea within us. Let me add that, there is little resistance to change in the department, hence a high chance of success of a fully developed M&E system here (Respondent 3). Since the ECDoH is the provincial public entity, its policies are more informed on the position of the provincial government, in this case, which has not been forthcoming as far as M&E systems, processes and practices are concerned. The quoted participant bemoans the inability of the national government to sell or market and support M&E policies and merits to its subordinate spheres. In the position of the ECDoH, the GWMES begins and ends in the Presidency. As a result, it is the public healthcare service rending in the ECDoH which takes a knock as observed by the research. However, there was an overwhelming perception from the respondents in the study that the Department was more than ready for the adoption and assimilation of a newly- established M&E into its service delivery systems. As far as my knowledge is concerned, I do not think the public service in South Africa is doing enough to ensuring a uniform uptake of M&E into the entire public service. At present, some (provincial) government departments like the ECDoH are still using the old-fashioned practice of Performance Management and Development. It would be good if a universalised GWMES or an equal model to it is unveiled and implemented in all public entities in South Africa (Respondent 2). 173 The study infers that the failure by the ECDoH to move from the PMDS to M & E is a consequence of the mild lack of clarity in the government system in South Africa. For example, one respondent in the study based in East London probed the question why some public entities are still stuck with the PMDS which she branded ‘employee performance police’ while the holistic organization-wide practice of M & E has proven to be more efficient. While the challenge of poor infrastructure does not have a direct causal effect to the rolling-out of M&E into the ECDoH, its significant influence on the delivery of healthcare services should not be understated. Another respondent spoke strongly for policy congruency in the public sector as shown in the interview excerpt that follows. The universal (and often opaque) manner of policies that the national government develop for its subordinate government spheres has made expediting of community development problematic. There is a need for a more simplified and tailor-made M&E blueprint, one that can be understood by even the entry-level employee of the ECDOH. Within the ECDoH, enabling subordinate plans has to be in place on how best we can utilise M&E to attain our desired goals, which will be in harmony with national government targets (Respondent 21). The study further mentions that the issue of infrastructure development lagging behind in the Eastern Cape Province can be markedly improved through a universalised and holistic department-wide M & E framework. This has been discussed under the significance of the study in Section 1.7 of this thesis. In this regard hence, the study addresses the challenge as follows. 7.3.1.3. Infrastructural challenges in remote areas In a predominantly rural province, infrastructure remains a daunting challenge to the delivery of healthcare services to the people living in the rural enclaves of the Eastern Cape Province. During the interview sessions, a majority of the study’s respondents bemoaned the issue of dilapidated infrastructure in the rural areas. This study revealed the extent of remoteness prevalent in the Province. With over 60% of the inhabitants of the Province domiciled in rural areas, and a poverty headcount of 43% of the provincial population in 2015 (StatsSA, 2017:64), the public performance of ECDoH was going to experience M&E systems-related failure. Critical infrastructure 174 such as poor road, hospitals, clinics, and water shortages affects how the people access public healthcare services. On the question of how the remoteness of some areas in the Eastern Cape Province in relation to the M & E obligations, complimented by a poor network of infrastructure, has negatively affected the sustainable delivery of public healthcare services in the Province, a respondent is quoted below. One reason why we need to adopt and embrace a conventional M&E framework is that we have a huge population that cannot afford private healthcare, hence needs efficient public healthcare. Take for example the challenge of people in the rural areas who commute or walk long distances to get to a healthcare facility. They need a clinic or hospital within their vicinity (Respondent 8). Public healthcare professionals have been categorised as a scarce skill in South Africa. It is more serious when it comes to medical doctors. Due to the remoteness of some of the places in the Province, there is a general perception of some of the doctors favoring to work in a semi-urban or metropolises that to be placed in a remote rural hospital. This has been discussed in section 7.2 of this chapter. As a result of this, some critical human capital is in short supply in the ECDoH, a scenario that has affected how the people of the Province get much-needed public healthcare services. This also includes getting the said medical attention in an expeditiously and timely manner. The study advocates for the assignment of doctors be done within a conventional M&E system, one that can be designed to incentivise rural deployment and ensuring that there are not unnecessary shortages to critical staff. In the event that is done within a policy framework that is in the form of an M & E blueprint, rural dwellers would receive timely and quality healthcare, not mentioning that medical staff will be available as and when required. This particular impediment was summed-up by one interviewee in the study as follows. Another impediment is that healthcare professionals are in short, these are scarce skills and because of the predominantly rural nature of our province, some doctors do not want to be deployed in deep- lying rural enclaves. We understand that we do not have enough doctors and nurse in this Province, but is it a crime for one to stay in a rural area. Sometimes patients lose their lives due to a shortage 175 for example of surgeons. Lives could be saved if we would have a working model of predictable and ascertainable deployment (Respondent 42). In this ensuing section of the thesis, the impacts of and possible prospects of mitigating infrastructural challenges in an attempt to improve the efficacy of healthcare services delivery by the ECDoH in the Eastern Cape Province were discussed. Important to note is the causal effect that this factor has on the possible success of the ECDoH to deliver its mandate of sustainable healthcare provision to the people of the Province. The study further mentions that varying levels of infrastructural development between urban and rural areas have an effect on the availability of critical medical staff as discussed in Section 7.2 of the study. However, the availability of a working M&E framework would ensure that medical staff (qualified doctors) assignment is executed in an effective and efficient manner. Even if medical staff deployment requires the use of rural incentives, that can make a good effort towards making sure that nobody is denied their Section 27 right to public healthcare, including emergency medical treatment as stipulated in the Constitution (1996). The challenge of political will and leadership is discussed next. 7.3.1.4. Political commitment deficiencies As the custodians of policymaking, political heads have to endeavor to ensure that there is dedication towards attaining a given level of socio-economic development goals/objectives. The same applies in the designing and adopting of a uniform M&E framework for the public service entities in South Africa. Availability of the GWMES is a sign of noble ground-breaking intentions for improving efficiency in the public sector. However, the impetus that the GWMES gave to the public service needed to be equally harnessed and then cascaded throughout the entire public service. As it stands, it looks like there is not much of willingness by those holding the levers of political authority in the ECDoH to make sure that the delivery of public healthcare services is monitored and evaluated due to poor political will. Consequently, there is a disjointed M & E practice in the public service, with some entities including the ECDoH having a unique M & E system of practice. 176 Respondents 8, 21 and 26 did ascribe the different models utilised to manage performance in the public service as a unique way of intra-sector competition. In a normal setting competition across provinces on building the best public healthcare system would be fruitful. But such should not affect how essential services are provided. The study acknowledges the need for uniqueness and public service delivery competition in the public sector but some fundamental apparatus such as an M & E framework needs universalisation to include all provincial department like the ECDoH. Public entities such as the ECDoH can further use their ingenuity to determine how the implementation of such prescribed practices which encompass M & E is undertaken. Respondent 10 alluded to these issues in the above section as indicated below. There is much of lack of political will to adopt and sustain M&E in the ECDoH that is the key impediment that I have noticed for long. Most employees in our department perceive negatively about the practice of M & E as a police-like move that might make them resultantly lose a job of restructured organograms of job scopes. I also blame the rigid organisational structures and the absence of a nationwide strategy for implementing M&E in all public entities. It might be shocking that some fellow provincial public entities or departments in this province also lack working M&E framework. to me that a quite haphazard way of public service rendering (Respondent 10). The highlighted challenges related to political will and red tape based on an overreliance on bureaucracy are a sign that the public service in South Africa still has a lot of work to do towards being efficient. A continued stay with the now obsolete PMDS can be a sign of the fear of those in decision making echelons to change. Such changes can take the form of effective and less-bureaucratic organisational structures. These organograms are conducive for the implementation of proefficiency practices as M&E. The ECDoH should do away with bureaucratic processes and red tape which have long been blamed for their obsession on managing individuals’ performance at the expense of organisational success. This emphasis of PMDS as used by the ECDoH instead of M & E affects the ability for efficacy in the delivery of public healthcare services in the Eastern Cape Province. Moving from these organic ancient style practices like PMDS will not only lead to public service efficacy but additionally remove 177 the resistance to change in the ECDoH. In most cases thus, it is such a change that brings about people-centered public service delivery. The current M&E non-conformity has led to the ECDoH suffering many litigation costs due to sometimes sham healthcare service delivery. These costs have come through citizens suing the Department for botched operations, something that has tainted our reputation as a public entity. On another note, the upcoming National Health Insurance (NHI) will stand better chances of succeeding if there is a sustained practice of M&E in the provincial and national public healthcare departments (Respondent 13). The medical negligence that has tainted the ECDoH have also been lamented by Respondents 9 and 21, who revealed that such issues have oftentimes left the Department with “an egg on its face”. An effective and efficient M & E framework would ensure that medical staff and the general public healthcare workers are available as and when required thereby minimising these hostilities between the ECDoH and its constituency. The mooted introduction of the NHI is a step towards ensuring universal medicare and healthcare for all South African citizens, but it stands a better chance of succeeding if there would be M & E components in a holistic manner. That is ensuring that every aspect of the public healthcare system is kept under the radar with an eagle’s eye. This is one way that M & E can be used as a tool for public healthcare service delivery in the as outlined in the research objectives outlined in Section 1…of the study. The following section discusses shortfalls that the current organisational culture in the ECDoH has in relation to the need for efficient healthcare delivery in the era of M & E. 7.3.1.5. Shortcomings of the organisational culture As discussed earlier in Section 7.2 and 7.3 of this chapter, the 21st-century atmosphere of public healthcare service delivery demands flexible and leaner organisational structures. These are modernised public institutions that are built on practices such as delegation of authority and cut-off red tape and bureaucracy. One of the Public Administration paradigms of New Public Management (NPM) is premised on building and sustaining a quasi-private sector style public service where citizens are treated similar to private sector clients not some beneficiary of a social assistance programme. 178 The ECDoH can use these models to improve the efficacy of its public healthcare delivery practices. This can include the adoption and use of a client-centered approach that keeps citizens satisfied and is mostly premised on the bottom-approach to service delivery. In that manner, middle and lower level employees are liberated to make decisions and innovate without having to wait on some ‘one center of power’ to get overwhelmed by their workload and either make a rush decision or significantly delay decision making. In the context of the study, good governance (discussed in section 4.2 of this study) has been central to the need for M & E as an enabler of government efficiency in the ECDoH and South African public service in general. There is a growing need to transform from having scenarios of disempowered and demotivated subordinates into a conducive healthcare delivery atmosphere. Such a transformation can bring about an inspiring culture in an organisation, one that is based on a shared vision of efficiency in healthcare service delivery. In this regard, therefore, the study can infer that a culture that is pro-NPM pro-good governance is also supportive of M & E which tool for efficient service delivery. In one of the interviews of this study, a respondent said the following. A continued absence of an M&E framework in the ECDoH has affected both individual and organisational performance which has been below average. Consequently, that has affected the delivery of the healthcare mandate. The current organisational culture promotes mediocrity and needs to be duly transformed into a more professional and people-centered healthcare service rendering one. We have lower level employees who might be having the needed energy and ideas but because those on top cannot allow feedback and innovation, the ideas die a natural death. Also, the culture of rigidity has affected the improvement of efficiency in this Department (Responded 15). In the event that the ECDoH puts a working M&E framework in place, these hurdles to innovation will be exposed and subsequently resolved. In such a scenario, the overall performance of the organisation will be taken into account without an obsession onto how individual (and sometimes low-level subordinates) perform. That can create an opportunity for ECDoH to timeously ensure that under-performing staff is either re- assigned or relieved of their duties and responsibility. As alluded earlier in Section 7.3 of this chapter, the PMDS does not have the strong capabilities of exposing 179 organisational flaws since it emphasises on individual performance. Hence, an M & E framework will enable the scrutinising every aspect and component that is part of the ECDoH’s apparatus to delivery public healthcare services. The reliance of the ECDoH on a centralised culture of organisational management has delayed the implementation of pro-efficiency practices. Within the PMDS, the top management has been critiqued for failing to execute critical tasks (which may be universally implemented within a well-structured M & E system) in the time leading to healthcare delivery inefficacy. Furthermore, there has not been much efforts to expedite and rectify such impediments. One of the main demerits of the bureaucratic manner of organisational management has been the entrenched delays in decision making as seen in the ECDoH in this study. Red tape further delays the implementation of remedial action since that bureaucratic glitch which affects the diagnosis and subsequent correction of such anomalies. This will be addressed if a good M & E framework can be adopted and implemented in the ECDoH. Question eight of the interview discussion guide looked at continuous improvement as a tool for improved service delivery. The study established that modern practices of M & E should ensure that all public activities are carried out in time and variances instantly attended to and addressed. Waiting for the elapsing of a fiscal year or ‘harvest’ of a policy programme might be futile especially given that public healthcare is a critical public service area for the people. A respondent addressed the blatant bureaucracy as follows. The centralised manner of our Department has not been helping our quest for improving public healthcare delivery. For example, we have a challenge in the ECDoH of a slow pace in the processes of implementing the performance development plan for employees, which can imply that M&E framework can stall and hence face the same fate. However, I am hopeful that the current organisational culture of practicing too much centralisation can be transformed into a more flexible one. We need to improve the manner in which we deliver this critical public service of healthcare (Respondent 16). Poor infrastructure has been discussed in sections 7.2 and 7.3.1 of the Chapter as another impediment to the efficient delivery of public healthcare in the Eastern Cape 180 Province by the ECDoH. Within the same context, there has been a more particular challenge related to a shortage of critical medical staff like qualified doctors in rural areas more than their urban or peri-urban counterparts. The following section covers discussions on the challenge of low human capital resources and rural stigma affecting the assignment of medical staff. 7.3.1.6. Human capital constraints and rural stigma The major human capital challenge that has compounded public healthcare delivery in the Province is human capital shortages. This includes both understaffing and the scarcity of critical medical staff such as surgeons. The study revealed that the exceptionally skilled medical staff have fallen prey to the prevailing stigmatisation of rural deployment. Simply put, some qualified medical doctors in the Eastern Cape Province have seen rural deployment as being less attractive than working in cities and urban areas. Mention is hereby made that medical doctors and other support staff are in short supply in South Africa at large, thus mirroring the ECDoH situation. Moreover, having these professionals refusing rural deployment makes it worse. South Africa has had skills a scarcity challenge for long. Such as been another challenge that the post-1994 democratic dispensation had to grapple with. Further complicating this already precarious situation is the skills drain which has seen medical practitioners leaving public entities either for private sector ones or for the proverbial ‘greener pastures’ in foreign lands. Data gathered in the study from respondents 2 and 11 in this study established that critical medical staff such as heart surgeons and cardiologist are migrating to countries such as Canada in search of better opportunities. Another case in point was when critical medical staff and public healthcare professionals migrated into the private sector locally, leaving the Department grounded as mentioned by respondent 14. Respondents 6, 11, 16 and 20 alluded to this skills and human capital impediment as seen in the following interview excerpt from one of them. We have a rural stigma which has affected the delivery of healthcare services in the rural parts of the Eastern Cape Province. At times we have healthcare professionals and workers reluctant to be deployed in deep-lying rural enclaves especially in the former Transkei homeland. Even our 181 leadership sometimes visits the facilities in the mentioned areas when there is an urgent need such as incidences of public service delivery protests. We expect the gathering of ample data and rolling- out of an M&E framework to prioritise and address this rural-urban divide (Respondent 20). The delicate situation in the rural areas of the Eastern Cape has led to a charged and hostile relationship between the ECDoH and its constituency. If the said hostility is not amicably diffused in time, it can lead to the destruction of critical infrastructure through violent protests. The resolving of this hostility should be through deploying needed medical staff. Data gathered in the study further show a continued ruralurban bias, something which has led to some rural-urban migration driven by citizens’ search and the quest for superior healthcare. The citizens who migrate from urban areas sacrifice their all for the sake of a well-managed urban city or town’s healthcare system. Such a rural-urban divide between rural and urban areas needs to be addressed. According to respondents 9 and 13, the rural-urban migration has led to an exponential sprawling of informal settlements around metro or urban areas. A timely rolling-out of an M & E framework is anticipated to address these individual challenges towards universalisation healthcare delivery efficiency. Data in the study as discussed in section 7.3.1.8, further showed that the critical components for organisational and individual performance are both affected by staff shortages in the ECDoH. Without weighing on the prospects of the mooted M & E framework succeeding, the gaps in human capital resources are most likely to have a negative impact on the efforts to improve efficiency in the ECDoH. Respondents 15 and 19 in the study lamented the acute staff shortage in the department. They gave an example of the PMDS unit, which can be an equivalent of an M & E unit, as one of the understaffed departments in the ECDoH. In that regard, therefore, the shortages of staff in the ECDoH has affected the rolling-out of M&E and evaluation since the thought of expanding the scope and size of a department is more daunting that first filling those human capital gaps. The study can deduce that the shortages of both professional (medical) and administrative staff that currently is prevalent in the ECDoH has far-reaching consequences if there is a possibility of adopting and implementing an M&E framework. 182 A further human capital constraint relates to the frequent changes to those in the position of authority which has disrupted the flow of policy programmes such as the frequent changing of Directors in the ECDoH. It also affects the envisaged vision for the political heads, with most having to stay for short periods; way before their visions for the ECDoH gets into fruition. This periodic and sometimes impromptu change of political heads and accounting officers affect the realization of sustainable healthcare service delivery since the Department has to always adapt to a new leader who comes with new plans and priorities from time to time. A case in point is that between January 2016 and December 2017, the ECDoH has had a change in its HOD thrice, a new HOD every six months is a turnover that is too much for such a vital department. One of the tenets of good governance is the enforcement of public accountability. As conceptualised in Section 4.3 of this thesis, accountability is concerned with the act of ensuring that public officials are answerable for the decisions and action that they take. Public accountability also encompasses issues related to efforts to ensure that citizens get the best value for money and that the public services and goods are rendered in an efficient, economic and effective fashion. The study saw another key challenge to the efficient delivery of public healthcare services in the Eastern Cape Province to be poor enforcement of public accountability. This stems from the current practices which have little or no particular focus on how accountability can aid in improving the efficiency of the ECDoH. The aspect is hence detailed in the discussed which follows. 7.3.1.7. Poor accountability enforcement The study emphasises that public service delivery be a continuing process that comprises various interdependent components of equal importance. This implies that every aspect of the governance processes given an equal and deserved priority. One such aspect is the modern-day practice of tracing how the process of policy implementation progresses through various phases through M & E. Unlike ancient bureaucratic practices when public organisations were much concerned with the end product, M&E has been hailed as the game changer due to its emphasis on a due process of timeously tracking how public programmes are implemented. Not only that M & E aids in the vital timely correction of variances, but critically provides feedback to key stakeholders in the implementation process. Such merit, therefore, enables the 183 holistic management of programmes with all components being probed from prospects of maximises public benefit. Overall, the gathering of individuals and organisational performance data provides crucial feedback which can help prioritise critical areas. In the context of the study, critical infrastructure needs such as roads, clinics, hospitals as well as medical staff placement can be identified within a well-executed M & E system. Monitoring and evaluation will further lessen the burden of enforcing accountability since periodic and swift data and results are available for decision makers. In most cases, those in positions of authority such as the directors and managers in the ECDoH make decisions towards making public healthcare delivery more people-centered and efficient. The status quo in the ECDoH has been revealed to discourage the holistic enforcement of accountability as raised by one interviewee whose response is quoted as follows. Although the PMDS enforces of accountability particularly on individual employee performance, it is merely confined to an ex-post activity where assessments are done at the end of the year. It is again not designed to enforce overall organisational accountability. Such a format does not make it flexible to adapt to demands for changes in the policy implementation climate. It is biased because it is centered mostly on employees while there is not much emphasis on the trace and track of organisational policies. What if we are making employees perform optimally well within a stalling organisational policy, one which has a design flaw? (Respondent 32). As discussed in the excerpt from Respondent 32 in the preceding section of the thesis, existing PMDS in the ECDoH system is failing to foster organisational accountability. There is difficulty in ensuring that for example, that policymakers and public administrators are held accountable since the current tool in the form of the PMDS is merely confined to be ‘policing’ subordinate performance management. Despite the growing discontents and demerits of the existing PMDS in the ECDoH, pro-efficiency practices like M & E have neither been adopted nor implemented. At present, the ECDoH uses a skeletal M & E framework being superimposed onto the PMDS. In this regard, the study infers that adopting a working M & E framework in the ECDoH has the potential of enforcing accountability from policy makers, decision 184 makers, and public administrators. That can make gains in the sustainable delivery of healthcare services in the Province. The next section discusses the shortcomings related to professionalism in the ECDoH. 7.3.1.8. Professionalism shortfalls Henry (2016:25) posits that the success of any public organisation in the current competitive globalised world rests on the ability of its human capital to exercise courtesy and professionalism towards its clients and stakeholders. In the public sector setting professionalism can be viewed as the application of specialised knowledge to help solve complex public problems (Henry, 2016:291; Bowman, West & Back, 2014:10). In various academic circles, professionalism has been interchangeably used with pro-efficiency phrases such as ethical behavior, transparency, and impartiality. Section 195(1) (a) of the RSA Constitution (1996) is explicitly clear on the need for professionalism, through one of its basic and values and principles which govern Public Administration in South Africa that, “a high standard of professional ethics should be promoted and maintained”. The increasing cases of corruption and maladministration in the South African public service have seen a degrading of ethical and professional behavior amongst civil servants. This is because such malpractices are a clear sign of the failure of those perpetrating the lack of professional conduct. The ECDoH is one of the public entities which has taken a hit from these unethical patterns of public servants’ conduct as seen in the growing cases of unethical conduct in the delivery of healthcare services. In addition to the challenge of professionalism shortfalls, the unprofessional conduct of nurses and other staff members in the Province has been blamed for the current less efficient manner of healthcare service delivery. These unethical behaviors have affected the achievement of the overall mandate of the Department that is to deliver public healthcare to the people of the Eastern Cape Province. The study quotes one respondent in the citation below. Problems that we face include clinics opening two or three hours late and closing one or two hours early, while most of our clients or patients would have come from quite distant places. The early 185 closures of these clinics do not even consider the relatively long waiting times during medical attention and if there are still unattended clients. Clearly, this is a sign that clinic staff does not have an appreciation of how critical the timely delivery of healthcare service is to the people. This has damaged our image to the clients we serve and needs to be sorted out as soon as it possibly can (Respondent 35). In addition to the issues raised by the interviewee in the preceding quote, there has been a further impediment to sustainable delivery of public healthcare in the Eastern Cape Province. This challenge relates to the aptitudes of clinic and hospital staff. The study established through respondents 3, 7 and 17 which, the most unprofessional staff stationed in rural areas, in places perceived to be remote and hence cannot be timely inspected. These nursing staff members are sometimes performing dismally by the mere virtue of them perceiving to be far beyond the eyes of their supervisors. The study links this to failure by the ECDoH to monitor and evaluate all components of its public service delivery apparatus. In the presence of an M&E framework, the training needs of staff on professionalism would have been identified and implemented as required. In addition, public healthcare service delivery trajectory will be kept in check and inspectors would visit facilities frequently. In that regard, the ECDoH would treat everybody with the courtesy, professionalism, and consideration that they deserve. Below is an excerpt of a corresponding interview session on this particular matter. In my opinion, the ECDoH faces a challenge of attitudes in our facilities and clinics. For example, this season we have a high teenage pregnancy and sometimes our officials castigate these teen for falling pregnancy. We also need to desist from overdoing the motherly or elderly advice, that we can do it in private and avoid stigmatising the pregnant teens and even those infected and affected by HIV. Such issues need to be handled by trained professionals such as counselors. What will happen is that these people will feel embarrassed to follow their antiretroviral therapy and the infection rate keeps going up. We do not need an increase in antiretroviral therapy defaulters (Respondent 36). Although the relative importance of evaluating and managing employee progress and performance in an organisation remains prudent in the 21st century, there is a need for public entities such as the ECDoH to embrace emerging organisational improvement tactics such as M & E. These include but not limited to pro-efficiency practices which seek to deepen and widen the delivery of services to the public. Monitoring and evaluation is one such a modern practice. In this study, there have been various voices 186 against delayed transformation in the ECDoH as detailed in section 7.2 and 7.3 of this chapter. These opinions and views criticised the manner in which the PMDS is being utilised, with most respondents such as 8, 10, 20 and 25 criticising its biased evaluation of employees and obsession with financial rewards for performance. Taking cognisance of the reason behind PMDS in the public sector, which is performance management, this has not been the case in the ECDoH, as bemoaned by one respondent as follows. Presently, there is a challenge of the less accurate nature of employee evaluation. You will find out that everyone in the ECDoH is categorised as a satisfactory performer. Does it mean we do have under-performers or average performers? No, it does not in any degree or form. That is not a true reflection of performance evaluation. The PMDS is the ECDoH is so old-fashioned that those tasked with implementing it has lost interest in doing things right. If we continue like this, it will bite us in the most regrettable manner (Respondent 41). Furthermore, the study established through interactions with respondents 20 and 22 that the turnaround time in the ECDoH’s facilities is too long, and most time is lost in tea breaks, delayed opening and too long waiting periods. Such a needless loss of time results in a corresponding dissatisfaction of clients and sometimes litigation costs to the Department. Moreover, it is not easy for the Department’s hospitals to open 24 hours due to the crime prevalence which exposes its professionals to robberies and other crimes as highlighted by respondent 4 in this study. This is despite the ECDoH, having its own private contracted security guards. Three of the respondents (12, 16 and 19) indicated that the private security contractor provides merely entry-level security guards who are neither equipped nor trained to deal with serious crimes such as robberies. Also, in the event of internet network connectivity going offline, the lag and downtime have been too long and such slow response rates for technicians affect the timeous delivery of healthcare to the people (Respondent 10, 2017). In the same vein, patients or clients take too long to get attended, with these waiting periods painstakingly, especially given that some in the remote rural areas such as the former Transkei homeland area walk long distances to get to the nearest facility. The study argues that, that the mere existence of the challenges discussed in this section is indicative of the absence of M & E in the ECDoH. These can be mitigated if there is a working and well-implemented system of track and trace in the Department. 187 7.3.1.9. The burden of manual record keeping The influence of globalisation and the rapid expansion of ideas and information in the modern era has been driven mostly by Information and Community Technology (ICT). The public service in South African can move with the times by investing in appropriate technologies to ease the burden of manual record keeping and the overall administration of public entities such as the ECDoH. It is not surprising that this study established through respondents 5 and 22 that the ECDoH is still stuck with manual methods of managing and keeping records. Data sourced from respondents 3, 11 and 13 showed that crucial information is being kept in manual hard copy files which have inconvenienced how the Department delivers services to the people. There are many merits of ICT based ways of keeping records. ICT and e-governance have been proven to be one strategy that has improved access to public services by citizens, in an efficient manner (Anderson, Wu, Cho & Schroeder, and 2015:6). The researcher argues that, in developed economies such as the United Kingdom (UK), their efficient National Health Service (NHS) is a living example of how ICT has revolutionaries the way public healthcare services are being delivered. The following interview excerpt from an interviewee who addressed the issue of manualised record and data management, and the urgent need for ICT assimilation. In this Department, we need to seriously invest in ICT in this M&E framework to ensure that all records and digital evidence is kept and auditable. We can easily ensure that units or facilities which are stagnant or having below par performance are easily identified and investigated. The current level of e-government in the ECDoH is not intense enough to improve on the efficiency of healthcare service rendering in our constituency. Issues like client services, waiting times and customer satisfaction survey before one exist a facility will be useful. Technology can significantly help us reduce the burdensome reliance of manual records in the ECDoH (Respondent 37). Discussed challenges including rural stigma and poor staffing which can be resolved through intensified investment in ICT by the ECDoH. The study found out from respondents 2, 6 and 18 that manualised reporting has affected the efficacy of public healthcare service delivery by the ECDoH. It has become a labor-intensive process, which sometimes consumes valuable time for the ECDoH. In this regard heads of 188 various units have to spend time on manualised records that attending to urgent and other crucial aspects of the Department. As highlighted in the earlier section 7.3.1.4 of these chapters of the thesis, the prospect of the unveiling of the NHI is the South African public healthcare sector makes ICT assimilation a need. This can be a catalyst to the enrolment, monitoring, and evaluation of the vast records of citizens’ public healthcare profiles and both homogenous and divergent needs thereby doing away with current glitches and impediments as seen in the ECDoH. The study further regards ICT as a crucial game changer or catalyst to the adoption and implementation of an M & E framework. Such a method of managing employees and organisational goals can transform the effectiveness, efficiency, and economy in public service delivery. ICT has been instrumental in the improvement of good governance especially in terms of efficiency in public service delivery as argued in Chapter three. Public financial resources have been branded one of the scarcest resources in the public sector, hence the ECDoH’s efforts to sustainably delivery healthcare services has been inevitably affected by budgetary challenges as discussed in the next section. 7.3.1.10. Budgetary constraints The ECDoH has been constrained in the delivery of sustainable public healthcare to the people of the Eastern Cape Province by budgetary challenges. Apart from the allocation of fewer resources to the expansion of infrastructure, the expansion of public healthcare services in the ECDoH into deep-lying rural areas has faced a budgetary obstacle. Respondents have indicated that it was not easy for the ECDoH to expand and ensure that the public healthcare services that it provides are uniform across the entire province since the rural areas are faced with less budget allocation. As for their urban counterparts, infrastructure in urban areas such as roads has vastly improved since the dawn of democracy mainly due to the fact of most urban metros and town councils raising ample revenue and constructing their own facilities. A case in point is the evident differences in road networks that are in an urban metropolis like East London as compared to the gravel roads found in areas such as Tsolo, Tshabo, 189 Ndevana, and Qumbu. Contrarily, the case is different in rural areas with rural municipalities which struggle to raise revenue. Most respondents (for instance respodents1, 4, 7, 11, 16, 25 and 30) bemoaned the continuous existence of poverty in the rural areas as a factor affecting revenue base and prospects for socio-economic development in Eastern Cape Province. An example is the Nyandeni Local Municipality which has a primarily poor contingent living in rural villages such as Libode deep in the former homeland of Transkei. The study ascertained that the average income of families in these areas was less than R400 (US$34) per month with a majority of the residents living on state-funded social assistance grants. This figure was ascertained through Statistics South Africa (StatsSA)’s household poverty income surveys in 2016. Such subsistence is regarded as extreme poverty since the United Nations benchmarks extreme poverty to be living on less than US$40 per month, as shown in its Sustainable Development Goal programme (2015) of reducing the number of those living below US$1.5/day by 2030 (UN, 2015:2). In that regard, one cannot expect such an area to raise enough revenue to build the state of the art infrastructure such as roads and clinics. It is therefore inevitable that public services such as public healthcare services in rural areas will tend to be of lower quality than those in urban areas. While budgetary constraints will always persist in the delivery of public healthcare services, the continued existence of bureaucratic bottlenecks or further compounds an already delicate situation. According to respondents 5 (2017), the ECDoH has numerous complaints on how the issue of red tape has disadvantaged the delivery of public healthcare services. The approval of operational budgets in the ECDoH has taken a long time thereby sometimes having a knock-on effect on the staff members who will be running such a project. The following is an interview excerpt of one of the respondents in the study. Budgetary constraints have affected the promoting of the Department’s mandate in delivering healthcare services. This has mostly taken the shape of bureaucratic delays in the approval of the budgets for projects from the provincial head office. Sometimes we have to wait indefinitely until a time when one head tasked with approval decides to do their job. These are individuals with a huge workload and schedule, sometimes away on national conferences duty. Delegation of authority and responsibility would help a lot in these instances (Respondent 46). 190 Presented in this section of the thesis are the various impediments that have affected the delivery of sustainable public healthcare in the Eastern Cape Province. These are the numerous challenges that are both unique to the Province and homogenous to other parts of South Africa in relation to public healthcare service provision. The discussed challenges in section 7.2 and 7.3 of this chapter, having been expanded across various spectrums of public service delivery including inter alia, human capital deficiencies, lack of professionalism, rural stigma, poor accountability enforcement, financial constraints and slow pace of ICT assimilation. In one way or the other, these challenges have been blamed for the lack of efficacy in the delivery of public healthcare services in the Province. In the same vein, these challenges have either made it difficult for the adoption of M&E in relation to the implementation of the public healthcare services in the ECDoH are the consequence of the absence of the practice of trace and track of the policy programmes. While it is true that poverty and underdevelopment have been bemoaned as the cause of sometimes poor public healthcare services in the Province, it is the absence of 21stcentury compliant pro- efficiency practices encompassing M&E that exacerbates the bad situation. The adoption and implementation of such client-oriented practices can concurrently ensure that the ECDoH delivers on its mandate while keeping its clients constant and consistently satisfied. The study discussed the prospects of improving the efficacy of the ECDoH in the delivery of its mandate to the people of the Province, through using an M&E framework based on empirical evidence, in the following section. 7.4. DISCUSSION OF FINDINGS The synopsis and corresponding detailed discussion of some of the many challenges that public entities in South Africa face in a bid to implement M&E have proven that although a lot needs to be done, it is possible to achieve government efficacy. In addition, the highlighted challenges or constraints can be resolved in various cycles with some having a huge bearing hence requiring long term rectification in contrast to some that are short term in character. Emphasis is placed on the need to put people first in whichever activities that the government is involved in. That includes the 191 delivery of public healthcare to the people of the Eastern Cape Province by the ECDoH. Having an efficient, effective and economic model of the delivery of public healthcare services to the people of the Eastern Cape builds citizen confidence in their government. An efficient public healthcare service delivery framework builds vital rapport between the people and their government. According to Sigwejo and Pather (2016:6), a citizen-centered approach calls for the provision of citizen-oriented services including public healthcare, ones which meets the citizens’ expectations. In laymen terms, citizen-centered governments provide public services and resources custom-made to the actual service and resource needs of the citizens, especially given the need for efficacy in the delivery of public healthcare in the Eastern Cape Province. A citizen-centered bottom-up approach to public service delivery echoes the tenets of the Batho Pele (people first) Principles which seek to ensure that goods delivered by the government are tailor-made to suit the unique needs of societies and communities. In that regard, government entities can move from ancient practices such as the PMDS in the case of the ECDoH and embrace modern ones like M & E. Public entities like the ECDoH will embrace emerging practices to ensure that the people are given a greater value of money in services delivered; have recourse for remediation; have access to service information; get service standards that are of sound quality and above all are treated with utmost courtesy and consideration. Principally, the researcher argues that a Batho Pele premised public healthcare delivery model will be devoid of public service delivery protests, won't time to the late opening of clinics or tea breaks, as seen in the analysed data from the study. A question on the possible prospects of the improvement of government efficacy through an adoption and implementation an M & E framework can be answered in multifarious ways. Key evidence of an efficient and effective ECDoH after the implementation of a well-articulated M & E framework is the relative ability of such a system to above all, enforce accountability. This is derived from its ability to do a timely trace and track of all policy programmes including those which have something to do with staffing, infrastructural development, operational logistics and performance management. The study has analysed data which showed the failure of the efficiency 192 of the ECDoH due to its inability to adopt these pro-efficiency practices. In the event of the ECDoH utilising M & E, it becomes easy for variances and challenges to be resolved in time. Decisions that are critical to resolving challenges such as the ones discussed in the preceding section (7.2 and 7.3) of this Chapter can be swiftly made. The study perceives that there is nothing more encouraging than a decision maker who takes a certain organisational stance based on facts from M & E. Such scenarios can ominously drive the ECDoH towards being an efficient and client-centered public entity. That can be pivotal in correcting years of inefficiency which have come to characterise the department. In a developmental state like South Africa, M & E is the vice onto which the 3Es of efficiency, economy, and effectiveness is promoted and sustained in public entities such as the ECDoH. A developmental state is one that is centered on a holistic and universal transformation of its economy into a modern one derived primarily from the ability to make policies that promote sustained growth and socio-economic development (Swilling, Musango & Wakeford, 2016:652). In the context of South Africa, the task of addressing the disparities left by the apartheid era (including lack of access to quality healthcare) and keeping the state abreast with global trends has become the crux of the developmental state agenda (Swilling et al., 2016:660). In so doing, wastage of public funds and leakages through malpractices such as fraud is minimised thereby giving the people good value for money to entities like the ECDoH. With the numerous merits that the tracing and tracking of organisational performance within M & E, it is cardinal that the ECDoH expedite its implementation of the practice. On the issue of maladministration that has been taking place in the Department, there is a huge potential for the ECDoH to resolve it. The study pays particular attention to the reliance that the ECDoH has had on individual employee performance while neglecting an equally vital aspect of the overall organisation trajectory towards meeting its goals. The study, therefore, mentions that shifting attention from the old-fashioned PMDS and focusing on taking an eagle-eyed view of organisation performance can help expose weakness and enable a timeous rectification of variances. Consequently, less time is wasted on concentrating on less 193 critical aspects, thereby enabling the ECDoH to dedicate precious time to creating and sustaining efficiency. With improved quality of public healthcare at the core of the National Development Plan (NDP 2030), using an M & E framework to trace and track public healthcare service delivery can be handy to the ECDoH. This is because M & E is a pro-efficacy practice and is in line with the goals of the NDP, which are inter alia, improved public service delivery efficacy. Such a framework can assist in removing the service delivery backlogs in the Province, while concurrently smoothening all the intertwined functions that collectively promote the ECDoH’s vision and mission. Cognisance should be taken in this study that; the Eastern Cape Province has long been tagged to be one of the poorest regions in the Republic. Such a tag has had a serious negative connotation in the manner in which public services (including public healthcare) are been delivered. In addition, due to its vast remoteness, deep-lying rural enclaves have had the poorest healthcare facilities. Therefore, M & E can be the catalyst to the correction of this image and reality. An undeniable fact is that those domiciled in rural neighborhoods should equally enjoy the right to healthcare similar to any other citizen, as enshrined in Section 27 of the RSA Constitution (1996). In the process of adopting and implementing a functional M&E framework, there are however some practices that the ECDoH can do away with. Over and above all, is the reliance with the PMDS that has seen individual employee lose focus of the need for organisational success rather being glued to their solitary performance trajectories. In that regard, the researcher argues that the ECDoH can safely do away with the generic bonuses and improve performance bonuses based on a working M & E framework within the ECDoH. The employee performance should be tied to the relative contribution that it makes to overall organisation performance. In laymen terms, it will be individuals’ performance contribution as seen through a broader organisational performance lens. Additionally, the study emphasises that these modifications should be marketed to the entire ECDoH to guard against any friction of possibility for resistance. M & E awareness campaigns within the department should address the need for change and the merits it brings to the clients or citizens than how it can benefit ECDoH employees. The study also established the need for an organogram redesign 194 to eliminate inter alia, role ambiguity, red tape, and bottlenecked decision making that is overwhelming those in the position of power with tasks. This particular research finding has far-reaching implications to how modern-day public entities operate amidst the need to effectively remove bureaucratic residue. There is a huge prospect of the Eastern Cape Province’s healthcare standards to reach commendable heights. This is mainly due to the potential that the ECDoH has if it adopts and implements a feasible M & E framework, like the one proposed in Chapter eight of this study. Nonetheless, the implementation of M & E should be preceded by human capital capacitation. This has been another key finding of the study, that the skills levels in the Department are not that effective for transformation, therefore, are not requisite for the effective rolling-out and sustainable management of working M&E programmes in the ECDoH. In succinct terms, the skills and aptitudes of human capital resources are when judged on current levels are somewhat deficient as argued by respondent 24 in this study. Data in the study built a perception that unveiling M & E in the current atmosphere might be suicidal. This is due to the many inhibitions that the current tool of PMDS faces. Examples of some scenarios that the PMDS encounters are that there is much duplication of old assessments into new PMDS assessments. It will be essential that all ECDoH employees be inducted on how the M&E system works before it is implemented. A potential benefit to the delivery of public healthcare services by the ECDoH is that critical components such as staffing, recruitment of critical staff will be planned and cases of shortages might be minimised within an M & E framework. In a bid to further lay the groundwork for the implementation and subsequent success of an M & E system in the ECDoH, some drastic measures should be explored and if possible, be implemented. Key to these is the need to create and sustain a culture of data management in the Department. There is a need to put in place adequate systems for the collecting, collating and recoding of data linked to planned and actual performance (and variances) away from using estimates and sometimes misleading reports. The study revealed that information gathering and utilisation is at its lowest in the ECDoH. As argued in section 7.3.1.4. of this chapter, in order to resolve the performance challenges that it currently faces, the ECDoH is in dire need for noble 195 leadership which can ensure that M & E or other activities can be correctly implemented, especially the need for record keeping and data consumption. That is promoting data or facts backed decision making. For example, at present, it was established in the study that the filing of data on healthcare facilities and policy programmes was not in sync with the dictates of the District Information Management System. Another aspect that has a chance of improving the prospects of utilising M&E for government efficiency in the ECDoH relates to liquidly support. Budgetary support for the various components of M & E of public healthcare service delivery in by the ECDoH is needed to give effect to a smooth transition from current PMDS practices. Oftentimes, the Department has had delays in the rolling-out of projects because of delays in budgetary approval or the inherently limited resources that affect the South African public service. Firstly, there should be a delegation of authority and role clarity followed by strict accountability enforcement measures for those responsible for fuelling the policy programmes of the ECDoH. Monitoring and evaluation are in urgent demand, the ECDoH should trace and track employees’ performance be it mid-term or quarterly. A timely M & E would ensure that all employee duties and responsibilities are achieved in harmony with ECDoH’s vision, mission, and goals. Presented in this section of the Chapter is a discussion of findings in the study. These are discussions with an eye on the prospects of improving the efficiency of the ECDoH in delivering healthcare to the people of the Eastern Cape Province. While the study acknowledges the presence of perceived potential hurdles and current challenges, the ECDoH has a fair chance of eliminating the current level of inefficiency by adopting and implementing a working M & E framework. However, such a move needs to take a holistic approach where relevant stakeholders partake in its adoption while various other strategies precede such a move. This is because existing challenges to the efficacy of the ECDoH must be resolved before a new era of efficacy is ushered onto the scene. 196 7.5. CONCLUSION Monitoring and evaluation is a good governance practice and plays a part in enhancing the performance of the public service. It is also a superior version of the practice of performance management. Chapter analyzed and presented data. The analysis was mainly based on the impediments which have affected the efficacy of the ECDoH. It further progressed to discuss the findings within the context of the prospects of the Department to improve its healthcare delivery efficiency. In brief, despite the existence of a plethora of challenges to the entity’s efficacy and implementation of pro-efficiency practices, the ECDoH has good prospects of improving its efficacy and performance by adopting and implementing an M & E framework. Such an enhancement of performance is based on the ability of the Department to trace and track performance both individually and organisationally. Over and above, M & E is that is based on facts, therefore can lead to informed decision making on how the efficacy of the ECDoH can improve its performance. Such data and feedback can further be utilised to predict and diagnose problems before they derail public healthcare service delivery in one predominantly rural, poor and needy Province of South Africa, the Eastern Cape Province. On another hand, the absence of an M&E framework presently affects the issues surrounding human capital provision, training need analysis, determination of the Department’s infrastructural needs and the attraction of scarce skills. In a modern era characterised by high rates of ICT penetration, the ECDoH can further smoothen its use of M&E by intensifying its investment in ICT. Such a move can ensure that all components of public healthcare delivery monitored and evaluated against set targets, towards universal healthcare access for all people regardless of any arbitrary characteristic, from geographical location to income. In the next Chapter, the study develops, proposes and presents an M & E framework for consideration by the ECDoH as a performance enhancement tool for improved efficacy in the delivery of healthcare services to the people of the Eastern Cape Province. 197 CHAPTER EIGHT PROPOSED MONITORING AND EVALUATION MODEL 8.1. INTRODUCTION Public healthcare is one of the fundamental rights that every citizen in South Africa should enjoy. Apart from access to the same public service, the responsible authorities should further ensure that the rendering of this essential public service is done in an effective and efficient manner. The overall aim of the study was to explore how the ECDoH as the authority providing public healthcare services can best use M&E to efficiently and effectively deliver public healthcare services to its constituents. This thesis unfolded through the various sequential chapters, with the preceding one addressing one of the research objectives that sought to explore challenges affecting the effective and efficient delivery of public healthcare services in the Eastern Cape Province. Consistent with the analysis of inhibitions to the effective and efficient delivery of public healthcare services was the sixth research objectives of the study as outlined in Section 1.5 of the first Chapter of the thesis. The said objective sought to, “explore the avenues through which a feasible public service healthcare M&E model can be developed to help the ECDoH improve in the manner in which it delivers public healthcare services in the Eastern Cape Province”. It is the purpose of the current chapter of the thesis to fulfill that objective. Meanwhile, the study looked at the meaning and the implication of the concept model which is oftentimes interchangeably used with a particular framework. For purposes of this study, a conceptual model and framework are used synonymously. This implies that they are perceived to mean the same things. Their definitional forms are now explored as follows. A framework is conceptualised as, “a basic conceptual structure (as of ideas)” (Merriam-Webster Online Dictionary, 2018:3). On another hand, a conceptual model is defined as, “a usually miniature representation of something or a pattern of something to be made” (Merriam- Webster Online Dictionary, 2018:2). These terms are interchangeably utilised in this thesis because they both imply somewhat the involvement of a layout which details how public processes or programmes are going to be executed. In the context of the study, the term ‘model’ refers to the various phases or stages that the ECDoH should 198 consider following towards fully utilising M&E as a catalyst for achieving the outcome of enhanced performance. Such performance is interpreted to be implying a citizencentered bottom-up timely delivery of various public services including public healthcare services. The proposed model entails making public healthcare delivery more efficient, economic and effective. Such a feat is attainable if the ECDoH executes its activities in a fashion that transmits maximum benefit to clients or consumers of public services, the inhabitants of the Eastern Cape Province. In the coming section of this chapter, the proposed model for enhancing performance in the ECDoH is presented and discussed. 8.2. A PROPOSED MONITORING AND EVALUATION MODEL A nine-step model for utilising M&E for improving the efficiency (and performance) of public healthcare service delivery in the Eastern Cape Department of Health has been proposed as shown in figure 4 of the current section of this chapter. Its various important processes are now individually looked at. 8.2.1. Problem identification phase While the South African public service faces a range of problems, mention is made to the character of these obstacles being homogenous and unique to various entities. Furthermore, the relative impact of these public service problems varies from one public entity to another, hence requiring a contextualised diagnosis and resolving. In the case of the ECDoH, the preceding chapter of the thesis went at length to identify and solve these problems in Sections 1.3 of this study. In this regard, the first phase of the proposed model of public healthcare service delivery efficiency in the Eastern Cape Province centers on the identification of those problems. Principally, the essence of this stage is to ensure that whatever interventions that the ECDoH will adopt and implement are tailor-made towards resolving those problems. Such a diagnosis avoids somewhat ‘shooting without aim’ for the Department. 199 As discussed in Section 7.3 of Chapter Seven of the study, some of the challenges or problems that have affected the delivery of public healthcare services in the ECDoH include inter alia; organisational rigidity, absence of political will to ‘sell’ and create awareness on pro-efficacy practices such as M&E, human capital shortfalls, rural stigma, poor infrastructure development, budgetary constraints and lack of uniformity within the entire South African public service. In the context of the study, it is the vital process of problem identification that sets the foundation for the designing of appropriate interventions that seek to mitigate the impacts of these obstacles. It is during this phase of the model that all ensuing decisions and process are placed under an ongoing monitoring practice (ab initio) in order to ensure that all goes as planned. 200 Figure 4: Proposed monitoring and evaluation model for the Eastern Cape Department of Health 201 202 8.2.2. Preparatory phase Succeeding the problem identification stage of the proposed model for performance enhancement in the ECDoH, is the preparatory phase. It is in this particular stage that the Department gathers public resources and other required materials for building an efficient and effective healthcare delivery system. This precise phase starts with an audit of the Department’s public resources and readiness of the available materials to effectively address the identified challenges. Moreover, another critical activity of this particular phase centers on the engagement of various stakeholders who may have a hand in the rectification of the challenges at hand. These stakeholders also include employees of the ECDoH since they are the ones who will be directly involved in the implementation of whichever interventions that the public entity may choose to pursue. This is in line with the findings of the study, which show that the absence of stakeholder engagement affects the smooth delivery of public healthcare services as discussed in Section 7.4 of this study. Additional vital stakeholders include the citizens as the sole consumers of public healthcare services, the national Department of Health as well as the Department of Performance Management and Evaluation (DPME) in the Office of the Presidency. The reason for engaging the DPME rests in the need to ‘pluck some feathers of wisdom’ on how the GWMES has been a success story for them. Therefore, the ECDoH should adopt and assimilate best practices on M & E from the national sphere of government (in the Presidency) towards improving how it delivers public healthcare services. NGOs and other community based civic organisations can also be consulted since they are engaged in various public healthcare service delivery related projects which need to be streamlined with M&E practices of the ECDoH. Examples of such organisations are the Anova Health Institute (Company Registration Number: 2009/014105/08) dealing with HIV, Sexually Transmitted Infections (STIs) and Tuberculosis (TB) impact reduction projects in the Province. There is also the Beyond Zero (Company Registration Number: BZ-GF_TG 2003) an NGO that focusses on the strengthening of the referral systems and skills transfers within the ECDoH. Another key NGO which may need to be consulted in this phase is Khethimpilo which focusses on HIV and AIDS prevention and treatment in the Eastern Cape Province. 202 The preparatory phase also entails an audit of the available human capital skills base, the current organogram, organisational culture and the levels of public healthcare services penetration in the Province. Having a detailed picture of the public healthcare service delivery map or profile of the Province helps to know the components of the public healthcare systems that are urgently required in a given locality. It further helps prioritising how these challenges are to be addressed. 8.2.3. Planning phase According to the Business Dictionary (2015:2), planning (in the public service/sector) is the basic management function involving the formulation of the detailed plan(s) to achieve the optimum balance of needs or demands with the resources available to the (public) organisation. It is part of the multifarious functions of public service managers as posited by renowned Public Administration scholars Luther Gulick and Lyndall Urwick in an academic paper on administrative management theory in 1937 when they put forward the famous POSDCORB acronym (standing for Planning, Organising, Staffing, Directing, Coordinating, Reporting and Budgeting). In the context of the study, public planning is regarded as one of the most critical functions that determine the success or failure of ECDoH’s healthcare delivery policies and programmes. In the context of the proposed model, the planning process begins from the revisiting of vision and mission statement to determine if all is in sync with emerging public healthcare rendering demands, the statutory and regulatory framework which places the mandate of public healthcare services on the ECDoH, the holistic profiling of community healthcare profiles, the relative levels of involvement or engagement of the identified role players and corresponding public financial resources required to resolve the challenges to efficient performance by the Department. During this phase of the proposed model, the emphasis is placed on the need for due diligence in the formulation of detailed plans for the achievement of desired goals. The overall goal of this model or related plans will be to achieve enhanced performance. These plans should be explicit and give room for M&E to be implemented as they are carried out. In addition, the planning here is based on how the ECDoH can strike a balance between the need to resolve identified problems with innovating for enhanced, optimal and efficient performance as discussed in section 203 7.3.1.5 of this study. It is critical for the Department to make plans hinged on the 21st- century atmosphere where times have moved away from the use of PMDS to the utilisation of M&E. The ECDoH also has to ensure that plans are based on the need to enhance both individual and organisational performance. Such a direction will make organisational success to be the overarching aim of both subordinates and their superiors. Hence individual goal achievement becomes an enabler for organisational goal achievement through efficient and effective healthcare service delivery. The next phase of the model details designing of the public healthcare delivery programmes. 8.2.4. Design phase As far as plans are an essential component for a successful 21st-century public organisation, the corresponding design of how the drafted plans are going to be operationalised is equally vital. In this phase of the proposed M&E model, there are various important public activities that need to be carried out. Above all, there should be the determination of the Key Performance Indicators (KPIs) at both an organisational and individual level. These KPIs will set the foundations for determining the levels of performance that is tolerable, as well as the kinds of performance which are indicative of poor or intolerable performance. The ECDoH is in a position to likely have a smooth process of setting these KPIs since its continued use of the PMDS has smoothened the determination of KPIs which has been at the pinnacle of their tried and tested PMDS for long as discussed in the findings detailed in Section 7.3.1.1 of the previous chapter of this study. Further activities in this phase include the operationalisation of public healthcare delivery plans. Such can be done by way of ranking these policy programmes of action into short, medium and long term thresholds. By having such a categorisation, the Department can begin with the most urgent and less time-consuming plans, with the implementation of less urgent ones succeeding the short term plans. In the context of the study, the various challenges explored in Sections 7.3 and 7.4 of the preceding Chapter of the study are indicative of varying degrees of existing obstacles. For instance, rural underdevelopment and public infrastructure usually rank high on the priority list. Challenges such as the attitude of medical and support staff 204 can be ranked low, thus requiring action well after rural healthcare infrastructure (a high priority area) has been addressed. It is important for the study to mention that all challenges have to be resolved regardless of their perceived ranking on the design phase. Also, the design phase has to be informed most importantly with the readiness of the public organisation to embrace and adopt the pro-efficiency practice of M&E. KPIs are a vital tool that determines how performance will be traced and tracked, therefore showing the prime importance of this phase of the proposed model. The timely correction of variances requires a conducive atmosphere, one where all plans are designed to collectively work towards the attainment of the ECDoH’s public service delivery mandate. Which is the efficient, effective, economic and sustainable delivery of public healthcare services to its areas of jurisdiction. While the ultimate ex- post evaluation is vital to the efficacy and effectiveness of the proposed model, the study values the process of monitoring which starts ab initio and continues across the various chronological phases of the model to be of equal importance. 8.2.5. Centralised implementation phase Continuing from the project design phase is a vital stage whereby the planned public projects are implemented. Notably, this is a holistic and centralised implementation. While the preceding phases of the proposed model (problem identification, preparation, planning, and design) all involved some form of monitoring, it is from the monitoring stage that results begin to be measured and traced against set performance goals. In this phase, the ECDoH should ensure that the planned public projects or interventions are put into action taking cognisance of the gravity and impact of the challenges that these plans seek to alleviate. Similar to the design phase, the implementation of the interventions and planned programmes for sustainable public healthcare in the Eastern Cape Province should be done according to the ranking on the priority barometer. There should also be the factoring of the perceived impact of the plans in determining the kinds of public projects that should be implemented. As mentioned in the preceding section 8.2.4 of this Chapter, the addressing of massive infrastructure disparities between urban and rural areas should take preference in contrast to issues such as clinic operating hours. As feedback from the ab initio monitoring process begins to filter in, the Department has the liberty to consider revising public programmes of actions of policy components based on a hands-on 205 assessment of the public healthcare delivery atmosphere in the Eastern Cape Province. It is crucial for the Department to always take note and be cognisant of the need for a tailor-made public healthcare delivery system. Additional factors that should always inform the tasked implementers of the public programmes of action are the need for timely delivery of services, efficiency on how these services are delivered as well as giving the public service client the best value for money. This is related and in line with the practice of good governance as discussed in Section 3.2 and 4.2 of the study. The ECDoH should further make sure that the various pro-efficiency reforms and interventions are always financed on time to avoid budgetary bottlenecks as discussed in Section 7.3.1.10 of the study. This ensures that there are no bureaucratic bottlenecks to the approval of project finances. Such an arrangement, therefore, dedicates precious public resources including time, to the implementation than operational procedures. In the context of the study, the plans which needs adopted and implemented include, infrastructure development, human capital provisioning, budgeting, engagement of policymakers in a bid to build political will towards M&E in the South African public service, budgetary fluency, education of the organisation of the benefits of M&E and the comprehensive investing in the ICT infrastructure. In the spirit of smooth performance tracing and tracking, monitoring has to be strengthened from this stage onwards rather than waiting for the final evaluation phase to discover improper designs or other flaws in the projects or interventions. 8.2.6. Performance data collection phase Informed by its statutory mandate derived from Section 27 of the RSA Constitution (1996), the ECDoH has to ensure that its performance gives effect to the sustainable delivery of public healthcare services. Efficiency is another yardstick that determines the success of the Department to achieve that feat. While efficiency is seen as doing things right, there are various indicators that can benchmark if a public entity is performing in a pro-efficiency fashion. In order to determine efficiency, KPIs need to be constant and consistently measured against actual performance. In this regard, therefore, the sixth phase of the proposed model in Section 8.2 of this chapter details 206 the collection of vital performance data. While individual or employee performance can be important to the achievement of organisational goals, it is the section of organisational performance that is measured and contrasted against predetermined yardsticks. In so doing, the ECDoH will be in an informed position to take appropriate, if possible corrective action before the whole process of public healthcare service delivery is affected. The KPIs should spread to various fronts including enabling infrastructure to human capital skills and aptitudes. These KPIs determine if the department is on course. In the case of the data showing things going off-course, the organisation can implement interventions to correct such variances. Within the M & E model and context collecting data can help the planning of future performance since historical data can act as the basis of setting future goals. Critical skills such as those of cardiologist can be budgeted and availed in time through performance data and resource auditing. Data collection needs to be spread across short, medium and long-term thresholds in order to guard against vacuums or monitoring fatigue. Such can happen if entities like the ECDoH go for longer periods without monitoring happening. While most organisations use a fiscal year as the eventual feedback generation tool, monthly, quarterly and bi-annual collection of data can be healthy for an organisation such as the ECDoH. A key guide to how data will be collected is the need to gather factual performance trends, which become useful feedback in the delivery of public healthcare service in the Eastern Cape Province. This is due to the fact that feedback is critical in its ability to inform decision makers and takers on appropriate courses of action. In the context of the study thus, data will be collected on how all components of the healthcare infrastructure or entities are collectively working towards enhanced service rendering. Such a goal also centers on how efficiency in the Department can be improved to the benefit of the citizens. 8.2.7. Analysis of the feedback phase Expert analysis of feedback is also another important stage of the proposed model. In this phase, the expert analysis of collected performance data takes place. This is an in-depth analysis of the various components of the public healthcare delivery system, 207 from the relative performance and contribution of infrastructure, human resource provisioning to the statistics of access to public services of the constituency. The emphasis during this phase is placed on the need to provide detailed factually analysed feedback to the various components or units in the ECDoH. Such an availing of crucial performance feedback can aid these units to partially revamp or sustaining their activities giving effect to the attainment of the public healthcare delivery mandate by the Department. This enables the entire ECDoH to make informed decisions on whether to adopt revised performance plans as a whole or simply implement a partially amend service delivery plan. Also vital at this stage are the KPIs since the said feedback is analysed against the backdrop of predetermined performance targets. In laymen terms, feedback is just the outcome of how a unit or section of the ECDoH is faring against its set targets. The study values the positive contribution that timeously dissemination of feedback to responsible units plays in keep performance plans on track. In the sense of M&E and its contribution to the enhancement of performance in the ECDoH, availing feedback in time cuts down the inefficient delays that can derail the implementation or adoption of remedial action. Moreover, due to the nature of monitoring being an ab initio ongoing process, it is crucial for performance feedback to be time and expertly analysed and each piece of helpful information made available in time. In the case of the ECDoH, availing analysed feedback will help in the allocation of public finance, human capital, and other resources to critical processes. Feedback analysis and utilisation can eliminate unnecessary delays in adopting pro-efficiency amends to original plans. In the event of the original plan healthcare delivery programme such the vaccination of children against the six child killer diseases having not been optimally implemented, short, medium and long term feedback can enable the intensification of an intervention. In a nutshell, the proposed model is premised on generation, analysis, and dissemination of information for smooth trace and track of performance for building efficiency in the ECDoH. This is because performance planning is hugely dependent on the analysis of historical data and feedback. 8.2.8. Itemised reporting phase According to Kjurchiski (2014:6), the process of reporting is concerned with keeping those to whom the executive is duly responsible informed as to what is going on in an 208 organisation. The process of reporting encompasses various stakeholders within the organisation including the supervisor(s) and subordinates who need to be kept informed through records, research, and inspection (Kjurchiski, 2014:6). In that regard, a report is an account or statement that described in great detail an even situation that usually is a result of an observation or inquiry (Dictionary.com, 2016:2). In the context of the study and the need to sustainably deliver public healthcare services in the Eastern Cape Province, reporting becomes that process which keeps units, department(s), directorates and teams up to date with almost all aspects of how they are functioning towards organisational goal achievement. The mentioned units, units include Human Resources, Corporate Service, Clinical Services, Finance, and PMDS. While the overall goals of the ECDoH are vital to achieving, it is the attainment of goals at the unit level (Human Resources, Corporate Services, Clinical Services, and Finance) that correspondingly leads to overall organisational success. The proposed performance enhancement model has a seventh phase where reports are prepared and disseminated on the scale of units or components. Therefore, since the model seeks to resolve identified challenges, reports are prepared for example to provide information and feedback on the issue of public infrastructure, human capital provisioning, operation or logistical issues, all of which collectively lead to the possible success of the ECDoH. The reporting is premised on how the efficiency of the unit and organisation is exponentially improving. Principally, these reports and data, as well as feedback, are aimed at instilling an effective M&E culture and system. Once again, these reports are benchmarks on both the KPIs and the ECDoH statutory obligation to deliver sustainable healthcare service to the people of the Eastern Cape Province. To a greater extent the utilisation of reports and facts contained therein is dependent on the ability of those tasked with leading their units or components to embrace 21st century pro-efficiency citizen-centered practices such as M & E. Such pro-efficiency M & E conscious leaders should be groomed within the ECDoH to eradicate the resistance of change as well as the reluctance to embrace time-compliant practices. The Department further needs to move away from its current reliance on the obsolete PMDS and ensure that reporting (feedback) driven decision making can become the driving force behind organisational performance enhancement. 209 8.2.9. Ex-post evaluation phase According to Van der Waldt (2004:67) evaluation is a process of investigation which determines whether or not stated objectives have been reached and the nature of the process undertaken. The study has argued the vitality of evaluation to the achievement of public service delivery objectives in the South African public sector fraternity. In the sense of the proposed performance enhancement model, ex-post evaluation concerns the ultimate analysis on whether the goals of improved efficiency within the ECDoH have been attained. Furthermore, it seeks to establish if each and all of the items or components of the public healthcare delivery fraternity have managed individually and universally to achieve its targets. For example, gauging to see if enough public healthcare infrastructure has been improved, if critical medical and support staff has been made available throughout the Province including outlying rural areas such as Tsolo, Libode, and Qumbu in contrast to more urbanised areas such as Bhisho and East London. Focus for evaluation in the ECDoH should be two-pronged, with facets on how access to public healthcare can be continuously improved as well as how prompt those public healthcare services are rendered. With the rise in citizen-centered public service delivery and the locally renowned Batho Pele principles, fundamental public services like healthcare need to be made available easily, quickly and effectively. The study has persistently advocated for a duly economic, effectiveness and efficiency based delivery of public healthcare to the people of the Eastern Cape, a primarily poor province in the entire Republic. While evaluation is an ex-post activity, it is equally important since it is an essential final action in the M & E process. The evaluation further enables the organisation to ascertain its ability to meet goals within the context of a periodic episode of monitoring ab initio. Due to the fact of both monitoring and evaluation complement each other, they are both efficiencies inducing agents in the public healthcare service delivery. Compounded by increasing uncertainty in the organisational environment in the 21st century, it is the M & E system that ensures that policy programmes, interventions, and projects do not significantly veer off-course. This is particularly important especially given the unpredictability and inability of business or public entity to 210 manipulate the macro (external) environment, leaving it with only its microsegment to control for timely adaptation. This further implies that organisations such as the ECDoH need to adapt their internal environments to the fullest to compensate for the uncertainties which can come from the external environment. The study, therefore, infers that the ECDoH has to adopt the proposed model both in part or its entirety as a tool and can aid in the transformation of the healthcare service rendering in the Eastern Cape Province. In the end, it is this timely tracking of performance that reveals grey areas and loopholes such as staff shortages and budgetary shortfalls that need resolving in time for improved citizen satisfaction and public confidence. A plethora of anticipated results of the proposed model is discussed in the Section that follows. 8.3. EXPECTED OUTCOMES OF THE PROPOSED MODEL The adoption and implementation of the proposed model are anticipated to yield positive results for the ECDoH. Some of the expected outcomes of the model are a good working relationship between the Department and the citizens which will further crystalize into less public service delivery protests linked to healthcare. This is related to the recent spate of public service delivery protests in deep-lying rural enclaves as a consequence of citizen demanding public health clinics or healthcare facilities within their vicinity. The study acknowledges the fact that the rural parts of the Province have a high number of frequent patients needing regular visits to the existing public healthcare facilities. Some are on antiretroviral therapy while others suffer from other chronic ailments. It is further anticipated that there will be more efficiency in public healthcare service delivery in the Eastern Cape Province, timely deployment of critical medical staff, shorter lag times for emergency services, intensive investment in appropriate performance-enhancing technologies, role clarity, ethical conduct, more delegation of authority and leaner organisation practices as discussed in section 8.2 of this chapter. It is of utmost importance that there is a timely deployment or assignment of medical and auxiliary staff such as cardiologists who are currently in short supply. 211 As argued in Section 7.3.1.6 of the previous Chapter in this study, due to the absence of well-planned and executed human capital provisioning, the Department is persistently losing critical staff to private and overseas healthcare entities such as the British National Health Service. This skills leakage can be addressed with timely public human resources provisioning with a well implemented M&E model. The study argues that the revision of the long overdue organogram of the ECDoH into being leaner can aid in fast-tracking decision making, hence dealing a blow of bureaucratic red tape that is currently rampant. An efficient, economic and effective public entity does not only lead to people-centered service rendering but has hordes of other benefits including reduced mortalities, satisfied clients and better quality of living. 8.4 CONCLUSION Essential services such as public healthcare are basic necessities for daily living. In South Africa, Section 27 (1) (a) of the Constitution (1996) places a vivid mandate on the state to ensure that everyone has access to public healthcare. In fulfillment of this obligation, the state utilises public entities such as the ECDoH to deliver services to people. However, because of the decentralised format of government in South Africa, subsidiary provincial public entities are entrusted with delivering public services such as healthcare services within their areas of jurisdiction. Synonymous with the various yardsticks used to gauge socio-economic development in modern societies such as the prevalence of poverty, there are numerous public healthcare services delivery challenges that continue to blight the Eastern Cape Province. One such obstacle is an inability of the ECDoH to efficiently deliver public healthcare to its constituency as argued in Section 1.3 of this study. Amidst the rising challenges, modern practices such as M&E have proven to be an effective catalyst to ensure that public service delivery such as public healthcare is done in an efficient fashion. Principally, M & E has proven to be a game changer when it comes to constant and consistently enhancing the performance of public entities as discussed in section 5.5 of this study. The absence of M & E in the ECDoH is worrisome, and further dents efforts to improve access and swiftness of healthcare service by the people. In light of this background, the study proposed a performance-enhancing M & E model for consideration by the ECDoH in line with the (six) research objective as contained in Section… of this study. 212 Central to the proposed model is the ab initio undertaking of monitoring of activities that collectively seek to further the goals of the ECDoH. This continuous monitoring is handy in making sure that vital performance data is gathered as early as possible and predetermined plans are compared against actual results. Above all, remediation and corrective interventions can be timeously executed. The model shown in Section 8.2 of this chapter is comprised of various phases which include problem identification, planning, preparation, project design, centralised implementation, expert and holistic data analysis, feedback dissemination, reporting, and ex-post evaluation. Mention is hereby made that, the proposed phases are of equal importance and the ECDoH has to use its discretion in determining the types of interventions that are more urgent. Overall, the model seeks to improve the ECDoH’s delivery of public healthcare services regardless of the target areas, implying that, be it an infrastructure project, logistical procedure or intergovernmental intervention, the model overall serves the same purpose. The next Chapter presents the conclusions and recommendations of the study. 213 CHAPTER NINE SUMMARY, CONCLUSION AND RECOMMENDATIONS 9.1. INTRODUCTION Theoretical and empirical evidence were discussed throughout the various stages and sections (see sections 1.1 to 8.4) of the thesis has proven that M&E is a convenient performance enhancement catalyst. The aim of this closing chapter is to summarise, conclude and make recommendations to the study. Public entities like the ECDoH should take advantage of M&E’s many merits such as accountability. Over and above, the ECDoH should strive to improve the effectiveness and efficiency aspects of the public healthcare service delivery through monitoring and evaluation of their activities and performance. Such an improved public healthcare delivery practice will ensure that the citizen gets quality services for the improvement of their living standards. The study is premised on a background of public healthcare services as offered by the ECDoH being confronted with numerous public service delivery challenges. There is a general perception in academic and societal circles that the Province is one of the poorest among South Africa’s nine provinces because of its high unemployment rate and the poor public healthcare services to the people residing in the province. In the process of ensuring that everyone has equal access to the fundamental public services, there is a need for economy, efficiency, and effectiveness in the policy programmes utilised by the ECDoH in that regard. The study sought to explore how modern people-centered and pro-efficacy practices such as M & E can be instrumental in improving the healthcare services plight of the people of the Eastern Cape Province. There are numerous challenges inhibiting such feat at present and the study sought to discuss these and other related issues through various Chapters of the thesis as shown in the table which follows, which illustrates attainment of the aims of the study. 214 Research Question(s) Research Objective(s) Corresponding Evidence Thesis Chapter Which theoretical framework and Determine the central theoretical NPM and good governance have orientation can form the foundation framework and orientation which can been used as the central theories to of M&E in the public sector with Chapter 3 particular reference to South Africa? form the foundation of M&E in the the study since they both speak to (Pages 43-77) public services efficiency with and further M&E and efficiency particular reference to the ECDoH. practices in government. What is the character of the M&E Establish the character of the M&E The study managed to argue and discourse in Public Administration as discourse in Public Administration discuss the current M&E discourse an enabler of public service delivery in relation to public service efficiency in relation to the ECDoH within the context of Public Chapter 2 efficiency with respect to the and its prospects of improving the Administration. It was seen that rendering of healthcare services. (Pages 17-42) ECDoH? M&E is a modern practice improving government efficiency Which themes emerge from M&E to Ascertain the themes emerging from Emerging themes include M&E (as a serve as prescripts to help the M&E that serve as prescripts to help good governance practice, enforcer ECDoH develop a tailor-made M&E system for improving the delivery of the ECDoH develop a tailor-made of accountability, public participation Chapter 4 healthcare service in the Province? M&E system for improving the as a practice linked to M&E and delivery of healthcare service in the (Pages 78-89) KPIs as benchmarks for efficiency. Province. What is the connection between Determine the relationship between The linkage between M&E and M&E and performance management public service M&E and performance performance was established to be and how can this management in the public service solid. M&E is an improved version of relationship be utilised to enable the ascertaining how the former can the PMDS. Systems like the former to improve on the latter’s Chapter 5 effectively help improve the prospects GWMES are good governance prospects of improving public (Pages 90-123) service efficiency? of the latter towards the delivery of practices that seek to persistently quality healthcare services by the improved government and service ECDoH in the Eastern Cape Province. delivery efficiency in the ECDoH. What challenges are inhibiting on Investigate the challenges that the Numerous identified challenges the prospects of the ECDoH to fully ECDoH is facing in using public included lack of political will, Chapter 7 have and utilise an operational service M&E in improving its infrastructural challenges, human (Pages 138-169) M&E framework? effectiveness and efficiency in capital, professionalism shortfalls, and budgetary constraints. delivering healthcare services in the Eastern Cape Province. 215 How can a feasible M&E model be Explore the avenues through which a A proposed 9 phase model is designed to help the ECDoH feasible public service M&E model presented where the ECDoH significantly improve its efficiency can be developed in order to help the ensures that it prepares, designs, Chapter 8 and effectiveness towards ECDoH improve on the manner in implements, monitors and always which it delivers healthcare services (Pages 170-183) delivering quality healthcare undertake an ex-post evaluation of in the Eastern Cape Province. services? its service rendering activities. Table 2 Summary of Research Questions, Objectives and Evidence Source: Author’s own illustration (2018) Illustrated in Table 5 is an annotated synopsis of the study, vividly showing how the research questions, objectives have been addressed through evidence. The table also shows the ranges within the thesis, where such evidence is situated. Important to note is that the study gathered enough theoretical and empirical evidence to adequately answer the research questions (see section 2.1 to 7.5) of the thesis. Overall, the study sought to contribute to the resolving on the problem stated in Chapter 1 (see section 1.3), which was that of poor performance and absence of pro- efficiency systems such as M & E in the ECDoH, leading to an inability for the Department to attain sustainable healthcare service delivery. Meanwhile, the study offers chronological summarisation of the key arguments and findings in the Section that follows. 9.2. SUMMARY AND CONCLUSIONS OF THE STUDY The first chapter of the thesis offered the introduction and background of the study. This was done by providing both an academic and practical exposition of M&E in South Africa. The key argument in this chapter was that, in the modern public service, M&E has become dominant in determining the success of public organisations since it allows for timely trace and track of public performance. In that regard, it is essential for all public entities to use it as a performance enhancement tool. However, it was discussed in the problem statement see section 1.3 that the ECDoH does not have a functional M&E system leaving it to rely on the now obsolete PMDS. As a result, the Department faces many public healthcare service delivery challenges, which can be alleviated by the adoption and implementation of a working M&E model (see section 8.2). The chapter further presented the research questions and objectives as summarised in Table 5. Additional discussions in chapter 1 centered on the 216 significance of the study together with the preliminary layout of the thesis. As the foundation of the study, this particular chapter plays a crucial role in positioning the study on a firm foundation where the exploration of M & E as a tool for effective service delivery, was premised. Chapter 2 progressed with a wide-ranging and detailed discussion on the M&E discourse in Public Administration. In this section of the thesis, the scholarly and practical implications and meanings of monitoring and evaluation were provided (see section 5.1 to 5.3). There was also a discussion of the overview of the historical genesis of both Public Administration and public administration in relation to monitoring and evaluation as a discourse. From the 19th century era of former American statesman Woodrow Wilson, Public Administration has always been evolving, eventually developing into the current discourse of M&E as advanced by other scholars. Since that time, there has always been an emphasis on the need for government efficiency. Important to note is that the genesis of M&E in South Africa has been historically credited to the Presidency of Thabo Mbeki and its unambiguously conceptualised (and practiced) GWMES. A detailed discussion on the ontological and epistemological aspects of Public Administration is offered with arguments on whether it is an art or science (see section 2.3.3 to 2.4). Chapter 2 concluded by discussing the locus and focus of M&E in Public Administration and government practice, which are mostly to improve how government delivers public services. Whilst looking at the curriculum developments (see section 2.6) the context in South African universities and public institutions. Chapter 3 covered the central theoretical framework that has been used to guide the study. These included the discourse on good governance and the NPM paradigm. The Chapter further discretely conceptualised governance and the compound phrase of good governance as a hybrid concept and phenomenon of many governance practices which ensures that there is proper managing of the state’s resources, effectively and efficiently. Good governance was further unpacked within the context of M&E and the need for the later in trying to achieve the goals of the former. In laymen terms, in order for good governance to occur in the 21st century, public entities like the ECDoH, have to ensure that their policies and programmes are subjected to a rigorous 217 monitoring and evaluation process. Good governance as discussed in this thesis has tenets which include citizen participation, the supremacy of the rule of law, oversight emphasis and ethical conduct to mention a few (see section 3.2 of the thesis). In the end, if public entities such as the ECDoH need to substantially achieve the goal of good governance as well as positive outcomes such as client/citizen satisfaction, timely and sustainable delivery of public services, such public entities have to embrace and employ M&E practices. In relation to NPM, the study argued that NPM is the modern public service practice that borrows private sector practices for improved efficiency. Such practices include M&E. Themes emerging in M&E were the focus of Chapter 4. In this Chapter, the study argued that there are various themes that emerge from the utilisation of M&E both in scholarship and practice. In this regard, therefore, the various themes namely public accountability included that which shows that M&E is an enabling tool promoting good governance. Such a theme emanates from the underlying aim of M&E is to ensure that the process of public service delivery is done in a professional manner. Other themes which the study presented were that M&E is an enforcer of accountability, derived from its ability to timeously measures output and contrast it with predetermined goals or KPIs (see section 4.3). The same effect that the M&E exerts in relation to good governance was argued to further elucidate the significance to enforce transparency in the public service. Another vital aspect covered in Chapter 4 is that of public participation, a tenet which can determine how the public service delivery programmes of the ECDoH are approved or accepted by the public healthcare service receivers of that province. M & E was further seen to be directly linked to performance measurement which is one of the building blocks to the improvement of individual and organisational performance (see section 5.5 of the thesis). A linking of M&E and performance management was presented in Chapter 5 of the study. This took shape through a discussion of the similarities and dissimilarities between the two variables. A consensus was reached through evaluative arguments that M & E is an advanced tool of performance management. While the ECDoH still heavily relies on performance management, through its PMDS, mention was made in the discussions that there is a need to upgrade to a more 21st-century compliant 218 practice such as M&E. The study further argued and suggested that the ECDoH should adopt the formalised GWMES which the Presidency has implemented to a positive effect at the national sphere of government. If the Department has to embrace, adopt and implement M&E as a whole at a later stage, they should consider modeling it on the GWMES of 2004. Further discussions were done on why (possibly) the practice of performance management is fairly obsolete, obsessed on the individual employee rather than deeper and wider organisational performance (see section 7.3 of the thesis). It is the study’s standpoint that M&E might have been the brainchild of performance management but there is a need for public entities to uniformly adopt and utilise M & E. The research methodology was discussed in Chapter 6 of the thesis, where discussions focussed on the paradigm, methods and ethical aspects applied in this research study. In short, a qualitative paradigm was used in the study because the researcher was driven by a need to understand the perceptions and opinions of the respondents in the study of monitoring and evaluation policy as a tool for performance enhancement in the public service, which was made up of the employees of the ECDoH (see section 6.2.4 of the thesis). Such perceptions and opinions were based and analysed on the current practices related to performance management in the Department imbued with inefficiencies and inconsistencies. In the same chapter, the argument was advanced on how such inefficiencies and inconsistencies can be improved through M&E for enhanced performance and efficiency. The non-probability sampling design was utilised in the selecting of a representative sample of cumulative 50 respondents including those in the Department’s PMDS unit (see section 6.2.4 of the thesis). The researcher used semi-structured interviews and a database of literature (secondary sources) to collect both theoretical and empirical data. Data were analysed using a thematic qualitative process that included thematic coding and analysis. For ethical compliance, the study was ethically cleared by the North-West University Research and Ethics Committee and ethical principles of social research were observed including the respondents’ right to consent and confidentiality. The ethical clearance number of this study is NWU-00567-17-A7. An analysis of the data followed in Chapter 7 of the thesis where the data was first coded into various themes and then presented in various topical discussions. The 219 Chapter first located the purpose of the analysis to the 5th research objective which sought to expose the challenging the use of M&E in the ECDoH (see section 1.5). A brief look at the locus and focus of public healthcare service provision was discussed to set the stage for the need for sustainable public healthcare provision. Thereafter, a holistic analysis of the case study following, where the various challenges such as the lack of political will, rural stigma, infrastructure disparities, logistical problems, human capital shortfalls, and budgetary constraints were identified. The Chapter concluded by exploring prospects of enhancing the performance of the ECDoH through M&E. It was argued and concluded that the ECDoH stands to achieve enormous benefits from the adoption of a new effective and efficient M&E model given the current challenges and exposed impediments. From the onset, the exploration of the prospects of performance enhancement in the ECDoH by the researcher in relation to proposing an effective and efficient M&E model was discussed in Chapter 8 of the thesis as shown in Figure 4 (see section 8.2). A brief synopsis of the implication of the terms “model” and “framework” was provided, with an intention to interchangeably using both these two terms in the study. In short, both terms refer to a structure or plan of how something is to be executed or carried out. Hence the proposed model sought to, within the context of the ECDoH, resolve current performance management challenges of the ECDoH and also implement a practice of a timely, effective and efficient M&E system. The Chapter proposed and developed a 9 phase model for consideration by the ECDoH. These phases include inter alia, a problem identification, preparation, planning, design, centralised implemented, data collection, data analysis, itemised report, punitive evaluation, and anticipated results. The study emphasised that it is important for the Department to ensure that there is an ab initio monitoring culture which should be given equal importance with the ex-post evaluation. In addition, there is a need to ensure that performance data is gathered once it becomes available to institute corrective interventions in time (see section 8.2). Since the service delivery journey continues infinitely, public entities like the ECDoH should always ensure that their actual performance is contracted against set goals and KPIs to ensure that the people get the service they deserve in record time as expected. 220 In the opening sections of the current Chapter namely 9, mention was made that its sole aim is to summarise, conclude and give recommendations of the study. The following section gives various recommendations for ECDoH’s consideration. 9.3. RECOMMENDATIONS OF THE STUDY In this section of the study, two dimensions of recommendations are provided, that is first, those supporting the proposed model, and secondly, those in areas which future researchers can consider exploring. In this regard thus, the former is now presented in the immediate section, while the latter follows in Section 9.3.2. 9.3.1. Recommendations on the proposed performance enhancement model The presented model is shown in Figure 5 (see section 8.2) of the previous Chapter of the thesis shows the various phases that the ECDoH should consider following towards enhanced public healthcare service delivery. Throughout the thesis, the study refers to a raft of pro-efficacy interventions which can be adopted and implemented to give effect to the sustainable delivery of public healthcare services by the ECDoH. In addition, the study saw it prudent to discuss the numerous interventions in detail to substantiate the prospects of the proposed model to attain its predetermined goals. In short, the goals sought to be a catalyst for enhanced performance by the Department within the premise of M&E. These are covered in this section (9.3.1 of the study) as supporting the proposed model (see section 8.2 of the thesis). In line with the proposed M&E model and the overall objective of the study, the following discussions cover the suggested performance-enhancing recommendations. 9.3.1.1. Organogram redesign The challenges inhibiting the efficient delivery of public healthcare services in the Eastern Cape Province were detailed in Chapter 7 of the thesis (see section 7.3 of the thesis). One of these was the demerits of reliance of the Department on obsolete organisational structural practices which are marred in bureaucratic delays and red tape. The advent and adoption of modem day practices like NPM have given rise to leaner, manageable and accelerate decision making and implementation tools mechanisms. As recommendations of the study suggest, the ECDoH has to consider revising and re-structuring its organogram to liberate junior management and 221 subordinates in decision making. Furthermore, leaner organisational structure lessens the burden on top management, therefore ensuring that they concentrate on demanding strategic and demanding tasks as argued by Keita (2014:24) (see section 3.3 of the thesis). Empowering lower level line managers and team leaders within the ECDoH makes the adoption and assimilation of M&E practices easier and quicker. Teams and units constantly gather performance data and compare with set objectives and determine if programmes are in sync with wider goals of the ECDoH. 9.3.1.2. Investment in performance-enhancing technologies Organisational efficiency and performance in the present day public sector have been the center of focus especially when it comes to efforts towards citizen satisfaction. ICTs have managed to enable both the improvement of access to services as well as service quality. For example, the use of ICTs by the National Health Service (NHS) since 2002 in the United Kingdom (UK) has led to improved access to public healthcare services amongst British residents. Another important aspect on the merits of using appropriate technology in the design, evaluation, and implementation of public services is that it makes data or vital information easily collectible and analysable as seen in the UK’s NHS. Since the practice of M & E predominantly depends on a timeous and meticulous collection of performance data, in order for public entities such as the ECDoH to effectively gauge if set goals are gradual and eventually achieved. Technologies can also make the remediation of adverse situations swiftly. The study strongly recommends that the ECDoH adopts and fuses its practices with appropriate ICT systems which helps in the tracing and tracking of public healthcare service delivery and performance. The continued reliance of the ECDoH on the outdated PMDS and manual record keeping has crippled the adoption and utilisation of M&E since it makes the tracing or tracking of performance cumbersome and burdensome. An amicable and effective solution to this challenge would be an intensive investment into working ICTs which are telecommunication and internet services. 222 9.3.1.3. Addressing the rural assignment stigma The rural profile of most areas in the Eastern Cape Province has become somewhat a disadvantage to those domiciled in these enclaves. As covered in Chapter 7 of the thesis 9see section 7.3), the deployment of critical medical and other support staff in these areas has become an Achilles heel for the Department. Complicating this further is the scarcity of medical professionals, which has led to a substantial exodus of these staff to private and foreign entities as discussed in section 7.3.1.6 of this thesis. Within a well-executed, articulated and planned M&E model and system, plans should be there to ensure there is never a perceived or actual shortage of critical staff. Such can be achievable through a vivid strategic human resources planning practice which ensures that the resource of human capital has a working and infinite succession plan. In the context of this particular recommendation, there is a vital need for the ECDoH to ensure that each and every goal set towards the delivery of public healthcare services, has a feasible short, medium and long term human capital strategy. Changes to the public healthcare service delivery expectations of the Department would require corresponding adjustments to the provision of both critical medical and support staff. As discussed in section 7.3.1.6 of the thesis, there is a need for the use of incentives to attract and retain competent staff as well as making it attractive for staff to feel motivated to work in a rural setting. To a greater extent, rural areas such as the Eastern Cape Province have a high prevalence of public healthcare service delivery disparities caused by the apartheid regime as compared to their urban counter sites. A sector-wide intervention is needed to ensure that the proverbial ‘brain- drain’ that has led the public sector to continuously lose critical human capital to the private and foreign entities is curtailed. 9.3.1.4. Human capital training and development Professionalism, good ethical conduct and treating public healthcare service delivery as a professional activity is needed in the ECDoH. Data analysis covered in section 7.3 of this thesis showed that some medical and support staff in the Department have shortfalls in their treatment of clients and the wider public healthcare services sector. In this regard the study recommends that staff training in relation to needs analysis be conducted periodically, staff training (and development) adopted and fresh 223 aptitudes be utilised in the ECDoH. The study mentions that there is a constant and consistent need for updating the skills of its employees (see section 7.3 of the study). Such an organisational setting and culture is especially vital given the changes in the public healthcare service in terms of emerging challenges. There is also the inevitable influence of globalisation and advancements in ICTs (see section 7.3 of the thesis). Remaining stuck with using the ancient practice of performance management in the ECDoH affected the effective delivery of public healthcare services. A move onto an M & E framework would ensure that public healthcare services are delivered, timely, tracked all the time to ensure that every plan and programme of action remains on its intended course. 9.3.1.5. Intergovernmental approach to performance enhancement The success of the proposed M&E model for the ECDoH (see section 8.2) is dependent on the ability of the entire South African public sector to cooperate and work together towards the attainment of the goals of both individual entities and the sector as a whole. This is spread across both socio-economic development and logistical spectrums of public service rendering. This implies that intergovernmental cooperation is not only needed in the policy programmes which fight poverty and inequality, but also on the overall management of the performance of public entities. Critical to these arguments is that the study mentions that the success of the public healthcare service delivery programmes rendered by the ECDoH will be more pronounced if other public healthcare service providers also offer their duties and responsibilities in a sustainable, economic, efficient and effective manner too (see RSA 1996, Section 41). Data analysis in this study exposed various dimensions of impediments including the exposure of public healthcare facilities to crime, the disjuncture in M&E practices across the public healthcare service system together with differences in socioeconomic development levels across provinces and localities (see section 7.3). In this regard the study recommends that some public sector-wide interventions to tackle these prevalent challenges like crime, other social problems that are affecting the public healthcare service delivery and a wide assortment of socio-economic development challenges must be eradicated since they collectively (direct or 224 indirectly) impact on the success of the performance-enhancing initiatives such as M & E in the ECDoH. It is anticipated that an all-inclusive intergovernmental culture of public sector functioning can enhance performance and make sure that there is a conducive condition for the uniform adoption of pro-efficiency practices such as M&E in each and all public entities. 9.3.1.6. Improving political will in enhancing performance The discussions and arguments in this study are indicative of the need for more input from the leadership of the ECDoH for the adoption and utilisation of M&E to enhance the performance of the Department. One problematic issue in this particular aspect lies in the national government and its willingness to reign over its subsidiary spheres of government. While the existing statutory and regulative provisions accord provincial governments autonomy over how it operates (See Chapter 3 of the Constitution of the Republic of South Africa), there is no corresponding willingness to ensure uniformity in public service delivery. One such area is the adoption of the tried and tested GWMES model into provincial governments and their respective entities. The formalised manner that the GWMES in the Presidency is structured and implemented is a testament to the potential it has in improving how entities such as the ECDoH can utilise it to their advantage. However, the status quo has shown that the subsidiary entities such as the ECDoH use obsolete practices such as the PMDS and there are no interventions from the political heads to flag these practices. Additionally, there has not been enough political will on the provincial leadership to ensure that provincial entities embrace and use M&E to ensure efficiency in service delivery. As a result of this, there is a haphazard scenario especially in the Eastern Cape Province, where public service entities have developed their quasi (or ad hoc) M&E model. These models have been less uniform and their implementation has also been less identical, hence the public service has to explore ways by which there are uniformity and flexibility in how they operate. Emphasis should be on how they can enhance their service delivery practices to give effect to both improve access and efficiency. In the context of the study, a politically willing leadership would enforce the adoption of a conventional and uniform M&E framework for the ECDoH for enhanced public healthcare service delivery to the people on the Eastern Cape Province. 225 9.3.1.7. Creating a uniform public sector A uniform public sector has innumerable advantages both to individual entities such as the ECDoH and the entire public sector and service in general. These advantages include inter alia, an easiness to make and enforce regulations, uniform implementation and monitoring of public activities, use of universalised data and feedback gathering tools, public centralised control and monitoring of performance as well as easy dissemination of public information across the various spheres of government. In addition, a uniform public sector and service can smoothen the distribution of critical public resources to areas where they are urgently needed. A case in point relates to the scarcity of critical medical staff such as cardiologists in rural hospitals in the Eastern Cape Province as compared to the abundance of same professionals in urban cities such as those in the Gauteng Province (see section 1.3). A unified public service and sector would ensure an equal distribution of both public financial and human capital resources such as medical practitioners. Issues like the rural stigma such as ‘the poorest province’ as a popular reference tag associated with the Eastern Cape Province’s socio-economic status, should be dispelled. The study acknowledges the independence of provincial spheres of government, but the national government should not only intervene when there are catastrophic signs of maladministration but when the service delivery trajectory of a province is not as efficient and effective as it should be. As a recommendation of the study, the entire South African public service and sector should explore various ways to leverage public practices to ensure that the competition brought by the principle of devolution of powers do not build less uniform public practices but are a platform of spreading pro- efficiency public performance interventions to areas where they are needed. 9.3.1.8. Using impromptu facility visitation The proposed M&E model discussed in Chapter 8 of the thesis (see section 8.2 of the thesis) shows that there is a need for monitoring and evaluation of the Department’s activity ab initio. Such a continuous tracing of performance as part of the M&E process ensures that the ECDoH always stays in the know of how its public performance is faring against predetermined goals. Important to such a culture of monitoring and ex-post evaluation is the ability of those leaders who have policy 226 oversight to keep their subordinates and units in the loop. Such a feat can be achieved through the use of numerous management approaches which encompass unannounced facility visits like the ones that the Minister in the Presidency, Jeff Radebe embarked on in 2017 when he visited public healthcare care facilities around the country including those in rural areas of the Eastern Cape Province like Lusikisiki. This is particularly critical mainly in outlying rural areas in the Eastern Cape Province where public healthcare officials engage in unprofessional conduct due to the remoteness of the places. And have a perception that their facility is beyond the reach as compared to those deployed in urban areas. The study established the prevalence of such public practices to be high in the Province, and hence the need for surprise visits by provincial and national healthcare officials. When done consistently within laid-down operational procedures, impromptu visits to healthcare facilities have the potential of being instrumental in ensuring that healthcare service staff perform efficiently and effectively. Moreover, it helps solve challenges associated with poor staff attitudes towards clients in rurally situated facilities which sometimes open late and close early. Such a practice can be a vital catalyst for the use of M&E as a performance enhancement tool in the ECDoH. 9.3.1.9. Pledges and ensuring a stricter code of conduct A signature of the employment contract and a pledge to abide by the Code of Conduct for Public Servants (1999) has proven to be deficient in the context of the ECDoH. The study explores the prospects that while the Code of Conduct for Public Servants (1999) is explicit in writing, it is its current public implementation and monitoring that is lacking in the area of public service healthcare delivery in the Eastern Cape Province’s by the ECDoH. The study revealed a horde of professionalism and employee commitment to public healthcare delivery challenges in the ECDoH (see section 7.3) therefore showing the need to improve on how public accountability is enforced when it comes to the pledge to serve the people and also to establish an emergency response plan to effectively and efficiently resolve these challenges associated with public healthcare service provision in the ECDoH. As a key recommendation of the study, the ECDoH needs to strive to ensure that the consequences of non-performance and/or failure to abide by the Code of Conduct for 227 Public Servants (1999) are made severe including punitive measures like financial penalties. Such a move is instrumental in making sure that public servants serving in the ECDoH have the people of the Eastern Cape Province at heart, therefore, ensuring that they too enjoy their fundamental human right to healthcare. Coupled with human capital interventions such as skills development of ensuring that there are periodic analyses of training and development needs of the Department, the punitive consequences of poor performance can be appropriate. As argued earlier in section 9.3.1.4 of this Chapter, aspects of ethical and professional conduct can be mitigated by conducting refresher courses and training sessions in a bid to create and maintain a culture of efficient performance. The efficacy of this strategy is dependent on the willingness of public servants to serve the people over their personal ambitions. The study further argues that if the ECDoH premises its public healthcare service delivery practices on the needs of the people to always ensure that efficiency is maintained, recurrent challenges such as poor staff attitudes can be eradicated. The human resource department of the ECDoH through its recruitment, selection, induction and placement practices has to make sure that both its existing and new staff members are always accustomed to the ECDoH vision and mission (or objectives) as seen in its strategic value proposition. The ECDoH (2016) declares that one of its goals is to have productive, client-centered and professional human capital that is always cognisant of the eternal need for efficient healthcare service rendering. 9.3.1.10. Legislative and policy interventions As far as the public sector and/or service want to attain enhanced performance and compliance of public entities with stipulations for M&E, the current national legal and regulatory framework is somewhat falling short of making it happen. In that regard, the study recommends the exploration of the kinds of legal and policy interventions can be put in place to give effect to universal M&E practices and uniform tenets of performance in the public sector. An example is a regulation mandating that every public entity in South African has and implements a well-structured M&E framework. Suggestively, the areas that can be made more effective through more statutes and regulations are the requirement that each and every public entity has a working M&E system. A public service M & E framework should be universalised for ease of implementation and adoption. Within such a framework, public entities such as the 228 ECDoH to periodically report feedback to responsible authorities to ensure that there can be an informed adoption of interventions. The study values regulations on the need for a smooth universalised system of the deployment and placement of critical medical and support staff across provinces. In laymen terms, new regulations are needed to make sure that it is not solely the responsibility of the ECDoH to source and keep critical medical staff such as cardiologists. Mention is made that, all existing and new regulations on performance and M & E practices have a clause of stiff punishment being mooted on culprits. Precaution should be taken though, that the fresh legislation on M & E suggested above are constitutionally valid and do not infringe on employees’ labor and other rights. The overall goals of new regulations on M & E are for the public entities such as the ECDoH to adapt to new challenges in the globalised village and remain efficient in the delivery of public healthcare services. Public healthcare services can be argued to be a very significant contributor to the quality of life or living standards in a 21stcentury society. This is because of the fact that a healthy society is most likely to be tranquil and well-nourished as opposed to a sickly one where mortality rates are high. The following section covers the recommendation of the study related to areas that future researchers might be interested to explore. 9.3.2. Recommendations on future studies While the focus of this thesis was on exploring M&E as a performance enhancement tool for the ECDoH as discussed in chapters 1 to 8 of this thesis, future studies can explore some of the following topical areas: (i) Exploring the good governance principle/tool as an enforcer of public accountability in the public service in relation to public healthcare services. (ii) Prospects of implementing the Government-Wide Monitoring and Evaluation System uniformly throughout the entire public service in South Africa. (iii) National Health Insurance (NHI) policy and beneficiation scheme in the South Africa public health management: Prospects, Potential Pitfalls, and Sustainability requirements. 229 (iv) Human Capital Impediments to the sustainable delivery of public healthcare services in the South African public administration context. 9.4. CONCLUDING REMARKS Public healthcare service provision is a fundamental right and government obligation that is essential for individuals and communities. It is one of the prudent tenets that determine a society’s quality of living standard. The study explored the enhancement of the performance of the ECDoH through a working M&E model that entrenches the importance of tracing and tracking the performance of a public entity (see section 8.2). Scholarly and other arguments backing the adoption and implementation of M&E in the ECDoH has been discussed at length (see section 2.1 to 7.5), with a focus on its ability to ensure a sustainable public healthcare delivery system. A case study of the Eastern Cape Province specifically the ECDoH is used, a region marred by massive infrastructural and socio-economic development challenges which have correspondingly affected the prospects of improvement of both access and quality of public healthcare services rendered to its inhabitants. While challenges have been identified, which are impediments affecting the prospects of the ECDoH to capitalise on the merits of M&E in its performance of various activities towards attaining its mandate (see section 1.3), these challenges can be resolved via a raft of measures including an adoption of the proposed M&E model (see section 8.2). The proposed model emphasises on the need for creating an economic, effective and efficient ECDoH, one that ensures that the people of the Eastern Cape get their choice of public healthcare services, timely, at the preferred quality. Furthermore, the model signifies various phases that can collectively eradicate the impediments to efficient public healthcare service delivery. Throughout the thesis, the study argued for the utilisation of M & E as both a time compliant and a pro-efficiency practice (see Chapter 1 to 8 of this thesis). A key merit of M&E is that it allows for timely correction of variances, hence the ECDoH does not have to wait for an ex-post evaluation to adopt a remedial action to an activity or project. A recurring challenge to the smooth and hassle-free adoption of the M&E model is that these practices are being designed and adopted in varying forms in the public sector. Hence there is a need for ensuring uniformity in the M&E practices of the entire public sector. 230 In an era where pro-efficiency practices have taken center stages, such as NPM, good governance and M&E, the ECDoH has to do away with its PMDS or scant monitoring and evaluation framework. The Department has to adopt a full pledged M & E model for more holistic management of its public healthcare services performance. As argued in the analysis and discussion of data in Chapter 7 and 8 of the thesis, at present, the Department’s long overdue use of the PMDS myopically places the emphasis of organisational efficiency on individual performance, which is an obsolete approach to improving on the efficiency of the organisation. Acknowledging the rural nature of most of the Province, there is a need for a sector wide approach to addressing some of the major public healthcare-related challenges like poor infrastructure first before turning attention to M&E. Principally, the researcher is optimistic that the South African public sector can universalise M&E and collectively work to ensure that public services such as public healthcare are efficiently delivered. 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Monitoring and evaluation mechanisms for sustainable development in Sedibeng District Municipality. Vanderbijlpark: North-West University. (Thesis-PhD). 261 P. Bag X6001, Potchefstroom 2520, South Africa E-mail: sandiso.mahlala@gmail.com QUESTIONNAIRE SURVEY EXPLORING MONITORING AND EVALUATION POLICY AS A TOOL FOR PERFORMANCE ENHANCEMENT IN THE PUBLIC SERVICE: THE CASE OF THE EASTERN CAPE DEPARTMENT OF HEALTH Introduction You are invited to participate in the study with the title outlined above being undertaken by myself, Sandiso Mahlala (Student No. 26769549) as part of an academic degree of Doctor of Philosophy (Public Management and Governance) at the North-West University. Essentially, the purpose of the study is to gather data on the how monitoring and evaluation can be used to enhance performance in the Eastern Cape Department of Health (ECDoH). Precisely, the study examines the current practices in managing performance in the ECDoH and explore various ways through which monitoring and evaluation can become a useful tool for enhancing the current levels of performance in the department. Background to the research The practice of monitoring and evaluation (M&E) is still evolving in South Africa. Public entities and government departments are gradually grasping and streamlining their monitoring and evaluation polices in line with government requirements. However, some have up to now, not been able to put a function M&E policy in place, thereby resorting to old practices of performance management. With the wide array of benefits which monitoring and evaluation as a policy, can bring to a public entity such as the Eastern Cape Department of Health, the study explores how performance can be enhanced through a working policy. This study could be of great value in addressing performance gaps and related challenges in the performance of the public sector. By way of a questionnaire survey, it will be possible to draw conclusions on the possibility of enhancing the performance of the Eastern Cape Department of Health (ECDoH) by adopting of a working M&E policy. Procedure If you agree to participate voluntary in this study you will be invited to complete the questionnaire survey where you will be able to share your experience and information on the current reality on the Eastern Cape Department of Health’s M&E practices. You are, as part of the human capital of the ECDoH perceived as the most knowledgeable member of the department by the research team. You are free to ask questions or concerns regarding the research to the fieldworker that will convey it to the head of the project. Risks or discomforts There are minimal risks associated with participation in this questionnaire survey. The process may sometimes become exhausting as you answer the questions. It will take approximately 30 minutes for you to complete the questionnaire. All information given by you will be held in strict confidence and will be used for the purpose of this study only. No personal identification will be possible when the information is used. The principal researcher (Sandiso Mahlala) and the fieldworkers will consider and respect the participants throughout the study. Benefits There will be no direct benefit to you from participating in this study. Your participation will help the researchers in exploring and identifying a baseline data set on the state of monitoring and evaluation in the department. Your participation can however assist in results that can possibly contribute to enhanced performance and better delivery of healthcare services in the Eastern Cape Province. Consent 262 You are free to decline to participate in this study, or withdraw or stop participation at any time without any consequences or penalty. Your decision to participate or not to participate in this study will not have influence on both your present and future status in this community. Participant’s signature Date 263 QUESTIONNAIRE SURVEY The answers to the questionnaire should be provided to the fieldworker by a knowledgeable participant who works within the Eastern Cape Department of Health. 1. INSTRUCTIONS TO FIELD ASSISTANT 2. The participant who volunteers to participate should please answer ALL the questions. 3. Some questions ask you to specify the answer on the line(s) provided (this is where open questions occur and you must write down the exact words of the interviewee) 4. The principal researcher study will keep this page with your personal information separately and safe. The information will only be used when there is a need for a follow-up visit. 1: Activist Identification 1.1 Activist registration A Eastern Cape Department of Health (i.e. section, division, directorate, branch) B Locality: Name/s of household member providing the information to the field assistant Ward/Area Contact number (cell/tel) Work address 1.2 Please indicate the participant skills with languages (Good=1a; Not so good=1b; Poor=1c) 1 2 3 4 Language Speak Read Write Understand a English 1a 1b 1c 1a 1b 1c 1a 1b 1c 1a 1b 1c b IsiXhosa 1a 1b 1c 1a 1b 1c 1a 1b 1c 1a 1b 1c c IsiZulu 1a 1b 1c 1a 1b 1c 1a 1b 1c 1a 1b 1c d Afrikaans 1a 1b 1c 1a 1b 1c 1a 1b 1c 1a 1b 1c Result of visit (for recordkeeping on the completion of questionnaire by participant) Visit 1 Visit 2 Date dd / mm / yyyy dd / mm / yyyy Field assistant/s name/s Notes by principal researcher 264 Signature principal researcher 2(a): Biographical profile of participants (CODING) Use the given codes to complete the grid that follows (see 2b) Age in years: 1=20 to 24; 2=25 to 29; 3=30 to 34; 4=34 to 39; 5=40 to 44; 6=45+ Education level: 1=None; 2=Primary school; 3=Secondary/High school; 4=Trade school; 5=College/University; Gender: 1=Female; 2=Male Level of functionality within the department: 1=Top management; 2=Middle management; 3=Low management; 4=shop floor worker Type of contract of employment: 1=Full-time(permanent); 2=Fixed term; 3=Short-term Ethnicity: 1=White; 2=Coloured; 3=Asian; 4=Indian; 5=Black African Marital status 1=Never married; 2=Currently lawfully married; 3=Common law/living with partner; 4=Widowed; 5=Divorced; 6=Separated 2 (b): Biographical profile of participants (mark with an X based on the codes provided in 1) Biographical details 1 2 3 4 5 6 Age Education level Gender Level of functionality with the department Type of contract of employment Ethnicity Marital status 265 3: Understating of monitoring and evaluation in the public service Do you agree with the following statements on monitoring and evaluation? 1 2 Agree Disagree a) Monitoring and evaluation is a good governance practice b) Monitoring and evaluation can enhance performance in the public service c) Monitoring and evaluation is an enhanced version of the practice of performance management d) As an employee of the ECDoH, I am in support of monitoring and evaluation e) The government is doing enough to ensure that M&E is rolled-out into the entire public service. 4(a): Monitoring and Evaluation and the ECDoH Monitoring and evaluation in the ECDoH 1 2 Agree Disagree a) Is there a need to improve the M&E policy of the ECDoH? b) Do you think the ECDoH has embraced M&E well? c) Does the adoption of a solid M&E policy in the ECDoH have the potential to significantly improve the performance of the department? d) Does the ECDoH not get affected by resistance to change in policy or practices in relation to M&E practices? e) Does adopting a policy improvement on M&E have a chance to eradicate the healthcare service delivery backlogs that the department currently has, if any? 4(b): Monitoring and evaluation in the ECDoH Can you explain your answers to section 4(a) above, in this section? ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ 266 ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ................................................................................................................................................. ............................ ........................................................................................................................................ 5(a): Government Wide Monitoring and Evaluation System (GWMES) and the ECDoH This section looks at the influence of ECDoH- wide MES on M&E 1 2 Yes No a) ECDoH MES can contribute to M&E in the public service as an example of best practice in the SA public service? b) Rolling-out M&E province-wide strengthens ECDoH MES and the provincial public service efficacy? c) ECDoH MES is a catalyst for effective and efficient service delivery in the 21st century d) The ECDoH can support the developmental state imperatives by adopting M&E and the organisations wide aims of the ECDoH MES. e) A sustained use of MES can ensure the delivery of healthcare to all citizens of the EC province regardless of geographic location of other characteristics. 5(b): Explanations of answers to 5(a) Can you explain your answers to section 5(a) above, in this section? ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. 267 ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ........................................................................................................................................ 6: Enhancing service delivery through M&E in the ECDoH (coding for Likert scale measurements on selected statements for use in 6(b)) Response Corresponding code Strongly agree 1 Agree 2 Neutral 3 Disagree 4 Strongly disagree 5 6(b): Enhancing the performance of the ECDoH through a working M&E policy What is your opinion on the following statement(s) 1 2 3 4 5 a) In a developmental state, M&E is crucial for enhanced performance b) The ECDoH needs a more concrete M&E policy to improve efficacy c) M&E ca serve as a diagnostic and corrective tool therefore ensuring that healthcare service delivery programmes in the ECDoH are on the right track. d) Tracing and tracking performance can also make sure that wastages of public funds is minimised in relation to the ECDoH. e) The ECDoH can benefit from a working M&E policy since it can identify variances and flag areas that need attention as timeously as possible. f) Healthcare is a critical aspect of public services, hence there is need to improve its delivery, through M&E, since it is a core human right accorded by the Constitution (1996) g) Data management and the adoption and implementation of remedial action is one of the key aspects of M&E in relation to the ECDoH. h) There is need for the development of specific skills for the current ECDoH workforce for the smooth implementation of a working M&E policy, in the same provincial department. i) M&E is broader than performance management, and the ECDoH has been overwhelmed by perceptions that the same entity in lagging behind in its utilisation of the practice. j) Do you personally have any objection in the adoption and use of M&E to improve how we deliver services in the ECDoH? 6 (c): Explanation of answers to number 6(b) 268 Can you explain your answers to section 6(b) above, in this section? ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ........................................................................................................................................ 7. Challenges affecting the current performance of the ECDoH. (Coding for responses to Question 7(a)) Response Code Huge impact 1 Little Impact 2 No Impact 3 7(a): Challenges affecting the performance of the department 1 2 3 a) The absence of political will to adopt a working M&E policy in the ECDoH b) Skills scarcity and the lack of ample acknowledge about M&E and the benefits tied to using it within the ECDoH c) Negative staff attitude perceiving M&E as the policing of performance, and potential of losing a job as a result of revised organisational structures and systems. d) Weak enforcement of the requirements for M&E from the national government e) Rigid organisational structures and systems crippling the implementation of change 269 d) Poor data management infrastructures related to record keeping f) Too manualised record keeping and tracing of required data g) Poor leadership and lack of strategy for change management within the ECDoH therefore making leaders change averse. h) Belief in the classical and ancient ways of managing organisations and reluctance to embrace 21st compliant strategies aimed at promoting organisational efficacy. i) Absence of a nationwide strategy aimed at using M&E strategy for the enhancement of the performance of the entire Department of Health in South Africa. 7(c): Suggested strategies for resolving the mentioned challenges If you were to offer advice, what can be done to resolve the challenges impacting the ability of the ECDoH to utilise M&E for enhancing its performance? ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………………… 8(a) Organisational performance and monitoring and evaluation 270 Can you give your opinion on the following matters, selected from the provided choices 1 2 3 Aspects of organisational performance Above Average Below Average Average a) Individual performance without M&E b) Overall organisational performance with no working M&E policy c) Ability to meet set goals with no working M&E policy d) Ability to provide quality healthcare to rural areas without a working M&E framework e) Ability to meet healthcare delivery goals in urban and semi- urban areas f) Staff readiness for the rolling-out of a viable M&E policy within the ECDoH g) Organisational preparedness for the adoption of a working M&E policy h) Leadership willingness on the need for designing and adopting a working M&E policy within the ECDoH i) Levels of anticipation on the service consumers on the ability of the ECDoH to revamp its delivery of healthcare services in localities and the entire province 8(b): Further discussions related to the above selections Can you provide detailed discussions to your selection in section 8(a) above ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………… 271 9: Advice to the ECDoH If you were to advise your organisation, what can you say in relation to the use of M&E ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ………………………………………… 10: Interrelated aspects which need attention Which other areas require attention as a way of ensuring a smooth implementation and utilisation M&E in the ECDoH …………………………………………………………………………………………………………………………… … …………………………………………………………………………………………………………………………… … …………………………………………………………………………………………………………………………… … ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ………………………………………… 11: Sector-wide concerns in the success of M&E in South Africa Can you discuss any other public sector-wide concerns that you have in weighing on the prospects of M&E to improve public service delivery efficacy ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ………………………………………… The End Thank you for taking your time to complete this questionnaire North West University Ethics declaration 272 Project title: M & E policy as a tool for performance enhancement in the Eastern Cape Department of Health. Project Leader/Supervisor: Prof Barry Hanyane Student: S. Mahlala Ethics number: N W U - 0 0 5 6 7 - 1 7 - A 7 Institution Project Number Year Status Status: S = Submission; R = Re-Submission; P = Provisional Authorisation; A = Authorisation Application Type: N/A Commencement date: 201706-29 Expiry date: 2018-12-29. 273 Faculty of Arts School of Social and Government Studies P. Bag X6001, Potchefstroom 2520 Republic of South Africa Cell: +27 (0)78 633 5312 E-mail: sandiso.mahlala@gmail.com RE: REQUEST FOR PERMISSION TO UNDERTAKE AND ACADEMIC RESEARCH STUDY IN THE EASTERN CAPE DEPARTMENT OF HEALTH Title of study: Monitoring and evaluation policy as a tool for performance enhancement in the public service: the case of the Eastern Cape Department of Health My name is, Sandiso Mahlala (Student No. 26769549) a full-time student currently undertaking my Doctor of Philosophy (PhD) in Public Management and Governance with the North-West University in Potchefstroom. As part of my curriculum requirements, I am engaged in an academic research study that requires me to collect, analyse and interpret empirical data from the Eastern Cape Department of Health (ECDoH). Essentially, the purpose of the study is to gather data on the how monitoring and evaluation can be used to enhance performance in the ECDoH. Precisely, the study examines the current practices in managing performance in the ECDoH and explore various ways through which monitoring and evaluation can become a useful tool for enhancing the current levels of performance in the department. Overall, the study seeks to ensure that the performance in the ECDoH is optimal and above-board to ensure that the basic and critical human right to healthcare in realised by all those who call the Eastern Cape Province of South Africa their home. It is from the above background that, this letter seeks permission for me as the researcher to interact with the relevant officials, office-bearers and stakeholders in the gathering of empirical data in the ECDoH. Data will be collected using semi-structured questionnaires and focus group discussions. I pledge to abide by strict ethical and professionalism principles in the process of gathering, analysing and publishing data, therefore the rights of participants to privacy, confidentiality and consent are well guaranteed. In the end, the researcher hopes the study to be of significant benefit to the ECDoH, the government and the people of the Eastern Cape Province in the effective provision of healthcare services. The findings and results of the study can be made available upon completion of the study upon request and the researcher will publish these in an academic thesis and journals. Your assistance towards the realisation of the academic effort is utmost appreciated. Yours sincerely Sandiso Mahlala. 274 Faculty of Arts School of Social and Government Studies P. Bag X6001, Potchefstroom 2520 Republic of South Africa Cell: +27 (0)78 633 5312 E-mail: sandiso.mahlala@gmail.com INFORMED CONSENT FORM: SEMI-STRUCTURED INTERVIEWS Title of study: Monitoring and evaluation policy as a tool for performance enhancement in the public service: the case of the Eastern Cape Department of Health You are invited to participate in the study with the title outlined above being undertaken by myself, Sandiso Mahlala (Student No. 26769549) as part of an academic degree of Doctor of Philosophy (Public Management and Governance) at the North-West University. Essentially, the purpose of the study is to gather data on the how monitoring and evaluation can be used to enhance performance in the Eastern Cape Department of Health (ECDoH). Precisely, the study examines the current practices in managing performance in the ECDoH and explore various ways through which monitoring and evaluation can become a useful tool for enhancing the current levels of performance in the department. Overall, the study seeks to ensure that the performance in the ECDoH is optimal and above-board to ensure that the basic and critical human right to healthcare in realised by all those who call the Eastern Cape Province of South Africa their home. Please note that by signing and consenting to participating in the study: (i) Your participation in this semi-structured interview is voluntary and you may choose to withdraw from the interview at any particular time without getting reprimanded; (ii) You are guaranteed of your ethical rights to privacy and confidentiality and thus you are not obliged to disclose personal information that can identify you as a participant to this study; (iii) You agree to have your responses to be captured by a voice recorder; (iv) The results of the study shall be ethically handled, made available to all stakeholders, and will be published in an academic thesis as well as academic journals; (v) Your cooperation and participation in this academic endeavour is appreciated since it will enable the study to realise its objectives and help improve the performance of the ECDoH in the delivery of healthcare to the people of the Eastern Cape Province and the Republic of South Africa at large. Participant’s Signature Date 275