MASERU — Last year, just before the national assembly elections in May, the former Prime Minister Pakalitha Mosisili launched the national decentralisation of primary health care services in Maseru at the Convention Centre.
Decentralisation was seen as central to the government’s ongoing efforts to reform the public sector under the auspices of the Public Sector Reform and Improvement Programme.
The historic launch followed more than seven years of nationwide consultations meant to ensure greater understanding of the little known concept and test the readiness of councils, ministries, civil society, and the public to operationalise the decentralisation concept.
Stakeholders who included the Ministry of Health, which was spearheading the process, district councils and the Ministry of Local Government and Chieftainship Affairs, had to define the roles of each party and more importantly, the role of the Prime Minister in the whole process that entailed reforming public services to ensure provision of better services.
The process was also a learning curve, not only for the parties closely involved but also for various ministries whose innovation would demand they partnered (through a devolution mechanism) with other entities to operationalise various services on their behalf.
However, after the coalition government came into power, decentralisation of primary health care services went into an “uncertain” state.
There was confusion in some quarters as to what it was and whether it was taking away powers from one ministry to the other.
For some, it became a political issue and undid the progress that had been made.
Lesotho Times’ Tsitsi Matope caught up with the health services’ decentralisation advisor and resident coordinator and technical advisor of the Ministry, Tsoele Mpopo to discuss the challenges and progress made so far since the launch of decentralisation and ushering in of the new coalition government.
LT (Lesotho Times): Decentralisation of primary healthcare services was launched but it was not rolled-out, what is the situation more than a year after the new coalition government took over?
TM (Tsoele Mpopo): We are back at trying to make the current government understand what decentralisation is all about.
Basically, there is a lot of work around building conceptual and operational understanding of the value and benefits of decentralisation.
LT: Do you think it’s going to be easy since it took the previous government more than seven years to grasp the concept and take it seriously?
TM: It is going to be a challenge but I am convinced it is possible and can be made easy if there is more consultation at the macro level, for example, at cabinet level.
If it is understood at that level, it would just take working on aligning the structures and systems.
LT: What are the key issues that you think the new government needs to understand?
TM: Different sectors should see tangible value in decentralisation.
Ministries should visualise the end result of operationalising decentralisation and should be in a position to determine value (opportunity cost) of decentralising through a devolution framework vis-a-vis operating through centralisation and de-concentration decentralisation framework.
They should understand inter-governmental relations and have the capacity to clarify operational relationships between councils, sector ministries, civil society, the communities and other local governance structures.
LT: And where does the office of the Prime Minister come in?
TM: The role of the office of the Prime Minister as custodian of the public service and related public sector reforms including decentralisation, should be discussed, defined and agreed upon.
For example in Rwanda the decentralisation reform is led by President Paul Kagame and elected mayors sign yearly performance contracts with the President.
So is the case in other countries like Uganda and Tanzania where the heads of government are responsible for driving the decentralisation reforms.
LT: So back home, where is the confusion?
TM: Well some people think decentralisation of health services means handing over primary health care to the Ministry of Local Government and Chieftainship Affairs and making the ministry take over control of the health facilities, which is not the case.
It is the “fall under” component that seems to be confusing a lot of people, especially because this is a new government.
LT: Tell us about the background of decentralisation of primary health services.
TM: Well for starters, the decentralisation of primary health care services is the brainchild of the Ministry of Health which decided to partner, through a devolution process, with councils in an effort to improve service delivery and management of the primary health care services.
The healthcare services decentralisation strategic plan 2009 clearly defines the type of decentralisation the health sector wants to pursue and there is no mention of authority being decentralised to the Ministry of Local Government.
There is mention of authority being decentralised to the councils under the local government service.
LT: So the Ministry of Health is partnering with the local government service, which is responsible for managing local authorities and not the ministry of local government?
TM: Yes, ideally power should be seen with the service providers not another central government ministry.
LT: Can you please clarify the status of the councils.
TM: Well the truth is that councils are not departments or units of the Ministry of Local Government; they are governments in the true sense of the word government.
They are responsible of executing only those functions outlined in the Local Government Act within the policy direction set by central government (concerned central government ministries).
They are body corporates with the legal authority to exercise powers bestowed unto them by the Local Government Act with policy guidance from the central government
LT: Do you mean a wrong precedence was set to present this notion that councils are under the Local Government Ministry?
TM: To some extend yes there has been that perception that councils are a certain ministry’s portfolio.
LT: What is the danger of taking such an approach, of wanting to own councils?
TM: There is great danger because it erodes the value sectors can attach to decentralisation, which is what the government is supposed to promote in its public service reforms to help systems work better.
It also cripples and fails to unleash the latent capacity inherent in a decentralised system.
LT: What is the role of the Ministry of Local Government in this process?
TM: The Local Government Act defines the role of the Minister of Local Government.
My personal interpretation of the particular section of the law is that, working with the Local Government Service, the Ministry of Local Government is responsible for getting councils ready for decentralisation particularly by putting appropriate policies and laws to govern the local government sphere.
This is with an assumption that the Ministry of Local Government consults all stakeholders and sectors including the Prime Minister’s office to develop such guiding frameworks.
LT: Do you think councils, considering that they have not been operating as corporates and some of them are not well resourced, are ready to operationalise decentralisation of primary health care?
TM: On some aspects yes and others, no.
For example I don’t think the appropriate financial management systems and a clear inter-governmental relationship framework that guides their relations with sectors are in good order.
However, I have observed that they have a strong will to assume responsibility and, provided there is enough support from the central government they will not have a problem getting their systems ready.
I feel that, more investment should target the growth of the local government service, civil society and the councils themselves.
LT: Which areas within the councils needs attention?
TM: They should work at having the necessary capacity to demand the full operationalisation of the local government.
Paradoxically, operationalising the local government will come from the government, the civil society and the councils themselves. As far as I am concerned, the government has done its part because the laws are in place, the councils have been elected, some structures have been established and budgets dedicated.
This alone shows some form of commitment from the government.
What we need is a strong presence of the civil society in decentralisation, we need empowered chief executives at the local government level and we really need the central government to accept that it has to realign and support the necessary change management processes.
LT: So the challenge is with operationalisation?
TM: Yes, there may be challenges with operationalisation, which the councils should champion.
LT: Why are they not championing the decentralisation, are they weak?
TM: The councils are not really weak.
I don’t feel they do not have capacity but I feel they should be supported to unleash the capacity they have and to see themselves beyond simply being an appendage of the Ministry of Local Government because honestly they are more than that.
LT: How have the communities contributed to the councils’ state of affairs?
TM: Communities, media included, have failed to build local government systems.
We have failed to demand the full operationalisation of the law that is already in place and the media should have also come out strong to ask why.
LT: So why are the councils so incapacitated?
TM: You see, for a long time efforts to grow Lesotho’s decentralisation system have predominantly been supply-driven and biased towards building capacity at the central government level and not with the councils themselves to demand and operationalise local government.
We have, for a long time, expected the central government to operationalise local government when in actual fact a strong and viable local government service could demand and ultimately operationalise the proper functioning of councils.
LT: Who is supposed to directly work on these systems?
TM: The local government services — office of the director general of local government service, civil society, central government and all stakeholders in local governance.
LT: But why was this transformation not worked on during the past seven years when the decentralisation education process started?
TM: I think the office of the Director General of Local Government service is in a better position to respond to this question.
The office is cooperative and I have observed willingness on their part to strengthen the local government service.
LT: So do you see it happening now?
Are there signs that the new government wants to build sound, self-sustained and profit-making councils?
TM: We have to wait and see but yes positive signs are there.
I remain optimistic that it will happen in this lifetime.
The Deputy Prime Minister and Minister of Local Government Mothetjoa Metsing has started a consultative process to develop a national policy for decentralisation.
LT: How is this process working?
TM: The process raises awareness about decentralisation and provides a platform for all stakeholders to put suggestions forward on the type and form of decentralisation Lesotho should adopt.
LT: Have you also interacted with other local governance stakeholders to assess their level of commitment towards working on councils’ capacity to receive decentralisation?
TM: Yes, I have interacted with the current Director General of Local Service (Miss Libetso) and saw her passion to build a viable local government service.
I have also interacted with ministers from other sectors and also noticed that they do not have a problem with the principle but yes, they do have some issues with how it would be operationalised.
LT: Let’s talk about the role of the Ministry of Health in this decentralisation of primary healthcare services.
TM: Yes, the Minister of Health, Dr Pinkie Manamolela, is in full support of efforts to revitalise primary health care through promoting community participation and ownership of health services by the public.
The Ministry of Health remains in charge of the health sector because it decided through the health services decentralisation strategic plan, to decentralise its services.
LT: Does the ministry of health play a role in building the necessary capacity for councils?
TM: Yes, the capacity of councils’ political structures in order to help them understand and exercise their role in supporting the provision of improved health services.
LT: So the ministry will work directly with the councils?
TM: Yes, on the supervision of the facilities and also monitoring councils’ adherence to agreements.
They will also provide direction in line with policy frameworks.
LT: Where does the Ministry of Health draw its experience from?
TM: Well, this is not the first time they have established more or less similar partnerships.
We already have similar working relationships with institutions like the Christian Health Association of Lesotho (CHAL).
The ministry has devolved some of its responsibilities to CHAL and this operationalised through a clear memorandum of understanding which sets the parameters of work and defines roles, relationships and responsibilities of the different parties.
CHAL receives a subvention from the government, the Ministry of Health but this does not mean the ministry is involved in the health facilities’ day-to-day operations.
However, the Ministry of Health expects provision of health indicators and other deliverables agreed upon.
The Minister of Health remains the sole custodian of health services in the country.
Her office may decide to decentralise this authority to institutions like CHAL, Red Cross, councils and others but whether Basotho are healthy or not will remain a constitutional obligation of the minister in charge of health.
LT: In other words, the credit goes to the Ministry of Health?
TM: Well, we can all take the credit when systems function properly because we all have a role to make the system deliver.
But yes, the Ministry of Health gets the credit because it is the one intending to revitalise its primary healthcare.
It remains responsible and has to be accountable by virtue of being the ministry mandated by law to manage and control all aspects of health and also the one expected to implement policy.
LT: And your last words.
TM: I am convinced Basotho and the leadership we had in the past and the leadership we have now do not have a problem with the value of decentralisation.
They do not have a problem with the promises a decentralisaition system can bring to the nation.
Yes there may be issues in relation to how we operationalise decentralisation in Lesotho, but these are ongoing processes which would allow us to contribute towards improving this reform that will see Lesotho a better place. And yes, I remain very optimistic that we are on the right track.