The OLPGLLG and the subsequent enabling legislation were meant to further clarify roles and responsibilities between the levels of government and their respective administrations. The organic law was intended to give the role of policy setting to the national government, in order to ensure consistency and unity of national direction. If national health policy is to be carried out, the provincial governments must fund priorities in these areas, and allocate staff into the priority activities. If they do not, however, there is little the national government can do about it. The national government has done very little in the way of establishing mechanisms to ensure that provinces fund important areas of national policy. During the interview process for the 2001 functional and expenditure review of the health sector, one provincial administrator told a member of the review team, ‘You may have a National Health Plan and a national policy that says health is a top priority, but that’s irrelevant because in our province health is a fourth or fifth priority’.

Even though the intentions of the political and constitutional reforms are commendable, experiences so far in many provinces in fulfilling these intentions are far from convincing. Poor management practices coupled with inadequate allocation of resources, lack of staff capacity, and poor state of facilities and infrastructure at district level are just a few areas that do not support the intention of the reform. The political will may be there, but the public service machinery simply does not have the capacity to deliver.

One of the current underlying issues is that of staff motivation and the required levels of competency. Staff now have to work within a health sector that on the one hand has a clear vision with established prioritized policies but on the other hand is without clear standards, and suffers from eroded and weakened management systems. They have to operate under complex management procedures with weak provincial, district and local health managerial competence. In many cases, their technical skills have not been updated and their technical competence has been allowed to erode during the post-independence period. Disillusioned health workers in many provinces know that provincial governments are choosing not to prioritize health services for resource allocation.

The disillusionment and de-skilling is not confined to provincial health staff. The national Department of Health is also struggling to maintain a cadre of highly skilled and motivated leaders, after a succession of disappointments and continually deteriorating health statistics. Unwittingly, the escalating level of dependence on donor funds to maintain even the most basic of health services has probably played a role in increasing the disempowerment of senior health officials. The sheer numbers of donors and their technical advisers in some areas has probably undermined the leadership and influenced direction of the Department of Health. The expectations of donors and their teams to ‘be serviced’ by senior health staff, reduces time available for focusing on core business. An unanticipated consequence of donor interest and support for the health sector, in some provinces, has been the premeditated under-resourcing of health services by provincial governments, in the expectation that donors will fill the gap. This has been consistently reinforced over a number of years.