Abstract
Orientation: There is a misalignment between the strategic goals of the public health sector, which include strengthening health systems to produce desired health outcomes, and the human resource management of the human resources for health.
Research purpose: This study aimed to describe the extent and identify the factors influencing the human resource management in achieving the strategic objectives of the public health sector.
Motivation for the study: Managers in the public health sector can develop interventions and effective procedures to improve alignment in the human resource management of the human resources for health to improve health outcomes.
Research approach/design and method: A qualitative descriptive study design with an interpretivist approach was utlised to conduct the study. A document review and sixteen face-to-face interviews were conducted, eight human resource (HR) practitioners and eight line managers purposively selected from an urban and rural district.
Main findings: The public health sector provides a unique context that requires different considerations for human resource management. Human resource managers and line managers do not only have different backgrounds and orientations but they also function in different contexts (administrative vs. clinical) in the public health sector. The factors influencing effective human resource management are as follows: the lack of capacity to implement key HR strategies in the public health sector, competing priorities and the absence of clear roles in performing human resource practices.
Practical/managerial implications: There is a need to foster a partnership approach between the HR manager and line manager to provide effective human resources management as it is complex and fractured, particularly during change and decentralisation.
Contribution/value-add: This article addresses the research gap on human resource management in the public health sector shifting focus from individual practices to a systems thinking approach in strengthening human resource management. It also makes a theoretical contribution by adding context to human resource management as a key requirement for implementation decision making.
Keywords: human resource management; alignment; district health system; decentralisation; public health sector.
Introduction
Orientation
The majority of human resource management (HRM) research is located in the private sector, and although there are opportunities for knowledge transfer, the public health sector has distinctive features that makes HRM complex and HR performance different from the private sector. Knies et al. (2024) identified three distinctive characteristics of the public health sector: firstly, unlike the private sector, the bottom line is not maximising profit, but service delivery; secondly, the selection of the bundle of human resource (HR) practices as not all practices are suitable for application in the public sector because of the nature of the service provided. Finally, the relationship between HRM and outcomes is influenced by the absence of managerial autonomy and the high prevalence of red tape functioning in bureaucratic system (Knies et al., 2024). Human resource management practices such as recruitment and selection, training and development, performance appraisal and payroll are influenced by labour legislations and collective bargaining agreements as well as the professional norms and values of the public sector workers (Boselie et al., 2021b). For example, Kravarati and Johnston (2020) posit that adopting decentralised talent management practices is complex and challenging for the public health sector as the organisation functions according to a legal-bureaucratic institutional logic rather than a market-managerial logic, which reflects New Public Management.
The fundamental component and most decentralised form of governance for most public health systems, which is in charge of providing health services, is a district health system. In a district health system to achieve organisational objectives, HRM entails the management of choices relating to policies and practices that collectively shape the employee relationship (Boselie et al., 2021a). From a theoretical standpoint, a configurational perspective to HRM provides a holistic approach to determine how the patterns of independent and dependant variables relate to each other to identify the unique patterns of factors while acknowledging system interaction effects and interrelationship with others (Colbert, 2004).
In the public health sector, there are two key role-players responsible for HRM in a district health system. Dedicated HR practitioners responsible for the administration of the HR practices and line managers who oversee and manage human resources for health (HRH) in a clinical service delivery setting. The line manager having the ambiguous situation of having two priorities: the organisational managerial priorities and the clinical profession priorities (Wilkenson et al., 2019). Fanelli et al. (2020) conducted a systematic literature review to define the domains of competences for middle management in the healthcare sector and identified eight main topics: human resource management, leadership, communication, organisational design, quality, analysis (operation and project management), programming, and costing. Buchelt et al. (2020) found that line managers in hospitals have a lack of management expertise in dealing with the problems, and the strategic role of HR professionals is not supported by organisational solutions and their entanglement in organisational structures restricts their ability to assist the adjustments needed to get towards Healthcare 4.0. Although it is anticipated that the role-players should be working synergistically to create a seamless and effective HRM system, in reality this relationship is often complex and fractured, particularly during processes of change and decentralisation.
The HR framework of alignment posited by Becker et al. (2001) concurred by Han et al. (2019) was utilised to investigate the HRM in the public health sector. Internal and external alignment are the two primary categories of alignment linking to high performance work systems and organisational performance (Becker et al., 2001; Han et al., 2019). The degree to which HRM functions are connected with one another is referred to as internal alignment, and the degree to which the HRM system is in line with the organisation’s goals is referred to as external alignment (Boselie et al., 2021b; Han et al., 2019).The assessment of internal and external HR alignment provides empirical insights into the HRM functions by assessing the linkages between the HRM functions, the HRM system and the operational and strategic objectives of the organisation (Boselie et al., 2021b). This article’s objectives are to explain and analyse HRM in the public health sector, shed light on the factors affecting alignment, and identify areas where the HRM of HRH can be improved.
Research purpose and objectives
The purpose of this article is to assess the internal and strategic alignment of HRM within the human resource function and with the strategic objectives of the organisation. The objectives were:
to assess the internal alignment of HRM functions within the HRM system to assess the strategic alignment of the HRM system with the operational and strategic objectives of the organisation to explore the factors which hinder or strengthen the district-based HRM of the public health workforce.
Literature review
The majority of the research studies on people management and high-commitment management are on commercial enterprises, whereas research on HRM in public services is very under-researched compared to corporate HRM (Fanelli et al., 2022; Wilkenson et al., 2019). Where research is conducted in the public health sector, it tends to focus on specific health occupation categories and not HRH as a collective. De las Heras-Rosas et al. (2021) conducted a bibliometric study on research conducted on HRM in health services and suggest that throughout time, research on organisational aspects associated to nurses has been the most prevalent and centralised field of study. They also argue that the lack of interest in the other groups, such as doctors, specialists, auxiliary staff, or administrative structure, is not justified.
With a larger spectrum of stakeholders to please than corporate organisations, public service organisations like in the case of the public health sector tend to be more pluralistic, including: national government, elected or nominated members, professional organisations, trade unions, key client groups and the wider public (Brunetto & Beattie, 2020). Stanton et al. (2023) highlight the differing agendas of key role-players and their interest in HRM. Considering the financially constrained environment of the public health sector, HRM can boost staff productivity and morale at work, which would ultimately increase organisational performance and patient care standards (Stanton et al., 2023). In the public health sector, motivators such as distributed leadership styles that fit organisational and individual characteristics can increase motivation of the HRH (Belhriti et al., 2020), enhance relationships with colleagues and improve the level of achievement (Kitsios & Kamariortou 2021), highlighting the importance of non-financial aspects in improving the organisational performance through effective HRM.
Human resource management is regarded as a collection or system of procedures that delineates employment relations where the collection or system of human resource practices includes practices such as selective hiring and selection, socialisation, training and development, performance appraisal and pay, employee autonomy, teamwork, and job design (Boselie et al., 2021a). In addition to being a component of the larger health system, HRM is a system that consists of a network of specific, interconnected relationships between a number of interdependent pieces. Wilkenson et al. (2019) argue that larger collections of interventions (so-called ‘bundles’) can have an influence on the financial and human performance of hospitals, supporting the idea that individual HRM policies do not have a major impact. The authors developed four bundles of HRM interventions based on their study of intervention clusters: employee voice, performance management, training, and recruiting. These interventions, when combined, had a significant and favourable influence on both financial performance and employee turnover.
Although this shift from ‘hard’ to ‘soft’ HRM has been slow in terms of the management of professionals, there have been some good advances in HRM during the past 10 years (Bruenetto & Beattie, 2020). When activities are handled from a strategic viewpoint and strategically connected to the organisation’s mission and strategy, strategic HRM (SHRM), a unique approach, can contribute to and build a lasting competitive advantage (Alfawaire & Atan, 2021; Armstrong, 2020; Chadwick & Flinchbaugh, 2021; Gupta, 2020). The paradigm shift from personnel to strategic HRM recasts HRM’s function in the organisation from managing personnel to serving as a strategic partner (Aust et al., 2020; Dixit & Sinha, 2020; Indiparambil, 2019). Also, HRM functions have been transferred to line managers in the policy environment (Renkema et al., 2020). However, an important component of this paradigm shift in HRM is for the HR practitioner to take on a more strategic role and add value, the devolution of HRM functions to the line managers and HRM to adopt a monitoring and evaluation methodology. The public health system is actively making the switch from HRM to strategic HRM.
Research design
Research approach
The elements impacting the alignment of the HRM in the public health sector are described in great detail using a qualitative exploratory study (Muzari et al., 2022). People are free to voice their opinions and unique realities as they observe and come into contact with them through qualitative studies (Pope & Mays, 2020).
Research strategy
The research technique was to conduct a case study, an empirical investigation into a phenomenon in the real world context when the boundaries between the phenomenon and context are not clear (Yin, 2014). The study looks at the district health system’s HRM system alignment, the factors influencing HRM in that system, as well as how HRM activities are carried out.
Conceptual framework
The Becker et al. (2001) HR Alignment Framework and the Boselie et al. (2005) HRM and Performance Framework were used to develop the conceptual framework. The conceptual framework draws together the various concepts and approaches placing the concepts of strategic HRM and alignment at the centre stage of HRM, adding the context of institutional, organisational, and contingent factors, depicting their relationship and impact on the HRM outcomes and organisational performance (Appendix 1).
Research method
Research setting
The research setting is two health districts in the one province representing an urban and rural district while they share the same policy and provincial management structure. They comprise different staff establishments, population size and management structures.
Research participants and sampling methods
The study population were the line managers: operational, primary healthcare (PHC) and assistant PHC managers and human resource practitioners comprising of different job titles: Human Resource Practitioner, Personnel Administrator, Assistant Director Human Resource, and Deputy Director Human Resource.
A sample of eight participants from the HR Practitioner cluster were purposively selected using the following criteria:
more than 5 years’ experience in HRM authority and responsibility for HRM authority and responsibility in monitoring human resources.
Four line managers were selected in each district, based on their experience and knowledge in the public health sector and having to perform both HRM functions and health service management. The following criteria were used to purposively select the line managers:
the manager must have been in this position for more than 5 years the manager must have been performing HRM functions and monitoring for more than 3 years the manager has to have more than five subordinates with direct accountability to the manager the manager must have had training in HRM or general management in the last 5 years.
Data collection methods
Data collection was preceded by a review of the documents (see Table 1). The document review’s two main objectives were to: (1) identify and examine the recommended and actual HRM practices; and (2) describe and comprehend the district HRM context. The document review provided insight into the district HRM environment, as well as HRM practices and functions.
Semi-structured interview guides were used to prepare and carry out in-person, in-depth interviews with line managers and HR managers. Moreover, they allowed to gain a better understanding of the particular context, duties, and difficulties related to HRM. All interviews were audio-recorded and then transcribed verbatim.
Strategies employed to ensure data quality and integrity
Case study research uses a variety of sources, creating a database of case studies, and preserving a chain of evidence (Schoch, 2020; Yin, 2014). The quantity of data sources ensured objectivity and construct validity for the HRM construct, which is related to how extensively a construct – in this case, HRM – has been investigated or researched. Construct validity was proven by the data collecting methods of document reviews and interviews, and as a result, the evidence for this research converging in terms of content, evidence, and criteria employed. A clear and accurate record of the method used for data collection and analysis was supplied by the thorough field notes and case study notes that were retained as part of the study and included in the case study database. The built-up, documented, and supported chain of evidence establishes the applicability of the findings. All original evidence has been preserved. Using a document review and semi-structured interviews, data source triangulation enabled a comprehensive and detailed description of a complex phenomenon (Nilmanat & Kurniawan, 2021).
The researcher considered her prior experience, biases, and other personal characteristics that might have influenced the study while reflecting on how she and the research method had shaped the findings and interpretation (Olmos-Vega et al., 2023). The researcher has collaborated closely with several role-players over the years on a variety of initiatives, but most recently has concentrated on improving the capabilities of HR managers at the two case study locations and creating a monitoring system for them. As a result, the researcher has a thorough grasp of the structure, policies, and practices of the HRM programme, which has the benefit of enabling him or her to appreciate the context in which HRM is practised. By maintaining contact, we were able to build relationships with the staff in the district health system and discover solutions to problems that arose there.
Data analysis
Thematic coding analysis was conducted as a constructionist method and serves ‘to examine the ways in which events, realities, meanings and experiences are the effects of a range of discourses operating within society’ (Lochmiller, 2021, p. 2030). Coding is the first step in the analytical method, which is crucial. Continuous coding refers to the process of comparing newly acquired data with previously coded data and labelling related data with the same code. The four processes followed in the analysis of the articles and interview transcripts were data management, coding, developing themes, and writing case study summaries. The first step was to create a data management system. Each transcript, document, and recording was given a label before being placed in case files that represented the two case studies.
Coding the transcripts was the second step. The coding and recoding procedure included assigning codes to various transcript portions, merging codes that were similar, and eventually defining each code. All transcripts were examined before coding began. Sticky notes were utilised to organise the paragraphs in the transcripts during the first coding process, which was performed on paper for each segment. Using this technique, an initial coding list was produced, which was then loaded into the qualitative analysis software ATLAS.ti version 6.
The codes were divided into themes in the third step. Finally, 344 codes were developed into five main themes. The final phase was the production of a case study topic summary sheet. Because creating a thematic map was deemed inappropriate for this inquiry, using the topics to create a description of the case study was utilised. Two case study summaries with extensive descriptions were used to complete the analysis.
After completing the steps required to obtain ethical approval from organisational bodies in accordance with procedural ethics. The researcher’s admission into the study locations was also authorised by the District Management Teams for each district. The objectives of the study were explained to the participants. The participants were assured of the anonymity of their contributions and were informed of their right to decline participation. It was made clear that participation was voluntary, and they were given contact information, so the researcher could get their consent to communicate with them after carefully weighing the possible social and political repercussions.
The participants were verbally told that the study is for a PhD and will be published. In addition, they were informed that they could decline or leave the research at any moment without repercussions or losing any benefits. The informed consent form was given to the participants after they had received the participant information sheet and verbal descriptions of the study. Although confidentiality was maintained by removing names of specific individuals, it is easy to identify the research district because of the nature of the study.
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of the Western Cape’s Senate Research Committee. The Western Cape Department of Health provided permission to collect the data in the two districts with reference number 12/9/14.
Results
Theme 1: Human resource management functions, roles and responsibilities
Description of a human resource practitioner in the public health sector
The dedicated human resource practitioners comprise a range of staff with different job titles: Senior Personnel Officer, HR Practitioner, HR Manager, Assistant Director: HR, and Deputy Director: HR. Managing a specific component or set of components, ensuring that rules, guidelines, and compliance are executed, as well as approving and authorising HR processes within the specific HR component, are all the tasks and responsibilities of HR practitioners. The health system reorganisation led to the HR Practitioners’ reporting line being preserved at a sub-district health service level; therefore, there is no direct or indirect reporting line to the District HR Office.
The HRM functions, which were collected from the job descriptions of HR Practitioners and other archival sources, provide a detailed picture of the HRM functions performed in the public health sector (Table 2). These HRM responsibilities follow the traditional concept of HRM, which involves finding, choosing, training, and inspiring people. This undercuts the paradigm change meant to take place in favour of a strategic HRM plan that positions HRM as a strategic partner with the public health organisation.
| TABLE 2: Human resource categories, components and functions. |
Uncertainty over how things would turn out and how the atmosphere would alter added to the stress and worry caused by the reorganisation of HRM. This quotation supports the notion that HR Practitioners have low morale: ‘I am very de-motivated at the moment’ (P6: Interview ASD 2.doc – 6:64).
In addition, previously: ‘a diploma in HR gives you an edge’ (P1: HR Practitioner 2.doc – 1:114); however, recently a qualification in HR is now a requirement ‘They have changed it now, yes, previously it wasn’t but they want to professionalise HR now’ (P1: HR Practitioner 2.doc – 1:115).
Description of line managers in the public health sector
The key line managers responsible for HRM were identified as: Facility Manager (frontline manager), Operational Managers (clinical supervision), Assistant PHC Manager and PHC Manager (frontline managers). Table 3 depicts differences between the different types of line managers and their respective HR activities and deliverables.
| TABLE 3: Line managers’ human resource activities and deliverables. |
Theme 2: Policy context of the decentralisation of human resource management functions
Human resource management in a district health system must adhere to the Public Service Act of 1994. It describes the form of the organisation and its personnel, how services may be provided in the public sector, how those services can be terminated, and what the duties, rights, and privileges of workers are (Public Service Act 1994, 1994).
The Public Service Act, which establishes standards for conduct, financial disclosure, anti-corruption, and ethical management, is implemented in accordance with the Public Service Regulations. It also includes requirements for organisational structures, service provision, planning (specifically, the creation of strategic plans, plans for human resources, and plans for information technology), and annual reporting on employment, leave, and working conditions. The Public Service Regulations provide the framework for the organisation of HRM in the public health field.
The operations management framework and management responsibility and accountability are two key management concerns that are directly taken from the Public Service Regulations and are pertinent to this study. The first management issue draws on regulation 36 which states that:
An executive authority shall establish and maintain an operations management framework, which shall include:
an approved service delivery model a list of all core mandated services provided by the department mapped business processes for all services standard operating procedures for all services service standards for all services a service delivery charter referred to in regulation 37 a service delivery improvement plan referred to in regulation 38. (Republic of South Africa, 2016: p. 55)
In the public health sector, the District Health Management Team is referred to in this operations management framework to emphasise the value of standardisation and decentralisation. However, Regulations 39 and 48 allocate specific HRM obligations which are performed by both the HR practitioner and line manager. Furthermore, the District Health Management Team is responsible for creating job descriptions under regulation 39, although the Head of Department is in charge of managing leave under regulation 48 (Public Service Regulations 2016, 2016). These two rules in the Regulations allocating HRM functions cause uncertainty between the main role actors, HR practitioners and line managers.
In the public health sector, the decentralisation of HRM is framed by two important policy documents: the Human Resources for Health in South Africa HRH Strategy for the Health Sector: 2012/2013–2016/2017 and the White Paper on Human Resource Management in the Public Service from 1997.
The White Paper on Human Resource Management in the Public Service (WPHRM) is a policy framework that encourages the growth of HRM techniques that support an effective and efficient public service, with an emphasis on the objective of economic and social change (Department of Public Service and Administration, 1997). The WPHRM recommends two things: a shift from administration to management, which is at the centre of the larger public service transformation initiative, and the decentralisation and alignment of HRM tasks with line operations. Firstly, decentralisation, underlies the public service transformation in the following two forms:
Devolution: The shift of final responsibility and accountability from the centre to the periphery, namely from the centre to the executing authority.
Delegation: Assigning functions, powers and authority to a lower level. (Department of Public Service and Administration, 1997, p. 12)
Giving line managers responsibilities for managing human resources is the second. Experts in human resources are now required to offer line managers advice and direction while also making sure that human resource practices and policies are centred on the strategic objectives of the company. According to the HRH Strategy for the Health Sector 2012/2013–2016/2017, the line manager receives help and advice from the HR department:
This is because, increasingly, in global Best Practice organisations, the central role in the management of the organisation’s HR has to be played by Line Managers. The role of the HR department is to act as a professional, internal consultant and to support management in their HR responsibilities. (Department of Health South Africa, 2011, p. 112)
More specifically, the WPHRM proposes that human resource practitioners develop:
[A] more professional role, providing advice and guidance to management on such matters as employment legislation, Public Service-wide policies and norms, labour market trends, and employee development issues. They will also continue to administer many of the day-to-day personnel management activities, such as organising recruitment competitions, and administering entry and termination of services. (Department of Public Service and Administration, 1997, p. 13)
In line with the expectations of the line manager and in agreement are the daily people management duties of the human resource professionals. This shows a close working relationship between line managers and human resource professionals as both are responsible for carrying out administrative day-to-day personnel management tasks. The transfer of HR responsibilities from the HR practitioner to the line manager is clearly mentioned in the policy, although it is not made clear which precise responsibilities should be transferred.
The second key policy document, the HRH Strategy for the Health Sector (under Objective 6.3 Clarify roles and responsibilities of HRM function and Line Managers) outlines the decentralisation process and suggests that additional HRM responsibilities must be transferred from the district to the facility level. The HRH Strategy for the Health Sector: 2012/2013 – 2016/2017 announces two strategies: professionalising HR and delegating HRM tasks to the line manager to strengthen the HRM of the public health sector in South Africa.
The first strategy, Professionalising HR is aimed at improving the human resource practices in the public health sector, as suggested by the HRH Strategy for the Health Sector: 2012/2013 – 2016/2017. It stipulates that the professional HR practitioners in the public services should:
possess formal general management qualifications, including training in best practice HR management undergo training in specific government policies and procedures relating to HR, recruitment, induction, procurement and finance have competencies in soft leadership skills fostered through mentorship and training; be managed against performance targets that include key performance indicators in HR (Department of Health South Africa, 2011, p. 61).
The White Paper on Human Resource Management in the Public Sector suggests the second strategy, which aims to decentralise and align HRM obligations with line roles in service delivery (White Paper on Human Resource Management in the Public Service, 1997). Line managers will assume formal HR tasks that were previously handled by HR Practitioners at district or provincial offices.
According to the WPHRM, more authority over employee behaviour, career advancement, and performance evaluation is handed to line managers. Formal HR activities that were previously handled by HR practitioners at district or provincial offices will now be undertaken by line managers.
Complex communication patterns were created as a result of the decentralisation process and the transfer of HR duties from the district level to the substructure level. As a result of the substructure’s handling of HR issues rather than the District HR Office, the devolution of functions to the substructure had the largest impact on how HR processes were carried out:
‘[T]he communication between the substructure offices and the district office has changed now with the devolvement of the staff coming down. Now everything is not coming to the district office anymore.’ (P6: Interview ASD 2.doc – 6:34)
Therefore, the issue is the substructure’s capability, not whether the District HR Office is still in charge of managing human resources. The intricacy is increased by the nature of the issue and choosing who will be in charge of it: ‘… it depends what type of issue it is and who’s got the delegation to deal with it. Then we approach it via that line of communication’ (P10: Interview DD.doc – 10:67). For example, the District HR Office must handle all labour relations issues if the substructure lacks a Labour Relations HR Practitioner or another person qualified to handle these issues.
A clear and pertinent reporting line must be established in order to specify the power and influence over implementation methods and accountability. The Deputy Director HR Manager’s ability to standardise and oversee the execution of HR rules is impacted by the reporting structure. One significant finding is that HR Practitioners report to the District’s Director of Health Services rather than the District’s Director of HRM: ‘… the technical arm is with the district office and the reporting line is with the director’ (P5: Interview ASD 1.doc – 5:58). Because there is no reporting line to the Director of HRM at the District Office, there is no responsibility for non-compliance with policies and procedures. When a district HRM function undergoes the decentralisation process, three reporting structures are created: the District, Substructure, and Hospitals. The fundamental reason for this being a reporting issue is that a director of human resources appointed to a hospital reports directly to the chief executive officer of the hospital rather than to the underlying management organisation. Hospitals and other health institutions are included under the district management structure in the Comprehensive Service Plan 2010; however, in practice, this is not the case.
Theme 3: Responsibility shifts
The first responsibility shift is the transition from HR generalist to HR specialist which has an influence on the responsibilities of the HR practitioners and the overall functionality of the HRM function. A key challenge raised was the HR practitioners’ capacity for performing specialised duties, which can jeopardise the efficacy and efficiency of HRM tasks. It is believed that with time, HR practitioners will be more proficient in one specialist area in HR: ‘… previously you oversaw, you will respond to all the functions, now you are going to be responsible for a specific function’ (P4: Interview AD-DD3.doc – 4:166). However, this would be contradictory to having a general understanding of and awareness of advancements in the many HR fields. In response, because all policies across all HR categories would flow via the Employment, Policy and Practices HR Category, HR Practitioners like to work in this component to stay current on policies and developments:
‘… [A]s long as I’m abreast with the policies and what’s happening within the department I will not lose sight of the operations, although I am not involved in the operations.’ (P1: ASD HRM 1.doc - 5:63)
The capacity to carry out the specialised HRM tasks that are now needed of them is impacted by the change from generalist to specialist: ‘… their lack of capacity in a specific area then causes them to be uncertain and insecure with things’ (P7: DD HRM Manager1.doc – 7:122). As a result:
‘Now they not experts, remember they used to be general experts acting in all the little pieces in all hospital administrations. Now all of a sudden you take that post away and you tell them to only focus on that specific area. Their knowledge will have to increase significantly.’ (P7: DD HRM Manager 1.doc – 7:48)
Consequently, the question of whether HR practitioners are capable of carrying out the HRM tasks necessary for a specialised approach arises.
The second responsibility is the assignment of tasks previously performed by the line manager to the HR practitioner. The transition of responsibilities between the HR practitioner and the line manager is demonstrated through the exit interview. The exit interview that was previously the responsibility of the line manager, for example, will now form part of the responsibilities of the HR practitioner:
‘There is going to be a new policy on the exit interview. Obviously the old didn’t work; the Line Manager didn’t take responsibility, not all Line Managers. I don’t think it’s a question that they didn’t assume responsibility I think that they couldn’t see what value was added.’ (P4: Interview AD-DD3.doc – 4:128).
Another example is the compilation of the job description from HR practitioner to line manager: ‘HR must assist with job description; it’s also a responsibility of each Line Manager as this is an agreement between you and that specific individual’ (P4: Interview AD-DD3.doc – 4:118). The idea is that because the employee reports to the line manager, they should take on certain typical HR practitioner responsibilities:
‘[A]nything around the employer itself they try to sort of shift instead of managing. The person actually report to you direct so you in a position to address certain things otherwise get the information and feed it back to the employee.’ (P4: Interview AD-DD3.doc – 4:133)
Theme 4: Priority differences: Service delivery needs versus human resource policy and prescripts
The two role-players encounter distinct priorities: the line managers focus on providing health services, whereas the HR practitioner prioritises compliance with HR policy and prescripts. The HR practitioners expressed their concern about the non-compliance to HR policies and prescripts: ‘the managers sometimes want to do things to satisfy the service delivery needs, and not always according to the book, as it should be done’ (P9: Interview DD.doc – 9:14). In fact, one of the HR Practitioners expressed that: ‘They don’t wanna bend the rules, they wanna break it completely’ (P9: Interview DD.doc – 9:10) to attain their objective of responding to service delivery needs.
The difference in priorities is expressed explicitly by one of the facility managers: ‘I think the compliance to me is not the main issue but filling of my post to make sure that I have enough people on the floor’ (P2: Interview Line Manager 2 FAC MX.doc – 2:35). The HR practitioner stresses HR compliance while the line manager is more focused on filling open positions. This creates a conflict of interest between the HR practitioner and line manager.
The two primary role-players’ capacity to cooperate to meet the strategic goals is impacted by these competing priorities: ‘… those are basically where we go head to head with the CEO’s, or with other HR Officers, to say: but this is not how it should be done’ (P9: Interview DD.doc – 9:15).
Theme 5: Role confusion
Role confusion between the HR practitioner and line manager was revealed after the functions and people had been devolved, despite the fact that job descriptions for each role actor had been written. The HR practitioners admitted their confusion about the new positions and delegations as they awaited more instructions to define duties and responsibilities:
‘The HR delegations were not clear, specifically on what to delegate to who and whose delegation lies where with regards to signing off of documents. I don’t know what my role really is.’ (P6: Interview ASD 2.doc – 6:60)
This notion was supported by line managers:
‘I think there is a lot of overlapping at the moment there is a lot of things that I think I’m doing and that the HR is supposed to be doing.’ (P2: Interview Line Manager 2 FAC MX.doc – 2:39)
It is unclear how much of these consequences are start-up issues rather than genuine problems with the decentralisation of the HRM function as the devolution process was only beginning and delegations and structures were being constituted at the time the study was carried out. A new HR structure was created as a result of the restructuring process; however, HR practices other than using a specialised approach have not changed.
Role confusion may also be related to prior experiences with how HRM functions were carried out since things are still performed in the same way they were in the past. A mind shift is therefore required:
‘The managers also still need to get accustomed to the human resource management practices, we have always been doing it with the District HR Office. Now it’s just that changeover that has to take place, that mind shift.’ (P10: Interview DD.doc – 10:19)
Discussion
The National Health Act 2004 (No 61 of 2003) provides the legislative framework for the South African health system and delineates three tiers: national, provincial, and district (The National Health Act 2004, 2004). The 1997 White Paper for Transformation of the Health System emphasised that PHC, which is the focus of the national health system, will be delivered through a district health system (White Paper for the Transformation of the Health System in South Africa, 1997).
In South Africa’s public health system, the policy environment has shown a commitment to a paradigm shift away from the more conventional people management approach towards strategic HRM and the devolution of HRM to line managers. Two policies serve as the cornerstones of HRM in the public health sector: the Human Resources for Health in South Africa HRH Strategy for the Health Sector: 2012/2013–2016/2017 and the White Paper on Human Resource Management in the Public Service from 1997. However, this study could not find evidence of a paradigm shift from people management to strategic HRM. Where traditional HRM theories are dominant, the challenge of paradigm shift is encountered (Harney & Collins, 2021). Heunis et al. (2019) found that South Africa is implementing the National Health Insurance (NHI) and PHC re-engineering policies and concomitantly introduced the HRH strategy, highlighting the fact that the lack of alignment of HRH policies threatens the successful implementation of NHI and PHC re-engineering.
A district health system’s HRM programme must be internally and externally aligned in order for it to offer value to the organisation beyond just providing administrative support (Mostafa, 2021). According to the study’s findings, the HRM programme was not internally aligned because most HR processes and tasks were carried out independently of one another. Moreover, HR Practitioners were not trained as HR specialists, and the paradigm shift to strategic HRM had not yet taken place. Baird et al. (2019) found that hospital HR Practitioners should transition from ‘softer’ duties and conventional HR tasks like staffing and performance evaluation to a more strategic level, where HR strategies are synchronised with and reinforce the hospital’s vision and mission and link the organisation’s strategy to HR strategies. The study also found that the HRM programme’s goals were not in line with those of the organisation, which can indicate a lack of dedication to achieving organisational goals.
The creation, direction, and coordination of HRM strategies in public sector organisations are predicated on the existence of a public sector-wide HRM strategy, as well as line manager ownership of HRM (Järvalt & Liiv, 2010). Vertical and strategic alignment were not seen in the districts, despite the existence of an HRM strategy and the devolution of HRM to line management. Boselie et al. (2021b) argue that due to the complexity of fit and alignment that these notions might have to be reframed by HR experts to better represent the complexities and volatility of modern models of strategy and organisation. They propose that an ecosystem approach can aid in our understanding of alignment’s dynamic processes as well as its static properties. It is difficult to apply HRM construct in all organisational contexts because it is most effective in small to medium-sized organisations that have little internal structural and occupational difference and focus on a limited number of strategic objectives. Snell and Morris (2021) posit that HR researchers have an opportunity to reframe concepts of fit and alignment to better reflect the complexities and dynamics of contemporary models of strategy and organisation suggesting an ecosystem perspective that studies the processes of alignment, not just its static features.
The ability of line managers to conduct HR tasks is constrained because of their lack of HRM training, despite the fact that they have stated a willingness or desire to do so. The continued prevalence of the idea that HRM is based on inherent and natural abilities could be the cause of the lack of attention given to line manager skill development in HR procedures (Kehoe & Han, 2020; McCartney et al., 2021). In addition, when extra HRM responsibilities are imposed on the line managers in conducting HRM, role theory offers insights where role ambiguity occurred in the lack of clearly defined roles and responsibilities. When the two policies were adopted, both line managers and HR practitioners expressed uncertainty about their roles, duties, and expectations with relation to their positions.
Practical implications
Human resource management system has to be strengthened by taking measures to encourage partnership between the HR and line manager in the planning, monitoring, and management of the public health staff. Such a cooperation can serve as a channel for the exchange of skills and knowledge related to HRM duties. A roles and competency framework will be useful for clarifying and assigning each of the two primary role-players, their respective roles and responsibilities. Capacity development initiatives to improve the HRM skills of the line manager and the training of HR specialists would significantly boost this partnership.
Limitations and recommendations
Despite being restricted to one province, the research offers insights about decentralisation of HRM that may not be practical to investigate in other areas. It is advised that collaboration within and between HR components be established and monitored in order to promote vertical alignment. Further research in the HR professionals’ and line managers’ role definition will eliminate the role uncertainty and aid to clarify and present each role-players’ specific functions and responsibilities. It is proposed that a collaboration could be framed by a ‘horizontal’ accountability framework where the role-players could hold one another accountable for jointly attaining the HR objectives and deliverables. It is also recommended that a monitoring and evaluation structure be created and used as an accountability framework for a district-based HRM system.
Conclusion
According to the research, the paradigm shift towards strategic HRM that is described in the HRM policy has not yet happened. The study also discovered that, although having comparable HRM system designs and structures, the two district case studies had distinct implementation strategies for their policies, each of which was determined by the unique local requirements in each district. Similar issues in the two districts were highlighted by the case studies, including job uncertainty, a lack of HRM competence, a misalignment of the internal HRM function components, and a strategic misalignment with the organisation’s goals. In addition, unclear roles and responsibilities made it difficult to implement HR policies, processes, and procedures.
Acknowledgements
This article is partially based on the author’s thesis entitled ‘Decentralised Human Resource Management in a District Health System: case studies in the Western Cape Province, South Africa’, towards the degree of Doctor of Philosophy in Public Health, Faculty of Community and Health Sciences, University of the Western Cape, South Africa, with supervisors: Professors Uta Lehmann and Helen Schneider, received November 2017.
Competing interests
The author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article.
Author’s contributions
V.E.M. declares that she is the sole author of this research article.
Funding information
The author received no financial support for the research, authorship, and/or publication of this article.
Data availability
The data that support the findings of this study are available from the corresponding author, V.E.M. upon reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the author and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The author is responsible for this article’s results, findings, and content.
References
Alfawaire, F., & Atan, T. (2021). The effect of strategic human resource and knowledge management on sustainable competitive advantages at Jordanian universities: The mediating role of organisational innovation. Sustainability, 13(15), 8445. https://doi.org/10.3390/su13158445
Armstrong, M. (2020). Armstrong’s handbook of strategic human resource management (7th ed.). Kogan Page. Retrieved from https://www.perlego.com/book/2037185/armstrongs-handbook-of-strategic-human-resource-management-improve-business-performance-through-strategic-people-management-pdf (Original work published 2020)
Aust, I., Matthews, B., & Muller-Camen, M. (2020). Common good HRM: A paradigm shift in sustainable HRM?. Human Resource Management Review, 30(3), 100705. https://doi.org/10.1016/j.hrmr.2019.100705
Baird, K., & Tung, A. (2023). Green human resource management: The role of positive levers of control and environmental performance measures in managing performance. International Journal of Manpower, 44(5), 880–899. https://doi.org/10.1108/IJM-01-2022-0005
Belrhiti, Z., Van Damme, W., Belalia, A., & Marchal, B. (2020). Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: A realist evaluation. BMJ Open, 10(1), e031160. https://doi.org/10.1136/bmjopen-2019-031160
Becker, B., Huselid, M.A., & Ulrich, D. (2001). The HR scorecard linking people, strategy, and performance. President and Fellows of Harvard College.
Boselie, P., Van Harten, J., & Veld, M. (2021a). A human resource management review on public management and public administration research: Stop right there… before we go any further…. Public Management Review, 23(4), 483–500. https://doi.org/10.1080/14719037.2019.1695880
Boselie, P., Paauwe, J., & Peccei, R. (2021b). Picking up the HRM pieces: Why fit doesnt fit in the public sector. In S. Leixnering, M. Reihlen, & D. Jancsary (Eds.), Research handbook on HRM in the public sector (pp. 14–28). Edward Elgar.
Buchelt, B., Frączkiewicz-Wronka, A., & Dobrowolska, M. (2020). The organisational aspect of human resource management as a determinant of the potential of polish hospitals to manage medical professionals in healthcare 4.0. Sustainability, 12(12), 5118. https://doi.org/10.3390/su12125118
Colbert, B.A. (2004). The complex resource-based view: Implications for theory and practice in strategic human resource management. Academy of Management Review, 29(3), 341–358. https://doi.org/10.2307/20159047
Chadwick, C., & Flinchbaugh, C. (2021). Searching for competitive advantage in the HRM-firm performance relationship. Academy of Management Perspectives, 35(2), 181–207. https://doi.org/10.5465/amp.2018.0065
De las Heras-Rosas, C., Herrera, J., & Rodríguez-Fernández, M. (2021). Organisational commitment in healthcare systems: A bibliometric analysis. International Journal of Environmental Research and Public Health, 18(5), 2271. https://doi.org/10.3390/ijerph18052271
Department of Health South Africa. (2011). Human resources for health South Africa HRH strategy for health: 2012/2013–2016/2017. Retrieved from http://www.gov.za/sites/www.gov.za/files/hrh_strategy_0.pdf
Dixit, R., & Sinha, V. (2020). Addressing training and development bottlenecks in HRM: Facilitating a paradigm shift in building human capital in global organisations. In M.A. Turkmenoglu, & B. Cicek (Eds.), Contemporary global issues in human resource management (pp. 141–161). Emerald Publishing Limited.
Fanelli, S., Lanza, G., Enna, C., & Zangrandi, A. (2020). Managerial competences in public organisations: The healthcare professionals’ perspective. BMC Health Services Research, 20(1), 303. https://doi.org/10.1186/s12913-020-05179-5
Gupta, A.D. (2020). Strategic human resource management: Formulating and implementing HR strategies for a competitive advantage. CRC Press.
Han, J.H., Kang, S., Oh, I.S., Kehoe, R.R., & Lepak, D.P. (2019). The goldilocks effect of strategic human resource management? Optimizing the benefits of a high-performance work system through the dual alignment of vertical and horizontal fit. Academy of Management Journal, 62(5), 1388–1412. https://doi.org/10.5465/amj.2016.1187
Harney, B., & Collings, D.G. (2021). Navigating the shifting landscapes of HRM. Human Resource Management Review, 31(4), 100824. https://doi.org/10.1016/j.hrmr.2021.100824
Heunis, C., Mofolo, N., & Kigozi, G.N. (2019). Towards national health insurance: Alignment of strategic human resources in South Africa. African Journal of Primary Health Care and Family Medicine, 11(1), 1–7. https://doi.org/10.4102/phcfm.v11i1.1928
Järvalt, J., & Randma-Liiv, T. (2010). Public sector HRM: The case of no central human resource strategy. Baltic Journal of Management, 5(2), 242–256. https://doi.org/10.1108/17465261011045142
Indiparambil, J.J. (2019). Strategic to sustainable human resource management: Shifting paradigms of personal managerial trends. International Journal of Business and Management Invention (IJBMI), 8(3), 65–70.
Kehoe, R.R., & Han, J.H. (2020). An expanded conceptualization of line managers’ involvement in human resource management. Journal of Applied Psychology, 105(2), 111. https://doi.org/10.1037/apl0000426
Knies, E., Boselie, P., Gould-Williams, J.S., & Vandenabeele, W. (2024). Strategic human resource management and public sector performance: Context matters. The International Journal of Human Resource Management, 35, 2432–2444. https://doi.org/10.1080/09585192.2017.1407088
Kravariti, F., & Johnston, K. (2019). Talent management: A critical literature review and research agenda for public sector human resource management. Public Management Review, 22, 75–95. https://doi.org/10.1080/14719037.2019.1638439
Lochmiller, C.R. (2021). Conducting thematic analysis with qualitative data. The Qualitative Report, 26(6), 2029–2044. https://doi.org/10.46743/2160-3715/2021.5008
McCartney, S., Murphy, C., & Mccarthy, J. (2021). 21st century HR: A competency model for the emerging role of HR Analysts. Personnel Review, 50(6), 1495–1513. https://doi.org/10.1108/PR-12-2019-0670
Mostafa, A.M.S. (2021). 12. HRM and organisational effectiveness in the public sector. In B. Steijn, & E. Knies (Eds.), Research handbook on HRM in the public sector (p. 159). Edward Elgar.
Muzari, T., Shava, G.N., & Shonhiwa, S. (2022). Qualitative research paradigm, a key research design for educational researchers, processes and procedures: A theoretical overview. Indiana Journal of Humanities and Social Sciences, 3(1), 14–20.
Nilmanat, K., & Kurniawan, T. (2021). The quest in case study research. Pacific Rim International Journal of Nursing Research, 25(1), 1–6.
Olmos-Vega, F.M., Stalmeijer, R.E., Varpio, L., & Kahlke, R. (2023). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher, 45(3), 241–251. https://doi.org/10.1080/0142159X.2022.2057287
Pope, C., & Mays, N. (Eds.). (2020). Qualitative research in health care (pp. 111–134). Wiley-Blackwell.
Public Service Act 1994. (1994). Testimony of Republic of South Africa. Retrieved from https://www.dpsa.gov.za/dpsa2g/documents/acts…/psact1994/PublicServiceAct.pdf
Public Service Regulations 2016, 1. (2016). Testimony of Republic of South Africa. Department of Public Service and Administration.
Renkema, M., Bos-Nehles, A., & Meijerink, J. (2020). Implications of self-managing teams for the HRM function. Baltic Journal of Management, 15(4), 533–550. https://doi.org/10.1108/BJM-06-2018-0230
Schoch, K. (2020). Case study research. In G. Burkholder et al. (Ed.), Research design and methods: An applied guide for the scholar-practitioner (pp. 245–258). Sage Publications, Inc.
Schultz, C.M. (2021). The future and the role of human resource management in South Africa during the Fourth Industrial Revolution. SA Journal of Human Resource Management, 19, 11. https://doi.org/10.4102/sajhrm.v19i0.1624
Snell, S.A., & Morris, S.S. (2021). Time for realignment: The HR ecosystem. Academy of Management Perspectives, 35(2), 219–236. https://doi.org/10.5465/amp.2018.0069
The National Health Act 2004. (2004). Pub. L. No. 61 of 2003. Retrieved from https://www.chr.up.ac.za/undp/domestic/docs/legislation_55.pdf%0A%0A
White Paper on Human Resource Management in the Public Service. (1997). Testimony of Department of Public Service and Administration. Retrieved from https://www.dpsa.gov.za/dpsa2g/documents/acts…/white-papers/pservicedec.pdf
White Paper for the Transformation of the Health System in South Africa. (1997). Testimony of National Department of Health. Retrieved from https://www.ipasa.co.za/…GeneralHealth/…/1997WhitePaperTransformation
Wilkinson, A., Muurlink, O., Awan, N., & Townsend, K. (2019). HRM and the health of hospitals. Health Services Management Research, 32(2), 89–102. https://doi.org/10.1177/0951484818805369
Yin, R. (2014). Case study research design and methods (5th ed.). Sage.
Appendix 1
Framework for Optimising HRM in a District Health System
| 
Hide
Show all
Email this article (Login required)
