Clinical-managers in South Africa: a qualitative enquiry into the combination of clinical and managerial roles in healthcare
Keywords: qualitative research
neo-institutionalism
management
leadership
healthcare management
clinical manager
institutional logics
clinician-manager
healthcare leadership
hybrid clinician-manager
professional ethics
hospital manager
thematic analysis

Clinicians who occupy managerial roles, clinician-managers, are widespread throughout the South African healthcare system and play a key role in influencing the quality of care that is delivered to patients. They face competing clinical and managerial priorities, often engage in ongoing clinical work, face resource constraints and are confronted with ethical dilemmas. In this research programme, I explored the research question: how do clinician-managers combine their clinical and managerial roles in the South African healthcare system?
I conducted 33 in-depth interviews with current and former clinician-managers as well as key informants, complemented by fieldnotes and document reviews. Most of the clinician-managers had worked in district or regional hospitals, although some participants had also worked in primary and tertiary care centres, and most were based or had been based in the public healthcare system. Participant experiences also included rural and urban settings. I used a constructivist paradigm, and approached my data analysis using thematic analysis and theorisation. My research makes an original contribution to understanding how clinician-managers learn to manage, how they view the logics of work and what their normative role is.
My main findings included that clinician-managers enter into their roles through a variety of routes and rely on heterogenous learning strategies to enact their roles. I theorised this through three lenses, namely functionalism (professional roles are more or less given and serve to stabilise society), the critical lens on power (professionals amass power and are motivated at least partly by self-interest) and neo-institutionalism (by enacting their roles, professionals both produce and reproduce the social order).
Using an institutional logics framework, I found that clinical logic differed from clinicians’ perceptions of managerial logic. Within this framework, I showed how some participants had constructed an assimilated clinical-managerial logic, which had incorporated aspects of managerial procedure and language to serve clinical goals, which has important implications for healthcare management.
I also found that clinician-managers play a normative role – in determining what ought to be done by the healthcare organisation – when faced with ethical dilemmas. Through considering how participants balance prioritising patients, the healthcare organisation, colleagues, and procedure, my analysis made the ethical dimensions of these conflicts explicit. Recent public examples described in-depth in the South African media have portrayed some of these conflicts between clinician-managers and clinicians and I have used one such example to demonstrate how my research could be applied to better understand how and why such conflicts arise and what could be routes for resolution.
Through this thesis, I have provided a detailed description and theorisation of clinician-managers’ role combination in the South African setting. I have also related these findings to empiric work on clinician-managers in the United Kingdom, Kenya and other regions, and contrasted the findings to those settings with reference to contextual differences. Understanding clinician-managers’ role combination through theory provides new avenues to approach the training and support of these important role players in the healthcare system. I also recommend the creation of a national framework which outlines the knowledge and skills required of healthcare managers, and propose ways of empirically and theoretically grounding such initiatives.