Title: Exploring Knowledge, Attitudes, and Practices Towards Public Financial

Management Among Public Health Managers Working at a Non-Governmental

Organisation in Tshwane, South Africa: A Qualitative Study

Keywords: Public financial management, non-governmental organizations,

Public Finance Management Act, public health managers, qualitative study

Abstract

Introduction

Effective public financial management (PFM) is crucial for ensuring that public health
funds are utilized optimally to deliver the best possible services. In South Africa,
there's a significant need to enhance financial management practices within the
health sector to ensure that resources are used efficiently and transparently. Despite
the high level of tertiary education among health professionals in the country, efforts
to reform public financing systems have been fragmented and often placed at a low
priority. The Public Finance Management Act (PFMA) aims to improve accountability
and good governance in public finance, but its implementation faces numerous
challenges. This study seeks to understand the knowledge, attitudes, and practices
of public health managers regarding PFM, particularly within non-governmental
organizations (NGOs) that play a critical role in delivering health services.

Methods

This qualitative study explores the knowledge, attitudes, and practices towards PFM
among public health managers working at a non-governmental organization in
Tshwane, South Africa. Data were collected through semi-structured interviews with
12 public health managers, who were selected using convenience and purposive
sampling methods to ensure a diverse representation of experiences and
perspectives. The interviews focused on various aspects of PFM, including
budgeting, resource allocation, accountability, and challenges faced in financial
management. Data were transcribed, coded, and analyzed using thematic analysis
to identify key themes and insights.

Results
The study found that rigorous budget monitoring and the necessity of justifying all
expenses were critical components of effective financial management. Participants
emphasized the importance of accountability and careful planning in preventing
unnecessary spending. However, challenges such as unforeseen costs and the need
for adaptability in financial planning were also highlighted. Financial management
was primarily defined as involving budgeting and resource allocation, but also
included risk assessment and long-term planning.

Conclusion

Effective public financial management is essential for the sustainability of public

health projects. Training and development opportunities for public health managers
in financial management can significantly enhance the viability of health initiatives,
even after the withdrawal of donor support. More opportunities for collaboration
between finance and program managers are recommended to align expenditures
with programmatic results.

Key Messages

What is already known on this topic

Public financial management is vital for the effective delivery of health services, and
there is a global emphasis on improving the financial management skills of health
professionals. However, efforts to reform financial management systems in South
Africa have been fragmented and largely unsuccessful.

What this study adds

This study highlights the importance of rigorous budget monitoring, justification of

expenses, and the need for a comprehensive approach to financial management that
includes risk assessment and long-term planning. It also underscores the challenges
posed by unforeseen costs and the need for adaptability in financial planning.

How the study might affect research, practice, or policy

The findings suggest that enhancing financial management training for public health
managers and promoting collaboration between finance and program managers can
improve the sustainability and effectiveness of public health projects. This can inform
future reforms and training programs in financial management within the health
sector.

Section Headings

Introduction

Effective public financial management (PFM) ensures that public health funds are
utilized optimally to deliver services in the best possible manner. The global call for
universal health coverage and concerns about the management of public funds in
low- and middle-income countries necessitate well-rounded healthcare professionals
who are competent in financial management, leadership, and governance. In South
Africa, the Public Finance Management Act (PFMA) provides a framework for
improved financial accountability and transparency, yet its effective implementation
remains a challenge. This study aims to fill the gap in understanding how public
health managers perceive and practice PFM within the context of NGOs, which are
pivotal in the healthcare delivery system.

Materials and Methods

This study employed a qualitative research design, utilizing semi-structured

interviews with 12 public health managers from a non-governmental organization in
Tshwane, South Africa. The participants were selected using convenience and
purposive sampling to ensure a diverse range of experiences and perspectives. The
interviews were designed to explore the participants' knowledge, attitudes, and
practices towards PFM, covering topics such as budgeting, resource allocation,
accountability, and the challenges they face. Each interview was transcribed
verbatim, and the data were analyzed using thematic analysis to identify key themes
and patterns.

The thematic analysis process involved multiple stages, including familiarization with
the data, coding, theme development, and revision. Initial codes were generated
based on recurring concepts and phrases, which were then grouped into broader
themes. These themes were refined through iterative review and discussion among
the research team to ensure they accurately represented the data. The final themes
provided a comprehensive understanding of the participants' perspectives on PFM.

Results and Discussion

1. Demographic and Background Information

1.1 Age Band

Percentag
Age Band Frequency
e

20-29 2 14.3%

30-39 4 28.6%

40-49 4 28.6%

50-59 3 21.4%

60-69 1 7.1%

1.2 Highest Educational Level

Frequenc
Educational Level Percentage
y

Bachelor's Degree 7 50.0%

Master's Degree 6 42.9%

Doctorate 1 7.1%

1.3 Career Background

Career Background Frequency Percentage

Public Health and Community Health 5 35.7%

Business and Finance 3 21.4%

Social Work and Community

2 14.3%
Outreach

Public Policy and Research 2 14.3%

Health Education 2 14.3%

1.4 Years of Experience in Public Health

 Frequenc
Years of Experience Percentage
y

1-5 2 14.3%

6-10 3 21.4%

11-15 2 14.3%

16-20 2 14.3%

21-25 3 21.4%

26-30 1 7.1%

31+ 1 7.1%

1.5 Current Role at the Organization

Current Role Frequency Percentage

Program Director 1 7.1%

Finance Manager 1 7.1%

Senior Public Health Advisor 1 7.1%

Community Health
1 7.1%
Coordinator

Chief Financial Officer 1 7.1%

Program Assistant 1 7.1%

Outreach Coordinator 1 7.1%

Financial Analyst 1 7.1%

Operations Manager 1 7.1%

Project Manager 1 7.1%

Program Analyst 1 7.1%

Current Role Frequency Percentage

Senior Program Coordinator 1 7.1%

Community Program Leader 1 7.1%

Senior Epidemiologist 1 7.1%

1.6 Department

Department Frequency Percentage

Program Development 1 7.1%

Finance and
2 14.3%
Accounting

Policy and Research 2 14.3%

Community Health 1 7.1%

Finance 1 7.1%

Program Coordination 1 7.1%

Community Outreach 1 7.1%

Operations 1 7.1%

Project Management 1 7.1%

Program Analysis 1 7.1%

Community Programs 1 7.1%

Epidemiology 1 7.1%

FINDINGS

Strategies to Manage and Minimize Fruitless Expenditure

Theme: Rigorous Budget Monitoring and Justification of Expenses:

Participants emphasized the critical role of rigorous budget monitoring and the
necessity of justifying all expenses. For instance, Participant 3 stated, “We always
ensure that every expense is thoroughly planned and justified. No expenditure is
approved without a clear rationale.” This reflects a culture of accountability and
careful planning aimed at preventing unnecessary spending. The practice of
requiring detailed justifications for expenses ensures that each expenditure is
aligned with program goals and avoids waste.

However, despite these preventive measures, challenges persist in completely

eliminating fruitless expenditure. Participant 5 highlighted this by noting, “Even with
strict monitoring, unforeseen costs can arise. It’s crucial to stay vigilant and
continuously review our spending.” This observation underscores the unpredictable
nature of certain expenses and the importance of adaptability in financial planning.
Unforeseen events, such as sudden changes in project scope or unexpected
external factors, can complicate budget adherence. Therefore, while rigorous budget
monitoring is essential, it must be coupled with a flexible approach to address
unanticipated costs and ensure that resources are used efficiently.

Understanding of Financial Management

Theme: Budgeting and Resource Allocation as Central to Financial

Management:

Participants consistently defined financial management as primarily involving

budgeting and resource allocation. Participant 2 described it as “managing funds
effectively to achieve program goals,” while Participant 6 added, “making sure the
resources are used efficiently and within the budget.” These definitions highlight the
fundamental importance of planning and allocating financial resources to achieve
desired outcomes. Effective financial management requires a strategic approach to
distributing funds, ensuring that all expenditures contribute to the program's
objectives.

However, participants also acknowledged that financial management encompasses

more than just budgeting. Participant 7 elaborated, “While budgeting is a key part,
financial management also involves risk assessment and long-term planning.” This
broader view recognizes that financial management includes assessing potential
risks and planning for the future to ensure financial stability and sustainability. It’s
about balancing short-term needs with long-term goals, anticipating potential
financial challenges, and developing strategies to mitigate them. This comprehensive
approach is crucial for maintaining the financial health of a program and ensuring
that resources are used in the most effective way possible.

Experiences with Poor Financial Management Skills

Theme: Negative Impact on Program Outcomes and Resource Utilization

Participants shared that poor financial management often led to inadequate resource
allocation and negatively impacted program outcomes. For example, Participant 1
noted, “We had a significant shortfall due to poor budget planning, which affected our
ability to deliver key services.” This indicates that ineffective financial management
can disrupt program activities, leading to delays, reduced service quality, or even
project failure. The consequences of poor financial planning are far-reaching,
affecting not only the immediate financial stability of the program but also its long-
term viability and impact.

However, it is also important to consider that poor financial management can come
from systemic issues rather than individual incompetence. Participant 4 remarked, “It
wasn’t just a lack of skills; there were structural issues, like insufficient oversight and
unrealistic budgeting.” This statement points to the complexity of financial
management in large organizations, where structural problems such as inadequate
oversight, unrealistic budget expectations, and lack of proper financial controls can
contribute to poor outcomes. Addressing these issues requires more than just
improving individual skills; it necessitates a comprehensive review of organizational
processes and systems to ensure that financial management practices are robust
and effective.

Involvement in Budgeting Processes

Theme: Limited Involvement in Budgeting Decisions

Most participants indicated that their involvement in the budgeting process was
limited, often due to hierarchical structures within the organization. Participant 5
rated their involvement as 3/10, explaining, “We provide input, but final decisions are
usually made at a higher level.” This suggests that while lower-level managers may
have some influence, their role is often limited to providing data or feedback rather
than participating in the actual decision-making process. This limited involvement
can lead to feelings of disempowerment and a lack of ownership over budgetary
decisions.

However, there are distinctions to this limited involvement. Participant 6 mentioned,

“While we’re not the final decision-makers, our insights are considered, especially in
program-specific budgets.” This indicates that there is still a channel for input and
feedback from various levels within the organization, even if the final decisions are
made at a higher level. The challenge, therefore, lies in ensuring that this input is
valued and considered in the final budgeting decisions. Limited involvement can
sometimes be beneficial in streamlining decision-making processes and ensuring
that those with the most relevant expertise are making the critical financial decisions.
However, striking the right balance between inclusivity and efficiency is key to a
successful budgeting process.

Experiences with Good Financial Management Skills

Theme: Efficient Resource Utilization and Positive Program Impact

Participants agreed that good financial management resulted in efficient use of

resources and positive program outcomes. For instance, Participant 7 shared,
“When the budget is managed well, we can optimize our resources and achieve our
program goals without overspending.” This statement underscores the importance of
effective budgeting and financial oversight in maximizing the impact of programs.
Good financial management ensures that resources are allocated efficiently,
minimizing waste and maximizing the program's ability to meet its goals.

However, even with good financial management, challenges can still arise.
Participant 9 observed, “Even when everything is planned perfectly, unexpected
events can still cause budget issues. Flexibility and contingency planning are
crucial.” This highlights the importance of being prepared for unforeseen
circumstances and having contingency plans in place to address them. Good
financial management is not just about planning and executing a budget but also
about being adaptable and responsive to changes and challenges. It involves
continuously monitoring financial performance, identifying potential issues early, and
adjusting plans as necessary to keep the program on track.

Attitudes towards Financial Management Responsibilities

Theme: Shared Responsibility between Managers and Financial Experts

Participants generally believed that financial management should be a shared

responsibility between managers and financial experts. Participant 9 explained,
“While finance experts should handle the technical aspects, program managers need
to understand the basics to make informed decisions.” This reflects a recognition of
the importance of cross-disciplinary collaboration in financial management.
Managers, who are often more familiar with the programmatic aspects of the project,
need to have a basic understanding of financial principles to make informed
decisions and effectively oversee the financial aspects of their programs.

However, there are challenges in ensuring that program managers have the
necessary financial knowledge. Participant 4 noted, “Not all managers have the
financial literacy needed to make informed decisions. More training is necessary.”
This suggests that while shared responsibility is ideal, it requires a certain level of
financial insight among all involved parties. Providing training and professional
development opportunities can help link this knowledge gap and empower managers
to take a more active role in financial decision-making. Fostering a collaborative
environment where financial experts and program managers work closely together
can enhance the overall effectiveness of financial management within the
organization.

Essential Financial Management Skills for Public Health Managers

Theme: Budgeting, Financial Analysis, and Cost Management

Participants consistently highlighted budgeting, financial analysis, and cost
management as essential skills for public health managers. Participant 4 noted,
“Understanding how to allocate and manage funds is crucial for the success of any
health project.” These skills are critical in ensuring that resources are used
effectively and that the program can achieve its objectives within the allocated
budget. Effective budgeting and financial analysis allow managers to plan for both
expected and unexpected expenses, while cost management helps to keep
spending under control and prevent overspending.

However, participants also pointed out that practical experience is just as important
as theoretical knowledge. Participant 8 emphasized, “Knowing the theory is one
thing, but practical experience in managing budgets and finances is invaluable.” This
suggests that while formal training in financial management is important, hands-on
experience is equally crucial. Real-world experience helps managers to understand
the complexities and challenges of financial management and to develop the skills
needed to navigate them. Moreover, public health managers often operate in
resource-constrained environments, where the ability to manage limited funds
effectively can make a significant difference in the success of their programs.
Therefore, a strong foundation in budgeting, financial analysis, and cost
management, combined with practical experience, is essential for public health
managers.

Support for Improving Financial Management Skills

Theme: Inadequate Training and Need for Regular Refresher Courses

Many participants felt that the training provided was insufficient and expressed a
need for more regular refresher courses. Participant 6 commented, “We had some
basic training, but it wasn’t enough. I think we need more comprehensive and regular
training sessions.” This reflects a gap between the training needs of staff and the
support provided by the organization.

However, there is also a recognition that training alone is not sufficient. Participant 3
noted, “In addition to training, we need ongoing support and mentoring to apply
these skills in real-world scenarios.” This suggests that a holistic approach, including
both formal training and continuous professional development opportunities, is
necessary for building effective financial management skills.

Personal Decision-Making in Procurement

Theme: Research and Comparison as Key Decision-Making Processes

Participants mentioned that they conduct thorough research and compare options
before making high-value purchases, both personally and professionally. Participant
2 stated, “I always compare prices and features before buying anything expensive.
The same approach applies to procurement for our programs.” This indicates a
careful and deliberate approach to procurement, ensuring value for money.

However, there are challenges in applying these processes consistently across all
program areas. Participant 5 remarked, “While we try to apply the same thorough
process, sometimes time constraints or urgent needs make it difficult.” This
highlights the need for a balance between thoroughness and practicality in
procurement processes.

Role of Insurance in Program Management

Theme: Essential for Risk Management

Participants acknowledged the importance of insurance in managing risks

associated with program activities. Participant 8 remarked, “Insurance is crucial for
protecting our programs against unforeseen events, such as accidents or natural
disasters.” This highlights the role of insurance in ensuring program continuity and
financial stability.

However, there is also a need to carefully select the appropriate types and levels of
insurance. Participant 6 noted, “Not all insurance policies are necessary for every
project. It’s important to assess the specific risks and choose coverage accordingly.”
This suggests that while insurance is vital, it must be tailored to the unique needs
and risks of each program.
Personal Approach to Budgeting and Financial Management

Theme: Prudent Budgeting and Contingency Planning

Participants described their approach to budgeting as cautious and prudent, with

contingency plans in place for any shortfalls. Participant 5 shared, “I always try to
leave a margin in the budget for unexpected expenses. If there’s a shortfall, we
reallocate funds from less critical areas.” This strategy helps in managing financial
risks and maintaining stability.

However, despite careful planning, managing shortfalls can still be challenging.

Participant 7 noted, “Even with a contingency plan, some deficits are difficult to cover
without impacting other areas.” This highlights the limitations of budgeting strategies
and the need for flexibility and adaptability.

Linking Programmatic Performance to Financial Performance

Theme: Regular Monitoring and Adjustment of Financial Plans

Participants stressed the importance of regularly monitoring both financial and

programmatic performance to ensure alignment. Participant 7 explained, “We
conduct monthly reviews to compare our financials with our program targets. If we
see any discrepancies, we make adjustments to our plans.” This highlights the
ongoing nature of financial management and its critical role in program success.

However, there are challenges in accurately linking these two aspects. Participant 10
noted, “Not all program outcomes can be quantified financially, which makes it
harder to assess performance purely on financial terms.” This suggests that while
financial metrics are important, they should be complemented by qualitative
assessments to get a complete picture of program performance.

The results indicated that rigorous budget monitoring and the justification of
expenses are crucial for effective financial management. Participants highlighted the
importance of accountability and careful planning in preventing unnecessary
spending. Despite these measures, challenges such as unforeseen costs and the
need for adaptability in financial planning were evident. Financial management was
defined not only as budgeting and resource allocation but also as risk assessment
and long-term planning. Participants also noted the critical role of transparency and
communication in maintaining trust and ensuring effective collaboration between
finance and program managers.

The discussion section elaborates on these findings and their implications for public
health management and policy. It addresses the need for ongoing training and
professional development in financial management for public health managers. The
study also highlights the importance of fostering a culture of accountability and
continuous improvement within organizations. Additionally, the discussion considers
the broader implications of the findings for health policy and practice, suggesting
potential areas for future research and reform.

Funding Statement

This study received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.

Authors’ Contributions

 Chido Elis Machakanja: Conceptualization, data collection, data analysis,

manuscript writing.

 Dr. Moeketsi Modisenyane: Supervision, methodology guidance, manuscript

review.

 Dr. J Shirinde: Co-supervision, methodological support, critical revision of the

manuscript.

Word Count

The total word count of the article is 4,872 words, with five figures and tables
included.

Supplementary and Raw Data

Figures and images are submitted as separate files. Supplementary data is provided
online and linked in a suitable repository.

3. Limitations of the Research

Sample Size and Diversity:

The study was conducted with a relatively small and specific group of public health
managers from a single NGO in Tshwane, South Africa. This may limit the
generalizability of the findings to other organizations or regions. The results may not
fully capture the diversity of experiences and perspectives in different contexts.

Self-Reported Data:

The data collected through interviews are self-reported and subject to biases such as
social desirability bias, where participants may present themselves in a more
favourable light. This can affect the accuracy and reliability of the information
provided, potentially skewing the findings.

4. Recommendations

Training and Capacity Building:

To strengthen the team’s financial management capabilities, it’s important to

enhance our training programs with hands-on experiences and scenario-based
learning. Regular refresher courses, possibly held quarterly, can ensure that the staff
continuously improves and stays updated with the latest skills.

Collaboration and Communication:

Encouraging a team-oriented approach to financial management, which involves

both program managers and financial staff, can greatly enhance decision-making.
This collaboration fosters a comprehensive understanding of the financial
implications of their decisions, leading to better outcomes.

Insurance Coverage:

Expanding our insurance coverage to include liability, property, and health insurance
for our staff can offer significant protection. This coverage acts as a safety net,
shielding the organization from potential financial risks and providing employees with
security.

Financial Planning and Monitoring:

To maintain our financial health, we need to adopt more rigorous planning and
monitoring practices. This involves regular reviews of budgets and expenditures,
along with setting clear financial targets that align with our program goals, ensuring
we stay on track and can make necessary adjustments.

Risk Management:

Developing a thorough risk management strategy is essential. This strategy should

include contingency planning and regular risk assessments to help us respond
swiftly to unexpected challenges, thereby protecting the organization’s financial
stability.

Resource Allocation:

Efficiently allocating resources is crucial to achieving our objectives. By regularly

reviewing financial and program performance, we can identify areas of
underspending or overspending and make timely adjustments to optimize resource
use.

Stakeholder Engagement:

Increasing transparency and communication with donors and other stakeholders

about our financial management practices can build trust and strengthen
relationships. This openness demonstrates our commitment to accountability and
can attract additional funding opportunities.

Technology and Tools

Investing in modern technology and tools, such as budgeting software or financial

tracking systems, can streamline our financial management processes. These tools
enhance the efficiency and accuracy of our financial reporting, making it easier to
manage our finances effectively.

Professional Development:

Encouraging staff to pursue professional development opportunities in financial

management, such as certifications or advanced courses, will enhance their skills
and knowledge. This investment in our team benefits the organization by fostering a
more capable and knowledgeable workforce.

Policy Development:
Regularly reviewing and updating our financial management policies and procedures
ensures they align with best practices and regulatory requirements. This proactive
approach enhances compliance and reduces the risk of financial mismanagement,
safeguarding our organization’s future.

Reference Limit

The article includes 45 references.