The state and long-term care facilities in the Western Cape, South Africa before and during the COVID-19 pandemic: Rule enforcement or partnership?

South Africa contains large numbers of long-term care facilities (LTCFs) and experienced high rates of COVID-19 infection during the pandemic. This paper examines how state agencies in the Province of Western Cape engaged with facilities before and during the pandemic, and whether this represented an effective form of state stewardship. We draw on semi-structured interviews with LTCF managers and observational/documentary data obtained through collaborative engagement with government agencies. Pre-pandemic, state engagement with LTCFs mainly entailed funding for poor residents and tokenistic rule enforcement. There was little coordination between the two main regulatory agencies, with many facilities unregistered and entirely unregulated. There was an evident disconnect between official standards and the capacity of LTCFs to achieve them, which regulators did little to address. During the pandemic, many LTCFs turned to state agencies for guidance and support, but they were slow to respond. As the pandemic progressed, state agency coordination and responsiveness improved to some degree, especially during the roll-out of COVID-19 vaccines. The pandemic experience revealed the dysfunction of the established LTCF regulatory model, which focussed on largely performative rule enforcement and limited state funding. It calls for an approach based on partnerships between regulators and providers, establishing achievable goals and shared responsibility for service improvement.