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Summary Bulletin 5 - DHS-LG Discussion List
June 2002
The discussions were opened with a request from
the National Department of Health for input from members of the list for a
meeting to be held between the National Minister of Health and the National
Minister of Provincial and Local Government. Their discussions will be centred
on
- Division of powers between the categories of municipalities
- Definition of municipal health services
- Transitional arrangements – the operational challenges and the transactional costs associated with the transfer of staff, flow of funds etc
- Legislative process, including the National Health Bill and the Local Government Acts.
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There is need to harmonise the national health
system, in particular the district health system, with the transformation of the
local government system. This has been the challenge since discussions on the
district health system started in 1994. A clear way forward needs to be defined.
Financial Issues:
Many questions were immediately raised; ones
which the Western Cape and other provinces have been struggling with for a long
time include inter alia; -
- Assignment and its consequences for the use of funds raised by the district councils for PHC services. Can there be co-funding?
- Local municipalities have more leeway than district municipalities for fund raising.
- There needs to be caution with assigning functions to B municipalities with capacity within a district municipality as this could upset the balance within the C municipality.
- Funds are to be devolved from National to Local Government and therefore there would be a change in the provincial equitable share. How will this amount be determined?
- Who will be responsible for the costs of transfer of staff with assignment?
- Who will take responsibility for transferred assets, such as insurances?
A few practical ideas for solution to the funding
issues were shared: -
- Look at the issue of funding PHC services provided by local government from the equity aspect; i.e. by not supplying equal share for all, but by supplying to each according to his/her needs. The equitable share to be considered according to revenue generating potential and service use potential.
- Incremental funding and empowering of municipalities over a period of 5 years by national and provincial health authorities. Sustained funding of the assigned functions is the key issue.
Service Context:
- With handing over of a service, what power does the province have for planning and monitoring the services? This has not been established, even through the PFMA.
- A balance between PHC and hospital services is essential to ensure a seamless continuum of care between the levels of health care. This is particularly a problem when there is a split of the services between the spheres of government.
- Municipal health services and how this is finally defined could have an impact on whether PHC services could possibly be provincialised. This is in conflict with the proposed Health Bill, Section 42(1) which states that District and Metro Municipalities will be responsible for co-ordinating the provision of health services within the health district.
Before being able to answer the many questions
and plot the way forward, it is important to know where we are going and to
capture the vision for health services. These are clearly laid out in a recent
Department of Health document. (See Box 1)
Box 1
| REAFFIRMING THE DHS VISION
AND PROPOSING A GOAL The vision for the DHS can be expressed in
different ways but has not changed since its appearance in the ANC’s
Health Plan, the RDP and the White Paper for the Transformation of the
Health System. The vision is that people will experience seamless care
from primary to tertiary level, and that they will access this care
through integrated, comprehensive PHC services. The DHS will be the
foundation of the health system whose development will be guided by 12
principles spelled out in the White Paper of 1997. The goal is to have 53 health districts each
ultimately characterised by:
- Provision of comprehensive district health services (i.e. the PHC package plus district hospital services);
- A district health plan that is part of Integrated Development Plans (IDP);
- A structure and processes to facilitate cooperative governance, (to ensure joint planning and seamless service provision)
- Joint funding from municipalities and province(s);
- A single budget with clear components or budget lines;
- A single management structure;
- All staff part of a single public service; and
All staff employed by the district (or metro) municipality, or by the local municipality where service provision has been delegated to local level.
The end result will be a municipality-based
district health system with:
- Local government responsible for service delivery and the day-to-day management of all district health services.
- All district health staff employed by local government, but on the same conditions of service as provincial staff and able to transfer between the three spheres of government.
- Provinces providing most of the funding (at least outside the metro areas) and working closely with the district municipality in the processes of planning, budgeting, monitoring and evaluating all district health services.
The District Health System – Proposed
Way Forward: Discussion Document - 13 June 2002
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The ultimate goal is therefore for a
municipality-based DHS with all the staff and services devolved initially to the
district or metro municipality level.
Transition is difficult and likely to be
different in each province. A starting point is with functional integration and
cooperative governance. This requires a firm commitment to the vision and a
legislative framework within which to work.
A discussion as to the merits and de-merits of a
provincial-based DHS versus a municipality-based DHS followed. Some
correspondents supported the advantages of a provincial-based DHS and the
possibility of having to change the policy decision. It is thought that this
would be the easy solution to many of the problems mentioned and ensure that all
PHC (including the level 1 hospitals) were under the one management system.
However, the provincial-based DHS is not without problems, e.g. health is
dependent on other sources such as sanitation and housing and it is essential
that district health management are part of the local government IDP process;
transfer of staff from local government to province has problems with different
conditions of service and pay-packets.
There were equally strong views expressed on
municipality-based DHS. This is the vision of the National Department of Health
and the focus of the Health MinMEC decisions of February 2001. This vision needs
to be taken on board by all stakeholders in health services. Strong leadership
and a decisive strategic plan are required to ensure that the right
solution is found. This may not be the easiest solution, but with
commitment to the final goal of improving the services for the community, the
solution to the perceived barriers must be found.
Some practical experiences from the service
delivery level of the lack of strategic direction and positive leadership in
reaching the vision were shared.
- From Limpopo there came a plea not to separate the management of the clinics from the hospitals. Also to set up the DHS as defined by the WHO and within the framework of national policy, with appropriate decentralization of responsibilities and resources. These districts to be supported (not directed) by the provincial department of health.
- From KwaZulu-Natal was shared the frustration of planning services at the ground level, such as the provision of a PHC Gate Clinic at a district hospital. Who is responsible for this and other PHC services – provincial or local government? Decisions need to be made so that joint planning and functional integration can take place at the local level.
- The prolonged period of indecision is leading to ever increasing staff frustration because they do not know where they belong now or where they will be moved to in the future.
The bigger picture of the services must be kept
in mind and local government be empowered in a stepwise manner to ensure they
are strengthened and that the inter-government relationships are such that the
impact on service delivery is maximized. The present problems of clinics not
belonging to the same sphere of government, as the hospitals should be seen as a teething problem and not as an iceberg that will sink the
ship. A process of developing appropriate relationships between the
spheres of government is required.
According to a policy implementation expert, a
major issue that has prevented progress over the past ten years of
implementation of DHS is the lack of knowledge within the health sector of the
legislative and financial framework within which they operate. A policy decision
is made and all the correct channels of producing a white paper, legislation,
ministerial declaration etc are followed, but nobody actually understands the
practicalities of implementing the selected policy. A working knowledge of
labour relations, inter-governmental finances, administrative law etc is
essential for understanding the complexity of successful policy implementation.
With this knowledge and understanding, a single realistic implementation
framework could be developed within the National Health Bill.
Bulletin complied by Wendy Hall (hstwendy@sai.co.za)
Health Systems Trust.
23/07/2002
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