Summary Bulletin 2 - DHS-LG Discussion List

15 DECEMBER 2000

1. RESPONDING TO THE AMENDMENTS TO THE MUNICIPAL STRUCTURES ACT

The Municipal Structures Amendment Act (Act 33 of 2000) makes provision for

a) assigning municipal health services (MHS) to district and metropolitan municipalities (Categories A and C), and for

b) the National Minister of Provincial and Local Government to authorise local municipalities (Category B) to perform certain functions assigned to district municipalities (Category C).

Request to recommend

Provinces had to recommend which local municipalities (category B municipalities) should be authorised to take on MHS. Authorisation was to be done prior to the elections.

The health sector found it difficult to provide this information due to uncertainties about:

• the definition of MHS,
• the capabilities of both categories B and C in the new dispensation.

Furthermore, there were concerns about interrupted service delivery after the elections if such authorisations are done without proper planning and communication

MINMEC decisions:

The Minister of Health and Members of the Provincial Executive Councils responsible for health (MINMEC) decided on 20 October 2000:

1. It would be inappropriate to suggest the division of functions and powers between category B and C municipalities and to rush into the complex task of allocating health functions and powers to the various municipalities.
2. New municipalities must prioritise the amalgamation of all municipal health services within their boundaries and continue to render these services with the current resources, with support from provinces.

Planning the transition

The developments above led to a well-represented work-session on "Delivering Health Services after Local Government elections", called by the NDoH and held on 26 October 2000. The main aims were to develop a framework to manage the transformation and to consider tools to assist with resource allocation and planning.

The output of the work session was a document that was tabled at the National District Health Systems Committee (NDHSC). After further deliberations and discussions the document, "Statement by the National Department of Health on the Delivery of Health Services after the Local Government elections", was compiled and circulated, representing the concerns of the NDHSC.

2. DELIVERING HEALTH SERVICES AFTER THE LOCAL GOVERNMENT ELECTIONS

The section below contains a concise summary of the national document mentioned above, dated 15 November 2000, that has been viewed by many as "by far the clearest statement of the issues and the practical way forward".

Vision:

"The medium to long term vision is to strengthen Local Government to deliver comprehensive and integrated Primary Health Care services through the District Health System approach, in order to improve the effectiveness, responsiveness and accountability of the National Health System. (NHS)"

Attaining the vision in the short term, however, will not be possible due to several reasons:

• an absence of the complex systems required to handle such massive decentralisation of the NHS, simultaneously with the transformation of local government, and
• the varying management capacity within the health system during this evolution.

Defining MHS:

There is no legal definition for MHS. In the meantime Local Government is expected to continue delivering their current set of municipal services as outlined in the Health Act of 1977. It involves prevention, promotion, treatment and rehabilitation in personal primary health care services, as well as a range of environmental health services.

National consensus on the definition will be obtained through a national workshop in 2001 where the following partners are represented:

• Departments of health at all spheres of government.
• Department of Provincial and Local Government
• Department of Finance
• Municipal Demarcation Board

This will then feed into the Health Bill.

Division of Powers and Functions:

The division of powers and functions between Category B and C municipalities needs to be clarified.

Principles:

1. The legislative changes vests the responsibility and authority for MHS at the Category C level. The Health Sector supports this.
2. Category C municipalities are thus authorised to co-ordinate health service planning, delivery and resource allocation within the whole area of the district municipality.
3. Depending on the capacity of the local municipalities within a district municipality, the Category C municipalities may deconcentrate health functions to Category B municipalities.

Proposed process:

1. The status quo will remain for the period after the elections up to 30 June 2001. This means that:
   • The function and power for MHS rest with Category A and C municipalities.
   • Category B municipalities with capacity for MHS continue to render these services.
2. From 6 December 2000 until 30 June 2001 the Department of Health (DoH) will assess the performance and capacity of local government. This will assist them in proposing a division of power between category B and C municipalities. (An objective assessment tool must be developed to evaluate the capacity of local government to render MHS.)
3. The target is to have comprehensive, integrated service delivery by the 6 metropolitan councils (category A municipalities) through service agreements by 1 July 2001.
4. The province has to make sure that there are no gaps in the rendering of services throughout the province. Where a municipality does not have the capacity to render MHS, the province has to provide the services until the Category C municipality has been strengthened to render MHS.

Funding arrangements:

The major concerns regarding funding have been the route of funding and that local government would receive functions without proper funding.

1. Provinces commit not to devolve any functions that are not funded to local government.
2. The preferred route of funding of MHS is via provinces.

Proposed process:

1. After the elections, the budgets of municipalities will be unbundled so that those municipalities who render MHS receive budgets to do so, and those that do not, do not receive money for health services.
2. Mechanisms will be put in place to ensure resource allocation towards equity, efficiency and sustainability.

Key Programmes:

Principles:

The devolution of District Health Services to local government must be anchored on key programmes according to criteria such as:

• Burden of disease.
• Poverty alleviation.
• Impact on health status.
• Greatest potential to improve the health system.

Proposed health programmes:

• HIV and AIDS
• Sexually Transmitted Diseases.
• Tuberculosis.
• Maternal and Women’s Health.
• Child Health and Nutrition.

Monitoring:

Principles:

There is a need to develop a coherent framework, parameters and indicators to enable provinces to:

1. monitor the impact of health policies on health status, and
2. to measure the performance and efficiency of the health system.

Proposed parameters for monitoring:

The parameters should include the following:

1. Situation analysis
2. Management capacity
3. Financial management capacity
4. Personnel management capacity
5. Facilities audit
6. Transport management system
7. Drug management system
8. Health Information system

Action Plan for delivering health care after local government elections:

The action plan is structured around 3 phases (See the table below):

1. Phase 1: Immediately after the Local Government elections. (5 December 2000)
2. Phase 2:Period of amalgamation of services. (6 December 2000 – 31 June 2001)
3. Phase 3: Implementation of the district health system (DHS). (1 July 2001 onwards)

3. Other issues discussed on the List:

3.1 Planning:

Some discussion started about the "what" and the "how" of planning that is required in each district municipality towards a district health system.

3.2 Financial issues:

1. Municipalities spend about R1 billion (G. Munro) on health from their own finances. It is not clear what mechanisms will secure these funds for health.
2. The eventual definition of MHS would affect the formula of financial allocation to provinces and to local government. As Provinces prefer funding for MHS to go via provinces, it is not clear how the allocation formula would change.

3.3 Community Involvement:

Establishing community participation is a priority in both the health and local government sectors. The process, principles and framework for community involvement have not been determined. Furthermore, ward development forums are being established for local government. Health needs to take account of these and other Local Government processes

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