Publications
HST provides free electronic access to over 500 health systems research related reports, publications and papers. Close to 300 of these are publications that have been commissioned and funded by the Trust. Topics include among others district systems development, drug supply management, human resource development, informatics, legislation, finance, environmental health, mental health, lessons learnt, nutrition and sexually transmitted diseases / HIV/AIDS. The main publication of the HST is the annual South African Health Review. From 2005 all HST publications will be available in low resolution only. To explore the range of publications HST offers use the Advanced search to search using a variety of criteria.

Will districts become effective vehicles for improving the quality of care, or expensive paper-shuffling machines? Will district management teams walk an interminable treadmill, or slowly, but surely improve the quality of care? These are the niggling and uncomfortable questions that motivate participants in the Initiative for Sub-District Support (ISDS).

Over the past year, the ISDS has tried to develop systematic processes of support to management teams in selected districts in South Africa, aimed at strengthening their ability to improve the quality of health care. Through this experience, we hope to be able to share lessons with other districts to create a positive spin-off effect, demonstrate the process of district development, and pinpoint persistent obstacles.

The Initiative for Sub-District Support is not home to armchair critics nor purists. Rather, it tries to provide a practical context in which strategies of support can be developed, problems identified, and lessons openly shared. Its not about knocking peoples efforts, but about creating a knock-on of innovative ideas and systems. From this vantage point as participant observers, and a year down the line, we make the following observations:

The district health system (DHS) is recognised as the fundamental building block of South Africas unified health system, and is regarded as the ideal vehicle for the implementation of primary health care. But pressing problems, including financial and bureaucratic constraints, have often meant that district development has not been central to the process of health systems transformation and development. Policies and dynamics within and outside of the health sector that go against the central tenets of the district health system are jeopardising its potential to ensure the delivery of appropriate and effective health care. At risk is the establishment of a district health system that promotes population and needs-based health planning, and management centred around discrete geographical sub-divisions of the country.

If the district health system is to really take root and become an effective instrument for improving health care, it needs a very deliberate and sustained process of support. Everyone knows that putting district management structures in place is simply not enough. But our present hierarchical administration is not geared towards the kind of hands-on, down-to-earth support that district teams need to become agents for change. This paper identifies a number of strategic and technical issues that should be addressed to ensure that the district health system achieves its potential to improve the quality of health care in South Africa.