These are some of the issues that need well-planned implementation strategies
in order for a district health system to be set up in South Africa.
The delivery of good quality primary level services to all people in South
Africa is one of the key policy principles of the post-apartheid national health
system.
For this policy to be achieved there are a number of prerequisites including:
- Adequate resources, especially financial and human.
- Support systems that provide the infrastructure on which service delivery
can be built. Examples of these systems are drug supplies, transport and
communication.
- Health professionals who have the necessary competence and confidence to
do the job as well as the commitment.
- A managerial team that makes coherent plans based on the best information
available.
In the 1997 White Paper on Health many references are made to the
"district health system". This is the lowest of three levels in the
health system with the other two being the national and provincial levels. The
district health system is the administrative level closest to the patient, where
the bulk of decisions about local service delivery are taken. The concept of a
district health system has long been mooted by the World Health Organisation.
The district health system caters for all people in a designated geographical
area and it has a single management team responsible and accountable for the
district level health services.
In South Africa the situation that currently prevails is that rudimentary
district health services have been set up in most provinces. Almost all of these
fall under the administrative umbrella of the provincial health departments. At
the same time local government health departments around the country are also
rendering primary level health services. In many cases these services are well
integrated and synchronised with provincial primary level services. However, in
as many cases they are still fragmented and working autonomously.
A long-term policy decision has recently been endorsed by the top health
policy-making bodies in the country that the delivery of all primary level
services will fall under local government. The major consequences that result
from this policy have already been highlighted.
Between now and November 2000 there will be a massive structural
transformation of local government, probably the biggest ever seen in this
country. It is inevitable that much staff time will be spent on the internal
changes required for the creation of the new local authorities. New
relationships have to be established, new organisational identities have to be
created, new management structures need to be established with new organograms,
new functions and new goals with new lines of communication. New methods of
disbursing funds on new priorities have to be agreed upon. These are but some of
the issues facing the local government transformation forums.
On top of this internal turmoil the health sectors of province and local
government will amalgamate with the overwhelmingly bigger component of staff
moving from province to local government. In order for this exercise to be
implemented relatively smoothly in a way that ensures that the quality of
service delivery is maintained a number of factors need to be addressed or taken
into account.
LEGISLATION
There is no national legislation that can guide the formation of a district
health system, as the current Health Act of 1977 is very outdated. It is not
certain when national legislation will be introduced. In the absence of national
legislation each province will thus have to introduce its own legislation on the
matter setting out its broad policy. It is likely that without a national
template that there will be significant variability between provinces.
COMMUNICATION
There is a need for those affected by the policy of setting up a completely
new system of primary level care delivery to be adequately informed of the
implications. Health workers need to know how their work will be affected and
what will happen to their personal benefits. Users of the health system need to
be kept up to date regarding any changes in service delivery.
FUNDING
At present, nationally, the bulk of funding for primary level services comes
from tax revenue and is allocated to the provinces as part of the large
provincial block grant. In some urban areas, especially in the metropoles, a
significant amount of funding for health services comes from rates revenue
raised by the local authorities. The route and mechanism of funding, the level
of funding, the sustainability of funding and the monitoring of funding between
provinces and local authorities in respect of health services still needs full
discussion before decisions can to be taken.
STAFFING
Besides looking at the mechanisms of transfer of staff from provincial to
local authority establishments there are a number of important questions around
staff that need clear answers. Will there be parity in conditions of employment
and if yes, how and when will this parity be obtained? How will organogrames for
the district health system be set up and how will the management teams be
appointed? Will staff who have not directly worked on primary level services but
have supported these, say administratively, also be transferred to local
authorities?
CAPACITY
In some provinces (especially rural areas) there is likely to be a lack of
capacity at local government level to take on district health services
immediately post-election. In these circumstances will the health workers
currently working at local government level be seconded to provinces so that
integrated primary level services can be set up at provincial level with a view
to transferring these to local government as a going concern as soon as there is
capacity?
DEFINITION OF PRIMARY LEVEL SERVICES
There are no definitive guidelines on the scope and depth of primary level
services to be rendered by the district health services. The amount of resources
available is likely to be the single most important factor in defining what
services are delivered and how much of each service. For example will all people
who need prescription spectacles be able to get these services from their local
clinic? Transparent decisions about service norms and standards need to be known
so that the reasons for the inevitable rationing are made clear. There is a
danger that the limitless demand for curative care can overwhelm the ability of
services to provide preventive and promotive health services.
The successful implementation of a district health system rendering primary
level services could have a significant effect on improving the quality of life
of many South Africans. For success to be achieved clear leadership is required
by decision makers from health and local government at all three levels of
government. Only once there is a coherent strategic plan can pragmatic decisions
to implement be taken. |
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