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.
Published in: Reconstruct, Pg7
Pub Date: 9 April 2000 |
Publications
