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Provincial Governments Support for the District Health System

Provincial Governments Support for the District Health System. 5 & 6 August 2004. District Health System Development. Cornerstone of the NHS The development of the District Health System is a process of decentralisation of PHC to LG Aligned Health Districts to LG boundaries

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Provincial Governments Support for the District Health System

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  1. Provincial Governments Support for the District Health System 5 & 6 August 2004

  2. District Health System Development • Cornerstone of the NHS • The development of the District Health System is a process of decentralisation of PHC to LG • Aligned Health Districts to LG boundaries • Relationship to Metros and District Councils through SLA (Bs thru DC)

  3. Principles and elements • Based on Alma Ata Declaration 1976, ANC policy and WHO in developing countries with principles accessibility, equity etc Elements • Governance • Services • Capacity Development • Systems (HR HIS Finance etc) • Community Participation

  4. Gauteng

  5. Move to PHC services Hospicentric District Health System

  6. Governance • Constitution - accessibility, equity etc • National Health Policy • GHD District Health System through LG • Some provinces -provincialised & then decentralise • Legislation NHB & Gauteng DHS Act • Cooperative Governance • Consultation

  7. SPHERE POLITICAL OFFICIAL ORGANISATION CONSULTATIVE NATIONAL National Health Council (MinMEC) National Health Advisory Committee (PHRC) South African Local Government Association (SALGA) National Health Consultative Forum PROVINCIAL Provincial Health Council (PHA) Provincial Health Advisory Committee (PHAC) (SALGA) H & W Gauteng Provincial Health Consultative Forum METRO/DISTRICT District Health Council District Health Advisory Committee (SALGA) H & W Gauteng DHCF Community LOCAL Local Health Council Sub-District Health Committee (SALGA) H & W Gauteng LGHCF Community COMMUNITY Ward Councillor Health facility managers Ward Health sub-committee NGOs/CBOs Youth, Women etc CHW CDW Ward Committee Community

  8. Framework for Process • Joint Process of Province and Local Government officials • Principles and guidelines for joint District processes

  9. Defined issues to develop a District Service Plan • Definition of facilities • Package of PHC services with priority programmes • Referrals system • Workload ratios • Staffing • Finance expenditure • Resources and gaps

  10. Facilities PHC pkg of services within health sub- district area: • Clinics • Mobiles & satellites • Community outreach • Community Health Centres • District hospitals

  11. Sub-District Area 300,000 popul.

  12. Key outputs of this process • Single list of PHC facilities by type • Linkage of personnel and expenditure as well as activity data to facilities / cost centres • Accurate information on current staffing by standardised category • Affordable norm-based staff establishment for joint / devolved / integrated PHC services (management and facilities) • Rationalisation for equity & cost efficiency • Measurement of gap between current and future / ideal cost for improved PHC delivery in line with MTEF – joint District Health Plan

  13. Priority programmes • EPI & outbreak response co-ordination • Communicable diseases • Mother and child services • ANC/PNC and Primary obstetric services • Youth & school health services • HIV/AIDS/STI/TB • Nutrition • Non-communicable diseases and minor injuries • Chronic diseases hypertension, diabetes • Rehabilitation

  14. Support for priority programmes in Primary Health Care • Prevention, promotion, curative and rehabilitative PHC services at each facility • Facility and community outreach services • National Policy & provincial guidelines • Vertical support from Provincial office • At Health District -all programmes comprehensive & integrated (HIV/AIDS/TB specific co-ordinator) • Report through line function supervisors

  15. Ward Health Sub-committees

  16. Community participation • Constitutional rights • Patients Rights Charter • Batho Pele principles of public sector • Community development • Ward health sub-committees • hospital boards • Community based services

  17. Background • Process of community health committees started 1997/8 in terms of National District Health Policy • National Health Bill, ANC Policy, RDP Committees were used to draft Gauteng Policy • 73% Clinic/Community Health Committees established and meetings held • December 2000 new LG elections –2001 establishment of Ward Committees

  18. Background (contd) • 2002 Provincial Health Authority requested a revised vision/policy • Estimated only 52 % committees functioning • Training ongoing by health workers • Functions – health surveys in community, advisory to health staff, health promotion, campaigns, NGO & client complaint monitoring

  19. Progress Report

  20. Challenges • Not all Ward Committees established • Needs political commitment of Ward Councillors • Health facility managers in Ward need to be ex officio for accountability • Some Wards have 6 clinics - others none • Representatives of existing clinic committees • Health & Social Welfare combined at Ward level

  21. Ward Health and accountability WARD COMMITTEE COMMUNITY DEVEL.WORKERS(CDW) NGOs/CBOs WARD HEALTH SUB-COMMITTEE District Health Services Training supervision Community Health Technical support Workers (CHW) Community

  22. Community Health Workers (CHW) Guiding principles for implementation of policy document on CHW

  23. Background • NGO/CBO pivotal/effective means of services close to communities • Cadre of CHW both paid & unpaid are in health NGOs/CBOs across the country • Some CHW are being used in the formal sector • No standardised training (HWSETA) • Different procedures & contracts/SLA • No National framework

  24. Gauteng processes • Embarked on process to develop a Provincial policy on CHW • Formalising the funding & operational procedures • Conducting an audit of all health NGOs/CBOs and services • Workshop held to discuss training

  25. GDOH policy • Need for standardised name of cadre (Ancillary/CHW) CHW • Standardise service and supervision • Numbers CHW and areas of service • Multiskilled (HBC, DOTS, HIV, VCT) • Level NQF 1 and training decisions HWSETA • Not extension of formal health structure • Cost of roll –out & sustainability • Service Level Agreement and monitoring

  26. Implementation Plan • Workshop & establish District/sub-district Task Teams • Minimum stipend R500 for those under • Train TB DOTS supporters (1000 by 3/05)) • Train HIV/AIDS in TB DOTS • Align all training modules: IMCI, mental • Train all outstanding modules • Increase stipend to R1000 when all modules complete (3years)

  27. Aligning the CHW generic training • HIV/AIDS HBC • PMTCT/VCT • TB DOTS • IMCI/ Nutrition • ECD • Mental Health care • Care for disability

  28. Implementation plan progress • Register of all CHW –District/sub-district • Training commenced on 1000 TB DOTS • Generic course –69 days • Travelling funded by districts • Registration - CHW must belong to funded NPO • Minimum stipends- R500 at end course 04/5 • Career pathing –HWSETA accredit

  29. Implementation progress • Implementation structures –Prov. steering, district, sub-district task teams • Workshops held • Two weekly meetings • Monitoring of progress with reports • Training of NPO staff –will be trained in and financial and organisational management

  30. Intersectoral collaboration • National, provincial ,and local government • Social Welfare, Education, housing, safety & security, Dev. Planning & LG etc • Non-governmental organisations • universities & technicons • unions • private sector

  31. Funding Primary Health Care services • Provincial subsidies to LG • Municipal own funding • Staffing to render PHC services • Pharmacy drugs and laboratory costs • use of facilities & equipment • District Health Expenditure Review (DHER) cost per visit & capita per facility • cost centering • Control and PFMA

  32. Funding of PHC 2003/4 • The definition of PHC services traditionally included Personal PHC and Environmental Health Services. • The new definition of Municipal Health Services, for the sake of comparison of funding between the years, Environmental Health Services • Environmental Health Services funding is NOT included in PHC funding.

  33. Funding of services components : Provincial Funding : • Own Services • LG Cash Subsidy • Drugs (Provincial facilities and LG) • Laboratory (Provincial facilities and LG) • Programs (AIDS and Nutrition) • District Management Local Government own contribution

  34. CLINIC SUPERVISORY MANUAL

  35. Background • Implemented in Gauteng 2001 • Provincial Workshop November 2001 • District workshops • Regular, Red Flag and TB in-depth • Two to three monthly District reviews • Provincial Workshop August 2002 • Roll-out to EPI, STI, MCH & drug mgmt • Provincial Workshop March 2004 & full roll-out

  36. Review Regular

  37. In- depth Reviews

  38. Progress & challenges • Improvement of implementation to 75% overall • Adoption by MEC and MMCs Jan 04 • Adoption in Strategic Plan and PMAs • Roll-out all tools in 2004 • Specific drug/HIV/AIDS management emphasis • Quality supervision = quality service (TQM input>process>output)

  39. National principles on way forward • Definition of Municipal Health Services EHS • PHC delegation by SLA • National mechanism for transfer of staff (one public service) • National mechanism for funding • Provisional timeline startJuly 2004 • Interim measures Joint Management Functional integration

  40. Way Forward • Decentralisation of PHC services is going to take time • District Health System also involves hospitals which are not for decentralis. • Until all mechanisms are in place • Services continue • Work together and find solutions through joint structures

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