THE DISTRICT HEALTH SYSTEM A REALITY FOR SOUTH AFRICA?

1. THE DISTRICT HEALTH SYSTEMA REALITY FOR SOUTH AFRICA? District Health in South Africa Conference 5 and 6 August 2004 Dr Wendy Hall Health Systems Trust

2. INTRODUCTION • Health policy in South Africa • Primary Health Care through District Health System • Integration of multiple systems • Decentralisation • Provinces • Local Government • Multiple management systems developed

3. Are we developing a new fragmentation of management systems within the District Health System?

4. METHODOLOGY • Review of policy documents and legislation • Field work experience • “The Impact of Decentralisation of Health Services on Reproductive Health Services in Africa” – with Nuffield Institute for Health, Leeds – funded by European Union • Personal and colleagues’ experiences in the field

5. PAPER OUTLINE • Defining DHS – according to WHO • Vision for Health in South Africa – as outlined in • ANC National Health Plan – 1994 • White Paper on Health – 1997 • The Health Sector Strategic Framework – 1999 to 2004 • Health MinMEC decision – February 2002 • National Health Bill – 2003 • Current management systems for DHS • Implications of these for health services • Further research questions, recommendations, discussion points

6. DEFINITION OF DHSWORLD HEALTH ORGANISATION • Based on PHC • Self-contained segment of the national health system • Well-defined population • Clearly delineated administrative and geographic area • Includes all institutions and individuals providing health care – government, private and traditional

7. DEFINITION OF DHS (cont) • Interrelated elements – homes, schools, workplaces, communities • Includes self care, all health workers and facilities – up to and including • First level (district) hospital • Laboratory services • Diagnostics • Logistic support systems • Well co-ordinated by an officer assigned to this function – a single management team

8. FIGURE 1: WHO DISTRICT HEALTH SYSTEM MODEL KEY FIGURES 1 AND 3 REGIONAL OR PROVINCIAL OR NATIONAL LEVEL Line management DRUG & OTHER SUPPLIES Co-ordination SECOND LEVEL HOSPITAL Pt referral Drug Supplies • SUPPORT SERVICES • laboratory • transport • maintenance DISTRICT HOSPITAL • DISTRICT MANAGEMENT TEAM • financial & budgeting • personnel • planning & monitoring • training COMMUNITY HEALTH CENTRES AND CLININCS COMMUNITY BASED SERVICES MOBILE HEALTH SERVICES

9. DHS VISION FOR SOUTH AFRICA • Based on World Health Organisation definition and policies • Developed from experiences of health workers while in exile • Set out in many early policy documents • Included in the National Health Bill of 2003

10. ANC NATIONAL HEALTH PLAN1994 • Adopts the PHC approach – part of the National Health System • Strengthening of community level services • Development of the DHS • National Health Laboratory Services (NHLS) – integrated into PHC system • Cautions about decentralisation – “Decentralisation without co-ordination and planning could result in a more fragmented, inequitable system”(page 56)

11. FUNCTIONS OF LEVELS OF HEALTH SYSTEM • See diagram 2 • Focus on lower level – community with support from district level • In reality – where is the focus? Management level – taking resources from delivery level? OR Service delivery level – patient care?

12. Administration and Financing NATIONAL HEALTH SERVICES Support Services Health Care Planning and Human Resources Legal Unit Administration and Financing PROVINCIAL HEALTH SERVICES Health Care Support Services Planning and Human Resources DISTRICT HEALTH SERVICES Administration and Financing Health Care Support Services Planning and Human Resources COMMUNITY HEALTH SERVICES Health Care Community Health Centers Independent Providers INTERFACE BETWEEN THE COMMUNITY AND THE HEALTH SYSTEM Joint Planning Joint Monitoring Diagram 2: From: ANC Health Plan for SA Community Development

13. WHITE PAPER FOR HEALTH - 1997 “Changes dictated by the South African Constitution include the devolution of certain responsibilities for health services to the provincial and municipal levels. To give effect to this mandate, it is essential that, inter alia, a district health system (DHS), in which responsibility for service delivery is entrusted to the district level, be established as soon as possible.” (Chapter 2:Reorganising the health services: Priority for PHC

14. WHITE PAPER (cont) • Twelve Principles • overcoming fragmentation • equity • comprehensive services • effectiveness • efficiency • quality • access to services • local accountability • community participation • decentralisation • developmental and inter-sectoral approach • sustainability ALL PRINCIPLES OF PHC AND DHS

15. WHITE PAPER (cont) • Goal (also in Reconstruction and Development Programme document) • Single national health system • Based on a District Health System • “The country will be divided into geographically coherent, functional health districts. In each health district, a team will be responsible for the planning and management of all local health services for a defined population. The team will arrange for the delivery of a comprehensive package of PHC and district hospital services within national and provincial policies and guidelines.”

16. WHITE PAPER (cont) • Implementation strategies for the district: - • To be responsible for its budget and for planning its services • To develop effective referral systems with neighbouring districts • To provide the full-basket of PHC services • To ensure provision of all support services – finance, human resources, transport, laboratory, drugs and other supplies and maintenance services. • In collaboration between local and provincial government

17. HEALTH SECTOR STRATEGIC FRAMEWORK – 1999 TO 2004 • Ten Point Plan • Speeding up delivery of an essential package of services through the district health system; • Plan notes • While much progress in DHS development can be anticipated once current local government restructuring is complete, our challenge in the health sector is to consolidate gains in health care provision and to participate in the establishment of the district health system governed by local government where they have the capacity to render services.

18. HEALTH MINMEC DECISION – FEBRUARY 2002 • Reaffirmed PHC to be delivered through a municipal-based DHS • Reaffirmed the 12 principles of the White Paper • Committed themselves to a DHS that includes • A comprehensive district health service – PHC package plus district hospital services • A district health plan that is part of the IDP • Ensuring cooperative governance, joint planning and seamless service provision • Joint funding from municipalities and province • A single health budget • A single management structure • All staff being part of a single public service – ultimately to be employed by the district (or metro) municipality

19. NATIONAL HEALTH BILL 2003 • Establishes the district health system with many of the above principles included – see Chapter 5 • Defines municipal health services as a list of environmental health services – responsibility of local government • Provides for decentralisation of further PHC functions from provincial to local government • Provides for interim arrangements

20. WHAT IS THE PROBLEM? • We have policy – • We have legislation – • We have the will – • It will take time……… • And – we are getting there – • Or are we? The road has been longer and harder than ever anticipated. Are we on the right road?

21. SOME OF THE OBSTACLES • Complexity of integrating systems • Financing – who is responsible? • Human resources • Establishing local government • Other sectors • Delay in defining “municipal health services” • Changing priorities – dominance of HIV/AIDS • Separation of district services and district hospital

22. To overcome these, are we seeing time, effort , resources (money and people) being spent in establishing multiple bureaucratic systems to the possible detriment of service delivery?

23. MANAGEMENT SYSTEMS WITHIN THE DHS • See Diagram 3 • Health sub-district management • District hospital management • Regional and provincial hospitals management • Emergency medical services • Laboratory services • Public works department • Transport • Local government health services

24. FIGURE 3: DHS MANAGEMENT SYSTEMS IN SOUTH AFRICA PROVINCIAL DEPARTMENT OF HEALTH PROVINCIAL PUBLIC WORKS DEPARTMENT NATIONAL HEALTH LABORATORY SERVICES REGIONAL DIRECTOR REGIONAL EMS HEALTH SUB-DISTRICT = DHS UNIT REGIONAL / PROVINCIAL OFFICE SUB-DISTRICT MANAGER AND TEAM Health Areas Community Health Centres Clinics Mobiles Community DISTRICT HOSPITAL MANAGER AND TEAM First level hospital care Emergency services Drugs and supplies to clinics REGIONAL OR PROVINCIAL HOSPITAL Emergency Medical Services Laboratory Services NB – CURRENT MUNICIPAL HEALTH SERVICES ARE NOT INCLUDED Public Works

25. FIGURE 1: WHO DISTRICT HEALTH SYSTEM MODEL KEY FIGURES 1 AND 3 REGIONAL OR PROVINCIAL OR NATIONAL LEVEL Line management DRUG & OTHER SUPPLIES Co-ordination SECOND LEVEL HOSPITAL Pt referral Drug Supplies • SUPPORT SERVICES • laboratory • transport • maintenance DISTRICT HOSPITAL • DISTRICT MANAGEMENT TEAM • financial & budgeting • personnel • planning & monitoring • training COMMUNITY HEALTH CENTRES AND CLININCS COMMUNITY BASED SERVICES MOBILE HEALTH SERVICES

26. IMPLICATIONS FOR SERVICESon the ground experiences • Co-ordination of services requires multiple co-ordinating meetings • Ambulance services experiences • Laboratory services • Hospital and district services co-ordination • Drug supplies to clinics • Clinic maintenance • Transport - other than ambulances • Local government – provincial government

27. SEEKING SOLUTIONS • National Dept of Health – Policy on Functional Integration • Focus on provincial and local government services • Who is responsible to ensure integration? • Will managers need to spend inordinate time in co-ordinating meetings rather than overseeing service delivery? • And what is the cost to the health system?

28. STRATEGIC PRIORITIES FOR THE NATIONAL HEALTH SYSTEM – 2004 TO 2009 • Achievements – first 10 yrs • Functional integration of provincial and local government services • Development of some Service Level Agreements between province and local government

29. STRATEGIC PRIORITIES – 2004 TO 2009 (cont) • Challenges • Funding of municipal health services • Full funding for PHC • Elimination of fragmentation of services – provincial and local government • Strengthening quality of care • Strengthening community participation in the governance of PHC

30. POINTS FOR DISCUSSION • The process of transformation – complex and time consuming • Old systems – initially centralised to bring fragmented systems together – but • Has the bureaucracy been entrenched? Have plans been made to re-decentralise these? Have we developed too many new management structures? • Have we tried to do too much too quickly? • We need to monitor the impact on health service delivery and effectiveness of DHS • Other countries experiences – how do they do it? • Is our health system still too centralised?

31. RECOMMENDATIONS • To understand and monitor impact of DHS and decentralisation on health services delivery through – • the DHIS • other specific studies with qualitative components • Assess the financial cost of increasing middle management level and multiple vertical lines • Keep returning to the original vision to assess where we are at and where we want to be.

32. THANK YOU