Summary Bulletin 11 - DHS-LG Disscussion List

First Quarter 2004

The main issues tackled since November 2003 included: -

There appear to be more questions raised than answers provided during this quarter. Clear communication from the policy makers is urgently needed. Pleas for information and clarity have not been satisfactorily answered.

National Health Bill 2003

The National Health Bill was expected to be passed through the national and provincial houses of parliament before the end of 2003, and likely to be enacted as from 1^st July 2004. The Bill is still waiting to be signed into law.

An urgent need for health workers to have clarity on what the Health Bill means to them was expressed. Strategic issues and plans need to be communicated to people in the districts to correct any confusion and allay the fears of personnel. The Free State has published an implementation strategy for the province. This needs to be repeated in all provinces and actively disseminated throughout their province.

Implementation of the provisions of the Bill is potentially problematic for establishing district health system – a concern was expressed that local municipalities could dump their current functions onto the district municipalities.

Decentralising health functions to municipalities

Closely linked to the passing of the National Health Bill is the decentralising of health functions to local government. There was some active discussion on the issues, but no clear answer was provided by anyone from the provincial or national health departments.

District municipalities are to render municipal health services (MHS) as from 1 July 2004. MHS is defined in the Bill as environmental health services (EHS), excluding malaria, port health and control of hazardous substances. PHC becomes the full responsibility of the provinces, with the possibility of assigning some or all of these functions to local government through service level agreements. Issues raised in the discussions included: -

• Financing and budgeting
  • Addition of current provincial EHS services to the district municipalities will require additional funding, possibly from national. They are also required to fully fund EHS currently rendered by the local municipalities.
  • PHC services rendered by local or district municipalities must be fully funded by province – this needs to be finalised before 1 July 2004.
  • Funding needs to be determined during the provincial budget cycle and incorporated into the local government budget process. Gauteng provincial health was reported to have been through their own budgeting process but excluded local government and their possible requirements after 1 July 2004.
  • The process of concluding agreements with province or between district and local municipalities takes time – Cacadu District Municipality in Eastern Cape is actively working on these.
• Personnel
  • There appears to be no progress with mechanisms for transfer of staff from local to provincial government. This impacts on budgeting. It is not clear who should be budgeting for PHC? Staff can not easily be retrenched.
  • Changes in the Labour Relations Act effectively open employers to huge liabilities on transfer unless agreements are concluded with the Pension Funds before transfer. This is not new and transfers have been postponed twice before. But the LRA amendments have made inter-governmental transfers even more difficult.
  • The possibility of seconding of staff between the spheres of government was raised. This is being considered in the North West. There was no reply given on the list.
• Service Level Agreements
  • These are required between province and district and/or local municipalities before 1 July 2004 if services are not to collapse completely.
  • In Limpopo there is a feeling that SLAs are not applicable at present and that municipalities need to submit claims for services rendered – but there is no clarity as to what forms to use.
  • There are different types of agreements floating around: -
    • Agreement between provinces and municipalities is required in terms of the Public Finance Management Act to allow for the payment of subsidies or agency payments for the rendering of PHC services.
    • Vertical Service Level Agreements to regulate the performance of services on behalf of the provinces.
    • Agreements to allow the delegation or assignment of functions from one sphere of government to another.
    • Agreements to facilitate the transfer of services, staff, assets and liabilities between spheres of government.

The problem is that these are not clearly understood by everyone.

Environmental Health Services (EHS) and Municipal Health Services (MHS)

Position within the Health Services

EHS is seen as a cinderella programme. Initially it was considered part of PHC within the DHS and designated as a programme like MCWH or HIV/AIDS, but has now been side-lined. Municipal health services, which is defined in the National Health Bill as most of EHS, is receiving prominence as it becomes the responsibility of the metro and district municipalities. EHS is a vital component of PHC within the DHS and can improve health status. PHC services are still too curative orientated.

Environmental health practitioners are in the best position to convince policy makers and others of the importance of EHS. A bottom-up approach is required.

A 5 year strategic plan should be developed and then broken down into operational elements. The National Dept of Health, with DPLG and SALGA, should be leading the way as it is a national issue.

Consideration should be given to introducing a mid-level worker (Health Assistant or Environmental Health Technician) to work with the Environmental Health Practitioners (EHPs). A move from the inspectorate mentality to a developmental one is required, together with adequate and appropriate training.

Funding

The district municipalities are expected to render EHS services from 1 July 2004, but there is no clarity as to how these will be funded. They will be taking over services presently run by provinces and the local municipalities and do not have the revenue base to pay for all of these.

The proposed normative value of R13 per capita for funding of EHS is questioned. This may be sufficient to cover salaries, but will not cover the cost of running the services as they are envisaged.

Decision makers may agree that EHS is an integral part of PHC, but the budget allocation gives a totally different picture and is as low as 1% in some areas.

Personnel and training

Many EHPs are either leaving the service or moving into management positions. In places they are expected to take on a management role as well as continue their normal environmental work. EHS is not considered an essential service and are therefore not allocated posts; vacant posts are often used for employing other cadre of health workers. EHP will not benefit from the incentives being offered for scarce skills.

There has been support from national and NGOs for PHC training. A similar commitment is needed for EHS training. With the decentralisation of EHS as MHS to local government the EHPs are required to enforce legislation to ensure a safe environment. Training and status for the profession is required to challenge industries who have scientific backing to validate their operations as being environmentally friendly.

Strong leadership is required to pull the environmental health services together.

Summary prepared by: Wendy Hall [hstwendy@sai.co.za]
Health Systems Trust
April 2004

Keywords	This Item is associated with the Following Keywords: local government.
You Can Comment on this Item, or View other people's Comments
Easy Print Email to a friend