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Whos the boss - local government health services
Peter Barron
2000-04-13
The unification of health administrations (provincial and local government)is a complex process.
Local government is in the midst of fundamental change and restructuring. Long before this process is completed a large chunk of provincial health services and personnel will be grafted on to the newly formed local authorities. Over 50 000 health workers will be transferred from the provincial public service to local authority staff. Overall, local authority health budgets will increase more than five fold and there will be an injection of around R5 billion for health services into local government revenue. Local government will be responsible for the running of all primary level services including 24-hour emergency services and level 1 hospitals.
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 organogrammes 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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