Summary Bulletin 4 - DHS-LG Discussion List

January to April 2002

Issues debated:
  1. District Organogrammes
  2. District Planning
  3. Municipal-based vs Provincial-based District Health System

1.  District Organogramme

Some provinces are moving toward decentralisation of services from provincial to local government and there is now need to look seriously at the organizational design of the District Management Team. The Western Cape, for example, has accepted the move to a Municipal-based DHS with a target date set at July 2002. Clearly defined roles and functions of each DMT member is required.

Points to remember in drawing up a district organogramme are: -

  • Clear definition of terms used
    • "District" refers to District Municipality (type C municipalities) or Metros (type A municipalities)
    • "Sub-districts" are subdivisions of these
  • Other factors to consider are
    • Size and population of the district
    • Services to be offered
  • Structure should follow function
  • Every district is unique and there is no ideal, standard organogramme to fit all situations

Suggested minimum composition of a District Management Team is: -

  • District Manager
  • District Finance Manager
  • District Human Resource Manager
  • District Information Officer
  • District Pharmacist – with Sub-district Drug Co-ordinators
  • District Training Co-ordinator
  • District TB/HIV/AIDS Co-ordinator

Others will depend on level of services and management at each level.

An appeal was made that focus must not be on restructuring the management levels and filling only these posts. A decline in the number of filled operational level posts was noted.

2.  District Planning

The National District Health Unit is preparing District Health Planning Guidelines. The focus is on medium term planning (e.g. 3 years) and is aimed primarily at district and sub-district managers and to be available to Department of Health and Local Government. It will be designed to meet the needs of

  • Treasury – the performance information that they require
  • Planning – a situation analysis and annual report required for planning

A number of documents are already available and are valuable resources for developing a comprehensive guide for district planning or to be used in the districts. Many health districts have been re-aligned to fit into the new demarcations. It is important for the new local government councilors to be informed, in particular in regard to the two tiers of local government (B and C) and how they work with the provinces.

Other documents shared were: -

  • ISDS/HST – "Fitting Functionality to Boundaries" – still in the development stage
  • IDP Guide pack for municipalities from the DP&LG
  • Pharmaceutical Services Guides – from Eastern Cape
  • Gauteng Dept of Health templates and guidelines for planning, such as
    • Assessing accessibility and availability of services
    • Measuring the gap in services plans
    • Matching core PHC package to strategic plans
  • International guidelines – from Tanzania.

It is essential to include the services in the private sector in any situation analysis. This sector does service an important proportion of the community and its exclusion could have serious implications for the councilors’ understanding of health needs and therefore for planning. In the Western Cape this is happening to a limited extent, but does need to be expanded, particularly as the public sector is now gradually improving its own data collection processes. This can form a good basis for public-private partnerships.

A need to have a consolidated list of indicators that are tied to plans and objectives was identified, and to bring all these indicators together into one document. Sources identified were: -

  • National Districts Competition Indicators
  • "Well Functioning Districts" indicators
  • National reporting format indicators
  • Supervisory checklists and their indicators
  • Core package and expected outputs
  • PFMA reporting requirements

Another source of information that needs to be consolidated is the work being done by the "Metro consultants" as these cover such issues as staffing, legal instruments, laboratories and drugs.

Other issues of interest that were raised were: -

  • The concept and meaning of DHS
  • Who should be involved in planning? What has happened to the bottom-up approach?
  • The need to strengthen ability to implement strategies and plans and move away from what is perceived as a perpetual cycle of planning with little implementation at the end of the year.

3.  Municipal-based vs Provincial-based DHS

(NB – the contributions to this discussion were very full and rich and hence difficult to adequately summarise. It is worth spending time reading each contribution in full)

The proposed changes to the National Health Bill and the continued uncertainty of the route that this country will eventually take with DHS development and decentralization of PHC to local government has re-opened the debate on municipal-based versus provincial-based DHS. Confusion still reigns although the debate started in 1994. This confusion contributes to the low morale of health workers and the uncertainties which many people have as they remain in acting positions.

The final decision as to where DHS will be located is a political one. The MINMEC decision of February 2001 visualized a municipal-based DHS, but this seems to have changed with the proposed changes in the National Health Bill. The major effect of this uncertainty is that basic service delivery is compromised and standards in the quality of care to patients and communities are low and still fragmented. The actual location of DHS is less important than ensuring that in any given geographical area there is one management team responsible for planning, co-ordination, implementation and monitoring of PHC.

A decision needs to be made so as to avoid further waste of energy and money in trying to implement DHS when there is no clarity as to where it will fit into local government. Consideration could be given to use of different models in different parts of the country – for example Northern Cape is very different to Gauteng and the Metros are vastly different to the rural areas.

However, there is need to maintain the integrity of the continuum of health services within the DHS. PHC services cannot be split and must include community, clinics and level one hospitals. A split between these would result in different governance structures operating in the same system and health officials being answerable to two bosses. Hence the support for a minimalist definition of municipal health services, which, in accordance with the Constitution and local government legislation are to be devolved to district municipalities. The minimalist definition of MHS is environmental health only and is the preferred definition in the amended health bill. The split of environmental health from the rest of the PHC package is likely to do the least damage to service delivery. DHS and PHC would remain a provincial responsibility i.e. a provincial-based DHS.

It was further pointed out that local government would still have responsibility for PHC as part of their developmental strategies e.g. in provision of water and sanitation and in their required accountability to the local community. If there is a split in PHC the challenge will be to ensure functional integration of the services within a DHS.

The constitutional requirement of section 156(4) states that national and provincial governments must assign (not delegate) to a municipality, by agreement, where the capacity exists for the administration of a matter listed in Part A of schedules 4 or 5. This could result in the long term the national government overseeing 57 health districts and the phasing out of the provinces. Why then have provincial levels at all?

The final outcome is not known. But what ever happens the health services will have to live with the decision and do their best to develop the WHO-model DHS through approximating the provincial and municipal health systems. This must be a health service that is seamless to the patient, accountable to the community, effective and efficient.


Bulletin complied by Wendy Hall (hstwendy@sai.co.za),
Health Systems Trust.
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