DISTRICT HEALTH SYSTEM - PERFORMANCE FRAMEWORK [1999/2000]

· All the provinces have demarcated health districts. However, these boundaries will have to be redemarcated in line with the proposals of the Municipal Demarcation Board.

· Varying types of governance structures have been established throughout the country. For the first time, the Municipal Structures Act and the Municipal Systems Bill have provided a coherent framework for governance and public participation.

· The Department has developed a Primary Health Care Package.

· Norms and standards have also been developed for the PHC Package.

· This package provides an opportunity to integrate all vertical programmes.

· PHRC has taken a decision to strengthen local government to render comprehensive PHC services through the District Health System.

· It is expected that this decision will be ratified by MINMEC in March.

· The District Finance Task Team is developing a framework for equitable intra-district resource allocation. This work is being hampered by the lack of accurate information relating to health status utilisation patterns.

· The Health Financing and Economics Directorate has just completed the PHC costing exercise.

We have commissioned important work to support district health systems development. These include:

· The development of pro forma service agreements between provinces and local government for the delivery of primary health services by local government.

· The audit of current referral patterns and guidelines to improve the referral system within the district health system..

· There is a task team, which is developing a policy on the role and function of district hospitals, within the district health system.

· We meet with provinces and local every two months to monitor progress.

· Provinces are required to submit progress reports during these meetings.

· We have introduced a district competition that is held annually to judge the best developed rural and urban districts, countrywide.

As indicated above, all the provinces have demarcated district boundaries. These will have to be redemarcated in line with the proposals of the Municipal Demarcation Board. We expect that this process will be completed by the end of this year. This process has already begun and we are monitoring it closely. Some provinces have established inter-sectoral committees to co-ordinate this work. In others, the departments of local government co-ordinate the redemarcation process.

Many provinces have appointed district managers, notably the Eastern Cape, North West, Northern Cape, Northern Province, and Mpumalanga. In Gauteng, interim district management teams have been appointed. Interim District Co-ordinators have been appointed in Kwazulu-Natal. By and large, the district management structures are in place. The challenge will be to integrate these structures into local government, as local government develops the capacity to render comprehensive primary health care services.

The regional offices were established to facilitate the development of the district health system. The mistake we did in establishing regional offices was that we gave the same orders to regional directors, whether they we in rural or urban areas. It is now clear that the role of a regional office in central Johannesburg was to facilitate the delivery of services by the metropolitan council, whereas the role of the same office in Mount Frere, was to practically establish the district health system and to run the health services as an extension of the province. In line with these observations and the developments in local government transformation, the Director General and the Heads of Health have recommended that regional offices be phased out in favour of the new Metropolitan Councils [category A Municipalities] and District Councils [Category C Municipalities]. This will be as soon as possible, ensuring that there is minimum disruption in the delivery of health care services.

The National Health Authority or MINMEC co-ordinates policy development. The Provincial Health Restructuring Committee or the meeting of the Director general and Provincial Heads of Health are responsible for co-ordinating the implementation of policy, i.e. strategic and operational planning. Last year the Department developed a National Strategic Framework Document for the second term of this democratically elected Government.

This National Strategic Framework was adopted by MINMEC in September. Subsequently all the provinces assumed the responsibility to develop their own strategic plans. These plans are shared with the Director General and the Policy Analysis and Co-ordination Unit to ensure harmonisation of policies and plans between the spheres of Government. In short - the Strategic Framework Document has provided the mechanism to make this intergovernmental co-ordination possible.

The District Health System provides the conceptual framework, the strategy and a practical vehicle to bring to fruition the political commitment to decentralise health service delivery governance and management to the district level. It is also true that the decentralisation of financial accountability varies from province to province. This is dictated, in most cases, by the individual provincial treasuries. The new framework for decentralised management in the public service provides a framework in which human resources and general management can be decentralised. The Municipal Systems Bill that establishes a new administrative system for local government further complicates this. These pieces of legislation present the health sector with an opportunity to develop a coherent strategy for decentralising the authority for health service management and governance. Dr Tim Wilson will perhaps give more light on the decentralisation of management in hospitals.

Various provinces have established governance structures at the provincial level. The Western Cape has a Bi-Ministerial Committee between the Ministries of Health and Local Government. In the Northern Province a structure called the MENCOUN was established through which the MEC for Health consulted local government Councillors. In the Eastern Cape a bHS Task Team has been established as a mechanism for consultation between the MEC for Health and organised local government. A similar structure has been established in Kwazulu-Natal. There is a formal consultative forum in Gauteng that is called the Interim Provincial Health Authority. While contact is reasonably strong between most provincial Health Ministries and local government, the structures at community level are not as strong as one might desire them to be.

The Director General and the Provincial Heads of Health have adopted a proposal to establish legitimate governance structures in line with the Municipal Structures Act and the Municipal Systems Bill. These proposals are:

a) To establish a national Health Authority, which is similar to the MINMEC, possibly with the participation of the Chairperson of the Parliamentary Portfolio Committee on Health.

b) To establish a Provincial Health Authority which is convened by the MEC for Health. It is proposed that the members of the Provincial Health Authority should include the MEC for Local Government, the Councillor responsible for health in each of the District Councils and Metropolitan Councils, in provinces where these exist, the Chairperson of the Provincial Portfolio Committee on Health and representative of organised local government in the province.

c) To establish a District Health Authority which is convened by the Councillor who represents the District Council of the Metropolitan Council in the Provincial Health Authority. The members of the District Health Authority would comprise the Councillors responsible for health in each of the category B municipalities within the District Council, or the Health Committee, in the case of the Metropolitan Council.

With regards to public participation in the planning, management and monitoring of district health services, it was agreed to recommend to MINMEC that the health sector should adopt the framework for public participation in Chapter 3 of the Municipal Systems Bill.

The Unit dealing with Health Services and Quality Assurance will perhaps give more details on this item. But as far as the district health system is concerned, it was felt that the introduction of service agreements for the delivery of comprehensive primary health care services by local government, does present an opportunity to incorporate indicators that will measure efficiency, effectiveness and the assurance of quality in health service delivery.

The service agreements that will be piloted will offer an objective instrument for performance measurement. Chapter 7 of the Municipal Systems Bill also offers an instrument for performance measurement between local government and any sphere of government, with regards to service delivery.

It is our view that the local government legislative framework has by and large, addressed the many problems that existed between provinces and local government with regards to the delivery and funding of health service delivery.

This legislation has provided a clear policy framework with regards to municipal boundaries: roles, powers and functions; and the administrative system within local government. The Public Financial Management Act and the Local Government Financial Management Act will provide further clarification with regards to intergovernmental financial transfers and financing arrangements for service delivery. The decision to devolve the delivery of primary health care services to local government will also help to clarify the role of local government with regards to health service delivery. Likewise, this will oblige provinces to build the capacity of local government to fulfil this role.

· Align all health service district boundaries with the proposals of the Municipal Demarcation Board [December 2000].

· Ensure the alignment of service boundaries with other line function departments under the co-ordination of the Municipal Demarcation Board [September 2000].

· Ensure the establishment of the Provincial and District Health Authorities by 1 April 2001.

· Adapt the principles of public participation in the Municipal Systems Bill to implement community participation in the planning, management and monitoring of health services in districts where PHC services have been devolved to local government [1 April 2001].

· Support and monitor the implementation of the PHC package.

· Pilot performance-based service agreements between provinces and local government in the delivery of comprehensive PHC services [1 April 2001].

· Pilot the implementation of guidelines to improve referral systems within the district health system.

· Define the role of district hospitals with the district health system.

Management and systems issues

· Develop strategies to address the disparity in remuneration packages between health workers employed in the public service and local government [September 2000].

· Develop mechanism for the orderly transfer of staff between provinces and local government to support the delivery of PHC service by local government [September 2000].

· Co-ordinate district management training [ONGOING].

· Support the District Finance Task Team to develop a framework for equitable intra-district resource allocation [December 2000].

· Support the Health Financing and Economics Directorate to build financial management capacity at district level and to fine-tune the costing of the primary health care package [ONGOING].

· Support the National Health Information Systems Directorate to rollout the District Health Information System project to every district [ONGOING].

· Ensure the harmonisation of health legislation in line with the Constitution and other relevant legislation [ONGOING].

· IHL facilitated South Africa's participation in SABC activities.

· The Heads of State signed the SABC health protocol in August 1999.

· The SABC Health Ministers approved the regional HIV/AIDS strategy.

· A bilateral agreement was signed with Tunisia in November 1999.

· A declaration of Intent was signed with Uganda in August 1999.

· The Sasakawa health prize was awarded by the World Health Organisation to South Africa on two successive years, 1998 and 1999.

· At the World Health Assembly in 1999, the former Minister of Health, Nkosazana Zuma, was presented with the Tobacco Free World Award.

· South Africa assumed the chair of the Non-Aligned Movement.

· SA participated in the 49th WHO Regional Committee in Namibia. South

Africa piloted an important resolution on HIV/AIDS in this conference.

· The Minister of Health, Dr Manto Tshabalala-Msimang, led a delegation of about 15 people to look at the success of Uganda in dealing with HIV/AIDS.

Unit has established a database of all donor funding in public health sector

· Co-ordinate and monitor the participation of South Africa in the SABC Health Sector.

· Develop, implement and monitor an action plan to ensure the implementation of decisions taken by the SABC Health Ministers.

· Ensure the conclusion of bilateral cooperation agreements with SABC Member States, as per the Minister's direction.

· Advise the Director General and the Minister regarding opportunities to improve co-ordination and cooperation between SA and SABC, and the collaboration between International Collaborating Partners [Donors] and the region.

· Co-ordinate and monitor the participation of South Africa in continental organisations and institutions, e.g. OAU.

· Ensure the conclusion and implementation of all outstanding bilateral cooperation agreements and initiate new agreements as per the Minister's direction.

· Advise the Director General and the Minister regarding opportunities to establish mutually beneficial cooperation agreements between South Africa and African countries to promote health development and the interests of South Africa.

· Compile a database of all bilateral and multilateral cooperation agreements, evaluate progress with the implementation of these agreements and advise the Director General and the Minister accordingly.

· Ensure the conclusion and implementation of all outstanding bilateral cooperation agreements and initiate new agreements as per the Minister's direction.

· Advise the Director General and the Minister regarding opportunities to establish mutually beneficial cooperation agreements between South Africa and African countries to promote health and development and the interests of South Africa.

· Facilitate and co-ordinate the participation of South Africa in bilateral and multilateral missions and commissions, e.g. WHO, NAM, India-SA and US-SA Bi-national Commissions.

· Identify opportunities and facilitate the placement of South African nationals in international organisations.

· Advise the Director General and the Minister regarding opportunities for the participation of South Africa in international health forums.

· Review, improve and implement the policy on donor co-ordination within the Department and with provinces and local government.

· Identify opportunities for the health sector to access donor funds and direct the relevant programme managers to appropriate donors.

· Compile, maintain and monitor a database of donor funding and activities in the public health sector.

· Develop project management skills in the Unit to manage donor funds and activities.

· Produce regular reports on donor funding to be presented to management and stakeholders.

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