CHAPTER 2: LITERATURE REVIEW
2.5 O THER DEVELOPMENTS TOWARDS DECENTRALISATION AND PROGRESS MADE
2.5.2 D ISTRICT H EALTH S YSTEM DEVELOPMENTS AND PROGRESS MADE
Whilst the Demarcation Board was still working on municipal boundaries, work on implementing the DHS was in progress. As a way of taking the policy forward,
‘MinMec’ took the following key decisions: local government was to take
responsibility for the health districts, and these health districts were to be aligned with district and metropolitan municipal boundaries.
At the beginning of 1999, there were 39 health regions, 174 health districts and 843 municipalities nationally (Pillay et al., 2001). All health regions were provided with a management team and staff to sustain district development. In the majority of health districts, management staff was appointed. Great efforts were made by staff at district level to implement this concept. However, progress in amalgamating health systems at district level was slow (Pillay et.al, 2001).
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Following the demarcation of municipal boundaries, however, all this had to change.
Health district boundaries drawn before demarcation of boundaries in terms of the Local Government: Demarcation Act (Act 27 of 1998) (Republic of South Africa, 1998b) had to be aligned with metropolitan and district municipal boundaries. This meant that health district boundaries had to be redrawn in many provinces to align the 174 health district with the new municipal boundaries. This had a negative impact on health personnel who had worked very hard on the DHS concept and they
became demoralised (Cullinan, 2006). In some instances, the new health districts had very large catchment populations which created a huge challenge in their management in terms of the PHC approach (Barron & Sankar, 2000). Overall, there was not much progress made towards establishing the DHS in the provinces
because of the uncertainty that followed the local government transformation.
It was during 2001 that the District Health System (DHS) model was more firmly established and some important goals were achieved. These, as discussed by Barron and Asia (2002: 17), included:
“Putting in place a formal finalised version of the third sphere of government.
This meant that South Africa was to be covered by wall to wall metropolitan (Type A) municipalities and district (Type C) municipalities. Each of the district municipalities was sub-divided into two or more local (Type B) municipalities.
A health Ministerial Forum (MinMec) decision endorsed the vision of a municipality-based DHS in South Africa, where comprehensive Primary Health Care (PHC) services were to be delivered.”
The decision to deliver a comprehensive PHC service by municipalities meant that Personal Primary Health Care (PPHC) was also to become a district municipal
function. This would further add to the challenge facing district municipalities in terms of available resources, organisation and administration. However, this decision was later reversed when the National Health Act (Act 61 of 2003) (Republic of South Africa, 2003) assigned responsibility for PPHC, including its financing, to Provincial Departments of Health (Hall, Ford-Ngomane & Barron, 2005).
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By 2005, provinces were adopting different approaches and plans for the provision of PPHC, with some provinces opting for the Provincial Department of Health to
transfer all PPHC staff from municipalities, while others opted for local government PPHC staff to remain with the existing municipalities (Hall et.al, 2005). The KwaZulu- Natal province decided to maintain the status quo until further arrangements were made between provincial and local government. The plan included placing a moratorium on staff movement, pending creation of a single public service (Hall, et.al, 2005).
Since then, there has been some progress in transferring of PPHC to provincial level. In 2011, two KwaZulu-Natal municipalities (Emnambithi and Endumeni)
completed transfer of their PPHC staff to the Provincial Department of Health. These transfers happened as these local municipalities felt that the subsidy they were receiving from the Department of Health to render PPHC as part of their standing Service Level Agreement (SLA) was not enough to permit for service expansion or salary improvement for staff employed in these clinics (Greveling, 2011). More local municipalities are set to follow suit and transfer their PPHC services to the province.
The definition of MHS as defined in the National Health Act (Act 61 of 2003)
(Republic of South Africa, 2003) did not enjoy full approval from everyone. In 2008, the Independent Municipal and Allied Trade Union (IMATU) made a court application whereby they challenged various provisions of the National Health Act (Act 61 of 2003) (Republic of South Africa, 2003) on the grounds that they were inconsistent with various provisions of the Constitution of the Republic of South Africa (Act 108 of 1996) (Republic of South Africa, 1996) relating to the status and powers of local government. IMATU viewed the definition of MHS as inconsistence with the
constitutional provision in that the definition excluded “primary health care services”
as part of “health care service” The constitutional challenge was premised on the contention that the National Health Act created a single exhaustive national health system in which local government was obliged to participate, and which left no other space for municipalities to perform their functions as public providers of health services. IMATU argued that the definition of MHS was restricted to “environmental health services” and, therefore, disempowered municipalities from rendering
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services, including PPHC, which normally rested within their powers. In his ruling on this matter, Judge Makgoba stated: “It is declared that Municipal Health Services within the meaning of Section 1 of the National Health Act (Act 61 of 2003) includes health services ordinarily provided by municipalities at the time the Act came into operation” (Independent Municipal and Allied Trade Unions & Others v The
President of the Republic of South Africa, 2008). Section 34 of the National Health Act (Act 61 of 2003) (Republic of South Africa, 2003) states that “until a service level agreement contemplated in section 32(3) is concluded, municipalities must continue to provide, within the resources available to them, the health services that they were providing in the year before this Act took effect”.
Though slow, there has been some progress in terms of developments in
environmental health. Agenbag and Balfour-Kaipa (2008) stated that, by February 2007, some district municipalities were providing MHS. There were signs of progress in that MHS were receiving attention by being included in municipal planning
processes. However, the authors mentioned that the key role players, namely the South African Local Government Association (SALGA), the National Department of Health (NDoH) and the Department of Provincial and Local Government (now the Department of Co-operative Governance and Traditional Affairs (CoGTA)), which were designated to drive the transfer and devolution process had, up to that point, played an insignificant role in the process (Agenbag & Balfour-Kaipa, 2008).
In an attempt to decentralise and build a district-based PHC, too much emphasis had been placed on the structure and organisation of local services, thus leading to loss of impetus in systems development and service delivery. This further resulted in under-performance of PHC services in large parts of the country (Schaay & Sanders, 2008). According to Schaay and Sanders (2008), a combination of different factors, namely high rates of medical migration and severe health worker shortages; deep- seated imbalance of resources and inequities in the distribution of personnel; a complex and evolving burden of disease with emerging infectious and non- communicable epidemics; a curative-oriented health service; and deficiencies in managerial capacity and health system leadership at all levels; have continued to be an obstacle in the attainment of PHC in South Africa.
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Some of these issues have been taken into account in national planning. The 10 Point Plan of the Health Sector for the 2009-2014 period (Department of Health, 2010) is aimed at crafting an operational health system that is enabled to produce improved health outcomes. The 10 Point Plan (Department of Health, 2010) has identified the following priority areas:
i. Provision of Strategic leadership and creation of a social compact for better health outcomes;
ii. Implementation of National Health Insurance (NHI);
iii. Improving the Quality of Health Services;
iv. Overhauling the health care system and improve its management;
v. Improving Human Resources Management, Planning and Development;
vi. Revitalization of infrastructure;
vii. Accelerated implementation of HIV & AIDS and Sexually Transmitted Infections National Strategic Plan 2007-11 and increase focus on TB and other communicable diseases;
viii. Mass mobilisation for better health for the population;
ix. Review of the Drug Policy; and
x. Strengthening Research and Development.
The Minister of Health, Dr Motsoaledi, felt it was important to renew the health system using the PHC approach in order to implement the above priorities successfully (Department of Health, 2010). This involves a “re-engineered PHC”
approach, which requires the strengthening of the DHS, improved implementation of the basic system, and the assignment of responsibility and accountability to district management teams (DMT) for improved health of the population and the
management of the district.
A task team, led by Dr Yogan Pillay, was tasked with producing a strategy for “re- engineering PHC in South Africa”. A discussion document by the team notes that a great deal of work has been done in gearing up the health system for effective implementation of PHC (Barron, Shasha, Schneider, Naledi, Subedar, 2010). The authors, however, point out that little has been done to ensure that the PHC
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approach being implemented includes taking comprehensive services to
communities that have an emphasis on disease prevention, health promotion and community participation.
For the successful execution of PHC, a well-functioning DHS is necessary. The discussion document made the following recommendations relating to the DHS:
Full implementation of Chapter 5 of the National Health Act (Act 61 of 2003) pertaining to DHS;
A need for provincial legislation enabling formal creation of district councils which are to play an oversight role over district management teams (DMT);
Devolution of remaining personal health services from local municipalities and Metros to Provinces.
As shown in the diagram below, the task team envisions environmental health services as part of the specialist support teams, which are to render support to facilities.
Figure 1: PHC model within the District Health System (adapted from discussion document on Re- engineering Primary Health Care in South Africa)
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