Local Government Capacity for Health Service Delivery: briefing by Health Systems Trust

HEALTH PORTFOLIO COMMITTEE
6 November 2001
LOCAL GOVERNMENT CAPACITY FOR HEALTH SERVICE DELIVERY: BRIEFING BY HEALTH SYSTEMS TRUST

Chairperson: Dr SA Nkomo (ANC)

Documents handed out:
Health Sector Strategic Framework (1999-2004) [see Appendix]

SUMMARY
There is uncertainty around the definition of municipal health services that needs to be made clear by the National Health Department. That definition largely affects the responsibilities for service delivery and affects financial flows quite considerably.

Service agreements between the provinces and local governments need to be formalised. The Provincial Departments would have to be more skilled at planning, monitoring and evaluation and local governments would have to be more accountable to provincial departments than they have been in the past.

There are people working under provincial conditions of services and there are people working under local municipality conditions of services. When there is amalgamation there has got to be a transfer of staff, which would involve unions. Somewhere down the line there is also going to be costs involved in the equalisation process. When that happens, these issues need to be taken into account.

MINUTES
Health Systems Trust
Mr P Baron gave a background as to what is happening with the health sector and the decentralisation processes at local government. The framework with which they were working was that the health sector has a five-year plan, 1999-2004, known as a ten-point plan.

The plan covers legislative reform, improving the quality of care, and speeding up the delivery of essential package of services through the district health system.

Earlier this year a Minmec decision was taken that the long-term vision was for all district health services to fall under local government. This is the second biggest parameter under which they were working, namely, setting the time for the future where primary health care and the district health system falls under the direct control of local government.

The second issue Minmec decided upon was that an appropriate forum must be set up around provinces and local governments where issues around delivery, primary health care, and the district health system should be set up. In other words, a provincial health authority should be set up at political level composed of the MEC for Health and councillors for health from various District Councils.

Under the government's ten-point plan, the section under primary health care and the district health system, the comprehensive primary health package should be available in all clinics and community health centres by 2004. The key indicator of success would be when the municipality has a comprehensive health service within the health service agreement in the province.

In other words, the vision in terms of the ten-point plan is that by the year 2004 municipal health system would be in place whereby the district health system would be rendered by municipalities.

Where are we now in relation to this vision?
Presently in the provinces there are no formal municipality health services constituting the district health system. There is a fragmented health system; the provinces are rendering certain primary health services and the municipalities render the same services.

What is to happen in order for municipality based health services to be in place?

There were a number of key issues that need to be sorted out before the target could be reached which the Health department has set for itself:

There needs to be a change in the legislation. The current Health Act, 1977 is outdated and does not have the mechanisms to cope with the district health system. It was not on the agenda in 1977 and the amendments have not dealt with it adequately.

On the table at the moment is a draft Health Law that has been on the table for the last three years or so and one of the issues this draft Health Law has to deal with is the definition of the municipal health services.

The Chairperson asked which Act was inappropriate?

The current Health Act of 1977, Mr Baron replied, which does not adequately deal with the definition of the municipal health services. And why was it an issue to have the municipal health services clearly defined? The Constitution states that local government would be responsible for municipal health services without defining them. There is a vacuum, in legislative terms, in the definition of municipal health services and this has an effect on various roles and responsibilities and the financial accountability of provincial and local governments.

At this point the Chair suggested that Members should interact with this matter to make sure they understand it because next year the National Health Bill would be introduced. It was to have been introduced this year but was withdrawn so that it could take into consideration what was being discussed now.

Mr Baron pointed out that the reason why this was crucial was because it was constitutionally entrenched that the municipal health system becomes the responsibility of local government. However it was defined that that portion of health services would have to be funded out of the resources of local government. If it were defined broadly as the full range of primary health care services including district hospitals it means the local government would have to increase its revenues to cope with funding those services.

If it were defined very narrowly as an environmental health service only, then local government would find it quite easy to cope with it. Once the municipal health services were defined what health service mechanisms would be transferred to local government?

Discussion
Ms SF Baloyi (ANC) asked what are the roles of local and provincial governments? Is there any differentiation?

Mr Baron responded that within the framework of the district health system, in one geographical area all the primary health care is under the control of one management team, which should be under the control of the municipal health authority. This would help ensure inter-sectoral collaboration and render it closer to the community.

The role of the province would be responsibility over secondary/tertiary hospitals as well as coordination, monitoring and planning so that there could be a linkage between the two spheres of governments allowing the primary health care and provincial hospitals would link with each other.

Primary care would be under local government and provincial would have the monitoring and planning role.

Dr DH Baloyi (IFP) said that with the dispensation of the district health system and the comprehensive primary health services it was proposed that service delivery must enable the people on the ground to have access to all the basic services in a package. People should not go to one local government clinic and hop off to another clinic.

In restructuring health services the challenge of delivering everything could easily be met by big towns and cities while smaller towns cannot do so. This has a negative effect to people on the ground who are entitled to comprehensive primary health care services which is a challenge that has to be met.

Dr AN Luthuli (ANC) asked how municipalities would handle these responsibilities in terms of capacity by the year 2004?

Dr Baloyi gave an example of a boundary between Umbumbulu and Durban: facilities were previously owned by the city council and next to it is another facility owned by the province.

For the past five years those two establishments had decided, "illegally", to work together so that when one facility runs short of staff the other could access staff exchanges between each other, which was from goodwill. There is nothing enabling this process to take place.

Similarly in the Western Cape a decision was taken by the health managers that clinic A, B and C, that are close to each other because of the previous dispensation should close the other two and make one a functional one and use all the staff.

The problem arises with respect to reporting in terms of line functions and discipline. Legislation does not enable that process to take place. Theoretically, the resources that sit in provinces are the ones that need to go to the local government. For example, a primary health care nurse employed by the province needs to go to the local health government.

Dr Luthuli asked whether practically would this work especially as one moves away from the cities to rural areas.

Mr Baron responded that the objective is totally unrealistic. The capacity of local government to accept the complete package of services would not be there by the year 2004. Integrating the human resources and financial requirements to run a district health system into a local government that was currently not in existence was unlikely to happen in the next few years, especially in rural areas.

The cities and metros are likely to be the ones that start soonest and in the Western Cape a Cabinet decision was taken to phase in a transfer of facilities from the provincial administration of the Western Cape to the unicity of Cape Town.

Each province is taking their own steps around this. Although there are time frames that have been set for this at national level, provinces are quite unique and each province has its own challenges around different aspect of service delivery and local government. Hence they are following their own timetables and are passing legislation that has to comply with national legislation.

Ms Baloyi (ANC) asked whether that would not cause a problem for them because the provinces are already putting legislation in place that should start with national and then provincial?

Mr Baron replied that as far as the legislation goes it would be ideal if there was national legislation first and provinces followed but he was not an expert on that. But as he understands it the provincial legislation was done in a way that would follow the national if there were a difference afterwards.

Dr I M Cachalia (ANC) asked whether human resource development would cover the integrated management system?

Mr Baron responded that he was not quite sure what this question meant but thought that as the provincial health departments get more sophisticated, they are improving their information and financial systems and their human resource systems.

Dr Baloyi confirmed that in some provinces they have such systems in place, through the influence of the MINMEC.

Mr Baron clarified the point on municipal services claiming that it affects funding of services. Depending on how municipalities are funded, if it was a narrow definition it means the rest of the primary health care under the province would have to be transferred to local government and the province would be responsible for the funding of those services directly.

There would have to be service agreements, which would have to be tight because local government is wary of taking on things that was going to cost them money. If it's a broader definition the funding would go directly to local government and if it was narrow it would come via the provinces, which was one of the things that need to be resolved.

On service agreements, if local governments were rendering primary care, then there was need for a service agreement to make sure that there was integration between the levels of services. In other words, there would have to be tight service agreements between the province who was going to supply the resources and municipalities that was going to carry out the delivery of services. There are no examples of such service deliveries in the country at present.

Dr Luthuli asked whether was there a model of how this worked elsewhere.

Mr Baron responded that this was modeled on international experience, which was a WHO model.

Ms N Marawa (Director at the Director-General's office: Health) added that it was modeled after Botswana where they have effective decentralised district management although it was not exactly the same.

Dr Baloyi said they looked at several Third World countries and the final document entitled: District Health System (a Blue Document) was highly influenced by the British model based on deciding which was the functional geographic unit of service delivery.

This process was ahead of municipal demarcation and in matching it with demarcation areas there are huge gaps. But a decision was made to adopt the municipal definition of functional service delivery for districts A, B, and metros using that as functional definition of unit of service delivery. The Department of Health chose to run with the demarcation as per the municipal demarcation process.

Mr Baron illustrated his point with the Nelson Mandela Metropolitan in the Eastern Cape where he had been working for some time. In the Eastern Cape they have one type "A" municipality and five district councils type "C" municipalities.

Within those type C metropolitans they had 40 odd type B municipalities. They have combined some of the type Bs to make 24 service areas. Which means they have 5 district councils and the 5 district councils have been subdivided in 24 service areas which are comprised of either one B municipality, two B municipalities, or three B municipalities and have grouped them together.

At provincial level they are clustering all their provincial functions, education, health, housing around those service areas so that they coincide with the C municipality boundaries but within this type C metropolitan. They are getting themselves ready to work around the new boundaries that have been drawn up by the local government. Both type B and type C can deliver health services but what need to be made clear are the role, functions, and powers of these types from the Department of Provincial and Local Government.

Dr H Fast (FFC) added that there was a lack of clarity right now with respect to category C and B around certain functions such as water services. It seems health services would be a category C function but it also seems clear that many category Bs are rendering health services.

The relation then would be that category C municipality and district municipality would be the service authority responsible for funding and ensure that health services are delivered.

However, they could enter a service agreement with category B to stipulating that they could perform municipality services but not approach them in terms of funding and so forth.

In the Department of Provincial and Local Government and the Department of Health there is consensus around health that category C would be the service authorities and could contract services to category B to actually deliver the services.

There are some unusual situations in the country such as Mogaung where you have a city, which can deliver a good service and could do it better than category C. In that situation there is an option for category B municipality becoming a service authority for the entire C area.

That district council says they would be happy to give their entire health services to the city, which has more capacity than we have. That's an exception. But for most part the district municipalities would be the service authority and would enter a service agreement with category B. In the future it would be less confusing.

Cross Border Municipalities
Mr Baron said it was difficult enough to have one district health system in one municipality and to try and have that in two provinces would not be plain sailing. For instance in the Northern Cape and North West it seems there is going to be a cross local government agreement and the rest of the functions would have to fit in with what is agreed upon at a macro-level in government.

The two departments of local government at provincial level would make some kind of a cross border deal in those areas and the rest of the departments would have to fit in line with whatever deal is struck.

Different provinces have different ways of working, different standing orders to their staff and different protocols. Although ideally it was meant to be standardised the country has not developed in this way and so provinces have taken slightly different routes. Having everybody in a particular area working under one municipality with different ways of doing things is going to be a challenge.

One of the things that would have to be addressed over a few years is how the cross border district councils are going to function if they are going to take over the primary health care functions of two different provinces and amalgamate them into one working unit.

Ms N Marawa (Department) added that some critical issues involved here related to financial implications and how they are going to be addressed or resolved. At present provinces are losing money through covering others through the services they are offering.

Dr Nkomo (ANC) pointed out that there is also the capacity to collect. There is a very serious problem in Gauteng, which is having to carry the brunt, where people stream to the tertiary hospitals. He suggested that to resolve this the legislation should be allowed to run over a period to allow different viewpoints in order to resolve them.

Dr Baloyi (IFP) said it had been agreed that the level of delivery was a local government sphere and the assumption was that it should be the delivery of all services, such as health, welfare, education and so on. Local government is of the view that everything should happen through the Integrated Development Plan (IDP).

The IDP compels the local structure to look at what is being delivered with whom. They are determining what are priorities. It is not clear what role exists between the local government and IDPs, with respect to health, education, etc because the very demarcation into functional units by education is different from health, public works etc and the functional units determined by official local demarcation.

In other words, even at national level within the Departments the Ministries need to come to grips with what they want to happen on the ground. Health was the only Department saying that they were going to run with the demarcation as outlined by local government and manage service delivery at that level. This cannot happen in isolation. It has to have commitment from all other service delivery departments.

Ms N Marawa (Department) commented that the Integrated Development Plans are complex. The IDP is going to be the key instrument in terms of whatever services government plans to deliver. Government may plan from the bottom up, which is a useful approach in terms of national, provincial and local planning together. But planning nationally and then top down is problematic because the plans may not be the same and it would be a waste of resources. The issue of IDPs becomes key and is now an accepted planning instrument for government.

Dr Fast (FFC) asked whether municipalities are producing sound IDPs? About a year and a half ago they looked at 21 IDPs, which were funded, and out of that not a single IDP was good. The capacity of local government to plan properly has to be boosted before you can begin to roll out decentralisation. While national departments are being told to take IDPs seriously, she suggested not putting too much faith on the IDPs now. The IDPs should be rolled out but not too many assumptions should be made on the IDP.

Ms Baloyi (ANC) asked what functions belong to national, provincial and local government?

Ms N Marawa (Department) said the Local Government was working on the functions between the spheres of governments and there is an understanding that local government is going to be capacitated.

DPLG have six volumes of different approaches to IDPs that can be found on their website because different provinces and local governments would have a different setup. They would introduce you to their training programmes to train and support different managers at different levels to train and support managers.

Dr Baloyi added that even from 1994 the major challenge of provincial departments was carrying out the tasks set out in the Constitution. Provinces with service delivery units have not worked out very clearly how to build capacity, which is the function of province. Therein lies the challenge, so that there is clarity of role. To date there is not a single province that has worked out its capacitating programme for local government structures.

Dr Nkomo concluded that between 18 - 20 November there will be a National Health Summit and perhaps Members could do well to take up this issue because there would be representatives from province, local government and national level. There must be an engagement on this and hopefully the way forward would be fashioned out of that Summit. He asked the Department to include the issue of building the capacity of local government structures on the agenda.

The meeting was adjourned.

Appendix:
Health sector strategic framework
1999 - 2004 Department of Health

10 point plan for improving the quality of health service deliver

ð legislative reform
ð improving quality of care
ð speeding up delivery of an essential package of
services through the district health system
ð improving communication and consultation
within the health system and between the health
system and the communities we serve

MinMec
Long term vision is for all district health services to fall under local government

Appropriate forum to be set up where province/local government should discuss issues around delivery of PHC and the DHS

PHC and the district health system

Comprehensive primary health care package -
should be available in all clinics and CHCs by 2004
Provided free at the point of delivery
Vehicle for delivery is district health system
District health system to be governed by local government where there is capacity
Key indicator of success is a municipality which is rendering comprehensive health services within a service agreement with province

Key issues to be resolved

Legislation - current health act of 1977 outdated
Definition of municipal health services
Funding of district health services -
unfunded mandates
Conditions of service of health workers
Service agreements