District Health System: briefing

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Health

23 June 2003
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Meeting report

HEALTH PORTFOLIO COMMITTEE
24 June 2003
DISTRICT HEALTH SYSTEM: BRIEFING

Chairperson:
Mr. L. Ngculu (ANC)

Documents Handed Out:

Health Systems Trust Presentation
Health Information System Programme Presentation
District Health System and Local Government
Department on the District Health Systems Presentation (e-mail info@pmg.org.za as only hard copy is available)

SUMMARY
The District Health Systems has been an important vehicle for the delivery of Primary Health Care in an integrated and non-fragmented manner. The Department informed the Committee that the system was premised on the principles of equity, non-fragmentation, elimination of duplicity, provision of comprehensive services, effectiveness and efficiency. The Committee also heard that the system ensured quality service, improved access, and local accountability and community participation. The system was developmental and intersectional and one that promised sustainability.

MINUTES
The Chair informed members that the draft National Health Systems Bill was now available for them to familiarise with before the formal stage of deliberation. The Bill proposes a comprehensive framework for the National Health System and that the presentation by the Department should be seen in this light. He proposed that an informal session be held jointly with the NCOP so that members could familiarise themselves with the Bill so as to speed the legislating process.

Briefing-District Health Systems (DHS) and Development
Dr. Yogan Pillay - Cluster Manager informed the Committee that a DHS based on primary health care was a self-contained segment of the National Health System. This system comprised a well-defined population living within a clearly delineated administrative and geographic area and included all health activities in the area --both public and private. The rationale for the DHS was that it was part of the National Health System and that therefore a veritable vehicle for the delivery of the PHC in an integrated and non-fragmented manner.

Dr. Pillay further explained that the district concept derived from two rationales namely that - the implementation of the PHC strategy requiring decentralised management and the organisation of integrated systems which implies that one single team managed the district hospital and clinics. This system was premised on the principles of equity, non-fragmentation, elimination of duplicity, provision of comprehensive services, effectiveness and efficiency. Others were quality service, improved access, and local accountability and community participation. The system was also developmental and intersectional and one that promised sustainability.

Briefing by Mr Peter Barron
Mr. Barron identified five challenges that faced the implementation of the DHS namely; legislation, governance, equity, human resource development and improving the quality of care. On legislation he pointed out that there was uncertainty as to when the relevant law would be implemented and how different provinces would apply this peace of legislation. With regard to equity, he noted that different provinces spent different amounts of money on primary health care and that there were notable differences within provinces too.

As for human resource development Mr. Barron pointed out that there was an absolute shortage of numbers and that the Department lacked a clear human resource development plan. There was need for HIV/AIDS, data and managerial skills to be taught to the health professionals in order for them to cope with the current health care challenges. On governance he decried the administrative problems created by cross boundary areas noting that service delivery was also hampered by too much bureaucracy at the district level. In order to improve on delivery of health care he called on district management to set realistic targets that factor the impact of HIV/AIDS, which has exacerbated the incidence of TB and infant mortality.

Health Information Systems Programme, University of Western Cape
Mr. Vincent Shaw - from UWC's Department of Public Health Science informed the Committee that the Health Information Systems Programme (HISP) started as a local pilot project in three health districts in the Western Cape in 1994-98. This effort was a collaborative research and development effort between the UWC, UCT, the Norwegian Computing Centre and the Western Cape Department of Health. HISP's focus of activity was in the use of information in the health sector to improve service delivery. While the DHIS was seen as a tool to enable managers to access information for managing health services, the HISP team had the expertise in analyzing and developing systems to improve access to information in PHC settings as well as hospital settings.

Mr. Shaw reported that HISP has convened a number of courses at UWC on information systems, many of which had to contribute to establishing a cadre of people in the health sector in southern Africa who work in the management and use of information. He pointed out that the results from the pilot project were regarded as highly successful and the National Health Information Systems Committee for South Africa (NHIS/SA) adopted HISP processes and the DHIS software as a national standard in early 1999. The programme was rolled out to all the other eight provinces during 1999 and 2000, partially funded by the government and partially by the USAID-funded Equity project.

Discussion
Ms Kalyan (DA) asked if there were any minimum standards in health care delivery and what criterion was used to ascertain this.

Dr. Pillay replied that service level agreements had norms and standards that were based on best practices and one that conformed to the current legislation.

Ms Kalyan asked about the shortfalls in the personnel distribution and whether there were any timeframes to fill these vacancies.

Dr. Pillay said that the Department had been compiling a list of vacancies but that some provinces were still faced with the difficulty of quantifying the available posts.

Ms Malumise (ANC) asked if there were any mechanisms that had been put in place to support districts to successfully implement the proposed health systems measures.

Dr. Pillay replied that district municipalities would fund the environmental health services with support from the national treasury through the equitable share. Some districts were largely rural and that their tax base was almost zero hence would not have the capacity to fund their local projects unless support comes from the national Department.

Ms Malumise requested that members be supplied with information on the proposed DHS measures.

Dr. Pillay said that the Department was ready and willing to supply whatever information members sought as long as it is clearly specified what nature of information was in need.

Dr. Luthuli (ANC) noted that the issue of inter-provincial inequity had been around for quite some time and asked what plans, if any, the Department had put in place to address the issue.

Mr. Vuyo Mabope - (Special Assistance to the Minister) noted that there were several factors that complicated the issue of inter-provincial inequity. In the first place the budgetary share for the Department of health had not been expanding in tandem with the incidence of health inflation which he said tends to over-stretch the health Bill. Secondly, he pointed out that the health budget was not kept in line with economic growth and this explained the inequities of budgetary allocations to different Departments. Provincial allocations for the health budget had widened the inter-provincial inequities. He lamented the fact that the Department lacks sufficient data on the distribution of resources within district councils to help assess the level of inequities within provinces. He however reported that in fact the gap between the highest paid province and the lowest one had since narrowed significantly although there was still a long way to go before these inequities are completely obliterated.

Dr. Pillay reported that the Department was in the process of working on a document that comprehensively address the lingering issue of budgetary inequities and that if called upon by the Committee it would address the Committee on this aspect.

Ms Baloyi (ANC) asked how data on the DHS relate to the lowest unit such as a clinic such that nurses were able to interpret this information for utility in their daily routine.

Mr. Shaw replied that managers normally go out to talk to nurses at clinics on how to interpret data what was presented and that this information was then fed into the district data bank. He added that various tertiary institutions had been accredited to offer courses in health information systems to health personnel.

Ms Baloyi asked what the Department was doing to align government employees, salaries so as to remove the existing disparities between local government and central government employees.

Dr. Pillay replied that the issue of harmonizing salary scales for government employees was outside the Department's mandate but hoped that now that the President had raised this concern there would be a move towards a single public service salary scheme. He however cautioned that this was not an easy matter since it would have to involve the unions and other stakeholders.

Dr. Rabinowitz (IFP) asked the stage at which a most reliable information could be expected from the Department.

Dr. Pillay replied that once the draft Bill on the National Health Systems becomes law the flow of information should be expected to have improved.

Dr. Rabinowitz asked for a definition of what 'Environmental Health Services' entailed.

Dr. Pillay explained that the definition of what was covered by Environmental Health System is found in the draft National Health Systems Bill noting that it defined what the local authorities would provide in relation to other spheres of government.

Ms Mathibela (ANC) asked how the Department proposed to deal with the issue of human resources development whilst the actual situation on the ground was such that there was a worrisome exodus of health professionals from the public service.

Dr. Pilllay acknowledged that fact that retention of health personnel in the public service had been and continued to be a thorn in the flesh of government but noted that a whole array of interventional measures had been introduced to address this problem. He referred to the recent presentation the Department made to the Committee where a comprehensive human resource plan was unveiled to illustrate the seriousness with which the problem was being attended to.

Mr. Mabope offered that indeed the Department had advertised a senior post at the level of Chief Director specifically to deal with the whole question of human resources development.

The Chair commended the presenters for what he termed as a most informative interaction but noted that it is clear that a lot needs to be done in order to co-ordinate provision of health services in the country.

The meeting was adjourned.

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