District Health System: Department briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
16 August 2005
DISTRICT HEALTH SYSTEM: DEPARTMENT BRIEFING

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
Department PowerPoint presentation on the District Health System.
District Health System 2005:Clarification of some policy issues
Guidelines for District Health Planning & Reporting 2nd Edition
District Health Plan Indicators and Targets [please email [email protected]]

SUMMARY
The Department of Health briefed the Committee on the District Health System (DHS), outlining issues of health district boundaries, the creation of District Health Councils (DHCs) and District Health Plans. They also addressed the training of mid-level workers and community healthworkers; the importance of developing the District Health Information System (DHIS); the expansion and consolidation of Municipal Health Services (MHS) and Primary Healthcare (PHC) services. A strategy for rural healthcare was being developed. The Department had received a budget for the PHC Directorate, but various posts still needed to be filled.

The Committee was extremely concerned with the ongoing problem of financial inequities in healthcare between provinces. Other issues of concern included accommodation shortages for staff in rural areas; environmental health service delivery, the need for partnerships between provincial health departments and private institutions, and the need to resolve budget tensions between provinces and local authorities. The need for improved delivery of healthcare in rural areas was further recognised.

MINUTES

Department briefing
Dr T Wilson (Department National Director) briefed the Committee on the District Health System (DHS) as legislated in Chapter 5 of the National Health Act 61 of 2003. He emphasised the need to clarify the policy. District Health Councils (DHCs) would play an important role in promoting co-operative governance and functional integration in the implementation of the Act, and would include both public and private sectors. Services would include Municipal Health services (MHS), personal Primary Healthcare (PHC) and District Hospital services.

The boundaries of health districts and sub-districts were being set and any changes would be guided by the Members of the Executive Committee (MECs). All MECs for Health were required to establish DHCs, non-executive bodies comprising an elected chairperson, representatives of the MEC and three other members appointed by the MEC. A DHC was responsible for ensuring and monitoring service delivery from the clinics and communicating directly with the MEC. Effective DHCs would serve as a structure for co-operative governance and improving healthcare service delivery ’on the ground’

District Health Plans were in the process of being drafted. Simplified Department guidelines on drawing up these Plans had been distributed to districts. The Department aimed to hold one-day workshops in September in every health district, in order to begin the process of developing plans. The plans would then influence budget allocations so that district needs would be better met and services would be improved.

Human resources plans would also be drawn up so that staff shortages could be avoided. The United Kingdom (UK) would continue to entice South African doctors and nurses with better remuneration packages. A commitment had therefore been made to train community and mid-level workers such as pharmacy and medical assistants and community healthworkers to fill the void of professional emigration.

The data in the District Health Information System (DHIS) needed to be improved for all sub-districts. There was no adequate information at a district level. Such data would assist greatly in improving future planning and budget allocations.

Municipal Health Services were being expanded and comprised the majority of Environmental Health Services (EHS). There had been great inequity in services between cities and rural areas. The EHS would need to protect water, air, sanitation and waste from the threat of pollution. Community Service Environmental Health practitioners (EHP) were being introduced to assist communities, especially in rural areas.

The Department had been involved in lessening fragmentation in the health system, primarily by implementing one single budget. Funding was needed for personal PHC and for EHS. Clarity was needed on where responsibility lay for these areas. The provinces were responsible for personal PHCs and three EHS’, port health, malaria, and hazardous substances. Districts were responsible for all other EHS’. Additional funding had been requested from the Budget Council 2005/6 for provinces to fund all personal PHC in non-metro areas for R220 million.

Municipal Health Services (MHS) needed to be consolidated and expanded, especially in the rural areas. Adequate funding needed to be secured. Local Municipalities (LM) and District Municipalities (DM) needed to stop the ‘war’ about funding as communities suffered. Personal PHCs needed to be consolidated under a single management structure in all districts. If co-funding was to continue between provinces and cities, that needed to be a more firm political decision. Personal PHC in the non-metropolitan areas was chronically and severely under-funded, with large inequity between provinces. Some districts were spending as little as R30 per capita per annum on healthcare. Services in the more cost-effective clinics and CHCs needed to be strengthened to relieve the load on the more costly hospitals. More ‘gateway clinics’ were also needed. PHC funding further needed to be increased.

Their rural health strategy’s goals included an improved referral system; prioritisation of programmes; increased community participation; provision of staffing accommodation, incentives and support; and upgraded roads and transport systems for better healthcare access. Rural health was a community, district, provincial and national responsibility. A budget for a PHC Directorate had been allocated, although that had not yet been established.

Discussion
Dr A Luthuli (ANC) noted that there was little mobility of doctors, especially specialists, across the healthcare system. Such movement between hospitals and clinics would result in an improvement of conditions.

Dr Wilson agreed and suggested the use of a roster system. Some doctors would resist the idea and the Department needed to look at ways of overcoming any real obstacles such as transport and bad roads. There had been cases where clinic doctors had taken time off when specialists were brought in. The doctors at the local clinics needed to use those opportunities to learn from the specialists. Dr Wilson cited an example of complaints about overcrowding at the Edenvale Hospital. Upon investigation, the Department had discovered that the doctors at the hospitals thought the clinics were not providing good service and were having patients return to the hospital for ongoing treatment. In fact, the clinics in the area were operating very well and the doctors in the hospital needed to change their attitude towards clinic treatment.

Dr Luthuli cited an example of air pollution in Mandini caused by Sappi Ltd. Many children and the elderly were suffering from respiratory illness and no action had been taken by the Departments of Health or Environment to resolve the situation. Dr Wilson responded that the Department was working closely with Environmental Affairs and Tourism to improve those types of situations. Once the posts for the Environmental Health Directorate had been filled, greater clarity on the way forward would be achieved.

Dr Luthuli raised the long-standing issue of provincial inequities and wanted solutions. Dr Wilson referred the Committee to the Inter-governmental Fiscal Review document, which outlined the budget per capita between provinces. That information needed to be disseminated so those representatives from the poorer areas could complain about their budget allocations. The situation had improved since 1994 with the implementation of equitable shares. Provincial Health Departments currently had to fight for their share from the Provincial Treasury in a situation of ‘fiscal federalism’. Some provinces were more successful than others at this.

Ms P Tshwete (ANC) asked if districts were entitled to make funding requests to the National Treasury. Dr Wilson clarified that they were not able to do so. The Department had advocated for a greater proportion of money within the equitable share to go to the districts for Environmental Healthcare. That amount needed to doubled over the next few years.

Dr Wilson noted that important district information was lacking and needed to be collected. Provinces were encouraged to do Expenditure Reviews. The priority was to make funds available, but it was also important to ascertain the absorptive capacity of an area. The effective use of allocated funds often depended on the social cohesion of a district.

Mr I Cachalia (ANC) noted that the training of family physicians had not been mentioned in the report. Dr Wilson responded that Human Resources needed to look at appropriate training. There had been instances where clinics had not paid General Practitioners (GPs) for their services.

Ms M Madumise (ANC) asked if it was possible to forge partnerships with private institutions. She cited the example of mines, where it would be far easier for the employees’ families to be treated on the mines with the Department providing the necessary resources. Dr Lewis felt that such partnerships were indeed possible and a good idea in principle. It was important to establish good management contracts for those partnerships to be successful.

Ms D Kohler-Barnard asked how the proposed mid-level workers and community caregivers would be discouraged from also leaving for more lucrative packages overseas. Dr Lewis said that improvements in working conditions and salary packages were needed as eventually countries such as the UK would be interested in employing that level of worker. Given that young people enjoyed the experience of travelling and working overseas, the Department needed to recognise those workers’ skills on their return so that they could easily find employment in South Africa again.

Ms S Rajbally (MF) raised the issue of accommodation shortages for healthcare practitioners in the rural areas. Dr Wilson noted that in the past, healthcare workers such as nurses, often came from their work area and so accommodation had not been an issue. Nowadays people moved around far more and rural staff were recruited from over the country. Provinces were aware that rural areas offered very little accommodation. Plans for accommodation to be built next to new clinics had been budgeted for in the infrastructure grants.

Mr S Njikelana (ANC) asked if the introduction of a district health system meant that the relationship was changing between national, provincial and local spheres. Dr Lewis responded that there had been changes, but until a single healthcare system was established, provinces would provide employees to non-metro areas. Eventually it was hoped that provincial employees at district level would have sufficient delegated authority to run those services and make local decisions.

Mr Njikelana asked what interim measures were being implemented by the Deparment to resolve budget tensions between provincial employees and local authorities during the move towards a single budget. Dr Lewis agreed that tensions were ongoing and needed to be neutralised. Unless issues of co-funding were resolved in the metropolitan areas, provinces would take over all services in the cities in order to improve service delivery.

Mt Njikelana asked how the Department’s health system related to the Integrated Development Plans (IDPs). Dr Lewis said that the Department viewed the District Health Plans as being the health component of the IDP and the development of that plan needed to become part of the IDP process. IDPs were run by local government but were supposed to involve national and provincial departments. The practicalities of attending IDP hearings needed to be resolved.

Ms B Ngcobo (ANC) queried how effective the DHCs would be, and if one-day workshops would be sufficient. Dr Lewis responded that the workshops were viewed as a start to the planning and would be limited this year to health officials. Next year consultation would be improved. It needed to be part of the IDP process in the future.

Ms Ngcobo asked how different departments were working together to improve healthcare in the districts, especially where no roads to the clinics existed. She wanted to know about healthcare access for farm dwellers. Dr Lewis replied that they had been working with departments such as Transport to improve the road problems. Again, involvement in the IDP process would help greatly. Practical discussions about specific problems had to happen at a local level. Dr Lewis agreed that farm dwellers were among the most isolated, vulnerable and impoverished citizens. While it was costly to send out medical assistance for very few patients at a time, regular visits were being made and suggestions for improvements would be welcomed.

Ms Ngcobo asked how cross-border municipalities affected the Department’s health system. Dr Lewis acknowledged that cross-boundary municipalities had caused several problems. The Chairperson stated that a political decision had been taken to abolish such municipalities.

The Chairperson concluded that many of the issues raised needed to be practically observed. The Committee should use the oversight opportunities in Cape Town and later discuss results with the Department and plan a way forward. Following Ms Kohler-Barnard’s point about human resources, the Deputy Director-General should to present the Committee with the Human Resources plans.

The meeting was adjourned.