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TRANSPORT FOR HEALTH SERVICES IN A

DECENTRALISED DISTRICT HEALTH SYSTEM IN SOUTH

AFRICADistrict Health in South Africa Conference

5 and 6 August 2004

Dr Wendy HallHealth Systems Trust

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INTRODUCTION

Transport as a support service, excluding emergency services (ambulances)

Why transport? Essential resource for health services Neglected in health policies and strategic plans Policies and plans set outside of Dept of Health

by National Dept of Transport

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OBJECTIVE OF PRESENTATION

To put fleet management of transport for health on the agenda Few studies done Few publications

To share the complexity of current systems

To look at current policy directionsTo make recommendations

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METHODOLOGY

Local Government and Health Research Consortium Project – 2002/03

Literature reviewPolicy and other documentsPersonal and colleagues’ experiences in

the field

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ROLE OF TRANSPORT IN HEALTH

Delivery of health services Mobile services Supervisory visits to clinics and communities School health services DOTS and other community based projects

Patient transfers – elective and emergency Support services

Collection and delivery of supplies and drugs Collection of blood samples – laboratory services General administration Meetings

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STAKEHOLDERS National sphere

National Dept of Transport National Dept of Health

Provincial sphere Provincial Dept of Transport Provincial Dept of Health

Local sphere Local government – municipalities

Service delivery level – community served

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RELATIONSHIPSNational Govt

Provincial Govt

Local Govt

Service Delivery Level

PDoHPDoT

NDoHNDoT

Municipal Council

District Health System

Municipal run services

Provincial run services – clinics & hospitals

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ROLES AND FUNCTIONSNational Dept of Transport

Responsible for fleet management for all national and provincial sectors Government Motor Transport, Subdivision of

Corporate Services Division Government garages

Set policy and M&E of these policiesNegotiate contracts

Wesbank First Auto (RT460) – Fleet Management Service Provider

Tender RT77 – purchase of new vehicles

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ROLES AND FUNCTIONSNational Dept of Health

Hire vehicles from National Dept of Transport for own use Outsourced policies – away from base Subsidised vehicle scheme

No role in provision of transport for health service delivery

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ROLES AND FUNCTIONSProvincial Dept of Transport

Implement national policyEstablish Motor Transport Advisory

Committee – representation from all provincial departments

Management of provincial fleet – supported by Wesbank First Auto Purchase, licencing, repair and disposal of vehicles

Manage and monitor outsourcing contracts in the province

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ROLES AND FUNCTIONSProvincial Dept of Health

Hire vehicles for health services from PDoT

Liaise with PDoT and Wesbank First Auto in fleet management

Allocate vehicles to programmes, health regions, districts and sub-districts and hospitals for service delivery

Financially accountable – PFMA requirement

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ROLES AND FUNCTIONSLocal Govt – Municipal Councils

Provide transport for own health services within municipal boundaries Finance for purchase and maintenance Monitoring of fleet Allocation to services

Own policies – not subject to NDoT policies

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ROLES AND FUNCTIONSService Delivery Level

Provincial Services Day to day management of vehicles allocated

by PDoH Allocation of vehicles to services, programmes

etc Motivate to PDoH for new and replacement

vehicles

Municipal Services According to locally determined policies

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DECISION SPACE FOR TRANSPORT IN HEALTH

Nat Treasure

NDoT NDoH PDoT PDoH Prov local HM

Mun Health

Facility Man

Decisio

n S

pace

Wide

Sets guideline for PPPs

Wide

Sets policy for all govt sectors fleet manage.

Narrow

Outsource through contract between NDoT and private provider

Moderate

Implements and monitors national policy

Narrow to Moderate

Identifies needs; allocates vehicles; financially responsible

Narrow

Maintain and monitor vehicles;

Motivate for vehicles;

Wide

Own pool vehicles or from municipal pool;

Own policies

None

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RELATIONSHIPSNational Govt

Provincial Govt

Local Govt

Service Delivery Level

PDoHPDoT

NDoHNDoT

Municipal Council

District Health System

Municipal run services

Provincial run services – clinics & hospitals

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IMPLICATIONS FOR HEALTH SERVICES Complex relationship – inter-

government, inter-department, public-private

“No transport” – commonly heard cry

Delivery of medicines to clinic Outreach programmes Elective transfers TB sputum turn around times

Peri-natal and maternal mortality

Transport – avoidable cause 2.6% in 2000 and 5.3 % in

2001 – peri-natal 13.% in 1998 – maternal

deaths (between facilities)

Delays in licencing and repairs Role of First Auto Role of PDoH, PDoT and PDoF

Decentralisation of functions from PDoT to PDoH

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NATIONAL DEPT OF TRANSPORT STRATEGIES

Fleet management of national fleet – not core business of NDoT

General government policy of outsourcing non-core functions

Strategic Plan – 2002/2003 Implementation of private-public partnerships

(PPPs) where appropriate Improve reliability and availability of subsidised

transport

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SUBSIDISED CAR SCHEME

Transport Circular No 5 of 2003Supplements pool of vehicles availablePrescribed criteria –

Vehicle required as work facility Travel more than prescribed distance per month Satisfy Wesbanks financing requirements

Monitored by NDoT

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PUBLIC-PRIVATE PARTNERSHIPS

Outsourcing fleet management through a PPP to a company whose core business is fleet management

Private company manages the fleet Ensuring availability of vehicles

Guided by National Treasury Public-Private Partnership Guidelines

To date – signed in Northern Cape (2001) and Eastern Cape (2003)

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Both – theoretically improve availability of transport – but…..

Subsidised Cars Monitoring distances Non use on dirt roads Lack of funds for

petrol Travel alone – several

cars to same destination

PPP Managed by PDoT

Capacity required Departmental

committee Recent conference –

98% availability (no clear definition of this)

No user depts present Vehicles not requested

– too expensive

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Schemes are centrally developed and monitored and vertically implemented.

What is their impact on health service delivery in a decentralised DHS?

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LITERATURE REVIEW (1)

TransAid Worldwide (2001) Multi-country study –

Ghana, Cote D’Ivorie, South Africa and Zimbabwe

Importance of functional transport system – policy, operational management, fleet management, information, human resource management

Ghana – decentralised system with districts having full budgetary responsibility for transport found to be the best

South Africa – report recommends the DoH should manage their fleet in-house as it does not get value for money through their relationship with DoT

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LITERATURE REVIEW (2)

Collins, C et al – “A successful transport scenario for the health sector in developing countries”

Transport should be the responsibility of the health sector and “….not merely be seen as a support activity to be provided by others.”

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LITERATURE REVIEW (2a)

“Transport is a crucial area in which horizontal integration of health programmes at the decentralised district should allow for the flexible adaptable and more efficient use of scarce resource. Many of the management and planning problems involving transport derive from the vertical organisation of health services and, thereby, transport services.”

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RECOMMENDATIONSRESEARCH What is the impact of outsourcing transport management

and extending the subsidised car scheme on health service delivery? Are the policies, which might be good for some sectors, actually impeding health service delivery?

How will these policies operate in a decentralised health system in which local government is not subject to national policies for transport?

How can the equitable distribution of transport for health service delivery be assured in a decentralised system?

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RECOMMENDATION

The national and provincial departments of health should take full responsibility for the provision of transport for health services. Policies need to be developed independent of the Department of Transport and be appropriate to the health services.

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So – do I have any recruits for the

New

Transport Action

Campaign?

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THANK YOU