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FROM : DART (D r P. Mc La re n1 PHONE NO. : 833 3385693 Sep. 15 2888 87:29PM PO1 ) " U I I I K I C IA POLICY FOR THE DEVELOPMEWO OF A

DISTRICT HEALTH SYSTEM FOR SOUTH AFRICA. Executive Summary

IntroductionThe challenge facing the South African he8Hh system is lo be part o f n conlprc~hensivt!programmeto redress social and econoniic injustices, and l o ensure tllst omph~r:i s s placed on health nnd notjust on rncdical care. The so uth Afri can Goverrrmcnr of National Urrily, through its adoption of rileRoconsiruction and Devalapmont Programme (RDP) in 1904.. commi tled itself to rlie developmentof a District Health System based on tho Primary Hcalth Care Apprtiacl.~ s enc~nciatod t Alma Atain 1978. This approach i s the'philosophy bohind wliich many health systeins arorrnd Ihe wor ld havebeon reformod, and out of which has developed the cnnccpt'of the District Hs8It11System. Disiricl-based health services are now applied successlully in many cor~ntries,and have Leer1 ndaptod zo awide variety of situalions, irorn developing countries nn our own contine~rt , o rnore sophisticatedsvslems elsewhoro.A National Health Systsrn based on this approach is ns concerned y i t h keeping people healtlry, as

-it is wit h caring for th em when ih cy become tlnwell. 1hese ,r:orrccpts of "caring" s r~d wcllness" arepromoted most e{fecti voly and eff iciently by creating sniall rnanagemerlt itnits of tl-~e ealth systcrn.adapted to c a k r fo r local needs. These units - thc healili !iistricts . provide t l w frtrrncwork for ourhealth system, so that a single auih or ily ck n take re:;ponsibilhy lo r tile l ! ( :~ l i l ~f 1118 popu la tion init,$ area.A hopllthservice based on welltiess will, inre r alia:

emphaslso prevention, health education and prntnotion, cariy inte rven tiot~, ind rmhnbilitationbe rcspol isive t o communi ty needs by placing conlto l and mbnngcrnc:nt responsibililies st H locallevelctlirninate inequit ies and esrablish in'tersoctoral developriienfal links. inregrato inst itu~ iana l, onim.unity-based and prcvcnt ive,prograt~~~nes.)oth wi tl ~i nhe heal t l~ectorand with o ther sectors impacting o n health* reduce waste and eiimlnato duplication a?, all levels

The syslern must be structured such that no.ono in need is prevented from accessing any of tho levolsof care that t hey ma y require, rapidly and efficiently, ;lr>ds u c i ~ha1 all will receive the Ii inhest qualityaf care at all levels.Health Dlrtricts, -

J ...A hetilth disttict must be largo enough to be econclnricnlly e fficien t, but sniall enough t o ensuroeffecti ve management wh ich is accountable to local communities and is respnrlr;ive t(1 l o c ~ leedsthrough the participation of communities and o i s r ~ f in the planning and rnanaclemel-~tof ervices.

Thm World Health Organisation defines a District 14e.altIi System as follows:. . , . . . . . . " . . .A Disrr ict HealthSysrem b ~ s e dn Pr im ~r y eal tl i Care is a /nore o r less seM-corlmit?edsegrnent

of ?lieNafiona l Healrh Systen?. I t comprises first and foremost 0 wcll~dcfinedoptrlation, livingwithin a clea rly delineated adniinisrrativo and gcographicn l nfe8, wI1etI1cr urbdn O r r11reI. I tincltrdos a l l it7stirurions and individuals prom/irlir)g Jlealtli caf e ir i the di.s?lict, whethergovernmental, .socia lsecuri ty, non-governmcnlal, private, or trnditionol. A District I-lcnlth Systcnlrherefore consisrs o f s large varierv of inter-relared elernenrs rlior conrribure ro l ~eu lr lrn Irolnes,sul?nols, work placos, and cornmuniries, r11rollgA ?he ienlrh end orher related scclors. I t nclt~dcsself care an d all health care workers a nd facilities, up to an d ncluding ihe 11nsl~irelf tlrc firstrcaforral level, an d rlie approprior@ aboratory, other rh~gnost ic, en d ogistic sirpporr services.

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FROM : DART (Dr P.McLaren1 PHONE NO. : 833 3385693 Sep. 15 2888 87:38PM P82I l a2

The prilrclples that under-lie the development of aDistrict Hoalth Systemfor South Africa are thatllhe system mus t:

OvorconiofragmentationProrr'rote equityProvidecomprehensivesorvicesRc dornonstrablyelfect iveBe economicallyefficientProvide servicas oftho highesl qualityAllow accoss to allBa ~ccoun tab leothe localcommunities served ,Allow for fullcommunityparticipationDecontralisoappropriate powors - ,and functions. Be based on adeveloprnentsl an di r r t ~ r s e c t ~ r a lphilosophyBE sustairiahie

-

In South Africa, evety prcrvinco will hc d ivided into health districts, and thosize of each district will vary according to local corlditions. There will beabout 20 health districts in each province, and each will he large enouohto contain all the elements required for comprehensiv~!prirnsry healtlr caresorvicos. Each health district will usually contain one or more DistrictHospitals, Commuqity Health Centres, clinics and smaller facilities such nsniohilo units and visiting posts. Tho h oa lt l~ istrict will he part of a welldi3finod rafcrrnl notwork bo th within thc provir~ct: nd ss part of t haove rallNstional Health Systetn. 11 sl>ould coincide wi th similar areas of servicodelivery of o ther sectors, to enhance intersccto ral collaboration.The gonls for trarlsforrr~i~~gl ~ arehltli systetii ai this levol includo thefollowing:- Thare will hc a unitary national heoltlr servico lbascd on o District We ~l th

Systnn't that allows access for everybody to improve ll~eiriealth.The couti lry will be divided into geograptriclrlly colierel-11, unclional liealtlidistricts.. There will tze a sinole health servicc and hcnltl~netlngernenz teanr foreach health district.- The health team in each health disirid will be accuuntalblo to a singleauthority, within n ()rovinc:ial ~ n dational policy frz~riiework.- Ideally, in the long term, districthealtlr systenis should be part of LocalGovern~ncnt,where t l ~ e )oundaries of a trenlll i dislric7 coincido or art:coterminous wi ll i those of a local au1lrc)rity.- A sinole autl.iorily will he thc f?r$oyt.r of tliw district health team. '. Uniform salary and service conditions will be pliascd in lor sll publicsector health persorlnel, regardless vf the en?ployin[A authority.- The health team will be rr::;ponsible for providing co~ np re he ni ve cal lliservices througlioirt tho district up to and including nisiric t Hospital lovcl.

- Tho provincial Health ~iltholl itywill be responsible for i;upporting.monitoring, and bveluating district health services.- Services rendered by private (independelit) and ~ r il d i ti ~ r t n lractitionors.fiIGOs, and provincially.aided llospital scrvices will be seen as intcgral 10tho health district.

It is imporran1 tl ia t tli e boundar ies of hca llh district!; remain "soft" and open to iteyoliarion. Tliero willtl.rerefore be interim boundaties so that all staff know fo r which cunitnunilies they are rcspont;ihle ond l owhom thuy nre sccounteble.In the interim, each province vdill have a number of li ca li ii rcgiorr::, l o develop and support the Iiealtlldistric:lx, uiiiil such tim e as rh o Distr ict HbHlth System is fully established,~overnan 'ceThe vari ely o f conditions t hat exist throughout tho country both in pruvincial healill services as woll asLocal Govornmont, nisaris tha t a unifo rm solu tior~ or irr'imediate irnplen.~entaliori f the District HealthSystem cnnnolbe adopted. Conditions differ nor only between provinccs, lbut withirt ltrovirlces. Differantoptions aro tRerofore required, that can cwcxist both within the

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FROM : DfiRT (D r P.M cLare n1 PHONE NO. : 833 3385693 Sep. 15 2888 87:38PM P83 3Summary of district heal'th authority options

It is important i lia1 declslon-making should be devolve(l l o tho lowest npproprinto lcvcl. Those who provideservices must have th e pow er l o rake decisions about operational rnottors, esl:loc:ially over personrret aridfinancial issues. This decentralisation of functions and decision making is a rlHltlrHl cOllSC(1ucnCO of theestablishment of a Statutory District Health Aulllc~ rity, nd of thr: Locnl Government option wliele a localauthotily's botrnrlory is the sam e as lhnt o f thc hoaltll district.

PROVINCIAL OPTION,

Provincial Heal111Depen-rnent responsible for all dis.(rlct hoalth services

Il~sulficiontndcpondent co.PRCity and infrastructure atdistrict level.

For the provincial option, it is n ece ssa ryt hat tl> e inance and persorrnel funclions within a province are"daprrrtmentalised" t o h e different service cJepartmcnls. Dopartmental heads would bec(lrllc tho acc o~ ~n ti llofiicers, so that decisiorls i n delogatd financia l and personrlel f1111ctions o othcr levels - region, district,community - will re&wi th them, thus creating t h e necessary freedon? irrr der:enlrr~Ilsution and de legationof milrlagarnenr authorily. Similarly, under the L o c ~ l o vcr nm~ nt ption where a Melro(roli l~l1ub Slrrrc1~1rohas a nurnb$rZr.of heal th d is rr ic ~s , lrH1 Sub S truc ture needs to decenlr~liso unctions and powers l o thedislricls.

a, ,>,, . < , , . , , , . i . .. , ,, . '! ;itso f tho district, wh~ cln buld ba gorverlby a clinio. by a Community Hoalth Centre, a ntlmber of satellite clinics, by a Dist rict Hospital, or by

a combination of such acilities. The users of thoso fadilities should be an intcgr&l part of the healilrservices. and not merely 'be setr nas th e recipieh&of serviced: in drder t6r'ihi s to happen, theusers need to be otganised Into a structure which will relale t o tho l lei lth systein,end i t is suggastwdthat that structure be the Cornmunlty Health Commfrroa.

STRUCTURE AND PROCESS -in relation t o lhB Dislrict where n locnl govclnn~clnroull$ority'sbuunderiefi ar e lnr~ero f the rsucll ~et ropn l i t 8n,ll)

thst 8uthority will be tequired lo artahlish Kepa.irppoint Dist r ic t H~althManancrs for oac l l o f r l l e hesllhdistricts within it s area.--- , -

STATUTORY W ~ ~ T R I C THEAlTH AUTHOR IT^ 'Statutory District HoollhAII-thoriiy responsible for 811 dis.trict l~eulthervices

CONUITIONScabscity to devolv~'res-Unlisibiii'fy o dislrict levelbutno single l oca l Huthority will1capacity lo rendor comp-re1lcnl;ive services, andwhose bnundarios ore theeame as tho llaelth district.

on the Dlstrict

' LOCALGO V E . ~ N M ~ N *PTION '. . . . , , , .Locnl Gnvernment responsihlo for all distrlct hssltl~ o r v l c u s

--Sirlgls luci l l inlthority with capacity, wlbosu bvundalics nri!11111h a m e a s the health district.(Ideallya singlo DIstr11:l A~lthorily6 responsibla for 1180 lllr,-vision of al l scrvice~l.

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FROM : DART (D r P. Mc La re n1 PHONE NO. : 83 3 338569 3 Sep. 15 288 8 87:32PM PO1

The transition: steps to be takenThe transition la a Distrlct Healih System w itliir i each provinco should procoed i t i H pllasod manner.This process involves a numb01 of key steps which will be comlnon t o all provlnccs. I e rate, andin some cases the order, of pr o~ re ss lonhrough these s lcps will dif fer from p rov inr :~ o province,slt hou gll in most plovincos. sorno of these steps lrnvo already beon colnplelsd,

Establish regional boundarles within each province. Where possible these i)oundaries s/iouid beagraod inter-sectorally.Establish regional offices as sub-units of thc provirrclal Henlth Depnrtrrlrrnt, including tlieappoinrment of regional directors and regional office staff HS wr:ll as tl ie p1uvir:lori of o ff ices nntlequipment.Eslnblish inlerlrn health d~strirtboundaries, after approprlatc consulcat~or~ ith rclcvantstakeholders. These boundaries willbe subject to further nepotiations anrl rrmondmcnts.Establish inlorim Dislricl Health Management Courdinnting Teams in each ilrtcrim hoalrli dislrici.These teams should consist of tnsnagemenc representatives of each hr:altli authority wit hin t h eintorim healtlr district. The provincial MEC for 14ealih vgill dcsignatc or appoirll ntl i1.11orimDistrictHealth Manager.The functions o f tire; lntqrim Coordinating Te an ~ncludc, amongst others:- the coordination, joint mr inngement and ratiunalisalion m all cornrnnrrily and district4ovel pulllic ')sector heslth sorvices i n he district.- the promo tion of cooporation arld coordination o l 1l1e he nl tl ~;crviccs a1 conimuni lv level

between i he various authorities (including facilitation of t lie trainil-IQand c:iilxicity devulopmontnecessary for this process).- t h e formulation of s comprehensive lhcaltl-I plar~or the district. This includes lhe organisationof community level sorvices end referral syslerrrs.- tho eslablishmont or strengthening o l Cornniut-~ityjealtli Colnrnillee:; slid Hospital Boardswithit) the district. . , , , ,- tho dovelopment of tl ie districtinf'rastrucu,re i r ~ rc?paration or the implen.~t:ntalion of the ncxtphase of the District Health Syslem.

The intorim District Hcal th Ma na g~ nl cn t oordir~ nting earris will bo actively supporled by llrere ~i on al ffices of the prov!ncial llea lti i D'eprlrtrnents.Provinms lnusf dacido o n the,,g,qvernancp options that aro apljrop~ ialeor rlieir health districts. 'Tll ls wi llj equ lra national legis!alion enabling the cteation of lieal lti dis1ric:tr; and will ho fornialisodthrough provincial legislation. The MEC for Healui in each pr ov ir ~c ~ill then proclaini the li eal tl ~districts. Different options may co-@,xistw i t l ~ i r ~provinco.Estgbllsh Dist rict Healt h Councils In each heal111 d~strict. iAppoint District Health Manegers and district officc staff.Negotiate the transfer of staf f to the district hefilth authority ac co ld in ~o tho govamance op ti o~ ichosen.

, ,I t is onvissged that enabling nationai logislation will bo tabled in 1096, l o allow for t lie necessaryprovincial legislation t o fol low for t he establishment of functional healtli districts throughout 1110, . .c o u n ~ r y ' b ~he end of 1997. . .

SUPPOl lOQbv Ilv Otllish PDAand the Eulppten Union