IMPLEMENTING THE MUNICIPAL HEALTH SERVICES

(MHS) POLICY IN SOUTH AFRICA

“District Health in South Africa”

Conference : 5th & 6th August 2004Ross A. Haynes

ResearcherHealth Systems Trust

WHAT IS MHS?

decis

ions!!

MHS IS !!??

IMPLEMENTING MHS

the what

the how

impacts

THE PRESENTATION

This work forms part of a DANIDA-funded

project

MHS? WHERE DOES IT COME FROM?

• a Constitutional phenomena - powers and functions of municipalities

[section 156 (1)(a) Part B of Schedule 4]

Primary Health Care services

minimal “midi” maximal

• the original possibilities (definitions)

• previous health activities at municipalities - mainly local (B’s) and metro (A’s) municipalities - clinics (p&p) and environmental health services - focused on the urban areas (provs served non-urban) - included “own” funds

MINISTER OF PROVINCIAL AND LOCAL GOVERNMENT

• MHS devolution set for 1st July 2004

• A and C municipalities responsible

• C’s may delegate to B municipalities

SOME IMPORTANT DECISIONS

Health MinMEC >> NAT. HLTH BILL (Aug 2003)

• MHS is a “list of environmental health services”

WHAT IS MHS?

deci

sions

!!

MHS IS !!??

IMPLEMENTING MHS

the what

the how

impacts

THE PRESENTATION

MHS is ……….

• a “list of environmental health services” ..

• devolved to District and Metro municipalities ..

• as from 1st July 2004 ..

• which can be delegated to Local municipalities (i.e. agency basis)

Consider this in the light of • the new environmental health policy and• LGs position for intersectoral collaboration

• a “list of environmental health services” ..

“list of (9) environmental health services”• water quality monitoring• food control• waste management• health surveillance of premises

• surveillance and prevention of

communicable diseases, (excluding immunisations)

• vector control• environmental pollution

control• disposal of the dead• chemical safety

EH services retained as Provincial responsibilities

Other EH services delivered by municipalities ??

• port health• control of hazardous substances• malaria control

WHAT IS MHS?

deci

sions

!!

MHS IS !!??

IMPLEMENTING MHS

what

the how

impacts

THE PRESENTATION

the what

Implementing MHS … (the what)

District / MetroMunicipalities

Provincial structures

Local Municipalities1. Devolving the function

? Funding

? Staff transfers

? Equipment

? Agreements (SLA, MoU)

Some barriers• legislative environment• funding• policies / tools

Why District level?

MHS

MHS

1st July2004

WHAT IS MHS?

deci

sions

!!

MHS IS !!??

IMPLEMENTING MHS

the what

how

impacts

THE PRESENTATION

the how

Implementing MHS … (the how)

RESOURCES

MONITORING & EVALUATION

CO-ORDINATION & POLICY DEVELOPMENT

• are there monitoring tools and an EHIS system in place?

• MHS - a LG competency (DPLG) but ….. NDoH responsible for the health of the population (provinces?)

• no unfunded mandates! Treasury!!• what do the services cost? >>>• how many EHPs/support staff are

required? >>> • smoothing out the inequities

>> Report: Financing EHS in South Africa [www.hst.org.za]

How many EHPs are required? - Current numbers

Filled posts Total posts % filled

Eastern Cape 175 237 74%

Free State 158 158 100%

Gauteng 402 464 87%

KwaZulu Natal 350 576 61%

Limpopo 186 253 74%

Mpumalanmga 122 182 67%

Northern Cape 52 68 76%

North West 110 140 79%

Western Cape 316 357 89%

NATIONAL 1 871 2 435 77%

TABLE: EHPs post establishment in South Africa

How many EHPs/support staff are required? - Coverage

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Co

mm

un

ity

me

mb

ers

pe

r E

HP

population per EHP

FIGURE: Inter-provincial comparison of population size per Environmental Health Practitioner (filled posts)

1/15 000

36 437

Community members / EHP

How many EHPs/support staff are required? – Intra-provincial coverage

 Table: Coverage of EHP’s, per Metro and District Municipality, in the Eastern Cape Province

TOTALLGPROV

Population / EHP

EHP posts (filled)

population

Total/Average

DC44 Alfred Nzo

DC15 OR Tambo

DC14 Ukhahlamba

DC13 Chris Hani

DC12 Amatole

DC10 Cacadu

Nelson Mandela Metro

Eastern Cape Province

1 005 776

36 437175115606 376 391

50 03611011550 400

79 832210211 676 480

34 1321091341 321

35 71321147749 979

44 9803721161 664 251

22 83417170388 184

17 34158544

X

What do the services cost? - 1

82 261

15 208

10 456

22 811

26 509

73 532

108 307

22 945

31 020

Western Cape

North West

Northern Cape

Mpumalanga

Limpopo

KwaZulu Natal

Gauteng

Free State

Eastern Cape

1/15000Actual

Total costsOperational costs

Personnel costs

Per capita costs

18.18

4.95

11.61

6.56

5.43

7.80

11.53

8.48

4.86

17.35

9.22

13.40

12.46

9.50

14.01

17.96

9.68

11.82

10.768.78393 04880 284312 765NATIONAL

TABLE: EHS delivery costs (in R000s) in the country – for 2002/03 (provinces) and 2001/02 (LG)

National population (44,819,733) x 1/15 000 per capita cost (R10.76) = R482,26 mill.

Actual

What do the services cost? - 2

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

Eas

ter n

Cap

e

Free S

tate

Gau

teng

KwaZulu

Nata

l

Limpop

o

Mpum

alanga

Northern

Cap

e

North W

est

West

ern

Cape

NATIONAL a

vera

ge

Ran

ds

pe

r p

ers

on

per capitat cost (in R) of EHS

FIGURE: Inter-provincial comparison of per capita cost (in Rands) of delivering Environmental Health Services, for 2002/03 (provinces) and 2001/02 (Local Government)

R8.78 (actual per capita)

R10.76 (@1/15 000)

R13.00 (national figure)

Costing based on EHPs only. Cost

of delivery actually higher

with support staff.

WHAT IS MHS?

deci

sions

!!

MHS IS !!??

IMPLEMENTING MHS

the what

the how

impacts

THE PRESENTATION

impacts

Implications - actual and potential

• insecurity and demotivation

• lack of clarity - on LG budgeting processes - transfers and secondments - current status quo arrangements

• potential fragmentation

• enhanced intersectoral coordination

• urban / rural differences in MH services

• training of future EHPs

Implications - actual and potential

• MHS – a Constitutional disaster or golden opportunity ?

- stemming the flow

- preventative and promotive “high % diseases by environmental factors”

- developmental EHS / MHS

- intersectoral co-operation

- LG’s accountability to the people

IMPLEMENTING THE MUNICIPAL HEALTH

SERVICES (MHS) POLICY IN SOUTH AFRICA

“Strong leadership, the necessary political will anda high level of professionalism

can ensure effective implementation of the MHS policyleading to improved health status of the community.”

THANK YOU ….

delightfulfor being a wonderful audience attentive ???